The ruleset lays out how General Practice systems should search for specific clinical information in patient records. Firstly, the searches look for patients who already have cardiovascular disease and then filter out those whose lipid control is good; they then find those who have had difficulties with or have not wanted lipid lowering therapy in the past so that clinicians can consider what next steps to take, including offering one of the newer therapies.
For the remaining patients the searches then determine which of the available treatment options (several high intensity statin and other non-statin alternatives) may be suitable, taking into account relevant factors such as allergies, current lipid levels and kidney function. The end result is a list of patients for each group of possible treatment options which can be used by practices to review patient records and then call patients for review.
The cohorts of patients fall into several groups:
These are 3 cohorts that do not need further action as subsequent cohorts are subsets for action.
1. Patients with pre-existing cardiovascular disease: some of these patients may need further lipid management (LMREG).
2. Lipid management cohort: this is the group who need further management of their lipids (LMCX003).
3. Non-statin treatment cohort: this contains patients who are clinically eligible for non-statin treatments (LMCX015).
Cohorts for further action
Each cohort is mutually exclusive, for example a patient would only be included in one.
4. Patients with no recent lipid levels who need testing then running through these searches again (LMCX001).
5. Patients with good lipid control who need annual review (LMCX002).
6. Patients who have a reason not to have lipid lowering therapy - declined/contraindicated/not indicated/on maximum therapy. These patients are likely to have had problems with, or not want, statins so should be considered for non-statin therapy LMCX004, 010-012, 017).
7. Statin treatment cohorts: these identify patients who may be eligible for high dose statin treatment, or as high as renal function allows (LMCX005-007, 0018).
8. Patients eligible for the four types of non-statin treatment. Each cohort identifies patients who may be eligible for one or more of the four non-statin treatments in addition to those who appear not to be eligible for any (LMCX008, 019-040).
Patients identified as having suboptimal lipid control may include those with a reduction of non-HDL-C of >40% from baseline (national guideline target), as it cannot reliably be determined automatically which preceding value in a computerised record should be designated the baseline. The alternative national guideline thresholds for when there is no non-HDL-C value are therefore applied.
The national guidelines do not address patients refusing lipid management therapy so a common-sense approach was taken on managing repeat and non-repeat refusers and to suggest that they are still offered therapy, particularly as most will have declined only statins in the past.
'Adverse reaction', 'contraindicated' and 'not indicated' are recorded in general practice systems with very variable meanings or intentions and may be only temporary. Therefore, some patients with such codes are included in cohorts with the intention that the clinical assessment process will check the meaning and accuracy of these record entries.