1. Presented by Paul Wright MRPSII MRPha rmS Lead Cardiac Pharmacist, Barts Heart Centre, Barts Health NHS Trust Workshop written and prepared by Helen Williams FFRPS, MRPharmS

2.  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?

3. Hypertension CHD Heart Failure Anticoagulation

4.  CVD is still the most common cause of premature mortality  CHD alone accounts for >43,000 deaths per annum in the UK

5.  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 drug  We spend £1.2billion on CV drugs each year

6.  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 drug  We spend £1.2billion on CV drugs each year  Half of all CV drugs are probably never taken as prescribed  Strategies to improve adherence to drug therapies would have a bigger impact on outcomes then any new medical advance

7. 7 MORTALITY SOURCE: Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

8. 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: 380–386 Roger Boyle. 2011. www.pace-cme.org/legacy/files/presentaation.ppt

9. Capewell et al Heart 2006 92 521 Putting Prevention First 

10. Haynes RB. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2001, Issue 1. Adherence….

11. http://www.gpcontract.co.uk/browse/UK/Hypertension/13http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014

12. http://www.gpcontract.co.uk/browse/UK/Hypertension/13http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014 ….still over 1.6 million people with known hypertension and BP > 150/90mmHg

13. http://www.gpcontract.co.uk/browse/UK/Hypertension/13http://www.gpcontract.co.uk/browse/UK/Hypertension/13 2014 ….still over 1.6 million people with known hypertension and BP > 150/90mmHg ….still over 3.4 million people with known hypertension and BP > 140/90mmHg

15. >50,000 (24%) on BP register with BP stlll > 150/90mmHg >100,000 (48%) on BP register with BP still > 140/90mmHg

16. www.gpcontract.co.uk

17. HF patients on ACEI = 23% HF patients on BB = 17%

19. 16.7% on ACEI or ARB 12.4% on beta-blocker

22. 52 strokes per annum of which we could prevent ~ 36 with anticoagulation

23. Approx. 1,032 high risk patients not currently anticoagulated 52 strokes per annum of which we could prevent ~ 36 with anticoagulation

25.  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

28. 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 2.4 5 2 3.5 2.1 45.4 21.3 12.4 6.2 9.9 7.3 13.9 6.3 22.7 0 10 20 30 40 50 MenWomenMenWomenMenWomenMenWomen Normotensive Hypertensive Coronary disease Stroke Peripheral artery disease Cardiac failure Biennial age-adjusted rate per 1000

29. 29 Lewington et al. Lancet 2002 Blood pressure as a risk factor for CHD mortality 256 128 64 32 16 8 4 2 1 120140160180 Usual systolic blood pressure (mm Hg) IHD mortality (floating absolute risk and 96% CI) 256 128 64 32 16 8 4 2 1 708090100 Usual diastolic blood pressure (mm Hg) 110 Systolic blood pressureDiastolic blood pressure Age 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

30. 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

31. S Rationale for the Project Supplementary and independent prescribing introduced 2003/2006 1 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 P S 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/@e n/documents/digitalasset/dh_4133747.pdfttp://webarchive.nationalarchives.gov.uk/20130124072757/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@e n/documents/digitalasset/dh_4133747.pdf

32. 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 P S Medicines Use and Safety

33. S P S

34. Summary of prescribing interventions Drugs prescribedNew DrugTitrated Reduced or stopped ACEi231710 Alpha-blockers21 ARB811 Aspirin 6 Beta-blocker1 3 CCB15112 Digoxin 1 Fibrate 1 Frusemide 2 Statin2433 Thiazide6 4 Totals7933 S P S Medicines Use and Safety

35. 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 P S Medicines Use and Safety

36. At the end of 2013; QOF showed there were > 8000 hypertensive people in Lambeth failing to achieve a BP target < 150/90mmHg

37.  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

38.  Aim: improved medicines use to improve health outcomes in patients with chronic disease  Review of chronic disease registers  HF, hypertension, AF  Specialist pharmacist ‘Virtual Clinic’ with GPs  Identify and discuss medicines opt issues  Develop management plan to address in practice  GPs or pharmacist delivers individual patient management plans

39.  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

40.  37 practices submitted data for 1,079 patients  281 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

41.  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

42. 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

43.  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 ≤ 140/90mmHg Year% patients achieving QOF BP < 150/90mmHg 201176.4 201275.3 201378 201481

44.  Current prescribing guidelines and rationale  Clinical inertia  Non-adherence  Failure to engage patients  Role of community clinic – identifying appropriate patients for referral

45. 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

46.  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?

48. 1. BP checks and NHS health checks 2. 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….

50.  Significant burden to the NHS  Outcomes improved if managed by cardiac team:  8% mortality on cardiac wards  13% on medical wards  17% 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 2013 https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy

51. www.nice.org.uk NICE 2010 CG 108 Chronic Heart Failure http://www.nice.or g.uk/CG108 And ivabradine….(NICE 2012)

52. 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.

53. Incremental Benefit with HF Therapi es (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.

54. 16.7% on ACEI or ARB 12.4% on beta-blocker

55.  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

56.  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

57.  486 of 872 patients (56%) had LVSD  Only 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 GPs  Re-coding patients (n=345)  clarifying diagnosis (n-69)  clinical or drug interventions (n=357)  other: including care planning and follow up (n=184)

59.  Reduction in HF hospitalisations over next 2 – 4 years

60.  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

61.  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 optimisation  HF, hypertension, AF and anticoagulation  NMS / MUR plus for community pharmacy  Adherence support

62.  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?

63. Presented by Paul Wright MRPSII MRPha rmS Lead Cardiac Pharmacist, Barts Heart Centre, Barts Health NHS Trust Workshop written and prepared by Helen Williams FFRPS, MRPharmS