Evaluation of a cardiovascular disease opportunistic ...

Journal of Public Health | pp. 110 –116 | doi:10.1093/pubmed/fdp092

Evaluation of a cardiovascular disease opportunistic risk assessment pilot (‘Heart MOT’ service) in community pharmacies J.M.P. Horgan1, A. Blenkinsopp2, R.J. McManus3 1

NHS South Birmingham, Trust Headquarters, Moseley Hall Hospital, Alcester Road, Moseley, Birmingham B13 8JL, UK Medicines Management, Keele University, Staffordshire ST5 5BG, UK 3 Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK Address correspondence to Jonathan Horgan, E-mail: [email protected] 2

A B S T R AC T

and internationally. This study evaluated a targeted cardiovascular (CVD) assessment pilot in 23 community pharmacies in Birmingham, UK. Methods The CVD risk assessment service used near-patient testing and the Framingham risk equations administered by pharmacists to screen clients aged 40– 70 without known CVD. Outcomes assessed included volume of activity, uptake by deprivation and ethnicity and onwards referral. Results Complete data were available for 1130 of 1141 clients; 679 (60%) male, 218 (19%) smokers and 124 (11%) had a family history of CVD. Overall, 792 (70%) of clients were referred to their general practice: 201 (18%) at CVD risk of 20% or more, remainder with individual risk factor(s). Greater representation from Black (7.4%) and Asian (24.8%) communities and from average and less deprived quintiles than the affluent and most deprived was observed. Conclusions Community pharmacies can provide a CVD risk assessment service in a UK urban setting that can attract males and provide access for deprived communities and Black and Asian communities. A pharmacy service can support GP practices in identifying and managing the workload of around 30% of clients. Keywords circulatory disease, health services, screening

Introduction Cardiovascular disease (CVD) is the leading cause of death and disability worldwide.1 Premature CVD in the UK is significantly increased in men as well as in those with low social status and higher deprivation.2 Reducing cardiovascular morbidity and mortality is a key policy objective within the NHS and has been the subject of both a National Service Framework3 and a recent NICE guidance.4 Cardiovascular risk assessment and associated lifestyle advice and treatment have been adopted as part of this strategy.5,6 Such risk estimation is typically undertaken in general practice, but some groups of the public rarely visit their GP, so novel strategies to identify such individuals are required.7 One of these is the provision of CVD risk assessment

through community pharmacies which has been adopted as part of the national vascular risk screening programme.5 Community pharmacies in the UK combine retail over the counter pharmacy services with NHS commissioned services. There are 251 pharmacies in Birmingham, UK, and following service accreditation requirements in the new NHS pharmacy contract in 2005, an increasing proportion include a private patient consultation area suitable for health promotion activities, including cardiovascular risk assessment, smoking cessation advice or supply of emergency hormonal contraception.8

J.M.P. Horgan, Head of Medicines Management A. Blenkinsopp, Professor of the Practice of Pharmacy R.J. McManus, Professor of Primary Care Cardiovascular Research

110

# The Author 2009, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

Downloaded from http://jpubhealth.oxfordjournals.org/ by guest on August 29, 2016

Background Cardiovascular risk-based screening is proposed as a key intervention to reduce premature cardiovascular disease (CVD) in the UK

E VA LUAT I O N OF A C V D O P PO RTU N I S T IC R I S K A S S E S S ME N T P ILOT

Methods Setting

The study was conducted in Birmingham, UK, an area with significantly poor health and deprivation indicators (in the lowest 20% nationally).11 Following consultation with local stakeholders, a consortium including local health and government organizations commissioned a community pharmacybased cardiovascular risk assessment pilot service. The service had the particular aim of targeting men at high risk of CVD not otherwise engaged by the health service and started in November 2006. The following criteria were used to choose and invite pharmacies to become service providers: their interest to deliver the service, previous experience of CVD risk assessment, staffing levels, agreement to service specification and quality assurance requirements, suitable premises (including a private consultation area) and geographical location in or near to areas of deprivation. The service was branded as the ‘Heart MOT’ with a marketing strategy designed to appeal to males. The service was made available for both male and female clients. A number of methods were used to market the service to clients including posters and leaflets for pharmacies to display, a website, a centralized telephone number to support access and postal campaigns including a Valentines day heart themed mail shot. Pharmacies were encouraged to conduct their own marketing and to target this to men who may be visiting the pharmacy.

Population

Inclusion criteria for the service were people aged 40 –70 years, eligible for primary prevention of CVD who consented for sharing of identifiable information with their GP and anonymized information for evaluation. Those prescribed any existing CVD medication or who had been recently screened for CVD by their GP were excluded.

