Data-driven patient care supports Doctors to match eligible patients for risk assessments and reduce the risk of developing cardiovascular heart disease through QLD Government’s program, My health for life.

Sydney, 2nd April 2019 – Pen CS in collaboration with QLD Heart Foundation, Queensland Primary Health Networks and Queensland Government-funded My health for life program has implemented automated decision support in General Practice to help Doctors manage cardiovascular disease.  This coincides with a new dedicated MBS item for heart health checks that from 1st April this year will support General Practitioners and patients in assessing cardiovascular risk.

Cardiovascular disease (CVD) is one the biggest burdens on the Australian economy[1], killing one Australian every 12 minutes[2] and with 43,477 deaths attributed to CVD in Australia in 2017.

In General Practice, Doctors have a short consultation window to address the patient’s immediate concern.  Although opportune, there is little time left to focus on early identification of the patient’s risk of developing serious chronic disease. RACGP Guidelines recommend risk assessment for best practice, “In Australia, 64% of the adult population have three or more modifiable risk factors. As CVD is largely preventable, an approach focusing on comprehensive risk assessment will enable effective management of identified modifiable risk factors through lifestyle changes and, where needed, pharmacological therapy.”[3]

Pen CS’ challenge was to support Doctors’ early identification of risk factors, contributing to CVD and other chronic disease. The solution was to create a (Topbar) automated notification that prompts the Doctor when a presenting patient is eligible for a risk assessment and participation in My health for life. This notification supports the Doctor to ‘start a conversation’ with the patient.  There is no extra work for the Doctor and the patient benefits from extended care through the My health for life program.

Stephen Vines CEO Heart Foundation – Qld explains that “the new Pen CS program app developed for the My health for life program incorporates the absolute cardiovascular risk assessment result.  Patients with a score greater than 15% will trigger a notification as being eligible for referral to the program.  We see this as a positive step forward in supporting Queenslanders to reduce their risk of developing cardiovascular disease”.

For Doctors, the value is improved patient outcomes, implementation of best practice according to RACGP Guidelines and adherence for accreditation. The Topbar notification assists with meeting RACGP 5th edition Standards[4] on Preventive Health (Criterion C4.1) regarding health promotion and preventative care. Topbar notifications represent a systematic approach to preventative care.

A first stage implementation strategy for the new program app has been trialled with 7 practices across Brisbane North, North Queensland and Brisbane South PHNs to gain feedback from GPs and test the usefulness of the app in routine consultations.

Makiko Omae, Practice Manager from Cairns West Medical Centre, shares her successful experience using the new Topbar notification:

 “We have quite a large number of chronic disease patients, who need extensive health assessments and care plans completed. Topbar can quickly identify eligible patients and also help with our practice revenue. The higher levy will help cover costs and give better service quality to the patient.”

Since the program My health for life has commenced, 26% of all participants have lost weight, 50% of participants reduced their waist circumference.  Almost everyone (96%) plan to make further improvements to their health goals to reduce their health risks.

[1] Australian Institute of Health and Welfare 2011. Cardiovascular disease: Australian facts 2011. Cardiovascular disease series. Cat. no. CVD 53. Canberra: AIHW.

[2] Australian Bureau of Statistics 2018, Causes of Death 2017, ABS cat. no. 3303.0, September.

[3] Guidelines for the management of Absolute cardiovascular disease risk, endorsed by RACGP, ©National Stroke Foundation 2012.

[4] https://www.racgp.org.au/download/Documents/Standards/RACGP-Standards-for-general-practices-5th-edition.pdf