ABSTRACT
BACKGROUND AND AIMS: Telehealth plays an integral part in healthcare delivery. The impact of telehealth and the COVID-19 pandemic on medication prescribing and patient satisfaction with telehealth in cardiology clinics remains unknown. METHODS: A retrospective study of cardiology clinic patients at an Australian tertiary hospital was conducted; 630 patients seen before the COVID-19 pandemic (0.6% telehealth) and 678 during the pandemic (91.2% telehealth) were included. Medication changes, new prescriptions and time to obtaining prescriptions after clinic were compared. To evaluate patients' experiences, cardiology clinic patients reviewed during the pandemic were prospectively invited to participate in an electronic survey sent to their mobile phones. RESULTS: The overall rates of medication changes made in the clinic between the prepandemic and the pandemic periods did not differ significantly (26.9% vs 25.8%). Compared with prepandemic, new cardiac medication prescriptions during clinic were significantly less (9.3% vs 2.5%; P < 0.0001) and recommendations to general practitioners (GP) to initiate cardiac medications were significantly more (2.6% vs 9.1%; P < 0.0001). Time to obtaining new prescriptions was significantly longer in the pandemic cohort (median 0 days (range: 0-32) vs 10.5 days (range: 0-231); P < 0.0001). Two hundred forty-three (32.7%) patients participated in the survey; 50% reported that telehealth was at least as good as face-to-face consultations. Most patients (61.5%) were satisfied with telehealth and most (62.9%) wished to see telehealth continued postpandemic. CONCLUSION: Telehealth during the COVID-19 pandemic was associated with greater reliance on GP to prescribe cardiac medications and delays in obtaining prescriptions among cardiology clinic patients. Although most patients were satisfied with telehealth services, nearly half of the cardiac patients expressed preference towards traditional face-to-face consultations.
Subject(s)
COVID-19 , Cardiovascular Diseases , Patient Satisfaction , Telemedicine , Humans , COVID-19/epidemiology , COVID-19/prevention & control , Male , Female , Retrospective Studies , Middle Aged , Aged , Cardiovascular Diseases/drug therapy , Cardiovascular Diseases/epidemiology , Australia/epidemiology , Drug Prescriptions/statistics & numerical data , Aged, 80 and overABSTRACT
BACKGROUND: Guidelines advocate for intensive lipid-lowering in patients with atherosclerotic cardiovascular disease (ASCVD). In May 2020, evolocumab, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor, became government subsidised in Australia for patients with ASCVD requiring further low-density lipoprotein cholesterol (LDL-C) lowering. AIM: To identify barriers to prescribing PCSK9 inhibitors in hospitalised patients with ASCVD. METHODS: A retrospective 3-month, single-site, observational analysis was conducted in consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Lipid-lowering therapy prescriptions, including PSCK9 inhibitors, were assessed using electronic medical records, compared against the Australian Pharmaceutical Benefits eligibility criteria, and barriers to PCSK9 inhibitor use identified. RESULTS: Of 331 patients, 244 (73.7%) underwent PCI and 87 (26.3%) underwent CABG surgery. A lipid profile during or within 8 weeks of admission was measured for 202 (82.8%) patients undergoing PCI and 59 (67.8%) undergoing CABG surgery. In patients taking high-intensity statins on admission (n = 109), LDL-C ≥1.4, ≥1.8 and >2.6mmol/L was seen in 64 (58.7%), 44 (40.4%) and 19 (17.4%) patients respectively. High-intensity statin prescribing at discharge was high (>80%); however, ezetimibe was initiated in zero patients with LDL-C ≥1.4 mmol/L. There was variable advice given by clinicians for LDL-C targets. No patients met the criteria for subsidised PSCK9 inhibitor therapy, largely due to lack of qualifying lipid levels following combined statin and ezetimibe therapy. CONCLUSION: Prescribing of non-statin LDL-C-lowering therapies remains low in patients with ASCVD. Underprescribing of ezetimibe and suboptimal lipid testing rates are barriers to accessing subsidised PCSK9i therapy using current Australian eligibility criteria.
