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Copyright 2025 - Integrated Care Services Association

The Road Ahead: Communicating post Coronavirus - how the pandemic will shape the way NHS GP practices will communicate and engage in the future - Eastern Voice and Data

VoIP can help a doctor’s office or medical practice stay connected to patients through advanced call routing features and also help reduce overall communication costs

As the UK waits with bated breath for the roll out of the largest vaccination programme in history, the world has been in pandemic mode for close to a year and a half now. During this time, GP practices have had to dramatically change how they provide care for their patients in these unprecedented times. Under NHS guidance, remote consultation (via telephone, online message or video) has been rapidly introduced to replace face-to-face consultation with great success.

The approach to using digital tools in healthcare, largely driven by the NHS long term plan, forcing surgeries into a digital transformation only exasperated by the current pandemic. The ambition of the plan set out to offer digital-first primary care – where patients use online tools to access primary care services remotely by 2023/24. Despite this recent rapid adoption of digital technologies, the healthcare system still remains at the early stages of digital health, with many tools replicating physical methods and the use of outdated communication systems which hinder full transformation, such as the use of traditional ISDN lines.

The ISDN decline

ISDN channels were initially intended to provide end-to-end simultaneous handling of voice and data on a single link and network. However, as technologies have evolved, these channels have struggled to keep up with the rate of change. The increased desire for flexibility is at the heart of the ISDN decline. As of 2025, ISDN will be switched off and those remaining will be required to transfer over to VoIP (Voice over Internet Protocol), a telecommunications technology that’s hosted in the cloud, meaning you can use IP handsets, mobiles, or even a desktop application to make and receive calls.

The benefits to cloud communications

Today, surgeries are having to deal with new-fangled issues, such as virus mutations and a second wave of the virus. Achieving targets like reducing costs, improving communication with patients and increasing efficiency can seem a lesser priority, but a VoIP telephone system can support your surgery’s busiest periods and help put long-term solutions in place to reduce problems for patients and staff alike.

Another major benefit of transferring to the cloud, is the large cost savings when compared to traditional phone services. Cloud based communications eliminate the need to pay up-front for heavy and expensive installation, not to mention the regularly occurring maintenance charges. For many surgeries trying to manage more on less, this reallocation of budget can go along way and make substantial differences that directly impact patient care.

There is also the issue of lengthy patient wait times, which is attracting growing public attention due to the negative effects of waiting patients’ satisfaction levels. This combined with a huge influx of calls in a short timeframe can add real pressure to the running of a surgery, particularly in the morning for same-day emergency appointments. To support those turbulent moments, the flexible suite of tools, such as voicemail, call queuing, call recording, video, email, and automatic attendants, can be modified to meet the individual demands of the industry.

Aside from these benefits, a VoIP phone service fully supports remote and mobile working; GPs and other healthcare professionals can stay connected regardless of location, and a performance dashboard identifies call volumes that assists with the management of service demands.

VoIP is changing the way the medical world stays connected, regardless of the practice size. It provides a plethora of benefits for healthcare professionals by improving interactions and enhancements. By utilising these features, meetings, discussions, and seminars can be set up virtually, anywhere, at any time. It also allows for collaboration with patients and external experts as well as shared ideas, documents and file shares in a secure environment, through a call conferencing tool.

NHS England requirements

As part of the migration to cloud communications NHS England set out a series of regulations which surgeries and practices must comply with, these include:

  • Is the solution based externally in the Cloud?
    Hosted telephony is where phone systems are cloud-based, rather than taking up valuable space and resources in an office.
  • Does the solution integrate with the clinical system to make outgoing calls?
    Hosted telephony can integrate with industry-specific CRMs, can keep a record of call history and interactions with patients, as well as screen-pops on inbound calls to create a sense of customer service and care when answering calls.
  • Can I access outside practice premises to make outgoing calls?
    Take your surgery line with you wherever you go. With our hosted phone system, you can easily manage calls, video conferences, instant messaging and online meetings from any location.
  • Does the solution have features which manage peak demands?
    Our hosted telephony solution has a built-in receptionist console which helps reduce the time it takes for a call to come in and be transferred to the necessary department or individual. There are also features such as auto attendant, call queuing and statistic analysis to help your team plan and prioritise.
  • Does it meet the current needs of our surgery?
    It’s easy to add and manage users in minutes. No fixed hardware means connecting employees instantly, so you can scale up and down to suit your business needs. And, you can add and remove features as and when you need them to support you through the busiest moments.
  • Does it have visibility over wait times for patients?
    Our solution allows patient’s calls to be queued at network level before they are delivered to a handset at the practice. Comfort messages can be played too, which will give patients reassurance that their call will be answered soon and provide information such as opening hours.

