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Joint Working Initiatives


Title IMPROVING THE IDENTIFICATION AND TREATMENT OF PATIENTS WITH SUSPECTED FAMILIAL HYPERCHOLESTEROLEMIA AT RISK OF CARDIOVASCULAR DISEASE.  A DIGITAL SUPPORT PROGRAM FOR PRIMARY CARE IN BRISTOL, NORTH SOMERSET AND SOUTH GLOUCESTERSHIRE
Organisations Involved

Dr Graham Bayly Consultant Lipididologist of University Hospital Bristol in collaboration with Amgen Ltd.

OneCare Ltd (an affiliate of Bristol, North Somerset and South Gloucester CCG) IT Service Provider.
Joint Working Project Description

The overall aims of the project are to:

  • Transform the identification of patients at risk of Familial Hypercholesterolemia and patients at high risk of coronary heart disease in primary care in line with national guidelines.
  • Increase the use of the available genetic screening programme across the Bristol, North Somerset and South Gloucester footprint in appropriate patients, through better patient identification.
  • For OneCare Ltd to provide web hosting and Initial IT support for GP Practices by providing an “add on” of the EMIS Patient ID Tool in EMIS GP systems to Bristol, North Somerset and South Gloucester practices.
  • The Hospital Lipid Specialists will develop local guidelines and a referral pathway in line with national policies for referral and/or primary care ongoing patient reviews.
  • Training and Education will commence for Bristol, North Somerset and South Gloucester Practices to support the implementation of the EMIS Patient ID Tool and will be provided by OneCare Ltd to primary care physicians and primary care pharmacists.
  • To provide examples of good practice through a collaborative multidisciplinary approach which utilises all sectors of the primary care workforce and specialists within secondary care.
Expected Outcomes

The expected outcomes from this project are as follows:

  • Written guidelines to inform the identification and treatment of suspect Familial Hypercholesterolemia patients.
  • Ongoing availability of the EMIS Patient ID Tool offered to all practices in the Bristol, North Somerset and South Gloucester CCG footprint for identification in primary care of suspect Familial Hypercholesterolemia and Mixed Dyslipidemia patients.
  • Patient’s pharmacological management and lifestyle changes and behaviours can be addressed on a regular basis to improve overall health and well-being, this is key to reducing the morbidity and mortality associated with poorly managed hypercholesterolemia.
  • To produce a formal written evaluation of the project to demonstrate the benefits of using an add on patient identification system tool.

The project incorporates the principles of improved patient education regarding Familial Hypercholesterolemia associated risks, optimised medical and specialist care and advice closer to home.

UKIE-NPC-145-1019-079067a January 2020




Title REDUCING CVD EVENTS BY OPTIMISING CHOLESTEROL MANAGEMENT FOR HIGH RISK PATIENTS IN THE NORTH WEST COAST REGION
Organisations Involved Amgen Limited and Innovation Agency NWC
Joint Working Project Description

The aim of the Project has been designed to support the delivery of the NHS CVD aspect of the Long-Term Plan.

The focus will be to improve cholesterol management, in patients who are at a high risk of a CVD event or a further CVD event, to within parameters set by NICE guidelines with a focus on three areas:

  1. Support the clinical priority to reduce the number of CVD events.
  2. Ensure where appropriate, interventions are conducted in primary care by MDT teams within a primary care network (“PCN”) footprint.
  3. Use of population health analysis to identify cohorts of patients who are most in need of an intervention.
Expected Outcomes

Patients with persistently high cholesterol levels who are identified as high risk for a CVD event or a further CVD event will be reviewed and managed optimally, as per NICE guidance CG181 AND CG71.

Audit tools, treatment and referral pathways as well as Primary Care upskilling to build on current management of Cholesterol will be reviewed with an expected reduction in CVD events as a direct result of optimising cholesterol levels in the practices involved in the project.  

