Uptake of the NHS Health Check programme in an urban setting

Twenty years on from the introduction of the high risk strategy for stroke and cardiovascular disease prevention: a systematic scoping review

BACKGROUND AND PURPOSE

Early this century, the high risk strategy of primary stroke and cardiovascular disease (CVD) prevention for individuals shifted away from identifying (and treating, as appropriate) all at-risk individuals towards identifying and treating individuals who exceed arbitrary thresholds of absolute CVD risk. The public health impact of this strategy is uncertain.

METHODS

In our systematic scoping review, the electronic databases (Scopus, MEDLINE, Embase, Google Scholar, Cochrane Library) were searched to identify and appraise publications related to primary CVD/stroke prevention strategies and their effectiveness published in any language from January 1990 to August 2023.

RESULTS

No published randomized controlled trial was found on the effectiveness of the high CVD risk strategy for primary stroke/CVD prevention. Targeting high CVD risk individuals excludes a large proportion of the population from effective blood-pressure-lowering and lipid-lowering treatment and effective CVD prevention. There is also evidence that blood pressure lowering and lipid lowering are beneficial irrespective of blood pressure and cholesterol levels and irrespective of absolute CVD risk and that risk-stratified pharmacological management of blood pressure and lipids to only high CVD risk individuals leads to significant underuse of blood-pressure-lowering and lipid-lowering medications in individuals otherwise eligible for such treatment.

CONCLUSIONS

Primary stroke and CVD prevention needs to be done in all individuals with increased risk of CVD/stroke. Pharmacological management of blood pressure and blood cholesterol should not be solely based on the high CVD risk treatment thresholds. International guidelines and global strategies for primary CVD/stroke prevention need to be revised.

Integrated approach to cardiovascular disease in people experiencing homelessness: a qualitative study

BACKGROUND

Homelessness is associated with an increased risk of cardiovascular disease (CVD), beyond impact of socioeconomic status. CVD is preventable and treatable, though barriers to interventions exist for people experiencing homelessness. Those with lived experience of homelessness and health professionals with relevant expertise can help to understand and address these barriers.

OBJECTIVES

To understand, and make recommendations to improve, CVD care in homeless populations through lived and professional expertise.

METHOD

Four focus groups were conducted in March-July 2019. Three groups included people currently or previously experiencing homelessness, each attended by a cardiologist (AB), a health services researcher (PB) and an 'expert by experience' (SB) who coordinated participants. One group included multidisciplinary health and social care professionals in and around London to explore solutions.

PARTICIPANTS

The three groups included 16 men and 9 women, aged 20-60 years, of whom 24 were homeless and currently living in hostels, and 1 rough sleeper. At least 14 discussed sleeping rough at some point.

RESULTS

Participants were aware of CVD risks and relevance of healthy habits but identified barriers to prevention and health access, starting with disorientation affecting planning and self-care, lack of facilities for food, hygiene and exercise, and experiences of discrimination.

CONCLUSIONS

CVD care for those experiencing homelessness should account for fundamental problems of the environment, be codesigned with service users and cover key principles: flexibility, public and staff education, integration of support and advocacy for health service rights.

A cross-sectional study examining the equitability of invitation, uptake and coverage for NHS Health Check

BACKGROUND

The evidence for access to NHS Health Check (NHSHC) varies considerably across the country. This study examined the equity in invitation, uptake and coverage of NHSHC and impact of different invitation methods.

METHODS

This patient-level cross-sectional study from 52 general practices in Walsall used adjusted logistic regressions to examine the association between patient characteristics (age, sex, ethnicity and deprivation) and NHSHC access.

RESULTS

Over the 5-year study period, 61 464 people were eligible for NHSHC, 66% were invited, uptake was 74% and coverage was 55%. Males had lower odds of: invitation (AOR: 0.78, 95% CI: 0.75-0.81), uptake (0.73, 95% CI: 0.70-0.77) and coverage (0.69, 95% CI: 0.66-0.71). Compared with White, the 'Other' ethnicity group (mixed backgrounds, other Asians that are not South Asians and other ethnic groups) had lower odds of: invitation (0.74, 95% CI: 0.67-0.81), uptake (0.86, 95% CI: 0.75-0.98) and coverage (0.74, 95% CI: 0.68-0.81). The most deprived areas had lower odds of invitation, uptake and coverage. Opportunistic invitation had a 25-fold increase in odds of uptake.

CONCLUSIONS

The study has highlighted areas of inequities in access to NHSHC. The group most negatively affected were men, people from particular minority ethnic groups and people from deprived communities. Further actions are needed to reduce these inequities.

Blood pressure and cholesterol measurements in primary care: cross-sectional analyses in a dynamic cohort

Background

Guidelines on cardiovascular risk management (CVRM) recommend blood pressure (BP) and cholesterol measurements every 5 years in men aged ≥40 years and (post-menopausal) women aged ≥50 years.

Aim

To evaluate CVRM guideline implementation.

Design & setting

Cross-sectional analyses in a dynamic cohort using primary care electronic health record (EHR) data from the Julius General Practitioners’ Network (JGPN) (n = 388 929).

Method

Trends (2008–2018) were assessed in the proportion of patients with at least one measurement (BP and cholesterol) every 1, 2, and 5 years, in those with:

1. a history of cardiovascular disease (CVD) and diabetes mellitus (DM);

2. a history of DM only;

3. a history of CVD only;

4. a cardiovascular risk assessment (CRA) indication based on other medical history, or;

5. no CRA indication.

Trends were evaluated over time using logistic regression mixed-model analyses.

Results

Trends in annual BP and cholesterol measurement increased for patients with a history of CVD from 37.0% to 48.4% (P<0.001) and 25.8% to 40.2% (P<0.001). In the 5-year window from 2014–2018, BP and cholesterol measurements were performed respectively in 78.5% and 74.1% of all men aged ≥40 years and 82.2% and 78.5% of all women aged ≥50 years. Least measured were patients without a CRA indication (men 60.2% and 62.4%; women 55.5% and 59.3%).

Conclusion

The fairly high frequency of CVRM measurements available in the EHR of patients in primary care suggests an adequate implementation of the CVRM guideline. As nearly all individuals visit the GP at least once within a 5-year time window, improvement of CVRM remains possible, especially in those without a CRA indication.

Increasing uptake of National Health Service Health Checks in primary care: a pragmatic randomized controlled trial of enhanced invitation letters in Northamptonshire, England

BACKGROUND

Uptake of NHS Health Checks (NHSHCs) is sub-optimal. This study aimed to increase their uptake using behaviourally informed invitation letters.

METHOD

Patients registered with 6 general practices in Northamptonshire, England who were eligible for an NHSHC between 10 February 2014 and 31 January 2015 were randomized monthly, using a random number generator, to three trial arms: control (standard invitation), sunk costs (resources already allocated) and counterargument (against common barriers to attendance). The outcome measure was uptake of NHSHC by 12 weeks after 31 January.

RESULTS

In total, 6331 patients were randomized. After exclusions, due to ineligibility for the NHSHC, data were analysed for N = 6313 patients: N = 2123 control; N = 2085 counterargument; N = 2105 sunk costs. Overall, 2364 (37.45%) patients attended an NHSHC. Both intervention letters increased uptake compared to control, by 5.46% using counterargument (adjusted odds ratio (AOR) 1.32, CI 1.162-1.51, p < 0.001) and 4.33% using sunk costs (AOR 1.246, CI 1.10-1.42, p < 0.001), with no significant difference between the two.

CONCLUSION

Behaviourally informed invitation letters, containing sunk costs or counterargument messages, can improve the uptake of NHSHCs. The trial was registered with the International Standard Randomised Controlled Trial Registration Number Scheme (ISRCTN57110614).

Effectiveness of the population-based 'check your health preventive programme' conducted in a primary care setting: a pragmatic randomised controlled trial

Background

Health checks have been suggested as an early detection approach aiming at lowering the risk of chronic disease development. This study aimed to evaluate the effectiveness of a health check programme offered to the general population, aged 30–49 years.

Methods

The entire population aged 30–49 years (N=26 216) living in the municipality of Randers, Denmark, was invited to a health check during 5 years. A pragmatic household cluster-randomised controlled trial was conducted in 10 505 citizens. The intervention group (IG, N=5250) included citizens randomised to the second year and reinvited in the 5th year. The comparison group (CG, N=5255) included citizens randomised to the 5th year. Outcomes were modelled cardiovascular disease (CVD) risk; self-reported physical activity (PA) and objectively measured cardio respiratory fitness (CRF); self-rated health (short-form 12 (SF-12)), self-rated mental health (SF-12_Mental Component Score (MCS)) and, registry information on sick-leave and employment. Due to low participation, we compared groups matched on propensity scores for participation when reinvited.

