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Best practice and the collaborative power of the multidisciplinary team in cardiology

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From his base in Leeds, Dr Rani Khatib champions holistic, person-centred approaches and the collaborative power of the multidisciplinary team in cardiac care. Here, the newly appointed fellow of the European Society of Cardiology speaks to Allie Anderson about his innovative services that have enjoyed local, national and international acclaim, and how his own recent experiences as a patient have bolstered his professional work.

Dr Rani Khatib is a trailblazer in cardiology and cardiovascular pharmacy, achieving success locally and nationally through clinical work and research. As well as a consultant pharmacist in cardiology and cardiovascular research at Leeds Teaching Hospitals NHS Trust, he is visiting associate professor at the Leeds Institute for Cardiometabolic Medicine at the University of Leeds.

He has enjoyed acclaimed in Europe, too, sitting on cardiology allied professional groups for the European Society of Cardiology (ESC), and last year Dr Khatib was elected Fellow of the ESC in honour of his distinguished career.

‘It’s a huge recognition and becoming a Fellow of the ESC as a pharmacist rather than a cardiologist is an added bonus,’ Dr Khatib says. ‘The Society includes non-physicians as part of its structure because, simply, the care of patients with cardiology conditions requires input from multiple healthcare professionals.’

Dr Khatib embodies this multidisciplinary approach, not only contributing to but spearheading a number of pharmacy-led services at his Trust – and beyond. At their core are medicines optimisation and managing patient risk. ‘Cardiovascular disease is one of the biggest killers worldwide,’ he explains, ‘so there is a huge opportunity to ensure patients are on the right therapies and to optimise those therapies.’

Optimising medicines and adherence post-MI

Having noted suboptimal secondary prevention medicine (SPM) regimes and low adherence among myocardial infarction (MI) patients, Dr Khatib embarked on a project to ‘re-engineer’ post-MI care. Together with a consultant cardiologist, he established a post-MI multidisciplinary medicines optimisation clinic. Patients who had been hospitalised following an MI could see Dr Khatib, who is an independent prescriber, for a 30-minute consultation post-discharge to discuss any questions or problems they had with their medication.

He could manage patients autonomously but also escalate cases to the consultant cardiologist where necessary. ‘That was important because we worked together to identify the best set-up, so that we have access to each other, we work collaboratively, and we deliver what is best for the patients,’ Dr Khatib says.

Ahead of the clinic, patients were asked to complete a ‘My Experience of Taking Medicines’ questionnaire, known as MYMEDS. This self-reporting tool was designed to assess use of SMPs and to identify modifiable barriers – actual or perceived – to adherence. The completed questionnaire is a starting point for Dr Khatib to dig deeper.

‘It enabled patients to raise concerns about their medicines, whether that’s side effects or fitting medicines into their daily routine,’ he says. ‘Patients will often say “yes”, they remember to take their medicines, but if you have a further conversation using the MYMEDS tool, you might identify that they’re having problems swallowing the tablets so actually, they found taking them challenging.’ After identifying a barrier, Dr Khatib adds, he can work with the patient to overcome them.

The service was piloted between October 2015 and December 2016 among 270 patients. Optimisation of drugs improved significantly, with numbers of patients taking the recommended doses of ACE-inhibitors or ARBs increasing from 16.3% to 73.9%.

Patients reported significantly fewer concerns with their medications, non-adherence rates fell by up to 70.8% and readmission rates decreased.

Building on success to drive holistic cardiac care

In recent years, there has been a sharpened focus on holistic patient care and, with it, more emphasis on tackling multimorbidity. Patients with cardiovascular disease and type 2 diabetes have historically been managed by two distinct teams, but in Leeds, Dr Khatib spotted an opportunity to drive improvements in both specialties.

‘We identified that cardiology patients with type 2 diabetes were not necessarily receiving the best care,’ he says. ‘Newer diabetes medicines like SGLT2 inhibitors and GLP1 agonists also confer significant cardiovascular and renal benefits, so looking at the interplay between cardio-renal-metabolic seemed obvious.’

Dr Khatib established the CaReMe service, which streamlined cardio-renal-metabolic services into a ‘one-stop clinic’ for these comorbid patients. The consultant pharmacist-led clinic, supported by wider multidisciplinary teams, assesses patients six to eight weeks after an MI event.

