Predict & Prevent – Redesigning the local lipid management pathway

The South East London (SEL) Lipid Transformation and Optimisation Project (known as Predict and Prevent locally) aimed to redesign the local lipid management pathway, to ensure that patients would receive timely and appropriate care from the right healthcare professional. Through adopting a 'test and learn' approach, the aim was to transform lipid management across SEL to maximise patient outcomes and align with the broader vision for CVD prevention in the London region.

In late 2021, the Health Innovation Network (HIN) was asked to support the implementation of lipid optimisation in SEL as part of the Academic Health Science Network’s wider role in supporting lipid management across England. In collaboration with Amgen, the project's objectives were to:

• Implement patient searches, revise lipid management guidance, and pathways in primary care practices.
• Enhance lipid management and cardiovascular risk reduction for patients within primary and secondary prevention cohorts.
• Review and manage patients coded with FH or suspected FH, address secondary causes, facilitate specialist referrals for genetic diagnosis, and conduct coding reviews.
• Improve the knowledge and confidence in lipid management among primary care professionals, addressing statin hesitancy and intolerance, cardiovascular risk reduction, and therapy escalation.
• Increase the uptake of second-line therapies in accordance with NICE Guidance after optimising high-intensity statin treatment where feasible.

The evaluation undertaken by the Health Innovation Network highlighted several key findings, including:

• Improved prescribing trends: All six Primary Care Networks (PCNs) increased the percentage of prescribed high-intensity statins in CVD primary and secondary prevention between January 2022 and follow-up in March 2023. Compared to the previous year, 600 more patients received ezetimibe during the project duration in SEL.
• Notable improvements in primary and secondary prevention strategies: PCNs demonstrated progress in targeting priority patients for primary and secondary prevention strategies, with positive shifts in the distribution of patients across risk categories.
• Challenges in patient engagement and education: Patient anxiety and resistance to treatment presented challenges, highlighting the need for clear communication and a compassionate approach.
• Impact on staff: Clinicians reported personal knowledge development, exposure to expert knowledge and a broader understanding of lipid management.

Primary Care’s role in lipid management
The insights from this evaluation emphasise that Primary Care should retain a key role in identifying patients with high-risk of cardiovascular disease and FH, and optimising lipid management where possible.

Resource and workforce
The additional burden on clinicians’ time to successfully implement and deliver the lipids optimisation workstream needs to be recognised in the workforce and caseload planning. Having clearly defined roles, such as project and data management, will help with task delegation and reduce the impact of clinicians’ time on patient care.

Patient education and engagement
Patient-specific and targeted educational materials and communication strategies to improve patient understanding of lipid management and statin therapy should be introduced and standardised.

Wider PCN engagement and support
Facilitated wider PCN engagement should continue to be supported. The Community of Practice for lipids management was highlighted as a key factor that supported successful project delivery. The Integrated Care Board (ICB) could actively support the lipids optimisation workstream by providing the necessary resources, coordination, and data analysis support.

Professional development and training
The training and learning opportunities throughout the lipids optimisation project were highlighted as having a beneficial impact to staff professional development and patient care. Continued professional development and training opportunities for clinicians involved in the lipids optimisation workstream should be considered as part of ongoing support for the project.

Review of FH-coded patients
Two PCNs addressed the FH pathway during the project and both reported numerous incorrect coding of current FH on their systems It is recommended that a review of current FH-coded patients be added to the pathway as an additional step along with identification of possible new cases. Additionally, a knowledge-gathering exercise to examine how these errors frequently occurred may be useful to prevent future coding errors.

Match patient data at cohort level
Measuring clinical outcomes is an important driver for the sustainability of the lipid optimisation project. The current searches are limited in what they can currently compare. Future work should ensure patient data is matched at the cohort level between baseline and follow-up periods. This will allow for more accurate comparisons and assessment of the lipids optimisation project's impact on specific patient groups over time. The UCLPartners Search and Stratification Tools should be updated to extract cohort-level data, rather than population-level data. Where individual practices have created their own effective search templates or protocols, these should be shared among the wider Community of Practice.

Amgen would like to acknowledge all the clinicians, pharmacists, allied health care professionals and Health Innovation Network professionals within South East London who made the delivery of this joint working project possible.

The full HIN Evaluation Report can be accessed here.