BackgroundThe National Health Service (NHS) Health Check is a cardiovascular disease (CVD) risk assessment and management programme in England aiming to increase CVD risk awareness among people at increased risk of CVD. There is no tool to assess the effectiveness of the programme in communicating CVD risk to patients.AimsThe aim of this paper was to develop a questionnaire examining patients’ CVD risk awareness for use in health service research evaluations of the NHS Health Check programme.MethodsWe developed an 85-item questionnaire to determine patients’ views of their risk of CVD. The questionnaire was based on a review of the relevant literature. After review by an expert panel and focus group discussion, 22 items were dropped and 2 new items were added. The resulting 65-item questionnaire with satisfactory content validity (content validity indices≥0.80) and face validity was tested on 110 NHS Health Check attendees in primary care in a cross-sectional study between 21 May 2014 and 28 July 2014.ResultsFollowing analyses of data, we reduced the questionnaire from 65 to 26 items. The 26-item questionnaire constitutes four scales: Knowledge of CVD Risk and Prevention, Perceived Risk of Heart Attack/Stroke, Perceived Benefits and Intention to Change Behaviour and Healthy Eating Intentions. Perceived Risk (Cronbach’s α=0.85) and Perceived Benefits and Intention to Change Behaviour (Cronbach’s α=0.82) have satisfactory reliability (Cronbach’s α≥0.70). Healthy Eating Intentions (Cronbach’s α=0.56) is below minimum threshold for reliability but acceptable for a three-item scale.ConclusionsThe resulting questionnaire, with satisfactory reliability and validity, may be used in assessing patients’ awareness of CVD risk among NHS Health Check attendees.

ObjectiveTo determine coverage of NHS Health Check, a national cardiovascular risk assessment programme in England, in the first four years after implementation, and to examine prevalence of high cardiovascular disease (CVD) risk and uptake of statins in high risk patients. Method ResultsProgramme coverage was 21.4% over four years, with large variations between practices (0%-72.7%) and regions (9.4%-30.7%). Coverage was higher in older patients (adjusted odds ratio 2.88, 95% confidence interval 2.49-3.31 for patients 70-74 years) and in patients with a family history of premature coronary heart disease (2.37, 2.22-2.53), but lower in Black Africans (0.75, 0.61-0.92) and Chinese (0.68, 0.47-0.96) compared with White British. Coverage was similar in patients living in deprived and affluent areas. Prevalence of high CVD risk (QRISK2≥20%) among attendees was 4.6% One third (33.6%) of attendees at high risk were prescribed a statin after Health Checks. ConclusionsCoverage of the programme and statin prescribing in high risk individuals was low. Coverage was similar in deprived and affluent groups but lower in some ethnic minority groups, possibly widening inequalities. These findings raise a question about whether recommendations by WHO to develop CVD risk assessment programmes internationally will deliver anticipated health benefits. A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT3 HIGHLIGHTS  Coverage of the programme examined nationally was low in the first four years. Wide variation in coverage was observed between practices and English regions. Increases in statin prescribing were found in both high and lower risk patients. Only 1/3 of attendees at high risk were prescribed a statin after Health Check. Almost five times more patients at lower risk than high risk were offered a statin.

BackgroundCardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.MethodsBetween January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs). We assessed variation between local authorities in terms of age, sex, deprivation and ethnicity structures using two sample t-tests and within local authority variation in terms of ethnicity and deprivation using Chi squared tests and two sample t-tests respectively.ResultsUsing Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs – namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40–49 and 50–59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs.ConclusionsCommunity-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities therein.

ObjectiveTo determine if use of point of care testing (POCT) is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check (NHSHC) programme in the primary care setting.DesignObservational study and theoretical mathematical model with microcosting approach.SettingWe collected data on NHSHC delivered at nine general practices (seven using POCT; two not using POCT).ParticipantsWe recruited nine general practices offering NHSHC and a pathology services laboratory in the same area.MethodsWe conducted mathematical modelling with permutations in the following fields: provider type (healthcare assistant or nurse), type of test performed (total cholesterol with either lab fasting glucose or HbA1c), cost of consumables and variable uptake rates, including rate of non-response to invite letter and rate of missed [did not attend (DNA)] appointments. We calculated total expected cost (TEC) per 100 invites, number of NHSHC conducted per 100 invites and costs for completed NHSHC for laboratory and POCT-based pathways. A univariate and probabilistic sensitivity analysis was conducted to account for uncertainty in the input parameters.Main outcome measuresWe collected data on cost, volume and type of pathology services performed at seven general practices using POCT and a pathology services laboratory. We collected data on response to the NHSHC invitation letter and DNA rates from two general practices.ResultsTEC of using POCT to deliver a routine NHSHC is lower than the laboratory-led pathway with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of POCT can deliver NHSHC in one sitting, whereas the laboratory pathway offers patients several opportunities to DNA appointment.ConclusionsTEC of using POCT to deliver an NHSHC in the primary care setting is lower than the laboratory-led pathway. Using POCT minimises DNA rates associated with laboratory testing and enables completion of NHSHC in one sitting.

