CVD Workbook: Understanding and communicating CVD risk and management recommendations

4 minutes to Read + 56 minutes to Delve
Contributor
Richard French, Dr Noni Richards
21 April 2022
CVD workbook

This workbook consists of introductory reading and five distinct modules that encourage you to reflect on your CVD risk assessment and management practices, risk communication, cultural safety, and your engagement with young adult Māori and Pacific patients.

By completing all five modules, this workbook can help you to improve the uptake of CVD risk assessment and primary prevention of CVD in your practice.


Introduction


Is CVD risk assessment in primary care gaining momentum?

Cardiovascular disease (CVD) risk assessment is a key component of the primary care preventive medicine strategy. In 2018, a consensus statement was published by the Ministry of Health for Cardiovascular Disease Risk Assessment and Management for Primary Care.1 The recommendations were based on an update of evidence since the last major review published in 2012.

The team for the 2018 update was also tasked with investigating the expected real-world benefit to New Zealanders of having New Zealand-specific risk stratification and risk equations. As a result, the update introduced new five-year CVD risk prediction equations (NZ Primary Prevention Equations), for men and women aged 30 to 74 years, developed from the New Zealand PREDICT study data. Further, for Māori, Pacific, South Asian and mental health patient populations, the new recommendations were that risk assessment should begin earlier than for other population groups.1

CVD risk assessment in primary care also aligns with several indicators of The Health System Indicators framework – the latest iteration of health system performance measurement, or how well the health and disability system serves New Zealanders.2,3 Proactive and equitable implementation of CVD risk assessment contributes to several government priorities, including:

  • Improving wellbeing through prevention – high-level indicator, ambulatory sensitive hospitalisations for adults (age range 45 to 64); description, rate of hospital admissions for people aged 45 to 64 for an illness that might have been prevented or better managed in the community.
  • Strong and equitable public health system – high-level indicator, acute hospital bed day rate; description, number of days spent in hospital for unplanned care including emergencies.
  • Better primary healthcare – high-level indicator, people report being involved in the decisions about their care and treatment; description, percentage of people who say they felt involved in their own care and treatment with their GP or nurse.

Work to implement the framework continues into 2022 and the first update of the Health System Indicators framework was added in December 2021, using December 2019 as a baseline. Also feeding data into the framework is the quarterly primary care patient experience survey designed to find out about patients’ experience in primary care and conducted by the Health Quality & Safety Commission with support from the Ministry of Health.

The new Health System Indicators draw on both the earlier “System Level Measures” and modified elements of the previous “Health Targets”.4

The new consensus statement and the indicators framework have been two significant developments in the last four years. Not surprisingly, COVID-19 may have had an impact on the rate of implementation of both – in the first update to The Health System Indicators framework it was noted: “COVID-19 and the associated health response is impacting on many of the indicators reported and explain much of the apparent improvements or reductions from baseline.”3


Refocus and renew efforts on Māori and Pacific peoples


Enabling young adult Māori and Pacific peoples to proactively combat CVD

The focus of this resource is on reviewing CVD risk assessment and management, risk communication, cultural safety, and engagement with young adult Māori and Pacific patients in primary care, with the aim of improving the uptake of CVD risk assessment and primary prevention of CVD.

The evidence shows the much higher burden of CVD morbidity and mortality in Māori and Pacific people – and almost half of the deaths from heart disease each year in these populations are premature (before the age of 75) and avoidable.5 This is more than three times the rate for non-Māori.

The disparities in heart health outcomes are particularly stark when viewed by decile and ethnicity. Not only do avoidable deaths increase with deprivation, but there are startling inequities by ethnicity regardless of deprivation level.5 And while heart disease is, in part, a consequence of poverty, it is also a contributor to poverty – Māori and Pacific people are eight times more likely to receive jobseeker’s allowances than non-Māori as a result of disability caused by heart disease.6


Not only do avoidable deaths increase with deprivation, but there are startling inequities by ethnicity regardless of deprivation level – Heart Foundation white paper 5


Māori are disproportionally affected with heart failure and on average suffer onset about 15 years earlier than non-Māori. Atrial fibrillation, a common cardiac rhythm disorder associated with preventable stroke risk, is twice as likely to occur in Māori and, on average, presents 10 years earlier in Māori and Pacific people compared with non-Māori, non-Pacific people. The mortality rate from heart disease for Māori is more than double that for non-Māori. Māori men have a mortality rate almost six times that of the lowest risk group, non-Māori women.7

Access to healthcare is not equitable. Even though New Zealand has the tools for detecting, treating and managing heart disease, they are not accessed by everyone who needs them. Māori, Pacific and low-income New Zealanders, in particular, are still the least likely to receive healthcare when it matters most.5 The inequity is also displayed in the dispensing data for Māori and Pacific ethnicity patients.8

The 2018 publication of the consensus statement specified the need to start risk assessments for Māori, Pacific and South-Asian people 15 years earlier than for other ethnic groups – ie, in men from age 30 years and in women from 40 years.1

Communicating risk to individuals, in person rather than in virtual consultation, as part of shared decision making and CVD risk management is recommended. Patient communication and joint healthcare practitioner–patient management decisions are critical components of the CVD risk assessment and management process.1 This needs to be done effectively, recognising that decision support tools for different levels of health literacy are useful adjuncts to help patients understand risk.1

The healthcare practitioner must be able to effectively convey the risk, and provide advice in a culturally safe context, for the patient to be able to decide what to do about it.


