Pondering the complexities of preventing cardiovascular disease

He wasn’t a real uncle rather just a good friend of my dad but I remember him fondly, for he piqued my interest in theatre, taking me every year as a kid to the pantomime in the Wellington Opera House. Every year I would fall in love with the lead, be it Peter Pan or Robin Hood, invariably played by a slim, gorgeous actress.

One year Uncle Pete missed the panto. He was about 40 at the time. Smoked like a train. Dad took me to see him in the cardiac ward. Confined to bed for four weeks after a second heart attack. Didn’t do him any good. In those days you did what the doctor ordered, even if the treatment killed you. It was the same ward in which my dad died 18 years later and the same one I ended up in two months ago. Only one of the three of us survived to discharge. If only we had known then what we know now.

Cardiac care may be vastly better nowadays but why are young people still dying of cardiovascular disease in our nation?

We know what to do: lifestyle changes and prescription medications. Let us focus on the latter.

How good are you with your CVD prescribing? Are all your patients at increased risk of CVD, and not just those who have had a CVD event, on the preventive CVD medications they need to stop them becoming mortality statistics? Knowing yes, wanting yes, but are we doing what we should be doing? Is this why patients still end up in cardiac wards not on triple therapy? And then, what is your practice doing and what are your patients doing?

A study of 33,000 patients in Auckland and Northland indicated that 54 per cent of Māori, 40 per cent of Pacific and 46 per cent of non-Māori/non-Pacific peoples who were of guideline-indicated age for CVD risk assessment had no record of such assessment in the previous five years.²

We are all unique. Ourselves, our practices, our patients. Add in fellow health professionals; the media; and our patient’s families, world understanding and their complex interactions as some reasons why the success rates of high-level tactics to improve medicines adherence is poor. ^3,4

Therefore, when planning what you or your practice decide to implement to improve CVD medication outcomes, the actions must be tailored to both the clinical environment and to your patient’s world.

Here are a number of questions to provoke such planning.

The clinician

1. CVD risk assessment: are your patients who need CVD preventives being identified? Are you doing computer CVD risk assessments? Is the one you use accurate? Do you review patient risk at the correct interval?
2. Prescribing: do you follow the CVD guidelines? Have you read the latest version?
3. Workload: how do you address the CVD needs of patients with higher priority morbidities, particularly when you are busy? Do you have good practice support for this?
4. Communication: do you explain the need for CVD medication in a way that is clear and acceptable to your patient? Do you use visual aids eg, https://cvdcalculator.com to help communicate risk?

The patient

1. Do you identify patients who are likely to have difficulties taking regular medications? How many of your patients with poor control take drug holidays? Do you do anything about patients who are not collecting repeats?
2. Is difficultly accessing you, your practice or the pharmacy a cause of non-adherence? Is your practice’s repeat prescribing policy and process an access barrier to patients, especially those with a disability, or communication or cultural differences? Are your practice hours a similar barrier? Do patients really need to be seen every three months for a new prescription?
3. If you know your patient is non-compliant, what do you do proactively to address this? How well do you know them and their family? For those who do not have family, who supports them, who is close to them, who can you contact if you cannot contact your patient? Can you identify why they might be non-adherent? Is it persistent or intermittent? Is their personal health lower priority than others in their family? If you are not of their culture, do you understand theirs?

1. Assure that all high-risk CVD patients in your practice have been identified and prescribed appropriate medications. Audit your patient management system (PMS) at a practice level, focusing on Māori and Pacific peoples.

2. Identify any patients not collecting repeats from your practice or their dispensing pharmacy. Use your practice IT systems eg, ePrescribing indicators of when medications are dispensed, audits of your PMS (get to know your PMS better). Engage with your local pharmacies or use your clinical pharmacist to alert you to such patients.

3. Identify patients at risk from medication adherence problems using factors such as:

• Co-morbidities, particularly mental health.
• Previous non-adherence.
• Priority populations such as Māori, Pacific peoples and younger people.
• Socioeconomics: is the cost of repeats a likely barrier for your patient?
• Employment barriers such as multiple workplaces, long commuting times, anti-social work hours which impede access to your practice or to the pharmacy for repeats.

4. Systems

• Review your practice’s repeat prescribing policy for any barriers to patient access to repeats. Put yourself in a patient’s shoes.
• Review your practice's medicines reconciliation process, in conjunction with your clinical pharmacist, to target non-adherence.
• Use reminder systems for both your practice and for patients, such as automated SMS text messaging.

5. Patients

• Always check with patients when you see them, particularly if their CVD indicators are not in target, about medication adherence. Success at this will be totally dependent upon how comfortable your patient is with you and how well you know them and their world.
• Connectedness with patients is essential. It may be obvious that better doctor–patient communication is central to good medicines adherence⁷ but any disconnect between clinician and patient is likely to impede medication effectiveness.
• Delegate. Identify and involve other clinicians or support persons, either in practice or within the community, who might provide insight into a patient’s adherence issues. This is particularly important when your patient’s world is of a different culture to your own. The complexity of relationships in larger families must be understood when medication adherence motivation is required.
• Discuss with other clinicians, both within the practice and without, of patients whom you suspect are having medication adherence difficulties to identify potential ways for you to understand their world and identify motivational opportunities.
• If your clinical time is too pressured to address any of the above questions, delegate (as above) be it within your practice or to another primary care provider.

It may be teaching clinicians to suck eggs, but without a doubt, patient communication and cultural competence are two key principles to good CVD prescribing. This is nicely discussed in a BPACnz article penned by Dr Trevor Walker of his interview with Te Aroha GP Dave Colquhoun titled “What is Māori Patient-Centred Medicine for Pākehā GPs.”⁹

Dr Colquhoun’s key messages are:

• act with humility, warmth and respect
• establish linkages and connections
• involve the whānau
• offer to participate in some way.

Te ao Māori can teach us much wisdom for not only Māori but for all cultures, Western or non-Western and remember that even the best patients miss their medication. I know. Three times this month I have missed my perindopril and rivaroxaban. I may need that humility.

Jim Vause is an emeritus GP, living in Māpua, Tasman