presented by paul wright mrpsii mrpha rms lead cardiac pharmacist, barts heart centre, barts health...
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MEDICINES OPTIMISATION IN CARDIOVASCULAR DISEASE
Presented by Paul Wright MRPSII MRPharmS Lead Cardiac Pharmacist, Barts Heart Centre, Barts Health NHS
Trust
Workshop written and prepared by Helen Williams FFRPS, MRPharmS
Medicines Optimisation – Why do it?
What is the aim of medicines optimisation in CV Disease?
What represents value from a medicines optimisation perspective?
How is medicines optimisation being addressed in your area?
THE UNMET NEED……
HypertensionCHD
Heart FailureAnticoagulation
Some sobbering statistics…..? CVD is still the most common cause of
premature mortality CHD alone accounts for >43,000 deaths per
annum in the UK
Some sobbering statistics…..? 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 drugWe spend £1.2billion on CV drugs each year
Some sobbering statistics…..? 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 drugWe spend £1.2billion on CV drugs each year
Half of all CV drugs are probably never taken as prescribedStrategies to improve adherence to drug
therapies would have a bigger impact on outcomes then any new medical advance
7
MORTALITY
SOURCE: Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009
Capewell S, Morrison CE, McMurray JJ. Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart. 1999; 81: 380–386Roger Boyle. 2011. www.pace-cme.org/legacy/files/presentaation.ppt
0
2000
4000
6000
8000
10000
12000
14000
16000
Num
ber
of d
eath
s pre
vent
ed o
r po
stpo
ned
20 00 treatment levels If 80% of e ligible 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
“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….
http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014
Hypertension in England
http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014
Hypertension in England
….still over 1.6 millio
n people
with known hypertension
and BP > 150/90mmHg
http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014
Hypertension in England
….still over 1.6 millio
n people
with known hypertension
and BP > 150/90mmHg
….still over 3.4 millio
n people
with known hypertension
and BP > 140/90mmHg
• >50,000 (24%) on BP register with BP stlll > 150/90mmHg
• >100,000 (48%) on BP register with BP still > 140/90mmHg
Heart Failure: NHS England Data
www.gpcontract.co.uk
Heart Failure: NHS England Data
www.gpcontract.co.uk
HF patients on ACEI = 23%HF patients on BB = 17%
16.7% on ACEI or ARB12.4% on beta-blocker
HILLVIEW
FAMILY PRACTICE
THE LENNARD SURGERY
THE FAMILY PRACTICE
THE WELLS
PRING SURGERY
BRADGATE SURGERY
SOUTHMEAD AND HENBURY FAMILY PRACTICE
ST MARTIN
S SURGERY
FALLODON W
AY MEDICAL C
ENTRE
WELLS
ROAD SURGERY
SEA MILL
S SURGERY
WHITELA
DIES MEDICAL G
ROUP
HARTWOOD HEALT
HCARE
GRANGE ROAD SURGERY
NIGHTIN
GALE VALLE
Y PRACTICE
GLOUCESTER ROAD M
EDICAL CENTRE
GAYWOOD HOUSE SURGERY
ST GEORGE HEALT
H CENTRE
WESTBURY-O
N-TRYM SURGERY
LAW
RENCE HILL HEALT
H CENTRE
EASTVILLE M
EDICAL PRACTICE
AVONMOUTH MEDICAL C
ENTRE
THE WEDMORE PRACTICE
THE MALA
GO SURGERY
RIDINGLE
AZE MEDICAL C
ENTRE
BEECHWOOD M
EDICAL PRACTICE
THE ARMADA FAMILY PRACTICE
BROADMEAD MEDICAL C
ENTRE0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
0
5
10
15
20
25
30
35
40
45
50
Bristol CCG: Anticoagulation rates in patients at high risk of stroke (CHADS2 ≥2) - QOF 2013/14
Total number untreated pts QOF reported QOF actual
Perc
enta
ge o
n an
ticoa
gula
tion
Tota
l num
ber o
f pati
ents
HILLVIEW
FAMILY PRACTICE
THE LENNARD SURGERY
THE FAMILY PRACTICE
THE WELLS
PRING SURGERY
BRADGATE SURGERY
SOUTHMEAD AND HENBURY FAMILY PRACTICE
ST MARTIN
S SURGERY