Reflection modules


The modules below encourage you to reflect on your current practice and incorporate your learning into everyday activities. Each module is in a PDF format that you can download and save to your computer before starting. Once you've saved the document to your computer, follow the prompts and type your notes into the editable fields. When you have completed the activity, upload the completed PDF into your online CPD/CME record.

Module 1: Ethnic disparities in CVD morbidity and mortality

Module 2: CVD risk assessment – the New Zealand approach

Module 3: CVD risk management – the New Zealand approach

Module 4: Communicating cardiovascular risk

Module 5: Cultural safety


Professional college endorsements

This activity has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and has been approved for up to 1 CME credit for Continuing Professional Development (CPD) purposes. To claim your credits, log in to your RNZCGP dashboard to record this activity in the CME component of your CPD programme.

This activity has been endorsed by the Pharmaceutical Society of NZ Inc (PSNZ) as suitable for inclusion in a pharmacist’s CE records for Continuing Professional Development (CPD) purposes.

RNZCGP logoPSNZ logo

Acknowledgements

Written by: Richard French (BSc) and Dr Noni Richards (BPharm, PhD)

Reviewed by: Dr Fraser Hamilton (MBChB, FRNZCGP)

References

1. Ministry of Health. ​​​Cardiovascular Disease Risk Assessment and Management for Primary Care. Wellington. 2018. www.health.govt.nz/publication/cardiovascular-disease-risk-assessment-and-management-primary-care

2. Ministry of Health. Health System Indicators framework. 13 December 2021. www.health.govt.nz/new-zealand-health-system/health-system-indicators-framework (Accessed 8 February 2022)

3. HQSC New Zealand. Health System Indicators framework.10 December 2021. https://reports.hqsc.govt.nz/HSI/_w_00b10f0f/#!/ (Accessed 8 February 2022)

4. Johnston M. Health system gets new episode of the number games. New Zealand Doctor Rata Aotearoa. 1 September 2021. www.nzdoctor.co.nz/article/print-archive/health-system-gets-new-episode-number-games

5. The National Heart Foundation of New Zealand. Heart Foundation White Paper. Improving heart health outcomes for New Zealand. 4 August 2020. www.heartfoundation.org.nz/about-us/news/media-releases/urgent-call-for-a-co-ordinated-national-heart-health-action-plan

6. Ministry of Social Development. National Level Benefit Data for quarter ending September 2019. (Accessed March 2020).

7. Ministry of Health. Mortality Data Table 2017 (provisional). 2019. (Accessed March 2022).

8. He Ako Hiringa. Bulletin 10: Cardiovascular disease – a risky business. 28 January 2022. www.akohiringa.co.nz/education/cardiovascular-disease-a-risky-business

9. Ministry of Health. National Mortality Collection. 2014–2019 data. www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/collections/mortality-collection (Accessed August 2021).

10. Ministry of Health. Pharmaceutical Collection. 2014–2019 data. www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/collections/pharmaceutical-collection (Accessed August 2021)

11. Ministry of Health. Background to cardiovascular disease risk assessment and management. 16 January 2022. www.health.govt.nz/our-work/diseases-and-conditions/cardiovascular-disease/background-cardiovascular-disease-risk-assessment-and-management

12. BPACnz. Prescribing statins to reduce cardiovascular risk. 3 May 2021. https://bpac.org.nz/2021/statins.aspx

13. US National Library of Medicine. Eliminate Coronary Artery Disease (ECAD). Last update posted 15 May 2018. https://clinicaltrials.gov/ct2/show/NCT02245087

14. Adults US Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease: Preventive Medication. Final Recommendation Statement 13 November 2016. www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication

15. American College of Cardiology. Improving cardiovascular risk communications with your patients. 2022. www.acc.org/tools-and-practice-support/risk-communications (Accessed 6 March 2022).

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18. Zipkin DA, Umscheid CA, Keating NL, et al. Evidence-based risk communication: a systematic review. Ann Intern Med. 2014;161(4):270–80. doi:10.7326/M14-0295

19. Akl EA, Oxman AD, Herrin J, et al. Framing of health information messages. Cochrane Database Syst Rev. 2011;(12):CD006777. doi:10.1002/14651858.CD006777.pub2

20. Schrager SB. Five Ways to Communicate Risks So That Patients Understand. Fam Pract Manag. 2018;25(6):28–31.

21. Wells S, Kerr A, Eadie S, Wiltshire C, Jackson R. “Your Heart Forecast”: a new approach for describing and communicating cardiovascular risk? Heart. 2010;96(9):708–13. doi:10.1136/hrt.2009.191320

22. Duffy EY, Ashen D, Blumenthal RS, et al. Communication approaches to enhance patient motivation and adherence in cardiovascular disease prevention. Clin Cardiol. 2021;44(9):1199–1207. doi:10.1002/clc.23555

23. Frost H, Campbell P, Maxwell M, et al. Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews. PLoS One. 2018;13(10):e0204890. doi:10.1371/journal.pone.0204890

24. He Ako Hiringa. Bulletin 4: Being culturally competent is not enough. June 2021. www.akohiringa.co.nz/sites/default/files/public/2021-06/HAH%20Bulletin%20%234_FINAL.pdf

25. Medical Council of New Zealand. Statement on cultural safety. October 2019. www.mcnz.org.nz/assets/standards/b71d139dca/Statement-on-cultural-safety.pdf

26. Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 2019;18:174. doi.org/10.1186/s12939-019-1082-3

27. Health Navigator. What is cultural competence? March 2022. www.healthnavigator.org.nz/clinicians/c/cultural-competence