Current and future cardiovascular disease risk assessment in the European Union: an international comparative study

Current and future cardiovascular disease risk assessment in the European Union: an international... Abstract Background Risk assessment is central to primary prevention of cardiovascular disease (CVD), but there remains a need to better understand the use of evidence-based interventions in practice. This study examines: (i) the policies and guidelines for risk assessment in Europe, (ii) the use of risk assessment tools in clinical practice and (iii) the barriers to, and facilitators of, risk assessment. Methods Data were collected from academics, clinicians and policymakers in an online questionnaire targeted at experts from all European Union member states, and in 8 in-depth country case studies that were developed from a targeted literature review and 36 interviews. Results The European Society of Cardiology (ESC) produces European guidelines for CVD risk assessment and recommends the Systematic COronary Risk Evaluation tool, which is the most widely used risk assessment tool in Europe. The use of risk assessment tools is variable. Lack of time and resources are important barriers. Integrating risk assessment tools into clinical systems and providing financial incentives to carry out risk assessments could increase implementation. Novel biomarkers would need to be supported by evidence of their clinical effectiveness and cost-effectiveness to be introduced in clinical practice. These findings were consistent across Europe. Conclusions Efforts to improve the assessment of CVD risk in clinical practice should be carried out by or in collaboration with, the ESC. Increasing the use of existing risk assessment tools is likely to offer greater gains in primary prevention than the development of novel biomarkers. Introduction Cardiovascular disease (CVD) is the leading cause of death in Europe and accounts for 1.9 million deaths per year in the European Union (EU).1 In the past 30 years, CVD mortality has declined in most countries because of improved survival after coronary events and falling CVD prevalence.1–3 Healthier lifestyles, reductions in risk factor prevalence (particularly smoking) and pharmacological interventions for high blood pressure and high cholesterol primarily explain these improvements.4 Since the financial crisis, healthcare budgets in Europe have fallen in line with falling tax revenue.5 Some health services, such as the NHS in England, have increasingly focused on disease prevention to reduce demands on health services and decrease costs.6 Risk assessment remains central to primary prevention of CVD. It is carried out to encourage the modification of behavioural risk factors,7 guide equitable and cost-effective healthcare delivery and inform clinical decision making.8 CVD risk assessment may also influence clinicians’ prescribing behaviour.9 Numerous tools exist to estimate CVD risk.10 The Systematic COronary Risk Evaluation (SCORE) tool estimates the 10-year risk of fatal CVD.11 Others, such as QRISK212 and Framingham-based risk scores,13 estimate the 10-year risk of experiencing any CVD event. The predictive ability of existing tools varies, and novel biochemical and genetic biomarkers to improve cardiovascular risk prediction are currently being studied.14 However, there is often a disconnection between academic research and the use of evidence-based interventions in practice.15 This study was designed to address that problem in the European context. An online questionnaire targeted at experts across Europe and detailed country case studies were used to answer three research questions: (i) What policies and guidelines exist for CVD risk assessment? (ii) How is CVD risk assessment implemented in practice? (iii) What are the barriers to, and facilitators of, CVD risk assessment, including the use of novel biomarkers? Methods Data were collected from academic, clinical and policy experts in all 28 EU member states in an online questionnaire and from 8 in-depth country case studies. Online questionnaire The aim of the questionnaire was to improve our understanding of differences in attitudes towards, and policies for, CVD risk assessment in all member states, rather than to provide an accurate appraisal of each individual country. Participants were purposively sampled to ensure a range of expert views were captured. A scoping literature review of the use of, and guidelines for, CVD risk assessment tools in Europe informed the development of the questionnaire. An initial draft was circulated to the Public Health Genomics Foundation, the Andalusian School of Public Health in Granada and senior academics in health services research. The questionnaire (Supplementary data S1) was refined on the basis of comments received. Referencing the publicly funded healthcare system in their countries, respondents were asked to answer questions on guidelines and tools for CVD risk assessment, current use of risk assessment tools in clinical practice, barriers and facilitators of risk assessment in general, and specifically, for the use and potential uses of novel biochemical and genetic biomarkers. The questionnaire was sent to at least one senior stakeholder in CVD prevention at a government agency, regulatory agency, professional association, research organization or patient group in every member state. Contacts were identified from national cardiology and hypertension societies, European cardiovascular foundations and charities, authors of academic publications on CVD prevention and risk assessment (indexed in PubMed) and a small number of additional experts that were identified on an ad-hoc basis through the authors’ personal contacts. An initial invitation email was sent, with up to three follow-up reminders to non-respondents. Study information was provided to invitees at the start of the online questionnaire. The questionnaire was circulated online, in English, using Select Survey16 from November 2014 to March 2015. Case-studies The eight case studies were selected to reflect variation in: geographical location within Europe, health system financing mechanisms, the role of general practitioners (GPs) [Or equivalent primary care doctor in other European countries (e.g. family doctor)] as ‘gatekeepers,’ the impact of the financial crisis, CVD mortality, the burden of CVD and the cost of CVD (Supplementary appendix). The case studies were based on interviews and a targeted review of the relevant country-specific literature, including documents identified by interviewees and respondents to the questionnaire. The interviews were semi-structured, including open-ended questions and prompts (Supplementary data S2). Interviewees were asked about policies and guidelines for CVD risk assessment, barriers and facilitators of risk assessment, current monitoring of biomarkers (biochemical and genetic) and potential barriers to the use of more sophisticated CVD risk assessment tools. All interviewees gave verbal consent for their interview to be recorded and transcribed and were sent a copy of the case study to which their interview contributed. Interview participants were identified by the same means as those invited to respond to the questionnaire, with the aim of recruiting five interviewees per country, including at least one academic, clinical and policy expert. Potential interviewees were sent an invitation email and topic guide. The research team carried out the interviews in English, by telephone, between May 2015 and October 2015. Analysis Respondents to the questionnaire who only completed the initial question about country of residence were excluded from the analysis. Responses to each question were analyzed independently and non-response was considered on a question-by-question basis. Descriptive statistics by respondent and country were calculated and free-text responses were summarized. Interview transcripts were coded into organizing themes using NVivo17 and emerging findings were discussed with the wider study team. Country reports for each case study were developed using a narrative synthesis approach based on the interview transcripts, relevant free-text responses to the questionnaire and literature review and written using the same template. The eight reports were then thematically coded in a cross-country analysis using NVivo.17 Results Participants and respondents The questionnaire was sent to 560 experts across Europe. There were 163 responses to the first question about availability of guidelines in the respondent’s country. There were 135 responses (24% response rate) to at least one subsequent question, with respondents covering all member states except Austria. A median of three responses per country was received, ranging from 1 (Estonia, Romania, Slovakia) to 23 (United Kingdom). Respondents were mostly academics (58%) and/or clinicians (66%) and a small number were involved in policy (8%) (Supplementary data S3). Country case studies included Bulgaria, England, Finland, Germany, Greece, Latvia, Spain and Sweden. Thirty-six telephone interviews (3–5 per country) were conducted. Each country had at least one academic, clinical and policy representative. Table 1 provides a summary of key findings from the eight case studies; the full case studies can be accessed online (Supplementary data S4). Table 1 Key findings from case-studies Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Table 1 Key findings from