UKIE-NPC-145-1219-080406a January 2020




Title ESTABLISHMENT OF A NATIONAL FRACTURE LIAISON SERVICE IN IRELAND
Organisations Involved Royal College of Surgeons of Ireland (RCSI), FLS Steering Committee Ireland & Amgen Ireland Ltd
Joint Working Project Description

This partnership with the RCSI aims to establish a Fracture Liaison Service (FLS) database in existing FLS centres.  The FLS Database will collect data that demonstrates to policy makers support for a national FLS in all 16 trauma centres will improve care standards for osteoporosis patients, lead to early identification and treatment initiation to prevent further debilitating fragility fractures.

Expected Outcomes

Key outputs from the Joint Working Agreement include:

  • Demonstrate clinical and cost effectiveness of FLS, by increased identification, investigation & initiation of treatment.
  • Deliver KPI driven quality care improvement
  • Enable prescription initiation & adherence data
  • Development of FLS patient pathway

UKIE-NPC-NPS-1219-080190 December 2019




Title UPSKILLING PRIMARY CARE STAFF IN DETECTION, PROTECTION AND PERFECTION PATHWAY FOR PEOPLE WITH HETEROZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA, PRIMARY HYPERCHOLESTEROLAEMIA AND MIXED DYSLIPIDAEMIA.
Organisations Involved West Midlands Academic Health Science Network and Amgen Ltd in collaboration with Strategic Transformation Partnerships, Primary Care Networks and GP Practices.
Joint Working Project Description

The overall aim of the project is to upskill primary care staff in the detection, protection and perfection pathway for people with heterozygous familial hypercholesterolemia, primary hypercholesterolaemia and mixed dyslipidaemia which will reduce the cardiovascular disease risk for these patients.

  • To create and implement a West Midlands wide pathway for the detection and management of Familial Hypercholesterolaemia (FH), primary hypercholesterolaemia and mixed dyslipidaemia. This will align with the WMAHSN strategy of “detect, protect and perfect”. Identification of people at risk of FH, primary hypercholesterolaemia and mixed dyslipidaemia and optimising their pharmacological management as well as addressing lifestyle changes and behaviours to improve overall health and well-being, is key to reducing the morbidity and mortality associated with poorly managed hypercholesterolaemia.
  • To upskill primary care practitioners in the basics of FH, primary hypercholesterolaemia and mixed dyslipidaemia management around the detection, protection and perfection
  • To provide examples of good practice through a collaborative multidisciplinary approach which utilises all sectors of the primary care workforce and specialists within secondary care.
  • To create a local network of FH, primary hypercholesterolaemia and mixed dyslipidaemia champions in regional areas to provide peer networking and support/encouragement
  • To evaluate the impact and health economics of the upskilling in identifying patients with FH, primary hypercholesterolaemia and mixed dyslipidaemia optimising their management (pharmacological and non-pharmacological), and quantifying the benefits in terms of healthcare resource utilisation and impact on productivity e.g. through reduction in the number of FH, primary hypercholesterolaemia and mixed dyslipidaemia related heart attacks
  • Ensure patients have access to the right medications, at the right dose and at the right time with appropriate follow up and review
  • Our approach will be to:
    • Conduct systematic FH searches as NICE clearly outlines a strategy for case finding and diagnosis which can be implemented locally.
    • Increase uptake of NHS Health Checks to individuals between the ages of 40 and 74 – total cholesterol is measured as part of this check.  Then screen as per the guidance above and refer into WMFHS being aware that QRISK cannot be applied to patients with FH because it will underestimate the CV risk in this population
Expected Outcomes

The joint working project is designed to improve the identification and treatment of patients with familial hypercholesterolaemia, primary hypercholesterolaemia and mixed dyslipidaemia with the sole purpose of reducing their cardiovascular risk.

Key outputs from the joint working project will be:

  • To improve the skills and knowledge of primary care clinicians in detecting and treating familial hypercholesterolaemia, primary hypercholesterolaemia and mixed dyslipidaemia.
  • To increase the diagnosis of familial hypercholesterolaemia, primary hypercholesterolaemia and mixed dyslipidaemia.
  • To produce a formal written evaluation of the project.