Results

Participation in the first health check was 51% (N=2698) in the IG and 40% (N=2120) in the CG. In the IG 26% (N=1340) participated in both the first and second health checks. No intervention effects were found comparing IG and CG. Mean differences were (95% CI): modelled CVD risk: −0.052 (95% CI −0.107 to 0.003)%, PA: −0.156 (−0.331 to 0.019) days/week with 30 min moderate PA, CRF: 0.133 (−0.560 to 0.826) mL O₂/min/kg, SF-12: −0.003 (−0.032 to 0.026), SF-12_MCS: 0.355 (-0.423 to 1.132), sick leave periods ≥3 weeks: −0.004 (−0.025 to 0.017), employment: −0.004 (−0.032 to 0.024).

Conclusions

Preventive health checks offered to the general population, aged 30–49 years, had no effects on a wide range of indicators of chronic disease risk.

Trial registration number

NCT02028195.

Gender differences in factors influencing intention to undergo cardiovascular disease health checks: A cross-sectional survey

Background

Undergo a health check for cardiovascular disease (CVD) is an important strategy to improve cardiovascular (CV) health. Men are reported to be less likely to undergo cardiovascular disease (CVD) health check than women. Gender difference could be one of the factors influencing health seeking behaviour of men and women. We aimed to identify gender differences in factors influencing the intention to undergo CVD health checks.

Methods

This was a cross-sectional survey using mall intercept interviews. Malaysians aged ≥30 years without known CVD were recruited. They were asked for their intention to undergo CVD health checks and associated factors. The factors included seven internal factors that were related to individuals’ attitude, perception and preparedness for CVD health checks and two external factors that were related to external resources. Hierarchical ordinal regression analysis was used to evaluate the importance of the factors on intention to undergo CVD health checks, for men and women separately.

Results

397 participants were recruited, 60% were women. For men, internal factors explained 31.6% of the variances in likeliness and 9.6% of the timeline to undergo CVD health checks, with 1.2% and 1.8% added respectively when external factors were sequentially included. For women, internal factors explained 18.9% and 22.1% of the variances, with 3.1% and 4.2% added with inclusion of the external factors. In men, perceived drawbacks of health checks was a significant negative factor associated with likeliness to undergo CVD health checks (coefficient = -1.093; 95%CI:-1.592 to -0.594), and timeline for checks (coefficient = -0.533; 95%CI:-0.975 to -0.091). In women, readiness to handle outcomes following health checks was significantly associated with likeliness to undergo the checks (coefficient = 0.575; 95%CI: 0.063 to 1.087), and timeline for checks (coefficient = 0.645; 95%CI: 0.162 to 1.128). Both external factors 1) influence by significant others (coefficient = 0.406; 95%CI: 0.013 to 0.800) and 2) external barriers (coefficient = -0.440; 95%CI:-0.869 to -0.011) were also significantly associated with likeliness to undergo CVD health checks in women.

Conclusions

Both men and women were influenced by internal factors in their intention to undergo CVD health checks, and women were also influenced by external factors. Interventions to encourage CVD health checks need to focus on internal factors and be gender sensitive.

Telephone outreach by community workers to improve uptake of NHS Health Checks in more deprived localities and minority ethnic groups: a qualitative investigation of implementation

BACKGROUND

NHS Health Checks is a national cardiovascular risk assessment and management programme in England. To improve equity of uptake in more deprived, and Black, Asian and minority ethnic (BAME) communities, a novel telephone outreach intervention was developed. The outreach call included an invitation to an NHS Health Check appointment, lifestyle questions, and signposting to lifestyle services. We examined the experiences of staff delivering the intervention.

METHODS

Thematic analysis of semi-structured interviews with 10 community Telephone Outreach Workers (TOWs) making outreach calls, and 5 Primary Care Practice (PCP) staff they liaised with. Normalization Process Theory was used to examine intervention implementation.

RESULTS

Telephone outreach was perceived as effective in engaging patients in NHS Health Checks and could reduce related administration burdens on PCPs. Successful implementation was dependent on support from participating PCPs, and tensions between the intervention and other PCP priorities were identified. Some PCP staff lacked clarity regarding the intervention aim and this could reduce the potential to capitalize on TOWs' specialist skills.

CONCLUSIONS

To maximize the potential of telephone outreach to impact equity, purposeful recruitment and training of TOWs is vital, along with support and integration of TOWs, and the telephone outreach intervention, in participating PCPs.

A systematic review of factors influencing NHS health check uptake: invitation methods, patient characteristics, and the impact of interventions

Background

The NHS Health Check (NHSHC) is a risk assessment for those aged 40–74 without a pre-existing condition in England, with the aim of preventing stroke, kidney disease, heart disease, type 2 diabetes and dementia. Uptake has been lower than anticipated. Ensuring that a high percentage of eligible patients receive a NHSHC is key to optimising the clinical and cost effectiveness of the programme. The aim of this systematic review is to highlight interventions and invitation methods that increase the uptake of NHSHCs, and to identify whether the effectiveness of these interact with broader patient and contextual factors.

Method

A systematic review was conducted according to the PRISMA checklist. Papers were eligible if they explored the impact of at least one of (i) interventions, (ii) invitation methods or (iii) broader factors on NHSHC uptake. Ten databases were searched in January 2016 and seven were searched in March 2018. Nine-hundred-and-forty-five papers were identified, 238 were screened and 64 full texts were assessed for eligibility. Nine studies were included in the review.

Results

The nine studies were all from peer reviewed journals. They included two randomised controlled trials, one observational cohort and six cross-sectional studies. Different invitation methods may be more effective for different groups of patients based on their ethnicity and gender. One intervention to enhance invitation letters effectively increased uptake but another did not. In addition, individual patient characteristics (such as age, gender, ethnicity and risk level) were found to influence uptake. This review also finds that uptake varies significantly by GP practice, which could be due either to unidentified practice-level factors or deprivation.

Conclusions

Further research is needed to assess the effectiveness of different invitation methods for different population groups. Research should examine how existing invitation methods can be enhanced to drive uptake whilst reducing health inequalities.

Trial registration

This systematic review was registered with PROSPERO on 22.02.2016. Registration number CRD42016035626.

Variations of health check attendance in later life: results from a British birth cohort study

BACKGROUND

Older adults are advised to attend a number of preventive health checks to preserve health and identify risk factors for disease. Previous research has identified a number of health and social factors, labelled as predisposing, enabling and need factors, using Andersen's Behavioural Model of Health Service Use, that are associated with health care utilisation. We aimed to assess associations between factors from childhood and adulthood, and health check attendance in later life in a British birth cohort study.

METHODS

For 2370 study members from the MRC National Survey of Health and Development (NSHD), health check attendance was assessed at age 68. Study members were asked if they: attended blood pressure and cholesterol checks, had their eyes tested, received the influenza vaccine, attended colon cancer screening and dental checks. Health and social factors from childhood and adulthood were used in binomial regression models to test associations with health check attendance in men and women.

RESULTS

Health check attendance was high; 41% reported attending all six health checks within the recommended time frame. In multivariable models, being a non-smoker and having more health conditions in adulthood were associated with greater health check attendance in men and women. In women, childhood socioeconomic advantage, being more physically active in midlife and previously attending screening procedures, and in men, greater self-organisation in adolescence and being married were associated with attending more health checks in later life, following adjustments for childhood and adulthood factors.

CONCLUSIONS

A number of predisposing, enabling and need factors from childhood and adulthood were found to be associated with health check attendance at age 68, demonstrating the relevance of applying a life course perspective to Andersen's model in investigating health check attendance in later life. Health related factors were found to be stronger correlates of health check attendance than socioeconomic factors.

Applying behavioural science to increase uptake of the NHS Health Check: a randomised controlled trial of gain- and loss-framed messaging in the national patient information leaflet

BACKGROUND

The NHS Health Check (NHSHC) is a national programme for the prevention of non-communicable diseases. Patients aged 40-74 without an existing cardiovascular-related condition should be invited quinquennially. Uptake is lower than anticipated. We assessed the impact on uptake of two new behaviourally-enhanced leaflets (with the current national leaflet as a control), enclosed with the invitation letter: the first trial on the leaflet.

