Cardiovascular Risk Assessment Programme Research Articles

A cost-effectiveness evaluation of a high-sensitivity troponin I guided voluntary cardiovascular risk assessment program for asymptomatic women in Croatia

BackgroundTo estimate the effectiveness and cost-effectiveness of a high-sensitivity troponin I (hsTnI) guided cardiovascular risk assessment program in women in Croatia. MethodsAn observational study of a voluntary program for cardiovascular disease (CVD) risk assessment in women aged above 45 years with no specific symptoms, no confirmed or known coronary artery disease was conducted (WHP). Participants were stratified into three categories according to their hsTnI level. Subjects in the moderate or high-risk class were referred to cardiac work-up and invasive cardiovascular investigation as appropriate. Study information were applied to a discrete-event simulation model to estimate the cost-effectiveness of WHP against current practice. The number of CVD events and deaths, costs, and quality-adjusted life years (QALY) were assessed over 10 years from a societal perspective. ResultsOf 1034 women who participated in the program, 921 (89.1%), 100 (9.7%), and 13 (1.3%) subjects fall into the low, moderate, and high-risk class. Of 26 women referred for angiography, significant coronary artery disease (CAD) was diagnosed in 12 women (46.1%). WHP gained 15.8 (95%CI 12.8; 17.2) QALYs per 1000 subjects, increased costs by 490€ (95%CI 487; 500), decreased CVD-related mortality by 40%. At a willingness-to-pay threshold of 45,000 €/QALY, WHP was cost-effective with a probability of 90%. Model results were most sensitive to utility weights and cost of medical prevention. ConclusionsAssessing the cardiovascular risk in asymptomatic women with hsTnI and guiding those at higher risk to further cardiac testing, identified individuals with CAD, could reduce CVD related burden, and would be cost-effective.

Remote Monitoring of Cardiovascular Risks of Medical Rehabilitation of Ischemic Stroke Patients Using Information and Telecommunication Systems

Due to the high incidence of cerebral stroke, the relevance of the problem of medical rehabilitation for this category of patients is beyond doubt. The increase in disability rates due to movement disorders among stroke survivors (3.2 per 100,000 population) necessitates the introduction of innovative rehabilitation technologies. Patients with cerebral stroke have a high risk of cardiocerebral complications, which should not limit the possibilities of medical rehabilitation. Therefore, the control of possible MR-risks is an important organizational aspect and can be implemented through the introduction of information and communication (ICT) and telemedicine technologies. Conducting dynamic telemetric ECG monitoring during of medical rehabilitation allows to prevent the development of possible cardiovascular risks and personalize the medical rehabilitation program. Aim. To study the effectiveness of remote tele-ECG monitoring based on information and communication technologies for assessing the cardiovascular risks of medical rehabilitation in patients with ischemic stroke. Material and methods. The study included 83 patients with ischemic stroke, mean age 55 [51; 57]), women – 44.6%, men – 55.4%; 42 patients in the early and 41 patients in the late recovery periods of ischemic stroke. All patients underwent a complex of multimodal rehabilitation techniques to restore hand dysfunction and statolocomotor disorders, carried out sequentially during one visit. For the purpose of dynamic control of probable cardiovascular risks, objectification of the state of the cardiovascular system, correction of the intensity and duration of rehabilitation loads, a portable information and communication technologies-based telecardiac complex was used for ECG registration. The ECG parameters were assessed in real time, as well as the stored data on the CardioOblako service. Results and discussion. The spectrum of ECG changes in patients in the early and late recovery periods of ischemic stroke was revealed. The dependence of ECG indexes and their dynamics on the duration of ischemic stroke and its subtype was determined. Asymptomatic changes in the form of heart rhythm disorders (14,4% – supraventricular rhythm disorders, 9,6% – ventricular extrasystoles of the 1st class), as well as repolarization processes (9,6% of cases) were registered during the course of rehabilitation measures. When discussing the results obtained, the probable neurogenic character of cardiac rhythm and conduction disturbances as a consequence of central neurogenic cardiovascular regulation, which is stabilized by central nervous system neuroplasticity over time, is emphasized. At the same time, the literature indicates that these processes can be regulated by therapeutic and rehabilitative measures. In our study, correction of the intensity and duration of rehabilitation loads normalized the changes of ECG indices registered in the process of medical rehabilitation. Conclusion. We determined the need for a comprehensive cardiovascular risk assessment program for patients with IS with the participation of a therapist/cardiologist using dynamic telemetric ECG monitoring during of medical rehabilitation for the timely detection and prevention of cardiovascular complications of medical rehabilitation, personalization of the medical rehabilitation program.

