THE MEDCAL COMMUNITY HEART DISEASE PREVENTION PROGRAMME

Frequently asked Questions

What research is the program based on?

RISK uses two methods of assessing and display a patients risk factors:-

1. The relative areas and scores are based on the scoring system similar to that used by the Dundee disk which in turn was derived from the Scottish Heart Health Study. Information from the Framingham study and British regional heart study was also used to produce the relative values for each factor.

A.Smith WCS, Tunstall-Pedoe H Crombie IK,Tavendale R. Concomitants of excess coronary deaths-major risk factor and lifestyle findings from 10359 men and women in the Scottish Heart Health Study. Scot Med J 1989;34:505-5

B. Tunstall-Pedoe H. The Dundee coronary risk-disk for management of change in risk factors. BMJ 1991;303:744-7.

C Anderson et al - American Heart Journal January 1991 Volume 121 Number 1, part 2 pages 293-8.- Cardiovascular disease risk profiles.

D.The British Regional Heart Study >>> Ramsdale et al >>> Barrett-Conner et al.

2. The treatment bar percentage is based on the Framingham Equation

Anderson KM, Odell PM ,Wilson PWF, Kannel WB. Cardiovascular disease risk profiles. Am Heart J 1990;121:293-8

Why did you use the Scottish Heart Study rather than the Framingham work?

When we first developed this program the Framingham work was not freely available in this country. We developed our program at the time that the Dundee disc was produced and used this to check our results.

The relative Risk score is much more useful in patient education and so we continued to use it. When the Framingham work was available we found it did not significantly affect our program so we added it to calculate absolute risk for drug intervention but left the patient education part unchanged.

How does your program use the Framingham study equation?

The Framingham work produces an equation which gives you the chance of an individual getting a cardiac event over a period of time. It does not however allow you to change that result when the patient has taken your advice. This is because to do so that would clearly not be a provable effect as you have immediately gone outside the parameters of the data available from the study. This is because the work is an observation study not a trial of the effects of treatment. While this is very helpful in understanding the risks at a given point, it does not translate well into a patient education program so we use it to calculate risk events percentage over time in order to assist the doctor in deciding whether to prescribe drugs.

How does your program use the other studies?

Our programme is a patient education programme designed for the whole community. It covers all patients before and when on treatment for coronary heart disease risk factors. This requires a different approach as clearly the patient is interested in how they can improve their health and reduce their risk of a heart attack, not in a comparison with somebody else. We have also found that the majority of patients do not easily understand the meaning of percentages. This means that if you present the data as a percentage risk then in most cases you are not effectively communicating with the patients. The risk programme is therefore designed to simplify the presentation of the information in a way the majority of patients will understand. Allowing them to make life style changes which are based on understanding This is important if these changes are to be maintained.

Who is the program designed for?

The risk programme is designed for use in the whole community. It comes in several versions to cover the whole community. These are: -

1. Community Risk - a touch screen based programme for use by patients unsupervised. It therefore has a simplified version of the programme excluding some factors that patients do not usually have results for, unless they had already consulted a health professional. It recommends a full assessment if risk factor is significant(this can be set at different levels). Patients with existing disease have their lifestyle and compliance with medication reinforced thus increasing the community pool of CHD reduction.

It also gives education advice even to low risk patients so as to increase the community understanding of health living.

2. Risk CHD - this is the main programme for health professionals and is suitable for all professionals from secretary to consultant. This version is suitable for the majority of patient contacts with a professional.

3. Risk CHD Hospital is a slightly modified version of the above to suit the hospital environment.

Why use the thermometer and colour scheme?

The visual reinforcement of advice given in consultation has proved to be a major factor in the effectiveness and recall of the advice by patients. After much work we found that the traffic light colours were most effective in indicating the level of each individual risk factor and the thermometer plus colour has proved to be very effective in indicating effects on health. It uses the well-known fact that high temperature in health is bad and lowering it is an improvement thus giving the memory a reinforcement as the advice on CHD prevention fits in with previous knowledge.

The green colour indicates low risk from this factor (this also applies when treatment compliant) People with a green total score are unlikely to get CHD under the age 70 if this score is maintained. Patients with existing CHD cannot usually get a green score unless everything else is normal in this situation this is the lowest achievable and therefore their relative risk is low as it cannot be bettered. Their absolute risk may still be significant.

The orange (yellow on some screens) indicates that risk factors exist to a level where CHD is present or likely at some stage in their life.

A red scores indicate significant factors for risk of CHD present and disease present or likely.

These colour scores indicate to the patient the need for change and reinforce improvements made. A target score( the best that the individual can achieve is also indicated to encourage those who cannot achieve low risk scores.

It is not claimed that these levels indicate a specific absolute risk in the patient which will anyway vary significantly in different patients with the same risk factors. But does indicate to the individual their position with regard to risk factors

Estimation of absolute risk requires the full health professional version and the interpretation of a medical adviser. This is advised in all medium and high risk patients using the self assessment program. Absence of information always advise that the information be sought and a reassessment made except in the case of cholesterol which is advised if other risk factor present.

It is not recommended that cholesterol be measured in the absence of other risk factor.

Why do you not use a chance of getting an event in a period of time in your program?

We do offer this as a % risk using Framingham but it is not used in the main part of the program.

The use of tables, such as those produced in Sheffield and New Zealand, which predict your chances of getting an event in the next X years are a very useful community research tool. However, we have found them of little direct use in patient education.

