CVD Workbook: Understanding and communicating CVD risk and management recommendations

Is CVD risk assessment in primary care gaining momentum?

Cardiovascular disease (CVD) risk assessment is a key component of the primary care preventive medicine strategy. In 2018, a consensus statement was published by the Ministry of Health for Cardiovascular Disease Risk Assessment and Management for Primary Care.¹ The recommendations were based on an update of evidence since the last major review published in 2012.

The team for the 2018 update was also tasked with investigating the expected real-world benefit to New Zealanders of having New Zealand-specific risk stratification and risk equations. As a result, the update introduced new five-year CVD risk prediction equations (NZ Primary Prevention Equations), for men and women aged 30 to 74 years, developed from the New Zealand PREDICT study data. Further, for Māori, Pacific, South Asian and mental health patient populations, the new recommendations were that risk assessment should begin earlier than for other population groups.¹

CVD risk assessment in primary care also aligns with several indicators of The Health System Indicators framework – the latest iteration of health system performance measurement, or how well the health and disability system serves New Zealanders.^2,3 Proactive and equitable implementation of CVD risk assessment contributes to several government priorities, including:

• Improving wellbeing through prevention – high-level indicator, ambulatory sensitive hospitalisations for adults (age range 45 to 64); description, rate of hospital admissions for people aged 45 to 64 for an illness that might have been prevented or better managed in the community.
• Strong and equitable public health system – high-level indicator, acute hospital bed day rate; description, number of days spent in hospital for unplanned care including emergencies.
• Better primary healthcare – high-level indicator, people report being involved in the decisions about their care and treatment; description, percentage of people who say they felt involved in their own care and treatment with their GP or nurse.

Work to implement the framework continues into 2022 and the first update of the Health System Indicators framework was added in December 2021, using December 2019 as a baseline. Also feeding data into the framework is the quarterly primary care patient experience survey designed to find out about patients’ experience in primary care and conducted by the Health Quality & Safety Commission with support from the Ministry of Health.

The new Health System Indicators draw on both the earlier “System Level Measures” and modified elements of the previous “Health Targets”.⁴

The new consensus statement and the indicators framework have been two significant developments in the last four years. Not surprisingly, COVID-19 may have had an impact on the rate of implementation of both – in the first update to The Health System Indicators framework it was noted: “COVID-19 and the associated health response is impacting on many of the indicators reported and explain much of the apparent improvements or reductions from baseline.”³

Enabling young adult Māori and Pacific peoples to proactively combat CVD

The focus of this resource is on reviewing CVD risk assessment and management, risk communication, cultural safety, and engagement with young adult Māori and Pacific patients in primary care, with the aim of improving the uptake of CVD risk assessment and primary prevention of CVD.

The evidence shows the much higher burden of CVD morbidity and mortality in Māori and Pacific people – and almost half of the deaths from heart disease each year in these populations are premature (before the age of 75) and avoidable.⁵ This is more than three times the rate for non-Māori.

The disparities in heart health outcomes are particularly stark when viewed by decile and ethnicity. Not only do avoidable deaths increase with deprivation, but there are startling inequities by ethnicity regardless of deprivation level.⁵ And while heart disease is, in part, a consequence of poverty, it is also a contributor to poverty – Māori and Pacific people are eight times more likely to receive jobseeker’s allowances than non-Māori as a result of disability caused by heart disease.⁶

Not only do avoidable deaths increase with deprivation, but there are startling inequities by ethnicity regardless of deprivation level – Heart Foundation white paper ⁵

Māori are disproportionally affected with heart failure and on average suffer onset about 15 years earlier than non-Māori. Atrial fibrillation, a common cardiac rhythm disorder associated with preventable stroke risk, is twice as likely to occur in Māori and, on average, presents 10 years earlier in Māori and Pacific people compared with non-Māori, non-Pacific people. The mortality rate from heart disease for Māori is more than double that for non-Māori. Māori men have a mortality rate almost six times that of the lowest risk group, non-Māori women.⁷

Access to healthcare is not equitable. Even though New Zealand has the tools for detecting, treating and managing heart disease, they are not accessed by everyone who needs them. Māori, Pacific and low-income New Zealanders, in particular, are still the least likely to receive healthcare when it matters most.⁵ The inequity is also displayed in the dispensing data for Māori and Pacific ethnicity patients.⁸

The 2018 publication of the consensus statement specified the need to start risk assessments for Māori, Pacific and South-Asian people 15 years earlier than for other ethnic groups – ie, in men from age 30 years and in women from 40 years.¹

Communicating risk to individuals, in person rather than in virtual consultation, as part of shared decision making and CVD risk management is recommended. Patient communication and joint healthcare practitioner–patient management decisions are critical components of the CVD risk assessment and management process.¹ This needs to be done effectively, recognising that decision support tools for different levels of health literacy are useful adjuncts to help patients understand risk.¹

The healthcare practitioner must be able to effectively convey the risk, and provide advice in a culturally safe context, for the patient to be able to decide what to do about it.

The modules below encourage you to reflect on your current practice and incorporate your learning into everyday activities. Each module is in a PDF format that you can download and save to your computer before starting. Once you've saved the document to your computer, follow the prompts and type your notes into the editable fields. When you have completed the activity, upload the completed PDF into your online CPD/CME record.