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| Journal of the New Zealand Medical Association,
21-January-2011, Vol 124 No 1328
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Can general practitioners
provide effective cardiovascular disease (CVD) prevention? Dreams and
realities of CVD prevention
Reducing the impact of cardiovascular disease (CVD) is one
of the 6 health targets of the New Zealand (NZ) Ministry of Health
(MOH).1 This encourages at-risk individuals to
modify lifestyle through smoking cessation, improving nutrition, increasing
exercise and weight loss and to consider pharmacological treatment for blood
pressure, cholesterol and blood sugar levels.
Patients experience healthcare through individual
consultations and community activities. The complexity of CVD impact reduction
is best understood through patients’ perspectives, which include
individual and community approaches to non-pharmacological lifestyle
modification and pharmacological treatment.
Increasingly, database analysis for indicators of the
provision of quality care is used in NZ and international primary care settings
to evaluate practitioner or practice performance. The NZ CVD indicator defines
the well population eligible for ‘CVD risk assessment’ based on the
NZ CVD guidelines2 and is evaluated by counting
recorded CVD risk percentages.
The specific MOH target is to 'increase the percent of
eligible adults who have their CVD risk assessed' which assumes that such
activity translates to risk modification in currently well individuals and then
to improved health outcomes. Non-pharmacological lifestyle modification is
difficult to evaluate in a randomised controlled trial (RCT) setting but
observational data suggest significant benefits, including all-cause mortality
reduction.3 Pharmacological approaches are
amenable to randomised trials but the extent of long-term relevant benefits for
primary prevention remains
controversial.4–6
Individual non-pharmacological lifestyle modification advice
complements population-based healthy lifestyle activities. Patients are
influenced both through daily contact with their community and intermittent
contact with the medical profession but research is limited in addressing which
method (individual vs population) is most effective for reducing the impact of
CVD. Community-based research indicates multifaceted interventions are more
effective7–9 such as using multimedia
(e.g. Internet, videos) and local businesses (e.g. supermarkets) and providing
group-based support (e.g. weekly meetings, food planning courses, etc).
The “exchange concept, which means people
receive valued benefits in return for their efforts and changed
behaviours”11 may explain this success
and is part of social marketing strategies such as NZ’s recently
terminated 'Healthy Eating Healthy Action (HEHA): Oranga Kai – Oranga
Pumau'.10 Understanding whether services and
interventions are valued by a population is important.
The study reviews individual and population approaches to
reducing the burden of CVD that prevail in a geographically constrained rural
community. The challenge is to gauge whether populations gain more through GP
performance indicator programmes or by improved access to and use of activities
likely to improve lifestyle.
MethodsThis study aims to:
First aim—The PHO for
this practice used the BestPractice CVD risk
tool12 alone to assess performance indicators.
An audit of the patient population in Akaroa enrolled with the sole local health
centre was conducted to determine the eligible population for CVD risk
assessment as defined by the NZ CVD Guidelines (including ‘high
risk’ groups—refer Table 2).13 The
national performance indicator group uses a modified set of criteria based only
on gender, age and ethnicity to calculate the ‘vast majority’ of the
eligible population.2
Completed formal assessments of CVD risk recorded in
the practice management software were counted. These included the
‘BestPractice’ CVD risk calculation, men and women's ‘Wellness
Checks’14 and the Annual Diabetes Review.
Both the Wellness Checks and BestPractice CVD risk calculation were initiated in
the last 2 years and the diabetes review is annual, so an audit was done of the
last 2 years using the MedTech32 query builder in the practice software.
MedTech32 is the main software provider for NZ general practices.
Second aim—An exploratory survey
was designed to assess awareness, barriers and facilitators of access to
services in the same local community likely to promote improved lifestyle.
Through discussion with community organisers (e.g. health centre, social service
centre, pharmacy, school nutritionist, PHO community service coordinator and
community education coordinator) a list of 17 local services potentially
associated with CVD risk reduction was built (e.g. nutrition, physical activity
and psychological well-being [stress]).
