Students: Brenda Cournane (& Tamlin Clulow)
Supervisor: Dr Ian Sheerin, Dr Alistair Humphrey, Dr Greg Hamilton
Sponsor: National Heart Foundation of New Zealand
Introduction
Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in New Zealand, accounting for 41% of all deaths in 1999. Risk factor reduction is necessary to improve these statistics. In 2003 the New Zealand Guidelines Group (NZGG) published evidence-based guidelines for screening for cardiovascular risk factors. As individuals with multiple risk factors are at a greatly increased risk of a cardiovascular event, the NZGG recommends lifestyle changes and health interventions based on an individual's 5-year absolute risk of a cardiovascular event. The Canterbury District Health Board (CDHB) has identified CVD as high priority, and proposes a pilot 'screen and treat' programme for cardiovascular risk factors in primary health care. As a formative stage of the proposed screen and treat programme, this project will provide baseline data on the prevalence of cardiovascular risk factors at Practice A in Rangiora, before the commencement of screening.
Aims
The aim of the project is to audit patient records, identifying people aged 25-74 with cardiovascular risk factors that are documented in existing records, and looking at variations by gender, age, ethnicity and chronic health conditions. Details about “current practice” will also be documented.
Method
The focus of the study was on registered patients at Practice A, aged between 25-74yrs. Med Tech 32 Query Builder was used to generate a list of all patients in this age group and to identify those who had cardiovascular risk factors that were already identified by current practice. The medical record of each patient identified as having CVD risk factors was then scrutinised for recorded details of family health history, smoking, body weight and height, biochemical test results, personal history of CVD, diabetes and/or renal disease, information on physical activity and current medications. Data was entered into an Excel spreadsheet and analysed using SPSS.
Results
Out of 1216 patients at Practice A aged 25-74 years, 503 patients had documented cardiovascular risk factors. The most significant risk factor was age (60-74yrs), accounting for 61% of patients included in this study. Smoking was the most prevalent modifiable risk factor - highest among males in the 45-49 age group, and it was also the main risk factors identified in patients under 40 years of age.
The 73 patients with known cardiovascular disease were predominately NZ European males, although age-specific prevalence of CVD in female patients aged 70-74 was similar to that of male patients.
Despite the small sample of Maori patients identified with risk factors, the findings support trends in the health of the Maori population, with all Maori patients with known cardiovascular disease aged under 55 years, and disproportionately high rates smoking, when compared to NZ Europeans, particularly among females. The data supports the NZGG recommendation of risk assessments 10 years earlier for Maori.
Details regarding “current practice” revealed modest levels of documentation of information recommended by NZGG. Blood pressure, weight measurements and smoking details were all routinely recorded. However, there was a lack of information on BMI and waist measurements, with details recorded in only 14% and 6% of patient's notes, respectively. Also details regarding family history and physical activity were also less likely to be found in patient records.
The NZGG recommends cardiovascular risk assessments from the age 35 for men, and 45 for women, with known cardiovascular risk factors. This study showed that 55% of patients with CVD risk factors did not have the required information to perform such assessments. However, given that the main reason for this was no fasting lipid test, and the fact that 83% of patients had TC:HDL values recorded (fasting or non-fasting), this data reflects a gap between current practice and recommendations of the NZGG rather than an absence of information.
Recommendations
To meet with guidelines set by the NZGG, gaps in the current method of data recording need to be rectified, particularly in regards to fasting lipid tests, BMI, waist measurements and family history details. Overall, this general practice was found to have more comprehensive information than other practices that were audited in the area. It is considered that a systematic screening programme for CVD risk could be readily implemented at Practice A if the above improvements in information collection were incorporated into the practice.