Effects of Pharmacist-Led Education on Medication Knowledge and Confidence in Cardiac Rehabilitation Patients

Newly developed cardiovascular medications, with precise mechanisms of action and elevated potency, require specialized attention to avoid inappropriate prescribing.1 To meet current evidence-based guidelines, many medications are titrated for optimal mortality benefit during the period of cardiac rehabilitation (CR) initiation.2 Chronic conditions require complex models of care over an extended period of time, which involves coordinated inputs from a wide range of health professionals.3 Specifically, pharmacists are accessible and optimal members of interdisciplinary teams, and the clinical impact of pharmacy involvement in chronic disease management has been proven effective.4 The American Heart Association and the American College of Cardiology recommend that patients receive care from multidisciplinary teams to facilitate the implementation of guideline-directed medical therapy and address potential barriers to self-care.5 Autonomy and empowerment of patients play an important role in cardiac health and overall well-being. This study aimed to further expand the pharmacist role in chronic disease management and evaluate a novel approach of pharmacist-driven education in cardiovascular disease. The immediate accessibility and focused environment of a pharmacist within CR allow patients to ask intentional questions in a setting specific to these medications (see Supplemental Digital Content 1, available at: https://links.lww.com/JCRP/A469).6 It is well known that many comorbidities exist, which increase the personal risk for a cardiac event. Often, these comorbidities are treated using multiple medication regimens with different mechanisms and targets. Once a patient has experienced a cardiac event, the need for CR and additional medications is often required. This contributes to the overall medication burden for each patient and increases the likelihood of poor compliance secondary to lack of education, knowledge, and confidence. Medications a patient may be started on after a cardiac event include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, calcium channel blockers, and others—depending on patient-specific factors (see Supplemental Digital Content 2, available at: https://links.lww.com/JCRP/A470). The purpose of this study was to evaluate medication knowledge and confidence among phase II CR patients before and after pharmacist-led medication education. METHODS This was a single-center, prospective, survey-based quality improvement study conducted in a tertiary care hospital in the Upper Midwest. Patients were included in a four-step process for more than 6 wk, meeting bimonthly with an assigned CR pharmacist. Each participant followed an identical schedule of pre-survey, education, education reinforcement, and post-survey every 2 wk, respectively (see Supplemental Digital Content 2, available at: https://links.lww.com/JCRP/A470). Discussions were centered on patient-specific medication regimens (see Supplemental Digital Content 3, available at: https://links.lww.com/JCRP/A471). RESULTS Forty-one participants, enrolled in phase II CR program, completed the pre-education survey. Because of the COVID-19 pandemic and closure of the CR unit, two patients were lost to follow-up and a total of 39 participants were included in pre-/post-analyses. The participants had a mean age of 66 yr, 90% were male, and 95% were White. Baseline demographics of cardiac disease state, quantity of medications, markers of health literacy, and prior exposure to pharmacy education services were not obtained as part of this pilot study. The pre-survey subscales of general medication knowledge (range: 3-15), drug interaction knowledge (range: 3-15), and patient confidence (range: 2-10) had mean ± SD of 13 ± 2, 10 ± 4, and 8 ± 2, respectively. Within the drug interaction knowledge subscale, 29% of patients “strongly disagreed” with understanding drug-drug interactions, 22% with drug-food/beverage interactions, and 14% with all possible medication side effects. Statistically significant improvement was found in general medication knowledge (P = .004), drug interaction knowledge (P < .001), and patient confidence (P < .001; Table). Although all the questions associated with drug interaction knowledge and patient confidence improved significantly, change in general medication knowledge was more incremental, with only confidence about knowing indications exhibiting significant change. Table - Changes in Mediation Knowledge and Confidence in Domains in Cardiac Rehabilitation Patients Primary Outcome Range Pre-Surveya Post-Surveya Unchanged Increased Decreased P Value General medication knowledgeb 3-15 14 (13, 15) 15 (14, 15) 20 16 3 .004 Drug interaction knowledgeb 3-15 10 (6, 12) 13 (11, 15) 6 32 1 <.001 Confidencec 2-10 8 (6, 10) 10 (9, 10) 16 22 1 <.001 General knowledge I am confident that I know what all my prescribed medications are forb 23 14 2 .004 I can describe how to use all my prescribed medicationsb 28 9 2 .065 I can describe when to use all my prescribed medicationsb 32 5 2 .453 Drug interaction knowledge I can name all the medication I cannot take with each of my prescribed medicationsc 12 26 