Lipid management searches

NHS Digital have developed a lipid management search tool, which will support clinicians in General Practice by allowing them to proactively identify patients who may benefit from a treatment intervention, or a review in line with NICE guidance. 

This search tool is designed to be an additional resource to help optimise patient care in lipid management. It is a search tool providing an additional “tool in the toolkit” for primary care, however there is no mandate or direction that clinicians must change or deliver treatment. Any decision to progress with treatment will be after a clinical assessment and must be based upon a clinician’s decision about their patient.

The search support tool is based on primary care system information and uses a specific ruleset which can be run against patient records. This will provide clinicians with a list of patients with sub-optimal lipid levels despite current treatment, who would benefit from a lipid management review. Utilising specific criteria, clinicians will also be able to generate reports to identify different patient cohorts where there is a clear, unmet need for additional treatment options.  

These searches are designed to support practices in the management of patients with pre-existing cardiovascular disease whose lipid control is suboptimal, in accordance with national guidelines. They produce a series of patient cohorts which can be used for reviewing patient records and/or calling patients. 

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:

Headline cohorts

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).

Additional notes

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.

Lipid management searches are intended to support clinicians and help to provide better patient outcomes. Use of the tool is not mandatory, and it's an additional resource for healthcare professionals within primary care. 

Prevention is at the heart of the NHS Long Term Plan, with cardiovascular disease (CVD) highlighted as a central clinical priority. The Long-Term Plan calls for a focus on the identification of patients living with high-risk conditions such as atrial fibrillation, high blood pressure and high cholesterol. The LTP aims to prevent up to 150,000 heart attacks, strokes and dementia cases over 10 years (by 2029) by improving the treatment of these high-risk conditions.

Within secondary preventative actions, review and optimisation of lipid management treatment and care is a central part of helping patients reduce their risk of further cardiovascular events and tackle health inequalities. Large outcome trials have confirmed the benefit of cholesterol lowering therapies, however there is still a considerable variability in response of individuals to these medications, even when being treated with a high intensity regime.

Primary care has a crucial role in preventative medicine and tackling health inequalities; ensuring that a local approach is accessible to many people is one of the most effective ways of preventing further CVD events. 

The Lipid Management search ruleset has been developed with clinicians and piloted in General Practices using TPP, EMIS, and Cegedim systems. These pilots have all returned results which have been deemed accurate by clinical consensus. 

A) Accuracy of numbers in cohorts

The 3 key cohorts that need validation are:

• LM_REG - Register of cardiovascular disease for lipid management project
• LMCX003 - Lipid management cohort
• LMCX015 - Non-statin treatment cohort

Success criteria:

• LM_REG Cardiovascular disease: consists only of QOF code clusters so has been previously validated. No further check needed
• LMCX003 Lipid management cohort: the numbers in this cohort should equal the sum of the four subsequent individual statin treatment cohorts plus the non-statin treatment cohort
• LMCX015 Non-statin treatment cohort: the numbers in this cohort should equal all the twelve subsequent individual non-statin cohorts.

Where the numbers in LMCX003 or LMCX015 are less than their corresponding additive totals, this would indicate that patients are being wrongly included in a more detailed cohort. These would need investigation on an individual patient basis.

Where the numbers in LMCX003 or LMCX015 are more than their corresponding additive totals, this would indicate that patients are being omitted from the detailed cohorts. 

Given the relatively novel approach, it is difficult to determine an acceptable threshold or range to these data ahead of receipt, and any attempt to do so would be arbitrary. It has been proposed that on final review, the acceptable degree of accuracy will be determined through discussion and clinical consensus. For comparative purposes the difference in numbers described above will be assessed as a percentage of LM_REG Cardiovascular disease register and of LMCX003 Lipid management cohort.

B) Clinical assessment of percentage distribution of patients across cohorts

Clear metrics cannot be applied to this assessment but a review of all pilot data in one chart should make clear if there are any outliers that cannot be explained by expected variables, e.g. a high percentage of patients requiring up to date lipids, or a practice with many patients with excellent lipid control. 

Raise any queries, issues, or feedback about Lipid Management Searches to your supplier (TPP, EMIS, or Cegedim) through the usual routes.

If there is anything they can't help with, they will raise it with the NHS England Lipid Management programme.