FALLODON W
AY MEDICAL C
ENTRE
WELLS
ROAD SURGERY
SEA MILL
S SURGERY
WHITELA
DIES MEDICAL G
ROUP
HARTWOOD HEALT
HCARE
GRANGE ROAD SURGERY
NIGHTIN
GALE VALLE
Y PRACTICE
GLOUCESTER ROAD M
EDICAL CENTRE
GAYWOOD HOUSE SURGERY
ST GEORGE HEALT
H CENTRE
WESTBURY-O
N-TRYM SURGERY
LAW
RENCE HILL HEALT
H CENTRE
EASTVILLE M
EDICAL PRACTICE
AVONMOUTH MEDICAL C
ENTRE
THE WEDMORE PRACTICE
THE MALA
GO SURGERY
RIDINGLE
AZE MEDICAL C
ENTRE
BEECHWOOD M
EDICAL PRACTICE
THE ARMADA FAMILY PRACTICE
BROADMEAD MEDICAL C
ENTRE0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
0
5
10
15
20
25
30
35
40
45
50
Bristol CCG: Anticoagulation rates in patients at high risk of stroke (CHADS2 ≥2) - QOF 2013/14
Total number untreated pts QOF reported QOF actual
Perc
enta
ge o
n an
ticoa
gula
tion
Tota
l num
ber o
f pati
ents
52 strokes per annum of which we could prevent ~ 36 with anticoagulation
HILLVIEW
FAMILY PRACTICE
THE LENNARD SURGERY
THE FAMILY PRACTICE
THE WELLS
PRING SURGERY
BRADGATE SURGERY
SOUTHMEAD AND HENBURY FAMILY PRACTICE
ST MARTIN
S SURGERY
FALLODON W
AY MEDICAL C
ENTRE
WELLS
ROAD SURGERY
SEA MILL
S SURGERY
WHITELA
DIES MEDICAL G
ROUP
HARTWOOD HEALT
HCARE
GRANGE ROAD SURGERY
NIGHTIN
GALE VALLE
Y PRACTICE
GLOUCESTER ROAD M
EDICAL CENTRE
GAYWOOD HOUSE SURGERY
ST GEORGE HEALT
H CENTRE
WESTBURY-O
N-TRYM SURGERY
LAW
RENCE HILL HEALT
H CENTRE
EASTVILLE M
EDICAL PRACTICE
AVONMOUTH MEDICAL C
ENTRE
THE WEDMORE PRACTICE
THE MALA
GO SURGERY
RIDINGLE
AZE MEDICAL C
ENTRE
BEECHWOOD M
EDICAL PRACTICE
THE ARMADA FAMILY PRACTICE
BROADMEAD MEDICAL C
ENTRE0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
0
5
10
15
20
25
30
35
40
45
50
Bristol CCG: Anticoagulation rates in patients at high risk of stroke (CHADS2 ≥2) - QOF 2013/14
Total number untreated pts QOF reported QOF actual
Perc
enta
ge o
n an
ticoa
gula
tion
Tota
l num
ber o
f pati
ents
Approx. 1,032 high risk patients not
currently anticoagulated
52 strokes per annum of which we could prevent ~ 36 with anticoagulation
DISCUSS:
WHAT ARE THE BARRIERS TO MEDICINES OPTIMISATION IN CV DISEASE?
What opportunities are there to improve Meds Opt for CV Disease?
In primary care?
In secondary care?
Via the CCG?
Via the AHSN / SCN?
In reach / Out reach Post-discharge MURs Cardiac rehabilitation Community based
clinics Hypertension /
hyperlipidaemia Practice based
pharmacists Virtual clinics Community pharmacy Local GP delivery
schemes
EXAMPLES OF GOOD PRACTICE?
HYPERTENSION
Hypertensive patients are at increased risk of cardiovascular events
Framingham Heart Study – Risk of cardiovascular events by hypertensive status in patients aged 35-64 years; 36-year follow-up
9.5
3.3 2.45
23.5 2.1
45.4
21.3
12.4
6.2
9.97.3
13.9
6.3
22.7
0
10
20
30
40
50
Men Women Men Women Men Women Men Women
NormotensiveHypertensive
Coronary disease Stroke Peripheral artery disease
Cardiac failure
Bien
nial
age
-adj
uste
d ra
te p
er 1
000
29Lewington et al. Lancet 2002
Blood pressure as a risk factor for CHD mortality
256
128
64
32
16
8
4
2
1
120 140 160 180
Usual systolic bloodpressure (mm Hg)
IHD
mor
talit
y(fl
oatin
g ab
solu
te ri
sk a
nd 9
6% C
I)
256
128
64
32
16
8
4
2
1
70 80 90 100
Usual diastolic bloodpressure (mm Hg)
110
Systolic blood pressure Diastolic blood pressureAge at risk:
80–89 yrs
70–79 yrs
60–69 yrs
50–59 yrs
40–49 yrs
Age at risk:
80–89 yrs
70–79 yrs
60–69 yrs
50–59 yrs
40–49 yrs
Fig 7 Reduction in incidence of coronary heart disease (CHD) events and stroke in relation to reduction in systolic blood pressure according to dose and combination of drugs, pretreatment
systolic blood pressure, and age. *Blood pressure reductions are more uncertain and hence also reductions in disease incidence.