case-studies Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Stakeholders, guidelines and choice of risk assessment tool The majority of national cardiology societies endorse the European Society of Cardiology (ESC) prevention guidelines. Questionnaire respondents from most countries reported having national guidelines and respondents from two-fifths of countries reported having regional guidelines; although respondents from most countries reported that the national and international guidelines were used most frequently (table 2). These findings are consistent with the case studies (table 1) in that interviewees from most countries reported that the ESC is the key organization in the development of European guidelines for the prevention of CVD and that national guidelines for CVD risk assessment are often based on the ESC guidelines. Table 2 CVD risk assessment across Europe, guidelines and current practice (questionnaire findings) Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 a All responses are reported on a question by question basis. b The three ‘No’s’ came from Bulgaria, Spain, Cyprus. Table 2 CVD risk assessment across Europe, guidelines and current practice (questionnaire findings) Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 a All responses are reported on a question by question basis. b The three ‘No’s’ came from Bulgaria, Spain, Cyprus. We follow the European Society of Cardiology guidelines. Greece is part of Europe so we follow these guidelines mainly [Cardiologist, Academic, Greece]. Respondents from virtually all countries reported that CVD risk assessment tools are used in clinical practice and that the SCORE tool, which is recommended by the ESC, is the most frequently used, followed by Framingham-based tools. These findings were consistent across the questionnaire and case studies (table 2). SCORE has been calibrated for high-risk (e.g. Bulgaria and Latvia) and low-risk (e.g. Finland) countries, as well as for some individual countries (e.g. Germany, Greece, Spain and Sweden). However, the British Society of Cardiology does not endorse the ESC prevention guidelines and the National Institute for Health and Care Excellence recommends the QRISK2 tool.12 There is also regional variation within countries; some regions in Spain recommend a Framingham-based tool or the REgistre GIroní del COR (REGICOR, Girona Heart Registry) calculator, which is based on a calibrated Framingham model. Current use of CVD risk assessment tools in clinical practice Responses to the questionnaire suggest that CVD risk assessment tools are widely used by doctors in both primary and secondary care; although respondents in just under half of countries also reported use by other health professionals, such as practice nurses and pharmacists (table 2). This was supported by the case studies, which found risk assessment to be primarily the responsibility of GPs, usually taking place in primary care (table 1). However, in almost all countries, other health professionals also conduct risk assessments (table 2). Nurses undertake the majority of risk assessments for the English NHS Health Check Programme while cardiologists undertake the majority of risk assessments in Greece. The questionnaire findings suggest that, across Europe, risk assessment is perceived to be acceptable to patients and considered of clinical value (table 2). Interviewees reported that risk assessment tools are used in clinical consultations to guide clinical decision-making (e.g. prescribing decisions) and encourage lifestyle changes. I have here the SCORE system and the Framingham, and the REGICOR system in my computer, so I can easily estimate the risk of my patients with the information that I have in their records, but it’s not automatically something I can do … I do when I have to make some clinical decisions on that specific patient [GP, Spain]. Variation in implementation of risk assessment The populations targeted for risk assessment vary substantially between countries and regions, but are most commonly based on age or medical history. While little data is available on the use of risk assessment tools in Europe, the Spanish case study identified two research studies that illustrate the variability in the implementation of risk assessment. The first study found that only 36% of primary care practitioners surveyed used the Spanish adaptation of the European guidelines and only 40% calculated overall cardiovascular risk in more than 80% of their patients with at least one risk factor.18 The second study highlighted variable CVD prevention policy across Spanish regions and patchy implementation of risk assessment for target populations.19 Interviewees from all countries reported that risk assessment use varies between health professionals, practices and regions. Some use it regularly, others don’t use it at all, others use it sometimes and they can use different tools [GP, Academic, Germany]. They attributed the variation to differing attitudes towards prevention and constraints on time and resources. In some countries, interviewees also reported mixed views regarding the acceptability of risk assessment tools among clinicians (e.g. attitudes regarding clinicians’ roles in primary prevention) and scepticism about the effectiveness of risk assessment. I worry intensely about how effective it is and whether it’s just people being commissioned to provide the service without any real understanding of what that service entails and how to change the individual’s cardiovascular risk at the end of it [GP, Academic, England]. Interviewees from some countries (e.g. Bulgaria, Latvia, Finland and Sweden) reported that treatment and secondary prevention are prioritized over primary prevention. In some parts of the country general practices are not very well resourced and they need to concentrate on treating the sick … They don’t have or they don’t feel they have had time for preventative care. They have their hands full managing the sick patients [Cardiologist, Finland]. Others reported that risk assessment is often estimated based on individual risk factors, rather than using a risk assessment tool. The calculation itself is not the best, the most important thing is to be alert, to be alert for risks and to give the proper advices and we make the right, take the right decisions and take the right actions to prevent and to protect [GP, Academic, Bulgaria]. Barriers and facilitators of CVD risk assessment The questionnaire found that, for most countries, facilitators of risk assessment in routine practice include: guideline recommendations, training, financing, perceptions of importance to clinicians and patients, time and the availability of information technology (table 3). These results were generally consistent with case study findings; although interviewees emphasized lack of time and resources as particularly important barriers. GPs, in particular, reported being overburdened and lacking time to conduct risk assessments and follow-up with high-risk patients (table 1). Table 3 Current/future facilitators of CVD risk assessment (questionnaire findings) CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 Table 3 Current/future facilitators of CVD risk assessment (questionnaire findings) CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 GPs also have just 15 minutes for every patient and if the patient comes with the other problem, there is no time to calculate risk [Cardiologist, Latvia]. Similarly, interviewees in six out of eight case study countries reported shortages or under-utilization of nurses to carry out, or assist with, risk assessments (table 1). While respondents to the questionnaire reported that specific payments facilitate risk assessment (table 3), respondents from less than half of EU countries reported that specific payments exist for risk assessment (table 2). The case studies identified three types of financial barriers. At the health system level, interviewees reported a lack of resources for primary prevention and implementation of guidelines. At the clinician level, they reported a lack of re-imbursement for time spent carrying out risk assessments. In some parts of the country general practices are not very well resourced and they need to concentrate on treating the sick … They don’t have or they don’t feel they have had time for preventative care [Cardiologist, Finland]. At the patient level, they reported a lack of re-imbursement for costs associated with tests and treatments (table 1). Yes, but for instance, statins for primary prevention they are not … I think they are not re-imbursed at all. […] Now-a-days statins are re-imbursed for secondary prevention actually, rather than primary [Cardiologist, Academic, Bulgaria]. Interviewees suggested that simpler risk assessment tools that are integrated into electronic medical records might save time and increase usage. If something was made so that it was integrated with the normal system then it would be much, much more likely to be used [GP, England]. They also suggested that calibration of tools to specific populations, increased flexibility in the setting for risk assessment and training clinicians to use the tools would increase uptake. Novel biochemical and genetic markers of CVD risk While some established biomarkers (e.g. cholesterol and blood pressure) are monitored in routine clinical practice in most countries, novel biochemical and genetic markers are not routinely monitored in any country; they are used only in research. The