The solution – Horizon, a cloud-based phone system for your business

Horizon addresses all these needs and more. Designed for surgeries looking to improve productivity, increase collaborative team working and accelerate decision making to better serve patients and healthcare professionals.

For patients the experience is greatly improved instantly, calls can be answered in order, reducing frustration and complaints; less time is wasted on generic calls, as practice staff see a patient’s record when they call through on the ‘phone, and calls can be recorded and associated with the patient record to help GPs’ better understand a patient’s needs.

Simple to use powerful features

Easy to use interface
Horizon provides a broad range of call handling features that are accessed via the web. The dashboard gives you convenient access to information such as your call history, voicemail and recorded calls. Personalised settings are quick and easy to set, ensuring your calls are handled effectively.

Administrator Interface
Horizon provides IT managers with a powerful administrative management capability while giving employees freedom to control calls quickly and effectively. Set up is quick and easy and you can choose to pass down control to the user or you can retain control of the individual user features.

Call Recording
Record inbound, outbound or internal calls for compliance, customer service or audit purposes. This optional feature allows secure online playback and retrieval of call details. Set Horizon to record some calls, all calls or record calls on demand. Pause and resume a recording using the in-call menu option on the Horizon desktop app and certain handsets from the Horizon range of devices. 

Auto Attendant
You can use Auto Attendant to provide callers with call routing options for different areas of the business or create announcements to inform callers of details such as opening hours and website address when the office is closed.

Collaborate
Available as a simple upgrade to Horizon, Collaborate offers instant messaging, presence, voice and video calling with conferencing along with desktop, application and document sharing. Driven through a set of end user applications for Windows, Mac, Android and iOS.

Integrator
Open up even more of Horizon’s capabilities across your desktop with Horizon Integrator, a powerful piece of software that gives you control of your Horizon service from your desktop without having to log in to your Horizon portal. It also provides interaction with key programs such as Microsoft Outlook® and Skype® for Business.

Integrator CRM
Integrator CRM takes the Integrator software a step further. Compatible with over 20 of the top CRM packages including Salesforce and Microsoft Dynamics, Integrator CRM helps users to be even more efficient and productive by providing quick access to contacts and the ability to dial directly from your CRM system.

Call Queuing
Horizon Call Queuing helps you present a professional image to your customers by managing incoming calls effectively and delivering them to groups, as soon as users become available. It’s a low-cost way of managing your incoming calls professionally and provides constant information and choices to callers, reducing the risk of missing valuable incoming calls.

Receptionist Console
Manage incoming calls and call routing to single or multiple sites via a simple, easy-to-use interface. Horizon Receptionist Console adds a low-cost way of managing your key call routing and monitoring of multiple contacts or sites, where this is not achievable through a more traditional phone and sidecar solution. It ensures that every one of your calls is answered professionally and efficiently, improving customer service and increasing business efficiency.

Akixi Management Reporting
Through our partnership with Akixi, the leading hosted call-management service provider, you can now get a data feed for your Horizon service, which will let you export the statistics you need to help manage your business.

  • Instantly see what needs to be changed to improve customer service
  • Monitor time to answer and manage calls more efficiently
  • Analyse internal call patterns
  • See how many calls are being abandoned with the ability to return them
  • Optimise resources by ensuring the right number of operators are always in place

Post COVID-19 future

It is difficult to predict the long-term impact and outcome for working practices, especially in the grips of a global pandemic. The rise of the digital revolution is impacting and changing many aspects of our lives, reshaping industries and transforming many aspects of our healthcare system.

The rapid expansion of technology and digitalisation is going to play a major role in how healthcare is managed on a day-to-day basis. In the last few years there has already been a major shift in how certain aspects of healthcare are managed particularly in relation to cloud based telecommunication, and this trend is likely to continue exponentially in the coming decades.

To meet today’s needs of an ageing population, and to extend geographical reach, health systems will be required to expand their digital options if they want to service these patients and help them track and manage their care outside of the doctor’s office. A VoIP phone system provides a host of productivity features that can enhance the workforce, mobility, improve operational efficiency, and optimise the speed and quality of patient care.

