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