Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study
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.
References (31)
- et al.
Cardiovascular disease risk profiles
Am. Heart J.
(1991) - et al.
Statins for all by the age of 50 years?
Lancet
(2012) - et al.
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2013) - et al.
Primary care and population factors associated with NHS Health Check coverage: a national cross-sectional study
J. Public Health
(2013) - et al.
Uptake of the NHS Health Check programme in an urban setting
Fam. Pract.
(2013) What are the read codes?
Health Libr. Rev.
(1994)- et al.
Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent
J. Public Health (Oxf.)
(2013) - et al.
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
(2008) - et al.
Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: cross-sectional study
J. Public Health
(2011) Putting Prevention First—NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidance
(2009)
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
Cited by (40)
Implementing screening interventions in community pharmacy to promote interprofessional coordination of primary care – A mixed methods evaluation
2020, Research in Social and Administrative PharmacyCitation Excerpt :Recent estimates suggest that even the information required for absolute risk estimation is only documented for 42% of relevant patients in general practice,26 that formal CVAR rates are actually much lower than this,27 and that an estimated 21% of the population aged 45–74 years is at moderate or high risk of a CVD event and not receiving recommended optimal therapy.28 England's NHS Health Check, the first national program for absolute risk screening in primary care, demonstrates the difficulty with increasing coverage – aiming to screen 90% of the eligible population in primary care over five years, in fact a majority remained unscreened after four years.29,30 Pharmacy screening is one mechanism for supporting the high coverage rate necessary to reduce population health disease burden via ‘high risk’ screening approaches.31
Exploring Clinical Care Among Adults With Diabetes Mellitus: Alignment With Recommended Statin and Sulfonylureas Treatment
2019, Canadian Journal of DiabetesLocal authority commissioning of NHS Health Checks: A regression analysis of the first three years
2018, Health PolicyCitation Excerpt :As part of the broader evaluation, we conducted national surveys to try to address these evidence gaps, but response rates were insufficient to be used in the analyses presented here [11]. Compared with previous evaluations [19], our study found less regional variation in coverage rates. We identified one study with a similar unit of analysis: Artac et al. explored variation in coverage rates amongst local health authorities (Primary Care Trusts (PCTs)) in 2011 [4] and found higher coverage in PCTs with greater levels of deprivation.
Are cardiovascular disease risk assessment and management programmes cost effective? A systematic review of the evidence
2017, Preventive MedicineCitation Excerpt :Recent systematic reviews have cast doubt on the effectiveness of CVD risk assessment programme on CVD risk factors, improving morbidity and mortality (Si et al., 2014; Chang et al., 2016; Krogsbøll et al., 2012). In addition, emerging evidence from England's NHS Health Checks programme have contradicted key assumptions (Chang et al., 2015; Chang et al., 2016; Economic Modelling for Vascular Checks, 2008), where uptake of the programme was found to be 21% in contrast to the 75% assumed in the modelling projections (Chang et al., 2015). Further, doubts remain regarding the predictive accuracy in the epidemiological modelling from risk factors to clinical events (Cooney et al., 2010).
A cross-sectional study examining the equitability of invitation, uptake and coverage for NHS Health Check
2023, Journal of Public Health (United Kingdom)