Intervention

Cardiovascular risk factors, including blood pressure, nonfasting cholesterol/HDL cholesterol ratio, smoking and diabetic status, were measured in order to calculate a 10-year cardiovascular risk score using the Framingham equations.6 Anonymized data were entered into a secure web-based database for evaluation purposes. All patients received written and verbal advice from the pharmacist. Where overall CVD risk or an individual risk factor warranted further investigation, individuals were referred to their GP using a protocol based on national recommendations.12 Referral criteria are reproduced in Table 3. Patients identified as at ‘medium’ or ‘low’ risk of CVD were signposted where appropriate to local exercise, dietary, smoking cessation or other lifestyle advice services. Postcodes were used to identify the index of multiple deprivation (IMD) score for each client. IMD 2007 provides a method to compare clients in terms of a single score identified from a range of deprivation indicators. All patients provided signed consent to undergo cardiovascular risk screening and to the use of anonymized data for evaluation. The local ethics committee considered that as a service evaluation using anonymized data, ethical approval was not required.

Results The current paper concerns 1141 people who attended the 23 participating pharmacies between 1 June 2007 and 31 March 2008. Complete risk factor data were available for 1130 (99%). Analysis confirms that screening results were not completed due to identified family history excluding clients from the screening tests or the patients being unregistered with a GP. Four clients were not registered with a GP. It was possible to calculate deprivation indices for 996 (87%) with the remainder missing accurate postcodes. Fifteen (65%) of the pharmacies were from large or medium size national multiple pharmacy companies and eight (35%) of the pharmacies were small chain or independently owned. The location of pharmacies providing the


A systematic review of community pharmacy-based interventions for coronary heart disease found few studies of cardiovascular risk assessment: in the small number of studies reviewed, services were either open access or case finding using pharmacy-based patient medication records (PMRs) to identify patients to invite for testing.9 The former may duplicate effort with general practice as confirmed by Earle et al.’s10 study of open access blood pressure testing in six North London pharmacies which found that the majority of patients identified (79%) had previously diagnosed hypertension. Similarly, using pharmacy PMRs can identify only those patients with known risk factors or CVD and may still duplicate work with general practice. The current study aimed to investigate a targeted pharmacy-based CVD risk assessment service for primary prevention aiming to evaluate service feasibility, assess effectiveness of identifying at-risk individuals and of reaching disadvantaged groups and measure referrals from the service to local general practices.

111

112

J O U RN A L O F P U B L I C H E A LTH


Fig. 1 Distribution of participating pharmacies by IMD 2007 by quintiles.


Table 1 Population characteristics (n ¼ 1141) Characteristics

113

Table 2 Risk factors and cardiovascular riska

Population, n (%)

Mean (+95% CI) Systolic blood pressure

129.9 mmHg (+128.8, 130.9)

679 (60%)

Diastolic blood pressure

80.4 mmHg (+79.7, 81.0)

Female

451 (40%)

Total cholesterol

5.5 mmol/l (+5.4, 5.6)

Smokers

218 (19%)

Random blood glucose

6.0 mmol/l (+5.9, 6.1)

Unregistered with a GP

4 (0%)

Body mass index (BMI)

28.4 kg/m2 (+27.6, 29.2)

Waist circumference

90.0 cm (+89.0, 91.0)

Male

Ethnicity Black

84 (7%) (Birmingham 6%)a

Mean CVD riskb

11.6% (+11.0, 12.2)

Asian


Proportion with high CVD risk 20%

201 (17.8%)

White


Proportion with medium CVD risk

353 (31.2%)

Others


10– 19.9% Proportion with low CVD risk ,10%

Index of multiple deprivation for Birmingham

22

576 (51.0%)

Quintiles

(IMD 2007) (n ¼ 996)

a

Affluent

174 (18%)

Less affluent

178 (18%)

Average

210 (21%)

Less deprived

248 (25%)

Most deprived

186 (19%)

Unable to categorize

145b

Census 2001.23

a

b

Clients outside Birmingham or unable identify IMD.

service is shown in Fig. 1. Most were in or near areas in the most deprived or second quintiles. Table 1 presents the characteristics of clients using the service. Sixty per cent (679) of the clients screened were males and 20% were smokers. The majority were white (65%) with a slightly greater proportion from the third and fourth (average and less deprived) IMD quintiles for Birmingham, compared with both the most affluent and the most deprived quintiles. Mean risk factor data are presented in Table 2. The mean blood pressure was 130/80 mmHg and mean random blood glucose was 6.0 mmol/l. One in four people using the service was overweight (mean BMI 28 kg/m2, mean waist circumference 90 cm). Mean CVD risk was calculated at 11.6%. Raised 10-year cardiovascular risk of .10% was found in half, of whom 201 (17.8%) warranted general practice referral for a risk above 20%. The numbers of clients who were referred to their general practice are shown in Table 3 together with the primary reason for referral. Of the 70% of clients referred to their GP, 53% had either one or two risk factors. Raised blood pressure and total cholesterol were the main reasons for referral. There was a wide variation in the number of assessments carried out by each pharmacy during the 10-month period

Ten-year CVD risk calculated using the Framingham equations.