About Eastern Voice and Data

Having provided totally integrated technology to businesses, government bodies and local authorities for over 25 years, Eastern Voice & Data take the hassle out of modernising your technology. Whether you are moving premises, refurbishing or need to upgrade your current Business Telephone system, IT Network, Structured Cabling or changing to a VoIP/Hosted system. They will design the optimum solution based on your needs and budget, using best in breed technology that just works. Their specialist team will handle every aspect of the installation from beginning to end and will train your staff to use the systems, which means you will gain from your investment.

To find out more book your free site visit today - https://www.easternvoicedata.co.uk/contact-us

CCA calls for urgent change to the flu vaccine programme this winter - The Company Chemists’ Association

It is crucial that the government tells the public how to get the flu vaccination this winter. Patients, particularly those at risk from Covid, need reassurance from health care providers. They will need to know that they can get the vaccine from a community pharmacy in a Covid secure environment which is easy to access.

The Company Chemists’ Association (CCA) is the trade association for large pharmacy operators in England, Scotland and Wales. Our members are: Asda, Boots, LloydsPharmacy, Morrison’s, Rowlands Pharmacy, Superdrug, Tesco and Well. Between them, our members own around 6,000 pharmacies representing almost half of the pharmacies in the United Kingdom.

The CCA represents the interests of its members and brings together their unique skills, knowledge and scale for the benefit of community pharmacy, the NHS, patients and the public. Our vision is that everyone, everywhere, can benefit from world class healthcare and wellbeing services provided by their community pharmacy.

The pandemic has changed the delivery of the flu vaccine programme in 2020/21. These changes could have a long-lasting positive impact on flu vaccine targets. They may also lay the groundwork for other programmes, including Covid vaccinations.

The main challenges to delivering flu vaccinations this winter will be:

1. Getting those who at most risk to come forward to get the vaccine first.

This includes the over 65s and people vulnerable to Covid (those with respiratory and endocrine disorders) to protect them from co-circulating flu. Many people who are otherwise healthy have come forward early to get the vaccine. In some parts of the country there has been a ten-fold increase in demand. During the first four weeks of the flu vaccination service, community pharmacists have vaccinated over 650,000 NHS patients – three times the number vaccinated in the same period last year.

It is positive that the benefit of vaccination appears to be landing well with the public this year. However, we also need people to be aware of the process of staging the vaccine to priority groups.

Wholesalers deliver the vaccine to healthcare providers in batches throughout the flu season. Non-priority groups will therefore receive their vaccine in November and December.

Flu Jab

2. Reaching targets for priority groups

This year NHS England has set a target of 75% of each priority group to receive the vaccine. Last year the target met was 60%, with variability among cohorts. There are groups that may need specific targeting (e.g. pregnant women). As eligible groups have expanded, reaching these increased targets will be more challenging. As such, it is important that healthcare providers work together to reach patients.

3. Reassurance for nervous patients

We need those in at risk groups to come forward for the vaccine. The necessary safety measures, infection control, distancing and PPE are in place to protect the public in pharmacies. Additional measures such as sending patients information about what to expect from the flu service in advance will help. The vaccination process will be quicker for patients due to the flexibilities introduced this year. These include the removal of the need for written consent and permission for pharmacy to have closed door flu clinics.

We would like to see the following two steps taken to help overcome these challenges:

  1. Clear and targeted communication to the public, about how this year’s flu vaccine programme is being delivered. This would help reassure those who are eligible for the free NHS vaccine about when and where they can receive it.
  2. Proposed flexibilities to be come into place for this flu season. The Department of Health and Social Care has proposed widening the Patient Group Direction (PGD) to allow pharmacy technicians to deliver vaccines. We also expect regulations to be laid to allow community pharmacy to deliver in off-site locations including faith centres and community halls.

We believe that these changes, if introduced, could greatly support the future delivery of a Covid vaccine safely and at scale and pace.

CCA Logo

Content provided by The Company Chemists’ Association. For more information please visit www.thecca.org.uk

Obesity: Treat and Prevent - An evidence based action plan to reduce death from Covid-19 - Graham MacGregor, Chair of Action on Sugar and Action on Salt Professor of Cardiovascular Medicine

Obesity is a major risk factor for mortality from Covid-19.

These ten recommendations will support the nation to reach and maintain a healthy weight, without placing responsibility solely on the individual and by changing the food environment.

