Absolute Risk Approach to Aboriginal and Torres Strait Islander Cardiovascular Disease (2023)

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NAVIGATION

1. About
2. Overall Approach
3. Resources
4. CVD Guideline Updates
5. Outputs
6. Changes to Policy and Practice
7. Future Directions

ABOUT

Welcome to the Absolute Risk approach to Aboriginal and Torres Strait Islander CVD program webpage.

Our work aims to improve the prevention of heart disease in Aboriginal and Torres Strait Islander Peoples.

ABSOLUTE CVD RISK

Early identification and management of risk is key to preventing chronic disease, such as heart disease. Most CVD events such as heart attacks and strokes can be prevented with preventive care, timely screening and best practice management.

There has been good progress in CVD prevention for Aboriginal and Torres Strait Islander peoples. In the last 20 years, the rate of deaths from heart attacks and stroke has almost halved. However CVD still remains a leading cause of deaths in Aboriginal and Torres Strait Islander Peoples. High CVD risk begins earlier, mainly amongst those with diabetes and/or kidney disease.

An absolute risk approach to CVD is considered to be international best practice for CVD prevention. The approach combines information from several risk factors to calculate a person’s risk of having a stroke or heart attack in the next 5 years. The level of risk guides the recommended preventive measures. This can include lifestyle changes (quit smoking, eat a healthy diet) and starting blood pressure or lipid lowering medication. This holistic approach to managing CVD risk factors prevents over and under-treatment for CVD.

Absolute CVD risk assessment calculators exist online and within primary care software. The most up-to-date calculator recommended for use can be found here. Our team is in the process of working with software and guideline developers to ensure their calculators up to date.

Australian research has shown that there is inconsistent use of the absolute CVD risk assessment approach nationally (Heeley et al., 2010). There is also under-treatment, with as many as half of Aboriginal and Torres Strait Islander peoples thought to be at high CVD risk not receiving the recommended lipid-lowering medication (Calabria et al., 2018).

This program had three main streams of work:

• Revision and alignment of clinical practice guidelines
• Revision and improvement of Medicare Benefits Schedule items to support absolute CVD risk assessment
• Workforce education and engagement

In 2017, the Australian Government Department of Health provided funding for this program of work.

OVERALL APPROACH

In carrying out our work, our team had a focus on:

• Partnership with Aboriginal and Torres Strait Islander Peoples - Early and continuous engagement with key Aboriginal and Torres Strait Islander stakeholders across the research, primary health care, peak organisation and community sectors. We built partnerships with multiple organisations, and worked with Aboriginal and Torres Strait Islander research leaders to ensure that our work reflected community concerns and health priorities, first and foremost. This included consulting Thiitu Tharrmay, the Aboriginal and Torres Strait Islander Health Program Reference Group.
• Sustained stakeholder engagement - The team undertook strong stakeholder engagement throughout the life of the project from across government, primary health care, peak professional organisations, medical software and researchers. We worked closely with these stakeholders from the early stages of developing outputs through to communicating these changes and supporting their implementation through media and education.
• Practical and systematic solutions - We strove to provide systematic, evidence-based recommendations for policy and practice change that would provide options for real-world, sustainable change at the health system level.

Stakeholders included:

• Guideline developers
• Aboriginal and Torres Strait Islander Health peak bodies
• Aboriginal and Torres Strait Islander researchers and Aboriginal and Torres Strait Islander health practitioners
• Government bodies
• Primary Health Care Professional bodies
• Primary Health Care Software programs
• Research teams
• Marketing & communications

RESOURCES

Healthy Heart: Communities

Cardiovascular disease risk communication with Aboriginal and Torres Strait Islander Peoples: toolkit for health professionals.

The project team has created a toolkit to enhance knowledge and skills in CVD risk assessment and management. The Healthy Heart: Communities toolkit has been designed as a resource for all clinical staff in primary care, and aims to support conversations about CVD risk. During development, the team consulted the Australian National University’s Aboriginal Reference Group (Thiitu Tharrmay) and partnered with Saltwater People, an Indigenous-owned graphic design company based in QLD to create original artwork, design and layout. Original artwork was created by Tyrown Waigana.

The toolkit is designed for use across a variety of primary healthcare settings, and as a complementary resource to CVD Risk Communication Workshops that can be conducted within these settings.

This toolkit will help you:

• Facilitate discussions with your patient to motivate behavioural change
• Use culturally appropriate techniques to communicate risk to your patient
• Work in partnership with your patient.

The full toolkit including all resources can be downloaded in full colour from here and in black and white from here.

Information on the individual resources in the toolkit and how to use them are available below. If you have any questions or feedback on these resources, please email Dr Andrea Timothy.

Absolute CVD risk and Aboriginal and Torres Strait Islander peoples

This two page resource provides an overview of Absolute CVD risk and Aboriginal and Torres Strait Islander peoples, including statistics highlighting the differences from CVD risk in the general population. This can be used for your own reference, and these facts can be included in your discussions with your patients about their own CVD risk.

