Project Name: Midlands Medical Partnership (MMP) Lipid 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) who are at high risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance, in response to the needs of the CW Partner.
Planned Milestones:
- CWP kick-off meeting.
- Baseline data collated to measure project outcomes against.
- Clinical and operational pathway, policy and protocol creation.
- Confirmation of readiness to begin the clinical activity.
- Project progress check in meetings, including latest clinical activity data.
- Analysis of CWP data, submission of final CWP report, submission of outcomes summary.
- CWP wrap up meeting.
Expected Benefits:
For the Patient:
- 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.
- The additional capacity will provide additional time and support from GP Super Partnership 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 GP Super Partnership.
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.
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: September 2023 for 9 months
UK2309014916 | August-2023
Project Name: Midlands Medical Partnership (MMP) Lipid Project
Partner Organisation(s): Midlands Medical Partnership MMP LLP, Company Number OC340529 of 1128 Tyburn Road, Erdington, Birmingham, B24 0SY (the “CW Partner”)
Completion Date: 21.06.2024
Outcome Summary:
Improved the quality of care for patients and supported the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease who were not achieving lipid levels as specified in national and/or local guidance.
Key Project Outcomes Data:
296 patients had an optimisation of lipid medication.
Outcomes:
Key Outcomes
Patient Review and Optimisation:
Total Patients Reviewed: 472
Patients Optimised with Lipid-Lowering Therapy: 296
Optimisation Rate: 62.7%
The initiative successfully reviewed lipid profiles and treatment plans for 472 patients. Out of these, 296 patients (62.7%) received optimised lipid-lowering therapies, leading to better management of their lipid levels.
Reduction in Referrals to Secondary Care:
By optimising lipid-lowering therapies at the primary care level, 472 patients were effectively managed by their local GPs.
Improved Access and Convenience for Patients:
The initiative prioritised patient convenience by enabling local GP practices to manage lipid optimisation.
Patients benefited from:
Increased Access to Care: More patients could receive timely and effective lipid management services without the need for secondary care referrals.
Enhanced Convenience: Patients experienced greater convenience as they could be seen by their local GPs, reducing the need for travel and waiting times associated with secondary care appointments.
Continued Monitoring and Support: Local GPs provided continuous monitoring and support, ensuring that patients remained on optimal therapy regimens and adjustments could be made as needed.
Group Consult:
By inviting patients to group consults it streamlined the process of education and has helped patients understand the benefits LDL reduction. Patients were able to ask questions of clinicians but also other patients attending the sessions.
The CW Partner found having a lead GP and Lead Nurse delivering the sessions was very beneficial and was well received by patients.
Once the patients were educated they were offered appropriate therapies whilst in attendance which improved uptake as they did not need to return for Nurse appointment.
Educating in groups sessions saved clinical time as the education message was only delivered once to multiple patients.
The CW Partner found having groups of patients with similar co-morbidities was helpful when delivering the sessions – and ensuring patients ‘knew their numbers’ and were aware of their LDL levels before the group sessions was helpful to ensure they understood the benefits.
Conclusion
This Lipid Optimisation Initiative achieved its goals by effectively reviewing and optimising lipid-lowering therapies for the 472 patients reviewed, with 296 of those patients being optimised) of the patient cohort, reducing the need for secondary care referrals, and improving patient access and convenience through local GP management. This holistic approach not only enhanced the quality of lipid management but also promoted a more efficient and patient-centred healthcare system.
Recent CW Partner data indicates that 30% of the CW Partner’s BAME (Black, Asian, and Minority Ethnic) community attended the clinic, highlighting a significant aspect of ongoing health inequalities. This disparity underlines the necessity for targeted interventions to ensure equitable access and healthcare outcomes for all community groups.
Working alongside Novartis they have been very supportive with work and any queries we’ve had. Having a catchup every 3 months to help us identify if we are on the right path to meet the end goal.
Quote from Partner:
Dr Kay Crossman
“The lipid optimisation joint working project with Novartis has enabled our organisation to adopt a quality improvement approach to improving lipid optimisation therapy within our population. In addition to seeing improvements in LDL levels within the project timeframe, we have been able to embed knowledge, upskill our clinical workforce and implement internal processes to ensure a legacy effect for the future.”
Dr Aqil Chaudary
“In 3 decades as a GP this project has been one of the foremost initiatives that has made a difference in terms of preventative agenda in CVD and the management of LDL. Working with Novratis and developing very productive relationships has resulted in real patient outcomes”.
Conclusion:
The Lipid Optimisation Initiative achieved its goals by effectively reviewing and optimising lipid-lowering therapies (a baseline of 532 patients invited to clinic, 651 appointments offered, with 418 attending a lipid consultation clinic) of the patient cohort, reducing the need for secondary care referrals, and improving patient access and convenience through local GP management. This holistic approach not only enhanced the quality of lipid management but also promoted a more efficient and patient-centred healthcare system.
- 296 patients had an optimisation of lipid medication.
- Improved access and convenience for patients.
- Workforce has been upskilled across the PCN to anticipate increased lipid optimisation at a local level.
- Reduction in secondary care referrals for Lipid optimisation.
- Patients optimised to be reviewed for potential further optimisation.
- MMP to explore options with secondary care providers with the view to expand on work started within primary care setting.
References:
Patient Feedback
“Having the options explained to me and receiving information ahead of my appointment helped me to make a decision about my treatment. I am grateful that my GP is able to prescribe me treatments that previously I would have had to wait and go to hospital to receive.”
Anon. Patient comments supplied to the CW Partner.
FA-11324077 | September 2024