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The team does not and cannot offer clinical advice. If you have any urgent medical enquiries we urge you to contact your GP, or NHS Direct at www.nhsdirect.nhs.uk or by calling 0845 4647. In an emergency call 999

CVDPREVENT

A National Audit for Primary Care

CVDPREVENT is a national primary care audit that will automatically extract routinely held GP data covering diagnosis and management of 6 high risk conditions that cause stroke, heart attack and dementia. These are atrial fibrillation, high blood pressure, high cholesterol, diabetes, non-diabetic hyperglycaemia and chronic kidney disease. There will be no data burden for GPs.
 
The audit programme is being developed as a tool for professionally led quality improvement with an overarching CVDPREVENT Implementation Steering Group providing leadership including RCGP, NHS Digital, NICE, Public Health England, NHS England, British Heart Foundation, Royal Pharmaceutical Society, Primary Care Cardiovascular Society and several GPs. Working with PRIMIS, and funded by the British Heart Foundation, the group has developed a draft business rule set for condition specific metrics which will be published on completion via NHS Digital. PRIMIS has also conducted a feasibility report which concluded that the audit is feasible and that the optimal route for extraction of the audit dataset would be via the NHS Digital GP Extraction Service (GPES).
 
Why the focus on CVD prevention?
Cardiovascular disease (CVD) is common and places a major burden on individuals and society. It accounts for almost a quarter of all premature deaths and is a key driver of health inequalities, accounting for a quarter of the life expectancy gap between rich and poor. CVD is also largely preventable. Primary prevention through population measures and modification of lifestyle risk factors is essential and will have the greatest long-term benefit. However, there is also substantial benefit to be gained by improving detection and management of the high-risk conditions for CVD. Treatment of these conditions is highly effective at preventing heart attack, stroke and dementia. There’s more information on Public Health England’s action on CVD prevention in a recent issue of Public Health Matters.
 
Why do we need a CVD prevention audit in primary care?
Despite the impact of treatment on outcomes, large numbers of people are undiagnosed or under treated, partly because these conditions often have no symptoms to alert the patient and clinician, partly because treatment decisions are complex, and partly because GP consultations are highly pressured with often competing priorities.
 
Overall in England, 5 million people have undiagnosed high blood pressure, 40% of people with diagnosed hypertension are not treated to the NICE 140/90 target, and 40% of people with known atrial fibrillation who have a stroke have not been anticoagulated. There is substantial variation in these achievement levels between practices and between geographies. As well as this under treatment, there is a parallel risk of over treatment in these conditions: for example, individuals with frailty or co-morbidities may find that the benefits of medication are outweighed by the adverse effects.

NHS Long Term Plan CVD prevention priority
The NHS Long Term Plan has identified CVD prevention as a national clinical priority, with an ambition to prevent 150,000 strokes, heart attacks and cases of dementia over the next 10 years by improving the detection and management of high blood pressure, high cholesterol and atrial fibrillation.
 
Routine audit is the essential starting point for this ambition. Without real time data, GPs, practices and networks have no indication of the scale of the problem or the opportunity for improvement for patients and populations. Audit is the only way to systematically identify individuals whose high-risk conditions are sub-optimally managed, either through non-diagnosis, under treatment or over treatment.

What will the CVDPREVENT audit do?
CVDPREVENT will provide real time intelligence to drive professionally led quality improvement in GP practices and across Primary Care Networks (PCNs), generating granular, anonymised data across a broad range of metrics derived from NICE guidance.

CVDPREVENT outputs will include regular (e.g. quarterly) extraction of routinely recorded primary care data, requiring no active data input from GPs. Analysis and reporting will identify gaps, variation and opportunity in treatment at primary care network (PCN), Sustainability and Transformation Partnerships(STP)/Integrated Care Systems (ICS) and national level. This will support systematic quality improvement to reduce health inequalities and improve outcomes for individuals and populations.

It is also anticipated that a practice level reporting function will be available on GP systems, showing in real time for every practice how many patients with the high-risk conditions are potentially undiagnosed, under treated or over treated. Reporting will cover 10 clinical domains (summarised below).

When will CVDPREVENT be made available?
A first data extraction using NHS Digital’s GP Extraction Services (GPES) is planned for March 2020 with initial analysis being undertaken early in 2020/21. It is envisaged that national reporting will commence Spring/Summer 2020.

