Introduction

This quality standard covers identifying and assessing cardiovascular risk, and lipid modification for preventing cardiovascular disease, in adults (aged 18 years and over). For more information see the cardiovascular risk and lipid modification topic overviews.

Why this quality standard is needed

Cardiovascular disease (CVD) describes disease of the heart and blood vessels caused by the process of atherosclerosis, which includes coronary heart disease, peripheral arterial disease, stroke and transient ischaemic attack. CVD is the leading cause of death in England and Wales, accounting for almost one‑third of all deaths. In 2010, approximately 180,000 people died from CVD – around 80,000 of these deaths were caused by coronary heart disease and 49,000 were caused by strokes. Approximately 46,000 occurred in people aged 75 years or younger, and 70% of those were in men.

Mortality from CVD in the UK is falling. It is estimated that 60% of the CVD mortality decline in the UK during the 1980s and 1990s was attributable to reductions in major risk factors, mainly smoking. Drug treatment, including secondary prevention, accounts for the remaining 40%. Since 2000, immediate fatal CVD deaths have halved. However, morbidity appears to be rising. CVD has significant cost implications and was estimated to cost the NHS in England almost £6,940 million in 2003, rising to £7,880 million in 2010.

CVD shows strong age‑dependence and predominantly affects people older than 50 years. Risk factors for CVD include non‑modifiable factors (such as age, sex, family history of CVD and ethnic background) and modifiable risk factors (such as smoking, raised blood pressure and lipids, obesity and alcohol intake). CVD is strongly associated with low income and social deprivation, and there are higher rates in the north of England than in the south.

Cardiovascular risk assessment aims to identify people who do not already have CVD but who may be at high risk of developing it. A full cardiovascular risk assessment usually takes place in primary care and takes into account both non‑modifiable and modifiable risk factors. Those people identified to be at greatest risk can then be offered focused interventions, including help to stop smoking, and advice on diet and physical activity. If necessary, treatment for high blood pressure and lipids can be used to target modifiable risk factors and reduce the risk of developing CVD.

One of the main strategies for CVD risk management is the use of lipid‑lowering therapies, especially statins. Statin therapy needs to be a long‑term treatment to be fully beneficial. Key challenges in the field of CVD prevention include improving treatment adherence in people who have had CVD events, and convincing people who feel well that they need to make substantial lifestyle changes and need lifelong drug treatment. High‑quality information and communication on the benefits and risks associated with these therapies are needed.

The quality standard is expected to contribute to improvements in the following outcomes:

  • incidence of CVD events

  • mortality from CVD

  • patient experience of GP services.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1b Life expectancy at 75 i Males ii Females

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition**

Improving functional ability in people with long‑term conditions

2.2 Employment of people with long‑term conditions*/**

4 Ensuring that people have a positive experience of care

Overarching indicator

4a Patient experience of primary care i GP services

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)

Table 2 Public Health Outcomes Framework for England, 2013–16

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are in contact with secondary mental health services*

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.4 Under 75 mortality rate from all cardiovascular diseases (including heart disease and stroke)*

Aligning across the health and social care system

* Indicator shared with the NHS Outcomes Framework

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to cardiovascular risk assessment and lipid modification.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for cardiovascular risk assessment and lipid modification specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults having a cardiovascular risk assessment and adults being considered for lipid modification therapy.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing high‑quality risk assessment and lipid modification for cardiovascular disease are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in risk assessment and lipid modification for cardiovascular disease should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults who have a cardiovascular risk assessment and are considered for lipid modification therapy. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about cardiovascular risk assessment and lipid modification.