Assessing Cardiovascular Risk to Altering Risk Trajectories: Opportunities Revealed by England’s NHS Health Check Programme

Abstract

Objectives: To provide an overview of cardiovascular (CVD) disease risk among NHSHC attendees, to quantify how much of this risk burden can be captured by available risk metrics and to examine whether interventions are offered to attendees according to the level of underlying risk.

Design: A cross sectional observational study

Setting: National primary care data extracted by NHS Digital from 90% of General Practices (GP) in England. Participants included 5,102,758 individuals aged 40-74 years, attending an NHSHC, (2012- 2017), defined using primary care Read codes.
Intervention: The NHSHC, a national risk assessment, awareness and management intervention which focusses on key behavioural and metabolic risk factors for non-communicable disease and 10-year CVD risk.

Results: Measured risk factor prevalence, using established thresholds was high and similar to prior population estimates, while CVD specific risk factors varied by age and sex groups. A third of attendees had emerging risk including sub-optimal values of blood pressure (35.4%, systolic BP 130 to 140mmHg or diastolic 80 to 90mmHg) and cholesterol (37.3% total cholesterol 5 to <6mmol/L). This translated to 94.6% of attendees having ≥1 modifiable risk factor. Compared to 10-year risk, a lifetime risk metric offered an opportunity to identify these 33.5% of attendees with emerging CVD risk. Interventions were examined post-hoc by combined 10-year risk and lifetime risk scores. They were delivered based on underlying and emerging risk, but with room for further improvement.

Conclusion: There is a high burden of underlying and emerging CVD risk among NHSHC attendees. The value of the NHSHC can be maximised by altering risk factor trajectories in the young, communicating lifetime risk and promoting behavioural interventions, in parallel with greater use of medications in those already at high absolute CVD risk.

Note:
Funding Information: RSP (FS/14/76/30933) and JD (BHF chair) were funded by the BHF. Data extraction and analysis were funded by PHE.

Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; RSP has received speaker fees and honoraria from Amgen, Sanofi and Bayer and research grant funding from Regeneron for CVD prevention and cholesterol management; no other relationships or activities that could appear to have influenced the submitted work. JD is Senior Advisor to Public Health England on cardiovascular disease prevention, and has Chaired a review of the NHS Health Check programme for PHE.

Ethics Approval Statement: A Direction from the Secretary of State for Health and Social Care instructed NHS Digital with the legal requirement to carry out the NHSHC data extract.(17) This study was subject to an internal review by the Research Support and Governance Office in PHE to ensure that it was fully compliant with the UK Policy Framework for Health and Social Care Research (2017) and with all other current regulatory requirements. The review also covered all ethical considerations. No ethical issues were identified and thus review by an ethics committee was not required (Personal communication between Katherine Thomson & PHE Research Support Governance Office, 2019).

Keywords: Cardiovascular Disease Prevention, NHS Health Checks, Cardiovascular Risk, Public Health