Understanding primary prevention of cardiovascular disease

Nurses working in general practice play an important role in identifying those at risk of developing cardiovascular disease (CVD) and implementing person-focused risk reduction strategies. The NHS Health Check programme was designed to identify people between the age of 40 and 74 years with risk factors for CVD. Nurses in general practice have a key role to play in encouraging people to attend Health Checks and helping people to understand the potential benefits of CVD risk assessment and reduction strategies. Lifestyle interventions and pharmacological management allow modifiable risk factors to be managed in an evidence-based and person-focused way.

Cardiovascular disease risk communication in NHS health checks: video-stimulated recall interviews with practitioners

BackgroundNHS Health Check (NHSHC) is a national programme to identify and manage cardiovascular disease (CVD) risk. Practitioners delivering the programme should be competent in discussing CVD risk, but there is evidence of limited understanding of the recommended 10 year/centage CVD risk scores. Lifetime CVD risk calculators might improve understanding and communication of risk.AimTo explore practitioner understanding, perceptions and experiences of CVD risk communication in NHSHCs when using two different CVD risk calculators.Design & settingQualitative video-stimulated recall (VSR) study with NHSHC practitioners.MethodVSR interviews were conducted with practitioners who delivered NHSHCs using either the QRISK2 10-year risk calculator (n=7) or JBS3 lifetime CVD risk calculator (n=8). Data were analysed using reflexive thematic analysis.ResultsFindings from analysis of VSR interviews with 15 practitioners (9 Healthcare Assistants, 6 General Practice Nurses) are presented by risk calculator. There was limited understanding and confidence of 10-year risk, which was used to guide clinical decisions through determining low/medium/high risk thresholds, rather than as a risk communication tool. Potential benefits of some JBS functions were evident, particularly heart age, risk manipulation and visual presentation of risk.ConclusionsThere is a gap between the expectation and reality of practitioners’ understanding, competencies and training in CVD risk communication for NHS Health Check. Practitioners would welcome heart age and risk manipulation functions of JBS3 to promote patient understanding of CVD risk, but there is a more fundamental need for practitioner training in CVD risk communication.

The principles and pitfalls of screening in primary care

Screening is the investigation of undiagnosed disease in asymptomatic patients. Asymptomatic disease tends to occur before symptomatic disease, meaning screening should identify disease earlier in its course. Early disease is usually easier to treat, with less morbidity and mortality. Therefore, in theory, screening should reduce morbidity and mortality from disease. The UK has a national population screening programme for specific diseases. Also, GPs regularly perform health screening such as the NHS health check. This must be evidence-based, so that the benefits outweigh harms, and the process must be economical. Therefore, it is important to understand the principles and pitfalls of screening.

Increasing uptake of NHS Health Checks: an RCT using GP computer prompts

Background: Public Health England wants to increase the uptake of the NHS Health Check (NHSHC), a cardiovascular disease prevention programme. Most invitations are sent by letter, but opportunistic invitations may be issued and verbal invitations have a higher rate of uptake. Prompting staff to issue opportunistic invitations might increase uptake. Aim: To assess the effect on uptake of automated prompts to clinical staff to invite patients to NHSHCs, delivered via primary care computer systems. Design and setting: Pseudo-randomised Controlled Trial of patients eligible for the NHSHC attending GP practices in Southwark, London. Method: Eligible patients were allocated into one of two conditions: (1) No Prompt and (2) Prompt to clinical staff. The primary outcome was attendance at an NHSHC. Results: We recruited 15 of 43 (37%) practices in Southwark; 7564 patients were eligible for an NHSHC, 3778 (49.95%) in the control and 3786 (50.05%) in the intervention. Attendance in the intervention arm was 454 (11.99%) compared to 280 (7.41%) in the control group, a total increase of 4.58% (OR = 2.28; 95% CI = 1.46-3.55; p < 0.001). Regressions found an interaction between intervention and sex (OR= 0.65; 95% CI = 0.44-0.86, p = 0.004), with the intervention primarily effective on men. Comparing the probabilities of attendance for each age category across intervention and control suggests that the intervention was primarily effective for younger patients. Conclusion: Prompts on computer systems in general practice were effective at improving the uptake of the NHSHC, especially for men and younger patients.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users

Background Local authorities in England commission the NHS Health Check programme to invite everyone aged 40–74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme’s effectiveness, cost-effectiveness and equity impact remain uncertain. Aim To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme. Objectives The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level. Design Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases. Setting Local authorities in England. Participants Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England. Interventions The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other. Main outcome measures Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality. Results The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct ‘best buy’. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis. Limitations Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run. Conclusions Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making. Future work Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support. Study registration This study is registered as PROSPERO CRD42019132087. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