Subject(s)
Anticholesteremic Agents , Hydroxymethylglutaryl-CoA Reductase Inhibitors , Percutaneous Coronary Intervention , Humans , Anticholesteremic Agents/pharmacology , Proprotein Convertase 9 , Cholesterol, LDL , Retrospective Studies , Australia/epidemiology , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Ezetimibe/therapeutic use , SubtilisinsABSTRACT
BACKGROUND: Guidelines advocate multifactorial cardiovascular risk management in patients with diabetes and atherosclerotic cardiovascular disease. AIM: In hospitalised patients with diabetes following coronary artery bypass graft (CABG), we aimed to evaluate the impacts of decision-support algorithms for optimising glycaemia and lipid-lowering. We also assessed the safety of initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors near time of hospital discharge. METHODS: This was a single-site, pre- and post-intervention analysis of glucose and lipid management in consecutive hospitalised patients with diabetes undergoing CABG surgery. The intervention involved education and decision-support algorithms designed by a multidisciplinary committee to guide cardiac surgery unit clinicians. RESULTS: A total of 200 patients were included in the study. The pre- and post-intervention groups had similar baseline characteristics (HbA1c 7.9 ± 1.9% vs 8.1 ± 1.8%). Of 4092 blood glucose measurements, the incidence of levels between 5 and 10 mmol/L was not different post-intervention (55.5% vs 57.0%; P = 0.441). Fewer endocrinology consultations occurred (59.0% vs 45.0%; P = 0.048) and rates of hypoglycaemia remained low. High-intensity statin was prescribed in >90% pre- and post-intervention, although non-statin lipid-lowering agents remained <10% despite patients not achieving LDL-C targets. No 30-day readmissions for diabetic ketoacidosis occurred in patients prescribed SGLT2 inhibitors. CONCLUSION: The intervention did not improve inpatient glycaemia or increase non-statin lipid-lowering prescriptions in patients with diabetes following CABG surgery but did reduce reliance on specialty input. Initiation of SGLT2 inhibitor therapy near time of hospital discharge was not associated with safety concerns. Alternative interventions or strategies are required to optimise glycaemia and non-statin lipid-lowering therapy prescribing in this setting.
Subject(s)
Diabetes Mellitus , Hydroxymethylglutaryl-CoA Reductase Inhibitors , Sodium-Glucose Transporter 2 Inhibitors , Blood Glucose , Coronary Artery Bypass/adverse effects , Diabetes Mellitus/drug therapy , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Lipids , Treatment OutcomeABSTRACT
In this real-world study, the main barriers for not initiating SGLT2 inhibitor therapy early after an acute cardiac event are prescribing criteria around glycated haemoglobin and renal function. Initiation of SGLT2 inhibitors near to, or at, hospital discharge following the cardiac event was not associated with 30-day diabetic ketoacidosis readmissions.
Subject(s)
Acute Coronary Syndrome , Diabetes Mellitus, Type 2 , Diabetic Angiopathies , Diabetic Ketoacidosis , Hypoglycemic Agents , Sodium-Glucose Transporter 2 Inhibitors , Acute Coronary Syndrome/drug therapy , Acute Coronary Syndrome/etiology , Aged , Coronary Artery Bypass , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/drug therapy , Diabetic Angiopathies/drug therapy , Diabetic Angiopathies/etiology , Diabetic Angiopathies/surgery , Diabetic Ketoacidosis/etiology , Female , Humans , Hypoglycemic Agents/adverse effects , Hypoglycemic Agents/therapeutic use , Male , Middle Aged , Patient Care , Patient Readmission , Sodium-Glucose Transporter 2 Inhibitors/adverse effects , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use , Time-to-TreatmentABSTRACT
We previously showed that implementing algorithms for managing diabetes in acute coronary syndrome was associated with improved inpatient glycaemic control and increased sodium-glucose cotransporter 2 (SGLT2) inhibitor prescriptions. The present study performed 1 year later found that inpatient hyperglycaemia had relapsed to pre-intervention rates, although SGLT2 inhibitor prescriptions remained increased. We discuss the challenges of improving inpatient glycaemic control.
