Minimising permanent pacemaker implantation (PPI) after TAVI.

Increased demand for transcatheter aortic valve implantation (TAVI) procedures for patients with severe aortic stenosis has not been matched with a proportional increase in available resources in recent years. This article highlights the importance of developing integrated care pathways for TAVI, which incorporate standardised protocols for permanent pacemaker implantation (PPI) to ensure best practice, increase service efficiency and reduce rates of PPI post-TAVI.

Discussing Weight Management With Type 2 Diabetes Patients in Primary Care Using the Small Talk Big Difference Intervention: Protocol for a Randomized Controlled Trial.

BACKGROUND: Guidelines for the management of type 2 diabetes universally recommend that adults with type 2 diabetes and obesity be offered individualized interventions to encourage weight loss. Yet despite the existing recommendations, provision of weight management services is currently patchy around the United Kingdom and where services are available, high attrition rates are often reported. In addition, individuals often fail to take up services, that is, after discussion with a general practitioner or practice nurse, individuals are referred to the service but do not attend for an appointment. Qualitative research has identified that the initial discussion raising the issue of weight, motivating the patient, and referring to services is crucial to a successful outcome from weight management. OBJECTIVE: Our aim was to evaluate the effectiveness of an Internet-based training program and practice implementation toolkit with or without face-to-face training for primary care staff. The primary outcome is the change in referral rate of patients with type 2 diabetes to National Health Service adult weight management programs, 3 months pre- and postintervention. METHODS: We used the Behavior Change Wheel to develop an intervention for staff in primary care consisting of a 1-hour Internet-based eLearning package covering the links between obesity, type 2 diabetes, and the benefits of weight management, the treatment of diabetes in patients with obesity, specific training in raising the issue of weight, local services and referral pathways, overview of weight management components/ evidence base, and the role of the referrer. The package also includes a patient pamphlet, a discussion tool, a practice implementation checklist, and an optional 2.5-hour face-to-face training session. We have randomly assigned 100 practices in a 1:1 ratio to either have immediate access to all the resources or have access delayed for 4 months. An intention-to-treat statistical analysis will be performed. RESULTS: Recruitment to the study is now complete. We will finalize follow-up in 2018 and publish in early 2019. CONCLUSIONS: This protocol describes the development and randomized evaluation of the effectiveness of an intervention to improve referral and uptake rates of weight management programs for adults with type 2 diabetes. At a time when many new dietary and pharmacological weight management interventions are showing large clinical benefits for people with type 2 diabetes, it is vital that primary care practitioners are willing, skilled, and able to discuss weight and make appropriate referrals to services. TRIAL REGISTRATION: ClinicalTrials.gov NCT03360058; https://clinicaltrials.gov/ct2/show/NCT03360058 (Archived by WebCite at http://www.webcitation.org/74HI8ULfn). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12162.

Re-engineering the post-myocardial infarction medicines optimisation pathway: a retrospective analysis of a joint consultant pharmacist and cardiologist clinic model.

Background: Inadequate medicines optimisation and adherence are significant problems among patients taking secondary prevention medications following myocardial infarction (MI). A novel joint consultant cardiology pharmacist and cardiologist medicines optimisation clinic was initiated for patients recently discharged following MI. Methods: Patients completed a locally developed tool, the 'My Experience of Taking Medicines' questionnaire, designed to allow sharing of barriers to adherence with medications. They then attended a clinic with the consultant pharmacist or cardiologist (or both). Secondary prevention medicines needs and barriers to adherence were identified and discussed, and an action plan developed. The data provided are from a retrospective review of 270 post-MI patients attending the service between October 2015 and December 2016. Results: Mean age was 67.3 years and 67.8% were male. The mean time from discharge to first outpatient clinic attendance was reduced by 56.1% (49.4 days vs 88 days before the service began). More than 95% of patient without planned non-pharmacological intervention postdischarge did not need a cardiologist's input. Levels of medicines optimisation were improved substantially after attendance: patients receiving a recommended angiotensin-converting enzyme inhibitor/angiotensin receptor blocker dose increased from 16.3% to 73.9% (p<0.001); patients receiving a recommended beta-blocker dose increased from 6.2% to 46.1% (p<0.001). Patient concerns about their medications were significantly decreased (all p<0.001). Rates of non-adherence fell by 42.6%-70.8% at 3-6 months post-clinic. Readmission rates also declined after the service opened. Conclusions: A medicines optimisation and patient adherence strategy based on a joint consultant cardiology pharmacist and cardiologist clinic can improve both adherence and outcomes post-MI.

Linking hospital patient records for suspected or established acute coronary syndrome in a complex secondary care system: a proof-of-concept e-registry in National Health Service Scotland.

Aims: To implement secondary care electronic record linkage for patients hospitalized with suspected or known acute coronary syndrome (ACS) in a complex regional health care system and evaluate this e-Registry in terms of patterns of service delivery and 1-year outcomes. Methods and results: Existing electronic hospital records were linked to create episodes of care using (i) a patient administration system, (ii) invasive cardiovascular procedure referrals, and (iii) a catheter laboratory record. Data were extracted for admissions (1 October 2013-30 September 2014) with International Classification of Disease (ICD)-10 diagnosis of angina (I200-I209), myocardial infarction (I210-I229), other ischaemic heart disease (I240-I249) or heart failure (I50), linked to other sources to develop a secondary care ACS e-registry and analysed within a Safe Haven. Episodes of care were categorized into care pathways and evaluated in terms of patient characteristics, as well as service delivery metrics and outcomes including mortality. In all, 2327 patients had 2472 episodes of care. Diagnoses were hierarchically classified as ST-elevation myocardial infarction (STEMI) (586, 25.2%), non-ST-elevation myocardial infarction (NSTEMI) (1068, 45.9%), unspecified myocardial infarction (146, 6.3%), unstable angina (527, 22.6%) for the first hospitalization for each patient within the study period. Six care pathways were mapped. Percutaneous coronary intervention rate for STEMI was 80.2% and for NSTEMI 33.1%. Unadjusted all-cause mortality was 9.0% and 3.0% for STEMI and NSTEMI at 30 days, rising to 11.9% and 11.6% at 1 year. Analyses were validated by independent source data verification. Conclusion: The e-registry has enabled analysis of ACS hospitalizations in a complex health care system with implications for quality improvement and research.