case studies found that the main barrier to the monitoring of biomarkers is the lack of evidence on their clinical and cost effectiveness. Interviewees questioned the usefulness of additional biomarkers and reported a need to prove their clinical value, improve their sensitivity and/or specificity, prove their cost-effectiveness and simplify their use. Biomarkers have so far not contributed much. We went through biomarkers of different kinds, when we wrote the guidelines for management of people with diabetes, pre-diabetes and cardiovascular disease. And we actually couldn’t find any strong evidence for any biomarkers, and there are many, which actually told us something more than how the patient lived. Their blood pressure, their glucose, lipids and so on. So biomarkers are in the general perspective, not very useful, not yet [Cardiologist, Sweden]. Respondents to the questionnaire from most countries reported that monitoring biomarkers would be acceptable to both patients and clinicians (table 4) and interviewees generally did not foresee challenges regarding acceptability of novel biomarkers among patients and clinicians, provided that the conditions outlined above were met. Table 4 Novel biochemical/genetic biomarkers: future use and regulatory issues (questionnaire findings) Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Table 4 Novel biochemical/genetic biomarkers: future use and regulatory issues (questionnaire findings) Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Questionnaire respondents reported regulatory and legal concerns associated with the monitoring of biomarkers slightly more often for genetic biomarkers compared with biochemical biomarkers (table 4). However, interviewees did not identify any regulatory or legal issues, even when specifically questioned on such issues. Oh, well our data protection law is very strong, very severe, so probably, I don’t know, but if the information is anonymous. You know respecting the individual data protection, that shouldn’t be any trouble I think [Cardiologist, Spain]. Discussion This study describes how CVD risk assessment is carried out in practice across Europe. It highlights the key role of the ESC, the importance of primary care and variation both within and between countries in the implementation of risk assessment. It also confirms the need for reliable evidence on the clinical effectiveness and cost effectiveness of new interventions, such as novel biomarkers, prior to their introduction into clinical practice. The ESC’s first Joint European Guidelines for CVD prevention were published in 1994, and with the launch of a strategy in 2002 designed to ‘reduce cardiovascular deaths by 40%,’20 the organization has moved from simply providing evidence-based guidelines to influencing European cardiovascular risk management policies.20 This study’s findings, such as the widespread use of the SCORE tool and the shaping of national guidelines, reflect this broader role. We found little published evidence on CVD risk assessment in clinical practice across Europe. Consistent with the findings from this study, recent research from the Netherlands highlights the gap between positive policy intent and implementation of CVD risk assessment in practice,21 with patient, organization and health system factors all influencing implementation in primary care. A systematic review of breast cancer risk prediction models found that the model most widely implemented in practice was the one that was most widely available, rather than the model with the best predictive ability.22 This is consistent with findings from this research, where it was reported that embedding risk prediction into routine electronic patient records is a facilitator of use in practice and that the use of the SCORE tool is widespread despite being limited to the prediction of fatal cardiovascular events. Despite widespread endorsement and acceptance of ESC guidelines, this study identified important variations in the implementation of risk assessment, such as the populations targeted and variable implementation across health professionals, practices and regions. This variation across and within countries was primarily attributed to differing attitudes towards the effectiveness of risk assessment and the prioritization of treatment and secondary prevention over primary prevention. Such attitudes are likely an important barrier to CVD risk assessment and important for policy makers to note, although assessing the pervasiveness of such views was beyond the scope of this study. The barriers and facilitators to the implementation of risk assessment identified in this study mirror those observed for risk models for type 2 diabetes23 and the implementation of the NHS Health Check programme in England.24 Implementation was influenced by the perceived advantages (simplicity, ease of use and predictive ability) and disadvantages (workload, and implications of managing a positive score) of the tools. These in turn are affected by factors such as clinicians’ skills, influence or endorsement of tools, healthcare system design and external policies, incentives and competing priorities. This study highlighted three levels of financial barriers that would need to be addressed to improve the implementation of CVD risk assessment: resources for primary prevention and implementation of guidelines at the health system level; re-imbursement for time spent carrying out risk assessments at the clinical level and re-imbursement for costs associated with tests and treatment at the patient level. These findings suggest that overcoming the financial barriers to risk assessment is a key policy area. Investigations into the utility of novel factors for the assessment of cardiovascular risk are being undertaken. Many studies that have claimed that additional factors could offer further predictive value beyond the Framingham algorithm have well-documented flaws.25 Further work employing multiple biomarkers has found only limited predictive benefit over conventional risk scores.26 This study emphasizes the need to demonstrate the predictive value and cost-effectiveness of novel biomarkers prior to their implementation. The main strength of this research is the inclusion of opinions from academic, clinical and policy experts from virtually all EU member states, using a wide-ranging questionnaire and in-depth case studies. Although responses are always prone to subjectivity, the expertise of the respondents means that the results of this study are likely to reflect practice. Differences in the results between the questionnaire and case studies highlight the strength of using different methodologies to gain a clearer understanding of opinion. However, this study also has important limitations. Identifying stakeholders, academic literature and guidelines for some countries was challenging, which could reflect the language barriers of the research team or possibly a lack of resources for, or engagement with, cardiovascular risk assessment in some countries. Although the response rate was in line with expectations for this type of study27,28 and the questionnaire was not intended to be representative of all member states, the response rate was nevertheless low and variable across countries, which may be due to the questionnaire being written in English or the response burden because of the length of the questionnaire. The participation of civil servants and representatives of health ministries and regulatory agencies in the questionnaire was unexpectedly low and thus not fully captured by the questionnaire findings; however, policy stakeholders participated in interviews for all of the country case studies such that the views of this stakeholder group were included in the analysis. However, we also cannot rule out selection bias; it is conceivable that the respondents who viewed the ESC and other guidelines most favourably may also have participated in the development of the guidelines. Very few stakeholders from CVD charities and patient organizations participated in the questionnaire and interviews, despite being invited to participate, such that this research lacks a strong patient voice. This study provides valuable insight into CVD risk assessment across Europe, which will hopefully act as a useful baseline and provide reference data upon which future studies can draw. The ESC has a central role in informing practice in Europe, and efforts to improve CVD prevention are likely to benefit from being carried out by, or in collaboration with, the ESC. Although integration of risk assessment tools in clinical computer systems may improve uptake, there remain significant barriers to the widespread implementation of risk assessment tools, including lack of funding. Despite considerable interest in developing novel biomarkers to optimize cardiovascular risk assessment, it is likely that focusing efforts on increasing implementation of existing risk assessment tools will offer the greatest gains in primary prevention of CVD. Acknowledgements This study complied with the Declaration of Helsinki. It was subject to RAND Europe’s internal ethics process, and informed consent was obtained from all subjects. Funding This work was supported by the European Union’s Seventh Framework Programme [grant number 279233]. Conflicts of interest: None declared. Key points The ESC is important in CVD risk assessment and any changes in European risk assessment policy should be made by, or in collaboration with, the ESC. Guideline implementation and use of CVD risk assessment tools in practice is often sub-optimal. Lack of funding for risk assessment and following up patients identified as at risk is a key barrier to widespread implementation of CVD risk assessment in Europe. Novel biochemical and genetic markers of CVD risk are not currently used in routine clinical practice; such biomarkers would need to be endorsed in clinical guidelines and shown to be both effective and cost-effective in order to be introduced into routine clinical practice in Europe. Supplementary data Supplementary data are available at EURPUB online. References 1 Nichols MTN , Luengo-Fernandez R , Leal J , et al. European Cardiovascular Disease Statistics . European Heart Network . Available at: http://www.escardio.org/The-ESC/Initiatives/EuroHeart/2012-European-Cardiovascular-Disease-Statistics 2012 (28 November 2017, date last accessed). 