Background Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change. Objective The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy. Methods A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usability of the Web app, and patient satisfaction. The efficacy of the Web app will be assessed by changes in medication adherence and clinical risk factors by levels of the Web app compliance. Results This study is currently funded by the American Heart Association. Initial study recruitment will take place between February and July 2018 followed by patient follow-up. Patient level data will be obtained in January 2019. Data analysis will be completed by February 2019. Results will be submitted for publication in March 2019. Conclusions The potential of an app to improve patients’ lifestyle and management of cholesterol may inform the design of a randomized controlled trial and the delivery of more effective CVD prevention programs. International Registered Report Identifier (IRRID) PRR1-10.2196/9017

BACKGROUND Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change. OBJECTIVE The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy. METHODS A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usability of the Web app, and patient satisfaction. The efficacy of the Web app will be assessed by changes in medication adherence and clinical risk factors by levels of the Web app compliance. RESULTS This study is currently funded by the American Heart Association. Initial study recruitment will take place between February and July 2018 followed by patient follow-up. Patient level data will be obtained in January 2019. Data analysis will be completed by February 2019. Results will be submitted for publication in March 2019. CONCLUSIONS The potential of an app to improve patients’ lifestyle and management of cholesterol may inform the design of a randomized controlled trial and the delivery of more effective CVD prevention programs. INTERNATIONAL REGISTERED REPOR PRR1-10.2196/9017

Background Global trends in cardiovascular disease (CVD) exhibit considerable interregional and interethnic differences, which in turn affect long-term CVD risk across diverse populations. An in-depth understanding of the interplay between ethnicity, socioeconomic status, and CVD risk factors and mortality in a contemporaneous population is crucial to informing health policy and resource allocation aimed at mitigating long-term CVD risk. Generating bespoke large-scale and reliable data with sufficient numbers of events is expensive and time-consuming but can be circumvented through utilization and linkage of data routinely collected in electronic health records (EHR). Objective We aimed to characterize the burden of CVD risk factors across different ethnicities, age groups, and socioeconomic groups, and study CVD incidence and mortality by EHR linkage in London. Methods The proposed study will initially be a cross-sectional observational study unfolding into prospective CVD ascertainment through longitudinal follow-up involving linked data. The government-funded National Health System (NHS) Health Check program provides an opportunity for the systematic collation of CVD risk factors on a large scale. NHS Health Check data on approximately 200,000 individuals will be extracted from consenting general practices across London that use the Egton Medical Information Systems (EMIS) EHR software. Data will be analyzed using appropriate statistical techniques to (1) determine the cross-sectional burden of CVD risk factors and their prospective association with CVD outcomes, (2) validate existing prediction tools in diverse populations, and (3) develop bespoke risk prediction tools across diverse ethnic groups. Results Enrollment began in January 2019 and is ongoing with initial results to be published mid-2021. Conclusions There is an urgent need for more real-life population health studies based on analyses of routine health data available in EHRs. Findings from our study will help quantify, on a large scale, the contemporaneous burden of CVD risk factors by geography and ethnicity in a large multiethnic urban population. Such detailed understanding (especially interethnic and sociodemographic variations) of the burden of CVD risk and its determinants, including heredity, environment, diet, lifestyle, and socioeconomic factors, in a large population sample, will enable the development of tailored and dynamic (continuously learning from new data) risk prediction tools for diverse ethnic groups, and thereby enable the personalized provision of prevention strategies and care. We anticipate that this systematic approach of linking routinely collected data from EHRs to study CVD can be conducted in other settings as EHRs are being implemented worldwide. International Registered Report Identifier (IRRID) PRR1-10.2196/17548

BACKGROUND Global trends in cardiovascular disease (CVD) exhibit considerable inter-regional and inter-ethnic differences, which in turn affect long term CVD risk across diverse populations. An in-depth understanding of the interplay between ethnicity, socio-economic status and CVD risk factors and mortality in a contemporaneous population is crucial to informing health policy and resource allocation aimed at mitigating long-term CVD risk. Generating bespoke large-scale and reliable data with sufficient numbers of events is expensive and time consuming but can be circumvented through utilisation and linkage of routine collected data in electronic health records (EHR). OBJECTIVE We therefore aim to characterise the burden of CVD risk factors across different ethnicities, age-groups and socio-economic groups, and study CVD incidence and mortality by EHR linkage in London. METHODS The proposed study will initially be a cross-sectional observational study unfolding into prospective CVD ascertainment through longitudinal follow-up involving linked data. The government funded NHS Health Check programme provides an opportunity for the systematic collation of CVD risk factors on a large-scale. NHS Health Check data on approximately 200,000 individuals will be extracted from consenting GP practices across London that use the EHR Egton Medical Information Systems (EMIS) software. Data will be analysed using appropriate statistical techniques to: (i) determine cross-sectional burden of CVD risk factors and their prospective association with CVD outcomes, (ii) validate existing prediction tools in diverse populations and (iii) develop bespoke risk prediction tools across diverse ethnic groups. RESULTS Enrolment began January 2019 and is ongoing with initial results to be published mid-to-late 2020. CONCLUSIONS There is an urgent need for more real-life population health studies based on analyses of routine health data available in EHRs. Findings from our study will help quantify on a large scale, the contemporaneous burden of CVD risk factors by geography and ethnicity in a large multi-ethnic urban population. Such detailed understanding (especially inter-ethnic and socio-demographic variations) of the burden of CVD risk and its determinants, including heredity, environment, diet, lifestyle and socioeconomic factors, in a large population sample will enable development of tailored and dynamic (continuously learning from new data) risk prediction tools for diverse ethnic groups, and thereby enable personalised provision of prevention strategies and care. We anticipate that this systematic approach of linking routinely collected data from EHRs to study CVD can be conducted in other setting as EHRs are being implemented worldwide.