e-nudge trial
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Dr Tim HoltClinical Lecturer
Health Sciences Research Institute
The e-Nudge Trial: Identifying and addressing cardiovascular risk in
primary care
Lifestyle advice and drug therapy
The problem: identifying at risk individuals for cardiovascular disease in primary care
• Aim is to identify the population at > 20% risk of developing CVD in next 10 years, for preventive drug therapy and lifestyle advice
• Risk algorithms using different risk factors
– Classical factors: Age, sex, blood pressure, total and HDL cholesterol, smoking status
– Other factors: eg family history, ethnicity, deprivation, obesity, waist circumference, fasting triglycerides, renal impairment
• Risk assessment requires collation of information, only some of which is coded electronically
The e-Nudge Trial
• Tests a software tool developed in collaboration with EMIS
• Nineteen practices in Coventry and Warwickshire recruited with a range of practice demographics
• Software applied to a random half of the over-50 year population in each practice and will run for 2 years
• Software identifies 6 categories of patient• Screen alerts and continually updated lists of patients
in each category
The e-Nudge Trial
Group 1: Those with CVD or Diabetes whose blood pressure or cholesterol are out of target for the QOF
Group 2: Insufficient information for a CVD risk estimate, but possibly at risk
Group 3: Sufficient information, and at > 20% 10-year risk
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Outcomes
• Annual rates of cardiovascular events in each arm during the study
• Proportion of population identified at risk of CVD or with incomplete data at the end of the study in each arm
Holt TA, Thorogood M, Griffiths F, Munday S. Protocol for the 'e-Nudge trial': a randomised controlled trial of electronic feedback to reduce the cardiovascular risk of individuals in general practice. Trials 2006, 7:11 Available at: http://www.trialsjournal.com/content/7/1/11
Baseline dataGroup definition Number
identifiedProportion of over 50 year population (n=36,546)
Those over 50 years with known CVD or diabetes but either BP or cholesterol out of target in the past 15 months (QOF audit target)
3346 9.2%
Those aged 50-74 years with missing risk factor information who would be at >20% risk when assumed values are inserted 9657 26.4%
Those aged 50-74 years at >20% cardiovascular risk based on existing data
2152 5.9%
Holt TA, Thorogood M, Griffiths F, Munday S, Stables D. Identifying individuals for primary cardiovascular disease prevention in UK general practice. BJGP, in press.
Undiagnosed diabetes
• Baseline data from the e-Nudge trial also revealed a number of people with possible undiagnosed diabetes based on existing blood glucose data
• This led to a nationwide survey of practice records using the QRESEARCH database
About 1% of the UK population (600,000 people) have undiagnosed diabetes
Complications often present at diagnosis
Opportunities forprevention missed
Symptoms develop gradually
Cardiovascular risk raisedin those at risk of diabetes
The problem of undiagnosed diabetes
Strategy A
If a random value > 11.1 mmol/L or fasting value > 7.0 mmol/L then patient identified
(If the result non-specifically coded then result assumed to be random)
Strategy B
If the most recent value (random or fasting) was > 7.0 mmol/L then patient identified
Results
• 3.6 million records included• 3758 found through strategy A• 32,785 found through strategy B• A third of people over the age of 40 without
diabetes have had a blood glucose measurement recorded electronically in the past 2 years
Holt TA, Stables D, Hippisley-Cox J, O'Hanlon S, Majeed A. Identifying undiagnosed diabetes: Cross-sectional survey of 3.6 million patients' electronic records. British Journal of General Practice 2008;58:192-196.
Projected to the UK population
• Strategy A: 60,000 individuals likely to have undiagnosed diabetes
• Strategy B: 528,000 individuals with results that require follow up to clarify diabetes status
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• Ten people invited for finger prick blood glucose
• Borderline levels referred to GP for further investigations
• One person had diabetes and one had IGT
Daily Mail Survey 18th March 2008
Further research• Process evaluation to identify barriers to the process
of CVD risk reduction using electronic data• Ongoing interview study to examine the practicalities
of using the e-Nudge software in practice• Interviews with members of the public to explore
attitudes towards prevention vs treatment, polypharmacy, opportunistic vs systematic risk assessment, labelling, ‘medicalisation of ageing’, etc, etc……..
Collaborators
e-Nudge
Tim Holt
Margaret Thorogood
Frances Griffiths
Stephen Munday
QRESEARCH study
Tim Holt
Julia Hippisley-Cox
David Stables
Shaun O’Hanlon
Azeem Majeed
Funded through a PhD Studentship from DH/WMS
http://www2.warwick.ac.uk/newsandevents/pressreleases/gp146s_databases_could/