Wasim Baqir
I MET Mr D in clinic. He’s a 52 years old, well mannered chap who walked in looking a little confused.
“I’m not sure why I’m here?” he said. Neither was I, as the appointment screen offered no additional help!
On looking into this record, David and I discovered that he was one of 46 patients with Atrial Fibriliation (AF) who had been asked to see the practice pharmacist to review their treatment. All 46 patients were currently prescribed aspirin and were not on anticoagulation.
Mr D had been diagnosed with AF since 2006, and at the time was prescribed aspirin. I explained to him that the guidance on managing anticoagulation had changed and that we no longer considered aspirin alone to be effective in reducing risk of stroke [1].
Using a very badly drawn picture of a heart and a brain, I explained how a person with AF could have a stroke. Using the clinical system, we calculated the risk of a stroke (CHADSVasc=3) and risk of a bleed with anticoagulation (HASBLED=1). I then launched the MAGIC shared decision making tool – the NICE one is just as good; it’s a matter of personal preference. I explained that 37 people from 1,000 people like David are predicted to have a stroke because of AF in the next year. If all 1,000 people are anticoagualted then 25 from the 37 will be saved. I then explained that an additional 4 people (from the 1,000) would experience a serious bleed if all 1,000 were anticoagulated.
Mr D asked me about the treatment options and side effects. We discussed warfarin and the new oral anticoagulant drugs (NOACs) such as apixiban, rivaroxiban and dabigatran. He seemed unsure about what to do, so I printed off information leaflets for AF and anticoagulation and gave him a copy of the risks and benefits. We agreed to meet again when he was ready to make a decision.
Patient-centred care through shared decision making (SDM) with patients can be difficult, but if done well, it is a role that pharmacists can fulfil well across a number of different clinical areas (e.g. hypertension, cardiovascular risk, bone protection). My personal experience of using SDM in practice is better patient satisfaction, better adherence to treatment and less waste. To date, I have seen 43 of the 46 patients; 14 have been unsuitable for anticoagulation, 11 were prescribed anticoagulation (9 chose NOACs and 2 wanted warfarin) and 18 have refused treatment.
As for Mr D, he decided that he would take anticoagulation and chose rivaroxiban; a choice that reflected his current lifestyle.
Wasim Baqir is R&D pharmacist at Northumbria Healthcare NHS Foundation Trust
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References
[1] Atrial fribrillation: the management of atrial fibrillation. NICE CG180, 2014