2 Ford ES , Ajani UA , Croft JB , et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000 . N Engl J Med 2007 ; 356 : 2388 – 98 . Google Scholar CrossRef Search ADS PubMed 3 Tunstall-Pedoe H , Kuulasmaa K , Mahonen M , et al. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease . Lancet 1999 ; 353 : 1547 – 57 . Google Scholar CrossRef Search ADS PubMed 4 Di Chiara A , Vanuzzo D . Does surveillance impact on cardiovascular prevention? Eur Heart J 2009 ; 30 : 1027 – 9 . Google Scholar CrossRef Search ADS PubMed 5 Reeves A , McKee M , Basu S , Stuckler D . The political economy of austerity and healthcare: cross-national analysis of expenditure changes in 27 European nations 1995-2011 . Health Policy 2014 ; 115 : 1 – 8 . Google Scholar CrossRef Search ADS PubMed 6 NHS England , Five Year Forward View, 2014 . Available at: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (28 November 2017, date last accessed). 7 Capewell S , O’Flaherty M . Trends in cardiovascular disease: are we winning the war? CMAJ 2009 ; 180 : 1285 – 6 . Google Scholar CrossRef Search ADS PubMed 8 Payne RA . Cardiovascular risk . Br J Clin Pharmacol 2012 ; 74 : 396 – 410 . Google Scholar CrossRef Search ADS PubMed 9 Sheridan SL , Crespo E . Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature . BMC Health Serv Res 2008 ; 8 : 60 . Google Scholar CrossRef Search ADS PubMed 10 Matheny M , McPheeters ML , Glasser A , et al. Systematic Review of Cardiovascular Disease Risk Assessment Tools . Rockville, Maryland : Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews, https://www.ncbi.nlm.nih.gov/pubmed/21796824. 11 Conroy RM , Pyorala K , Fitzgerald AP , et al. , Score Project Group . Estimation of 10-year risk of fatal cardiovascular disease in Europe: the SCORE project . Eur Heart J 2003 ; 24 : 987 – 1003 . Google Scholar CrossRef Search ADS PubMed 12 Hippisley-Cox J , Coupland C , Vinogradova Y , et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2 . BMJ 2008 ; 336 : 1475 – 82 . Google Scholar CrossRef Search ADS PubMed 13 D’Agostino RB Sr , Vasan RS , Pencina MJ , et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study . Circulation 2008 ; 117 : 743 – 53 . Google Scholar CrossRef Search ADS PubMed 14 Zeller T , Hughes M , Tuovinen T , et al. BiomarCaRE: rationale and design of the European BiomarCaRE project including 300, 000 participants from 13 European countries . Eur J Epidemiol 2014 ; 29 : 777 – 90 . Google Scholar CrossRef Search ADS PubMed 15 Marshall MN . Bridging the ivory towers and the swampy lowlands; increasing the impact of health services research on quality improvement . Int J Qual Health Care 2014 ; 26 : 1 – 5 . Google Scholar CrossRef Search ADS PubMed 16 NVivo qualitative data analysis software; QSR International Pty Ltd. Version 10, 2012. Warrington, UK. 17 SelectSurvey.NET survey software; ClassApps.com LLP. Version 4, 2016. Overland Park, US. 18 Brotons C , Lobos JM , Royo-Bordonada MA , et al. Implementation of Spanish adaptation of the European guidelines on cardiovascular disease prevention in primary care . BMC Fam Pract 2013 ; 14 : 36 . Google Scholar CrossRef Search ADS PubMed 19 Royo-Bordonada MA , Lobos JM , Brotons C , et al. In the name of the Comite Espanol Interdisciplinario de Prevencion, Cardiovascular, [The condition of the cardiovascular prevention in Spain] . Med Clin (Barc) 2014 ; 142 : 7 – 14 . Google Scholar CrossRef Search ADS PubMed 20 O’Kelly S , Ryden L . The political power of heart doctors: with the European Heart Health Charter towards a European policy on cardiovascular disease . Eur J Cardiovasc Prev Rehabil 2009 ; 16(Suppl 2) : S58 – 60 . Google Scholar CrossRef Search ADS PubMed 21 Huntink E , Wensing M , Klomp M , van Lieshout J . Perceived determinants of cardiovascular risk management in primary care: disconnections between patient behaviours, practise organisation and healthcare system . BMC Family Pract 2015 ; 16 : 179 . Google Scholar CrossRef Search ADS 22 Meads C , Ahmed I , Riley RD . A systematic review of breast cancer incidence risk prediction models with meta-analysis of their performance . Breast Cancer Res Treat 2012 ; 132 : 365 – 77 . Google Scholar CrossRef Search ADS PubMed 23 Noble D , Mathur R , Dent T , et al. Risk models and scores for type 2 diabetes: systematic review . BMJ 2011 ; 343 : d7163 . Google Scholar CrossRef Search ADS PubMed 24 Krska J , du Plessis R , Chellaswamy H . Views of practise managers and general practitioners on implementing NHS Health Checks . Prim Health Care Res Dev 2015 ; 17 : 1 – 8 . 25 Tzoulaki I , Liberopoulos G , Ioannidis JP . Assessment of claims of improved prediction beyond the Framingham risk score . JAMA 2009 ; 302 : 2345 – 52 . Google Scholar CrossRef Search ADS PubMed 26 Wang TJ , Gona P , Larson MG , et al. Multiple biomarkers for the prediction of first major cardiovascular events and death . N Engl J Med 2006 ; 355 : 2631 – 9 . Google Scholar CrossRef Search ADS PubMed 27 Saunders C . Taking an Interest: What Makes Someone Respond to a Survey . Statistics Views , 2016 . Available at: http://www.statisticsviews.com/details/feature/8739491/Taking-an-Interest-What-Makes-Someone-Respond-to-a-Survey.html (28 November 2017, date last accessed). 28 Farrer N , Yehuda D . Weighting Online Surveys . Ipsos MediaCT , 2010 . Available at: https://www.ipsos.com/sites/default/files/publication/1970-01/Ipsos%20MediaCT%20_Weighting%20Online%20Surveys_062010.pdf (28 November 2017, date last accessed). © The Author 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Current and future cardiovascular disease risk assessment in the European Union: an international comparative study

Loading next page...
 
/lp/ou_press/current-and-future-cardiovascular-disease-risk-assessment-in-the-fwaaBmoIA4
Publisher
Oxford University Press
Copyright
© The Author 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
ISSN
1101-1262
eISSN
1464-360X
D.O.I.
10.1093/eurpub/ckx216
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Risk assessment is central to primary prevention of cardiovascular disease (CVD), but there remains a need to better understand the use of evidence-based interventions in practice. This study examines: (i) the policies and guidelines for risk assessment in Europe, (ii) the use of risk assessment tools in clinical practice and (iii) the barriers to, and facilitators of, risk assessment. Methods Data were collected from academics, clinicians and policymakers in an online questionnaire targeted at experts from all European Union member states, and in 8 in-depth country case studies that were developed from a targeted literature review and 36 interviews. Results The European Society of Cardiology (ESC) produces European guidelines for CVD risk assessment and recommends the Systematic COronary Risk Evaluation tool, which is the most widely used risk assessment tool in Europe. The use of risk assessment tools is variable. Lack of time and resources are important barriers. Integrating risk assessment tools into clinical systems and providing financial incentives to carry out risk assessments could increase implementation. Novel biomarkers would need to be supported by evidence of their clinical effectiveness and cost-effectiveness to be introduced in clinical practice. These findings were consistent across Europe. Conclusions Efforts to improve the assessment of CVD risk in clinical practice should be carried out by or in collaboration with, the ESC. Increasing the use of existing risk assessment tools is likely to offer greater gains in primary prevention than the development of novel biomarkers. Introduction Cardiovascular disease (CVD) is the leading cause of death in Europe and accounts for 1.9 million deaths per year in the European Union (EU).1 In the past 30 years, CVD mortality has declined in most countries because of improved survival after coronary events and falling CVD prevalence.1–3 Healthier lifestyles, reductions in risk factor prevalence (particularly smoking) and pharmacological interventions for high blood pressure and high cholesterol primarily explain these improvements.4 Since the financial crisis, healthcare budgets in Europe have fallen in line with falling tax revenue.5 Some health services, such as the NHS in England, have increasingly focused on disease prevention to reduce demands on health services and decrease costs.6 Risk assessment remains central to primary prevention of CVD. It is carried out to encourage the modification of behavioural risk factors,7 guide equitable and cost-effective healthcare delivery and inform clinical decision