1 <.001 I can name all foods/beverages I cannot consume with each of my prescribed medicationsc 17 21 1 <.001 I understand all of the possible side effects of all of my prescribed medicationsb 16 23 0 <.001 Patient confidence I do not know when/if I should call my physician about my medicationsb,d 19 3 17 .003 My overall confidence regarding taking all my medications is poorb,d 20 3 16 .004 aMedian (IQR).bSign test.cWilcoxin signed rank test.dA decrease is the desired direction for this question. At the conclusion of the CR patient intervention, patient ratings of satisfaction with medication explanations received and overall improvement in confidence taking medications had median (IQR) of 5 (4, 5) and 5 (5, 5), respectively. DISCUSSION This prospective study evaluated medication knowledge and confidence among phase II CR patients. This study found a statistically significant increase in patient-perceived medication knowledge and confidence, owing to novel approach of pharmacist-provided education and involvement to further expand the pharmacist role in chronic disease management, specifically in a CR unit. It has been established that enhancing knowledge, developing self-management skills, and building confidence are important variables associated with improving outcomes, including health-related quality of life among patients with chronic disease.1 Health care providers, and in this case specifically pharmacists, can play an integral role in collaborating with patients not only to enhance knowledge but also to build confidence. A key role in the appropriate management of chronic diseases care is dependent upon the patient, through effective adherence to complex therapeutic regimens, which relies on administration of drugs, lifestyle management, and follow-up care.3 Similar to previously published data, the results of this study indicate that bimonthly pharmacist involvement and education can have a positive impact on patient knowledge and confidence within CR units, supporting the overall goal of CR to improve patient cardiovascular health and prevent secondary cardiovascular disease events.7 Optimal CR program length is not well defined; however, average participation lasts 12 wks, but can last years.8 Majority of insurance companies provide coverage for a total of 36 sessions with each session of CR persisting for 30-45 min, offering a minimum of 18 hr and up to 27 hr of potential reimbursable pharmacist interaction and ongoing support from multidisciplinary staff. Altowaijri and colleagues1 conducted a systematic review of clinical and economic effectiveness of clinical pharmacist involvement in secondary prevention of cardiovascular disease. A total of 59 studies were identified with 68% of the outcomes showing that clinical pharmacy services were associated with intensified improvements in patient outcomes including knowledge, adherence, and quality of life.1 Prior research has evaluated the use of pharmacist collaborative models for patients with coronary heart disease or cardiovascular disease risk factors such as diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, heart failure, and tobacco use.7 Incorporation of pharmacy services into a CR program has been previously documented, mostly descriptive in nature with pharmacist engagement commonly reported in the literature as forms of drug education, obtaining drug histories, recommending optimal drug therapy, safety monitoring, documentation, and transitions of care communication with outpatient pharmacy services.7 Unsurprisingly, and as reflected in this study, pharmacist medication education in the CR setting has shown to improve patient understanding, knowledge, and confidence in regard to cardiac-related medications. The novelty of the current study compared with those previously conducted is the straightforward assessment of patient knowledge and confidence as a marker for improved outcomes. We observed a significant increase in patient-perceived general medication knowledge, drug interaction knowledge, and patient confidence following pharmacist-directed medication education, in addition to positive trends in patient satisfaction. This study had several limitations. It was a prospective nonrandomized study conducted in a single center with limited ability for follow-up due to the start of the COVID-19 pandemic. Patient demographics had little diversity, limiting generalizability of the study results. This may be potentially mitigated in future studies by including patients participating in all three phases of CR and additional populations of patients including chronic and end-stage kidney disease, cancer survivors, spontaneous coronary artery dissection, and those with left ventricular assist devices.9 Pharmacists are optimal interdisciplinary team members within CR departments, and pharmacy involvement significantly improves patient-perceived medication knowledge and confidence. Overall, patients were satisfied with pharmacist education and reported improvement in confidence after pharmacist-led education. When part of a CR team, pharmacists can play a vital role to ensure patient education and safety. Further research is required to determine the long-term outcomes of increased medication knowledge on overall patient outcomes.