UKIE-NPC-145-1219-080175a December 2019




Title IMPROVING THE IDENTIFICATION AND MANAGEMENT OF PATIENTS WITH FAMILIAL HYPERCHOLESTEROLAEMIA AND PATIENTS WITH HIGH CHOLESTEROL RISK IN PRIMARY CARE.
Organisations Involved Kent Surrey and Sussex AHSN Limited (KSS AHSN) and Amgen Limited.
Joint Working Project Description

The overall aim of the Kent Surrey and Sussex Academic Health Science Network, in collaboration with the local Clinical Commissioning Groups, Primary Care Networks, GP practices and Amgen is to implement targeted FH and high cholesterol risk assessment and medication review at a primary care level.

Expected Outcomes

The aim of the joint working project is to:

  • Bring together Clinical Lipid Specialists to develop local prescribing guidelines and a lipid referral pathway across primary and secondary care.
  • Develop and roll out a training and education initiative for primary care clinicians and pharmacists to assist them in use of the various IT audit tools available and to appropriately identify, refer and manage patients with high cholesterol and FH.
  • Provide Primary Care Networks (PCN) and GP Practices with the audit tools and resources to enable them to identify patients at high risk of FH and high cholesterol, evaluate medications, educate and treat patients with the sole aim of eliminating the excess coronary heart disease risk and premature mortality associated with FH.
  • Improve the patient experience by providing targeted specialist care within primary care and ensure better utilisation and more appropriate referrals to the specialist service, based at the local NHS trust across Kent Surrey and Sussex.
  • Through better identification of high-risk patients, increase the use of the genetic screening programme.
  • To further develop an FH service model which can be scaled up nationally.

UKIE-NPC-145-1119-079763a December 2019




Title IDENTIFICATION OF PATIENTS WITH VERTEBRAL FRACTURES FROM CT SCANS TAKEN DURING THE ASSESSMENT OF OTHER CONDITIONS.
Organisations Involved Royal Surrey County Hospital NHS Foundation Trust and Amgen. The opportunistic vertebral fracture case finding service (ASPIRE) was developed by Optasia Medical Limited.
Joint Working Project Description

The overall aim of the joint working project between Royal Surrey County Hospital NHS Foundation Trust and Amgen is to identify vertebral fractures in patients having CT scans whilst in hospital for other conditions. These patients will then be referred to the Fracture Liaison Service (FLS) to receive appropriate management.

Expected Outcomes

The joint working project is designed to support the implementation of The National Osteoporosis Clinical Guideline Group for the effective identification of vertebral fractures.

Key outputs from the joint working project will include the following:

  • Improvements in the identification of patients with vertebral fractures
  • Improvement in the quality of life for patients with vertebral fractures as a result of referral to a FLS to minimize the risk of future fracture.

UKIE-NPC-162-0718-066425a April 2019


 

TITLE NORTHERN BONE HEALTH PROJECT – FALLS AND FRACTURE PREVENTION, A POPULATION APPROACH.
Organisations involved Northern Health Science Alliance (NHSA)
AMGEN Ltd
AHSN – North East and North Cumbria (NENC)
AHSN - Innovation Agency
AHSN - Health Innovation Manchester
AHSN - Yorkshire and Humber
Interface Clinical Services (ICS)
Joint Working Project Description

The overall aim of the four Academic Health Science Networks (AHSNs) across the North of England, working in partnership with AMGEN, The Northern Health Science Alliance (NHSA) and Interface Clinical Services (ICS) is to support the Northern Region in leading innovation by targeting fracture risk assessment and Bone Sparing Medication Review at a Primary Care level. The aim of the joint working project is to identify patients at high risk of fracture, evaluate medications, educate and treat patients with the sole aim of future fracture prevention. The project will run over one year.

Expected outcomes

The joint working project is designed to support the implementation of NICE CG 146.

