CV risk assessment — is it worth investing?

Preventative healthcare currently presents community pharmacists with an opportunity to expand their service range and engage the public in taking measures to improve their health.

One area of interest is cardiovascular risk assessment.

This article describes the financial considerations that need to be addressed before setting up such a service.

Variables to measure

British guidelines recommend that to determine a patient’s 10-year risk of suffering a cardiovascular event, a healthcare professional would need to measure or determine:

• Total cholesterol (TC)
• High-density lipoproteins (HDL)
• Blood pressure
• Smoking status

In addition, blood glucose is often measured to screen for undetected diabetes and can be done at minimal additional cost.

Low-density lipoprotein (LDL) and triglyceride levels can be measured to identify conditions such as the metabolic syndrome. But measuring these factors is not needed to calculate a 10-year cardiovascular risk, so they might be considered as optional extras for patients who would like a complete assessment.

Equipment

Cardiovascular risk assessments should be carried out by trained staff using calibrated equipment that is approved by the Medicines and Healthcare products Regulatory Agency, says Michael Livingston, director of Heart UK, a charity that raises awareness of the risks of high cholesterol.

Cholesterol and glucose Some examples of the unit cost for monitors that measure both cholesterol and blood glucose are listed in Panel 1. Several monitors measure TC, but those that also measure HDL are less common and considerably more expensive.

Blood pressure There are many blood pressure monitors on the market and their quality varies. Your local GP or district nurse may offer advice about which brands of blood pressure monitor are the most reliable.

Consumables

Every monitor that performs a blood test requires a consumable piece of apparatus or test strip to perform each test. The cost of these consumables varies between products, and should be checked before purchasing the machine. Some example costs are shown in Panel 1

In addition to the testing apparatus, a lancet is needed to obtain the blood sample, and cotton wool or plasters are needed after the sample is taken. These cost 40–50p per test.

Blood pressure monitors operate at no consumable cost. A pharmacy may choose to offer blood pressure checks free of charge as a method of engaging the public in health awareness.

Disposal services

Taking blood samples for measuring cholesterol creates both sharps waste and soft tissue waste, says John Foreman, pharmacist and partner at Green Light Pharmacy, London. Green Light Pharmacy currently provides a cardiovascular risk assessment service in all of its branches, and Mr Foreman points out that this service requires additional disposal arrangements.

Green Light uses Cliniserve to dispose of clinical waste, which charges around £20 per collection (usually done every three months) and £10 per bin collected.

Insurance

Pharmacies that are insured by the National Pharmacy Association are covered to provide services that require taking blood samples. However, any pharmacy that starts providing a service that involves taking blood samples needs to inform the NPA of this.

Any pharmacies that are insured through other companies would need to contact their insurance provider to determine whether an additional insurance premium is required.

Staff vaccinations

Members of staff who handle blood samples require vaccination against hepatitis B, which is available through the NHS. However, Mr Foreman points out that staff would need time off work to be vaccinated. Consequently, a pharmacy proprietor may choose to pay for vaccinations to be done “in house”.

Writing and updating protocols

Guidance for setting up a service and writing standard operating procedures is available from the Royal Pharmaceutical Society and the National Pharmacy Association. Procedures also need to be reviewed and updated regularly.

“The clinical management of such a service takes up a lot of time because clinical guidelines are constantly being updated. I would recommend reviewing your procedures at least once a year,” says Mr Foreman.

Society guidelines recommend that consent is obtained from the individual before results are passed to the GP. Any individual who is identified as being at high risk of suffering a cardiovascular event but refuses such consent should be advised to seek medical advice.

Funding

Potential methods for funding a service will depend on local arrangements and demographics. As described in the January issue of Retail Round-up (p1), local residents may be willing to fund the service privately. Alternatively, the primary care trust, who may be under political pressure to develop preventative healthcare services, may be willing to commission the service.

Another possibility is local authority funding. Green Light Pharmacy is a partner in a community project in West Euston, London, entitled the Healthy Community Project. The project is overseen by the local council and run by the PCT, a medical centre, Green Light Pharmacy and a voluntary community group. The project has received part of its funding from a National Lottery grant.

Is it worth it?

Mr Livingston emphasises that people using a cardiovascular risk assessment service should receive a copy of the test results and personal action plan. It is estimated that this process takes 15–20 minutes. However, this does not have to be all done by the pharmacist, provided the support staff are suitably trained.

Primary care trusts that already commission this service pay between £25–£35 per patient. Considering the current political climate, pharmacy proprietors would be well advised to investigate further.