Project Name: Widnes GP Federation Lipid Optimisation Project

Project Summary: 

The CWP is structured such that a multi-disciplinary healthcare professional team will provide tailored care for patients, aligned with the Primary Care Network (PCN) Contract Direct Enhanced Service (DES) and the locally defined Cardiovascular plans.

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.  

The CWP will be led by a General Practitioner, alongside a multi-disciplinary team including; Clinical Pharmacist, Nurse, General Practitioner, and Healthcare Assistant, aiming to achieve:

  1. Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines
  2. Review of treatment options and decision on next steps in collaboration with ASCVD patients
  3. Counsel and optimise ASCVD patients where appropriate.

Planned Milestones:

  • Kick-off Meeting with Project Leads
  • Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table
  • Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity
  • Collection & submission of 3 months clinical activity data.
  • Project Review meeting to discuss project progress.
  • Development of business case. 
  • Collection & submission of 6 months clinical activity data.
  • Project Review meeting to discuss project progress.
  • 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.   
  • 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   
  • Easier access to lipid management care closer to home in the Primary Care setting

ANTICIPATED BENEFITS FOR THE ORGANISATION

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

 Start Date & Duration:​​​​​​​ June 2023 for 7 months

UK2306029515
UK | June 2023 | 659380

Project Name: Widnes Federation Lipid Optimisation Project 

Partner Organisation(s): Widnes Highfield Health Limited (Widnes Highfield Health GP Federation)  

Completion Date: 31 January 2024

Outcome Summary: 

Provision of Improved tailored-care lipid optimisation for widnes PCN patients with known atherosclerotic cardiovascular disease and uncontrolled lipids profile.

Key Project Outcomes Data:

  • 513 patients were identified to be included in the project with uncontrolled lipids.
  • 274 of these patients had non pharmacological intervention, including diet and lifestyle advice consultation to optimise their lipids.
  • 126 patients had one or more pharmacological intervention.

Outcomes: 

The lipids optmisation project identified all 513 patients, using the appropriate searches that required lipids optmisation,  in all 8 surgeries within widnes PCN.The search only identified those patients with pre-existing cardiovascular disease and are therefore at higher risk from cardiovascular events due to their uncontrolled lipids.

376 patients received clinical consultations by clinicians to discuss management of their uncontrolled lipids via different strategies including pharmacological and non-pharmacological intervention. All patients were invited and booked for repeat lipids blood tests organised within a 3 months interval period to track any improvement in their results. If results remained higher than target lipids range (as per NICE guidelines non HDL>2.5 or LDL >1.8) this was then followed by further clinical consultations and interventions if necessary from the clinicians.

At the conclusion of the project, 274 patients were discharged back to their GPs with non pharmacological interventions throughout the project timeline. This included advice on improving their cholesterol intake through dietary changes the emphasis of the impact on exercise on improving cardiovascular health. Discharge letters were sent to their individual surgeries outlining all consultations and any follow-up required.

102 patients included in the project had pharmacological interventions throughout the duration of the project.

All these patients were then discharged back to their GPs to continue repeat blood tests and administration of further injectable therapies at their individual surgeries. A total of 1816 healthcare interactions occurred across this project. 

Quote From Partner:​​​​​​​

“The lipids optimisation project brought a new and fresh perspective into how we treat cardiovascular health in our PCN and how lipids optimisation can be a vital part of it. The project was also a perfect example of how a multidisciplinary clinical approach in such projects can produce better patient outcomes”.

Basil Mohammed – Clinical Pharmacist (Widnes Highfield Health)

Conclusion:

Overall, the lipids optimisation project helped improve the lipid management many patients within widnes PCN. This is clearly demonstrated by the level of engagement shown by the 376 patients that participated. 

UK2409128874