Quality improvement in CVD prevention: a GP-pharmacist initiative

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Dudley, in the West Midlands, is an area of pronounced health inequalities. It is known, however, that patients from more disadvantaged areas are likely to benefit from structured lipid management.

With this in mind, and in order to make a difference to patient quality of life as well as to meet a new ICB target, the GPs and pharmacists at The Greens surgery in Dudley embarked on a collaborative initiative.

We set out to enhance the lipid profiles of patients with cardiovascular histories in alignment with NICE NG238 guidelines and local protocols for secondary prevention. Our primary goal was to lower LDL cholesterol levels to 2.0mmol/L or less, and non-HDL cholesterol levels to 2.6mmol/L or less. We would do this by optimising current lipid-lowering therapies or introducing new ones, as necessary.

Background

Prior to this initiative, only 32 per cent of patients with cardiovascular histories in our practice met the NICE NG238 secondary prevention target in the 2024/2025 financial year. This statistic marked the practice out as the lowest performer in Dudley (NICE, 2023). Recently, however, the Black Country Integrated Care Board (ICB) established a new compliance target of 55 per cent, highlighting the significant gap between this and the practice’s performance.

Dudley has formed a collaborative team of pharmacists, supported financially by the ICB and primary care network, who are integrated within each general practice. One of our key objectives is to fulfil the Medicines Optimisation Quality Improvement Scheme (MOQIS) target for lipid compliance in the secondary prevention of cardiovascular disease (CVD).

Given the substantial patient population needing assessment for lipid-lowering therapies, it was crucial for the GPs to work closely with the practice-based pharmacists to meet and surpass the new 55 per cent compliance benchmark.

Teamwork

In order to identify patients whose lipid profiles were not meeting the target, our senior pharmaceutical team conducted a thorough review. This search included patients who had not undergone blood monitoring for their lipid profiles in the past year, allowing for focused intervention.

In early April 2024, as Dudley’s lead pharmacist, Gurvinder shared a comprehensive improvement plan with our GPs during a clinical meeting, addressing the obstacles that stood in the way of achieving our target for secondary prevention. 

The session included training on various lipid-lowering medications, emphasising non-statin options such as ezetimibe, bempedoic acid and inclisiran (NICE TA733). Resources were made available to assist the GPs in selecting suitable treatments tailored to individual patient lipid profiles, ensuring compliance with the secondary prevention standards.

It was decided that the pharmacy team of Gurvinder and two other pharmacists would conduct reviews with patients during their three clinical sessions weekly, alongside their other practice and ICB obligations. The GPs would also assess patients during consultations and delegate follow-ups to the pharmacy team for patients whose lipid profiles were not on target. 

GP assistants played a vital role in informing patients about their outstanding blood monitoring needs, addressing previous gaps in monitoring from the prior year.

Inclisiran was designated as a ‘green’ medication on the Black Country prescribing formulary for initiation in primary care. Patients received resources to facilitate discussions and address any queries they may have about the drug, ensuring informed consent aligned with NICE TA77. 

Our pharmacy technician established a recall system to monitor due doses of inclisiran and notify patients for timely appointments.

For complex cases involving patients who were intolerant to lipid-lowering medications or not achieving targets even at maximum doses, collaboration with secondary care pathology was initiated for recommendations and necessary referrals. All patients were evaluated within the GP practice.

Our approach

Over the course of 12 months, 169 patients were assessed. Initially, the previous year’s data showed that only 54 patients (around 32 per cent) met their lipid targets. 

To meet the ICB’s 55 per cent compliance target for the MOQIS, our practice needed at least 93 patients to be within their lipid target levels. However, achieving this target would still leave 45 per cent of patients not achieving the secondary CVD prevention target. Our aim was therefore to try to achieve the compliance target and reduce the risk of CVD for as many patients as possible.

Following a structured approach that included counselling patients on the inclusion criteria for inclisiran as per NICE TA77, along with educational resources from the manufacturer Novartis, uptake of inclisiran increased. 

Our approach ensured that patients were well informed prior to starting the inclisiran regimen, following their consent. 

Evidence supports lipid-lowering therapy, specifically LDL-C reduction, in preventing recurrent cardiovascular events. For instance, Ray et al found the use of inclisiran to be effective in enhancing compliance with secondary prevention of cardiovascular disease, showing an LDL-C reduction of approximately 50 per cent (range 48-52 per cent) when used alone or alongside statins or ezetimibe.

Outcomes

Implementing this lipid optimisation initiative within our GP practice yielded substantial clinical and strategic advantages. By managing patients whose profiles were out of target, we aimed to improve outcomes, reduce hospital admissions and promote long-term cardiovascular health.

Among our patients, 60 had lipid profiles completed within the last year but were not meeting targets. These individuals, including those on existing lipid-lowering therapy and those with a history of CVD not currently on such therapy, were scheduled for clinical sessions with practice-based pharmacists to optimise or initiate treatment.

Additionally, GP assistants and healthcare assistants supported the completion of repeat lipid profiles, typically three months post-therapy initiation or optimisation. 

Furthermore, 55 patients with a history of CVD lacked a lipid profile from the past year. The practice’s administrative team, GP assistants and healthcare assistants facilitated the completion of these profiles. Once they had been completed, the GPs and pharmacists took the necessary actions for patients not meeting targets.

As a result of these interventions, by the end of March 2025, 104 patients (62 per cent) achieved the target for secondary prevention of CVD, nearly doubling the compliance rate from the previous year’s 32 per cent.

This improvement positioned the practice as approximately joint seventh highest in Dudley for the percentage of patients meeting the non-HDL target – a significant leap from being the lowest-performing practice the prior year.

The initiative is now being integrated into existing long-term condition reviews, maximising the current infrastructure and skills of our multidisciplinary team members. 

Pharmacists, nurses and GPs collaborated to initiate or intensify lipid-lowering therapy in accordance with NICE guidelines. Enhanced utilisation of EMIS searches streamlined case finding and recall processes, facilitating proactive management of high-risk populations.

Additionally, the project contributed to achieving QOF indicators and addressed health inequalities – something that is particularly relevant in our area. 

Further potential

The potential for this initiative lies in its sustainability, scalability and integration into routine care through implementing a pharmacist and general practice collaborative model. 

Future efforts may include the early initiation of cholesterol-lowering therapy for newly identified post-CVD patients to standardise lipid management. Digital tools, such as automated alerts, could enhance monitoring and foster continuous improvement. 

To maintain the benefits, the practice will need ongoing commitment to training, resource allocation for clinical time and support from the local ICB for easier access to newer treatments.

Implementing patient engagement strategies, such as group education, public awareness campaigns using posters in waiting areas and regular communication through digital channels, will empower individuals to manage their own risk, ensuring the long-term success of the programme.

Regular audits and outcome tracking will be essential for demonstrating impact and guiding further improvements.

Future reviews of secondary cardiovascular events among patients will assess the impact of the significant increase in those achieving target lipid profiles for secondary prevention. This will allow for comparisons to be made with the frequency of secondary cardiovascular events prior to the project, with the aim of identifying anticipated reductions.

Enhanced lipid management is expected to improve overall patient satisfaction and confidence in our service. In addition, financial incentives from achieving QOF targets could further support service development.

On a broader scale, this initiative positions the practice as a local leader in proactive CVD prevention within a deprived community, fostering opportunities for collaboration across the wider health economy.