A one-page survey was created with input from these
community organisers that asked three questions:
The questionnaire also asked participants to
record age, gender, whether a participant had children and whether they had a
health concern. Ethnicity data was not collected because this study was not
designed to assess cultural influences on CVD risk reduction.
Source population—Two anonymous
surveys were delivered to all post boxes on Banks Peninsula.
Sample population—CVD risk
assessment is generally 10 years later for women but the Wellness Checks begin
at age 45 years for both women and men. Analysis was limited to replies from the
sample eligible for CVD risk assessment: those 45 years and older.
Data entry and analysis—Data was
entered into an Excel spreadsheet and frequencies and proportions and
statistical tests were calculated using Excel and OpenEpi Version 2.3
software.15
ResultsPHO performance CVD risk assessment
indicator—The enrolled population of the Akaroa Health Centre is
1684 people. The PHO generated list16 given to
the health centre based on the performance indicator
criteria2 identified 694 people eligible for a
CVD risk assessment and 88/694 (12.7%) had a BestPractice CVD risk percentage
recorded.
Table 1. Eligible Population for CVD Risk
assessment from April 2007–April 2009
1 may include those
who have also had a Diabetes review or Wellness Check
2 may include those
who have also had a Diabetes review
3 includes those with
diabetes who have NOT had CVD risk calculated (i.e. not total population with
diabetes).
In contrast, this study found 742 individuals eligible for
CVD risk assessment, with 722 over 45 years of age. Of all those eligible
(n=742, Table 1), 88/742 (11.8%) had a BestPractice CVD risk percentage
recorded. An additional 50/742 (6.7%) had a Wellness Check and 25/742 (3.4%) a
Diabetic Review giving a combined total of 21.9% of eligible patients with a CVD
risk assessment. The difference between these data from the direct audit (21.9%)
and the PHO Performance estimate (12.7%) is significant (p<0.001).
The remaining (579/742; 78%) eligible population have not
had a CVD risk assessment. About two-thirds (389/579; 67.2%) of this group are
of the age group eligible for a Wellness Check (age 45 – 65yrs).
Obtaining the appropriate data was complex and
time-consuming: Seven sub-groups were used to determine the
‘eligible’ population based on the NZ Cardiovascular Guidelines
Handbook 200913 using variables of gender,
ethnicity, ‘high risk’ factors and age (see Table 2).
More than 15 separate MedTech32 Query builds were required
to identify patients in these subgroups. The queries then had to be manually
searched to remove duplicates of individuals and combine queries. Table 2 is
included solely to illustrate the complexity of this process and contains no
additional data.
Community awareness of lifestyle
resources—1400 surveys were delivered to households and 385
participants replied who were over 45 years of age (65 replied under 45 years of
age). There were 981 enrolled patients in the practice over the age of 45 years.
Assuming all survey respondents are enrolled in the practice, this is a response
rate of 39.2% (385/981).
Of 17 well-being services offered in the community,
respondents of the survey were aware of an average of 6.2 services (6.2/17;
36%). Six respondents recognised no services (6/385; 1.6%). Over half of
respondents (219/385; 56.9%) report participating in at least one of these
activities and this proportion is the same whether they had a health concern or
not.
The potential participation rate drops to 22% (219/981) if
non-responders don’t participate or increases the rate to 83% (815/981) if
they do participate. The best-recognised services are sports groups, dance
classes, TaiChi Classes and GP Wellness Checks (n/2369; 9 – 14.1%). Of PHO
supported services, awareness was 4.1% (96/2369) for smoking cessation, 2.6%
(62/2369) for Green Prescription, 2.5% (60/2369) for falls prevention exercise
programme, 1.8% (42/2369) for the ‘Appetite for Life’ nutrition
service, 1.4% (32/2369) for dietician services and 1.3% (30/2369) for the
‘Ageing/Changing’ fitness programme.
Table 2. Complexity of identifying sub-groups
without a BestPractice CVD calculation recorded (n = 742 –
88)
 ‘BPac risk’- Best Practice CVD risk
calculation; ‘DM review’- Annual Diabetes Review’
‘M/WWC’- Men’s or Women’s Wellness Check.