making.8 CVD risk assessment may also influence clinicians’ prescribing behaviour.9 Numerous tools exist to estimate CVD risk.10 The Systematic COronary Risk Evaluation (SCORE) tool estimates the 10-year risk of fatal CVD.11 Others, such as QRISK212 and Framingham-based risk scores,13 estimate the 10-year risk of experiencing any CVD event. The predictive ability of existing tools varies, and novel biochemical and genetic biomarkers to improve cardiovascular risk prediction are currently being studied.14 However, there is often a disconnection between academic research and the use of evidence-based interventions in practice.15 This study was designed to address that problem in the European context. An online questionnaire targeted at experts across Europe and detailed country case studies were used to answer three research questions: (i) What policies and guidelines exist for CVD risk assessment? (ii) How is CVD risk assessment implemented in practice? (iii) What are the barriers to, and facilitators of, CVD risk assessment, including the use of novel biomarkers? Methods Data were collected from academic, clinical and policy experts in all 28 EU member states in an online questionnaire and from 8 in-depth country case studies. Online questionnaire The aim of the questionnaire was to improve our understanding of differences in attitudes towards, and policies for, CVD risk assessment in all member states, rather than to provide an accurate appraisal of each individual country. Participants were purposively sampled to ensure a range of expert views were captured. A scoping literature review of the use of, and guidelines for, CVD risk assessment tools in Europe informed the development of the questionnaire. An initial draft was circulated to the Public Health Genomics Foundation, the Andalusian School of Public Health in Granada and senior academics in health services research. The questionnaire (Supplementary data S1) was refined on the basis of comments received. Referencing the publicly funded healthcare system in their countries, respondents were asked to answer questions on guidelines and tools for CVD risk assessment, current use of risk assessment tools in clinical practice, barriers and facilitators of risk assessment in general, and specifically, for the use and potential uses of novel biochemical and genetic biomarkers. The questionnaire was sent to at least one senior stakeholder in CVD prevention at a government agency, regulatory agency, professional association, research organization or patient group in every member state. Contacts were identified from national cardiology and hypertension societies, European cardiovascular foundations and charities, authors of academic publications on CVD prevention and risk assessment (indexed in PubMed) and a small number of additional experts that were identified on an ad-hoc basis through the authors’ personal contacts. An initial invitation email was sent, with up to three follow-up reminders to non-respondents. Study information was provided to invitees at the start of the online questionnaire. The questionnaire was circulated online, in English, using Select Survey16 from November 2014 to March 2015. Case-studies The eight case studies were selected to reflect variation in: geographical location within Europe, health system financing mechanisms, the role of general practitioners (GPs) [Or equivalent primary care doctor in other European countries (e.g. family doctor)] as ‘gatekeepers,’ the impact of the financial crisis, CVD mortality, the burden of CVD and the cost of CVD (Supplementary appendix). The case studies were based on interviews and a targeted review of the relevant country-specific literature, including documents identified by interviewees and respondents to the questionnaire. The interviews were semi-structured, including open-ended questions and prompts (Supplementary data S2). Interviewees were asked about policies and guidelines for CVD risk assessment, barriers and facilitators of risk assessment, current monitoring of biomarkers (biochemical and genetic) and potential barriers to the use of more sophisticated CVD risk assessment tools. All interviewees gave verbal consent for their interview to be recorded and transcribed and were sent a copy of the case study to which their interview contributed. Interview participants were identified by the same means as those invited to respond to the questionnaire, with the aim of recruiting five interviewees per country, including at least one academic, clinical and policy expert. Potential interviewees were sent an invitation email and topic guide. The research team carried out the interviews in English, by telephone, between May 2015 and October 2015. Analysis Respondents to the questionnaire who only completed the initial question about country of residence were excluded from the analysis. Responses to each question were analyzed independently and non-response was considered on a question-by-question basis. Descriptive statistics by respondent and country were calculated and free-text responses were summarized. Interview transcripts were coded into organizing themes using NVivo17 and emerging findings were discussed with the wider study team. Country reports for each case study were developed using a narrative synthesis approach based on the interview transcripts, relevant free-text responses to the questionnaire and literature review and written using the same template. The eight reports were then thematically coded in a cross-country analysis using NVivo.17 Results Participants and respondents The questionnaire was sent to 560 experts across Europe. There were 163 responses to the first question about availability of guidelines in the respondent’s country. There were 135 responses (24% response rate) to at least one subsequent question, with respondents covering all member states except Austria. A median of three responses per country was received, ranging from 1 (Estonia, Romania, Slovakia) to 23 (United Kingdom). Respondents were mostly academics (58%) and/or clinicians (66%) and a small number were involved in policy (8%) (Supplementary data S3). Country case studies included Bulgaria, England, Finland, Germany, Greece, Latvia, Spain and Sweden. Thirty-six telephone interviews (3–5 per country) were conducted. Each country had at least one academic, clinical and policy representative. Table 1 provides a summary of key findings from the eight case studies; the full case studies can be accessed online (Supplementary data S4). Table 1 Key findings from case-studies Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Table 1 Key findings from case-studies Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Case study themes Country Bulgaria Germany UK Greece Spain Finland Latvia Sweden Policies and guidelines     ESC prevention guidelines are endorsed X X X X X X X     Also have national guidelines X X X X X X X     Also have regional guidelines X X     The SCORE risk assessment tool is recommended X X X X X X X     Alternative risk assessment tools in addition to/instead of SCORE are also recommended X X X     Financial incentive for risk assessment X X Current practice     Risk assessment is primarily the responsibility of GPs and mostly takes places in primary care X X X X X X X     CVD risk assessment is acceptable to patients X X X X X X X     CVD risk assessment is targeted at specific population groups X X X X X X X X     Use of risk assessment is variable between health professionals, practices and regions and often is not frequently used X X X X X X X X     Risk assessment is often estimated based on risk factors rather than formally calculated X X X X X     Treatment and secondary prevention are prioritized X X X X X     There are mixed views regarding the acceptability of risk assessment tools for use in practice X X X X X X Barriers     Time constraints and clinician workload X X X X X X X X     Shortage/under-utilization of nurses X X X X X X     Funding for risk assessment and follow-up X X X X X     Lack of re-imbursement of medicines prescribed for primary prevention X X     Lack of awareness of risk assessment among clinicians X X X X     Lack of awareness of risk assessment among patients X X X Facilitators     Simple risk assessment tools X X X X     Incorporation of risk assessment tools into electronic medical records X X X X X     Calibration of risk assessment tools to national populations X X     Flexibility in the setting for risk assessment X X X     Training for clinicians X X X X     Awareness raising activities X X X X X Novel biochemical and genetic markers     Novel biomarkers not routinely monitored X X X X X X X X     Novel biomarkers primarily used in research X X X X     Lack of evidence on effectiveness of monitoring novel biomarkers X X X X X     Likely cost of monitoring novel biomarkers would be a barrier X X X X X X     Novel biomarkers would need to be clinically useful X X X X X     Novel biomarkers would need to improve the sensitivity and/or specificity of existing risk assessment tools X X X X     Novel biomarkers would need to be cost-effective X X X X X X Stakeholders, guidelines and choice of risk assessment tool The majority of national cardiology societies endorse the European Society of Cardiology (ESC) prevention guidelines. Questionnaire respondents from most countries reported having national guidelines and respondents from two-fifths of countries reported having regional guidelines; although respondents from most countries reported that the national and international guidelines were used most frequently (table 2). These findings are consistent with the case studies (table 1) in that interviewees from most countries reported that the ESC is the key organization in the development of European guidelines for the prevention of CVD and that national guidelines for CVD risk assessment are often based on the ESC guidelines. Table 2 CVD risk assessment across Europe, guidelines and current practice (questionnaire findings) Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 a All responses are reported on a question by question basis. b The three ‘No’s’ came from Bulgaria, Spain, Cyprus. Table 2 CVD risk assessment across Europe, guidelines and current practice (questionnaire findings) Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 Question/option (respondents) Number (%) of ‘Yes’ responsesa Number of countries with at least one endorsement Are CVD guidelines available?     