Opinion

---

Outcomes from the new CVD risk calculator depend on integration

---

Public consultation on an updated Australian guideline for assessing and managing cardiovascular disease (CVD) risk is now underway, including a proposed new algorithm for risk calculation.
 
The algorithm incorporates evolving knowledge on risk assessment and represents an important advance since the last guidelines were released in 2012.
 
The proposed new equation is based on the New Zealand PREDICT equation and will be calibrated to ensure it more accurately represents risk for the Australian population. It also includes new variables, including CVD medications, postcode as a measure of socio-economic status, and history of atrial fibrillation.
 
Reclassification factors have been introduced to account for other considerations, including ethnicity, family history and severe mental illness. Following consultation, the guidelines will be launched for use in early 2023.
 
Primary care now has a critical window of opportunity to consider how the CVD guidelines can work best on the front lines.  
 
There are significant current shortfalls in CVD risk assessment and management, with an estimated three quarters of people at high risk of their first CVD event not receiving basic recommended pharmacotherapies.
 
In the absence of coordination mechanisms, current implementation of CVD risk assessment is fragmented, leading to variations in care and inequity. For example, currently some clinical software packages offer built-in calculators, but many of these are out of date and clunky to use.
 
Existing calculators also underestimate risk for one in eight people aged between 45–74, and two in five Aboriginal and Torres Strait Islander peoples 18 years and older.
 
Some GPs use the Heart Health Check Toolkit resources, though manual entry of data for risk calculation can be inefficient and inaccurate. There are currently no mechanisms for updating guidelines or the algorithm more frequently, despite the increasing pace of evidence generation.
 
Likewise, there is no coordinated approach to ensure that risk assessments are coupled with best practice resources to communicate risk and make shared decisions about the next steps.
 
These problems mean that the benefits of the new CVD guidelines will be missed if implementation issues are not urgently addressed.
 
To maximise the benefit of the new guidelines, CVD risk assessment must be seamlessly integrated into the workflow of general practice. Clinical software functionality could be harnessed to achieve this in new ways:

• By prompting the need for CVD risk assessment
• Collating relevant variables from the clinical record
• Pre-populating parts of the calculation
• Generating patient facing shared decision-making resources about reducing risk

In Aotearoa New Zealand, some of these strategies have been used to achieve 90% coverage of CVD risk assessment for eligible people.
 
Achieving similar penetration in Australia requires prospective planning and leadership to consider and pursue different models for implementing the new guidelines.
 
One option would be updating software packages to include the new algorithms, but these updates are subject to vagaries of lead times and resourcing.
 
A by-vendor approach has not been successful in the past and contributes to some of the current variation in clinical practice. Alternatively, a standalone risk assessment website could offer a standardised approach and links to resource, but uptake is likely to be limited in busy general practice settings without integration into software workflows.
 
Instead, increasingly accurate risk assessment algorithms are likely to require more sophisticated approaches to integration and implementation. This could include ‘plug in’ technology which is agnostic to clinical software platforms but capable of a seamless interface, centralised updates and links to shared decision-making resources.
 
Getting this done would require new levels of cooperation, consultation and coordination across primary care, software providers and guideline developments, but has tremendous potential for benefits in CVD and beyond.  
 
The need for leadership and coordination is urgent because software integration is a clinical safety issue. Continued use of outdated calculators in clinical software packages risks inadequate assessment, and also raises the likelihood of mismatch between CVD risk assessment (using older algorithms) and management (using newer guidelines).
 
Poor alignment between risk calculation and treatment guidelines would have disproportionate effects on some communities. For example, the updated guidelines propose a more nuanced approach to considering how Aboriginal and/or Torres Strait Islander identity affects CVD risk.
 
However, without software integrated guidelines health professionals may simply disregard Indigenous status or apply outdated guidelines. This would mean that Aboriginal and Torres Strait Islander people – who are already under-served by the status quo – would not have CVD risks addressed properly.
 
General practice now has an opportunity to develop and implement a vision for harnessing the potential of risk assessment algorithms. GPs and primary care staff need the best possible systems to make delivery of high-quality care easy.
 
In consulting rooms details really matter: the number of clicks, the ease of use, the look and feel, the value of the outputs, recommendations and resources. Getting the user experience right is the key to getting CVD risk assessment done.
 
Governance systems are urgently needed to ensure outdated risk calculators are decommissioned from clinical software packages and replaced with something more accurate, effective and efficient.
 
The new CVD guidelines reflect a decade of new research and understanding of CVD risk and risk management. Getting them right on screen is the first step to putting them into practice.
 
Professor Banks is a member of the Expert Steering Group for the Updating of the Australian Guideline for Assessing and Managing Cardiovascular Risk and Chair of the Algorithm Working Group for the updating of the Guideline.
 
Log in below to join the conversation.

---

---

cardiovascular disease clinical guidelines CVD general practice implementation risk assessment

---