North East & North Cumbria Integrated Care Board, Pemberton House, Colima Avenue, Sunderland SR5 3XB

Project Name: County Durham Sub ICB Lipids Collaborative Working Project

Project Summary:

Across County Durham, medicines optimisation priorities are delivered quarterly by primary care pharmacists, nurses and General Practitioners (GPs) via an outcomes based workplan model. The workplan is made up of 8 workstreams each quarter. It is proposed that 1-2 workstreams per quarter would be focused on CVD and lipid optimisation in relation to this project.

Within the scope of this project, every patient identified within the proposed cohort for the quarter will be clinically reviewed and treatment initiated, optimised, or coded appropriately after discussion with the patient.

The County Durham Medicines Optimisation (MO) Team, as part of NENC ICB, will work with the Clinical Digital Reasource Collaborative (CDRC) to utilise the most appropriate clinical searches and digital tools to identify patients and support lipid management in secondary prevention.The CDRC will also support in the reporting of patient numbers and the outcomes of the work across the County Durham practices.

The following workstreams have been identified;

• Workstream 1/Pre-work: Review of patients with CVD but who are currently not on Lipid Lower Therpay (LLT).  Please note that workstream one will not form part of this collaborative working project as work has commenced outside of the project.

Workstreams in Scope of this project:

• Workstream 2: Review of patients on low/mod Intensity  LLT
• Workstream 3: Patients on high intensity LLT with elevated LDL-C levels
• Workstream 4: Review of patients not on very high Intensity LLT

The agreed phasing of the project will be as follows;

• Workstream 2: Q1 April – June 2023
• Workstream 3: Q2 and 3 July – December 2023
• Workstream 4: Q1 January – June 2024 

The main objective of this collaborative working project is to improve the quality of care for patients and support the early identification, review, and pharmacological and non- Pharmalogical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD).

Planned Milestones

Expected Benefits:

Anticipated benefits for patients:

• Reduce health inequalities by ensuring consistent and improved access to lipid management using a NICE-endorsed clinical pathway which will lead to optimal diagnosis and management of ASCVD.
• Enhanced patient experience of ASCVD with coordinated management of the condition.   
• Appropriate management of ASCVD may reduce the risk of heart attacks and strokes.  
• Improved access to the most appropriate medication for suitable patients to preserve health and prevent long-term events or mortality.
• Provide patient tailored support and education to promote adherence with treatment and modifiable risk factors resulting in the optimisation of non-HDL levels.
• Patient CVD management and lipid optimisation can be provided at a practice level within the local community, supporting the needs of  rural populations.
   

Anticipated benefits for the organisation:

• Increased proportion of patients receiving appropriate guideline-directed pharmacotherapy.  
• Reduced risk of admissions and re-admissions associated with CVD.
• Improved population health.
• Working towards the NHS Long Term Plan and the Core20PLUS5 national NHS approach to support the reduction of health inequalities.
• Improved clinician knowledge and skills in cholesterol management.
• Improved confidence and competence in the use of all NICE approved therapies including Novartis' medicines within primary care.
   

Anticipated benefits for Novartis:

• Opportunities for the appropriate use of Lipid lowering medicines in line with NICE guidelines, including Novartis’ medicine, where appropriate.
• Improved reputation and improved professional and transparent relationship and trust between Novartis and the NHS.
• Actioning and supporting national priorities. 
• Working collaboratively across health sectors.
   

Start Date & Duration: March 2023 for 15 months

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Project Name: County Durham Sub ICB Lipids Collaborative Working Project

Partner Organisation(s): North East & North Cumbria Integrated Care Board, Pemberton House, Colima Avenue, Sunderland SR5 3XB

Completion Date: 21st August 2024

Outcome Summary:

Within the scope of this project, over 13,000 patients with GP recorded CVD were identified within three different cohorts as follows;

• Patients on low/moderate intensity Lipid Lowering Treatment (LLT)
• Patients on high intensity LLT with elevated LDL-C levels
• Patients on suboptimal LLT 

Each identified patient was invited for clinical review and where appropriate, treatment was initiated, optimised, or coded after consultation with the patient.

All milestones relating to the project were successfully achieved in line with the executive summary.

Key Project Outcomes Data:

Across the 3 cohorts outlined above, 13,094 patients were identified as requiring review, and attended a review appointment as part of this project.

The 13,094 patients were broken down as follows;

• 4,658 patients had their lipid lowering therapy optimised 
• 4,457 patients were deemed not appropriate for pharmacological intervention e.g. maximum tolerated dose or greater risk v benefit in elderly
• 2,389 patients declined the review appointment
• 1,590 patients did not engage for a review appointment after 3 contact attempts

In total, 9,115  patients attended a review appointment across all 61 practices within County Durham Sub-ICB-Location and of those 4,658 patients received a pharmacological intervention.

Outcomes:

The project achieved the establishment and implementation of three workstreams within the Sub ICB. Fifteen months of clinical activity, identifying, reviewing, and optimising lipid lowering therapies in ASCVD patients took place from April 2023 to July 2024 and have ensured that all relevant patients were invited for review and, where appropriate, a pharmaceutical intervention was offered. 

The project has resulted in reductions in the proportion of patients with CVD who were on a sub-optimal dose or intensity (2.33% to 1.59%) and, who had sub-optimal non-HDL levels despite maximum tolerated statin (1.06% to 0.68%). The biggest improvement can be seen in those patients who were on a sub-optimal dose or intensity statin and have now had their LLT optimised in line with NEELI guidance².

The proportion of low and medium intensity statins as a percentage of all prescribed statins has reduced across County Durham practices from 27% in April 2023 to 20% in June 2024. Placing County Durham SICBL(Sub ICB Locations) in the top 10 performing SICBLs nationally for this measure.

The percentage of patients with CVD on lipid lowering therapy who are treated to target has increased from 32.8% in March 2023 (prior to project start) to 39.5% in March 2024. Although this data does not include the full project period to June 2024, County Durham are now achieving over the national ambition of 35% of patients treated to target.

Conclusion:

As a result of this collaborative working project, County Durham SICBL are now delivering against these opportunities.

On 6th November 2023 NHS England published a new infographic¹ outlining steps primary care teams can take to capitalise on the opportunity to improve cardiovascular health outcomes:

• Initiate and empower:  Identify and treat all people at high-risk of CVD with lipid lowering therapy (LLT) and support personalised care conversations.
• Optimise:  Consider use of high intensity statins and combination therapy with ezetimibe or other LLT whilst maintaining support for adherence to medication.
• Intensify:  Protect high risk patients by reducing lipid levels to target, intensifying LLT when required.

As a result of this project, the CW partner believes that these interventions may have reduced many avoidable hospital admissions and the incidence of cardiovascular events (e.g. heart attacks and strokes) by ensuring appropriate preventative optimisation of medicines to manage long-term conditions.

References:

1. NHS Lipids Infographic - https://www.england.nhs.uk/wp-content/uploads/2023/11/lipids-infographic.pdf
2. Northern England Evaluation and Lipid Intensification guideline (NEELI)  
    https://ntag.nhs.uk/wp-content/uploads/2023/11/NEELI-v2023.1.1-final.pdf

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