++High Risk sub-groups
(1), (3) & (7): read codes- current smoker, diabetes, obesity, [add
for (7)- IHD, renal disease]; prescriptions- anti-hypertensives, lipid lowering
[not included- gestational diabetes, IGT, renal, family history premature
CVD]
Around one-third (142/385; 36.9%) of respondents did not
attend any activities. Barriers reported were not enough time (28/142; 19.7%),
no need (10/142; 7%) and living too far away (10/142; 7%). Just under half
(65/142; 45.8%) gave no reason. Only 2 respondents (1.4%) stated cost as a
reason for non-attendance. Other comments were suggestions for services (30/162;
18.5%), positive comments about existing services (30/162;18.5%) and comments
about which activities people attended (29/162; 17.9%). Suggestions were mostly
about swimming pool and gym services. Table 2 lists the results of the
survey.
Table 3: Survey results from respondents over
45 years of age
Note: Numbers do not all add up to the
total due to non-responders.
DiscussionGovernment health targets to reduce the impact of CVD must
be understood from the perspective of patients who experience both individual GP
consultations and community activities. The PHO CVD risk performance indicator
programme (i.e. individual focus) monitors CVD risk percentage calculations of
patients entered into the screening part of MedTech as proxy for adequacy of
care. The accuracy of the numerator and denominator determines the validity of
these.
In this study, 11.8% of the eligible population of the
Akaroa Health Centre had a risk calculated as of April 2009 using the standard
measure. However, another 10.1% have had these risks assessed through other
routine care such as Wellness Checks or a Diabetes review. The total of 21.9%
meets the minimum target of 21.7% for the year ending June
30th 2009.
This illustrates that consideration of risk percentages
entered into one database alone erroneously assesses a practice as
under-performing by significantly underestimating the numerator. The complex,
manual and name-by-name approach needed to determine who needs a CVD risk
assessment is also a source of error in calculating the denominator.
By 2012 the government hopes to have 80% of an eligible
population assessed for CVD risks. The audit found more than 500 patients
needing a CVD risk assessment at the Akaroa Health Centre. Two-thirds of them
(67.2%, n=389) would be eligible for Wellness Checks, though funds are limited
for this. Furthermore, data entered into the Wellness Check electronic form are
not accessible to the BestPractice CVD risk calculator, requiring the additional
cost of manual data-entry for inclusion in CVD risk performance indicator
evaluation. The intricate query builds required to truly determine the eligible
population let alone the process of contacting these people (e.g., 500 in this
study) means this target is logistically difficult and inaccurate with
significant costs. Even if identification were feasible and accurate, minimal
incentives exist to entice an asymptomatic person to attend and pay for a
consultation to have this risk assessed.
Logistical opportunity costs were identified in the OXCHECK
trial where improved health outcomes were marginal after 3 years of health
checks and were reserved primarily for those already deemed ‘high
risk’ (e.g., established diabetes, CVD and slightly for those with
hypertension and hyperlipidaemia).17 The use of
limited resources for opportunistic screening and subsequent lifestyle
counselling during primary care consultations offers such small benefit that
justifying this activity is debateable.
17–19
National health targets that rely on clinical assessments of
asymptomatic people is a screening programme and yet CVD risk assessment has not
been subject to the evaluation process undergone by other screening programs
such as breast and cervical cancer. There is debate whether the criteria for a
screening program would be met, such as having a suitable test (e.g., CVD risk
calculation) that is precise and valid, the process of screening reducing death
and illness, cost-effectiveness of the programme and acceptability to the
population in terms of follow-up. For instance, this study highlights the
significant costs of one practice's accurate population-based screening.
A CVD screening based on the 'at risk' population defined in
the NZ CVD Guideline Handbook would have screening start age 45 years for men
and 55 years for women though this would be 10 years earlier for some segments
of the population. If the cut-off for screening was 74 years as used by the
Performance Indicator Programme, national CV screening would need to cover many
more people than existing adult screening programmes (e.g. breast: women aged
45-65 years; cervical: women aged 30-70 years).