TREAT

Provide guidance for identifying modifiable risk factors
To improve understanding of the many causes of obesity
Increase access and funding for bariatric surgery
Increase access and funding for evidence-based weight loss support

PREVENT

5. Ensure only healthy products are advertised and promoted
6. Adopt fiscal measures to promote healthy food (with income ringfenced to subsidise treatments)
7. Make nutrition labelling mandatory
8. Ensure only healthy food is provided to key workers in their workplaces
9. Improve nutritional profile by incremental reformulation of processed food and drink
10. Set up a new, independent and transparent food watchdog

Obesity and Covid-19

Increasing evidence demonstrates that obesity is an independent risk factor for more severe illness and death from COVID-191,2,3,4,5,6,7,8,9. Data shows that 78% of those infected and 62% of hospital deaths caused by the virus are in overweight or obese individuals1,2. Linking UK COVID-19 data to that of a population cohort (428,225 participants, 340 confirmed COVID-19 hospital cases) and to electronic health records (17,425,445 participants, 5,683 COVID-19 deaths) demonstrates that the more severe the obesity, the more likely to be hospitalised for COVID-19 and/or die from it1,2.

Other risk factors include age, ethnicity, deprivation, and underlying conditions such as heart or kidney disease and type 1 and type 2 diabetes. Obesity is the major risk factor that can potentially be modified meaning millions of people are living with an increased, but preventable, risk from COVID-19.

Treating and preventing obesity

The current NHS10 treatments recommended for severe obesity are bariatric surgery, supported weight loss services, advice, and orlistat, which can be prescribed by a GP. Not all treatments are available or accessible.

Beyond this, although there is an element of personal responsibility in both the treatment and prevention of obesity, this can only be equitably achieved with access to healthy, affordable food in an environment that supports the individual at every turn – not the current obesogenic environment within which we live11. Long planned and vital governmental measures to address this have been delayed by food industry lobbying and have now been put on hold due to the COVID-19 outbreak, at a time when they have never been more necessary.

The Childhood Obesity Plans chapters 2 and 3 (Prevention Green paper) and the Independent Report by the outgoing Chief Medical Officer make a series of recommendations to improve the nation’s health, focusing on children, but with evidence that they will contribute to preventing adult obesity via their impact assessments (Appendix 1). So far only the Sugar Reduction Programme and the Soft Drinks Industry Levy have been implemented. The status of the remaining recommendations, which Public Health England have repeatedly stated are needed, and how they are connected to the ten actions, are outlined in Appendix 1.

Action on Sugar and Action on Salt’s evidence-based action plan for the Prime Minister and government departments builds on accepted evidence and recommends stricter parameters necessary for the urgent nature of the pandemic. We ask for the government to immediately implement all these measures to help protect and support those living with obesity during the pandemic, whilst also improving health for all in the long term.

TREAT
Immediately put support in place for individuals to reach and maintain a healthy weight

1. Provide guidance for identifying modifiable risk factors

We recommend that the government provides guidance for self-identification of modifiable risk factors, in particular, weight status. Current recognised measures include Body Mass Index (BMI), waist circumference and the waist-hip ratio. For most people, BMI is a relatively straightforward, accurate and convenient way of assessing your risk12. Covid-19 data has shown that as the reported BMI increases, the risk of having severe illness from Covid-19 increases13. At this time it is not possible to access GP surgeries and other means of identifying risk, so it is vital that information is provided to encourage people to make these calculations at home to identify their risk.

2. To improve understanding of the many causes of obesity

Obesity is not a choice. Blame should not be placed on the individual, but instead there must be more emphasis on creating an environment that supports people living with obesity and prevents rather than encourages people to become obese. The existing and recognised framework to communicate the multifactorial root causes of obesity should be immediately implemented across government, NHS, the food industry, technology companies and the media14. This framework is designed to support those working in the field of obesity to communicate and work in a non-stigmatising manner relating to body weight or size, and to take the emphasis off personal responsibility.

3. Increase access and funding for bariatric surgery

Bariatric surgery or metabolic surgery is effective at treating those individuals with extreme obesity (BMI>40+). Patients can only be considered if they can demonstrate that they have tried various lifestyle changes which are often impossible to undertake within our current food environment, putting further distress on the individual. This surgery is a major operation and should not be taken lightly, however it should be properly funded to reduce waiting times to expediate access for high risk individuals. Currently the majority of individuals who would qualify for bariatric surgery are not able to access them due to limited funding for the NHS15.

4. Increase access and funding for evidence-based weight loss support

Fad diets are ineffective in the long term. There are some effective weight management support services for those that are suitable, however, access to these services through the NHS is limited and under-funded, with extensive waiting lists. Evidence based weight management services are available in some areas but are often dependent on stretched local authority funding, and are not accessible to everyone. Multi-disciplinary supported weight loss services should be adequately funded and signposted and their long-term effectiveness needs to be researched further, including the effectiveness of personalised technology16.

