The Bold Promise Project: a system change in primary care to support cardiovascular risk screening

To develop a series of system changes in primary care to facilitate cardiovascular risk screening of all eligible patients identified according to the current New Zealand Cardiovascular Guidelines (NZGG), and to provide the ability to measure and track clinical management of high risk patients.

Several system changes were developed within primary care practice management software to identify the patient cohort eligible for cardiovascular risk screening, to calculate cardiovascular disease risk (CVR), and to extract the data for reporting on screening outcomes and clinical management indicators in high risk patients. Following a baseline audit, the system changes were piloted over 12 months in three general practices with a combined enrolled patient population of 30,963.

A total of 6570 NZGG eligible patients were identified; 20.1% of these were Maori and 19.7% were Pacific people (mostly of Samoan, Tongan, Niuean, or Cook Islands origin). Over 12 months, screening rates for cardiovascular risk assessment increased from 4.7% to 53.5% for the cohort. Of the 3516 patients screened, 482 (13.7%) had established cardiovascular disease. A further 230 (6.5%) had diabetes without CVD and 646 (18.4%) had a 5-year CVD risk of > or = to 15% Management data was available in 232 (48.1%) of those with CVD, 74%, 65%, and 79% were on aspirin, statins, and blood pressure-lowering medication, respectively. Fifty-five percent exceeded the low density lipoprotein (LDL) target of 2.5 mmol/L, 62% had a systolic blood pressure (BP) above the target of 130 mmHg, 18% were still smoking, and only 9% met all clinical targets recommended in the guideline. Of 646 with a 5-year CVD risk > or = to 15%, management data was available in 347 (53.7%). Only 34% were prescribed aspirin, 40% were prescribed statins, and 57% were on blood pressure lowering medication. Forty percent of this group had a systolic BP >140 mmHg, 36% an LDL >3.5 mmol/L, with only 7% of patients meeting all the guideline clinical targets.

The system changes comprising this intervention have dramatically increased cardiovascular risk assessment rates in a primary care setting, and will facilitate appropriate targeting of intensive cardiovascular prevention measures to close the treatment gap observed.