Available online 29 March 2024

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Despite many patients being on statins before optimisation most were under treated.

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A pharmacist led service was implemented to optimise lipid lowering therapy.

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Goal was secondary prevention target of non-HDL cholesterol < 97 mg/dl.

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High intensity statin use increased from 39% before optimisation to 76% after review.

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41/216 (19%) of patients were at non-HDL target at baseline which improved to 92/137 (67%) after intervention.

Abstract

Background and Aims: Patients attending vascular or diabetic foot clinics commonly have atherosclerotic disease, are at increased risk of cardiovascular disease (CVD), merit high-intensity lipid-modifying therapy to maintain secondary prevention targets and are often sub optimally treated in primary care. We set out to assess the impact of a pharmacist led lipid optimisation clinic in these patients in an area with high levels of social deprivation.

Methods: We performed a clinical cohort study to assess the effectiveness of a pharmacist led clinic to optimise lipid lowering therapy by optimising of statin therapy and commencing additional lipid lowering therapy if applicable with monitoring of blood lipid profiles.

Results: Of the 216 patients (166 (77%) on statins) triaged by the pharmacist, 175 (81%) had non-HDL cholesterol levels above the target value of 97 mg/dL (2.5 mmol/L) with a mean non-HDL cholesterol level of 135.73 mg/dL (3.51 mmol/L). Pre optimisation by the prescribing clinical pharmacist 41/216 (19%) patients were at target with a mean non-HDL cholesterol of 135.5 mg/dL improving to 92/137 (67%) patients achieving the target non-HDL cholesterol level with a mean post optimisation non-HDL cholesterol of 94.35 mg/dL (2.44 mmol/L), odds ratio for being at target 8.67 [95% CI 5.30 – 14.20]. The calculated LDL cholesterol levels (Friedewald) demonstrated a mean reduction of 35.19 [95% CI 29.23 - 41.38] mg/dL (0.91 [95% CI 0.76 – 1.07] mmol/l). Proportion on high intensity statin increased from 65 out of 166 (39%) to 129 of 170 (76%) at follow up O.R. 4.89 [3.06 – 7.82], equivalent to an NNT = 3.

Conclusions: A pharmacist led service in undertreated and clinically challenging vascular and diabetic foot patients in an area of high social deprivation produced significant improvements in utilization of high intensity statin and other lipid lowering therapies and attainment of lipid goals.

Section snippetsINTRODUCTION

Cardiovascular disease (CVD) is the leading cause of death accounting for a quarter of all deaths in the UK and more than 100,000 hospital admissions1. Stroke causes 38,000 deaths and 100,000 admissions in the UK annually2. Associated healthcare costs are estimated to be £9 billion every year with an overall CVD burden of approximately £19 billion annually3.

CVD death rates vary with age, gender, time of the year (an excess of winter deaths), and also by socioeconomic status, with deaths from

METHODS

The setting for the study was at the Freeman hospital which is a tertiary referral vascular centre offering a full range of vascular services and which works closely with colleagues in cardiology and cardiothoracic surgery. It provides vascular services for patients in Northumberland, North Tyneside, Newcastle and Gateshead and tertiary services for the wider North East region. The large geographical area with a diverse patient population (1.2 million) has one of the highest rates of

RESULTS

A total of 216 individuals (161 seen in the peripheral vascular disease clinic and 55 in the diabetic foot clinic) were evaluated by the pharmacist (44 were directly referred by the team and 172 as a result of pharmacist triage). The demographics and initial blood lipid measurements of the entire sample are displayed in Table 1. There were no significant differences in age, gender breakdown, IMD decile, proportion on treatment or baseline blood lipid levels between referral source (all p>0.4).

DISCUSSION

We developed a pharmacist-led lipid optimisation service with pathways based on the national guideline (The Accelerated Access Collaborative)16 and the regional guideline (The Northern England Evaluation and Lipid Intensification Clinical Guideline)17. By applying pre-specified criteria to identify patients who are at the highest risk of CVD, high-risk patients were reviewed in a virtual clinic at the earliest opportunity for lipid optimisation and offered intervention by an appropriately

CONCLUSIONS

We have demonstrated that a pharmacist led service in undertreated and clinically challenging vascular and diabetic foot patients in an area of high social deprivation produced significant improvements in utilization of high intensity statin therapy and attainment of lipid goals. The service resulted in significant reductions in LDL cholesterol, non-HDL cholesterol, total cholesterol and triglycerides. Overall, a pharmacist led lipid optimisation service, as an adjunct to existing clinical

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CRediT authorship contribution statement

Matthew Hart Mpharm: Writing – original draft. Jon Rees: Writing – review & editing, Writing – original draft, Methodology, Formal analysis. Julia L Newton: Writing – review & editing, Supervision, Conceptualization. Gerard Stansby: Writing – review & editing, Supervision. Kate Mackay: Writing – review & editing, Supervision. Ahai Luvai: Writing – review & editing, Supervision, Methodology, Data curation, Conceptualization.

Declarations of competing interest

None

Use of AI and AI-assisted technologies statement

AI or AI-assisted technologies have not been used.

Data statement

Upon reasonable request, it can be expected that specific anonymous data will be shared to a qualified researcher.

Ethical Approval

Ethical approval was not required due to this being an innovation arising out of a baseline audit that showed low utilisation of lipid treatments.

Acknowledgements

This project was supported by a grant from Heath Innovation North East and North Cumbria (HI NENC) previously known as Academic Health Science Network North East and North Cumbria (AHSN NENC).

REFERENCES (17)

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© 2024 Published by Elsevier Inc. on behalf of National Lipid Association.