the developing role of pharmacy in managing cvd - … · •extended roles embedded in acute care...
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THE DEVELOPING ROLE OF PHARMACY IN MANAGING CVD
HELEN WILLIAMS FFRPS, FRPHARMS, PGDIP (CARDIOL), IPRESC
CONSULTANT PHARMACIST FOR CVD, SOUTH LONDON
CVD CLINICAL LEAD, LAMBETH AND SOUTHWARK CCGS
CLINICAL DIRECTOR FOR ATRIAL FIBRILLATION, HEALTH INNOVATION NETWORK
WHY PHARMACY?
• NHS frontline services struggling to cope with increasing demand
• GP numbers falling, HCPs leaving the NHS, funding cuts….
• Pharmacy is the only healthcare profession with predicted oversupply by 2025
• No cap on training places – increasing numbers of pharmacy schools and pharmacists in training
• Extended roles embedded in acute care – opportunity to utilise skills in new settings
• Medicines optimisation will deliver improve outcomes, reduce demand, save £££
DID YOU KNOW…..?
• CVD is still the most common cause of premature mortality
• CHD alone accounts for >43,000 deaths per annum in the UK
• One in every THREE prescriptions issued is the UK is for a CV drug
• We spend £1.2billion on CV drugs each year
• Half of all CV drugs are probably never taken as prescribed
• Strategies to improve adherence to drug therapies would have a bigger impact on outcomes then any new medical advance
ROLE OF PHARMACY IN CVD
1.Community pharmacy
2.GP practice-based pharmacists
3.Clinical Leadership
WHY USE COMMUNITY PHARMACY?
• Available on the high street & in supermarkets
• 99% of patients can access a pharmacy within 20 minutes by car and 96% by walking or public transport
• Longer opening hours, evenings and weekends
• Usually no appointments necessary – this may have to change!
• Most adults in the UK use pharmacies
• 84% of adults visit pharmacy at least once per year, 75% have visited within the last 6 months; most visit for health-related reasons
• = 1.6million visits to UK pharmacies daily
• = an average of 16 visits per user per year
• In London alone there are 1,800 community pharmacies
COMMUNITY PHARMACYOPPORTUNITIES
• DETECTION:
• NHS Health checks: Hypertension, diabetes, high CV risk
• AF case-finding using new technologies
• MANAGEMENT:
• Health Living Pharmacies, smoking cessation, weight management programmes, lifestyle advice & signposting
• Pharmacist prescribers managing LTCs – hypertension, anticoagulation in AF
• Disease monitoring – blood pressure, HbA1c, INRs
• Adherence support – New Medicines Service / Medicines Use Review
New Medicine Service (NMS)
Improve adherence10%
PHARMACISTS IN GENERAL PRACTICE
General practice provides safe, high quality and efficient care, with very high levels of patient satisfaction. It has a unique and vital place in the NHS…
Accessible, personal care built on a relationship from cradle to grave
Community based responsible for prevention and care of a registered population
Holistic perspective understanding the whole patient not just a disease
Comprehensive skills to diagnose & manage almost anything
Personal and population-orientated primary care is central …
if general practice fails, the whole NHS fails. Simon Stevens, General Practice Forward View
First port of call and
central point of care
for all, for life
#GPforwardview
The problems
www.england.nhs.uk
• Launched in November 2015
• Investment of £31.5 million over three years
• In February 2017: >490 pharmacists in >650 practices across 90 pilot sites
• Deadline for practice involvement in pilot has ended.