Visual guide for explaining CVD risk to patients

This one page resource is a visual explanation for your patient about their CVD risk and what it means for them, and can complement the use of motivational interviewing techniques.

After conducting the health assessment with your patient, which will include the use of a CVD risk calculator, this resource is a template that you can write on to help you talk through what CVD risk is, what your patients’ specific risk factors are, and how they contribute to their risk of heart attack or stroke in the next 5 years.

How to use this template:

1. Circle patients’ specific risk factors
2. Based on the CVD risk calculator’s output, insert whether your patient is at HIGH, MODERATE or LOW risk in the heart graphic
3. Convert this risk score to a proportion and enter the appropriate number in the corresponding statement, e.g. if your patient’s risk score is 10%, the statement should read “This means that if there were 100 people like you, we would expect 10 of them to have a heart attack or stroke within the next 5 years”
4. Indicate on the risk spectrum where they currently fall
5. Discuss what changes can be made to reduce their risk
6. Indicate on the risk spectrum where they would fall if they made these specific changes
7. Refer your patient to appropriate services

Communicate CVD risk effectively: Motivational interviewing and the 5 stages of change

This resource gives an introduction to motivational interviewing techniques and how they can be applied in your discussions about risk with patients. It includes background on the 5 stages of change. This can be used as a guide during your patient consultations.

Other helpful resources

This includes a handy guide to Medicare Benefits Schedule (MBS) item numbers relevant to CVD risk assessment, and useful links to ensure you provide the best health assessment for your patient.

Materials to guide workshops on risk communication

These are a suite of resources that can be used as supporting materials for CVD Risk Communication Workshops that can be conducted in your own practice. They include:

• Overview of the CVD risk communication workshop
• Case studies
• Role play debrief: how to identify motivational interview techniques
• Quiz: testing your knowledge about CVD risk and risk communication for Aboriginal and Torres Strait Islander peoples

CVD GUIDELINE UPDATES

New recommendations for CVD risk assessment and management in Aboriginal and Torres Strait Islander adults aged under 35 years

New recommendations for CVD risk assessment and management were published on 16^thMarch 2020 in the Medical Journal of Australia. The recommendations were endorsed by the National Aboriginal Community Controlled Health Organisation, Royal Australian College of General Practitioners, Central Australian Rural Practitioners Association and the Australian Chronic Disease Prevention Alliance, led by the Heart Foundation. The approach to early screening was developed in partnership with the Australian National University’s Aboriginal Reference Group (Thiitu Tharrmay) and other Aboriginal and Torres Strait Islander leaders in CVD prevention.

Main changes

The updated recommendations are for Aboriginal and Torres Strait Islander individuals to receive:

• Combined early screening for diabetes, chronic kidney disease and other CVD risk factors from the age of 18 years at latest
• Assessment of CVD risk using an Australian CVD risk calculator from the age of 30 years at the latest

Key messages

1. Most heart attacks and strokes can be prevented, and in the last 20 years, the rate of deaths from CVD in Aboriginal and Torres Strait Islanders peoples has almost halved
2. High risk of cardiovascular disease begins early among Aboriginal and Torres Strait Islander peoples and is mainly due to diabetes and renal disease
   1. It is recommended that there should be combined early screening for diabetes, chronic kidney disease and cardiovascular disease risk factors from the age of 18 years, with use of an Australian CVD risk calculator from the age of 30 years
3. What you can do:Assessment of CVD risk as part of a health check. The most important part of this check-up is working with your doctor to manage your risk factors to improve your heart health and help you live a healthier, longer life

OUTPUTS

The team has produced several reports to government, policy briefs, peer-reviewed papers, resources for health professionals and presented at national conferences. We have also hosted numerous stakeholder engagement roundtables and delivered presentations to government agencies throughout the program of work.

For more information on any of these, please contact the research team.

Combined outputs for program of work 2017-2020

Reports for the Australian Government Department of Health

Evidence Reports

1. Review of evidence for the alignment of guidelines on Aboriginal and Torres Strait Islander absolute cardiovascular disease risk
2. Evidence on how Aboriginal and Torres Strait Islander health assessments can be enhanced to support best practice cardiovascular disease risk assessment and management
3. Clinical decision support for cardiovascular disease prevention in primary care: a strategy to facilitate improved patient care

Strategy and status reports

1. StrategytosupportrevisionandalignmentofguidelinesforAboriginalandTorres Strait Islanderabsolutecardiovascular diseaseriskassessmentand management
2. Strategy to enhance Aboriginal and Torres Strait Islander health assessments to support best practice cardiovascular disease risk assessment and management
3. Status report on implementation of strategy to support revision and alignment of guidelines for Aboriginal and Torres Strait Islander absolute cardiovascular disease risk assessment and management
4. Summary report: Education for health professionals in Aboriginal and Torres Strait Islander absolute CVD risk assessment and management
5. Update of absolute cardiovascular disease risk calculators: a strategy to facilitate enhanced absolute cardiovascular disease risk assessment in Australian primary care
6. Strategy to promote awareness of revised guidelines for cardiovascular disease risk assessment in Aboriginal and Torres Strait Islander adults aged under 35