M R Law et al. BMJ 2009;338:bmj.b1665
©2009 by British Medical Journal Publishing Group
S
Rationale for the Project• Supplementary and independent prescribing introduced 2003/20061
• Numerous examples of individual pharmacists developing services utilising their prescribing qualification
• Projects have been reported, they often revolve around the activities of an individual prescriber
• Few data evaluating the impact of these services on patient outcomes.
• Aim: evaluate the impact of pharmacist prescribers on blood pressure (BP) management by drawing together the activities of pharmacist prescribers working across a wide geography
PS Medicines Use and Safety
Department of Health 2006. Improving Patients’ Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the NHS in England. http://webarchive.nationalarchives.gov.uk/20130124072757/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4133747.pdf
Results
• 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.
S
PS Medicines Use and Safety
S
PS Medicines Use and Safety
Summary of prescribing interventionsDrugs
prescribed New Drug TitratedReduced or
stoppedACEi 23 17 10
Alpha-blockers 2 1 ARB 8 1 1Aspirin 6Beta-blocker 1 3CCB 15 11 2Digoxin 1Fibrate 1Frusemide 2Statin 24 3 3Thiazide 6 4
Totals 79 33 33
S
PS Medicines Use and Safety
Sustainability?• Two clinics were already well established and funding has
been continued• A pharmacist-led hypertension and hyperlipidaemia
service based within locality settings has been commissioned by two South London CCGs• The aim being to reduce referrals to acute care by managing difficult to
control BP / lipids in a community setting
• Project data has been made available to support business cases for the development of more pharmacist-led clinics
• The evaluation tool has been shared through existing networks and can be found at
http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/Leadership-workforce/Non-med-presc/
S
PS Medicines Use and Safety
Project OverviewPrescribing Incentive 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 hypetensive patients with sustained BP > 160/100mmHg
Focus on high risk cohort and move BP towards target, even if target itself not achieved
Pharmacist-led Virtual Clinics
Aim: improved medicines use to improve health outcomes in patients with chronic disease
Review of chronic disease registersHF, hypertension, AF
Specialist pharmacist ‘Virtual Clinic’ with GPs Identify and discuss medicines opt issuesDevelop management plan to address in practice
GPs or pharmacist delivers individual patient management plans
Hypertension Meds Opt Project
Practices to identify all patients with BP≥160/100mmHg
Review management and select 20-30 patients for discussion at virtual clinic
VC 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
Results 37 practices submitted data for
1,079 patients281 patients (26%) did not respond to repeated invitations for a BP review from the practices
Of the remaining 798 patients, the average baseline sBP was 170.8mmHg and dBP was 94.8mmHg
BP Reductions 688 patients with sBP ≥ 160mmHg at
baseline – average sBP reduction of 26.9mmHg
208 patients with sBP ≥ 180mmHg at baseline - average sBP reduction in sBP of 37mmHg
43 patients with sBP ≥200mmHg at baseline average sBP reduction in sBP of 51mmHg
359 patients were identified with a dBP ≥ 100mg at baseline, and this was reduced by an average of 16.4mmHg
Fig 7 Reduction in incidence of coronary heart disease (CHD) events and stroke in relation to reduction in systolic blood pressure according to dose and combination of drugs, pretreatment
systolic blood pressure, and age. *Blood pressure reductions are more uncertain and hence also reductions in disease incidence.
M R Law et al. BMJ 2009;338:bmj.b1665
©2009 by British Medical Journal Publishing Group
Achieving targets 584 patients (73.2%) achieved a BP of <
160/100mHg 453 patients (56.8%) meet the QOF BP target
≤ 150/90mmHg 341 patients (42.7%) meet the clinical BP
target ≤ 140/90mmHgYear % patients
achieving QOF BP < 150/90mmHg
2011 76.4
2012 75.3
2013 78
2014 81
Key Areas addressed in VCs
Current prescribing guidelines and rationale
Clinical inertia Non-adherence Failure to engage patients
Role of community clinic – identifying appropriate patients for referral
Impact on GP practices….