• Evaluation
12
Clinical pharmacists in General Practice Pilot
www.england.nhs.uk
The role of pharmacists in general
practice
13
Clinical patient facing
roles
Long term conditions
Clinical Medication
Reviews
Home visits/care homes
Others: common ailments,
care plans, triage
Clinical Post/Pathology
Checking and reviewing
Action
Signposting/triage
Medicines optimisation
Repeat prescribing
Medicines
queries/requests
Liaising with others
Patient safety
Reducing admissions
Signing prescriptions
Productivity and access
Leadership/Management
Research
Health and social care
Vulnerable population
QOF/DES/LES
Extended hours
OOH
Medicine support
Telephone
Medicines related issues
Discharge/ reconciliation
Medicines information
Clinical effective audits
CQC
Education for staff
Integration
Further integration of GP
with primary and
secondary care
Community Pharmacy
Hospital pharmacy
Southwark Snapshot: Pharmacist Interventions in more detail
920 interventions in 2
weeksRECALLS (269)
- 44% for specific BT monitoring
- Potential saving of “blanket admin
recalls for rw”
-Specific to what the patient needs
REMAINDER (651)
- 3% ID and resolve of med errors
Improve patient safety
-12% deprescribing
Potential huge saving in Rx costs
Improving patient outcomes
14% meds optimisation
Improving patient outcomes
Improve QOF/KPI’s
www.england.nhs.uk
Next Phase….
15
• The GPFV includes a commitment to
deliver an additional 5,000 clinical
and non-clinical staff in general
practice.
• A commitment to have ‘a pharmacist
per 30,000 of the population
• Central investment of £112m to
extend pilot programme.
• Additional 1,500 pharmacists in
general practice by 2020/21
http://www.cochrane.org/CD011227/EPOC_prescribing-roles-health-professionals-other-doctors
MEDICINES OPTIMISATION SYSTEM LEADERSHIP
0
2000
4000
6000
8000
10000
12000
14000
16000
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rt fa
ilure
Myoca
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l Infa
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on
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nt ion
CA
BG
/ PTC
A
Com
munit
y Angin
a
Hyp
erten
sion
Unst
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ngina
Stati
ns for
1° prev
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20 00 treatment levels If 80% of eligible patients treated
Capewell et al Heart 2006 92 521
WHAT IF TREATMENT UPTAKES IN ENGLAND & WALES INCREASED?ACTUAL UPTAKES 50% 25,805 DEATHS POSTPONED
IF 80% ELIGIBLE PATIENTS 20,910 DEATHS POSTPONED
Putting Prevention First
Intervention Frequency
Increase BB 52
Increase ACEi 37
High intensity statin 28
Add ACEi 18
Add BB 8
Review lipid lowering 8
Add Clopidogrel 7
Switch BB and increase dose 6
Review anti-anginal therapy 4
Review BP control 3
Increase ARB 2
Add Omacor 2
Review Diuresis 2
Review BB 2
Add Statin 2
Review PPI 1
Review Other 1
CV risk assessment 1
Consider ARB 1
Diabetes review 1
Review aspirin dose 1
Total 187
South London Audit of Prescribing At Discharge from Cardiac Rehabiliation(2009)
“INCREASING THE EFFECTIVENESS OF ADHERENCE INTERVENTIONS MAY HAVE A GREATER IMPACT OF THE HEALTH OF THE
(WORLD) POPULATION THAN ANY IMPROVEMENT IN MEDICAL TREATMENT”
HAYNES RB. INTERVENTIONS FOR HELPING PATIENTS TO FOLLOW PRESCRIPTIONS FOR MEDICATIONS.
COCHRANE DATABASE OF SYSTEMATIC REVIEWS, 2001, ISSUE 1.
Adherence….
21
MORTALITY
SOURCE: Global
health risks:
mortality and
burden of disease
attributable to
selected major
risks. WHO 2009
http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014
Hypertension in England
PHARMACIST-LED HYPERTENSION CLINICS
• Data were collected from 7 clinics across South London from October 2011 to March 2012
• 336 patients were seen over the course of the 6 month data collection period.