PREVENT
The following ‘pandemic response’ measures build upon the existing evidence-based recommendations committed to by this government in the Childhood Obesity Plan Chapters 2 and 3 (Prevention Green Paper) and Time to Solve Childhood Obesity: An Independent Report by the Chief Medical Officer.

5. Ensure only healthy products are advertised and promoted

Advertising, price and placement promotions (such as end of aisles, point of sale) of more unhealthy foods and drinks manipulates choice, creating an environment where products high in salt, sugar and/or fat are more desirable. Food and drink companies should be banned from advertising any food or drink high in fat, salt or sugar (HFSS), as defined by the new Nutrient Profile Model17. There must also be mandatory restriction of price, point of sale and location promotions on all products high in salt, sugar and/or fat in all outlets where food and beverages are sold (including deliveries and online).

6. Adopt fiscal measures to promote healthy food (with income ringfenced to subsidise treatments)

In order to subsidise the expansion of weight management services provided by the NHS (actions 3 & 4), this government needs to raise revenue through ring-fenced fiscal measures.

The Soft Drinks Industry Levy has been successful in reducing sugar intakes via reformulation, and in raising much needed revenue for children’s services. The current sugar levy thresholds should be reduced, the rates increased, and it should be immediately applied to a calorie threshold in sugar sweetened milk and milkalternative drinks.

The current voluntary reformulation programmes have failed. Incremental mandatory reformulation targets must be set for salt, sugar and calories. Policed by a new independent food watchdog.

Fiscal measures that could be explored to enforce this could include:

  • Reformulation Levy: for non-compliance with the reformulation targets within the sugar and salt reduction programmes and the overdue calorie reduction programme
  • Energy Density Levy: for all calorie dense, nutritionally poor, processed foods
  • VAT Reform/subsidies: Using the VAT system to promote healthy food, as defined by the new Nutrient Profile Model (NPM)
  • Planning restrictions: Make it more difficult to open unhealthy food outlets and encourage healthier outlets by using a ‘nutrition rating scheme’ monitored by a new food watchdog18.

7. Make nutrition labelling mandatory

This government needs to seize on the opportunity of Britain’s exit from the EU and make colour-coded signpost labelling mandatory on all food, drinks and alcohol sold in retail, and to introduce calorie labelling for the out-of-home sector. While the out of home sector has been impacted by the virus, large, multinational food companies have been able to reopen, largely in more deprived areas and with limited menus which predominately feature HFSS products. Starting with companies with the resources to open, customers should be provided with nutrition information at the point of sale. Support and expertise should be provided by a new food watchdog.

8. Ensure only healthy food is provided to key workers in their workplaces is healthy

Key workers should have access to the highest nutritional quality food at their workplaces. This government must ensure all food provision to all key workers and others in public sector meets nutrition and sustainability standards, as set out in the Government Buying Standards. This includes schools, hospitals etc.

9. Improve nutritional profile of processed food and drink

This government must push forward with proposals to make long term and meaningful improvements to nutritional profile of processed food and drink. Nutritional quality can be improved by reducing excessive calories through sugar, saturated fat and/or alcohol content reduction, reducing salt, and increasing fruit, vegetable, fibre and micronutrients. This government can implement portion size restrictions for the food industry including the hospitality sector to adhere to, based on energy density, and ensure that all new products meet set thresholds for sugar, salt, calories and limits on the level of processing19.

10. Set up a new, independent and transparent food watchdog

A new, independent and transparent food watchdog, free from ministerial, industry and other vested-interest influences, should be immediately set up. This will enable them to make clear, independent, evidence-based information widely and freely available whilst working with technology companies and media outlets to halt
the spread of misinformation.

This new watchdog must put the primary focus on healthy diets, with physical activity encouraged for general health improvement. The watchdog should be well funded, for research and agility to respond to new evidence and innovative solutions.

For these treatment interventions to be effective the above measures for preventing obesity need to be actioned immediately.

“The UK is facing two major pandemics. One immediately, Covid-19 and the other a longer-term crisis with obesity. Clear evidence has emerged that the two pandemics interact. This is a major opportunity for the government and the food industry to prevent unnecessary suffering and death.”