In particular the age effect means that younger people(<50) with significant risk factors will show as low risk as their predicted "MI" will be more than 10 years away .This however is when CHD is best prevented by life style changes.

% risk calculations are really designed for the doctor to decide whether to offer drug therapy and this is only a very small part of the Risk CHD concept. It is also difficult and time-consuming to use them . The recent Heart Health Strategy publication has some 32 tables to cover a population, each of which needs to be an A4 size sheet. Although our strategy for making the programme easy to use may mean the occasional patient may get advice which is only 95 % accurate the benefits in enabling the programme to be used by professionals in all consultations are out weighed by these slight disadvantages. A 95% accurate usable programme is a great deal more effective than a 100% accurate but unusable programme.

What strategies make your program more effective as an educational tool?

The programme uses visual clues, change demonstration, colour reinforcements, action effects and written reinforcements.

1. Visual clues are colour changes and movements of the thermometer according to risk factors.

2. Change demonstration is the changing of the thermometer and colours according to changes you make in your life style.

3. Colour reinforcements are red, orange and green as with traffic lights.

4. Action effects Changes suggested give changes on the screen to indicate effect.

5. Written reinforcement The patient receiving a personalised printed copy of the advice given.

Why print Advice?

Patients respond to it and take notice more readily. They keep the advice sheets and refer back to them.

When can Risk be used?

Risk can be used with all patients from 16 years upwards. In all cases it will give advice as to how they can decrease their risk of coronary heart disease. Obviously in some this will prove more important than in others.

What computer hardware is required to use the programme?

The programme will run on any windows-based computer. It can also run on a local network. It should not interfere with any programme running on the computer at the same time and is designed to run with other programmes and interface to clinical general practice systems. We supply full details of how this can be done to the clinical supplier.

What do the percentages signify?

The program has two user set Framingham risk percentage these can be used to indicate when drug therapy is advised i.e. 15% 10 year risk for aspirin 30% 10 year risk for statin therapy.

What about Ethnic variations in risk factors?

As the main risk assessment includes loading for relatives with diabetes and family history as well as the Framingham factors it should prove much more accurate in predicting ethnic risk as the absence of these factors in Framingham make it underestimate risk in these populations.

(Some Asian populations have an increase of non insulin dependant diabetes leading to a greater rate of CHD. The addition loading of the main program of diabetic relative is helpful in picking out this increased risk)

Why do use ask about salt?

The question on salt has been included as it was in the base line assessment work. While salt was not included in the Framingham studies it is still considered a risk factor for Hypertension. Hypertension is one of the major causes of CHD. Patient prevention of hypertension will be be aided by reducing the excess salt in our diets (the average person consumes more than twice the recommended intake of salt) . We believe the value of 1 may be high compared with some of the other factors (0.5 might be more accurate) but we also believe the education value would be lost if we make the values difficult to understand.

Why do use particular dietary advice?

Our dietary advice is a simple set of advice which would if used lead to a health reasonably balance diet. Patients with specialist risk diabetes and hypercholesterolaemia should be referred for specialist dietary advice.

Fat (particularly saturated) and low bulk sugars and salt usually take a far bigger proportion of the diet that they should

Thus reducing fat intake and high salt and sugar preparations in the diet will lead in an increase in high bulk carbohydrate elements which bring the diet back towards a health diet. Recommending a health balance diet to most at risk patients will produce poor results as they do not know what it means. Our dietary advice follows the basic ideas of the Family heart Association with some modification to ease it implementation in the less well educated population.

Why is it possible to be low risk if diabetic?

The relationship between diabetes and CHD is complex. Few diabetics do not have additional risk factors. However a well controlled diabetic with no hypertension and no other risk factors (particularly no family history) is in fact at lower risk than a smoker or a patient with hypertension or hypercholesterolaemia. It is however unusual to find patients with this combination so a low risk diabetic is unusual. However target organ damage in a diabetic may well mean that the artery effects generally are equivalent in risk to a history of IHD and should on our opinion be loaded to this effect.

Why do you not ask about exercise in the desk top version and why ask for 3 hours exercise a week and much current advice suggests light exercise.

Exercise has been shown to help prevent CHD. In fact it is probably the most important life style change that can help prevent CHD. Unfortunately there is no research work that can give a relative figure to compare with other risk factors. This is largely as there is little work on how to measure exercise in real life as opposed to "GYM" exercise and as exercise varies a lot over years almost no work that can directly relate the amount of exercise to the risk of CHD.

Currently the British Heart Foundation recommend 30mins exercise 5 or more days a week hard enough to make you feel mildly out of breath. Our advise based on the best advice available then is 1 hour 3 or more time a week leading to breathlessness. Both advise starting slowly and building up and that any is better than none. Thus despite many new guide lines on exercise there has in fact been no real change over the last 10 years. We are therefore keeping our advice the same to make it easier for patients (consistency is important in getting results).

Why only these factors?

These are the only factors for which the research results shows reasonably consistent results.

Reviewed in the BMJ April 2001 other factors were considered as yet unproved. We expect that additional factors will be proven in the future and will include them when their relative risk is calculable.

You don't use PROCAM why?

Procam only produced an prediction algorithm in 1998 after our program was written we are currently assessing if it would be useful to included it (comparing the results in 3500 patients with Framingham).