Project Name: ASCVD Primary Care Lipid Management Collaborative Working Project

Project Summary:

The CWP will be led by a Clinical Pharmacist alongside a multi-disciplinary team; including Pharmacy Technician, Healthcare Assistant, Administrative Support, General Practitioner providing clinical oversight aiming to achieve:

  1. Identification of sub-optimally treated patients who are not achieving recommended targets for lipid management  
  2. Identification of patients who have previously not tolerated or refused alternative lipid modification therapies  
  3. Review of treatment options and decision on next steps in collaboration with patients  
  4. Counsel and optimise patients where appropriate  
  5. Early identification of at-risk patients who have not had intervention in their health and wellbeing 
  6. Identification of patients, following risk assessment review, of patients who are sub-optimally treated  

Planned Milestones:

  1. PCN Level Lipid Management pathway/protocol development. Clinical Audit and Clinical Audit Discussion with Member Practices.
  2. Collection of baseline data, in line with the measures of success contained within the Data Collection table above
  3. Collection & submission of 3 months clinical activity data.Project Review meeting to discuss project progress.
  4. Collection & submission of 6 months clinical activity data. Project Review meeting to discuss project progress.
  5. Collection & submission of 9 months clinical activity data. Project Review meeting to discuss project progress.
  6. Collection & submission of 12 months clinical activity data. Project Review meeting to discuss project progress.
  7. Development of Business Case and Poster
  8. Analysis of CWP data, submission of Final CWP Report, Submission of Outcomes Summary

Expected Benefits:

Anticipated benefits for Patients

  • Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.
  • Enhanced experience around ASCVD with ongoing management of the condition.  
  • Improved access to appropriate medication for suitable patients to preserve health and prevent long-term events 
  • The additional capacity will provide additional time and support from PCN HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, levelling health inequalities within the PCN. 

Anticipated Benefits for Granta PCN

  • Increased proportion of ASCVD patients reviewed by primary care  
  • Increased proportion of ASCVD patients receiving expert and timely review closer to home 
  • Reduction in ASCVD referral rates to secondary care 
  • Increased proportion of patients receiving guideline-directed pharmacotherapy 
  • Insight into benefits of primary care pharmacist led lipid management clinics in primary care  
  • Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES

Anticipated Benefits for Novartis

  • Insight on the appropriate use of ASCVD licensed medicines in line with NICE guidelines, including Novartis’s medicine 
  • Enhanced reputation, and supporting Novartis’ vision that no patient should have to wait for an extraordinary life by supporting high quality Collaborative Working with healthcare organisation which addresses the problem of health inequalities 
  • Ethical, professional, and transparent relationship between Novartis and healthcare organisation

Start Date & Duration: February 2023 for 16 months

UK2301189443

Project Name: ASCVD Primary Care Lipid Management Collaborative Working Project

Partner Organisation(s): Granta Medical Practices (“Lead Practice”) for and on behalf of the Granta Primary Care Network

Completion Date: September 2024

Outcome Summary:

This project successfully implemented a pharmacist-led strategy to optimise lipid management and medication in primary care. The aim was to improve lipid control, increase patient access to necessary treatments, and streamline the process of identifying and treating patients with elevated cardiovascular risk. Through collaboration between Novartis, Granta Medical Practices, and other stakeholders, the project was successfully integrated into routine practice, demonstrating the effectiveness of proactive lipid management.

Key Project Outcomes Data:

The service achieved the following outcomes:

  • Patient Reach: Over 2,562 consultations were conducted over 12 months.
    • Primary Prevention:
      • 1,856 patients with high cardiovascular risk (QRisk > 20%, CKD, or diabetes) were identified and optimised, representing a 105% increase from baseline.
    • Secondary Prevention (Not on Statins):
      • 496 patients with ASCVD who were not on statins were identified and reviewed, achieving a 101% increase from baseline.
    • Secondary Prevention (On Statins but Off-Target):
      • 210 patients on statins but not achieving target LDL levels were identified and optimised, representing a 120% increase from baseline.
  • Lipid Optimisation:
    • Primary Prevention Success: 26% of patients identified in the primary prevention cohort were started on statins during the first phase of the project. Clinics dedicated to lipid management were nearly three times more effective than routine appointments.
    • Secondary Prevention Success: 17% of patients not on statins were initiated on high-intensity statins, while 20% of those already on statins had their treatment further optimised (through additional medications such as ezetimibe or inclisiran).
    • LDL Reduction Achieved: 36% of patients with ASCVD achieved their target LDL levels after the intervention.
  • Improved Accessibility:
    • Appointment wait times were significantly reduced, with 30–50 appointments delivered weekly through a revised patient engagement process.
    • Mixed feedback on face-to-face versus phone consultations, but patients appreciated the proactive outreach.

Outcomes:

For Patients:

  • Empowerment and Engagement:
    The 'Know Your Numbers' campaign educated patients on their cholesterol levels and empowered them to make informed decisions about their health.
    Increased engagement with previously non-responsive patients, helping them become more proactive in managing their healthcare.
  • Prevention and Treatment Focus:
    The focus on prevention reduced unnecessary secondary care referrals and helped prevent adverse cardiovascular events. For example, 480 patients treated for primary prevention, with an estimated 43 cardiovascular events prevented.

For Healthcare Professionals and Organisations:

  • Upskilling of Pharmacists:
    Pharmacists were trained to manage lipid optimisation, enhancing the multidisciplinary team’s ability to deliver high-quality lipid management care.
  • Integration into Routine Care:
    The developed protocols were embedded into day-to-day practice, including a robust system to automatically flag patients for review based on blood test results and risk assessments.
    Statin initiation and optimisation pathways became part of standard multi-morbidity reviews in the clinic.
  • Sustainable Practices:
    A long-term lipid management clinic was established to continue the work initiated by the project, ensuring continuity of care for high-risk patients.

Conclusion:

This pharmacist-led project was a  success, effectively improving lipid management within Granta Medical Practices and increasing patient access to appropriate treatments. The collaborative approach between Granta Medical Practices and Novartis allowed the practice to engage patients more proactively, reducing cardiovascular risks and enhancing patient care. Upskilling pharmacists and integrating lipid management into routine practice have created a lasting impact, with continued efforts to optimise patient outcomes and reduce health inequalities in cardiovascular care.

The project demonstrated that dedicated time for lipid management can significantly improve clinical outcomes and patient engagement. It has now been embedded into routine care at Granta Medical Practices, aligning with the ICS's strategic goals of reducing health inequalities and promoting proactive healthcare management.

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