Table 3 Referrals to general practice (n ¼ 1130) Referral Criteria

Number (%)a

BP .140/90

370 (32.7%)

Cholesterol 6 mmol/l

340 (30.1%)

TC:HDL ratio 6

296 (26.2%)

Blood glucose ,4 or .10 mmol/l

34 (3%)

High CVD risk 20%

201 (17.8%)

Raised BMI 30 kg/m2 or a waist circumference

277 (24.5%)

of 88 cm (women) or 102 cm (men) Family history of CVD

124 (11.0%)

One or more of the above

792 (70.1%)

a

Clients could be referred for more than one risk factor.

ranging between 1 and 193. The median number of assessments per pharmacy in the 10-month study period was 35 (inter-quartile range 20 – 73). The mean number of assessments per pharmacy was 4.9 per month.

Discussion Main findings of this study

To our knowledge, this is the first study of a targeted pharmacy-based CVD risk assessment service for primary prevention. The study demonstrates that delivery of a one-stop cardiovascular risk assessment service by community pharmacies is feasible in the setting of a large city in the UK and identifies an appreciable number of individuals—around two-thirds of those screened—for


Based on 1130 clients evaluated.

b

114


whom intervention for cardiovascular risk or an additional risk factor is indicated. The majority of clients were men for whom attendance at general practice is known to be low13 and some success was had in targeting people from more deprived areas and with a minority ethnic background.

screened population with greater deprivation and ethnic diversity likely from the Grayland and Wilson screening frame.

What this study adds What is already known on this topic


There are few examples of community pharmacy-led cardiovascular risk assessment in the published literature. A systematic review by Blenkinsopp et al.9 of research conducted up to 2001 found that some previous studies used ‘case finding’ from the pharmacy computer system to find patients suitable for cardiovascular screening services or for improving medication management with CVD monitoring. In studies published since the systematic review, high-risk individuals were targeted in a US study by Snella14 and a UK study by Joubert and Choo,15 while Hourihan et al.16 evaluated an open access service in rural Australia. In contrast, the current study focused the service only on clients without previously diagnosed CVD and used targeted marketing and geographical location of premises to attract appropriate members of the public. The preferential uptake by men found in the current study is in contrast to previously published data on pharmacy-based tests: Lloyds pharmacy reported on their free pharmacy-based health monitoring services in the 2 years up to 2005.17 They found that twice as many women as men used their non-NHS services of 225 000 blood pressure tests and 550 000 blood sugar tests in the UK.17 A national survey of 1500 members of the general public found that fewer men use the pharmacist or pharmacy for health information than women (24% versus 41%).18 Grayland and Wilson19 have reported on a large-scale screening programme in community settings (such as football grounds and other venues) of 9200 men aged 40 years or over in Birmingham, UK. Invitations were sent by telephone and letter to males not on general practice CVD disease registers in 11 wards to attend large-scale screening events. The assessments identified 36% of patients with high CVD risk (18% in the current study). Similar results were obtained for raised blood pressure (30% versus 33% of clients in the current study) and cholesterol levels (35% versus 30%, respectively), but more clients were found to have high blood glucose levels (18% versus 3%). These differences maybe explained by a number of factors: different referral thresholds, the inclusion of men and women in the ‘Heart MOT’ study compared with men only in the Grayland and Wilson study and finally differences in