METHODS

A double-blind three-armed randomized controlled trial was conducted. The new leaflets were shorter (two pages, instead of four); one was loss-framed ('don't miss out') and the other was gain-framed ('make the most of life'). The participants were patients from 39 practices in Lewisham and 17 practices in NE Lincolnshire, who were allocated to interventions using a random-number generator and received one of the leaflets with their invitation letter from April-September 2018. The outcome measure was uptake of an NHSHC by November 2018. The trial was powered to detect a 2% effect.

RESULTS

Uptake was 17.6% in the control condition (n = 3677), 17.4% in the loss-framed condition (n = 3664), and 18.2% in the gain-framed condition (n = 3697). Leaflet type was not a significant predictor of NHSHC uptake in a logistic regression that controlled for demographic variables, with GP practice as a random effect. Statistically significant predictors of uptake included location (higher uptake in Lewisham), age (increased age was associated with increased attendance) and sex (higher uptake in females). The Bayes Factor comparing the null to a hypothesis of differences between conditions was 416, which is extreme evidence in favour of the null hypothesis.

CONCLUSION

There was no evidence for a meaningful effect of either a loss-framed or gain-framed behaviourally-informed leaflet type on uptake, which is surprising, given that behaviourally informed letters have improved uptake of NHSHCs. It is possible that people do not pay attention to leaflets that are enclosed with letters, or that the leaflet continues to support informed decision-making but this does not affect uptake.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03524131. Registered May 14, 2018. Retrospectively registered.

Using general practitioners to recruit individuals with low socioeconomic position to preventive health checks is feasible: a cross sectional study

Objective: To test whether demographic and health-related characteristics are associated with non-attendance of preventive health checks offered to individuals with low levels of education using proactive recruitment by the general practitioners. Design: A cross-sectional study. Setting: 32 general practice clinics in Copenhagen, Denmark. Subjects: A total of 549 individuals aged 45-64, with low levels of education, enrolled in the intervention group of a randomised controlled trial on preventive health checks offered by general practitioner. Main outcome measures: Non-attendance of the preventive health checks. Methods: (i) Descriptive characteristics of attendees and non-attendees and (ii) crude and adjusted multi-level logistic regression to examine associations of individual characteristics with non-attendance of preventive health checks. Results: Overall, 33% did not attend the prescheduled preventive health checks at their general practitioners. Non-attendees were more likely to live without a partner, be of non-Western origin, be daily smokers, have poor self-rated health, have higher pulmonary symptoms score, have increased level of stress, have low levels of self-efficacy, have metabolic risk factors or non-communicable diseases and have had no contact with their general practitioner within the past year. Conclusion: The findings suggest that, it is feasible to use general practitioners for recruiting individuals for preventive health checks. However, even in a trial targeting individuals with low levels of education, there are differences between attendees and non-attendees, with a more adverse health behaviour profile and worse health status observed among the non-attendees. KEY POINTS Current awareness • Non-attendance of preventive health checks offered to the general population is associated with low socioeconomic position and adverse health behaviours. Main statements • It is feasible to use general practitioners proactively in recruitment to preventive health checks offered to individuals with low socioeconomic positions. • In a trial targeting individuals with low levels of education, there were differences between attendees and non-attendees. • Non-attendance was associated with daily smoking, poor self-rated health, high stress and no contact with the general practitioner within the last year.

Health checks and cardiovascular risk factor values over six years' follow-up: Matched cohort study using electronic health records in England

BACKGROUND

The National Health Service (NHS) in England introduced a population-wide programme for cardiovascular disease (CVD) prevention in 2009, known as NHS Health Checks. This research aimed to measure the cardiovascular risk management and cardiovascular risk factor outcomes of the health check programme during six years' follow-up.

METHODS AND FINDINGS

A controlled interrupted time series study was conducted. Participants were registered with general practices in the Clinical Practice Research Datalink (CPRD) in England and received health checks between 1 April 2010 and 31 December 2013. Control participants, who did not receive a health check, were matched for age, sex, and general practice. Outcomes were blood pressure, body mass index (BMI), smoking, and total cholesterol (TC) and high-density lipoprotein cholesterol (HDL). Analyses estimated the net effect of health check by year, allowing for the underlying trend in risk factor values and baseline differences between cases and controls, adjusting for age, sex, deprivation, and clustering by general practice. There were 127,891 health check participants and 322,910 matched controls. Compared with controls, health check participants had lower BMI (cases mean 27.0, SD 4.8; controls 27.3, SD 5.6, Kg/m2), systolic blood pressure (SBP) (cases 129.0, SD 14.3; controls 129.3, SD 15.0, mm Hg), and smoking (21% in health check participants versus 27% in controls), but total and HDL cholesterol were similar. Health check participants were more likely to receive weight management advice (adjusted hazard ratio [HR] 5.03, 4.98 to 5.08, P < 0.001), smoking cessation interventions (HR 3.20, 3.13 to 3.27, P < 0.001), or statins (HR 1.24, 1.21 to 1.27, P < 0.001). There were net reductions in risk factor values up to six years after the check for BMI (-0.30, -0.39 to -0.20 Kg/m2, P < 0.001), SBP (-1.43, -1.70 to -1.16 mm Hg, P < 0.001), and smoking (17% in health check participants versus 25% in controls; odds ratio 0.90, 0.87 to 0.94, P < 0.001). The main study limitation was that residual confounding may be present because randomisation was not employed; health check-associated measurement introduced differential recording that might cause bias.

CONCLUSIONS

Our results suggest that people who take up a health check generally have lower risk factor values than controls and are more likely to receive risk factor interventions. Risk factor values show net reductions up to six years following a health check in BMI, blood pressure, and smoking, which may be of public health importance.

NHS Health Check and healthy lifestyle in Leicester, England: analysis of a survey dataset

AIMS

A major component of the National Health Service (NHS) Health Check in England is to provide lifestyle advice to eligible participants. The aims of the study were to explore the variations (in terms of uptake) in the NHS Health Check in Leicester and to determine its association with a healthy lifestyle.

METHODS

This cross-sectional study used data from the Leicester Health and Wellbeing Survey (2015).

RESULTS

The odds of having an NHS Health Check were found to be higher in Black and minority ethnic groups and in people of other religions. The odds were lower in people without a religion, residing in the fourth index of multiple deprivation quintile and in ex-smokers. No associations were found between having an NHS Health Check and describing a healthy lifestyle, following a healthy lifestyle, thinking of making lifestyle changes in the next 6 months, cutting down on/stopping smoking among current smokers, or amount of alcohol current drinkers would like to drink.

CONCLUSIONS

In Leicester, a few variations in having an NHS Health Check were found among different socio-economic, demographic and behavioural groups. No association was found between the NHS Health Check and a healthy lifestyle. Thus, the improvement work should focus on reducing these variations in having the NHS Health Check and bringing its benefits on promoting a healthy lifestyle.

Randomised controlled trial comparing uptake of NHS Health Check in response to standard letters, risk-personalised letters and telephone invitations

Background

NHS Health Check is a primary prevention programme offering cardiovascular disease (CVD) risk assessment to adults in England aged 40–74. Uptake remains a challenge and invitation method is a strong predictor of uptake. There is evidence of low uptake when using invitation letters. Telephone invitations might increase uptake, but are not widely used. We explored the potential to improve uptake through personalising letters to patient’s CVD risk, and to compare this with generic letters and telephone invitations.

Methods

HEalth Check TRial (HECTR) was a three-arm randomised controlled trial in nine general practices in Staffordshire (UK). Eligible patients were randomised to be invited to a NHS Health Check using one of three methods: standard letter (control); telephone invitation; letter personalised to the patient’s CVD risk. The primary outcome was attendance/non-attendance. Data were collected on a range of patient- and practice-level factors (e.g., patient socio-demographics, CVD risk, practice size, Health Checks outside usual working hours). Multi-level logistic regression estimated the marginal effects to explore whether invitation method predicted attendance. Invitation costs were collated from practices to estimate cost benefit.

Results

In total, 4614 patients were included in analysis (mean age 50.2 ± 8.0 yr.; 52.4% female). Compared with patients invited by standard letter (30.9%), uptake was significantly higher in those invited by telephone (47.6%, P < .001), but not personalised letter (31.3%, p = .812). In multi-level analysis, compared with the standard letter arm, likelihood of attendance was 18 percentage points higher in the telephone arm and 4 percentage points higher in the personalised letter arm. The effect of telephone calls appeared strongest in patients who were younger and had lower CVD risk. We estimated per 1000 patients invited, risk-personalised letters could result in 40 additional attended Health Checks (at no extra cost) and telephone invitations could result in 180 additional Health Checks at an additional cost of £240.

Conclusions

Telephone invitations should be advocated to address the substantial deficit between current and required levels of NHS uptake, and could be targeted at younger and lower CVD risk adults. Risk-personalised letters should be explored further in a larger sample of high risk individuals.

Trial registration

Registration number: ISRCTN15840751 date of registration: 24/10/2017.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6540-8) contains supplementary material, which is available to authorized users.

Healthy shopper? Blood pressure testing in a shopping centre Pop-Up in England

BACKGROUND

Improving detection of elevated blood pressure (BP) remains a public health need. We present results from a Pop-Up health check stationed in shopping centres in England. We hypothesise the rate of case detection is related to measurable 'unhealthiness' of the shopping centres.

METHODS

A Pop-Up health check was sited in four and three shopping centres sampled from the top ten unhealthiest and top 15 healthiest shopping regions respectively, following a report ranking towns/cities based on their unhealthy and healthy retail outlets. On one day in each shopping centre, people were approached and consented to BP testing. Outcome measure was people flagged with BP ≥ 140/90 mmHg (cases).

RESULTS

We detected 45 (22.6%) and 20 (13.1%) cases from testing 199 and 152 adults in the unhealthy and healthy locations respectively (relative risk 1.72; 95% confidence interval: 1.06 to 2.78). A measure of unhealthy retail outlets (e.g. fast-food outlets) within each shopping centre was associated with detection rate (R2 = 0.61; p = 0.04).

CONCLUSION

An association exists between cases of suspect hypertension found in a health check Pop-Up and measured 'unhealthiness' of the shopping centre site. Results hint at strategies for public testing of BP, potentially in the context of reducing health inequalities.

Local authority commissioning of NHS Health Checks: A regression analysis of the first three years

In April 2013, the public health function was transferred from the NHS to local government, making local authorities (LAs) responsible for commissioning the NHS Health Check programme. The programme aims to reduce preventable mortality and morbidity in people aged 40-74. The national five-year ambition is to invite all eligible individuals and to achieve an uptake of 75%. This study evaluates the effects of LA expenditure on the programme's invitation rates (the proportion of the eligible population invited to a health check), coverage rates (the proportion of the eligible population who received a health check) and uptake rates (attendance by those who received a formal invitation letter) in the first three years of the reforms. We ran negative binomial panel models and controlled for a range of confounders. Over 2013/14-2015/16, the invitation rate, coverage rate and uptake rate averaged 57% 28% and 49% respectively. Higher per capita spend on the programme was associated with increases in both the invitation rate and coverage rate, but had no effect on the uptake rate. When we controlled for the LA invitation rate, the association between spend and coverage rate was smaller but remained statistically significant. This suggests that alternatives to formal invitation, such as opportunistic approaches in work places or sports centres, may be effective in influencing attendance.

Delivery and impact of the NHS Health Check in the first 8 years: a systematic review

BACKGROUND

Since 2009, all eligible persons in England have been entitled to an NHS Health Check. Uncertainty remains about who attends, and the health-related impacts.

AIM

To review quantitative evidence on coverage (the proportion of eligible individuals who attend), uptake (proportion of invitees who attend), and impact of NHS Health Checks.

DESIGN AND SETTING

A systematic review and quantitative data synthesis. Included were studies or data reporting coverage or uptake and studies reporting any health-related impact that used an appropriate comparison group or before- and-after study design.

METHOD

Eleven databases and additional internet sources were searched to November 2016.

RESULTS

Twenty-six observational studies and one additional dataset were included. Since 2013, 45.6% of eligible individuals have received a health check. Coverage is higher among older people, those with a family history of coronary heart disease, those living in the most deprived areas, and some ethnic minority groups. Just under half (48.2%) of those invited have taken up the invitation. Data on uptake and impact (especially regarding health-related behaviours) are limited. Uptake is higher in older people and females, but lower in those living in the most deprived areas. Attendance is associated with small increases in disease detection, decreases in modelled cardiovascular disease risk, and increased statin and antihypertensive prescribing.

CONCLUSION

Published attendance, uptake, and prescribing rates are all lower than originally anticipated, and data on impact are limited, with very few studies reporting the effect of attendance on health-related behaviours. High-quality studies comparing matched attendees and non-attendees and health economic analyses are required.

Automated recruitment and randomisation for an efficient randomised controlled trial in primary care

BACKGROUND/AIMS

Use of electronic health records and information technology to deliver more efficient clinical trials is attracting the attention of research funders and researchers. We report on methodological issues and data quality for a comparison of 'automated' and manual (or 'in-practice') methods for recruitment and randomisation in a large randomised controlled trial, with individual patient allocation in primary care.

METHODS

We conducted a three-arm randomised controlled trial in primary care to evaluate interventions to improve the uptake of invited NHS health checks for cardiovascular risk assessment. Eligible participants were identified using a borough-wide health check management information system. An in-practice recruitment and randomisation method used at 12 general practices required the research team to complete monthly visits to each general practice. For the fully automated method, employed for six general practices, randomisation of eligible participants was performed automatically and remotely using a bespoke algorithm embedded in the health check management information system.

RESULTS

There were 8588 and 4093 participants recruited for the manual and automated methods, respectively. The in-practice method was ready for implementation 3 months sooner than the automated method and the in-practice method allowed for full control and documentation of the randomisation procedure. However the in-practice approach was labour intensive and the requirement for participant records to be stored locally resulted in the loss of data for 10 practice months. No records for participants allocated using the automated method were lost. A fixed-effects meta-analysis showed that effect estimates for the primary outcome were consistent for the two allocation methods.

CONCLUSIONS

This trial demonstrated the feasibility of automated recruitment and randomisation methods into a randomised controlled trial performed in primary care. Future research should explore the application of these techniques in other clinical contexts and health care settings.

TRIAL REGISTRATION

Current Controlled Trials, ID: ISRCTN42856343 . Registered on 21 March 2013.

Cardiovascular risk at health checks performed opportunistically or following an invitation letter. Cohort study

Background

A population-based programme of health checks has been established in England. Participants receive postal invitations through a population-based call–recall system but health check providers may also offer health checks opportunistically. We compared cardiovascular risk scores for ‘invited’ and ‘opportunistic’ health checks.

Methods

Cohort study of all health checks completed at 18 general practices from July 2013 to June 2015. For each general practice, cardiovascular (CVD) risk scores were compared by source of check and pooled using meta-analysis. Effect estimates were compared by gender, age-group, ethnicity and fifths of deprivation.

Results

There were 6184 health checks recorded (2280 invited and 3904 opportunistic) with CVD risk scores recorded for 5359 (87%) participants. There were 17.0% of invited checks and 22.2% of opportunistic health checks with CVD risk score ≥10%; a relative increment of 28% (95% confidence interval: 14–44%, P < 0.001). In the most deprived quintile, 15.3% of invited checks and 22.4% of opportunistic checks were associated with elevated CVD risk (adjusted odds ratio: 1.94, 1.37–2.74, P  < 0.001).

Conclusions

Respondents at health checks performed opportunistically are at higher risk of cardiovascular disease than those participating in response to a standard invitation letter, potentially reducing the effect of uptake inequalities.

Enhanced Invitations Using the Question-Behavior Effect and Financial Incentives to Promote Health Check Uptake in Primary Care

Background

Uptake of health checks for cardiovascular risk assessment in primary care in England is lower than anticipated. The question-behavior effect (QBE) may offer a simple, scalable intervention to increase health check uptake.

Purpose

The present study aimed to evaluate the effectiveness of enhanced invitation methods employing the QBE, with or without a financial incentive to return the questionnaire, at increasing uptake of health checks.

Methods

We conducted a three-arm randomized trial including all patients at 18 general practices in two London boroughs, who were invited for health checks from July 2013 to December 2014. Participants were randomized to three trial arms: (i) Standard health check invitation letter only; (ii) QBE questionnaire followed by standard invitation letter; or (iii) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by standard invitation letter. In intention to treat analysis, the primary outcome of completion of health check within 6 months of invitation, was evaluated using a p value of .0167 for significance.

Results

12,459 participants were randomized. Health check uptake was evaluated for 12,052 (97%) with outcome data collected. Health check uptake within 6 months of invitation was: standard invitation, 590 / 4,095 (14.41%); QBE questionnaire, 630 / 3,988 (15.80%); QBE questionnaire and financial incentive, 629 / 3,969 (15.85%). Difference following QBE questionnaire, 1.43% (95% confidence interval -0.12 to 2.97%, p = .070); following QBE questionnaire and financial incentive, 1.52% (-0.03 to 3.07%, p = .054).

Conclusions

Uptake of health checks following a standard invitation was low and not significantly increased through enhanced invitation methods using the QBE.

Early Detection of Undiagnosed Hypertension Based on Occupational Screening in the Hotel and Restaurant Industry

Blood pressure is the most important, modifiable risk factor for cardiovascular diseases. Lifestyle factors and also workload are the main, potential risk factors for the development of hypertension. This study focused on the early detection of unknown hypertension by screening employees in the hotel and restaurant industry (HRI). 148 HRI employees without hypertension (mean age: 34 years, men: 45%) self-measured their blood pressure during rest and for 24 hours of a normal workday. Individuals with a resting blood pressure ≥ 135/85 mmHg were classified as hypertensive. A further analysis investigated whether the currently applicable thresholds for hypertension during work, leisure, and sleep were exceeded on a working day. At rest, 36% of the study participants suffered from hypertension, which increased to 70% under workload and 46% during leisure time and dropped to 8% during sleep. Normal nocturnal dipping (10–20%) occurred only in 18% of cases; 78% were extreme dippers (>20%). Occupational hypertension screening is a suitable component of preventive healthcare. Resting blood pressure measurement alone is insufficient for the early detection of risk individuals and should be supplemented by 24-hour ambulatory blood pressure monitoring under working conditions. The impact of workload on blood pressure needs to be given more attention in the guidelines.

Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records

BACKGROUND

A national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake.

OBJECTIVE

To evaluate the effectiveness of an enhanced invitation method using the question-behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks.

DESIGN

Three-arm randomised trial and cohort study.

PARTICIPANTS

All participants invited for a health check from 18 general practices. Individual participants were randomised.

INTERVENTIONS

(1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation.

MAIN OUTCOME MEASURES

The primary outcome was completion of the health check within 6 months of invitation. A p-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving 'opportunistic' health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction.

RESULTS

In total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) -0.12% to 2.97%; p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI -0.03% to 3.07%; p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was -0.01% (95% CI -1.59% to 1.58%; p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an 'opportunistic' health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99; p < 0.001).

CONCLUSIONS

Uptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42856343.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.

Development of a questionnaire to evaluate patients' awareness of cardiovascular disease risk in England's National Health Service Health Check preventive cardiovascular programme

BACKGROUND

The National Health Service (NHS) Health Check is a cardiovascular disease (CVD) risk assessment and management programme in England aiming to increase CVD risk awareness among people at increased risk of CVD. There is no tool to assess the effectiveness of the programme in communicating CVD risk to patients.

AIMS

The aim of this paper was to develop a questionnaire examining patients' CVD risk awareness for use in health service research evaluations of the NHS Health Check programme.

METHODS

We developed an 85-item questionnaire to determine patients' views of their risk of CVD. The questionnaire was based on a review of the relevant literature. After review by an expert panel and focus group discussion, 22 items were dropped and 2 new items were added. The resulting 65-item questionnaire with satisfactory content validity (content validity indices≥0.80) and face validity was tested on 110 NHS Health Check attendees in primary care in a cross-sectional study between 21 May 2014 and 28 July 2014.

RESULTS

Following analyses of data, we reduced the questionnaire from 65 to 26 items. The 26-item questionnaire constitutes four scales: Knowledge of CVD Risk and Prevention, Perceived Risk of Heart Attack/Stroke, Perceived Benefits and Intention to Change Behaviour and Healthy Eating Intentions. Perceived Risk (Cronbach's α=0.85) and Perceived Benefits and Intention to Change Behaviour (Cronbach's α=0.82) have satisfactory reliability (Cronbach's α≥0.70). Healthy Eating Intentions (Cronbach's α=0.56) is below minimum threshold for reliability but acceptable for a three-item scale.

CONCLUSIONS

The resulting questionnaire, with satisfactory reliability and validity, may be used in assessing patients' awareness of CVD risk among NHS Health Check attendees.

Does use of point-of-care testing improve cost-effectiveness of the NHS Health Check programme in the primary care setting? A cost-minimisation analysis

OBJECTIVE

To determine if use of point of care testing (POCT) is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check (NHSHC) programme in the primary care setting.

DESIGN

Observational study and theoretical mathematical model with microcosting approach.

SETTING

We collected data on NHSHC delivered at nine general practices (seven using POCT; two not using POCT).

PARTICIPANTS

We recruited nine general practices offering NHSHC and a pathology services laboratory in the same area.

METHODS

We conducted mathematical modelling with permutations in the following fields: provider type (healthcare assistant or nurse), type of test performed (total cholesterol with either lab fasting glucose or HbA1c), cost of consumables and variable uptake rates, including rate of non-response to invite letter and rate of missed [did not attend (DNA)] appointments. We calculated total expected cost (TEC) per 100 invites, number of NHSHC conducted per 100 invites and costs for completed NHSHC for laboratory and POCT-based pathways. A univariate and probabilistic sensitivity analysis was conducted to account for uncertainty in the input parameters.

MAIN OUTCOME MEASURES

We collected data on cost, volume and type of pathology services performed at seven general practices using POCT and a pathology services laboratory. We collected data on response to the NHSHC invitation letter and DNA rates from two general practices.

RESULTS

TEC of using POCT to deliver a routine NHSHC is lower than the laboratory-led pathway with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of POCT can deliver NHSHC in one sitting, whereas the laboratory pathway offers patients several opportunities to DNA appointment.

CONCLUSIONS

TEC of using POCT to deliver an NHSHC in the primary care setting is lower than the laboratory-led pathway. Using POCT minimises DNA rates associated with laboratory testing and enables completion of NHSHC in one sitting.

Evaluation of community provision of a preventive cardiovascular programme - the National Health Service Health Check in reaching the under-served groups by primary care in England: cross sectional observational study

Background

Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.

Methods

Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs). We assessed variation between local authorities in terms of age, sex, deprivation and ethnicity structures using two sample t-tests and within local authority variation in terms of ethnicity and deprivation using Chi squared tests and two sample t-tests respectively.

Results

Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs – namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40–49 and 50–59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs.

Conclusions

Community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities therein.

'I should have taken that further' - missed opportunities during cardiovascular risk assessment in patients with psoriasis in UK primary care settings: a mixed-methods study

BACKGROUND

Unhealthy lifestyle is common in psoriasis, contributing to worsening disease and increased cardiovascular disease (CVD) risk. CVD risk communication should improve patients' understanding of risk and risk-reducing behaviours; however, the effectiveness of risk screening is debated and evaluation currently limited.

OBJECTIVE

To examine the process of assessing for and communicating about CVD risk in the context of psoriasis.

DESIGN

Mixed-methods study in English general practices to (i) determine proportions of CVD risk factors among patients with psoriasis at risk assessment and (ii) examine patient and practitioner experiences of risk communication to identify salient 'process' issues. Audio recordings of consultations informed in-depth interviews with patients and practitioners using tape-assisted recall, analysed with framework analysis.

PARTICIPANTS

Patients with psoriasis (n = 287) undergoing CVD risk assessment; 29 patients and 12 practitioners interviewed.

RESULTS

A high proportion of patients had risk factor levels apparent at risk assessment above NICE recommendations: very high waist circumference (52%), obesity (35%), raised blood pressure (29%), smoking (18%) and excess alcohol consumption (18%). There was little evidence of personalized discussion about CVD risk and behaviour change support in consultations. Professionals reported a lack of training in behaviour change, while patients wanted to discuss CVD risk/risk reduction and believed practitioners to be influential in supporting lifestyle management.

CONCLUSIONS

Despite high levels of risk factors identified, opportunities may be missed in consultations to support patients with psoriasis to understand CVD risk/risk reduction. Practitioners need training in behaviour change techniques to capitalize on 'teachable moments' and increase the effectiveness of risk screening.

Experiences of patients and healthcare professionals of NHS cardiovascular health checks: a qualitative study

BACKGROUND

NHS Health Checks are a national cardiovascular risk assessment and management programme in England and Wales. We examined the experiences of patients attending and healthcare professionals (HCPs) conducting NHS Health Checks.

METHODS

Interviews were conducted with a purposive sample of 28 patients and 16 HCPs recruited from eight general practices across a range of socio-economic localities. Interviews were audio recorded, transcribed, anonymized and analysed thematically.

