Cardiovascular disease prevention: risk assessment (modifiable risk factors)

Indicator type

General practice indicator suitable for use in the Quality and Outcomes Framework.

Rationale

For primary prevention of CVD, NICE recommends using a systematic strategy in primary care to identify people who are likely at high risk of CVD. Once an increased risk has been found, many CVD risk factors are modifiable through lifestyle changes or medical interventions. See NICE's indicators on primary prevention with lifestyle changes and primary prevention with lipid-lowering therapies.

This indicator focuses on those who have modifiable risk factors as highlighted in the QRISK3 assessment tool because these patients are more likely to have higher CVD risk.

QRISK3 is validated in people aged 40 to 84 years, but this indicator starts at 43 years to provide a 3‑year window for the recording of an initial risk score. A frequency of 3 years was chosen because CVD risk may change more rapidly in people with a modifiable risk factor. CVD risk can be estimated based on existing factors already recorded in primary care electronic medical records.

The indicator excludes people with type 1 diabetes, CVD, familial hypercholesterolaemia, chronic kidney disease stage 3 to 5 (in line with NICE guidance) as they are at high risk and should proceed directly to lifestyle modification and lipid-lowering therapies. People on current lipid-lowering therapies or with a previous CVD risk score of 20% or more are excluded as repeat assessment is unnecessary.

CVD risk can be estimated based on existing factors already recorded in primary care electronic medical records. However, the accuracy of estimated risk scores will be affected if relevant data is not accurately recorded in GP records, especially in vulnerable and underserved populations. To mitigate perpetuating or exacerbating existing health inequalities, 'batch coding' without clinical judgement should be avoided. Additionally, resultant data should be disaggregated by deprivation, ethnicity, age and gender to help reduce the risk of widening health inequalities.

Source guidance

Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE guideline NG238 (2023), recommendations 1.1.1 to 1.1.3

Specification

Numerator: The number of people in the denominator with a recorded CVD risk assessment score in the preceding 3 years.

Denominator: The number of people aged 43 to 84 years with a modifiable risk factor.

Calculation: Numerator divided by the denominator, multiplied by 100.

Definitions: A modifiable risk factor is one or more of the following:

CVD risk assessment should preferably be undertaken using QRISK3; however, proposed indicator construction would include clinical codes for QRISK, QRISK2 and QRISK3 risk scores. For this indicator, estimated risk scores would be acceptable using factors already recorded in primary care electronic medical records, but 'batch coding' without clinical judgement should be avoided.

Exclusions: People with any of the following:

Current lipid-lowering therapies is defined as a prescription in the last 6 months of the reporting period.

CVD is defined as angina, previous myocardial infarction, revascularisation, ischaemic stroke or transient ischaemic attack, or symptomatic peripheral arterial disease. Existing NHS Quality and Outcomes Framework (QOF) registers could be used: CHD001, STIA001 excluding people with a history of haemorrhagic stroke, and PAD001.

Expected population size: Analysis of data from the Clinical Practice Research Datalink (CPRD) Aurum March 2024 dataset shows that 12.3% of people in England were aged 43 to 84 years with a modifiable risk factor and no type 1 diabetes, CVD, familial hypercholesterolaemia, chronic kidney disease stage 3a to 5, current treatment with lipid-lowering therapies or a risk score of 20% or more ever recorded: 1,230 patients for an average practice with 10,000 patients. To be suitable for use in QOF, there should be more than 20 patients eligible for inclusion in the denominator, per average practice with 10,000 patients, prior to application of personalised care adjustments.

ISBN: 978-1-4731-6424-6