Graham MacGregor
Chair of Action on Sugar and Action on Salt
Professor of Cardiovascular Medicine

Action on Sugar
Action on Sugar is a group of scientific experts concerned with sugar and obesity and its effects on health. It is working to reach a consensus with the food industry and Government over the harmful effects of a high calorie diet, and bring about a reduction in the amount of sugar and fat in processed foods to prevent obesity and type 2 diabetes.

@actiononsugar

actiononsugar.org

Action on Salt
Action on Salt is a group concerned with salt and its effects on health, supported by 25 expert scientific members. Action on Salt is successfully working to reach a consensus with the food industry and Government over the harmful effects of a high salt diet, and bring about a reduction in the amount of salt in processed foods as well as salt added to cooking, and the table, to prevent high blood pressure and cardiovascular disease.

@actiononsalt

actiononsalt.org.uk

References
Throughout the article, ‘sugar’ refers to ‘free sugars’ and ‘drink’ refers to both alcoholic and non-alcoholic drinks.

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1 Ho FK, Celis-Morales CA, Gray SR, et al. Modifiable and non-modifiable risk factors for COVID-19: results from UK Biobank. medRxiv 2020. [Epub ahead of print]

2 The OpenSAFELY Collaborative, Williamson E, Walker AJ, et al. OpenSAFELY: factors associated with COVID-19-
related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv 2020. [Epub ahead of print]

3 Simonnet A, Chetboun M, Poissy J, et al. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation. Obesity (Silver Spring, Md) 2020. [Epub ahead of print]

4 Lighter J, Phillips M, Hochman S, et al. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission. Clin Infect Dis 2020. [Epub ahead of print]

5 Yu T, Cai S, Zheng Z, et al. Association Between Clinical Manifestations and Prognosis in Patients with COVID-19. Clin Ther 2020. [Epub ahead of print]

6 Kalligeros M, Shehadeh F, Mylona EK, et al. Association of Obesity with Disease Severity among Patients with COVID-19. Obesity (Silver Spring, Md) 2020. [Epub ahead of print]

7 Petrilli CM, Jones SA, Yang J, et al. Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City. medRxiv 2020. [Epub ahead of print]

8 Ong SWX, Young BE, Leo YS, Lye DC. Association of higher body mass index (BMI) with severe coronavirus disease 2019 (COVID-19) in younger patients. Clin Infect Dis 2020. [Epub ahead of print]

9 Huang R, Zhu L, Xue L, et al. Clinical findings of patients with coronavirus disease 2019 in Jiangsu province, China: A retrospective, multi-center study. PLoS Negl Trop Dis 2020; 14: e0008280.

10 NHS. Treatment of Obesity: https://www.nhs.uk/conditions/obesity/treatment/

11 HHSC. Time to solve childhood obesity: CMO special report: https://www.gov.uk/government/publications/time-tosolve-childhood-obesity-cmo-special-report

12 NHS. Healthy Weight Calculator: https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/

13 Green WD, Beck MA. Obesity Impairs the Adaptive Immune Response to Influenza Virus. Ann Am Thorac Soc 2017; 14: S406-S9.

14 Dr Stuart W., Scaled Insights and Obesity UK. Positive Communication About Obesity: https://static1.squarespace.com/static/5975e650be6594496c79e2fb/t/5e5c1158bd974c78734258de/1583092058005/Positive+Communication+About+Obesity.pdf

15 Rubino F et al. Bariatric and metabolic surgery during and after the COVID-19 pandemic: DSS recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery.Lancet, 2020, S2213-8587(20)30157-1

16 NHS England. Prevention Tier 2 weight Management Services: https://www.england.nhs.uk/ltphimenu/prevention/tier-2-weight-management-services/

17 Department of Health. 2011. The Nutrient Profiling Model https://www.gov.uk/government/publications/the-nutrientprofiling-model: (New Nutrient Profile Model (NPM) to be immediately released and replace current NPM and measures of food and drinks High in Salt, Fat and Sugar (HFSS))

18 The Food Standards Agency Food Hygiene Rating Scheme: https://www.food.gov.uk/safety-hygiene/food-hygienerating-scheme

19 NOVA classification system: http://www.fao.org/3/ca5644en/ca5644en.pdf

Content provided by Graham MacGregor, Chair of Action on Sugar and Action on Salt, Professor of Cardiovascular Medicine.Content provided by Graham MacGregor, Chair of Action on Sugar and Action on Salt, Professor of Cardiovascular Medicine. For more information please visit actiononsugar.org and actiononsalt.org.uk.

