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

doi:10.1016/j.ypmed.2015.05.022

Preventive Medicine

Volume 78, September 2015, Pages 1-8

https://doi.org/10.1016/j.ypmed.2015.05.022 Get rights and content

Highlights

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Coverage of the programme examined nationally was low in the first four years.
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Wide variation in coverage was observed between practices and English regions.
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Increases in statin prescribing were found in both high and lower risk patients.
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Only 1/3 of attendees at high risk were prescribed a statin after Health Check.
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Almost five times more patients at lower risk than high risk were offered a statin.

Abstract

Objective

To 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.

Method

Study sample was 95,571 patients in England aged 40–74 years 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.

Results

Programme 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 70–74 years) 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.

Conclusions

Coverage 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.

Introduction

The burden of cardiovascular disease (CVD), type 2 diabetes mellitus and chronic kidney disease is substantial in developed countries and rising rapidly in developing countries (Murray et al., 2013). Despite downward secular trends, CVD remains the largest single cause of mortality in England, accounting for around 34% of deaths annually (Townsend et al., 2012). Cardiovascular disease also contributes significantly to health inequalities, with prevalence of risk factors, established disease, adverse health outcomes and premature death being disproportionately high in people in lower socio-economic classes and ethnic minority groups (Townsend et al., 2012).

Many countries have begun prioritising cardiovascular risk assessment programmes with CVD prevention strategies, for instance the Million Hearts initiative in the United States and More Heart and Diabetes Checks in New Zealand (Frieden and Berwick, 2011, Ministry of Health). Recently the World Health Organisation published a global action plan for 2013–2020 (World Health Organization, 2013), with targets to achieve 25% relative reduction in premature mortality from non-communicable diseases including CVD and diabetes; and at least 50% of eligible people (aged 40 or above with a 10-year CVD risk ≥ 30%) to receive drug therapy and counselling by 2025.

The National Health Service (NHS) Health Check programme implemented by the Department of Health in April 2009, invites all people in England aged 40–74 years, who are not currently on a vascular disease register, for a CVD risk assessment every five years. Attendees are communicated their CVD risk in a Health Check and provided with tailored risk management strategies and healthy lifestyle advice.

Evaluation of the NHS Health Check programme is facilitated by the very high use of electronic health records in English primary care, though current evidence mostly comes from local studies with short follow up of patient outcomes. Therefore the main aim of this study was to evaluate coverage of the NHS Health Check programme nationally in the first four years following its implementation. Secondary aims were to assess the prevalence of cardiovascular risk factors and statin uptake among Health Check attendees.

Section snippets

Data source

We obtained a longitudinal dataset from the Clinical Practice Research Datalink (CPRD), one of the world's largest primary care databases. CPRD continuously collects anonymised electronic medical records from participating general practices in the United Kingdom (Duff, 2012), it is nationally representative and covers approximately 8% of the population (Lawrenson et al., 1999, van Staa et al., 2013). Recent research has found good validity in CPRD data, and the database has been extensively

Variation in Health Check coverage

Health Check coverage was 21.4% (20,409/95,571) during the first four years of the programme, with wide variations between general practices (0%–72.7%). Characteristics of Health Check eligible patients and programme coverage by patient subgroups are displayed in Table 1. There was significant variation in coverage between English regions from 9.4% in Yorkshire and Humber to 30.7% in the North East.

Adjusted results for coverage are also shown in Table 1. We observed a strong practice effect via

Key findings and comparison with other studies

Coverage of the NHS Health Check programme was low at 21.4% in the first four years after programme implementation. Coverage ranged from 9.4% to 30.7% between English regions, and varied widely between general practices (0%–72.7%). The large variation in coverage present is consistent with previous studies and may reflect the phased initial roll-out of the programme (Artac et al., 2013a, Artac et al., 2013b, Dalton et al., 2011). Our findings are consistent with previous local studies which

Conclusions

Coverage of the NHS Health Check programme and statin prescribing in high risk individuals was low in the first four years of the programme. Substantial work needs to be undertaken to standardise operating procedures for the programme, to raise awareness about potential benefits among the public and NHS professionals, and to reduce barriers to attendance. Our finding of very low programme coverage and statin prescribing in a health system with universal health coverage and well developed

Contributors

KC, MS, JL, AM and CM designed the study, MS and MW acquired the data. KC analysed the data, JL advised on statistical issues. All authors discussed data analyses and interpreted the results. KC, CM, MS and AM wrote the first draft of the manuscript. All authors critically revised and approved the final manuscript. KC had full access to all the data used in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. KC is the guarantor.

Funding

This report is an independent research commissioned and funded by the Department of Health Policy Research Programme (National Evaluation of the NHS Health Checks Programme, ttagdel 009/0051). The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health.

Conflict of interest

KK is an advisor to the NHS Health Check programme and informed some elements of the programme. This study was conducted as part of activities supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands.

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

Highlights

Abstract

Objective

Method

Results

Conclusions

Introduction

Section snippets

Data source

Variation in Health Check coverage

Key findings and comparison with other studies

Conclusions

Contributors

Funding

Conflict of interest

Am. Heart J.

Lancet

Lancet

Primary care and population factors associated with NHS Health Check coverage: a national cross-sectional study

J. Public Health

Uptake of the NHS Health Check programme in an urban setting

Fam. Pract.

What are the read codes?

Health Libr. Rev.

Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent

J. Public Health (Oxf.)

Clinical guidelines and evidence review for lipid modification: cardiovascular risk assessment and the primary and secondary prevention of cardiovascular disease

Lipid Modification: Full Guideline May

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

J. Public Health

Putting Prevention First—NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidance

Independent Scientific Advisory Committee for Medicines and Healthcare Products Regulatory Agency (MHRA) Database Research Annual Report

The “million hearts” initiative — preventing heart attacks and strokes

N. Engl. J. Med.

Validation and validity of diagnoses in the General Practice Research Database: a systematic review

Br. J. Clin. Pharmacol.

Performance of the QRISK cardiovascular risk prediction algorithm in an independent UK sample of patients from general practice: a validation study

Heart