Primary Care
Today, cardiovascular disease (CVD) is attributed to over 20 million deaths a year making it the world’s number one killer. In the UK, CVD affects seven million people and causes one in four premature deaths a year.
With such statistics, CVD remains a major priority across the NHS and is regarded as the single biggest area where lives could be saved in the years to come. By 2029, the ambition is to prevent over 500,000 heart attacks and strokes.
We know that CVD and risk factors such as obesity and high cholesterol are largely preventable. And yet, early heart disease deaths have risen to a 14-year high.
In response, programmes targeted at combatting CVD are increasingly focusing on novel models of upstream intervention and detection, particularly within primary care. Indeed, at practice, PCN and ICB level there are a number of examples of innovative work taking place. Here, we explore these approaches.
CVD has been closely linked to health inequality. People living in areas of deprivation in England are four times more likely to die prematurely from CVD than those in the least deprived. In response, the NHS Confederation’s Health Inequalities Improvement Programme is an example of a population health approach that is successfully targeting CVD health inequalities.
Serving one of the most deprived patient populations in North London, one third of which lives with CVD, the ICB identified the BME population as twice as likely to present to A&E with a CVD condition. To provide more support and facilitate early intervention, a 5-step collaborative model was developed, aligned with Core20PLUS5 and the Major Conditions Strategy.
With a goal to redesign services and improve access, experience and outcomes, system partners across the ICB have come together to co-develop solutions. This includes the hospital trust, primary care teams, community services and the council.
The programme has focused on three areas: (1) supporting individuals with CVD known to primary care and on disease registers to achieve control; (2) understanding barriers to better heart health by engaging with local communities; and (3) working with communities to develop solutions for primary prevention based on insights.
The programme has helped to foster collaboration across boundaries and shared decision making. For example, enabling multidisciplinary management of CVD conditions by connecting primary and secondary care clinicians and developing integrated pathways. Patients who were previously uncontrolled have been identified and a practice support plan has been co-developed by the ICB and clinicians.
One of the biggest priorities for CVD prevention remains early detection.
In the UK, it’s estimated that 6-8 million people are living with undiagnosed or uncontrolled high blood pressure. One of our biggest preventative weapons against CVD is of course data. In recent times we’ve seen the emergence of CVD Prevent which offers a national data tool to identify undiagnosed patients and gaps.
There are also a number of data-driven programmes that are yielding results in this regard. Notable examples feature collaborative working between PCNs and integrated care systems and multidisciplinary teams of data analysts, GPs and social prescribers. Leveraging linked data across general practice, acute and community settings, models have successfully found vulnerable groups at risk of heart failure.
Using segmentation and risk stratification, a PCN identified a large proportion of patients aged over 40 living in areas of deprivation. Multiple risk factors were found to be prevalent including hypertension, poor mental health and obesity. Patients were then offered a medication review alongside a group consultation and support from a social prescriber to adopt healthier habits.
A virtual model was utilised to conduct consultations. Results from the programme identified 100 patients at potential high risk of heart failure, illustrating the benefits of implementing a population health management analysis model.
Cholesterol is a leading risk factor for CVD with high LDL cholesterol (LDL-C), attributed to one in four heart and circulatory disease deaths in the UK. Conversely, every 1 mmol/L reduction in LDL-C is correlated with a 22% reduction in major vascular events after one year.
Lipid lowering therapies (LLT) such as statins are a vital tool against cholesterol, with around eight million adults taking some form of LLT medication. However, there are many who are not. UCL partners Size of the Prize has modelled the potential impact of optimal treatment:
“Across England, if just 90% of people with CVD were treated with statins, 13,000 heart attacks, strokes and deaths would be prevented in three years. If treatment rates were increased to 95%, around 22,000 events would be prevented.”
- UCL Partners, Size of the prize, CVD
NHS England has identified three core ways to improve lipid management in general practice: (1) initiating treatment with LLT for patients at risk alongside personalised care conversations; (2) optimising therapy with high intensity statins and combination therapy while providing support for adherence; and (3) intensifying LLT as required for patients deemed at high risk.
A number of examples within the NHS have been shared to that end. For example, one PCN has implemented a standard operating procedure for standardised medication and clinical review of a group of 1000 patients at risk.
Pathways searches were conducted and the patient cohort was risk stratified to guide prioritisation and intervention. Remote consultations were offered with a pharmacist. Results from the programme included optimisation of lipid therapy for more than 70 patients while 128 received lifestyle medication advice. 15 were advised around current lipid medications. 65% found the review experience to be either good or very good.
Similarly, here at Suvera, we are working with a number of partners to deliver interventions for CVD. Our virtual clinics adopt an integrated, holistic approach, targeting the triple aim of cardiovascular disease prevention – better blood pressure control, cholesterol and diabetes management. In short, a one-stop shop to reduce risk and improvement prevention and management of CVD.
A notable example is our work with South One Newham PCN where we have taken on full management of the PCN’s cholesterol and hypertension register. The Suvera care team has also reviewed patients at risk of harm due to medication errors (includes PPIs for NSAIDs, high risk medications) and those living with severe frailty (including care homes, assisted living, virtual ward, palliative care).
An automated call-recall system pre-booked patients in for consultation with the care team. Patients could access a full review of blood pressure, weight/BMI and lifestyle, with goal setting and onward planning. Medication was initiated or titrated as required. Patients on hypertension and cholesterol registers had consultations with a multi-morbidity specialist, discussing management of both conditions with the same clinician.
The service has surpassed structured medication review targets, drove case-finding and delivered maximum attainment in key cholesterol and hypertension performance indicators.
For example, we have averaged 88.6% for CHOL001 (% patients with CVD prescribed lipid lowering therapy) and maximum achievement for CHOL 002 (patients with CVD whose treatment is optimised to achieve lipids targets).
In hypertension, the service has averaged 77.4% for HYP008 and delivered maximum achievement for HYP 009. 80% of patients on average have achieved hypertension control, an increase of approximately 800 additional patients at target, based on PCN performance prior to Suvera. An additional 223 patients with hypertension were also added to the register, an increase of around 8% of patients who are now receiving appropriate treatment.
Additionally, Suvera completed the 22/23 financial year surpassing Investment and Impact Fund (IIF) targets for SMR01 and SMR01b, achieving 71.4% and 79.9% respectively.
This piece points to some consistent themes in programmes that have driven successful CVD prevention and management.
This includes system-wide collaboration, utilisation of linked data and multidisciplinary teams that feature not only clinicians, but analysts, prescribing pharmacists and social prescribers. While close engagement with local communities is vital to more closely understand and reduce health inequalities that persist around CVD.
Adopting an integrated approach that tackles multiple risk factors can yield significant results, and be both effective and efficient. And with renewed calls to prioritise heart health globally and for cardiovascular plans at national level, Suvera stands ready to support GP practices, PCNs and ICBs to prevent and manage CVD.