Results

PDSA Cycle 1
STUDY: 51 patients were reviewed in the pharmacist-led clinic during the first year of the project. The use of ACEI (or ARB) increased from 89% in the baseline audit (n=51/57) to 94% (n=48/51). The mean percentage of ACEI (or ARB) target dose also increased from 44% in the baseline audit to 72%, with 57% (n=29/51) patients achieving the full ACEI (or ARB) target dose compared with 21% in the baseline audit (n=12/57). The use of beta-blockers increased from 82% in the baseline audit (n=47/57) to 96% (n=49/51). The mean percentage of beta-blocker target dose also increased from 31% in the baseline audit to 56%, with 29% (n=15/51) of patients achieving the full beta-blocker target dose, compared with 7% (n=4/57) in the baseline audit. The results were published in abstract form.17
ACT: The service steering group in collaboration with the local strategic cardiology planning committee endorsed a plan to roll the clinics out across all hospital sites in the health authority and to widen the inclusion criteria to include all grades of LVSD post-MI.

PDSA Cycle 2
STUDY: 58 patients with any grade of LVSD post-MI were identified in the baseline Glasgow Royal Infirmary audit. Ninety-one per cent (n=53/58) of Glasgow Royal Infirmary patients were prescribed an ACEI (or ARB). The mean percentage of ACEI (or ARB) target dose was 48%, with 24% (n=14/58) of patients achieving the full target dose. Ninety-one per cent (n=53/58) of Glasgow Royal Infirmary patients were also prescribed beta-blockers. The mean percentage of beta-blocker target dose was 33%, with 7% (n=4/58) of patients achieving the full target dose.
A further 143 patients were reviewed at the pharmacist-led clinics during the second year of the project, making the running total 194 patients. The use of ACEI (or ARB) was 95% (n=185/194). The mean percentage of ACEI (or ARB) target dose increased from 72% in PDSA Cycle 1 to 77%, with 65% (n=126/194) of patients achieving the full ACEI (or ARB) target dose. The use of beta-blockers dipped slightly from 96% in PDSA Cycle 1 to 93% (n=180/194). The mean percentage of beta-blocker target dose decreased slightly from 56% in PDSA Cycle 1 to 52%, with 28% (n=54/194) patients achieving the full beta-blocker target dose.
ACT: The service steering group endorsed the plan to continue sequential roll-out across the regional health authority.

PDSA Cycle 3
STUDY: 76 patients with any grade of LVSD post-MI were identified in the baseline New Victoria Infirmary audit and 64 patients were identified in the Southern General Hospital audit. 88% (n=67/76) of New Victoria Infirmary patients and 97% (n=62/64) of Southern General Hospital were prescribed an ACEI (or ARB). The mean percentage of ACEI (or ARB) target dose was 42% for New Victoria Infirmary and 61% for Southern General Hospital, with 18% (n=14/76) of patients achieving the full target dose at New Victoria Infirmary and 38% (n=24/64) at Southern General Hospital. Eighty-eight per cent (n=67/76) of New Victoria Infirmary patients and 89% (n=57/64) of Southern General Hospital were prescribed beta-blockers. The mean percentage of beta-blocker target dose was 28% at New Victoria Infirmary and 41% at Southern General Hospital, with 3% (n=2/76) of New Victoria Infirmary patients and 11% (n=7/64) of Southern General Hospital patients achieving the full target dose. Baseline medication optimisation in the Southern General Hospital was higher than other sites, potentially due to the baseline consultant cardiologist-led post-MI clinic.
A further 260 patients were reviewed at the pharmacist-led clinics during the third year of the project, making the running total 454 patients. The use of ACEI (or ARB) was 97% (n=440/454). The mean percentage of ACEI (or ARB) target dose increased from 77% in PDSA Cycle 2 to 80%, with 68% (n=307/454) patients achieving the full ACEI (or ARB) target dose. The use of beta-blockers was 92% (n=416/454). The mean percentage of beta-blocker target dose was 51%, with 29% (n=130/454) patients achieving the full beta-blocker target dose.
ACT: The service steering group endorsed the plan to continue sequential roll-out to the final hospital site.

