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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
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THE DEVELOPING ROLE OF PHARMACY IN MANAGING CVD - … · •Extended roles embedded in acute care –opportunity to utilise skills in new ... •99% of patients can access a pharmacy

Jul 19, 2020

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Page 1: THE DEVELOPING ROLE OF PHARMACY IN MANAGING CVD - … · •Extended roles embedded in acute care –opportunity to utilise skills in new ... •99% of patients can access a pharmacy

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

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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 £££

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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

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ROLE OF PHARMACY IN CVD

1.Community pharmacy

2.GP practice-based pharmacists

3.Clinical Leadership

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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

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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

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New Medicine Service (NMS)

Improve adherence10%

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PHARMACISTS IN GENERAL PRACTICE

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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

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#GPforwardview

The problems

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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

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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

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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

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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

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http://www.cochrane.org/CD011227/EPOC_prescribing-roles-health-professionals-other-doctors

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MEDICINES OPTIMISATION SYSTEM LEADERSHIP

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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

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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)

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“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….

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21

MORTALITY

SOURCE: Global

health risks:

mortality and

burden of disease

attributable to

selected major

risks. WHO 2009

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http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014

Hypertension in England

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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

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http://www.cochrane.org/CD011227/EPOC_prescribing-roles-health-professionals-other-doctors

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At the end of 2013; QOF showed there were >

8,000 hypertensive people in Lambeth failing to

achieve a BP target < 150/90mmHg

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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

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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

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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

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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

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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

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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

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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

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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

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OUTCOMES?

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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

[email protected]