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Rison SCG, Dostal I, Ahmed Z, Raisi-Estabragh Z, Carvalho C, Lobo M, Patel R, Antoniou M, Boomla K, McManus RJ, Robson JP. Protocol design and preliminary evaluation of the REAL-Health Triple Aim, an open-cohort CVD-care optimisation initiative. Eur Heart J 2021. [PMCID: PMC8524644 DOI: 10.1093/eurheartj/ehab724.3170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Effective treatment of cardiovascular disease (CVD) in primary care could be improved. We aim to assess the efficacy of a scalable treatment optimisation programme in unselected community populations in South East England, with the triple aim of improved blood pressure control in people with hypertension, increased high-intensity statin use in people with CVD and reduced gastrointestinal bleeding in patients on antithrombotic medication.
Method
This observational study comprises an open cohort of approximately 200,000 adults at high cardiovascular risk registered with general practitioners in five South East England Clinical Commissioning Groups (CCGs). An intervention programme is planned in four of these CCGs with a further non-intervention CCG acting as a control group. The intervention will consist of: clinical guidelines and educational outreach; virtual patient-reviews software; peer-performance “dashboards” and, where available, financial incentives.
The study will examine 3 primary outcomes: 1. Diagnosed hypertension with a blood pressure <140/90mmHg; 2. Diagnosed CVD on a high-intensity statin; 3. A cardiovascular indication for antithrombotic therapy with one or more factors for increased risk of gastrointestinal bleeding (e.g. age ≥65) on gastroprotection. A further 17 secondary outcomes related to these three aims will be assessed.
Analysis
We will use an interrupted time series analysis over 18 months, representing the pre-implementation, implementation and the post-implementation phases with comparison to the control CCG and applicable national Quality and Outcomes Framework and national prescribing statistics (e.g. OpenPrescribing). Secondary outcomes include an equity impact analysis with results stratified by age, gender, ethnic group and index of deprivation.
Preliminary data
We present preliminary data on Key Performance Indicators (KPIs) collected from 191 GP practices including [percentage achievement on 01/09/2019, on 01/09/2020]: 1. Patients with hypertension and most recent blood pressure ≤140/90mmHg [68.7%, 60.6%]. 2. Patients eligible for treatment with a high-intensity statin on such treatment [53.8%, 55.8%]. 3. Patients on antithrombotics with ≥1 risk factors for gastrointestinal bleeding on gastroprotection [59.0%, 60.1%]. We also present our virtual patient-review software tool and outcome visualisation dashboard.
Conclusion
The REAL-Health Triple Aim initiative is a large-scale primary care cardiovascular risk reduction initiative which was launched almost contemporaneously with the United Kingdom's first SARS-CoV-2 related lockdown. Preliminary data justify the need for the Triple Aim initiative and give us an insight on the impact of the pandemic on its implementation.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Barts CharityBritish Heart Foundation
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Affiliation(s)
- S C G Rison
- Queen Mary University of London, Clinical Effectiveness Group, London, United Kingdom
| | - I Dostal
- Queen Mary University of London, Clinical Effectiveness Group, London, United Kingdom
| | - Z Ahmed
- Queen Mary University of London, Clinical Effectiveness Group, London, United Kingdom
| | | | - C Carvalho
- Queen Mary University of London, Clinical Effectiveness Group, London, United Kingdom
| | - M Lobo
- William Harvey Research Institute, London, United Kingdom
| | - R Patel
- Barts Heart Centre, London, United Kingdom
| | - M Antoniou
- Barts Heart Centre, London, United Kingdom
| | - K Boomla
- Queen Mary University of London, Clinical Effectiveness Group, London, United Kingdom
| | - R J McManus
- University of Oxford, Nuffield Department of Primary Care Health Science, Oxford, United Kingdom
| | - J P Robson
- Queen Mary University of London, Clinical Effectiveness Group, London, United Kingdom
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Abstract
Abstract
Background
Hypertension and hypercholesterolaemia are major modifiable risk factors for cardiovascular diseases (CVD) with available effective and low-cost treatments. However, their suboptimal treatment remains widespread. We characterise treatment gaps in a large urban population and quantify the potential long-term health and economic impact with optimised use.
Methods
We studied 1 million UK urban residents served by 123 primary care practices in 2019. We categorised antihypertensive treatment in adults with diagnosed hypertension, and statin treatment in adults with diagnosed CVD, into optimal, suboptimal and not treated following UK clinical guidelines. A long-term CVD model was used to project cardiovascular events avoided, years of life and quality-adjusted life years (QALYs) gained, and healthcare costs saved with optimised treatments for individual patients accounting for their socio-demographic characteristics and risk factors.
Results
21,954 (24%, mean age 59 years; 49% female) of the 91,828 adults with hypertension were either suboptimally treated (20%) or untreated (4%) and 9,062 (38%, mean age 69 years; 43% female) of the 23,723 adults with CVD were either suboptimally treated (24%) or untreated (14%). Per 1000 patients (95% CI) optimised over lifespan, hypertension treatment would prevent 154 (72–230) major vascular events (MVEs, including heart attack, stroke or arterial revascularisation) and 69 (28–103) vascular deaths, and gain 769 (436–1038) QALYs for those sub-optimally treated, and prevent 138 (68–201) MVEs and 50 (21–76) vascular deaths, and gain 674 (386–920) QALYs for those not treated; statin treatment would prevent 68 (46–88) MVEs and 17 (12–21) vascular deaths, and gain 145 (113–178) QALYs for those sub-optimally treated, and prevent 260 (190–319) MVEs and 55 (40–68) vascular deaths, and gain 535 (412–651) QALYs for those not treated (Figure). Hospital cost savings net of medication costs were about £1100 per person over their remaining lifespan.
Conclusion
Optimising preventive cardiovascular treatments in UK primary care is likely to cost-effectively reduce cardiovascular risk and improve life expectancy, while reducing population inequalities.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Barts Charity, British Heart Foundation, and Health Data Research UK Predicted benefits from optimisation
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Affiliation(s)
- R Wu
- Queen Mary University of London, Institute of Population Health Sciences, London, United Kingdom
| | - S Rison
- Queen Mary University of London, Institute of Population Health Sciences, London, United Kingdom
| | - Z Raisi-Estabragh
- Queen Mary University of London, William Harvey Research Institute, London, United Kingdom
| | - I Dostal
- Queen Mary University of London, Institute of Population Health Sciences, London, United Kingdom
| | - C Carvalho
- Queen Mary University of London, Institute of Population Health Sciences, London, United Kingdom
| | - J Robson
- Queen Mary University of London, Institute of Population Health Sciences, London, United Kingdom
| | - B Mihaylova
- Queen Mary University of London, Institute of Population Health Sciences, London, United Kingdom
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