anagement of ardiovascular Risk ssessment at Ngati ahu Haurora auranga

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1 anagement of ardiovascular Risk ollowing its ssessment at Ngati ahu Haurora auranga RESENTATION FOR RNZCGP CONFERENCE 2012 REGISTRAR AY R LUKE BRADFORD

2 Background Cardiovascular Risk Assessment PHO Performance Program (CVRA) is part of the National The Performance Program is measured purely on CVRA number completed There are comprehensive guidelines for the management of the risk calculated as laid out by NZGG There is no external audit processs for the management of that risk

3 Our Practice Te Whare o Ngati Kahu Hauora Enrolled population of % Maori 1.5 Full time equlavent Dr + GP registrar 1 full time nurse Whanau ora, alcohol and drug counselling, kuia / kaumatua program Satellite clinics CVRA rate of 85% which is highest in Western Bay and one of the highest in the country

4 Aim To identify whether the assessment of cardiovascular risk in Ngati Kahu Hauora resulted in appropriate risk management, follow up and patient advice/treatment.

5 Methodology All CVRA risk assessments in 3 months Feb 2012-April records interrogated for age, sex and ethnicity and whether this were a first or repeat assessment % CVRA, correct FU, CVRA comm mented on notes and if the patient was informed of the result within 3/12 The focus of the data was on whether individual risk factors were addressed and whether FU for each indentified risk factor was planned For those with CVRA >15% or Total Chol >8 the commencement of appropriate medication was looked at

6 Results 82 CVRAs 41 First time 41 Repeats Male 35 (42.6%); Maori 26 (74.3%), 8 European (22.9%), 1 Other High Risk (OHR) (2.8%) Average age (range 35 79) Females 47 (57.4%); Maori 34 (72.3%), European 12 (25.5%), Other Low Risk (OLR) 1 (2.1%) Average age (range 42 81)

7 Totals: 73.2% Maori, 24.4% European, 1.2% OHR, 1.2% OLR European Maori Other high risk Other low risk

8 % 5yr Cardiovascular Risk by Framingham percentage category Less than 5% 5-9% 10-14% 15-19% Greater than 20% 18% 6% 28% 29% Average Maori risk 14.2% Average European risk 10.2% 19%

9 Patient informed of the CVRA res sult within 3 months: Yes 22 (26.8%) No 60 (73.2%) CVR risk commented on in notes s: Yes 27 (32.9%) No 55 (67.1%)

10 Recall The recall guidelines are <10% risk reassess at 5yrs % 14% reassess at 2 years % 19% Reassess 1 year. >2 20% At least annual FU. Correct recall in sample: 53 (64.6%). Incorrect: 28 (34.1%) NA (left surgery) 1 (1.2%) NZGG recommends setting mutually agreed on FU recalls for all risk factors identified Risk factor FU planned and documented: Yes 24 (29.3%) No 53 (64.6%) NA (either left or no identifiable RFs) 5 (6.1%)

11 Individual Risk Factors Smoking history recorded in all Smokers; of whom 20 received cessation advice 6 did not Alcohol consumption: Recorded 11 Not recorded 71 BMI: Recorded + weight advice if overweight 13 (15.9%) No BMI recorded or no advice if high 69 (84.1%)

12 For those with CVR >10% (no.53) 50 Risk factor management Number of patients Yes No BP discussed or treated Cholesterol discussed Exercise discussed Diet discussed BMI discussed Risk factor

13 15 patients had a CVR >20% all should have been on aspirin, statin and where warranted BP or diabetic meds 16 Drug therapy in tho ose with CVR >20% Number of patients Yes No Aspirin Statin Drug therapy commenced Other

14 23 patients had a CVR of 15-19% over 5yrs. The guidelines state for aspirin plus other risk factor altering medication after a 3-6 month trial of risk factor modification. Date was collected in June 3 months after the last CVRA 25 Drug therapy in patien nts with a CVR 15-19% 19% 20 Number of patients Yes No 5 0 Aspirin Statin Drug th herapy Other

15 Conclusions 1 Ngati Kahu Hauora (NKH) is performing a high % of CVRA and in the main these are appropriate The relative risk difference between Maori and European patients at NKH is in keeping with the national expected results given that ethnicity bestows an automatic 5% increase in risk to the Maori population NKH has a significant number of aggressive management The recalls for repeat CVRA weree in the main correct and can easily be corrected to 100% with health provider education or a small reminder sheet next to each work station Individual risk factor FU planning was poor high risk patients who warrant

16 Conclusions 2 The fact that under 1 in 3 CVRA resulted in any discussion with the patient of the result or even mention of it in the patient s notes brings in to question whether the assessments are being carried out for the good of the patient or the good of the statistics/earnings. Smoking status is well documented and aggressively approached is terms of risk management. The same cannot be said for other risk factors especially BMI, exercise and diet, which are observed problems within our patient group. The use of aspirin is woeful Statin use could be improved markedly

17 Recommendations An education session for all clinical practitioners within the practice on CVRA and appropriate FU including that for risk factors. This should be backed up with a small reminder sheet next to all work stations Automatic BMI calculation during enrolment and for all patients when weighed as part of a normal visit Individual risk factor advice packs based on diet, exercise, weight loss, smoking and alcohol moderation as well as cholesterol which can be given appropriately after any given CVRA Discussion of cardiovascular risk after assessment with all patients A frank discussion amongst prescribers regarding the need for more aggressive use of aspirin, statins and anti-hypertensives. Re audit in 1 year to measure changes as a result of implementation of the above

18 The danger arising from doing well in a screening program like this, is that it can mislead public health clinicians, planners and politicians into thinking they can tick the mission accomplished box for preventing cardiovascularr disease

19 References Cardiovascular Disease Risk Assessment. Best Practice Journal 37, August New Zealand Guidelines Group Primary Care Handbook Cardiovascular Disease. Best Practice Journal 17, October Assessing cardiovascular disease: what the experts think. Best Practice Journal 33, December 2010

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