Policy briefs

1. Opportunities to prevent cardiovascular disease in Aboriginal and Torres Strait Islander Australians
2. Earlier screening for heart health, chronic kidney disease and diabetes for Aboriginal and Torres Strait Islander peoples
3. Evidence on how Aboriginal and Torres Strait Islander health assessments could be enhanced to support best practice cardiovascular disease risk assessment and management
4. Incorporating best practice cardiovascular disease assessment and management within health assessments (MBS items 715 and 701 – 707)

Educational resources

• Healthy Heart: Communities Cardiovascular Disease risk communication with Aboriginal and Torres Strait Islander peoples: Toolkit for Health Professionals.

Key engagements and presentations

• Three presentations to the Indigenous Health Division, Australian Government Department of Health have been delivered
• Presentations to the MBS Review Taskforce: General Practice and Primary Care Clinical Committee and Aboriginal and Torres Strait islander Reference Group
• Presentation to the Aboriginal and Torres Strait Islander Health Services Data Advisory Group
• Two major stakeholder roundtables have been facilitated by the ANU team with participation by experts in CVD prevention from across Australia:
  
  • February 2018 - CVD Guideline stakeholder Roundtable
  • November 2019 - National Roundtable on Absolute CVD Risk (led by the Heart Foundation)

Academic peer-reviewed papers

1. Paige, E, Agostino, J, Phillips, C et al 2019, 'Living Guidelines for Absolute Cardiovascular Disease Risk Assessment and Management', Heart, Lung and Circulation, vol. 28, no. 6, pp. 829-832. doi.org/10.1016/j.hlc.2019.01.014
2. Paige E, O’Donoughue Jenkins L, Agostino J, Pennings S, Wade V, Lovett R, Daluwatta A, McLoughlin K, Banks E. Aboriginal and Torres Strait Islander absolute cardiovascular risk assessment and management: systematic review of evidence to inform national guidelines. Public Health Res Pract. 2020;30(2):e29231910. doi.org/10.17061/phrp29231910
3. Agostino, J, Wong, D, Paige, E et al 2020, 'Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement', Medical Journal of Australia, vol. 212, no. 9, pp. 422-427. doi.org/10.5694/mja2.50529
4. Butler et al. 2020 Public Health Research and Practice Relation of personal characteristics and cardiovascular risk factors to receipt of Aboriginal and Torres Strait Islander health assessments.

Conference presentations

1. APNA National Conference 2019, Australian Primary Health Care Nurses Association (April 2019). Cobranded with the Heart Foundation.
2. GP19 Conference, Royal Australian College of General Practitioners (October 2019) Seminar on Navigating pitfalls in absolute CVD risk assessment, and interactive workshop on Managing the trifecta: CVD, CKD and diabetes.
3. 5th Annual Ngar-Wu Wanyarra Aboriginal and Torres Strait Islander Health Conference, University of Melbourne (October 2019) How to heal a broken heart - The importance of culture, communication and clinical interactions.

CHANGES TO POLICY AND PRACTICE

Several changes to policy and practice have resulted from the work of this program. These include:

• Alignment of age to commence CVD risk screening for Aboriginal and Torres Strait Islander peoples as published in the consensus statement
• Alignment of NACCHO/RACGP Health Assessment Templates: The ANU team contributed to work led by NACCHO and RACGP seeking to improve health assessment templates. This included advocating for enhancement of templates to have a more patient-centred focus and inclusion of absolute CVD risk assessment and management as part of routine health assessments. The templates have been endorsed by NACCHO and the RACGP.
• Contributing to the work of the Health Services Data Advisory Group to revise the national Key Performance Indicators (nKPIs) to accurately reflect absolute CVD risk assessment guidelines
• Ongoing work with peak bodies for workforce educational resources: We are working with NATSIHWA to tailor educational materials around CVD risk communication for members’ CPD program.
• Alignment of MBS 699 with new guidelines: The Heart Health Assessment item (MBS 699) was introduced by the Australian Government in early 2019. The eligibility for MBS 699 aligns with recommendations to assess absolute CVD risk in Aboriginal and Torres Strait Islander person aged 30 years and above, and that the assessment includes calculation of absolute CVD risk using an appropriate absolute CVD risk calculator.
• In-principal agreement to update absolute CVD risk calculators in line with the latest evidence:
  
  • From the Heart Foundation, for the NVDPA (ACDPA) absolute CVD risk calculator http://cvdcheck.org.au/
  • From Medical Director and Best Practice for absolute CVD risk assessment calculators within software packages.

FUTURE DIRECTIONS

This program of work came to a close in August 2020. Aspects of the work will be continued in a new program of work also funded by the Australian Government Department of Health.

More information on the next phase of work can be found here.