Any CVD risk assessment guidance (n = 158) 143 (90.5) 27/28     National guidelines (n = 163) 124 (76.1) 24/28     Regional guidelines (n = 139) 93 (66.9) 11/27 Most frequently reported guidelines (where there is more than one type of guidance)     International (n = 100) 42 (42.0) 18/26     National (n = 100) 53 (53.0) 17/26     Regional (n = 100) 5 (5.0) 4/26 Are CVD risk assessment tools parts of routine clinical practice? (n = 115) 90 (78.3) 25/26 Tools reported as the most widely used by clinicians     ASSIGN (n = 128) 6 (4.7) 2/27     CUORE (n = 128) 11 (8.6) 1/27     ESH risk chart (n = 128) 16 (12.5) 8/27     FINRISK (n = 128) 5 (3.9) 4/27     Framingham-based calculator (n = 128) 38 (29.7) 15/27     PRECARD (n = 128) 0 (0.0) 0/27     PROCAM (n = 128) 4 (3.1) 2/27     QRISK (n = 128) 20 (15.6) 2/27     Reynolds (n = 128) 1 (0.8) 1/27     RISKARD (n = 128) 0 (0.0) 0/27     SCORE (n = 128) 89 (69.5) 26/27     WHO/ISH (n = 128) 3 (2.3) 3/27     Another tool (n = 128) 14 (10.9) 5/27  Endorsed more than one tool (n = 55) Who uses CVD risk assessment tools?     Used by GPs (n = 114) 98 (86.0) 26/27     Used by specialists in office based practice (n = 110) 95 (86.4) 27/27     Used by specialists in hospital outpatients (n = 106) 92 (86.8) 27/27     Used by practice nurses (n = 97) 27 (27.8) 11/26     Used by unlicensed nurse assistant/aide (n = 90) 8 (8.9) 3/26     Used by pharmacists (n = 98) 22 (22.4) 10/26 Current practice     Specific payments for the use (n = 113) 22 (19.5) 10/26     Considered acceptable to patients (n = 110) 102 (92.7) 25/26     Considered important for patients understanding/decision making (n = 110) 99 (90.0) 25/25     Considered important for healthcare professionals decision making (n = 108) 95 (88.0) 25/26     Specific consultation time (n = 114) 31 (27.2) 13/25     Training for clinicians (n = 112) 64 (57.1) 24/26     Clinician access to computers (n = 124) 121 (97.6)b 26/26 a All responses are reported on a question by question basis. b The three ‘No’s’ came from Bulgaria, Spain, Cyprus. We follow the European Society of Cardiology guidelines. Greece is part of Europe so we follow these guidelines mainly [Cardiologist, Academic, Greece]. Respondents from virtually all countries reported that CVD risk assessment tools are used in clinical practice and that the SCORE tool, which is recommended by the ESC, is the most frequently used, followed by Framingham-based tools. These findings were consistent across the questionnaire and case studies (table 2). SCORE has been calibrated for high-risk (e.g. Bulgaria and Latvia) and low-risk (e.g. Finland) countries, as well as for some individual countries (e.g. Germany, Greece, Spain and Sweden). However, the British Society of Cardiology does not endorse the ESC prevention guidelines and the National Institute for Health and Care Excellence recommends the QRISK2 tool.12 There is also regional variation within countries; some regions in Spain recommend a Framingham-based tool or the REgistre GIroní del COR (REGICOR, Girona Heart Registry) calculator, which is based on a calibrated Framingham model. Current use of CVD risk assessment tools in clinical practice Responses to the questionnaire suggest that CVD risk assessment tools are widely used by doctors in both primary and secondary care; although respondents in just under half of countries also reported use by other health professionals, such as practice nurses and pharmacists (table 2). This was supported by the case studies, which found risk assessment to be primarily the responsibility of GPs, usually taking place in primary care (table 1). However, in almost all countries, other health professionals also conduct risk assessments (table 2). Nurses undertake the majority of risk assessments for the English NHS Health Check Programme while cardiologists undertake the majority of risk assessments in Greece. The questionnaire findings suggest that, across Europe, risk assessment is perceived to be acceptable to patients and considered of clinical value (table 2). Interviewees reported that risk assessment tools are used in clinical consultations to guide clinical decision-making (e.g. prescribing decisions) and encourage lifestyle changes. I have here the SCORE system and the Framingham, and the REGICOR system in my computer, so I can easily estimate the risk of my patients with the information that I have in their records, but it’s not automatically something I can do … I do when I have to make some clinical decisions on that specific patient [GP, Spain]. Variation in implementation of risk assessment The populations targeted for risk assessment vary substantially between countries and regions, but are most commonly based on age or medical history. While little data is available on the use of risk assessment tools in Europe, the Spanish case study identified two research studies that illustrate the variability in the implementation of risk assessment. The first study found that only 36% of primary care practitioners surveyed used the Spanish adaptation of the European guidelines and only 40% calculated overall cardiovascular risk in more than 80% of their patients with at least one risk factor.18 The second study highlighted variable CVD prevention policy across Spanish regions and patchy implementation of risk assessment for target populations.19 Interviewees from all countries reported that risk assessment use varies between health professionals, practices and regions. Some use it regularly, others don’t use it at all, others use it sometimes and they can use different tools [GP, Academic, Germany]. They attributed the variation to differing attitudes towards prevention and constraints on time and resources. In some countries, interviewees also reported mixed views regarding the acceptability of risk assessment tools among clinicians (e.g. attitudes regarding clinicians’ roles in primary prevention) and scepticism about the effectiveness of risk assessment. I worry intensely about how effective it is and whether it’s just people being commissioned to provide the service without any real understanding of what that service entails and how to change the individual’s cardiovascular risk at the end of it [GP, Academic, England]. Interviewees from some countries (e.g. Bulgaria, Latvia, Finland and Sweden) reported that treatment and secondary prevention are prioritized over primary prevention. In some parts of the country general practices are not very well resourced and they need to concentrate on treating the sick … They don’t have or they don’t feel they have had time for preventative care. They have their hands full managing the sick patients [Cardiologist, Finland]. Others reported that risk assessment is often estimated based on individual risk factors, rather than using a risk assessment tool. The calculation itself is not the best, the most important thing is to be alert, to be alert for risks and to give the proper advices and we make the right, take the right decisions and take the right actions to prevent and to protect [GP, Academic, Bulgaria]. Barriers and facilitators of CVD risk assessment The questionnaire found that, for most countries, facilitators of risk assessment in routine practice include: guideline recommendations, training, financing, perceptions of importance to clinicians and patients, time and the availability of information technology (table 3). These results were generally consistent with case study findings; although interviewees emphasized lack of time and resources as particularly important barriers. GPs, in particular, reported being overburdened and lacking time to conduct risk assessments and follow-up with high-risk patients (table 1). Table 3 Current/future facilitators of CVD risk assessment (questionnaire findings) CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 Table 3 Current/future facilitators of CVD risk assessment (questionnaire findings) CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 CVD risk assessment Number (%) of ‘Yes’ responses Number of countries with any ‘Yes’ responses Recommendation in guidelines 113/121 (93.4) 26/26 Specific payment for use 67/112 (59.8) 23/26 Acceptable to patients 98/108 (90.7) 24/25 Important for patients understanding/decision making 107/114 (93.9) 25/26 Important for healthcare professionals decision making 101/109 (92.7) 26/26 Specific consultation time 69/107 (64.5) 21/26 Training for clinicians 98/113 (86.7) 24/26 Clinician access to computers 111/117 (94.9) 26/26 GPs also