Background

Commissioned by NHS England, NHS Digital have developed a Patient case finding tool for use in GP systems as part of work to improve lipid management in the NHS. The tool will provide an additional facility for proactive Patient management in the secondary prevention of Cardiovascular disease (CVD).

The purpose of the tool is to enable proactive identification of Patient cohorts at GP practice level within the CVD secondary prevention pathway, who may benefit from a review of their lipids medication to support optimisation of their care. Patients may be returned from searches, who could benefit from treatment and care at any point in the lipid management pathway – as set out in the NICE-endorsed AAC national pathway. These may include newer therapies such as bempedoic acid and inclisiran, as well as treatments like PCSK9Is, prescribed routinely in secondary care.

NHS Digital has produced a technical specification to support the identification and management of Patients on a lipid pathway. This pathway is outlined by NICE. [Cardiovascular disease prevention overview - NICE Pathways]

Outline Plan

It has been decided that the most appropriate route to deployment is to split the work into 2 work packages:

1. To create individual cohorts of Patients at different stages of the pathway to support call and recall of those Patients (Lipid Management - Stage 1)
2. To create a decision support workflow in the user interface of the GP system to support point of care management (Lipid Management - Stage 2)

Summary of Change

NHS Digital has provided a technical specification which comprises of three related documents:

• An algorithm/workflow that describes the full pathway, including clinician prompts;
• Business rules, derived from the pathway, which specify the individual searches and outputs that support the algorithm
• Code clusters to support the searches

There is a wish to implement this in two stages; what follows describes how this might be achieved for Stage 1. 

Stage 1: Searches based on business rules & code clusters

The rules and code clusters are interdependent so are considered together. These contain specifications for 33 searches with broadly three groups of outputs for active use:

• Outputs for Patients with previously recorded reasons not to have lipid lowering treatment;
• Outputs for candidates for various statin therapies;
• Outputs for candidates for various non-statin therapies

Each output is mutually exclusive (apart from 6 background outputs), i.e. any one Patient can only appear in one output.

The rules are written in a format familiar to GPIT System Suppliers, i.e. the same as QOF. These need to be implemented as a whole in the sequence specified to be of use to practices. They provide outputs in the form of mutually exclusive lists of Patients with defined characteristics which will support a targeted approach to care, e.g. Atorvastatin 20mg candidate cohort or Ezetimibe/Inclisiran candidate cohort. The lists may be used outside the consulting room for call and recall or to identify Patient Records for review.

If desired, these rules can also be used to build user interface alerts of the sort commonly provided in GP systems for QOF targets.

Update to Patient Information Maintenance - GP: 

E00304 - Patient-based report on lipid management

As a Health or Care Professional

I want to generate a Patient-based report on lipid management  

So that I can identify patients who may benefit from treatment intervention or review

Acceptance criterion 1: generate a Patient-based report on lipid management

Given the Health or Care Professional is permitted to generate a report

When they select to generate a Patient-based report on lipid management

Then the report results are displayed

Full Specification

Patient Information Maintenance - GP v3.0.0

Note: Changes to Patient Information Maintenance - GP v3.0.0 include changes as part of the delivery of;

• RM140 Lipid Management Stage 1
• RM148 COVID Vaccinations Extract
• RM149 Flu Vaccinations Extract

Changes specific to each change is outlined in the Summary of Change section of the respective Roadmap Item

Assurance Approach

• NHS Digital Clinicians produce a Clinical Safety Case (CSC) and Hazard Log (HL).
• NHS Digital present clinical safety case to Clinical Safety Group
• Foundation Suppliers review the Clinical documentation and confirm they remain compliant to DCB0129, following a review of the documentation
• Run a pilot, with a minimum of two sites per foundation system 
• Review pilot feedback, looking at the percentage distribution across cohorts.
• Random Patient sampling, identify one Patient per cohort (for a maximum of five cohorts) and ask GP’s to confirm Patients have been correctly included in the search. The five cohorts are;

1. LMCX002 Retest lipid profile in 12 months.
2. LMCX012 Lipid lowering therapy contraindicated or not indicated.
3. LMCX005 Atarvastatin 80mg candidate cohort.
4. LMCX023 Ezetimibe or Bempedoric acid + Ezetimibe candidate.
5. LMCX040 No suitable options available cohort.