It uses an adapted version of the MYMEDS tool – MYMEDS-Cardiometabolic – so as well as optimising medicines use and adherence, the consultant pharmacist provides a comprehensive review of the patient’s cardiovascular, diabetes and renal management needs. Such needs include key cardio-renal-metabolic biomarkers; analysis of risk factors; post-MI SPMs; and dietary, weight management and other lifestyle advice.

National adoption of best practice in cardiology

As well as improving patient outcomes, services like these highlight the crucial role of consultant pharmacists in multidisciplinary teams. They also create opportunities to expand input from appropriately trained senior pharmacists. Such initiatives free consultants to deliver other specialist services, thereby increasing capacity.

Moreover, Dr Khatib’s work has been taken further to not only reach patients in Leeds but nationally as well, notably with PCSK9 inhibitors. Designed to treat high cholesterol in patients who are not suitable for or poorly controlled on other lipid-lowering therapies, PCSK9 inhibitors are underused in optimising lipid management according to Dr Khatib.

‘We are always trying to improve access to innovative medicines, and bring what pharmacy can offer into the patient pathway to forward the cardiovascular agenda,’ he comments. ‘So, to improve access to these drugs, we set up another pharmacist-led, multidisciplinary clinic.’

Established in 2017, the clinic – the only service that was prescribing PCSK9 inhibitors in the Leeds area – also provides patient support, education and monitoring to promote adherence, as well as tackling statin intolerance.

The service proved successful and has yielded significant improvements in patients’ total and LDL cholesterol levels that are maintained at 12-month follow-up. It was deemed cost-effective and patient feedback was positive.

Furthermore, the project caught the attention of stakeholders at the Accelerated Access Collaborative (AAC), a UK-wide initiative aimed at extending access to high-quality healthcare, through improving uptake of the best treatments, for example. Harnessing his experience delivering the pharmacy-led service, Dr Khatib worked with NHS England and the AAC to develop a NICE-endorsed national lipid management pathway and the statin intolerance pathway.

‘Our model, uniquely, established a centralised service run by a consultant cardiology pharmacist and advanced cardiology pharmacists. We offered a vehicle for these medicines to be prescribed and demonstrated that lipid optimisation doesn’t have to be managed only by lipidologists,’ Dr Khatib explains. ‘We need to tap into the pharmacy profession more, and through collaboration with cardiology and lipidology colleagues the patient receives the best care, and the pharmacist is well-supported to deliver it.’

Patient-centricity as a priority

Dr Khatib believes that person-centred care must underpin every aspect of pharmacy. ‘As much as we talk about it, it’s often missed because it’s not as easy to apply as we think,’ he comments. However, being on the other side of the patient-clinician partnership has given Dr Khatib a broader understanding of the dynamics.

Having contracted Covid-19 in November 2020, he spent seven months in hospital in what he describes as ‘a terrible ordeal’ that caused multiple organ failures and cardiac arrests. This left him with extensive deconditioning and multiple morbidities – all of which he has documented in a Journal of Cardiac Failure editorial. His book with full reflections and lessons about this experience will soon be published.

‘I continue to live the patient experience and it has opened my eyes to a lot of things you only see as a patient, and not as a healthcare professional,’ he says, adding that it gives him a fresh perspective on patient need when it comes to multidisciplinary working.

‘Often patients said they preferred to see a cardiologist because they felt they’re more likely to get a rounded view, rather than just a medicines-focused discussion, which triggered something in my mind: we need to change the way we do pharmacy-led clinics to a more patient-centred approach,’ he explains.

This requires what Dr Khatib calls a ‘zoom out’ mindset, aided by tools like MYMEDS to support a holistic view. ‘So, when patients tell me about their experiences, I am ready to hear about their anxiety, their challenges going back to work, or how they’re getting on with lifestyle modifications,’ he comments. ‘I may not be able to solve those problems, but I can be considerate of them.’

In that way, Dr Khatib believes, pharmacy-led services can tick patient-centricity boxes while also helping to improve adherence and outcomes. He concludes: ‘I believe this is a better way of delivering the medicines optimisation concept.’

This article is part of our Clinical Excellence series, which offers valuable first-hand insights into how experts from renowned Centres of Excellence are pursuing innovative approaches to optimise patient care across the UK and Europe.

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