Experience in implementation of cardiovascular absolute risk assessment and management in Australian general practice

To the Editor: Cardiovascular absolute risk (CVAR) assessment (the probability of a cardiovascular event over 5 or 10 years calculated from multiple risk factors) has been recommended as a means of more accurately tailoring cardiovascular disease primary prevention strategies to the patient’s risk level (1–4). Although the use of CVAR assessment has been advocated for some time, the lack of an implementation strategy has hindered its translation from guideline into practice both in Australia (5–8) and overseas (9–11). Our team has developed a theoretical implementation model of CVAR assessment and management using multiple strategies to encourage use (12,13). We conducted a study in Sydney from 2006 to 2008, aiming to explore general practitioners’ (GPs) experience of implementing CVAR assessment and management, the feasibility of our model and patients’ experience of the impact of implementation in their doctor’s practice. We recruited five GPs and 25 patients to participate. Based on the CVAR implementation model (12), GP intervention included face-to-face training in their practices using the CVAR assessment (electronic calculator and paper-based chart) and management guideline (3) and regular telephone support. Patients completed a self-assessment questionnaire prior to seeing the GP. In the encounter, GPs assessed CVAR and then negotiated treatment goals with patients, provided education and pharmacotherapy, referred to other providers and arranged follow up according to the guideline. Participants were also followed up for 3 months, with their information collected by in-depth interviews (GPs: face-to-face, patients: by phone) and questionnaires. Qualitative data were analysed using thematic analysis (14) in nvivo 7 software (15) and quantitative data in spss software (16). The Human Research Ethics Committee of the University of New South Wales gave ethical approval for this study. Apart from one patient with a baseline CVAR >30% who died of a heart attack during 3 month follow-up period, all other patients completed the study. Before this study, none of the participating GPs used CVAR assessment routinely for their patients and two of them had never assessed CVAR. By the end of the study, they had all started using it in their routine practice and used the results more often to help inform their medication and referral decisions (especially to determine the threshold at which to initiate medication treatment). All GPs preferred the CVAR electronic calculator to the CVAR paper chart because: it was easy to use, took less time to use and allowed them to modify risk factors and recalculate CVAR. It allowed GPs to negotiate treatment options with their patients by demonstrating the outcomes for particular actions, such as the control of blood pressure or smoking cessation. Many patients also reported liking to see on the screen the impact of change in individual modifiable risk factors (e.g. smoking, BP or lipids) on their overall level of risk. Most GPs reported that using an electronic calculator to assess CVAR was an effective tool to help educate and motivate patients to make lifestyle changes. Most patients also reported that GPs mainly used CVAR results to recommend changing lifestyle rather than medications. Both GPs and patients agreed that CVAR consultation took a longer time (approximately 20 min) than usual. They generally reported more involvement of each other in the CVAR consultation. Many patients felt that their GPs’ care in the CVAR consultation was better than their usual care in terms of consultation content and time. In general, our results suggest that the implementation experience of CVAR assessment and management is successful, and the CVAR implementation model is feasible. Computer decision support programmes are commonly used to improve the effectiveness of the consultations (17). Other research suggests that integrated electronic calculators appeared more helpful than the paper-based risk prediction charts (18). In this study, GPs and patients preferred an electronic CVAR calculator to a paper-based chart. GPs especially liked the way the electronic calculator allowed them to visually demonstrate improvement in patient risk in response to management, as this positive communication was also encouraging to patients. In Australia, dissemination of CVAR assessment tools has so far been in paper-based format rather than an electronic calculator. Thus, incorporation of the electronic CVAR calculator as a visual aid into current practice software may be a necessary condition for widespread adoption of CVAR in general practice. There is good evidence for a positive relationship between the duration of consultations and the quality of care (19–21). In this study, GPs and patients generally reported that approximately 20 min were spent on CVAR assessment and management during the consultation, allowing GPs and patients’ sufficient time to assess the CVAR and discuss the result and management. Another research has found that after establishing that a patient was ‘at risk’ of CHD, primary care physicians reported spending an average of 16.5 min discussing risk factors and lifestyle changes or treatment (22). This suggests that a longer consultation with appropriate remuneration may be necessary for conducting proper CVAR assessment and management.