Furthermore, the usual screening programme criteria require
a reduction in death or illness from CVD as a
result.20 Given the paucity of evidence for the
effectiveness of such CVD primary prevention methods and the significant
resources required for such a large population 'at risk', CVD screening may not
be the most cost-effective approach. (Though one model suggested this CVD risk
screening would be the equivalent cost to a cervical screening program.
21)
Pharmacological and non-pharmacological primary prevention
of CVD are equally important to reduce the impact of CVD. Since the most
effective approach to non-pharmacological management (individual vs population)
is not clear both require consideration. In Akaroa, population-based lifestyle
modification activities exist alongside GP CVD risk assessments.
Adults over 45 years in the Akaroa community report
awareness of 36% of lifestyle promoting resources available with a participation
rate of 56.9%, though actual participation may be as low as 22% or as high as
83% depending on the behaviour of non-responders. Most comments from respondents
centred on reasons for not attending. Reasons were predominantly a lack of time
or need of the service, which suggest these activities are not highly valued or
acceptable, despite good levels of awareness.
There are significant flaws in the current
performance-indicator approach to individual CVD risk management, including
minimal evidence for the suitability of CVD risk calculations, effect on
reducing death and illness and the acceptability of this approach. The community
survey suggests barriers to participation in health-promoting activities.
Effective approaches to CVD impact reduction are likely to be
multifaceted,7–9 acceptable, relevant and
valued by the population so that in exchange a population improves their
lifestyles.
Alternative use of PHO resources would be to offer extended
‘lifestyle consults’ (e.g., akin to Mental Health and Sexual Health
consults) and provide subsidised pedometers for weight
reduction.22 Funding the cost-effective Green
Prescription programme to cover the population eligible for CVD risk assessments
may be more efficient at changing outcomes than calculating risk
percentages.23
There are several limitations of this study. Evaluation only
included patients who had a Best Practice CVD risk calculated, a Diabetes Annual
Review or a Wellness Check though there are other ways to assess CVD risk,
including data not entered into the screening section of the MedTech software.
Furthermore, neither this study nor the PHO list of eligible patients excluded
those already diagnosed with CVD, which may have falsely inflated both the
denominator and the numerator. Interestingly, the BestPractice risk calculator
includes a ‘personal CVD event’ as a risk, though in theory a
patient with a personal event has no need for this calculation.
While the response rate was reasonable for a single mailed
questionnaire it may not be a representative sample. There was a predominance of
female respondents (59.2%).
ConclusionIn a resource-restricted health system there is an
obligation to ensure appropriate use of such resources. This study suggests the
current performance indicator approach is not practical, subject to error and
may have significant opportunity costs. Furthermore, barriers exist to
population participation in health-promoting activities, if these are
recommended to individuals. Research is limited to guide the most effective
approach to CVD prevention. Implementing a population-based screening programme
usually requires evidence from pilots conducted as randomised controlled trials.
Evidence for the individual components of treatment is not
sufficient, and the limited evidence from primary care RCTs such as the OXCHECK
study is not strong. Though an individual approach has a role, especially in
secondary prevention, a population-based approach that reflects local interests
and contributes to environmental modification may well be the most effective use
of money. This approach is the historical foundation of successful population
interventions for public health issues such as those aimed at reducing
infectious disease.
Competing interests: None.
Note: This study was done as a GP
Registrar project as part of the requirements of the academic year.
Author information: Emily Gill, GP
Registrar, Akaroa Medical Centre, Akaroa, Canterbury; Dee Mangin, Associate
Professor, Department of GP, Christchurch Medical School, University of Otago,
Christchurch
Acknowledgements: Ethics approval was given
for this audit and survey by the Upper South A Regional Ethics Committee (Ref-
URA/09/10/EXP). Funding was provided by the Rural Canterbury
PHO and the lead author. We also thank the many people who donated their time
and services to this project including the Akaroa Medical Centre team, the Rural
Canterbury PHO, Alison Wilkie, the Heartland’s team, Mary the Akaroa
postie, and Jesse Galloway who did the data-entry.
Correspondence: Emily Gill, 1829/24B
Moorfield Rd, Johnsonville, Wellington, New Zealand. Email: emily.gill@actrix.co.nz
References:
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