Primary prevention of cardiovascular disease Locally enhanced services and QRISK

1. Primary prevention of cardiovascular disease Locally enhanced services and QRISK Sajid Khan GPST1 & Rose Kennedy GPST1 2013

2. Contents • Risk assessment tools • QRISK2 • Locally enhanced services LES / NHS health checks

3. Background • Cardiovascular disease (CVD) • Stroke/TIA • Myocardial infarction/Angina • UK’s biggest cause of death – 191 000/year • GPs play a significant role in the prevention of CVD • Evidence from RCTs supports the effectiveness of statins • Silent risk factors

4. How to use risk assessment tools • The tool is an aid in modifying lifestyle, using anti-hypertensives and lipid-lowering medication • Patient centered approach – identifying ICE and patients preferences • A total CVD risk of over 20% over 10 years is considered high risk • People with moderate-to-high risk – lifestyle modifications and discuss options

5. Risk assessment tools • Previously the Framingham study was used • A cohort study of affluent white patients in Framingham, USA • Underestimated risk for diabetic patients, the most socially deprived • Limited variables • Is familiar to GPs • Now shifted towards to QRISK2

6. QRISK2 • Created from data of a cohort of 1.28 million anonymised UK primary care patients with no evidence of diabetes or CVD and followed for 10 years with CVD as an end point • Calculator available on EMIS, SystmOne and http://www.qrisk.org • Current version uses multiple parameters

7. Website - http://www.qrisk.org/

8. QRISK2 continued • Calculated risk is calibrated to the UK population • Additional variables such as obesity, social deprivation and ethnicity • Updated every year due to changing social norms (obesity rising, smoking falling) • Interactive with patients – changing variables http://www.qintervention.org/ • Less well established than Framingham Advantages Disadvantages

9. Consultation skills – communicating risk • Risk Perception • Different concepts of health risk • Patients often believe that it’s the doctors role to look after their health • Patients often rational and logical in some areas but careless in others (eg well controlled diabetic who continues to smoke) • The doctor’s role • Personal choice and shared decision making • Meeting of experts – the doctor with a knowledge of statistics/medicine and your patient with their health beliefs and concerns • Accept that patients will continue to do things you disagree with

10. Enhanced Services • Provide core (essential and additional) services to their patients. • Extra services they provide are called Enhanced Services

11. Enhanced Services • Enhanced services are currently commissioned through your local CCG and can be delivered by a range of other service providers ‘AQPs’

12. Enhanced Services • Local enhanced services (LESs) • Schemes agreed by CCG in response to local needs and priorities, sometimes adopting national service specifications. • Directed enhanced services (DESs) • Schemes that CCGs are required to establish or to offer contractors the opportunity to provide, linked to national priorities and agreements.

13. National directions currently cover eight DES schemes • Childhood immunisation • Influenza and pneumococcal • Violent patients • Minor surgery • Extended access • Alcohol reduction • Health checks for people with learning disabilities • Patient participation

14. Kirklees locally enhanced services • D-Dimer LES (GHCCG only) • TB LES • Minor Surgery for non-registered patients (NKCGG only) • Near Patient Testing • Treatment Room LES • Vasectomy • Zoladex//Prostap • Urgent appointments and urgent home visits for Kirklees residents registered with a GP practice participating in the 12/13 choice of GP practice pilot • Managing Diabetes • BP 24 Hours Monitoring • Care Homes LES

15. Further LES • Implanon /Nexplanon • Alcohol Identification & Brief Advice (IBA) • Alcohol Shared Care • Drugs Shared Care • NHS Health Checks (Vascular) • Smoking Cessation • Weight Management

16. NHS health checks • The NSF for Coronary Heart Disease recommended the identification and management of patients at high risk of developing Coronary Heart Disease. • NICE guidance-recommend patients, who do not have established Cardiovascular Disease (CVD) or diabetes, are risk assessed for CVD, and if their risk of a CVD event is found to be 20% or greater in the next ten years, are offered aspirin, statins and management of hypertension (if hypertensive) and reviewed on an annual (12 monthly) basis. • DOH- In April 2008 they launched the publication of “Putting Prevention First” which set out plans for the NHS to introduce a integrated programme of vascular risk assessment and management for those aged 40 and 74. These are now known as NHS Health Checks. • Ultimate aim: prevention of disease.

17. NHS Health Checks

18. LES:Future • As part of the changes to the NHS LES contracts have been transferred to Clinical Commissioning Groups and Kirklees Council from 1/4/13

19. Summary • GPs play an important role in the primary prevention of CVD • Risk calculators should be viewed as only screening tools. • QRISK2 is UK specific and easy to use • NHS health checks – include QRISK2