Portable hand-held self-monitoring blood cholesterol devices for the monitoring of patients on lipid lowering treatment - J Bolodeoku MBBS, MSc, MBA, DPhil, FRCPath

Point of Care Testing (POCT) in the monitoring of hypertensive and diabetic patients for blood pressure and glucose has been shown to be beneficial 1,2,3,4,5,6,7,8.

In the management of patients with hyperlipidaemia, it is the normal practice that after initiating pharmacological interventions such as statins, fibrates, bile acid sequestrants and more recently, PCSK9 inhibitors, the patients are expected to have follow up laboratory test done at some appropriate time point. Patients will usually have these blood tests done at the local hospital laboratory or General Practice (GP) who would have the blood sample sent to the local hospital laboratory prior to their visit in order to have the cholesterol estimations ready for their out-patient visit. This way of conducting blood cholesterol measurements is not optimum as most clinicians are usually making a judgement call on one blood lipid profile estimation when the more optimum procedure will be to make the call after a review of more than one lipid profile. This would require the patients to attend the local hospital laboratory or General Practice (GP) at least more than once (route A in figure 1), this could be quite a bother to patients and therefore the question is can portable hand-held self-monitoring of blood cholesterol (SMBC) (route B in figure 1) be of benefit in the management of these patients?

Figure 1 - Showing routes A and B in the monitoring of blood cholesterol in a lipid clinic 

Figure 1 - Showing routes A and B in the monitoring of blood cholesterol in a lipid clinic

The POCT devices for measuring cholesterol vary from hand-held self-monitoring blood cholesterol devices such as the Accutrend Plus, BeneCheck Plus, CardioChek PA, Cholestech LDX®, Veri-Q, 3in1, the elemark™, to the compact desktop analyser such as the Cholestech LDX®. They measure a number of lipid fractions (total cholesterol, triglycerides, high density lipoprotein, low density lipoprotein) and ratios on whole blood, plasma or serum collected from the finger or venous blood using reflectance or biosensor technology with single-use, disposable, dry reagent test strips, rotors or cassettes. The Cholestech LDX is one of the well-studied lipid testing POCT devices but it is a desk top analyser, this review focuses on the portable handheld self-testing devices such as the Accutrend Plus, BeneCheck Plus, CardioChek PA, Veri-Q, 3in1 and the elemark™.

There are several factors that should be considered that will influence the lipid estimations such as the accuracy, the precision and practical usage of the devices and the person day to day lipids variation. These factors will be discussed in relation to several of the portable hand-held self-monitoring blood cholesterol devices on the market and in the literature.

Accuracy

The CardioChek PA was one of the two point-of-care (POC) cholesterol testing devices that was directly compared to a laboratory method using a venous sample to determine device accuracy. The conclusion was that the device produced clinically equivalent values when compared to the same patients’ samples analysed in a reference laboratory and operated within industry accuracy standards11,12. The Accutrend® Plus total cholesterol (TC) and triglyceride (TG) concentrations correlated very well (r >0.80) with laboratory reference method used13. Recently, TC, and TG results from the elemark™ device were shown to correlate very highly with those of laboratory method using the AU5800 Analyzer (Beckman Coulter Inc., IN, USA)14.

Precision

The laboratory analytical precision is measured as coefficient of variation percent (CV%). The Cholesterol Reference Method Laboratory (CRMLN) cholesterol certification criteria for total cholesterol (TC) is < or = 3%, for and high density lipoprotein-cholesterol (HDL-C) is < or = 4% and for low density lipoprotein-cholesterol (LDL-C) < or = 4% and HDL-C < or = 4% and the National Cholesterol Education Programme (NCEP) recommended precision performance criteria for laboratory TC is < or = 3% and HDL-C < or = 6%15,16. The precision (within and within-run precision) for the CardioCheK PA, was 3.7% for total cholesterol and 6.2% for HDL-C for level 1 concentration and 3.6% for TC and 3.5% for HDL-C for level 2 concentration17. In an evaluation by the UK NHS Purchasing and Supply Agency of the CardioChek PA, showed for TC an imprecision of 12%, for HDL-cholesterol 22% and for TG 14%10. In a recent study, it was shown that there was comparable precision between the FDA cleared, CE marked, CLIA waived and CRMLN certified CardioChek PA and the elemark™. The lipid precision profile of both devices (CardioChek PA - 5.4 – 8.3% for TC, 3.4% – 5.5% for HDL-C, 9.4% – 14.0% for LDL-C and elemark™ - 3.0% – 5.3% for TC, 4.3% – 6.2% for HDL-C and 5.5% – 14.4% for LDL-cholesterol)18. In addition, the inter-assay precision of the Multicare Cholesterol system was 4.51% (range, 2.38% - 8.54%) for TC and 3.29% (range, 1.06% - 7.45%) for TG19.