It is important to consider the findings from the current study in the context of the new national vascular risk assessment (VRA) programme for England.5 Service commissioners will need to consider the contribution that different service providers could make. For many commissioners, a general practice-based service in which people are invited to attend may seem an obvious choice. This study has shown that community pharmacy-based screening is feasible across a range of providers including both large pharmacy chains and independently owned pharmacies. The question then is what community pharmacy-based VRA might usefully add. The national survey by the Reader’s Digest and Proprietary Association of Great Britain found that people from deprived social communities use pharmacy more frequently than those from more affluent communities.18 Community pharmacy has unique characteristics to support community-based health testing services. Pharmacies may be perceived by the public as a less ‘medical’ model with easier access, compared with GP surgeries, for ‘well people’ who are interested in finding out more about their health. Pharmacy premises are located in a wide range of settings to support access by different types of communities. Some are in deprived areas or are part of prime retail environments from which proactive marketing can be used to attract target groups of the public. These attributes are likely to have increased the proportion of both men and minority ethnic populations screened. There have been recommendations for pharmacies to adopt social marketing techniques to deliver lifestyle changes and public health campaigns.20 Jesson20 has argued that pharmacies will be able to target these to deprived communities. This study may support that view. The ‘Heart MOT’ service used some of the key principles of social marketing including a defined market (males within an age range), and a number of marketing techniques to attract clients, for example, direct engagement in pharmacies, themed mailings and branding designed to appeal to men. However, a true social marketing approach was probably not delivered as these marketing techniques were developed with limited consumer needs assessment and consumer feedback. Later evaluation on the service has identified better information about the effectiveness of some of these marketing techniques.21


It is impossible to say how many of the clients who used the pharmacy service would have responded to a direct invitation to attend their GP surgery had that been offered. However, access is a key attribute of community pharmacy: opening hours tend to be long and the range within this pilot covered 7 days a week with late evening opening. A major UK survey found that the public use pharmacy as a health information and advisory source and that people in relatively more deprived social classes use pharmacies more frequently compared with the more affluent.18 This supports the notion that pharmacy can develop services that could be proactively marketed to those patients in the most deprived communities.

The main strength of this study is that it provides data from a large group of individuals who chose to attend a community pharmacy for CVD risk assessment. However, data were only collected for those attending a CVD risk assessment and so do not include people who requested a test or expressed an interest but were not subsequently tested. It is possible that some clients were not assessed because the pharmacy was already fully booked with tests that week or trained staff were unavailable and the client did not return. The Framingham equation was used in the risk assessments as recommended by the relevant NICE guideline for cardiovascular risk assessment.4 It is recognized that these equations may overestimate risk in the UK population in general while underestimating risk in those from deprived populations or who are at the highest risk. Newer risk calculation tools may prove to be more accurate in the future, but at the time that this study was undertaken, Framingham was considered the most appropriate choice. There were a small proportion of missing data, particularly with regard to deprivation; however, given that the vast majority of those screened had full data sets, this is unlikely to have impacted on the overall results. A further limitation of this study is that it could only evaluate cardiovascular risk assessment in community pharmacies with no comparison of results with primary prevention efforts in other primary care settings. Although 30% of clients were assessed through pharmacies without the need to attend their GP surgery, 70% required referral to their GP and data are not available regarding the consequences of such referral, including the number of clients who were retested by their GP or the proportion that actually attended. Similarly, there are no data to confirm that clients signposted to other services such as smoking cessation or obesity services actually attended. The integration of pharmacy-based risk screening

with other primary care services would be important if such screening was rolled out on a wider scale, for example, through the National Vascular Screening Programme. The study demonstrates that pharmacies can attract clients from deprived populations when positioned within these geographical areas. The study results do not tell us what would have happened if the pharmacies had been spread equally across socioeconomic areas. In this scenario, as more affluent communities tend to access health promotion services, it is likely given similar marketing that uptake of the service would be greater by more affluent populations than deprived. Care should be taken when commissioning this type of service to ensure that it does not worsen health inequalities. Only four clients presenting for the service were not registered with a GP. This figure is likely to be lower than the actual number because in the planning stages, the presentation of unregistered patients was not expected. A consistent method to record them was thus not implemented until some months later. Prior to this, patients would not have been assessed as they could not consent to sharing the information with a GP. The fact that four clients who were unregistered with a GP did present for the service demonstrates that there would be opportunity to target this to greater numbers of unregistered clients. The effectiveness of pharmacy to engage clients who are unregistered would be worthy of further study and it would be interesting to identify what types of marketing might best be used for this client group. The study did not include an economic analysis which would be important to include in further research now that feasibility is established. The contract price of the intervention was £10 per client assessed which is low but excludes the set up costs, pharmacy overhead costs, equipment, marketing and NHS management costs. Furthermore, onwards referral and repeat testing could conceivably increase costs further. There was a wide variation in the volume of activity by the individual pharmacies with a mean of five assessments per month and a range of total number of clients assessed from 1 to 193 per pharmacy over the 10 months. Influencing factors may have included the effectiveness of the local advertising by the pharmacy to the public and internal pharmacy issues such as the number of trained staff or availability of the consultation room (for example, where the pharmacy provided other services requiring its use). Attempts to identify pharmacies that can deliver a high volume before commissioning similar services will be important for commissioners. This may be possible with a more systematic assessment of each pharmacy prior to contracting the service to include staffing levels compared with


Limitations of this study

115

116


all other services provided and an assessment of a marketing plan for the service by the pharmacy. It is likely that there has been a clustering of risk assessments around those pharmacies who delivered the greatest volume of activity. All pharmacies were chosen based on their geographical location within or near to deprived areas, so greater uptake by some pharmacies should not affect the outcomes by deprivation.