Key outputs from the service may include the following:

  • Patient education around osteoporosis; including the importance of a healthy diet and exercise
  • Optimisation of treatment and support for primary and secondary fracture prevention
  • Support for GP practices to achieve the QOF osteoporosis indicators
  • Establishment of a process and educational legacy for primacy care NHS organisations that supports sustained quality improvement in the management of patients with osteoporosis
  • An evaluation of the project to determine the lessons learnt and the optimal way to scale the project nationally.

UKIE-NPC-162-0319-073126a March 2019


 

TITLE THE IMPACT OF THE INTRODUCTION OF TRASTUZUMAB BIOSIMILAR ON PATIENTS AND NHS SERVICES
Organisations Involved Amgen Ltd and The Christie Hospital
Joint Working Project
Description

The project is to conduct a detailed review of the Christie’s process and patient experience of transition to a trastuzumab biosimilar or initiation of a trastuzumab biosimilar. The aim will be to a) ensure that patients experience a smooth transition and are able to feedback on every element of the process b) collect clinician feedback on the transition process and identify factors for change. Results from this project will facilitate improved process and outcomes for other patients coming into the system both for this trastuzumab biosimilar transition and also for future biosimilars that are expected to emerge.

As a result of the project, the Christie will establish a system whereby they can monitor and assess all patients either transferred onto trastuzumab biosimilar or commenced on trastuzumab biosimilar.

Expected Outcomes The project will:
  • Gather the views and opinions of clinical staff, to inform and support the strategies used for the introduction of future biosimilars
  • Gather useful insights from patients about information provided to them during the transitioning period
  • Enable a more streamlined experience for the patient to be established
  • Identify patients who want to stay on the originator and understand their rationale
  • Identify the patients who were transferred back to originator and the reasoning

UKIE-NPC-KJTI-1118-069634a December 2018


 

TITLE
IDENTIFICATION OF PATIENTS WITH VERTEBRAL FRACTURES FROM CT SCANS TAKEN DURING THE ASSESSMENT OF OTHER CONDITIONS.
Organisations Involved
Bradford Teaching Hospitals NHS Foundation Trust and Amgen. The opportunistic vertebral fracture case finding service (ASPIRE) was developed by Optasia Medical Limited.
Joint Working Project Description
The overall aim of the joint working project between Bradford Teaching Hospitals NHS Foundation Trust and Amgen is to identify vertebral fractures of patients having CT scans whilst in hospital for other conditions. These patients will then be referred to the Fracture Liaison Service (FLS) to receive appropriate management.
Expected Outcomes

The joint working project is designed to support the implementation of The National Osteoporosis Clinical Guideline Group for the effective identification of vertebral fractures.

Key outputs from the joint working project will include the following:

  • Improvements in identification of patients with vertebral fractures.
  • Improvement in quality of life for patients with vertebral fracture, via referral to a FLS to minimize the risk of future fracture.

UKIE-NPC-162-0718-066085 August 2018


 

TITLE
DEVELOPMENT OF EDUCATIONAL RESOURCE & IDENTIFICATION OF HIGH RISK CVD/FH IN IRISH PRIMARY CARE SETTING.
Organisations Involved
The Irish College of General Practitioners (ICGP) and Amgen Ireland Ltd.
Joint Working Project Description
The development of identification processes for patients at high risk of premature cardiovascular disease (CVD) and possible Familial Hypercholesterolemia (FH) in the Irish Primary Care setting
Expected Outcomes

The aim of this joint working project is a partnership between Amgen and the ICGP to raise awareness amongst GPs of patients at high risk of premature CVD/ FH in the general practice setting.

The key deliverables from the project:

  • Develop an educational resource to raise awareness amongst GPs of high risk CVD/ FH and detecting this disease.
  • Create a sample case finding audit tool to be placed on the ICGP audit site and promoted by ICGP in the professional competence audit cycle year 2018-2019 to support identification of high risk CVD/FH patients.
  • Write a formal evaluation of the pilot project including aggregate data from a sample of practices nationally that will better inform future system changes for patient identification and referral networks.