Evaluation of the Diabetes Screening Component of a National Cardiovascular Risk Assessment Programme in England: a Retrospective Cohort Study

Type 2 Diabetes (T2D) is increasing but the effectiveness of large-scale diabetes screening programmes is debated. We assessed associations between coverage of a national cardiovascular and diabetes risk assessment programme in England (NHS Health Check) and detection and management of incident cases of non-diabetic hyperglycaemia (NDH) and T2D. Retrospective analysis employing propensity score covariate adjustment method of prospectively collected data of 348,987 individuals aged 40–74 years and registered with 455 general practices in England (January 2009-May 2016). We examined differences in diagnosis of NDH and T2D, and changes in blood glucose levels and cardiovascular risk score between individuals registered with general practices with different levels (tertiles) of programme coverage. Over the study period 7,126 cases of NDH and 12,171 cases of T2D were detected. Compared with low coverage practices, incidence rate of detection in medium and high coverage practices were 15% and 19% higher for NDH and 10% and 9% higher for T2D, respectively. Individuals with NDH in high coverage practices had 0.2 mmol/L lower mean fasting plasma glucose and 0.9% lower cardiovascular risk score at follow-up. General practices actively participating in the programme had higher detection of NDH and T2D and improved management of blood glucose and cardiovascular risk factors.

Defining the Process of a Cardiovascular Risk Assessment Program: Lessons Learned From Cardiac Assessment of Elite Soccer Players in the United Kingdom.

Retrospectively analyze the cardiac assessment process for elite soccer players, and provide team physicians with a systematic guide to managing longitudinal cardiac risk. Descriptive Epidemiology Study. Cardiac assessments incorporating clinical examination, 12-lead ECG, echocardiography, and health questionnaire. Soccer players at 5 professional clubs in England, the United Kingdom. Data was retrospectively collected, inspected, and analyzed to determine their clinical management and subsequent follow-up. Over 2 years, 265 soccer players, aged 13 to 37 years with 66% of white European ethnicity, were included in the cohort. Eleven percent had "not-normal" assessments, of these assessments, 83% were considered gray screens, falling into three broad categories: structural cardiac features (including valvular abnormalities), functional cardiac features, and electrocardiogram changes. After cardiology consultation, all assessments were grouped into low, enhanced and high-risk categories for ongoing longitudinal risk management. Overall clear-cut pathology was identified in 2%. Cardiovascular assessment is a vital tool in identifying athletes at risk of sudden cardiac death to mitigate their risk through surveillance, intervention, or participation restriction. The decision whether a player is fit to play or not requires a robust risk assessment followed by input from a multidisciplinary team that includes both the team physician and cardiologist. This educational article proposes a clinical management pathway to aid clinicians with this process. Sudden cardiac death is the important medical cause of death during exercise. The team physician should assume responsibility for the management of the longitudinal risk of their players' cardiac assessments in conjunction with sports cardiologist.

Telephone outreach by community workers to improve uptake of NHS Health Checks in more deprived localities and minority ethnic groups: a qualitative investigation of implementation.

NHS Health Checks is a national cardiovascular risk assessment and management programme in England. To improve equity of uptake in more deprived, and Black, Asian and minority ethnic (BAME) communities, a novel telephone outreach intervention was developed. The outreach call included an invitation to an NHS Health Check appointment, lifestyle questions, and signposting to lifestyle services. We examined the experiences of staff delivering the intervention. Thematic analysis of semi-structured interviews with 10 community Telephone Outreach Workers (TOWs) making outreach calls, and 5 Primary Care Practice (PCP) staff they liaised with. Normalization Process Theory was used to examine intervention implementation. Telephone outreach was perceived as effective in engaging patients in NHS Health Checks and could reduce related administration burdens on PCPs. Successful implementation was dependent on support from participating PCPs, and tensions between the intervention and other PCP priorities were identified. Some PCP staff lacked clarity regarding the intervention aim and this could reduce the potential to capitalize on TOWs' specialist skills. To maximize the potential of telephone outreach to impact equity, purposeful recruitment and training of TOWs is vital, along with support and integration of TOWs, and the telephone outreach intervention, in participating PCPs.

