Background:

Raised cholesterol remains a key modifiable risk factor for cardiovascular disease (CVD), including heart attack, stroke and peripheral vascular disease. Dyslipidaemia frequently co-exists with other co-morbidities such as hypertension, obesity, diabetes, auto-inflammatory disease, chronic kidney disease, etc., contributing to cumulative cardiovascular risk.

Serum cholesterol vs HDL ratio, alongside other risk factors, is used to calculate an individual’s QRISK3 score, estimating their 10-year risk of a cardiovascular event. Evidence-based lipid-lowering therapies and lifestyle interventions can significantly reduce this risk.

In Mid and South Essex, lipid optimisation remains a system priority. Performance against national QOF indicators highlights significant opportunities to improve outcomes for patients with established CVD. 

Aim:  

To support primary care in identifying, risk stratifying, and engaging patients most at risk of cardiovascular disease who may benefit from improved lipid management, while supporting delivery of NICE guidance and QOF priorities. 

Objectives:

• To identify patients at increased cardiovascular risk who may benefit from lipid lowering therapies.

• To support review and optimisation of cholesterol management in patients with and without established CVD.

• To improve recording of key cardiovascular risk factors, including cholesterol levels, BMI, smoking status, and QRISK3 score.

• To support patient engagement with lifestyle interventions and appropriate lipid-lowering therapies.

• To support primary care in maximising QOF performance, particularly for secondary prevention indicators.

• To screen, identify and manage patients with possible (familial) hypercholesteremia.

Project overview:

All participating Primary Care Network (PCN) colleagues and practices will gain access to their region’s tailored ECLIPSE lipid pathways, including their lists of eligible patients cohorted according to the following methodology:  

Cohort:

Patients aged 40 years and over who meet one or more of the following criteria:

• Primary prevention: Patients without established CVD who have an elevated QRISK3 score, and who may benefit from lipid-lowering intervention.

• Secondary prevention: Patients with a coded history of cardiovascular disease (e.g. heart attack, stroke, peripheral arterial disease) who are not currently optimised to NICE guideline-recommended lipid targets.

Patients will be grouped into lipid optimisation pathways and allocated to intervention groups according to their clinical profile and indicative management needs.

Patient lists can be filtered by factors such as CKD status, deprivation level, age, ethnicity, and gender, enabling PCN and practice teams to prioritise specific demographics and address health inequalities specific to their local area.

Patient engagement – PEGASUS:

For enhanced support, PCNs can opt into the PEGASUS-led stream of patient digital engagement, which enables Eclipse to directly contact patients on behalf of the practice.

PEGASUS (Patient Engagement Governance Assuring Standardised Utilisation of Services) is a centralised, digital-first engagement model designed to improve uptake and equity of access.

Through PEGASUS, Eclipse will directly engage with patients to:

• Inform and educate patients about cholesterol, QRISK3, cardiovascular risk, lifestyle and lipid-lowering therapies.

• Capture additional risk factors via a dynamic questionnaire.

• Assess openness to lifestyle support and treatment options.

• Gain consent for initiating lipids medication, where appropriate

• Support non-responding or digitally deprived patients by expert telephone engagement from the ECLIPSE Virtual Support Team (VST).

Engagement Models: