What are the cost-savings and health benefits of improving detection and management for six high cardiovascular risk conditions in England? An economic evaluation

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.

NHS Health Check attendance is associated with reduced multiorgan disease risk: a matched cohort study in the UK Biobank

BACKGROUND

The NHS Health Check is a preventive programme in the UK designed to screen for cardiovascular risk and to aid in primary disease prevention. Despite its widespread implementation, the effectiveness of the NHS Health Check for longer-term disease prevention is unclear. In this study, we measured the rate of new diagnoses in UK Biobank participants who underwent the NHS Health Check compared with those who did not.

METHODS

Within the UK Biobank prospective study, 48,602 NHS Health Check recipients were identified from linked primary care records. These participants were then covariate-matched on an extensive range of socio-demographic, lifestyle, and medical factors with 48,602 participants without record of the check. Follow-up diagnoses were ascertained from health records over an average of 9 years (SD 2 years) including hypertension, diabetes, hypercholesterolaemia, stroke, dementia, myocardial infarction, atrial fibrillation, heart failure, fatty liver disease, alcoholic liver disease, liver cirrhosis, liver failure, acute kidney injury, chronic kidney disease (stage 3 +), cardiovascular mortality, and all-cause mortality. Time-varying survival modelling was used to compare adjusted outcome rates between the groups.

RESULTS

In the immediate 2 years after the NHS Health Check, higher diagnosis rates were observed for hypertension, high cholesterol, and chronic kidney disease among health check recipients compared to their matched counterparts. However, in the longer term, NHS Health Check recipients had significantly lower risk across all multiorgan disease outcomes and reduced rates of cardiovascular and all-cause mortality.

CONCLUSIONS

The NHS Health Check is linked to reduced incidence of disease across multiple organ systems, which may be attributed to risk modification through earlier detection and treatment of key risk factors such as hypertension and high cholesterol. This work adds important evidence to the growing body of research supporting the effectiveness of preventative interventions in reducing longer-term multimorbidity.

Transforming global approaches to chronic disease prevention and management across the lifespan: integrating genomics, behavior change, and digital health solutions

Chronic illnesses are a major threat to global population health through the lifespan into older age. Despite world-wide public health goals, there has been a steady increase in chronic and non-communicable diseases (e.g., cancer, cardiovascular and metabolic disorders) and strong growth in mental health disorders. In 2010, 67% of deaths worldwide were due to chronic diseases and this increased to 74% in 2019, with accelerated growth in the COVID-19 era and its aftermath. Aging and wellbeing across the lifespan are positively impacted by the presence of effective prevention and management of chronic illness that can enhance population health. This paper provides a short overview of the journey to this current situation followed by discussion of how we may better address what the World Health Organization has termed the "tsunami of chronic diseases." In this paper we advocate for the development, validation, and subsequent deployment of integrated: 1. Polygenic and multifactorial risk prediction tools to screen for those at future risk of chronic disease and those with undiagnosed chronic disease. 2. Advanced preventive, behavior change and chronic disease management to maximize population health and wellbeing. 3. Digital health systems to support greater efficiencies in population-scale health prevention and intervention programs. It is argued that each of these actions individually has an emerging evidence base. However, there has been limited research to date concerning the combined population-level health effects of their integration. We outline the conceptual framework within which we are planning and currently conducting studies to investigate the effects of their integration.

Diabetes and Cardiovascular Diseases Risk Assessment in Community Pharmacies: An Implementation Study

The implementation of a new service is often challenging when translating research findings into routine clinical practices. This paper presents the results of the implementation study of a pilot project for a diabetes and cardiovascular diseases risk-assessment service in Belgian community pharmacies. To evaluate the implementation of the service, a mixed method was used that follows the RE-AIM framework. During the testing stage, 37 pharmacies participated, including five that dropped out due to a lack of time or COVID-19-related temporary obligations. Overall, 502 patients participated, of which 376 (74.9%) were eligible for according-to-protocol analysis. Of these, 80 patients (21.3%) were identified as being at high risk for the targeted diseases, and 100 (26.6%) were referred to general practice for further investigation. We presented the limited effectiveness and the key elements influencing optimal implementation. Additional strategies, such as interprofessional workshops, a data-sharing platform, and communication campaigns, should be considered to spread awareness of the new role of pharmacists. Such strategies could also promote collaboration with general practitioners to ensure the follow-up of patients at high risk. Overall, this service was considered easy to perform and feasible in practice but would require financial and external support to ensure its effectiveness, sustainability, and larger-scale implementation.

What factors influence differential uptake of NHS Health Checks, diabetes and hypertension reviews among women in ethnically diverse South London? Cross-sectional analysis of 63,000 primary care records

BACKGROUND

Uptake of health checks among women has not been examined in relation to patient and General Practitioner (GP) practice level factors. We investigated patient and practice level factors associated with differential uptake of health checks.

METHODS

Primary care records from 44 practices in Lambeth for women aged 40-74 years old (N = 62,967) from 2000-2018 were analysed using multi-level logistic regression models. An odds ratio (OR) >1 indicates increased occurrence of no health check.

FINDINGS

The mean age (IQR) of the included female sample (aged 40-74 years) was 52.9 years (45.0-59.0). Adjusted for patient-level factors (age, ethnicity, English as first language, overweight/obesity, smoking, attendance to GP practices, and co-morbidity), the odds of non-uptake of health checks were higher for Other White (OR 1.24, 95% confidence interval 1.17-1.33), and Other ethnicity (1.20, 1.07-1.35) vs. White British. It was also higher for 50-69 year olds (1.55, 1.47-1.62), 70-74 year olds (1.60, 1.49-1.72) vs. 40-49 year olds. These ORs did not change on adjustments for practice level factors (proportion of patients living in deprived areas, proportion of patients with ≥1 chronic condition, ≥3 emergency diabetes admissions annually, GP density/1000 patients, quality outcome framework score of ≥ 95%, and patient satisfaction scores of ≥80%). Non-uptake was lower for Black Caribbeans, Bangladeshis, overweight/obese patients, frequent practice attenders and comorbid patients.

INTERPRETATION

Differential uptake in health checks remained after adjustment for patient and practice level factors. Better measures of social determinants of health and of practice context are needed.

FUNDING

NIHR Research for Patient Benefit Programme (NIHR202769).

NHS Health Check programme: a rapid review update

OBJECTIVE

To update a rapid review published in 2017, which evaluated the NHS Health Check programme.

METHODS

An enlarged body of evidence was used to readdress six research objectives from a rapid review published in 2017, relating to the uptake, patient experiences and effectiveness of the NHS Health Check programme. Data sources included MEDLINE, PubMed, Embase, Health Management Information Consortium (HMIC), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Global Health, PsycINFO, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov and the ISRCTN registry, Web of Science, Science Citation Index, The Cochrane Library, NHS Evidence, OpenGrey and hand searching article reference lists. These searches identified records from between January 1996 and December 2019. Screening, data extraction and quality appraisal using the Critical Appraisals Skills Programme checklists were performed in duplicate. Grading of Recommendations Assessment, Development and Evaluations was implemented. Data were synthesised narratively.

RESULTS

697 studies were identified, and 29 new studies included in the review update. The number of published studies on the uptake, patient experiences and effectiveness of the NHS Health Check programme has increased by 43% since the rapid review published in 2017. However, findings from the original review remain largely unchanged. NHS Health Checks led to an overall increase in the detection of raised risk factors and morbidities including diabetes mellitus, hypertension, raised blood pressure, cholesterol and chronic kidney disease. Individuals most likely to attend the NHS Health Check programme included women, persons aged ≥60 years and those from more socioeconomically advantaged backgrounds. Opportunistic invitations increased uptake among men, younger persons and those with a higher deprivation level.

CONCLUSIONS

Although results are inconsistent between studies, the NHS Health Check programme is associated with increased detection of heightened cardiovascular disease risk factors and diagnoses. Uptake varied between population subgroups. Opportunistic invitations may increase uptake.