National Diabetes Audit 2015–2016 shows variations in care processes and targets

National Diabetes Audit 2015–2016 shows variations in care processes and targets

Impact of the National Health Service Health Check on cardiovascular disease risk: a difference-in-differences matching analysis.

The National Health Service Health Check program in England is the largest cardiovascular risk assessment and management program in the world. We assessed the effect of this program on modelled risk of cardiovascular disease, individual risk factors for cardiovascular disease, prescribing of relevant medications and diagnosis of vascular disease. We obtained retrospective electronic medical records for a randomly selected sample of 138 788 patients aged 40-74 years registered with 462 English general practices participating in the Clinical Practice Research Datalink between 2009 and 2013. We used a quasi-experimental design of difference-indifferences matching analysis to compare changes in outcomes between Health Check attendees and nonattendees, with a median follow-up time of 2 years. Overall, 21.4% of the eligible population attended a Health Check. After matching (n = 29 672 in each group), attendees had a significant absolute reduction in modelled risk for cardiovascular disease (-0.21%, 95% confidence interval [CI] -0.24% to -0.19%) and individual risk factors: systolic blood pressure (-2.51 mm Hg, 95% CI -2.77 to -2.25 mm Hg), diastolic blood pressure (-1.46 mm Hg, 95% CI -1.62 to -1.29 mm Hg), body mass index (-0.27, 95% CI -0.34 to -0.20) and total cholesterol (-0.15 mmol/L, 95% CI -0.18 to -0.13 mmol/L). Statins were prescribed for 39.9% of attendees who were at high risk for cardiovascular disease. The program resulted in significantly more diagnoses of selected vascular diseases among attendees, with the largest increases for hypertension (2.99%) and type 2 diabetes mellitus (1.31%). The National Health Service Health Check program had statistically significant but clinically modest impacts on modelled risk for cardiovascular disease and individual risk factors, although diagnosis of vascular disease increased. Overall program performance was substantially below national and international targets, which highlights the need for careful planning, monitoring and evaluation of similar initiatives internationally.

Experiences of patients and healthcare professionals of NHS cardiovascular health checks: a qualitative study.

BackgroundNHS Health Checks are a national cardiovascular risk assessment and management programme in England and Wales. We examined the experiences of patients attending and healthcare professionals (HCPs) conducting NHS Health Checks.MethodsInterviews were conducted with a purposive sample of 28 patients and 16 HCPs recruited from eight general practices across a range of socio-economic localities. Interviews were audio recorded, transcribed, anonymized and analysed thematically.ResultsPatients were motivated to attend an NHS Health Check because of health beliefs, the perceived value of the programme, a family history of cardiovascular and other diseases and expectations of receiving a general health assessment. Some patients reported benefits including reassurance and reinforcement of healthy lifestyles. Others experienced confusion and frustration about how results and advice were communicated, some having a poor understanding of the implications of their results. HCPs raised concerns about the skill set of some staff to competently communicate risk and lifestyle information.ConclusionsTo improve the satisfaction of patients attending and improve facilitation of lifestyle change, HCPs conducting the NHS Health Checks require sufficient training to equip them with appropriate skills and knowledge to deliver the service effectively.

Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study

ObjectiveTo determine coverage of NHS Health Check, a national cardiovascular risk assessment programme in England, in the first four years after implementation, and to examine prevalence of high cardiovascular disease (CVD) risk and uptake of statins in high risk patients. MethodStudy sample was 95,571 patients in England aged 40–74years continuously registered with 509 practices in the Clinical Practice Research Datalink between April 2009 and March 2013. Multilevel logistic regression models were used to assess predictors of Health Check attendance; elevated CVD risk factors and statin prescribing among attendees. ResultsProgramme coverage was 21.4% over four years, with large variations between practices (0%–72.7%) and regions (9.4%–30.7%). Coverage was higher in older patients (adjusted odds ratio 2.88, 95% confidence interval 2.49–3.31 for patients 70–74years) and in patients with a family history of premature coronary heart disease (2.37, 2.22–2.53), but lower in Black Africans (0.75, 0.61–0.92) and Chinese (0.68, 0.47–0.96) compared with White British. Coverage was similar in patients living in deprived and affluent areas. Prevalence of high CVD risk (QRISK2≥20%) among attendees was 4.6%. One third (33.6%) of attendees at high risk were prescribed a statin after Health Checks. ConclusionsCoverage of the programme and statin prescribing in high risk individuals was low. Coverage was similar in deprived and affluent groups but lower in some ethnic minority groups, possibly widening inequalities. These findings raise a question about whether recommendations by WHO to develop CVD risk assessment programmes internationally will deliver anticipated health benefits.

Influences on individuals' decisions to take up the offer of a health check: a qualitative study.

Health checks are promoted to evaluate individuals' risk of developing disease and to initiate health promotion and disease prevention interventions. The NHS Health Check is a cardiovascular risk assessment programme introduced in the UK aimed at preventing cardiovascular disease (CVD). Uptake of health checks is lower than anticipated. This study aimed to explore influences on people's decisions to take up the offer of a health check. Semi-structured interviews were conducted with people registered at four general practices in South London. The interview schedule was informed by the Theoretical Domains Framework. Data were analysed qualitatively using the Framework method using NVivo for data management. Twenty-seven participants invited for a health check were included in the study. Seventeen received the health check while 10 either did not attend or failed to complete the check. Five themes emerging from the data included a lack of awareness of the health check programme, beliefs about susceptibility to CVD, beliefs about civic responsibility, issues concerning access to appointments, and beliefs about the consequences of having a check. Health check programmes need to raise public awareness to ensure that people are informed about the objectives and nature of the programme in order to reach an informed decision about taking up the invitation. Emphasizing the benefits of prevention and early detection might encourage attendance in those who are reluctant to burden the public health-care systems. Extending outreach initiatives and increasing 'out of hours' provision at local community sites could facilitate access.

Effectiveness of a national cardiovascular disease risk assessment program (NHS Health Check): Results after one year

ObjectiveWe aimed to assess whether the National Health Service (NHS) Health Check, a systematic cardiovascular disease (CVD) risk assessment and management program, was associated with reduction in CVD risk in attendees after one year. MethodsWe extracted data from patients aged 40–74years, with high estimated CVD risk, who were registered with general practices in a deprived, culturally diverse setting in England. We included 4748 patients at baseline (July 2008–November 2009), with 3712 at follow-up (December 2009–March 2011). We used a pre–post study design to assess changes in global CVD risk, individual CVD risk factors and statin prescription in patients with a complete and partial Health Check. ResultsThere were significant reductions in mean CVD risk score (28.2%; 95% confidence interval (CI)=27.3–29.1 to 26.2%; 95% CI, 25.4–27.1), diastolic blood pressure, total cholesterol levels and lipid ratios after one year in patients with a complete Health Check. Statin prescription increased from 14.0% (95% CI=11.9–16.0) to 60.6% (95% CI=57.7–63.5). ConclusionsThe introduction of NHS Health Check was associated with significant but modest reductions in CVD risk among screened high-risk individuals. Further cost-effectiveness analysis and work accounting for uptake is required to assess whether the program can make significant changes to population health.

Variations in the organization and delivery of the 'NHS health check' in primary care

To evaluate the organization of the new cardiovascular risk assessment programme, NHS Health Checks, in general practices. All 99 general practices in two inner London boroughs were invited to participate in a cross-sectional survey by completing an online questionnaire. Data were analysed for 66/99 (67%) eligible practices. Training attended for delivering the Health Check included measurement methods (43%), delivering risk information (65%) and advising on lifestyle change (62%). The Framingham risk score was used by 66% of practices, the QRisk score by 12% and both by 8%. Advice given to patients identified as high risk was 'usually' brief at 26% of practices, advice was given verbally at 92% of practices, in written form at 74% and through interactive visual materials at 29%. Statins were 'usually' prescribed to high-risk patients by 34% of practices and antihypertensive drugs by 22%. The follow-up of high-risk patients was by means of a register with regular recall at 51% of general practices. There is considerable diversity in general practices' implementation of the NHS Health Check. A formal quality assurance process may be required in order to optimize the implementation of the NHS cardiovascular risk assessment programme.

Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: cross-sectional study

The UK is embarking on a national cardiovascular risk assessment programme called NHS Health Checks; in order to be effective, high and equitable uptake is paramount. A cross-sectional study, using data extracted from electronic medical records of persons aged 35-74 years estimated to be at a high risk of developing cardiovascular disease, to examine the uptake of the Health Checks using logistic regression and statin prescribing. A total of 44.8% of high risk patients invited for a Health Check attended. Uptake was lower among younger men but higher among patients from south Asian (AOR = 1.71 [1.29-2.27] compared with white) or mixed ethnic backgrounds (AOR = 2.42 [1.50-3.89]), and patients registered with smaller practices (AOR = 2.53 [1.09-5.84] <3000 patients compared with 3000-5999). The percentage of patients confirmed to be at high risk of CVD prescribed a statin increased from 24.7 to 44.8%. Uptake of cardiovascular risk assessment and prescribing of statins in high risk patients was considerably lower than projected in the first year of NHS Health Checks programme. Targeting efforts to increase uptake and adherence to interventions in high risk populations and reinvesting resources into population wide strategies to reduce obesity, smoking and salt intake may prove more cost-effective in reducing the burden of cardiovascular disease in the UK.

Implementing a standardized community-based cardiovascular risk assessment program in 20 Ontario communities

The aim of the study is to describe the implementation of the Cardiovascular Health Awareness Program (CHAP) in 20 mid-sized communities across Ontario, Canada, and identify key factors in the successful multi-site delivery of a collaborative cardiovascular risk assessment and management program. Lead organizations were identified and contracted following a request for proposals. An Implementation Guide detailed steps in community mobilization and delivery of volunteer-led pharmacy-based cardiovascular risk assessment sessions. Process data were collected through final reports; a debriefing meeting; and interviews with program staff. All 20 communities successfully implemented CHAP. Overall, 99% (338/341) of family physicians agreed to receive assessment results and 89% (129/145) of pharmacies held sessions. Five hundred and seventy-seven volunteers conducted 27,358 risk assessments for 15,889 unique participants. Essential program components were consistently included, however, variations in materials, processes and support occurred. Factors in program success included: local expertise, centralized support, identification and engagement of local physician and pharmacist opinion leaders and a balance of standardization and flexibility. Monitoring delivery of a multi-community cardiovascular risk assessment program yielded key factors in program success to inform development of a sustainable and transferable model.

Improving Outcomes in High-Risk Populations Using REACH®

The high prevalence of cardiovascular disease and its associated mortality rates mandate that risk reduction strategies be addressed in high-risk populations, including those diagnosed with atherosclerotic vascular disease, heart failure, and diabetes mellitus. Hospital-based systems that can identify and guide management of these high-risk populations can be effective adjuncts to patient care.In 2001, an inpatient cardiovascular risk assessment program called REACH was developed at Advocate Lutheran General Hospital (ALGH), a community teaching hospital in Illinois. REACH uses an intranet-based data repository capable of prospectively identifying high-risk patients by displaying an alert on the inpatient computerized medical record. Management and education protocols are accessed through various links. An assessment and treatment plan is incorporated into the discharge instructions and sent to the primary care physician.A total of 9035 patients at ALGH were included in the analysis (n = 2807 at baseline and n = 6007 at year 6). Adherence to pharmacological therapy and monitoring of lipid profile improved in all 5 of the inpatient populations. Statistically significant improvement was noted in all outcomes in the cardiovascular and stroke populations (P < 0.05). In populations with diabetes and heart failure, all but one showed a statistically significant improvement. In the peripheral vascular disease population, 2 of the 5 showed statistically significant improvement. Adherence to outcome criteria in all high-risk populations over the 6-year time frame resulted in a 119% change in guideline compliance.The REACH program successfully uses patient information systems to provide a quality improvement tool that promotes optimal patient management of high-risk vascular disease states.