NHS Health Check programme: a protocol for a realist review

IntroductionThe NHS Health Check aims to identify individuals at increased risk of cardiovascular diseases (CVDs) among the adult population in England. The Health Check includes calculation of CVD risk and discussion of pharmacological and lifestyle approaches to manage risk, including referral to lifestyle support services. The programme is commissioned by Local Authorities (LAs) and is delivered by a range of different providers in different settings. There is significant variation in activity, with uptake ranging from 25% to 85% in different areas, and clear evidence of variation in implementation and delivery practice.Methods and analysisWe aim to understand how the NHS Health Check programme works in different settings, for different groups, so that we can recommend improvements to maximise intended outcomes. To do so, we will undertake a realist review and a survey of LA public health teams. Our review will follow Pawson’s five iterative stages: (1) locate existing theories, (2) search for evidence, (3) article selection, (4) extract and organise data and (5) synthesise evidence and draw conclusions. Our review will include documents describing local implementation alongside published research studies. We will recruit a stakeholder group (including Public Health England, commissioners and providers of Health Checks, plus members of the public and patients) to advise us throughout. Our survey will be sent to all 152 LAs in England to gather detailed information on programme delivery (including COVID-19-related changes) and available referral services. This will enable us to map delivery across England and relate these data to programme outcomes.Ethics and disseminationEthical approval is not required for this review. For the survey, we have received approval from the University of Kent Research Ethics Committee. Our findings will be used to develop recommendations on tailoring, implementation and design strategies to improve delivery of the NHS Health Check in different settings, for different groups.PROSPERO registration numberCRD42020163822.

NHS Health Checks: Equity and outcomes 2009-17: An observational study

Background: The NHS Health Check cardiovascular prevention programme is now 10 years old. Aim: We describe NHS Heath Check attendance, new diagnoses and treatment in relation to equity indicators. Design and Setting: Using a national general practice database 2009-17, we compared NHS Health Check attendance and new diagnoses and treatments, by age, gender, ethnic group and deprivation. Results: In 2013-17, 590,218 eligible people age 40-74 years attended an NHS Health Check (16.9%) and 2,902,598 (83.1%) did not attend. South Asian ethnic groups were most likely to attend and women more than men. New diagnoses were more likely in attendees than non-attendees; hypertension 25/1000 attendees vs 9/1000 in non-attendees; type 2 diabetes 8/1000 vs 3/1000; chronic kidney disease 7/1000 vs 4/1000. In people aged 65 or older, new atrial fibrillation was diagnosed in 5/1000 attendees and 3/1000 non-attendees and for dementia 2/1000 versus 1/1000 respectively. Type 2 diabetes, hypertension and CKD were more likely in more deprived groups, South Asian and black African/Caribbean ethnic groups. Attendees were more likely to be prescribed statins, 26/1000, than non-attendees 8/1000; and anti-hypertensive medicines, 25/1000 vs 13/1000 non-attendees. However, of the 117,963 people with 10% or greater CVD risk eligible for statins only 9,785 (8.3%) were prescribed them. Conclusions: NHS Health Checks uptake remains low. Attendees were more likely than non-attendees to be diagnosed with type 2 diabetes, hypertension and CKD and receive treatment with statins and antihypertensives. Most attendees received neither treatment nor referral. Of those eligible for statins, fewer than 10% were treated.

Incorporating a brief intervention for personalised cancer risk assessment to promote behaviour change into primary care: a multi-methods pilot study

Background Approximately 40% of cancers could be prevented if people lived healthier lifestyles. We have developed a theory-based brief intervention to share personalised cancer risk information and promote behaviour change within primary care. This study aimed to assess the feasibility and acceptability of incorporating this intervention into primary care consultations. Method Patients eligible for an NHS Health Check or annual chronic disease review at five general practices were invited to participate in a non-randomised pilot study. In addition to the NHS Health Check or chronic disease review, those receiving the intervention were provided with their estimated risk of developing the most common preventable cancers alongside tailored behaviour change advice. Patients completed online questionnaires at baseline, immediately post-consultation and at 3-month follow-up. Consultations were audio/video recorded. Patients (n = 12) and healthcare professionals (HCPs) (n = 7) participated in post-intervention qualitative interviews that were analysed using thematic analysis. Results 62 patients took part. Thirty-four attended for an NHS Health Check plus the intervention; 7 for a standard NHS Health Check; 16 for a chronic disease review plus the intervention; and 5 for a standard chronic disease review. The mean time for delivery of the intervention was 9.6 min (SD 3) within NHS Health Checks and 9 min (SD 4) within chronic disease reviews. Fidelity of delivery of the intervention was high. Data from the questionnaires demonstrates potential improvements in health-related behaviours following the intervention. Patients receiving the intervention found the cancer risk information and lifestyle advice understandable, useful and motivating. HCPs felt that the intervention fitted well within NHS Health Checks and facilitated conversations around behaviour change. Integrating the intervention within chronic disease reviews was more challenging. Conclusions Incorporating a risk-based intervention to promote behaviour change for cancer prevention into primary care consultations is feasible and acceptable to both patients and HCPs. A randomised trial is now needed to assess the effect on health behaviours. When designing that trial, and other prevention activities within primary care, it is necessary to consider challenges around patient recruitment, the HCP contact time needed for delivery of interventions, and how best to integrate discussions about disease risk within routine care.