Biological Variation

Lipid concentrations vary within the course of the day and the ranges of within person biological variability (expressed as the coefficient of variation percent) that have been described in the literature for healthy volunteers, shows the CV% ranges for total cholesterol is 2.5% - 10.9%, for HDL-cholesterol is 3.6% - 12.4%, for LDL-cholesterol 7.8% - 13.6% and for triglyceride 12.9% - 40.8%20-23. The within person day to day variation in a healthy volunteer was assessed using three of the cholesterol testing POCT devices, the 3in1, CardioChek PA and elemark™ and their respective CV% fell within the CV% described in the literature: for the 3in1, total cholesterol 6.9% and triglyceride 34%; for the CardioChek PA, total cholesterol 9.4%, triglyceride 23% HDL-cholesterol 7.0%, LDL-cholesterol 14% and triglyceride 23.11%; for the elemark™ total cholesterol 5.0%, triglyceride 30% HDL-cholesterol 13% and LDL-cholesterol 13%24.

Practical Usage

The MultiCare system was easy to be used by patients, when their self measured estimations of either total cholesterol or triglyceride were compared with the results of a professional operator performed on the same device. On a second sample, there was very good correlation (r= 0.978) with a mean difference of 0.28% between the two sets of results19. In a randomised study, investigating the value of home monitoring of lipids, one group of patients received the hand-held device (CardioChek PA) and measured and reported their lipid levels for 6 months using a phone call, whilst the other group had their lipids measured in the usual care group in a traditional laboratory setting. The results showed that mean LDL-C decreased from 186 mg/dL (4.8 mmol/L) to 117 mg/dL (3.0 mmol/L). In the usual care group, whilst a similar reduction of LDL-C decrease from 162 mg/dL (4.2 mmol/L) to 105 mg/dL (2.

7 mmol/L) was observed in the patients using the home monitoring, there was no significant difference between the mean changes. In addition, there was also no significant difference between the two groups with regards to mean changes in HDL-C and triglycerides25. Recently, we evaluated the performance (intra-individual variation, intra-assay precision and comparative data) of the 1drop™ smart phone in measuring total cholesterol. 1drop™ Smartphone is a smart phone (figure 2) used to determine total cholesterol. In this pilot study, on a healthy volunteer, the 1drop™ demonstrated a within in person variation CV% of total cholesterol of 7.3% and an intra-assay precision of 6%. In the comparative study, the total cholesterol estimates of the 1drop™ device were on average 6%, 13% and 23% more than the total cholesterol estimates of the Mission, Prima 3in1 and CardioChek, respectively27.

Figure 2 - Figure showing photograph Galaxy J3 with the specially designed smartphone cover and membrane containing dried reagents (1drop™ TC total cholesterol test cartridge) 

Figure 2 - Figure showing photograph Galaxy J3 with the specially designed smartphone cover and membrane containing dried reagents (1drop™ TC total cholesterol test cartridge)

In conclusion, the portable hand-held self-monitoring blood cholesterol devices correlate very well with the traditional laboratory cholesterol methods. Even though it appears that both the precision criteria (CRMLN and NCEP) are quite stringent for the portable hand-held self-monitoring blood cholesterol devices, as all of the devices exceeded the expected analytical precision for TC of < or = 3%, for HDL-C of < or = 4%/6% and for LDL-C of LDL-C < or = 4%, they have a reasonable precision profile and they can be used very well by patients. This review highlights the potential of self monitoring hand-held devices to be used in the management of patients undergoing therapeutic intervention, where there is a requirement to monitor the lipid levels in response to the interventions. There is a need for more real-world experience in the use of these devices, in the management of these patients, in the primary and outpatient settings, to fully understand the true benefit and impact these devices have in the management of patients undergoing therapeutic intervention. Hopefully as self-monitoring of blood glucose is routine in the management of patients with diabetes mellitus, self-monitoring of blood lipids will become routine in the management of patients undergoing treatment and monitoring of their lipid profiles.

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Content provided by J Bolodeoku MBBS, MSc,
MBA, DPhil, FRCPath
Address:
Lipid Clinic, Department of Cardiology
Basingstoke & North Hampshire Hospital
Aldermaston Road, Basingstoke
Hampshire, United Kingdom
RG24 9AN
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Tel No. +44 07765401135

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