The results of the new cardiovascular risk calculator depend on the integration

Opinion


Benefits of updated guidelines will be missed if implementation issues are not addressed urgently, say a GP and CVD researcher.

About three-quarters of Australians at high risk of their first cardiovascular disease event are not receiving recommended basic drug therapies.


A public consultation on an updated Australian guideline for cardiovascular disease (CVD) risk assessment and management is underway, including a proposed new algorithm for calculating risk.


The algorithm incorporates the evolution of knowledge on risk assessment and represents an important advance since the publication of the last guidelines in 2012.


The proposed new equation is based on the New Zealand PREDICT equation and will be calibrated to ensure it more accurately represents the risk to the Australian population. It also includes new variables, including CVD medications, postal code as a measure of socioeconomic status, and history of atrial fibrillation.


Reclassification factors were introduced to take into account other considerations, including ethnic origin, family history and serious mental illness. After consultation, the guidelines will be launched for use in early 2023.


Primary care now has a critical window of opportunity to consider how CVD guidelines can best work on the front line.


There are currently significant gaps in cardiovascular risk assessment and management, with approximately three-quarters of people at high risk of their first cardiovascular event not receiving basic recommended drug therapies.


Without coordination mechanisms, the current implementation of CVD risk assessment is fragmented, resulting in variations in care and inequities. For example, some clinical software packages currently offer built-in calculators, but many of these are outdated and difficult to use.


Existing calculators also underestimate the risk for one in eight people aged 45 to 74 and two in five for Aboriginal and Torres Strait Islander people aged 18 and over.


Some GPs use resources from the Heart Health Check Toolkit, although manual data entry for risk calculations can be inefficient and inaccurate. There is currently no mechanism to update the guidelines or algorithm more frequently, despite the increasing pace of evidence generation.


Similarly, there is no coordinated approach to ensure that risk assessments are combined with best practice resources to communicate risks and make shared decisions on next steps.


These issues mean that the benefits of the new CVD guidelines will be missed if implementation issues are not addressed urgently.


To maximize the benefits of the new guidelines, cardiovascular risk assessment must be integrated seamlessly into the general practice workflow. Clinical software features could be leveraged to achieve this in new ways:

  • By creating the need for a cardiovascular risk assessment
  • Gather relevant variables from the clinical record
  • Prefill parts of the calculation
  • Generate shared decision resources for patients in the face of risk reduction

In Aotearoa, New Zealand, some of these strategies were used to achieve 90% CVD risk assessment coverage for eligible individuals.

Achieving similar penetration in Australia requires forward planning and leadership to consider and pursue different models for implementing the new guidelines.

One option would be to update the software packages to include the new algorithms, but these updates are subject to the vagaries of time and resources.

A per-provider approach has not been successful in the past and contributes to some of the current variations in clinical practice. Alternatively, a stand-alone risk assessment website could offer a standardized approach and links to resources, but adoption is likely to be limited in busy general practice settings without integration into software workflows.

Instead, increasingly accurate risk assessment algorithms will likely require more sophisticated approaches to integration and implementation. This could include “plug-in” technology independent of clinical software platforms, but capable of a seamless interface, centralized updates, and links to shared decision-making resources.

Achieving this would require new levels of cooperation, consultation and coordination between primary care, software providers and guideline development, but this has enormous potential benefits for cardiovascular disease and beyond. of the.

The need for leadership and coordination is urgent because software integration is a matter of clinical safety. Continued use of outdated calculators in clinical software packages risks inadequate assessment and also increases the likelihood of a mismatch between CVD risk assessment (using older algorithms) and management (using new new guidelines).

Misalignment between risk calculation and treatment guidelines would have disproportionate effects on some communities. For example, the updated guidelines offer a more nuanced approach to examining how Aboriginal and/or Torres Strait Islander identity affects CVD risk.

However, without guidelines built into the software, health professionals can simply ignore Indigenous status or apply outdated guidelines. This would mean that Aboriginal and Torres Strait Islander people – who are already underserved by the status quo – would not see CVD risks properly addressed.

General medicine now has the opportunity to develop and implement a vision to exploit the potential of risk assessment algorithms. General practitioners and primary care staff need the best possible systems to facilitate the delivery of high quality care.

In consulting rooms, details really matter: number of clicks, ease of use, look and feel, value of results, recommendations and resources. Getting the user experience right is key to getting a CVD risk assessment.

Governance systems are urgently needed to ensure that outdated risk calculators are removed from clinical software packages and replaced with something more accurate, effective and efficient.

The new cardiovascular disease guidelines reflect a decade of new research and knowledge about cardiovascular disease risk and risk management. Putting them directly on screen is the first step to putting them into practice.

Professor Banks is a member of the expert steering group for the update of the Australian guideline for the assessment and management of cardiovascular risk and chair of the algorithm working group for the update of the guideline.

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