Improving cardiovascular disease management in Australia: NPS MedicineWise

Cardiovascular disease (CVD) is the largest cause of premature death in Australia; it accounted for over a third of all deaths in 2007.1 Over the past decade, NPS MedicineWise (previously known as the National Prescribing Service) implemented a number of educational programs on cardiovascular management in primary care, including two programs on the use of antithrombotics in atrial fibrillation (AF) and secondary stroke prevention,2,3 as well as programs for improving management of heart failure.4-6 NPS MedicineWise used a mix of interventions, both passive (eg, written education materials) and active (eg, one-on-one educational visits, general practitioner clinical audits, case studies), to deliver these programs, to maximise reach among GPs and to reinforce program key messages. Educational visits have been shown to be effective in changing health professional practice.7

The veteran community in Australia is further supported to achieve optimal use of medicines through the Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES) program.8 In addition to the NPS MedicineWise programs, one of the Veterans’ MATES interventions also targeted warfarin use.9

The aim of this research was to evaluate the effect of these NPS MedicineWise interventions on the use of medicine and medical tests. The research focused on evaluating the effect of the key educational messages targeted in the interventions, which were to:

• consider warfarin in all patients with atrial fibrillation and who are at moderate-to-high risk of stroke, and aspirin in those at low risk (delivered as part of the 2003 and 2009 therapeutic programs on antithrombotic use in atrial fibrillation and secondary stroke prevention2,3);

• consider aspirin as the drug of choice for secondary stroke prevention (delivered as part of the 2003 and 2009 therapeutic programs on antithrombotic use in atrial fibrillation and secondary stroke prevention2,3);

• confirm heart failure with an echocardiogram (delivered as part of the therapeutic program on heart failure management from 20086); and

• use low-dose spironolactone in moderate-to-severe heart failure as it confers additional mortality benefit for patients (part of the 2004 and 2008 programs on heart failure management5,6).

Of the four areas evaluated, all were associated with improvement in practice at 6 to 12 months after the most recent intervention, with relative effect sizes ranging from 1.27% to 4.31% (Box 2 and Box 3). Three of the trend lines showed a sustained constant month-to-month increase (Box 2 and Box 3). Further, the monthly increase in the rate with the intervention effects was 3–10 times higher than the increase shown by the trend line without the intervention. For example, the rate of aspirin use in secondary stroke prevention, when accounting for the effect of the February 2009 program, increased by 0.29% each month (compared with the previous month), compared with 0.03% monthly increase in the rate without the intervention.

There was an abrupt increase in the use of aspirin and warfarin in AF around the time of the interventions, followed by a slow decrease in the trend over time towards the estimated rate without intervention (Box 3).

Our results showed that over half of the population with a prior hospitalisation for AF received warfarin or aspirin treatment. The results are comparable with an American study that reported use of warfarin by 42% of patients with AF at high risk of stroke, and by 44% of patients with moderate stroke risk.12

Aspirin significantly reduces the risk of stroke in patients who experienced a transient ischaemic attack (TIA) or stroke,13 and should be given as soon as possible after onset and continued as long-term antiplatelet therapy.14 Our analysis showed that an increasing number of patients were receiving aspirin as a monotherapy after a TIA or ischaemic stroke event, reaching around one-quarter of the at-risk group in March 2010.

Symptoms of heart failure can be non-specific, and many at-risk patients remain undiagnosed in the early stages.15 If heart failure is suspected, further investigations are required, including an echocardiogram, as it provides information about the type of heart failure and thus treatment implications.16,17 We found that echocardiography was requested before diagnosis of incident heart failure for one in five at-risk people.

Low-dose spironolactone (25 mg), when added to loop diuretic and angiotensin-converting enzyme inhibitor therapy, can improve prognosis in patients with moderate-to-severe heart failure.18 Around 11% of our patients with heart failure were given low-dose spironolactone. This rate is similar to the 11% rate of spironolactone use in patients with chronic heart failure reported by a Dutch study in 2000.19

This evaluation has shown that the NPS MedicineWise programs delivered in primary care were effective in improving prescribing and service use in cardiovascular management, with relative effects ranging from 0.63% to 4.31% 12 months after the intervention. The NPS MedicineWise used a combination of passive and active interventions to reinforce their key messages. Active components such as one-to-one educational visits have been shown to be effective in improving health professional practice, providing small but consistent changes in prescribing (median, 4.8%), and small-to-moderate effects on other professional performance (eg, screening tests).7,20 Although small to moderate, such changes might be potentially important when hundreds of patients are affected.7

There are several limitations to our study. There is no way to ascertain whether the GPs who are responsible for changes in prescribing and medical test requests are also the ones who received the information through the NPS MedicineWise program or other sources. The data does not provide direct diagnostic information; thus our analyses rely on previous hospitalisation records, including documentation of a medication regimen to define the presence of a condition, and therefore there are likely to be a number of people with the conditions of interest who are omitted from the study population.

Nevertheless, the results of this study are likely to be generalisable to the overall Australian population, as there are only slightly more general practice visits (rate ratio, 1.17; P < 0.05) and hospitalisations (rate ratio, 1.21; P < 0.05) in the veteran population per year than in other Australians aged 40 years and over.21 Veterans receive slightly more prescriptions annually than other Australians aged 40 years and over (rate ratio, 1.13; P < 0.05).21 This suggests that our study results are likely to reflect the general Australian population, but may slightly overestimate the utilisation rates.

In conclusion, NPS MedicineWise programs delivered in primary care are associated with significant changes in drug use patterns and service use in cardiovascular management. The quality use of medicines programs implemented as an initiative of the National Medicines Policy have the potential to improve Australia’s medicines and health environment.

3 Monthly time series showing effects of NPS MedicineWise educational programs targeting quality use of medicines in cardiovascular management

* The changes in Safety Net copayments in January 2005 contributed to the decrease in the rate around that time.