 
August 2019

CVDPREVENT Audit Reports – Summary Table

Domain 1

Smoking

  1. Smoking status in people with high risk conditions (HRC)
  2. Smoking interventions in people with high risk conditions who smoke

Domain 2

High blood pressure

  1. BP control to thresholds specified in NICE guidance (HT, T2DM, T1DM, CKD)
  2. HBPM/ABPM following diagnosis in last year
  3. eGFR in last year
  4. Lifestyle advice in last year (smoking, alcohol, diet)
  5. Case finder - High BP >90 days ago (stratified to systolic above 140, 160, 180) with no HT diagnosis
  6. Case finder - any HRC or on statins - BP checked in last 12m

Domain 3

Lipids

  1. Familial Hypercholesterolaemia diagnosed or with TC/LDLc in at risk range
  2. Very high TC investigated for secondary causes and referred
  3. TG >10 investigated for causes (TFT, LFT, HbA1c)
  4. At risk range TC/LDLc assessed for FH
  5. Statin treatment as secondary prevention (pre-existing CVD)
  6. Statin treatment as primary prevention as per NICE: FH, QRisk >20%, Qrisk 10-20%, CKD, T1DM
  7. Over 40 with no CVD with high cholesterol and no QRisk assessment
  8. Case finder any of HRC not on statins with TC recorded in last 12 months

Domain 4

Atrial fibrillation

  1. CHA2DS2-VASc performed in last year (except where previously 2 or more)
  2. HASBLED performed before anticoagulation
  3. CHA2DS2-VASc score 2 or more and prescribed anticoagulant
  4. TTR in last 12 months if on warfarin
  5. Review in last 12 months if on anticoagulant
  6. Case finder - any CVD or HF, DM, HT, CKD and pulse rhythm checked in last 12 months

Domain 5

CKD 3-5

  1. Appropriate interval eGFR tests (as per NICE)
  2. ACR in last 12 months
  3. Proteinuria (of appropriate degree) treated with ACEi/ARB
  4. CKD 4-5 - ever had Ca/PO4/PTH tested
  5. CKD 3b-5 - Hb in last 12 months
  6. Case finder - last 2 eGFR (>2 weeks apart) below 60 and CKD not coded
  7. Case finder - most recent eGFR (>4 months ago) abnormal but not rechecked and CKD not coded

Domain 6

Non-diabetic hyperglycaemia

  1. NDH and ever referred to diabetes prevention lifestyle programme
  2. HbA1c or FPG in last 12 months
  3. BMI recorded in last 12 months
  4. Case finder - Latest HbA1c 42-47 without NDH or diabetes code
  5. Case finder - Previous gestational diabetes without HbA1c in last 12 months

Domain 7

Type 2 Diabetes

  1. Diagnosis in last 12 months referred for diabetes education
  2. Last HbA1c at target
  3. All 8 care processes coded in last 12 months
  4. Retinal screening in last 12 months
  5. Case finder - latest HbA1c results >48 and no diabetes code

Domain 8

Type 1 Diabetes

  1. Diagnosis in last 12 months referred for diabetes education
  2. Most recent HbA1c (in last 6 months) <48
  3. Review of CVD risk factors coded in last 12 months
  4. All 8 care processes coded in last 12 months
  5. Retinal screening in last 12 months

Domain 9

NHS Health Check

  1. Of those eligible (40-74 and no exclusion criteria), % who have had NHSHC invite in 5 years
  2. Of those eligible (40-74 and no exclusion criteria), % who have had NHSHC in 5 years

Domain 10

Indicators of potential treatment related harm

  1. Hypertension on treatment with latest systolic BP below 100
  2. Hypertension on treatment, and palliative care or GSF or severe frailty, with latest systolic BP below 110
  3. Diabetes on treatment with latest HbA1c (<90 days ago) below 42
  4. Diabetes on treatment and over 80 with latest HbA1c (<90 days ago) below 48
  5. Diabetes on treatment with co-morbidities that may reduce life expectancy (CKD 3-5, heart failure, stroke/TIA) with latest HbA1c (<90 days ago) below 58
  6. Palliative care or severe frailty code and being treated with statins
  7. AF and CHA2DS2VASc=0 or 1 being treated with anticoagulants

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The team does not and cannot offer clinical advice. If you have any urgent medical enquiries we urge you to contact your GP, or NHS Direct at www.nhsdirect.nhs.uk or by calling 0845 4647. In an emergency call 999