CVDACTION helps primary care teams to achieve a Step Change in CVD prevention. It has 2 core elements:

• An easy-to-action smart data platform that routinely identifies all patients with cardiovascular-kidney-metabolic conditions who are not on guideline directed therapy, and makes it easy to prioritise and fit to capacity;

• 12 months transformation support for teams to adapt pathways, work proactively, manage multiple conditions and optimise treatment at scale

CVDACTION brings together the major cardiovascular-kidney-metabolic conditions that drive outcomes, activity and cost. The platform identifies every patient with CVKM conditions who is not on NICE recommended treatment, with dashboards designed for simplicity so that clinicians can see the whole picture and prioritise easily, fit workload to capacity, and optimise at scale.

Late diagnosis and under treatment of high risk conditions like high blood pressure, high cholesterol, chronic kidney disease, diabetes and heart failure is widespread and longstanding.

The CVDACTION Impact Model shows that a realistic Step Change in treatment of these conditions (secondary prevention) would prevent around 20,000 heart attacks, strokes, heart failure and kidney failure episodes every year.

To achieve this, the critical step is to make it routine to identify and optimise patients who are not on the right treatment. CVDACTION is designed for this.

CVDACTION brings together the major cardiovascular-kidney-metabolic conditions that drive outcomes, activity and cost. The platform identifies every patient with CVKM conditions who is not on NICE recommended treatment, with dashboards designed for simplicity so that clinicians can see the whole picture and prioritise easily, fit workload to capacity, and optimise at scale.

The CVDACTION conditions include high blood pressure, high cholesterol, chronic kidney disease, diabetes, pre-diabetes, heart failure, obesity and atrial fibrillation.

Under use of NICE recommended treatments in CVKM conditions is widespread: just under a third of people with hypertension have uncontrolled blood pressure; one in six people with cardiovascular disease are on no lipid learning therapy; and a third of patients with either CKD, heart failure or diabetes are not on SGLT2 inhibitors. And there is substantial variation between different localities.

Step Change is defined in the CVDACTION Impact Model as a minimum realistic level of improvement in uptake of CVD prevention medicines that are NICE recommended but underused.  An example of sStep Change is to increase from 70% to 80% of patients with hypertension treated to target.

The Cardiovascular Disease Modern Service Framework lays out 12 Immediate Priorities for the NHS. Six of these priorities set ambitious targets for improvements in uptake of secondary prevention medicines - for blood pressure, cholesterol, diabetes, chronic kidney disease and heart failure. These targets wll only be achieved with Step Change improvement. Standard incremental improvement will not deliver this.

CVDACTION helps teams deliver on all the  MSF prevention priorities by routinely identifying every patient with high risk CVKM conditions who is not on recommended treatment and making it easy to act on the data to optimise at scale. All CVDACTION indicators can also be filtered by age, gender, deprivation, ethnicity, severe mental illness and learning disability, allowing targeted action on health inequalities.

CVDACTION brings together the major cardiovascular kidney metabolic conditions that drive outcomes, activity and cost. The platform identifies every patient with CVKM conditions who is not on NICE recommended treatment, with dashboards designed for simplicity so that clinicians can see the whole picture and prioritise easily, fit workload to capacity, and optimise at scale - delivering Step Change improvement.

There is robust evidence that treating CVKM conditions like high blood pressure and cholesterol prevents heart attacks, strokes and other serious events. But getting treatment right can be difficult in real world primary care where consultations are always time pressured with multiple problems address, the CVKM conditions usually come with no symptoms to alert the patient, and there is no mechanism to routinely search records for people who are not on optimal treatment.

Heart attacks, strokes and other serious cardiovascular events are highly preventable. Supporting people to tackle lifestyle risk factors such as smoking, obesity and physical inactivity is essential for long term prevention, but with limited impact in the short term.

Secondary prevention, treating conditions like high blood pressure, high cholesterol, diabetes and chronic kidney disease, is very effective at preventing CVD in the shorter term. The CVDACTION Impact Model (Powering the Prevention Shift) shows that Step Change improvement in secondary prevention can deliver a major impact on population health, NHS activity and costs within 3 years, with ICBs breaking even within 12 months.

The CVDACTION Impact Model (Powering the Prevention Shift) is a health economic analysis based on a discrete-time, cohort-based Markov model that simulates disease progression and event occurrence over a 15-year time horizon, with annual cycles. The model captures the natural history and clinical outcomes of cardiovascular disease in high-risk individuals and evaluates how more effective use of four NICE approved but underused treatments impacts on those outcomes.

The 4 treatments are blood pressure control, lipid optimisation, RAA therapy, and SGLT2 inhibitors.  The outcomes considered are heart attack, stroke, heart failure admissions and end stage kidney disease.

3 improvement scenarios were considered: full uptake (unlikely in real world); advanced uptake (aspiration for high performing systems); and Step Change (a minimum realistic level of improvement).

