The recently published Primary Care Networks (PCN) cardiovascular disease (CVD) prevention and diagnosis Directed Enhanced Service (DES) focuses on lipid management in terms of increasing uptake of statins and improving the detection and diagnosis of familial hypercholesterolaemia (FH) from April 2022.
UCLPartners Proactive Care Frameworks support this by helping integrated care systems, PCNs and individual GP practices to identify and address unmet need in cholesterol management. Standardised searches, which run on EMIS and SystmOne, identify and prioritise people requiring lipid intervention; for example, identifying those with established CVD or who are at risk of developing CVD and who are not on a statin first, followed by those not on an appropriate intensity and/or dose of a statin and then those not achieving targets despite an appropriate intensity and dose of a statin.
The frameworks take lessons from effective approaches to lowering cholesterol, and help primary care teams put these into practice. These include:
Lifestyle change is key to cholesterol lowering. An important element of the proactive care frameworks are the resources for the wider workforce to support behaviour change and self-management. These include scripts and protocols for healthcare assistants, healthy living coaches and social prescribers to use in their conversations with patients; as well as links to educational resources for patients.
Drug therapy with statins and other medicines is very effective – every 1mmol/l reduction in low-density lipoproteins (LDL) cholesterol reduces risk of a cardiovascular event by 25%. The frameworks include algorithms to support prescribing clinicians in optimising lipid lowering therapy, including a selection of lipid lowering therapies and intensification of therapy, dealing with adverse effects and supporting patients with shared decision making.
People with high cholesterol who also have other risk factors (e.g. high blood pressure, diabetes, smoking) are at significantly greater risk of CVD and have most to gain from a reduction in cholesterol. The frameworks recognise that patients rarely present with single conditions and risk factors and take a multi-morbidity approach to ensure holistic care.
FH is high risk but very treatable. Half of men with FH will have a heart attack or stroke before age 50 and a third of women before age 60. Statins are highly effective at reducing this risk. Searches for FH include patients without an FH diagnosis with a history of high lipid levels – >7.5mmol/L if under 30 years old and >9mmol/L if over 30 years old; alongside those with a current FH code to ensure the diagnosis has been confirmed. The process of reviewing these patients has been semi-automated in order to minimise the burden in general practice. Patients with suspected FH require referral for confirmation of the diagnosis by genetic testing. Specialist centres will advise on the initial management of people with FH, and support cascade testing for family members; but prescribing recommendations for FH are covered to support general practice with longer-term care.
The UCLPartners Proactive Care Frameworks support GP practices to optimise lipid management, utilising the skills of the wider workforce.
All of the Proactive Care Framework resources are free and can be accessed at uclpartners.com/proactive-care/