Subject(s)
Acute Coronary Syndrome , Diabetes Mellitus, Type 2 , Hyperglycemia , Acute Coronary Syndrome/drug therapy , Diabetes Mellitus, Type 2/drug therapy , Glucose , Humans , Hyperglycemia/drug therapy , Hypoglycemic Agents/therapeutic use , Inpatients , SodiumABSTRACT
Recent cardiovascular safety trials on sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists have demonstrated the significant cardiovascular and renal benefits of these medications. Diabetes organisations have revised their medication guidelines to include a focus on disease outcomes for cardiovascular disease, heart failure and renal disease. This article summarises latest evidence, guideline recommendations and current Australian Pharmaceutical Benefits Scheme requirements.
Subject(s)
Cardiovascular Diseases , Diabetes Mellitus, Type 2 , Sodium-Glucose Transporter 2 Inhibitors , Australia/epidemiology , Cardiovascular Diseases/drug therapy , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/prevention & control , Diabetes Mellitus, Type 2/drug therapy , Diabetes Mellitus, Type 2/epidemiology , Glucagon-Like Peptide-1 Receptor , Humans , Hypoglycemic Agents/therapeutic useABSTRACT
BACKGROUND AND AIMS: Outcomes after coronary artery bypass graft (CABG) surgery have improved due to advances in surgical technique and post-operative care. We aimed to describe contemporary clinical characteristics and short-term post-operative outcomes in diabetic patients undergoing CABG surgery. METHODS: A retrospective analysis of patients who underwent CABG surgery over a 4.5-year period in a Western Australian tertiary hospital was performed in September 2019. The cohort was stratified according to pre-operative diabetes status. RESULTS: A total of 1327 patients underwent CABG surgery, of which 572 (43.1%) had diabetes. Diabetic patients were more likely to be female (24.7% vs. 13.9%, p < 0.001) and have dyslipidaemia (83.0% vs. 68.1%, p < 0.001), hypertension (82.0% vs. 68.7%, p < 0.001), raised body mass index (29.8 ± 5.6 vs. 28.7 ± 5.1 kg/m2, p < 0.001), prior myocardial infarction (62.8% vs. 54.8%, p = 0.004), prior stroke (8.6% vs. 5.0%, p = 0.010), congestive cardiac failure (20.2% vs. 15.1%, p = 0.014), reduced estimated glomerular filtration rate (86.7 ± 36.1 vs. 90.8 ± 32.1 ml/min/1.73 m2, p = 0.036) and three-vessel coronary artery disease (74.8% vs. 67.3%, p = 0.003). Post-operative wound infections (3.1% vs. 1.5%, p = 0.022), new dialysis requirement (2.9% vs. 1.0%, p = 0.009) and 30-day hospital admission (13.1% vs. 8.5%, p = 0.007) was more likely in diabetic patients, but not myocardial infarction (3.0% vs. 2.0%, p = 0.247), stroke (1.4% vs. 0.8%, p = 0.286) or 30-day mortality (2.4% vs. 1.7%, p = 0.354). No significant differences were detected in short-term outcomes between patients with non-insulin (n = 398) versus insulin treated (n = 174) diabetes. CONCLUSIONS: Diabetic patients continue to represent a higher-risk cohort, highlighting the need for further strategies to reduce short-term adverse outcomes following CABG surgery.
Subject(s)
Coronary Artery Bypass/adverse effects , Coronary Artery Disease/surgery , Diabetes Mellitus/drug therapy , Insulin/therapeutic use , Postoperative Complications/pathology , Tertiary Care Centers/statistics & numerical data , Aged , Australia/epidemiology , Coronary Artery Disease/pathology , Diabetes Mellitus/epidemiology , Diabetes Mellitus/physiopathology , Female , Follow-Up Studies , Humans , Hypoglycemic Agents/therapeutic use , Male , Middle Aged , Postoperative Complications/etiology , Prognosis , Retrospective StudiesABSTRACT
The coronavirus disease 2019 (COVID-19) pandemic has greatly impacted healthcare services around the world. Pharmacists are front-line healthcare professionals and integral members of the healthcare team. The deployment of a specialized 'COVID pharmacist' within our institution has demonstrated that the skills of the pharmacist can be adapted, expanded and utilized to alleviate the pressure of doctor shortages, reduce healthcare worker exposure to infected patients, contribute to therapeutic decisions and work collaboratively to tackle the challenges faced during this pandemic. This commentary details an Australian hospital pharmacy response to the COVID-19 pandemic, describing the unique clinical and practical contributions made by a specialized COVID pharmacist in our institution.