Project Name: North Kerrier East PCN Lipid Optimisation Project

Project Summary:

The main objective of the CWP is to improve the quality of care for patients and support the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner.

  • Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines.
  • Identification of ASCVD patients who have previously not tolerated or refused alternative lipid modification therapies.  
  • Review of treatment options and decision on next steps in collaboration with ASCVD patients.
  • Counsel and optimise ASCVD patients where appropriate, who are at the highest risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance.  Such patients shall be stratified by the CW Partners preferred criteria established in : CVD Prevention: Lipid Pathway – Resources for Health and Care – Health Innovation Manchester. 

 

Eligible for injectable therapies:

  • Not on a statin therapy

  • Not eligible for injectable therapies

  • On suboptimal statin therapy or dose

 

  • Early identification of at-risk patients who have not had intervention in their health and wellbeing
  • Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated
  • On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably

Planned Milestones:

  1. Kick off Meeting & Collection of baseline data, in line with the Project Outcome Measures & Data Collection table.
  2. Confirmation of clinical and operational pathway, policy and utilisation of current protocol, and readiness to begin the clinical activity 
  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 7.5 months clinical activity data. Project Review meeting to discuss project progress.
  6. Development of business case / Case for change 
  7. Analysis of CWP data, submission of Final Project 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.

  1. Enhanced experience around ASCVD with ongoing management of the condition.
  2. Improved access to appropriate medication for suitable patients to preserve health and prevent long-term events.
  3. Easier access to lipid management care closer to home in the Primary Care setting.
  4. 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, leveling health inequalities within the PCN.
     

Anticipated benefits for the CW Partner

  • 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
     

Benefits to 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 organisations which addresses the problem of health inequalities. 
  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation  

Start Date & Duration: November 2023 for 8 months. 

GB2311207622

Project Name: North Kerrier East PCN Lipid Optimisation Project

Partner Organisation(s): North Kerrier East PCN, Leatside Health Centre, Forthnoweth, Redruth, TR15 1AU (lead Practice)

Completion Date: September 2023

Outcome Summary:

This project improved the quality of care for patients and supported the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD)

Key Project Outcomes Data:

Relevant patients were identified using Lipid Search tools and coding checked and updated where required and invited for a review of lipid therapy

117 patient reviews and optimisation appointments were completed as part of this project.

An increase in patients achieving lipid targets as defined in QOF CHOL002 (Percentage of patients on the QOF Coronary Heart Disease, Peripheral Arterial Disease, or Stroke/TIA Register, who have a recording of non-HDL cholesterol in the preceding 12 months that is lower than 2.5 mmol/L, or where non-HDL cholesterol is not recorded a recording of LDL cholesterol in the preceding 12 months that is lower than 1.8 mmol/L.) was obtained from 24% to 42% and from 37% to 60% respectively at each site.

Outcomes:

As a result of this collaborative working project, the number of patients within the PCN meeting target for lipid optimisation has  improved, ensuring patients are being managed appropriately. This project has enabled us to go beyond QoF targets and help more patients.

Conclusion:

The project was successfully completed in line with Executive Summary.

FA-11361481