RESULTS

Patients were motivated to attend an NHS Health Check because of health beliefs, the perceived value of the programme, a family history of cardiovascular and other diseases and expectations of receiving a general health assessment. Some patients reported benefits including reassurance and reinforcement of healthy lifestyles. Others experienced confusion and frustration about how results and advice were communicated, some having a poor understanding of the implications of their results. HCPs raised concerns about the skill set of some staff to competently communicate risk and lifestyle information.

CONCLUSIONS

To improve the satisfaction of patients attending and improve facilitation of lifestyle change, HCPs conducting the NHS Health Checks require sufficient training to equip them with appropriate skills and knowledge to deliver the service effectively.

Exploring equity in uptake of the NHS Health Check and a nested physical activity intervention trial

BACKGROUND

Socio-demographic factors characterizing disadvantage may influence uptake of preventative health interventions such as the NHS Health Check and research trials informing their content.

METHODS

A cross-sectional study examining socio-demographic characteristics of participants and non-participants to the NHS Health Check and a nested trial of very brief physical activity interventions within this context. Age, gender, Index of Multiple Deprivation (IMD) and ethnicity were extracted from patient records of four General Practices (GP) in England.

RESULTS

In multivariate analyses controlling for GP surgery, the odds of participation in the Health Check were higher for older patients (OR 1.05, 95% CI 1.04-1.07) and lower from areas of greater deprivation (IMD Quintiles 4 versus 1, OR 0.37, 95% CI 0.18-0.76, 5 versus 1 OR 0.42, 95% CI 0.20-0.88). Older patients were more likely to participate in the physical activity trial (OR 1.04, 95% CI 1.02-1.06).

CONCLUSIONS

Younger patients and those living in areas of greater deprivation may be at risk of non-participation in the NHS Health Check, while younger age also predicted non-participation in a nested research trial. The role that GP-surgery-specific factors play in influencing participation across different socio-demographic groups requires further exploration.

Targeted case finding in the prevention of cardiovascular disease: a stepped wedge cluster randomised controlled trial

BACKGROUND

Individuals at high risk of cardiovascular disease (CVD) are undertreated.

AIM

To evaluate the effectiveness of a programme of targeted, nurse-led case finding for CVD prevention in primary care.

DESIGN AND SETTING

Targeted case finding for CVD prevention was implemented in urban West Midlands general practices between February 2009 and August 2012, and evaluated as a stepped wedge cluster randomised trial.

METHOD

Untreated patients aged 35-74 years and at ≥20% 10-year CVD risk were identified, invited for assessment by a project nurse, and referred to their GP for treatment initiation. The primary outcome was the proportion of high-risk patients prescribed antihypertensives or statins after exposure to the intervention compared with an equivalent period of time prior to exposure. Secondary outcomes included assessment of CVD risk factors.

RESULTS

In 26 sequentially randomised general practices the exposed group consisted of 2926 untreated high-risk patients identified at the start of the intervention, with 2969 patients identified at the start of the unexposed period. The trial was well balanced in terms of age, sex, and cardiovascular risk factors. In the exposed period 19.7% of patients were prescribed antihypertensives or statins, and 10.8% of patients in the unexposed period. After adjustment for clustering and temporal effects the risk difference was 15.5% (95% CI = 3.9 to 27.1, P = 0.009). Assessment of lipid levels increased significantly, at 26.4% (99% CI = 5.3 to 47.5, P = 0.001) CONCLUSION: Targeted case finding programmes can increase the number of high-risk patients started on antihypertensive and statin treatment.

Untreated hypertension in the UK household population - Who are missed by the general health checks?

Hypertension is an age-related, long-term condition and a leading risk factor for premature death and disability worldwide. Due to its asymptomatic nature it can often be left undiagnosed. Long-term treatment is available, but blood pressure can also be reduced through health behaviour changes in weight control, smoking cessation, higher physical activity levels, reduced salt and alcohol intake, and healthful diets if discovered early. This paper investigates the prevalence and characteristics of those with untreated (compared to treated) hypertension who did not have a history of cardiovascular disease (CVD); a group who is in effect missed by general health checks. Untreated hypertension was studied in 8933 individuals aged 40-74 years representative of the UK household population, who were interviewed and underwent a physical health examination in their home, 2010-2012. The prevalence of untreated hypertension without a history of CVD was 7% for men, 2% for women, and 5% overall. Untreated hypertension was particularly high among the 55-64 year age group. Age and sex-adjusted analyses found strong positive associations with male gender, smoking, self-reported good-excellent health, full fat dairy preference, white bread preference, higher alcohol consumption, and living alone. Strong negative associations were found for possessing 5 + prescription drugs, statins or antiplatelets, being diagnosed with diabetes or possessing antidiabetics, and long-term limiting illness status. Notably, many reported their health as good to excellent. A fact which emphasises the importance of motivating individuals to take part in the general health checks for an asymptomatic condition such as hypertension.

The effectiveness of an enhanced invitation letter on uptake of National Health Service Health Checks in primary care: a pragmatic quasi-randomised controlled trial

BACKGROUND

The National Health Service Health Check (NHS HC) is a population level public health programme. It is a primary prevention initiative offering cardiovascular risk assessment and management for adults aged 40-74 years (every five years). It was designed to reduce the incidence of major vascular disease events by preventing or delaying the onset of diabetes, heart and kidney disease, stroke and vascular dementia . Effectiveness of the programme has been modelled on a national uptake of 75% however in 2012/13 uptake, nationally, was 49%. Ensuring a high percentage of those offered an NHS HC actually receive one is key to optimising the clinical and cost effectiveness of the programme.

METHODS

A pragmatic quasi-randomised controlled trial was conducted in four general practitioner practices in Medway, England with randomisation of 3511 patients. The aim was to compare attendance at the NHS HC using the standard national invitation template letter (control) compared to an enhanced invitation letter using insights from behavioural science (intervention). The intervention letter includes i) simplification - reducing letter content for less effortful processing ii) behavioural instruction - action focused language iii) personal salience - appointment due rather than invited and iv) addressing implementation intentions with a tear off slip to record the date, time and location of the appointment. Logistic Regression explored the association between control and intervention group and attendance at a health check.

RESULTS

29.3% of patients who received the control letter and 33.5% of those who received the intervention letter attended their NHS HC (adjusted odds ratio 1.26, 95% confidence interval 1.09-1.47, p < 0.01). This was an absolute difference in uptake of 4.2 percentage points for those receiving the intervention letter.

CONCLUSIONS

An invitation letter applying behavioural insights was more effective than the existing national template letter at encouraging attendance at an NHS HC. Making small, no cost behaviourally informed changes to letter invitations can improve uptake of the NHS HC. Further research is required to replicate the effect with more robust methodology and powered for sub-group analysis including socio-economic status.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66757664 , date of registration 28/3/2014.

Who uses NHS health checks? Investigating the impact of ethnicity and gender and method of invitation on uptake of NHS health checks

Background

NHS Health Checks is a national risk assessment prevention programme for all individuals aged 40-74 that reside in England. Through the systematic assessment of an individual’s ten year disease risk, this programme aims to provide early identification and subsequent management of this risk. However, there is limited evidence on how socio-demographic factors impact on uptake and what influence the invitation method has on uptake to this programme.

Methods

NHS Health Check data from April 2013 to March 2014 was analysed (N = 50,485) for all 30 GP Practices in Luton, a culturally diverse town in England, UK. Data was collected for age, ethnicity, uptake (attendance and non attendance) and invitation method (letter written, verbal face-to-face, telephone). Actual usage of NHS Health Checks was determined for each ethnic group of the population and compared using Chi-square analysis.

Results

The overall uptake rate for Luton was 44 %, markedly lower that the set target of 50–75 %. The findings revealed a variation of uptake in relation to age, gender, level of deprivation. Ethnicity and gender variations were also found, with ‘White British’ ‘Black Caribbean’ and ‘Indian’ patients most likely to take up a NHS Health Check.

However, patients from ‘Any Other White Background’ and ‘Black African’ were significantly less likely to uptake an NHS Health Check compared to all other ethnic groups. Ethnicity and gender differences were also noted in relation to invitation method.

Conclusions

The findings revealed that different invitation methods were effective for different ethnic and gender groups. Therefore, it is suggested that established protocols of invitation are specifically designed for maximizing the response rate for each population group. Future research should now focus on uncovering the barriers to uptake in particular culturally diverse population groups to determine how public health teams can better engage with these communities.

Assessing potential local routine monitoring indicators of reach for the NHS health checks programme

OBJECTIVES

Success in reaching target populations is an important factor in determining the impact of public health programmes. The NHS Health Check (NHSHC) Programme is directed towards reducing excess cardiovascular mortality in England. As the programme is locally commissioned, local monitoring of programme reach is essential. This study aimed to assess indicators of programme reach available to local service commissioners.

STUDY DESIGN

Ecological.

METHODS

The programme reach of NHSHC was assessed in three health districts in the North East of England. Local data returned from GP practices to commissioners on their NHSHC activities was collated for the period October 2010 to March 2013 together with related national published data. Three candidate indicators were chosen and the association between each of these and NHSHCs at GP practice level was examined by univariate logistic regression.

RESULTS

Data were available from 101 GP practices, together undertaking almost 20,000 health checks a year. Number of NHSHCs by practices explained most (77-92%) of the variance the numbers identified at high risk of cardiovascular disease (two for every ten NHSHCs). NHSHCs were not associated with growth in GP practice disease registers for either diabetes or hypertension. NHSCHs predicted practices identification of new cases of hypertension (with one case identified for every ten checks), albeit the proportion of variation explained was much more variable (2-60%) less consistent effect.

CONCLUSIONS

Data routinely available to NHSHC commissioners can support monitoring programme reach, with numbers of new cases of hypertension being the most promising indicator of reach.

The provision of NHS health checks in a community setting: an ethnographic account

BACKGROUND

The UK National Health Service Health Checks programme aims to reduce avoidable cardiovascular deaths, disability and health inequalities in England. However, due to the reported lower uptake of screening in specific black and minority ethnic communities who are recognised as being more at risk of cardiovascular disease, there are concerns that NHS Health Checks may increase inequalities in health. This study aimed to examine the feasibility and acceptability of community outreach NHS Health Checks targeted at the Afro-Caribbean community.

METHODS

This paper reports findings from an ethnographic study including direct observation of four outreach events in four different community venues in inner-city Bristol, England and follow up semi-structured interviews with attendees (n = 16) and staff (n = 4). Interviews and field notes were transcribed, anonymized and analysed thematically using a process of constant comparison.

RESULTS

Analysis revealed the value of community assets (community engagement workers, churches, and community centres) to publicise the event and engage community members. People were motivated to attend for preventative reasons, often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing or prompting some to make healthy lifestyle changes. The NHS Health Check provided an opportunity for attendees to raise other health concerns with health staff and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality.

CONCLUSIONS

Outreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and in promoting the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes.

Implementation of NHS Health Checks in general practice: variation in delivery between practices and practitioners

Aim To evaluate NHS Health Check implementation in terms of frequency of data recording, advice provided, referrals to community-based lifestyle support services, statin prescribing and new diagnoses, and to assess variation in these aspects between practices and health professionals involved in delivery.

BACKGROUND

Most NHS Health Checks are delivered by general practices, but little detail is known about the extent of variation in how they are delivered in different practices and by different health professionals.

METHODS

This was an observational study conducted in a purposively selected sample of 13 practices in Sefton, North West England. Practices used previously recorded information from their clinical management systems to identify patients with cardiovascular disease (CVD) risk ⩾20%, a potentially cost-effective approach. The evaluation was conducted during the first year of delivery in Sefton. Data were extracted from medical records of all patients identified, regardless of Health Check attendance. Findings Of the 2892 patients identified by the 13 practices, 1070 had received an NHS Health Check at the time of the study. Of these, only 936 (87.5%) had a recorded CVD risk score, with risk ⩾20% confirmed in 92.0%. Estimated risk category was correct in 456/677 (67.4%) of patients with estimated and actual risk scores. Significant variation was found between practices and health professionals in parameters recorded, tests requested, advice given and referrals for lifestyle support. Only 45.3% of patients had body mass index, smoking, alcohol, exercise, blood pressure and cholesterol all recorded. Lifestyle advice and referral into lifestyle services were documented in 80.6% and 6.4% of attenders, respectively, again with significant variation between practices and professionals. Statin prescribing rose in attenders from 19.6% to 34.6%. A similar proportion of attenders and non-attenders received new diagnoses.

CONCLUSION

Effort is required to reduce variation in how practices deliver and follow-up NHS Health Checks, to ensure the consistency of the programme.

Lessons learned from England's Health Checks Programme: using qualitative research to identify and share best practice

Background

This study aimed to explore the challenges and barriers faced by staff involved in the delivery of the National Health Service (NHS) Health Check, a systematic cardiovascular disease (CVD) risk assessment and management program in primary care.

Methods

Data have been derived from three qualitative evaluations that were conducted in 25 General Practices and involved in depth interviews with 58 staff involved all levels of the delivery of the Health Checks. Analysis of the data was undertaken using the framework approach and findings are reported within the context of research and practice considerations.

Results

Findings indicated that there is no ‘one size fits all’ blueprint for maximising uptake although success factors were identified: evolution of the programme over time in response to local needs to suit the particular characteristics of the patient population; individual staff characteristics such as being proactive, enthusiastic and having specific responsibility; a supportive team. Training was clearly identified as an area that needed addressing and practitioners would benefit from CVD specific baseline training and refresher courses to keep them up to date with recent developments in the area. However there were other external factors that impinged on an individual’s ability to provide an effective service, some of these were outside the control of individuals and included cutbacks in referral services, insufficient space to run clinics or general awareness of the Health Checks amongst patients.

Conclusions

The everyday experiences of practitioners who participated in this study suggest that overall, Health Check is perceived as a worthwhile exercise. But, organisational and structural barriers need to be addressed. We also recommend that clear referral pathways be in place so staff can refer patients to appropriate services (healthy eating sessions, smoking cessation, and exercise referrals). Local authorities need to support initiatives that enable data sharing and linkage so that GP Practices are informed when patients take up services such as smoking cessation or alcohol harm reduction programmes run by social services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0365-z) contains supplementary material, which is available to authorized users.

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

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 40-74years 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 70-74years) 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.

A retrospective evaluation of the NHS Health Check Programme in a multi-ethnic population

BACKGROUND

The NHS Health Check Programme was introduced in 2009 to improve primary prevention of coronary heart disease, stroke, diabetes and chronic kidney disease; however, there has been debate regarding the impact. We present a retrospective evaluation of Leicester City Clinical Commissioning Group.

METHODS

Data are reported on diagnosis of type 2 diabetes, hypertension, chronic kidney disease, high risk of type 2 diabetes and high risk of cardiovascular disease. Data on management following the Health Check are also reported.

RESULTS

Over a 5-year period, 53 799 health checks were performed, 16 388 (30%) people were diagnosed with at least one condition when diagnosis of being at high risk of cardiovascular disease was defined as ≥20%. This figure increased to 43% when diagnosis of high cardiovascular risk ≥10% was included. Of the 3063 (5.7%) individuals diagnosed with type 2 diabetes, 54% were prescribed metformin and 26% were referred for structured education. Of the 5797 (10.8%) individuals diagnosed at high risk of cardiovascular disease (≥20%), 64% were prescribed statins.

CONCLUSIONS

A high proportion of new cases of people at risk of cardiovascular disease were identified by the NHS Health Check Programme. Data suggest that this has translated into appropriate preventative measures.

Neighborhood deprivation is strongly associated with participation in a population-based health check

Background

We sought to examine whether neighborhood deprivation is associated with participation in a large population-based health check. Such analyses will help answer the question whether health checks, which are designed to meet the needs of residents in deprived neighborhoods, may increase participation and prove to be more effective in preventing disease. In Europe, no study has previously looked at the association between neighborhood deprivation and participation in a population-based health check.

Methods

The study population comprised 12,768 persons invited for a health check including screening for ischemic heart disease and lifestyle counseling. The study population was randomly drawn from a population of 179,097 persons living in 73 neighborhoods in Denmark. Data on neighborhood deprivation (percentage with basic education, with low income and not in work) and individual socioeconomic position were retrieved from national administrative registers. Multilevel regression analyses with log links and binary distributions were conducted to obtain relative risks, intraclass correlation coefficients and proportional change in variance.

Results

Large differences between neighborhoods existed in both deprivation levels and neighborhood health check participation rate (mean 53%; range 35-84%). In multilevel analyses adjusted for age and sex, higher levels of all three indicators of neighborhood deprivation and a deprivation score were associated with lower participation in a dose-response fashion. Persons living in the most deprived neighborhoods had up to 37% decreased probability of participating compared to those living in the least deprived neighborhoods. Inclusion of individual socioeconomic position in the model attenuated the neighborhood deprivation coefficients, but all except for income deprivation remained statistically significant.