• 229 had uncontrolled BP (68%)
• 44 had unmonitored BP within the last 9 months (13%)
• 63 were referred with BP already controlled to <140/90mmHg
• Pharmacist-led community hypertension service commissioned as a result
http://www.cochrane.org/CD011227/EPOC_prescribing-roles-health-professionals-other-doctors
At the end of 2013; QOF showed there were >
8,000 hypertensive people in Lambeth failing to
achieve a BP target < 150/90mmHg
Hypertension Project Overview
Prescribing Improvement scheme 2013/2014
QOF targets are unattainable in a proportion of patients
Any reduction in BP = reduction in |risk of CV events
Project aimed to address BP control in a cohort of hypertensive patients with sustained BP > 160/100mmHg
Focus on high risk cohort and move BP towards target, even if target itself not achieved
Practices to identify all patients with BP≥160/100mmHg
Review management and select 20-30 patients for discussion at virtual clinic
Virtual Clinic led by Specialist Cardiac pharmacist
Practice to implement recommendations from VC in selected patients and submit data on BP control across entire cohort with BP≥160/100mmHg
Interventions
Distribution of local hypertension guidelines
Review at a virtual clinic with specialist cardiovascular
disease pharmacists
GP Practices to identify all patients with BP≥160/100mmHg
Review management and select 20-30 patients for discussion at
virtual clinic
Virtual Clinic led by Specialist Cardiac pharmacist
GP Practice to implement recommendations across whole cohort
Referral of selected patients to a pharmacist-led
community hypertension service or a secondary care
hypertension service
Blood pressure reductions
• Improvement in BP noted across
all age groups with a tendency
towards greater improvements
with increasing age - younger
age groups less likely to engage
• Improvement noted across both
genders – males were less likely
to engage
• Improvement noted across all
ethnic groups – Caucasian
patients were the most likely to
engage with interventions
45 practices submitted data for 1,982 patients
1526 patients were successfully followed up
https://www.stroke.org.uk/sites/default/files/08k.pdf
AF and Strokes Southwark CCG 2015
Of 22 stroke patients with known AF and not anticoagulated in 2014 – 41% died and 37% were left with moderate to severe disability
LAMBETH / SOUTHWARK CCGS AF PROJECT
• Project proposal developed
• Virtual clinic model to review all AF patients not anticoagulated
• Funding for a/c specialist pharmacist support secured from industry (Bayer, BI, Pfizer/BMS)
• GP engagement secured through embedding programme in GP Delivery scheme / Prescribing Improvement Scheme (£)
• Agreed service specification with local acute trust
• Provided resources to GP practices – audit data collection, virtual clinic guide, prescribing guidance
THE ‘VIRTUAL CLINIC’ MODEL
• Bring specialist skills into general practice
• Anticoagulation pharmacists, nurses, haematologists
• Practice to identify all patients on AF register not currently anticoagulated and collate relevant data:
• CHA2DS2VASc and HASBLED
• Treatment to date (why not currently anticoagulated)
• Any other relevant info
• Virtual clinic with GPs to discuss anticoagulant options and develop patient management plans
• GP practice to implement patient management plans and report outcomes
VIRTUAL CLINIC DISCUSSIONS COVERED:
• Confirming a correct AF diagnosis
• Correct coding of AF on the GP system
• Cleaning the AF register
• Correct use of stroke and bleeding risk scores
• Assessing benefits and risks of anticoagulation
• Explain benefits and risks of anticoagulation to patients
• Dispelling myths and misconceptions
• Explaining the role of left atrial occlusion devices where anticoagulation is contraindicated
OUTCOMES?
• Across 91 GP practices, 1,574 patients with AF not currently receiving anticoagulation were reviewed over 5 months.
• 1,292 additional patients were anticoagulated
• •Lambeth: 567 additional patients have been anticoagulated which will prevent up to 20 strokes per annum
• Southwark 725 additional patients have been anticoagulated which will prevent up to 25 strokes per annum.
• It is expected that this increase in anticoagulation will prevent up to 45 AF-related strokes per annum
OUTCOMES?
EMERGING ROLES IN PHARMACY
1. Community Pharmacy: The Frontline
• Detection, prevention, prescribing, monitoring , lifestyle, adherence
2. GP Practice Based Pharmacists• Medication review, meds opt, adherence, specialist clinics
3. Medicines Optimisation: System Leadership• Strategy, commissioning, audit, medicines opt programmes