Integrated Clinical Decision Support Systems Promote Absolute Cardiovascular Risk Assessment: An Important Primary Prevention Measure in Aboriginal and Torres Strait Islander Primary Health Care

Abstract

BackgroundAboriginal and Torres Strait Islander Australians experience a greater burden of disease compared to non-Indigenous Australians. Around one-fifth of the health disparity is caused by cardiovascular disease (CVD). Despite the importance of absolute cardiovascular risk assessment (CVRA) as a screening and early intervention tool, few studies have reported its use within the Australian Indigenous primary health care (PHC) sector. This study utilizes data from a large-scale quality improvement program to examine variation in documented CVRA as a primary prevention strategy for individuals without prior CVD across four Australian jurisdictions. We also examine the proportion with elevated risk and follow-up actions recorded.MethodsWe undertook cross-sectional analysis of 2,052 client records from 97 PHC centers to assess CVRA in Indigenous adults aged ≥20 years with no recorded chronic disease diagnosis (2012–2014). Multilevel regression was used to quantify the variation in CVRA attributable to health center and client level factors. The main outcome measure was the proportion of eligible adults who had CVRA recorded. Secondary outcomes were the proportion of clients with elevated risk that had follow-up actions recorded.ResultsApproximately 23% (n = 478) of eligible clients had documented CVRA. Almost all assessments (99%) were conducted in the Northern Territory. Within this jurisdiction, there was wide variation between centers in the proportion of clients with documented CVRA (median 38%; range 0–86%). Regression analysis showed health center factors accounted for 48% of the variation. Centers with integrated clinical decision support systems were more likely to document CVRA (OR 21.1; 95% CI 5.4–82.4; p < 0.001). Eleven percent (n = 53) of clients were found with moderate/high CVD risk, of whom almost one-third were under 35 years (n = 16). Documentation of follow-up varied with respect to the targeted risk factor. Fewer than 30% with abnormal blood lipid or glucose levels had follow-up management plans recorded.ConclusionThere was wide variation in CVRA between jurisdictions and between PHC centers. Learnings from successful interventions to educate and support centers in CVRA provision should be shared with stakeholders more widely. Where risk has been identified, further improvement in follow-up management is required to prevent CVD onset and reduce future burden in Australia’s Indigenous population.

Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement

“…A 2018 study using nationally representative data from the 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey found that 1.1% of Aboriginal and Torres Strait Islander peoples aged 18–24 years (95% CI, 0.0–2.5%) and 4.7% Aboriginal and Torres Strait Islander peoples aged 25–34 years (95% CI, 2.0–7.5%) were at high absolute risk of having a primary CVD event in the next 5 years . These findings support those previously reported in specific Aboriginal and Torres Strait Islander populations . The proportion of people aged 25–34 years at high risk (4.7%) is similar to that seen in non‐Indigenous people aged 45–54 years (4.0%), the age from which absolute CVD risk assessment is recommended for this population under the current NVDPA guidelines .…”

Aboriginal and Torres Strait Islander absolute cardiovascular risk assessment and management: systematic review of evidence to inform national guidelines

“…Five articles met our inclusion criteria. Studies included Aboriginal and/or Torres Strait Islander people (age range 18-76 years) from the Northern Territory 7-10 , Queensland 10,11 , Western Australia 10 and South Australia. 10 Approximately equal numbers of men and women were included, and all studies were of fair or good quality.…”

“…Two studies described absolute CVD risk profiles in Aboriginal and Torres Strait Islander communities. 9,10 High absolute CVD risk commenced at an early age, with approximately 6-9% of those aged 20-34 years having moderate (10-15% over 5 years) or high (>15% over 5 years) absolute CVD risk. 9,10 There was evidence that the Framingham Risk Equation underestimated CVD risk by around 1.5-2.5 times when used alone, without applying criteria for clinically determined high risk.…”

“…9,10 High absolute CVD risk commenced at an early age, with approximately 6-9% of those aged 20-34 years having moderate (10-15% over 5 years) or high (>15% over 5 years) absolute CVD risk. 9,10 There was evidence that the Framingham Risk Equation underestimated CVD risk by around 1.5-2.5 times when used alone, without applying criteria for clinically determined high risk. 8,11 In the study by Wang and Hoy, observed rates of coronary heart disease were estimated at 11 cases per 1000 person-years compared with a predicted rate of 4.4 per 1000 person-years estimated using the Framingham Risk Equation.…”

Emerging evidence of the value of health assessments for Aboriginal and Torres Strait Islander people in the primary healthcare setting

“…Indigenous clients had four-fold higher odds of having a CVRA if they had received an Indigenous-specific health assessment (1388 client records from 48 Indigenous PHC centres in the Northern Territory, 2012-14) (Matthews et al 2017). Cardiovascular risk assessments are not directly specified in the MBS item 715 descriptor despite their recognised role in curbing the onset of cardiovascular disease.…”