have just 15 minutes for every patient and if the patient comes with the other problem, there is no time to calculate risk [Cardiologist, Latvia]. Similarly, interviewees in six out of eight case study countries reported shortages or under-utilization of nurses to carry out, or assist with, risk assessments (table 1). While respondents to the questionnaire reported that specific payments facilitate risk assessment (table 3), respondents from less than half of EU countries reported that specific payments exist for risk assessment (table 2). The case studies identified three types of financial barriers. At the health system level, interviewees reported a lack of resources for primary prevention and implementation of guidelines. At the clinician level, they reported a lack of re-imbursement for time spent carrying out risk assessments. In some parts of the country general practices are not very well resourced and they need to concentrate on treating the sick … They don’t have or they don’t feel they have had time for preventative care [Cardiologist, Finland]. At the patient level, they reported a lack of re-imbursement for costs associated with tests and treatments (table 1). Yes, but for instance, statins for primary prevention they are not … I think they are not re-imbursed at all. […] Now-a-days statins are re-imbursed for secondary prevention actually, rather than primary [Cardiologist, Academic, Bulgaria]. Interviewees suggested that simpler risk assessment tools that are integrated into electronic medical records might save time and increase usage. If something was made so that it was integrated with the normal system then it would be much, much more likely to be used [GP, England]. They also suggested that calibration of tools to specific populations, increased flexibility in the setting for risk assessment and training clinicians to use the tools would increase uptake. Novel biochemical and genetic markers of CVD risk While some established biomarkers (e.g. cholesterol and blood pressure) are monitored in routine clinical practice in most countries, novel biochemical and genetic markers are not routinely monitored in any country; they are used only in research. The case studies found that the main barrier to the monitoring of biomarkers is the lack of evidence on their clinical and cost effectiveness. Interviewees questioned the usefulness of additional biomarkers and reported a need to prove their clinical value, improve their sensitivity and/or specificity, prove their cost-effectiveness and simplify their use. Biomarkers have so far not contributed much. We went through biomarkers of different kinds, when we wrote the guidelines for management of people with diabetes, pre-diabetes and cardiovascular disease. And we actually couldn’t find any strong evidence for any biomarkers, and there are many, which actually told us something more than how the patient lived. Their blood pressure, their glucose, lipids and so on. So biomarkers are in the general perspective, not very useful, not yet [Cardiologist, Sweden]. Respondents to the questionnaire from most countries reported that monitoring biomarkers would be acceptable to both patients and clinicians (table 4) and interviewees generally did not foresee challenges regarding acceptability of novel biomarkers among patients and clinicians, provided that the conditions outlined above were met. Table 4 Novel biochemical/genetic biomarkers: future use and regulatory issues (questionnaire findings) Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Table 4 Novel biochemical/genetic biomarkers: future use and regulatory issues (questionnaire findings) Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Biochemical Genetic ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ ‘Yes’ responses/ All responses (%) Countries with at least one ‘Yes response’ Future use     Concerns about financing in routine practice 54/99 (54.5) 21/26 64/96 (66.7) 23/25     Acceptable to clinicians 105/109 (96.3) 26/26 71/87 (81.6) 24/25     Acceptable to patients 101/102 (99.0) 26/26 75/84 (89.3) 23/25 Existing regulatory/legal issues     Data protection 49/101 (48.5) 20/26 64/98 (65.3) 23/25     Confidentiality 47/100 (47.0) 18/26 60/95 (63.2) 20/25     Discrimination 22/89 (24.7) 12/25 29/85 (34.1) 13/24     Professional negligence 26/77 (33.8) 13/24 28/75 (37.3) 15/24     Consent 48/94 (51.1) 18/25 66/90 (73.3) 21/25 Questionnaire respondents reported regulatory and legal concerns associated with the monitoring of biomarkers slightly more often for genetic biomarkers compared with biochemical biomarkers (table 4). However, interviewees did not identify any regulatory or legal issues, even when specifically questioned on such issues. Oh, well our data protection law is very strong, very severe, so probably, I don’t know, but if the information is anonymous. You know respecting the individual data protection, that shouldn’t be any trouble I think [Cardiologist, Spain]. Discussion This study describes how CVD risk assessment is carried out in practice across Europe. It highlights the key role of the ESC, the importance of primary care and variation both within and between countries in the implementation of risk assessment. It also confirms the need for reliable evidence on the clinical effectiveness and cost effectiveness of new interventions, such as novel biomarkers, prior to their introduction into clinical practice. The ESC’s first Joint European Guidelines for CVD prevention were published in 1994, and with the launch of a strategy in 2002 designed to ‘reduce cardiovascular deaths by 40%,’20 the organization has moved from simply providing evidence-based guidelines to influencing European cardiovascular risk management policies.20 This study’s findings, such as the widespread use of the SCORE tool and the shaping of national guidelines, reflect this broader role. We found little published evidence on CVD risk assessment in clinical practice across Europe. Consistent with the findings from this study, recent research from the Netherlands highlights the gap between positive policy intent and implementation of CVD risk assessment in practice,21 with patient, organization and health system factors all influencing implementation in primary care. A systematic review of breast cancer risk prediction models found that the model most widely implemented in practice was the one that was most widely available, rather than the model with the best predictive ability.22 This is consistent with findings from this research, where it was reported that embedding risk prediction into routine electronic patient records is a facilitator of use in practice and that the use of the SCORE tool is widespread despite being limited to the prediction of fatal cardiovascular events. Despite widespread endorsement and acceptance of ESC guidelines, this study identified important variations in the implementation of risk assessment, such as the populations targeted and variable implementation across health professionals, practices and regions. This variation across and within countries was primarily attributed to differing attitudes towards the effectiveness of risk assessment and the prioritization of treatment and secondary prevention over primary prevention. Such attitudes are likely an important barrier to CVD risk assessment and important for policy makers to note, although assessing the pervasiveness of such views was beyond the scope of this study. The barriers and facilitators to the implementation of risk assessment identified in this study mirror those observed for risk models for type 2 diabetes23 and the implementation of the NHS Health Check programme in England.24 Implementation was influenced by the perceived advantages (simplicity, ease of use and predictive ability) and disadvantages (workload, and implications of managing a positive score) of the tools. These in turn are affected by factors such as clinicians’ skills, influence or endorsement of tools, healthcare system design and external policies, incentives and competing priorities. This study highlighted three levels of financial barriers that would need to be addressed to improve the implementation of CVD risk assessment: resources for primary prevention and implementation of guidelines at the health system level; re-imbursement for time spent carrying out risk assessments at the clinical level and re-imbursement for costs associated with tests and treatment at the patient level. These findings suggest that overcoming the financial barriers to risk assessment is a key policy area. Investigations into the utility of novel factors for the assessment of cardiovascular risk are being undertaken. Many studies that have claimed that additional factors could offer further predictive value beyond the Framingham algorithm have well-documented flaws.25 Further work employing multiple biomarkers has found only limited predictive benefit over conventional risk scores.26 This study emphasizes the need to demonstrate the predictive value and cost-effectiveness of novel biomarkers prior to their implementation. The main strength of this research is the inclusion of opinions from academic, clinical and policy experts from virtually all EU member states, using a wide-ranging questionnaire and in-depth case studies. Although responses are always prone to subjectivity, the expertise of the respondents means that the results of this study are likely to reflect practice. Differences in the results between the