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Dr Tim HoltClinical Lecturer

Health Sciences Research Institute

The e-Nudge Trial: Identifying and addressing cardiovascular risk in

primary care

Lifestyle advice and drug therapy

The problem: identifying at risk individuals for cardiovascular disease in primary care

• Aim is to identify the population at > 20% risk of developing CVD in next 10 years, for preventive drug therapy and lifestyle advice

• Risk algorithms using different risk factors

– Classical factors: Age, sex, blood pressure, total and HDL cholesterol, smoking status

– Other factors: eg family history, ethnicity, deprivation, obesity, waist circumference, fasting triglycerides, renal impairment

• Risk assessment requires collation of information, only some of which is coded electronically

The e-Nudge Trial

• Tests a software tool developed in collaboration with EMIS

• Nineteen practices in Coventry and Warwickshire recruited with a range of practice demographics

• Software applied to a random half of the over-50 year population in each practice and will run for 2 years

• Software identifies 6 categories of patient• Screen alerts and continually updated lists of patients

in each category

The e-Nudge Trial

Group 1: Those with CVD or Diabetes whose blood pressure or cholesterol are out of target for the QOF

Group 2: Insufficient information for a CVD risk estimate, but possibly at risk

Group 3: Sufficient information, and at > 20% 10-year risk

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Outcomes

• Annual rates of cardiovascular events in each arm during the study

• Proportion of population identified at risk of CVD or with incomplete data at the end of the study in each arm

Holt TA, Thorogood M, Griffiths F, Munday S. Protocol for the 'e-Nudge trial': a randomised controlled trial of electronic feedback to reduce the cardiovascular risk of individuals in general practice. Trials 2006, 7:11 Available at: http://www.trialsjournal.com/content/7/1/11

Baseline dataGroup definition Number

identifiedProportion of over 50 year population (n=36,546)

Those over 50 years with known CVD or diabetes but either BP or cholesterol out of target in the past 15 months (QOF audit target)

3346 9.2%

Those aged 50-74 years with missing risk factor information who would be at >20% risk when assumed values are inserted 9657 26.4%

Those aged 50-74 years at >20% cardiovascular risk based on existing data

2152 5.9%

Holt TA, Thorogood M, Griffiths F, Munday S, Stables D. Identifying individuals for primary cardiovascular disease prevention in UK general practice. BJGP, in press.

Undiagnosed diabetes

• Baseline data from the e-Nudge trial also revealed a number of people with possible undiagnosed diabetes based on existing blood glucose data

• This led to a nationwide survey of practice records using the QRESEARCH database

About 1% of the UK population (600,000 people) have undiagnosed diabetes

Complications often present at diagnosis

Opportunities forprevention missed

Symptoms develop gradually

Cardiovascular risk raisedin those at risk of diabetes

The problem of undiagnosed diabetes

Strategy A

If a random value > 11.1 mmol/L or fasting value > 7.0 mmol/L then patient identified

(If the result non-specifically coded then result assumed to be random)

Strategy B

If the most recent value (random or fasting) was > 7.0 mmol/L then patient identified

Results

• 3.6 million records included• 3758 found through strategy A• 32,785 found through strategy B• A third of people over the age of 40 without

diabetes have had a blood glucose measurement recorded electronically in the past 2 years

Holt TA, Stables D, Hippisley-Cox J, O'Hanlon S, Majeed A. Identifying undiagnosed diabetes: Cross-sectional survey of 3.6 million patients' electronic records. British Journal of General Practice 2008;58:192-196.

Projected to the UK population

• Strategy A: 60,000 individuals likely to have undiagnosed diabetes

• Strategy B: 528,000 individuals with results that require follow up to clarify diabetes status

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• Ten people invited for finger prick blood glucose

• Borderline levels referred to GP for further investigations

• One person had diabetes and one had IGT

Daily Mail Survey 18th March 2008

Further research• Process evaluation to identify barriers to the process

of CVD risk reduction using electronic data• Ongoing interview study to examine the practicalities

of using the e-Nudge software in practice• Interviews with members of the public to explore

attitudes towards prevention vs treatment, polypharmacy, opportunistic vs systematic risk assessment, labelling, ‘medicalisation of ageing’, etc, etc……..

Collaborators

e-Nudge

Tim Holt

Margaret Thorogood

Frances Griffiths

Stephen Munday

QRESEARCH study

Tim Holt

Julia Hippisley-Cox

David Stables

Shaun O’Hanlon

Azeem Majeed

Funded through a PhD Studentship from DH/WMS

http://www2.warwick.ac.uk/newsandevents/pressreleases/gp146s_databases_could/