UKIE-CC-145-0718-066560a July 2018


 

TITLE
QUALITY IMPROVEMENT PROJECT - INTRODUCTION OF A NOVEL PATHWAY TO IMPROVE LIPID CONTROL IN POST TRANSIENT ISCHEMIC ATTACK (TIA), STROKE AND PATIENTS WITH PERIPHERAL VASCULAR DISEASE (PVD)
Organisations Involved
University Hospitals of Leicester NHS Trust (UHL) and Amgen UK.
Joint Working Project Description

The aim of the joint working project to develop a clinical pathway for optimisation of lipid levels in patients with TIA, stroke or PVD patients at UHL that if successful could be adopted on a UK wide scale.

Expected Outcomes

The joint working project is designed to improve lipid management services for patients by developing a care pathway which aims to:

  • Reduce variation in care of lipid management
  • Implement a cross departmental approach to lipid management
  • Improve medicine optimisation of lipid medication
  • Demonstrate potential financial benefits through improvements in care

The key out puts from the project are to:

Develop an optimal clinical pathway for patients post TIA, stroke and patients with PVD.

Complete a health economic benefit analysis of the above pathway

UKIE-NPC-145-0618-065600a May 2018



TITLE
IMPROVING THE IDENTIFICATION AND TREATMENT OF PATIENTS WITH FAMILIAL HYPERCHOLESTEROLEMIA (FH) IN PRIMARY CARE.
Organisations Involved
Academic Health Science Network for the North East and North Cumbria (AHSN-NENC) and Amgen Ltd in collaboration with Clinical Commissioning Groups, GP Practices and PRIMIS.
Joint Working Project Description

The overall aims of this project are to:

  • Identify patients at high risk of Familial Hypercholesterolemia (FH), evaluate medications, educate and treat patients with the sole aim of reducing excess coronary heart disease risk and premature mortality associated with Familial Hypercholesterolemia (FH).
  • Increase the utilisation of the genetic screening programme across the AHSN footprint through better patient identification.
  • Improve the patient experience by providing more specialist care within primary care and ensure better utilisation and more appropriate referrals to the specialist service base with the NHS Trust.

To develop a Familial Hypercholesterolemia (FH) service model which can be scaled up nationally.

Expected Outcomes

The expected outcomes from this project are as follows:

  • A written document to inform the treatment of Familial Hypercholesterolemia (FH) patients in primary care including information on implementing patient identification using a Familial Hypercholesterolemia (FH) patient identification tool and clinical review at a practice level.
  • A toolkit to include training materials on Familial Hypercholesterolemia (FH) and its treatment for healthcare professionals in primary care and the use of the Familial Hypercholesterolemia (FH) patient identification tool.

The project incorporates the principles of improved patient education, medicines optimisation and treatment close to home.

UKIE-NPC-145-0318-062450 February 2018



Title REDUCING CVD EVENTS BY OPTIMISING CHOLESTEROL MANAGEMENT FOR HIGH RISK PATIENTS IN THE NORTH WEST COAST REGION
Organisations Involved Amgen Limited and Innovation Agency NWC
Joint Working Project Description

The aim of the Project has been designed to support the delivery of the NHS CVD aspect of the Long-Term Plan.

The focus will be to improve cholesterol management, in patients who are at a high risk of a CVD event or a further CVD event, to within parameters set by NICE guidelines with a focus on three areas:

  1. Support the clinical priority to reduce the number of CVD events.
  2. Ensure where appropriate, interventions are conducted in primary care by MDT teams within a primary care network (“PCN”) footprint.
  3. Use of population health analysis to identify cohorts of patients who are most in need of an intervention.
    Expected Outcomes

    Patients with persistently high cholesterol levels who are identified as high risk for a CVD event or a further CVD event will be reviewed and managed optimally, as per NICE guidance CG181 AND CG71.

    Audit tools, treatment and referral pathways as well as Primary Care upskilling to build on current management of Cholesterol will be reviewed with an expected reduction in CVD events as a direct result of optimising cholesterol levels in the practices involved in the project.  

        UKIE-NPC-145-1219-080406a January 2020