Dr Tim Holt

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The e-Nudge Trial Identifying and addressing
cardiovascular risk in primary care

• Dr Tim Holt
• Clinical Lecturer
• Health Sciences Research Institute

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Lifestyle advice and drug therapy
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The problem identifying at risk individuals for
cardiovascular disease in primary care

• Aim is to identify the population at gt 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

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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

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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 gt 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, 711 Available
at http//www.trialsjournal.com/content/7/1/11
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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.
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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

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About 1 of the UK population (600,000 people)
have undiagnosed diabetes
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The problem of undiagnosed diabetes
Symptoms develop gradually
Complications often present at diagnosis
Opportunities for prevention missed
Cardiovascular risk raised in those at risk of
diabetes
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Strategy A

• If a random value gt 11.1 mmol/L or fasting value
  gt 7.0 mmol/L then patient identified
• (If the result non-specifically coded then result
  assumed to be random)

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Strategy B

• If the most recent value (random or fasting) was
  gt 7.0 mmol/L then patient identified

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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 200858192-196.
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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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Daily Mail Survey 18th March 2008

• Ten people invited for finger prick blood glucose
• Borderline levels referred to GP for further
  investigations
• One person had diabetes and one had IGT

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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..

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Collaborators

• e-Nudge
• Tim Holt
• Margaret Thorogood
• Frances Griffiths
• Stephen Munday

• QRESEARCH study
• Tim Holt
• Julia Hippisley-Cox
• David Stables
• Shaun OHanlon
• Azeem Majeed

Funded through a PhD Studentship from DH/WMS
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http//www2.warwick.ac.uk/newsandevents/pressrelea
ses/gp146s_databases_could/