Psychosocial risk factors for coronary heart disease in UK South Asian men and women

Background:South Asian people in the UK and other western countries have elevated rates of coronary heart disease (CHD). Psychosocial factors contribute to CHD risk, but information about psychosocial risk profiles...

Prevalence of peripheral artery disease in at risk individuals in the community: Results from a mobile cardiovascular risk assessment program

Prevalence of peripheral artery disease in at risk individuals in the community: Results from a mobile cardiovascular risk assessment program

Designing a Cardiovascular Disease Prevention Web Site for Latinos: Qualitative Community Feedback

Latinos are the largest minority group in the United States, yet there is currently a lack of Web sites that focus on Latino health. This article shares qualitative research results obtained from Latinos, with a focus on creating a culturally sensitive, bilingual, interactive, computer-based cardiovascular disease risk assessment and behavioral goal-setting program. This project is a substudy of the Latinos Using Cardio Health Actions to Reduce Risk (LUCHAR) grant, a 5-year trial, funded by the National Heart, Lung, and Blood Institute, whose primary aim is the primary prevention of cardiovascular disease in Latinos. Ten focus groups, five in English and five in Spanish, were conducted at six community sites with trained, bilingual facilitators in Denver, Colorado. Results from the focus groups are used to make recommendations on how to develop a culturally sensitive cardiovascular health care Web site for Latinos.

Smoking status recording in GP electronic records: the unrealised potential

To investigate the recording of smoking status and factors associated with the recording of smoking status in general practitioner (GP) electronic medical records (EMRs) in New Zealand, and the suitability of this source as a prevalence measure. General practices affiliated with an Auckland-based primary health organisation. Patients registered with 84/107 (78.5%) eligible GPs who had used EMRs for at least a year and had PREDICT-CVD, a web-based cardiovascular disease risk assessment and management decision support program, integrated with their practice software. Audit of EMRs using data from an evaluation of PREDICT-CVD. The proportion of EMRs audited (Maori, non-Maori) with smoking status recorded and, among those with smoking status recorded, also Read-coded, and factors associated with greater recording of smoking status. Smoking status was recorded among 49.6% of Maori and 38.3% of non-Maori prior to the installation of PREDICT-CVD. Among those with smoking status recorded, smoking status was also Read-coded among 49.8% of Maori and 62.3% of non-Maori. Factors associated with greater recording of smoking status were installation of PREDICT-CVD, male sex, Maori ethnicity, cardiovascular disease and diabetes. Age was also associated with the recording of smoking status. General practitioner electronic medical records in New Zealand are currently not a suitable source of smoking prevalence data, even if manually searched, as a large proportion of records did not have smoking status recorded. Such records are an even less suitable source of smoking prevalence if data extraction by remote querying (using Read codes) is relied upon. The potential to estimate the prevalence of smoking from GP records has not yet become a reality. Installation of electronic decision support systems, such as PREDICT-CVD, could improve the recording and Read-coding of smoking status, and thereby the availability and accessibility of these data.

Coronary Risk Status of Police Officers Compared to Age-Matched Males

Police work is a sedentary occupation with an occasional need to respond to high physical demands. An adequate level of fitness is a hiring requirement for new police personnel. However, few departments mandate minimal fitness standards after initial employment despite heart disease being the most common cause of death for police officers. PURPOSE: The purpose of this study was to compare the coronary risk profile scores of police officers (PO) to age matched males (AM) from the general population. Coronary risk profile was assessed using criteria developed by the Cooper Clinic in Dallas, TX. Male police officers were compared to age-matched males in our Cardiovascular Risk Assessment Program database. RESULTS: Subjects were grouped in 10 year age increments (20–29, 30–39, 40–49, 50–59). After age 20–29 there was a higher coronary risk score in police officers compared to age matched males. CONCLUSION: The risk of developing coronary artery disease is higher in police officers when compared to age-matched males in the general population. Based on these data it appears that officers would benefit from mandated fitness programs designed to improve cardiovascular risk status.Figure