questionnaire and case studies highlight the strength of using different methodologies to gain a clearer understanding of opinion. However, this study also has important limitations. Identifying stakeholders, academic literature and guidelines for some countries was challenging, which could reflect the language barriers of the research team or possibly a lack of resources for, or engagement with, cardiovascular risk assessment in some countries. Although the response rate was in line with expectations for this type of study27,28 and the questionnaire was not intended to be representative of all member states, the response rate was nevertheless low and variable across countries, which may be due to the questionnaire being written in English or the response burden because of the length of the questionnaire. The participation of civil servants and representatives of health ministries and regulatory agencies in the questionnaire was unexpectedly low and thus not fully captured by the questionnaire findings; however, policy stakeholders participated in interviews for all of the country case studies such that the views of this stakeholder group were included in the analysis. However, we also cannot rule out selection bias; it is conceivable that the respondents who viewed the ESC and other guidelines most favourably may also have participated in the development of the guidelines. Very few stakeholders from CVD charities and patient organizations participated in the questionnaire and interviews, despite being invited to participate, such that this research lacks a strong patient voice. This study provides valuable insight into CVD risk assessment across Europe, which will hopefully act as a useful baseline and provide reference data upon which future studies can draw. The ESC has a central role in informing practice in Europe, and efforts to improve CVD prevention are likely to benefit from being carried out by, or in collaboration with, the ESC. Although integration of risk assessment tools in clinical computer systems may improve uptake, there remain significant barriers to the widespread implementation of risk assessment tools, including lack of funding. Despite considerable interest in developing novel biomarkers to optimize cardiovascular risk assessment, it is likely that focusing efforts on increasing implementation of existing risk assessment tools will offer the greatest gains in primary prevention of CVD. Acknowledgements This study complied with the Declaration of Helsinki. It was subject to RAND Europe’s internal ethics process, and informed consent was obtained from all subjects. Funding This work was supported by the European Union’s Seventh Framework Programme [grant number 279233]. Conflicts of interest: None declared. Key points The ESC is important in CVD risk assessment and any changes in European risk assessment policy should be made by, or in collaboration with, the ESC. Guideline implementation and use of CVD risk assessment tools in practice is often sub-optimal. Lack of funding for risk assessment and following up patients identified as at risk is a key barrier to widespread implementation of CVD risk assessment in Europe. Novel biochemical and genetic markers of CVD risk are not currently used in routine clinical practice; such biomarkers would need to be endorsed in clinical guidelines and shown to be both effective and cost-effective in order to be introduced into routine clinical practice in Europe. Supplementary data Supplementary data are available at EURPUB online. References 1 Nichols MTN , Luengo-Fernandez R , Leal J , et al. European Cardiovascular Disease Statistics . European Heart Network . Available at: http://www.escardio.org/The-ESC/Initiatives/EuroHeart/2012-European-Cardiovascular-Disease-Statistics 2012 (28 November 2017, date last accessed). 2 Ford ES , Ajani UA , Croft JB , et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000 . N Engl J Med 2007 ; 356 : 2388 – 98 . Google Scholar CrossRef Search ADS PubMed 3 Tunstall-Pedoe H , Kuulasmaa K , Mahonen M , et al. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease . Lancet 1999 ; 353 : 1547 – 57 . Google Scholar CrossRef Search ADS PubMed 4 Di Chiara A , Vanuzzo D . Does surveillance impact on cardiovascular prevention? Eur Heart J 2009 ; 30 : 1027 – 9 . Google Scholar CrossRef Search ADS PubMed 5 Reeves A , McKee M , Basu S , Stuckler D . The political economy of austerity and healthcare: cross-national analysis of expenditure changes in 27 European nations 1995-2011 . Health Policy 2014 ; 115 : 1 – 8 . Google Scholar CrossRef Search ADS PubMed 6 NHS England , Five Year Forward View, 2014 . Available at: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (28 November 2017, date last accessed). 7 Capewell S , O’Flaherty M . Trends in cardiovascular disease: are we winning the war? CMAJ 2009 ; 180 : 1285 – 6 . Google Scholar CrossRef Search ADS PubMed 8 Payne RA . Cardiovascular risk . Br J Clin Pharmacol 2012 ; 74 : 396 – 410 . Google Scholar CrossRef Search ADS PubMed 9 Sheridan SL , Crespo E . Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature . BMC Health Serv Res 2008 ; 8 : 60 . Google Scholar CrossRef Search ADS PubMed 10 Matheny M , McPheeters ML , Glasser A , et al. Systematic Review of Cardiovascular Disease Risk Assessment Tools . Rockville, Maryland : Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews, https://www.ncbi.nlm.nih.gov/pubmed/21796824. 11 Conroy RM , Pyorala K , Fitzgerald AP , et al. , Score Project Group . Estimation of 10-year risk of fatal cardiovascular disease in Europe: the SCORE project . Eur Heart J 2003 ; 24 : 987 – 1003 . Google Scholar CrossRef Search ADS PubMed 12 Hippisley-Cox J , Coupland C , Vinogradova Y , et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2 . BMJ 2008 ; 336 : 1475 – 82 . Google Scholar CrossRef Search ADS PubMed 13 D’Agostino RB Sr , Vasan RS , Pencina MJ , et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study . Circulation 2008 ; 117 : 743 – 53 . Google Scholar CrossRef Search ADS PubMed 14 Zeller T , Hughes M , Tuovinen T , et al. BiomarCaRE: rationale and design of the European BiomarCaRE project including 300, 000 participants from 13 European countries . Eur J Epidemiol 2014 ; 29 : 777 – 90 . Google Scholar CrossRef Search ADS PubMed 15 Marshall MN . Bridging the ivory towers and the swampy lowlands; increasing the impact of health services research on quality improvement . Int J Qual Health Care 2014 ; 26 : 1 – 5 . Google Scholar CrossRef Search ADS PubMed 16 NVivo qualitative data analysis software; QSR International Pty Ltd. Version 10, 2012. Warrington, UK. 17 SelectSurvey.NET survey software; ClassApps.com LLP. Version 4, 2016. Overland Park, US. 18 Brotons C , Lobos JM , Royo-Bordonada MA , et al. Implementation of Spanish adaptation of the European guidelines on cardiovascular disease prevention in primary care . BMC Fam Pract 2013 ; 14 : 36 . Google Scholar CrossRef Search ADS PubMed 19 Royo-Bordonada MA , Lobos JM , Brotons C , et al. In the name of the Comite Espanol Interdisciplinario de Prevencion, Cardiovascular, [The condition of the cardiovascular prevention in Spain] . Med Clin (Barc) 2014 ; 142 : 7 – 14 . Google Scholar CrossRef Search ADS PubMed 20 O’Kelly S , Ryden L . The political power of heart doctors: with the European Heart Health Charter towards a European policy on cardiovascular disease . Eur J Cardiovasc Prev Rehabil 2009 ; 16(Suppl 2) : S58 – 60 . Google Scholar CrossRef Search ADS PubMed 21 Huntink E , Wensing M , Klomp M , van Lieshout J . Perceived determinants of cardiovascular risk management in primary care: disconnections between patient behaviours, practise organisation and healthcare system . BMC Family Pract 2015 ; 16 : 179 . Google Scholar CrossRef Search ADS 22 Meads C , Ahmed I , Riley RD . A systematic review of breast cancer incidence risk prediction models with meta-analysis of their performance . Breast Cancer Res Treat 2012 ; 132 : 365 – 77 . Google Scholar CrossRef Search ADS PubMed 23 Noble D , Mathur R , Dent T , et al. Risk models and scores for type 2 diabetes: systematic review . BMJ 2011 ; 343 : d7163 . Google Scholar CrossRef Search ADS PubMed 24 Krska J , du Plessis R , Chellaswamy H . Views of practise managers and general practitioners on implementing NHS Health Checks . Prim Health Care Res Dev 2015 ; 17 : 1 – 8 . 25 Tzoulaki I , Liberopoulos G , Ioannidis JP . Assessment of claims of improved prediction beyond the Framingham risk score . JAMA 2009 ; 302 : 2345 – 52 . Google Scholar CrossRef Search ADS PubMed 26 Wang TJ , Gona P , Larson MG , et al. Multiple biomarkers for the prediction of first major cardiovascular events and death . N Engl J Med 2006 ; 355 : 2631 – 9 . Google Scholar CrossRef Search ADS PubMed 27 Saunders C . Taking an Interest: What Makes Someone Respond to a Survey . Statistics Views , 2016 . Available at: http://www.statisticsviews.com/details/feature/8739491/Taking-an-Interest-What-Makes-Someone-Respond-to-a-Survey.html (28 November 2017, date last accessed). 28 Farrer N , Yehuda D . Weighting Online Surveys . Ipsos MediaCT , 2010 . Available at: https://www.ipsos.com/sites/default/files/publication/1970-01/Ipsos%20MediaCT%20_Weighting%20Online%20Surveys_062010.pdf (28 November 2017, date last accessed). © The Author 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

The European Journal of Public HealthOxford University Press

Published: Jan 4, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off