Conclusion

Neighborhood deprivation was associated with participation in a population-based health check in a dose-response manner, in which increasing neighborhood deprivation was associated with decreasing participation. This suggests the need to develop preventive health checks tailored to deprived neighborhoods.

Method of invitation and geographical proximity as predictors of NHS Health Check uptake

BACKGROUND

Uptake of NHS Health Checks remains below the national target. Better understanding of predictors of uptake can inform targeting and delivery. We explored invitation method and geographical proximity as predictors of uptake in deprived urban communities.

METHODS

This observational cohort study used data from all 4855 individuals invited for an NHS Health Check (September 2010-February 2014) at five general practices in Stoke-on-Trent, UK. Attendance/non-attendance was the binary outcome variable. Predictor variables included the method of invitation, general practice, demographics, deprivation and distance to Health Check location.

RESULTS

Mean attendance (61.6%) was above the city and national average, but varied by practice (47.5-83.3%; P < 0.001). Telephone/verbal invitations were associated with higher uptake than postal invitations (OR = 2.87, 95% CI = 2.26-3.64), yet significant practice-level variation remained. Distance to Health Check was not associated with attendance. Increasing age (OR = 1.04, 95% CI = 1.03-1.04), female gender (OR = 1.48, 95% CI = 1.30-1.68) and living in the least deprived areas (OR = 1.59, 95% CI = 1.23-2.05) were all independent positive predictors of attendance.

CONCLUSIONS

Using verbal or telephone invitations should be considered to improve Health Check uptake. Other differences in recruitment and delivery that might explain remaining practice-level variation in uptake warrant further exploration. Geographical proximity may not be an important predictor of uptake in urban populations.

Views of practice managers and general practitioners on implementing NHS Health Checks

As part of an evaluation of a contract with general practices to deliver the national NHS Health Checks programme in Sefton, North West England, we surveyed general practitioners (GPs) and practice managers (PMs) in all 55 practices. The contract required practices to identify individuals from their practice registers with potentially high cardiovascular disease risk, and provide annual reviews. Responses were obtained from 43/178 GPs and 40/55 PMs representing 56 and 73% of practices, respectively. There was variation in many aspects of implementation. Time and software were viewed as barriers to implementation, the increased nurse workload impacted on other services and payments were insufficient to cover costs. The main enabler for successful implementation was IT support. Fewer than half the respondents viewed the programme as beneficial to their practice. Findings have been used to address many issues raised. Practices need more support from commissioners to help implement NHS Health Checks.

A process evaluation of the NHS Health Check care pathway in a primary care setting

BACKGROUND

More evidence is needed concerning the implementation of the NHS Health Check programme in order to identify areas for improvement. The aim of the study was to investigate the way in which the Gloucestershire NHS Health Check programme care pathway was followed and interpreted compared with national programme indicators.

METHODS

A cross sectional review of Gloucestershire's Health Checks was undertaken to assess programme performance via a primary care audit of key indicators within a cohort of 83 GP practices and an eligible population of 210 513. Data were assessed to compare differences between practices and to compare county data with national indicators.

RESULTS

The annual programme uptake was 49.8% and a total of 1031 patients were diagnosed with cardiovascular disease (CVD). Variations in the detection of modifiable risk factors in relation to the NHS Ready Reckoner were identified: diabetes (-0.04%), CKD (-0.9%), hypertension (-19.9%); obesity (-7.1%); low physical activity (-57.7%) and smoking (-14.3%).

CONCLUSIONS

Disparities in uptake and implementation of the care pathway demonstrate inconsistencies in the application of processes and knowledge. There appears to be an overestimation of CVD risk by the Ready Reckoner tool likely to be attributable to a failure to adjust for existing local early identification efforts in primary care and prevention.

The NHS Health Check programme: implementation in east London 2009-2011

OBJECTIVES

To describe implementation and results from the National Health Service (NHS) Health Check programme.

DESIGN

Three-year observational open cohort study: 2009-2011.

PARTICIPANTS

People of age 40-74 years eligible for an NHS Health Check.

SETTING

139/143 general practices in three east London primary care trusts (PCTs) serving an ethnically diverse and socially disadvantaged population.

METHOD

Implementation was supported with education, IT support and performance reports. Tower Hamlets PCT additionally used managed practice networks and prior-stratification to call people at higher cardiovascular (CVD) risk first.

MAIN OUTCOMES MEASURES

Attendance, proportion of high-risk population on statins and comorbidities identified.

RESULTS

Coverage 2009, 2010, 2011 was 33.9% (31,878/10,805), 60.6% (30,757/18,652) and 73.4% (21,194/28,890), respectively. Older people were more likely to attend than younger people. Attendance was similar across deprivation quintiles and was in accordance with population distributions of black African/Caribbean, South Asian and White ethnic groups. 1 in 10 attendees were at high-CVD risk (20% or more 10-year risk). In the two PCTs stratifying risk, 14.3% and 9.4% of attendees were at high-CVD risk compared to 8.6% in the PCT using an unselected invitation strategy. Statin prescription to people at high-CVD risk was higher in Tower Hamlets 48.9%, than in City and Hackney 23.1% or Newham 20.2%. In the 6 months following an NHS Health Check, 1349 new cases of hypertension, 638 new cases of diabetes and 89 new cases of chronic kidney disease (CKD) were diagnosed. This represents 1 new case of hypertension per 38 Checks, 1 new case of diabetes per 80 Checks and 1 new case of CKD per 568 Checks.

CONCLUSIONS

Implementation of the NHS Health Check programme in these localities demonstrates limited success. Coverage and treatment of those at high-CVD risk could be improved. Targeting invitations to people at high-CVD risk and managed practice networks in Tower Hamlets improved performance.

A qualitative investigation of non-response in NHS health checks

Background

Improving uptake of NHS Health Checks has become a priority in England, but there is a lack of data on the perceptions of programme non-attenders. This study aimed to explore how non-attenders of NHS Health Checks perceive the programme, identify reasons for non-attendance and inform strategies to improve uptake.

Method

This qualitative study involved individuals registered at four general practices in Stoke-on-Trent, UK, who had not taken up their invitation to a NHS Health Check. Semi-structured face-to-face and telephone interviews were audio-recorded and transcribed verbatim for Thematic Analysis.

Results

Interviews were completed with 19 males and 22 females (mean age 52.9 ± 8.5 years), who were socio-demographically representative of the non-attender population. Four main themes identified related to: the positive perception of the Health Check concept among non-attenders; the perceived lack of personal relevance; ineffective invitation method and appointment inconvenience were common barriers; previous experience of primary care can influence uptake.

Conclusions

Fundamental requirements for improving uptake are that individuals recognise the personal relevance of Health Checks and that attendance is convenient. Incorporating more sophisticated and personalised risk communication as part of the invitation could increase impact and promote candidacy. Flexibility and convenience of appointments should be considered by participating general practices.

Patients' willingness to attend the NHS cardiovascular health checks in primary care: a qualitative interview study

BACKGROUND

The NHS Cardiovascular Health Check (NHSHC) programme was introduced in England in 2009 to reduce cardiovascular disease mortality and morbidity for all patients aged 40 to 74 years old. Programme cost-effectiveness was based on an assumed uptake of 75% but current estimates of uptake in primary care are less than 50%. The purpose of this study was to identify factors influencing patients' willingness to attend an NHSHC. For those who attended, their views, experiences and their future willingness to engage in the programme were explored.

METHOD

Telephone or face-to-face interviews were conducted with patients who had recently been invited for an NHSHC by a letter from four general practices in Torbay, England. Patients were purposefully sampled (by gender, age, attendance status). Interviews were audio recorded, transcribed verbatim and analysed thematically.

RESULTS

17 attendees and 10 non-attendees were interviewed. Patients who attended an NHSHC viewed it as worthwhile. Proactive attitudes towards their health, a desire to prevent disease before they developed symptoms, and a willingness to accept screening and health check invitations motivated many individuals to attend. Non-attendees cited not seeing the NHSHC as a priority, or how it differed from regular monitoring already received for other conditions as barriers to attendance. Some non-attendees actively avoided GP practices when feeling well, while others did not want to waste health professionals' time. Misunderstandings of what the NHSHC involved and negative views of what the likely outcome might be were common.

CONCLUSION

While a minority of non-attendees simply had made an informed choice not to have an NHSHC, improving the clarity and brevity of invitational materials, better advertising, and simple administrative interventions such as sending reminder letters, have considerable potential to improve NHSHC uptake.