A risky business?

Since April 2009, the Quality and Outcomes Framework (QOF) has rewarded UK general practices for “cardiovascular risk assessment at the outset of diagnosis using an agreed risk assessment treatment tool” for all new patients diagnosed with hypertension. It is concerning that the current tool relies largely on data that may be inappropriate for the UK.

Most GP computer systems provide risk scores derived from a study started in 1948, in a largely Caucasian population, of 5,209 people (aged 30–62 years) from Framingham, Massachusetts, USA. In 1971, the study enrolled 5,124 of the original participants’ adult children and their spouses. Measured risk factors (blood pressure, cholesterol, diabetes, smoking history and left ventricular hypertrophy on ECG) and subsequent cardiovascular events, were used to generate the Framingham risk equation. Many GP computer systems can now also calculate another predictor of cardiovascular risk: QRISK. This is based on retrospective data from 531 general practices in England and Wales from 1993 to 2008, covering 2.3 million patients aged 35–74 years (including 22,013 South Asian, 11,595 black African, 10,402 black Caribbean and 19,792 Chinese people). It relates first incident cardiovascular disease (CVD) event to risk factors: ethnicity, age, sex, smoking status, systolic blood pressure, cholesterol, body mass index, family history of CVD, a deprivation score, and treated hypertension. Also, it estimates risk in diabetes, renal disease, rheumatoid arthritis and atrial fibrillation. The National Institute for Health and Clinical Excellence (NICE) guideline on lipid modification recommended using Framingham 10-year risk equations instead of QRISK in May 2008. This was due to concerns about inadequate validation of QRISK, and whether it would be freely available for incorporation into clinical systems. Although a paper published in June 2008 provided convincing validation of QRISK,1 NICE is yet to revisit its advice. While there may be major training issues in …