Conclusion

Acknowledgements The authors wish to thank all the staff at participating community pharmacies for their support, Birmingham Health and Wellbeing Partnership and Heart of Birmingham tPCT, Birmingham East and North PCT and NHS South Birmingham.

5 Department of Health. Putting prevention first. Vascular checks: risk assessment and management. 2008. 6 Anderson KM, Odell PM, Wilson PW et al. Cardiovascular disease risk profiles. Am Heart J 1991;121:293– 8. 7 McManus R, Mant J. Commentary. Community pharmacies for detection and control of hypertension. J Hum Hypertens 2001;15:509 – 10. 8 Department of Health. Pharmacy in England: building on strengths—delivering the future. 2008. 9 Blenkinsopp A, Anderson C, Armstrong M. Systematic review of the effectiveness of community pharmacy-based interventions to reduce risk factors for coronary heart disease. J Public Health Med 2003;25(2):144 – 53. 10 Earle KA, Taylor P, Wyatt S et al. A physician – pharmacist model for the surveillance of blood pressure in the community: a feasibility study. J Hum Hypertens 2001;15:529 – 33. 11 Noble M, McLennan D, Wilkinson K et al. The English Indices of Deprivation 2007. London: Communities and Local Government, 2008. 12 JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. 2005;91(Suppl V):1 – 52. 13 Men’s Health Forum. The gender and access to health services study. Final report.Department of Health, 2008. 14 Snella KA. Pharmacy- and community-based screenings for diabetes and cardiovascular conditions in high-risk individuals. J Am Pharm Assoc 2006;46(3):370– 7.

Conflict of interest: J.M.P.H. manages a PCT service which includes community pharmacy-based CVD provision.

15 Joubert F, Choo G. Developing a coronary heart disease service from a community pharmacy. Int J Pharm Pract 2003;11(Suppl):R80.

Funding

16 Hourihan F, Krass I, Chen T. Rural community pharmacy: a feasible site for a health promotion and screening service for cardiovascular risk factors. Aust J Rural Health 2003;11:28– 35.

The Birmingham and Wellbeing Partnership funded the screening pilot and evaluation. R.M. is funded by an NIHR Career Development Fellowship. No funder had a role in the study design, analysis, or interpretation of data; in the writing of the report or in the decision to submit the paper for publication.

17 Pharmaceutical Journal (PJ). News. More women than men get their blood pressure checked. Pharm J 2005;274:698.

References

20 Jesson J. Creating a demand for better health by using social marketing techniques. Pharm J 2007;278:776.

1 Sproston K, Primatesta P. Health Survey for England 2003. London: Stationary Office, 2004. 2 Preventing Chronic Disease: A Vital Investment. Geneva: World Health Organisation, 2005. 3 Department of Health. National Service Framework for Coronary Heart Disease: Modern Standards and Service Models. London: The Stationary Office, 2000.

18 Reader’s Digest and Proprietary Association of Great Britain (PAGB). A picture of health. A survey of the nation’s approach to everyday health and wellbeing. London: Reader’s Digest Association Ltd, 2005. 19 Grayland J, Wilson R. Improving male life expectancy in Birmingham. Public Health 2008, doi:10.1016/j.pubh.2008.10.029.

21 Horgan J, Blenkinsopp A, Spencer-Jones C. Patient feedback on the ‘Heart MOT’: a community pharmacy cardiovascular risk assessment service. IJPP 2009; Suppl 2:B37. 22 Office of Deputy Prime Minister (ODPM). The English Indices of Deprivation 2007. London: The Stationary Office, 2007. 23 Office of National Statistics (ONS) Census. 2001.


Targeted cardiovascular risk assessment can be successfully provided through community pharmacies widening access and choice, particularly for men and people in deprived communities. Referral of those screened onto general practice was high, and so further research is needed to investigate the cost-effectiveness and public satisfaction of such a service.

4 National Institute for Health and Clinical Excellence (NICE). Clinical Guideline 67. Lipid Modification Cardiovascular Risk Assessment and the Modification of Blood Lipids for the Primary and Secondary Prevention of Cardiovascular Disease. 2008.