E-nudge Trial

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E-nudge Trial

  1. 1. Dr Tim Holt Clinical Lecturer Health Sciences Research Institute The e-Nudge Trial: Identifying and addressing cardiovascular risk in primary care
  2. 2. Lifestyle advice and drug therapy
  3. 3. The problem: identifying at risk individuals for cardiovascular disease in primary care <ul><li>Aim is to identify the population at > 20% risk of developing CVD in next 10 years, for preventive drug therapy and lifestyle advice </li></ul><ul><li>Risk algorithms using different risk factors </li></ul><ul><ul><li>Classical factors: Age, sex, blood pressure, total and HDL cholesterol, smoking status </li></ul></ul><ul><ul><li>Other factors: eg family history, ethnicity, deprivation, obesity, waist circumference, fasting triglycerides, renal impairment </li></ul></ul><ul><li>Risk assessment requires collation of information, only some of which is coded electronically </li></ul>
  4. 4. The e-Nudge Trial <ul><li>Tests a software tool developed in collaboration with EMIS </li></ul><ul><li>Nineteen practices in Coventry and Warwickshire recruited with a range of practice demographics </li></ul><ul><li>Software applied to a random half of the over-50 year population in each practice and will run for 2 years </li></ul><ul><li>Software identifies 6 categories of patient </li></ul><ul><li>Screen alerts and continually updated lists of patients in each category </li></ul>
  5. 5. The e-Nudge Trial <ul><li>Group 1 : Those with CVD or Diabetes whose blood pressure or cholesterol are out of target for the QOF </li></ul><ul><li>Group 2 : Insufficient information for a CVD risk estimate, but possibly at risk </li></ul><ul><li>Group 3 : Sufficient information, and at > 20% 10-year risk </li></ul>
  6. 6. CAN PUT DEPARTMENT LOGO OR DETAILS IN THIS AREA
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  8. 8. Outcomes <ul><li>Annual rates of cardiovascular events in each arm during the study </li></ul><ul><li>Proportion of population identified at risk of CVD or with incomplete data at the end of the study in each arm </li></ul>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
  9. 9. Baseline data Holt TA, Thorogood M, Griffiths F, Munday S, Stables D. Identifying individuals for primary cardiovascular disease prevention in UK general practice. BJGP , in press . Group definition Number identified Proportion 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%
  10. 10. Undiagnosed diabetes <ul><li>Baseline data from the e-Nudge trial also revealed a number of people with possible undiagnosed diabetes based on existing blood glucose data </li></ul><ul><li>This led to a nationwide survey of practice records using the QRESEARCH database </li></ul>
  11. 11. About 1% of the UK population (600,000 people) have undiagnosed diabetes
  12. 12. Complications often present at diagnosis Opportunities for prevention missed Symptoms develop gradually Cardiovascular risk raised in those at risk of diabetes The problem of undiagnosed diabetes
  13. 13. Strategy A <ul><li>If a random value > 11.1 mmol/L or fasting value > 7.0 mmol/L then patient identified </li></ul><ul><li>(If the result non-specifically coded then result assumed to be random) </li></ul>
  14. 14. Strategy B <ul><li>If the most recent value (random or fasting) was > 7.0 mmol/L then patient identified </li></ul>
  15. 15. Results <ul><li>3.6 million records included </li></ul><ul><li>3758 found through strategy A </li></ul><ul><li>32,785 found through strategy B </li></ul><ul><li>A third of people over the age of 40 without diabetes have had a blood glucose measurement recorded electronically in the past 2 years </li></ul>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.
  16. 16. Projected to the UK population <ul><li>Strategy A : 60,000 individuals likely to have undiagnosed diabetes </li></ul><ul><li>Strategy B : 528,000 individuals with results that require follow up to clarify diabetes status </li></ul>
  17. 17. CAN PUT DEPARTMENT LOGO OR DETAILS IN THIS AREA
  18. 18. CAN PUT DEPARTMENT LOGO OR DETAILS IN THIS AREA
  19. 19. CAN PUT DEPARTMENT LOGO OR DETAILS IN THIS AREA
  20. 20. CAN PUT DEPARTMENT LOGO OR DETAILS IN THIS AREA
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  23. 23. <ul><li>Ten people invited for finger prick blood glucose </li></ul><ul><li>Borderline levels referred to GP for further investigations </li></ul><ul><li>One person had diabetes and one had IGT </li></ul>Daily Mail Survey 18 th March 2008
  24. 24. Further research <ul><li>Process evaluation to identify barriers to the process of CVD risk reduction using electronic data </li></ul><ul><li>Ongoing interview study to examine the practicalities of using the e-Nudge software in practice </li></ul><ul><li>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…….. </li></ul>
  25. 25. Collaborators <ul><li>e-Nudge </li></ul><ul><li>Tim Holt </li></ul><ul><li>Margaret Thorogood </li></ul><ul><li>Frances Griffiths </li></ul><ul><li>Stephen Munday </li></ul><ul><li>QRESEARCH study </li></ul><ul><li>Tim Holt </li></ul><ul><li>Julia Hippisley-Cox </li></ul><ul><li>David Stables </li></ul><ul><li>Shaun O’Hanlon </li></ul><ul><li>Azeem Majeed </li></ul>Funded through a PhD Studentship from DH/WMS
  26. 26. http://www2.warwick.ac.uk/newsandevents/pressreleases/gp146s_databases_could/

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