PDSA cycle 4
STUDY: A further 431 patients were reviewed at the pharmacist-led clinics during the fourth year of the project, making the running total 885 patients. Overall use of ACEI (or ARB) was 97% (n=856/885). The mean percentage of ACEI (or ARB) target dose was 79%, with 66% (n=585/885) patients achieving the full ACEI (or ARB) target dose. The use of beta-blockers was 92% (n=813/885). The mean percentage of beta-blocker target dose dipped slightly from 51% in PDSA Cycle 3 to 48%, with 25% (n=218/885) patients achieving the full beta-blocker target.
ACT: The service steering group planned to consolidate the clinic within each hospital site, embedding it in routine care delivery, without any immediate plans for further expansion within the health authority. Discussions were undertaken with Scottish Government about rolling the clinics out to other Scottish health authorities and funding was secured from NHS Education for Scotland to allow sequential national expansion of the ‘Teach and Treat’ programme.
The table 1 summarises the baseline audits and four PDSA cycle results. The figures 1 and 2 show medication optimisation over the length of the programme compared with the combined baseline audits across the five hospitals.
Table 1  Comparison of ACEI (or ARB) and beta-blocker optimisation in baseline audits versus pharmacist-led clinics
PDSA Cycle 1 (1 September 2013–31 August 2014)  PDSA Cycle 2 (1 September 2014–31 August 2015)  PDSA Cycle 3 (1 September 2015–31 August 2016)  Combined baseline audits  PDSA Cycle 4(1 September 2016–31 August 2017)
Initial baseline audit(n=57)  Pharmacist clinics(n=51)  Baseline audit new site(n=58)  Pharmacist clinics*(n=194)  Baseline audit new site(n=76)  Baseline audit new site(n=64)  Pharmacist clinics*(n=454)  Baseline audit all sites (n=255)  Pharmacist clinics*(n=885)
Hospitals  1, 2  1, 2  3  1, 2, 3, 4†  5  6  1, 2, 3, 4†, 5, 6  1, 2, 3, 5, 6  1, 2, 3, 4†, 5, 6, 7‡
Semiquantitative LVSD grading range  Moderate–severe  Moderate–severe  Mild–severe  Mild–severe  Mild–severe  Mild–severe  Mild–severe  Mild–severe  Mild–severe
Age  67.1  60.4  67.5  62.6  61.4  62.2  62.1  64.3  62.1
Baseline blood pressure, mm Hg (mean)§  119/68  123/77  125/69  122/74  118/69  135/80  123/73  124/72  123/72
Baseline pulse, beats per minute (mean)§  68  68  69  67  66  67  67  67  66
Number of pharmacist reviews (mean)  N/A  4.6  N/A  4.2  N/A  N/A  4.2  N/A  4.1
ACEI (or ARB) dosing, n (% patients)
 0% of target dose  6 (11)  3 (6)  5 (9)  9 (5)  9 (12)  2 (3)  14 (3)  22 (9)  29 (3)
 1%–24% of target dose  3 (5)  1 (2)  9 (16)  5 (3)  6 (8)  3 (5)  11 (2)  21 (8)  35 (4)
 25%–49% of target dose  23 (40)  8 (16)  14 (24)  25 (13)  29 (38)  15 (23)  41 (9)  81 (32)  86 (10)
 50%–74% of target dose  13 (23)  9 (18)  14 (24)  26 (13)  18 (24)  19 (30)  72 (16)  64 (25)  124 (14)
 75%–99% of target dose  0 (0)  1 (2)  2 (3)  3 (2)  0 (0)  1 (2)  9 (2)  3 (1)  26 (3)
 100% of target dose  12 (21)  29 (57)  14 (24)  126 (65)  14 (18)  24 (38)  307 (68)  64 (25)  585 (66)
Mean percentage of target ACEI/ARB dose­­  44%  72%  48%  77%  42%  61%  80%  48%  79%
Beta-blocker dosing, n (% patients)
 0% of target dose  10 (18)  2 (4)  5 (9)  14 (7)  9 (12)  7 (11)  38 (8)  31 (12)  72 (8)
 1%–24% of target dose  9 (16)  5 (10)  8 (14)  17 (9)  20 (26)  8 (13)  46 (10)  45 (18)  111 (13)
 25%–49% of target dose  19 (33)  12 (24)  29 (50)  57 (29)  30 (39)  17 (27)  130(29)  95 (37)  262 (30)
 50%–74% of target dose  14 (25)  13 (25)  11 (19)  43 (22)  11 (14)  20 (31)  83 (18)  56 (22)  166 (19)
 75%–99% of target dose  1 (2)  4 (8)  1 (2)  9 (5)  4 (5)  5 (8)  27 (6)  11 (4)  56 (6)
 100% of target dose  4 (7)  15 (29)  4 (7)  54 (28)  2 (3)  7 (11)  130 (29)  17 (7)  218 (25)
Mean percentage of target beta-blocker dose  31%  56%  33%  52%  28%  41%  51%  33%  48%
1=Royal Alexandra Hospital, 2=Vale of Leven Hospital, 3=Glasgow Royal Infirmary, 4=West Glasgow Ambulatory Care Centre, 5=New Victoria Hospital, 6=Queen Elizabeth University Hospital, 7=Inverclyde Royal Hospital.
*Running tota.
†Baseline data not available for site four due to original hospital site closing during time period.
‡Baseline data not available for site four due to lack of cardiac rehabilitation database.
§Result taken from first cardiac rehab or first pharmacist review postdischarge.
ACEI, ACE inhibitor; ARB, angiotensin receptor blocker;LVSD, left ventricular systolic dysfunction; N/A, not applicable; PDSA, Plan–Do–Study–Act.
Figure 1   ACEI (or ARB) optimisation over the length of the programme compared to baseline.
*Moderate to severe left ventricular systolic dysfunction patients only; **running total; ACEI, ACE inhibitor; ARB, angiotensin receptor blocker; PDSA, Plan–Do–Study–Act.
Figure 2   Beta-blocker optimisation over the length of the programme compared to baseline.
*Moderate to severe left ventricular systolic dysfunction patients only; **running total; PDSA, Plan–Do–Study–Act. Patients in the pharmacist-led clinics were statistically more likely to be prescribed ACEI (or ARB) and beta-blocker compared with patients in the combined baseline audits (n=856/885 (97%) vs n=233/255 (91%), p<0.001 and n=813/885 (92%) vs n=224/255 (88%), p=0.048, respectively). Patient’s in the pharmacist-led clinics were also more likely to be on full target dose ACEI (or ARB) and beta-blocker compared with baseline (n=585/885 (66%) vs n=64/255 (25%), p<0.001 and n=218/885 (25%) vs n=17/255 (7%), p<0.001, respectively). The mean dose of ACEI (or ARB) and beta-blocker was also higher compared with baseline (79% vs 48% of target dose, p<0.001% and 48% vs 33% of target dose, p<0.001, respectively).