GP practices report: a more systematic approach to the call
and recall lead GPs identified within practices regular clinical meetings focusing on BP
management better liaison with practice nurses increased awareness of non-adherence greater usage of the community
hypertension clinic for complex patients
Future work… There remains a cohort of patients that do
not respond for frequent requests for review of BP management CCG now needs to consider how this group can
be better engaged Utilise community pharmacists in
supporting adherence through provision of the new medicines service and medicines use reviews
Other Virtual clinics – AF and anticoagulation?
Opportunities for Pharmacy…?
1. BP checks and NHS health checks2. Community outreach to improve patient
engagement Ethnicity Socioeconomic class
3. NMS / MURs Disease awareness, health beliefs, adherence
4. Educating and supporting HCPs Virtual clinic model
5. Pharmacist prescribers….
HEART FAILURE
Heart failure Significant burden to the NHS Outcomes improved if managed by
cardiac team:8% mortality on cardiac wards13% on medical wards17% on other wards (2011/12)20% mortality of seen by specialist team post discharge cf. 32% if not referred
Aim for better identification and input from multidisciplinary specialist teams
Department of Health 2013https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy
www.nice.org.uk
NICE 2010 CG 108 Chronic Heart Failurehttp://www.nice.org.uk/CG108
And ivabradine….(NICE 2012)
Incremental Benefits with HF Therapies(Cumulative % Reduction in Odds of Death at 24 Months)
-28% to -49%P<0.0001
-54% to -71%P<0.0001
-68% to -81%P<0.0001
-75% to -86%P<0.0001
-77% to -88%P<0.0001
-72% to -87%P<0.0001
Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.
Incremental Benefit with HF Therapies(Cumulative % Reduction in Odds of Death at 24 Months Associated with Sequential Treatments)
+20% to -68%P=0.1566
-43% to -91%P<0.0001
-70% to -96%P<0.0001
Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.
16.7% on ACEI or ARB12.4% on beta-blocker
NICE Quality statement 7
People with chronic heart failure due to left ventricular systolic dysfunction are offered angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists licensed for heart failure if there are intolerable side effects with angiotensin-converting enzyme inhibitors) and beta-blockers licensed for heart failure, which are gradually increased up to the optimal tolerated or target dose with monitoring after each increase
www.nice.org.uk
Southwark HF virtual clinics
35 practices in Southwark over 6 month period
GPs incentivised to participate via medicines QIPP plan
Utilised HF pharmacist in community HF team 872 patients reviewed and action plan
developed
Payment to GPs based on delivery of action plans
Southwark HF VCs results
486 of 872 patients (56%) had LVSDOnly 43% (207 patients) were on maximum
daily doses or maximum tolerated doses of a suitable ACEI/ARB and BB.
955 recommendations made and actioned by GPsRe-coding patients (n=345)clarifying diagnosis (n-69)clinical or drug interventions (n=357) other: including care planning and follow up
(n=184)
And, what will success look like?
Reduction in HF hospitalisations over next 2 – 4 years
Taking Meds Optimisation forward…
Greatest need is in primary care Engage CCG through LTC lead, CVD steering
grp Demonstrate the value in investing in
medicines Align with local and national priorities Agree consensus guidance across all local
providers Utilise all available funding streams
(pharma?) Utilise your local specialists
Community based clinics, virtual clinics Community pharmacy to support medicine
adherence
Opportunities for Pharmacy to Optimise Medicines
Full integration into acute care clinical teams
Better interface communication Consensus primary / secondary care
guidance Chronic disease care reviews
Practice based pharmacists Virtual clinic model
Pharmacist led-services for meds optimisationHF, hypertension, AF and anticoagulation
NMS / MUR plus for community pharmacyAdherence support
Medicines Optimisation – Why do it?
What is the aim of medicines optimisation in CV Disease?
What represents value from a medicines optimisation perspective?
How is medicines optimisation being addressed in your area?
MEDICINES OPTIMISATION IN CARDIOVASCULAR DISEASE
Presented by Paul Wright MRPSII MRPharmS Lead Cardiac Pharmacist, Barts Heart Centre, Barts Health NHS
Trust
Workshop written and prepared by Helen Williams FFRPS, MRPharmS
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