The model was built for every ICB in England and shows that Step Change improvement results in major impact on outcomes, activity and spend with major savings in health and social care and the wider economy within 3 years, with 20,000 fewer serious cardiovascular events expected every year.

The CVDACTION Impact Model shows that within 3 years, Step Change improvement in uptake of 4 NICE recommended but underused treatments (blood pressure, cholesterol, SGLT2i and RAASi) will result in:

57,000 fewer heart attacks, strokes, heart failure admissions and end stage kidney disease; 430,000 fewer bed days (equivalent of 2 hospitals emptied for a year); £1.1 billion NHS and social care savings, and £1.2 billion gains for the wider economy. Overall £1 investment returns £14 in 3 years, with ICBs seeing cost neutrality in 12 months.

Teams using CVDACTION receive 12 months hands on implementation support that is adapted for local context, needs and local leadership. It includes engagement with leadership and wider teams, onboarding, project management, support with priority setting, adapting pathways and workflows, education and mentoring, data feedback, progress tracking, troubleshooting and QI cycles.

High blood pressure

High cholesterol

Chronic kidney disease

Diabetes

Pre-diabetes

Heart failure

Obesity

Atrial fibrillation

CVDACTION complements other tools but brings significant added value. There are many sources of data for primary care teams. The challenge is having the capacity and ways of working to act on the data

CVDACTION brings together the major CVKM conditions that drive demand, cost, inequalities and premature mortality. The result is not just a collection of search outputs that is complex to prioritise and action, but data that is curated, focused on impact and easy to action in real world primary care. By enabling targeted action on these connected high impact conditions, CVDACTION helps Primary Care Networks and ICBs to move beyond incremental improvement to drive Step Change in care and outcomes with rapid impact on population health.

Domains, cohorts - ix that drive outcomes, HI.

All CVDACTION indicators can be filtered by age, gender, deprivation, ethnicity, severe mental illness and learning disability. This enables teams to identify cohorts of patients in vulnerable or disadvantaged populations who are at higher risk of heart attacks and stroke because of poorly controlled risk factors like blood pressure and cholesterol. This allows PCNs and ICBs to tak targeted at-scale action on health inequalities.

Primary care clinicians like CVDACTION and positive feedback is very common. A frequent comment is that it is not adding to burden, but helping teams to work differently to reduce burden.

"Blown away", "Amazing tool", "Invaluable", "Transformative", "Game changing", "brilliant".

CVDACTION data can be viewed at multiple levels including PCN and ICB, with appropriate role-based access to patient identifiable data or aggregated data. ICBs can see aggregated data for every practice or PCN covering all 130 indicators. This provides a population view of gaps and opportunities across the 8 high impact CVKM conditions that drive outcomes, activity, spend and inequalities.

The health inequalities filters (age, gender, ethnicity, deprivation, severe mental illness and learning disability) enable ICBs to target resources and activity on vulnerable or disadvantaged populations whose risk factors are not well managed, and to take at-scale action on health inequalities.

The Cardiovascular Disease Modern Service Framework lays out 12 Immediate Priorities for the NHS. Six of these priorities set ambitious targets for improvements in uptake of secondary prevention medicines - for blood pressure, cholesterol, diabetes, chronic kidney disease and heart failure. These targets wll only be achieved with Step Change improvement. Standard incremental improvement will not deliver this. All of the MSF prevention indicators are included in CVDACTION.

CVDACTION helps teams deliver on all the  MSF prevention priorities by routinely identifying every patient with high risk CVKM conditions who is not on recommended treatment and making it easy to act on the data to optimise at scale. All CVDACTION indicators can also be filtered by age, gender, deprivation, ethnicity, severe mental illness and learning disability, allowing targeted action on health inequalities.

CVDACTION helps primary care teams to see the whole picture at a glance, to safely prioritise, and to target healh inequalities, generating numbers that fit workflow and capacity. The 12 months practical support brings project management and mentoring, helps teams to adapt ways of working and develop workforce skills, improving care and outcomes, reducing demand and meeting QOF and other targets.

CVDACTION is separate from but adds value to CVDPREVENT. In CVDPREVENT, the national primary care audit, data is anonymised. Practices and PCNs can see gaps and opportunities in treatment optimisation, but they cannot see who the patients are that need optimisation. To take action in response to the data (eg low levels of blood pressure optimisation), teams have to find or build searches to identify the patients and then find capacity and workflow to accommodate them.

CVDACTION complements CVDPREVENT but has a broader range conditions and indicators. CVDACTION identifies and stratifies all patients with 8 CVKM conditions whose treatment is suboptimal, with 130 indicators and a range of health inequalities filters. Dashboards are designed for simplicity making it easy for primary care teams to prioritise, fit to capacity and optimise at scale.

CVDACTION was initially developed in UCLPartners under the leadership of Dr Matt Kearney OBE and Laura Boyd. Matt has a clinical background as a GP and was the first National Clinical Director for Cardiovascular Disease Prevention. In that role fe founded CVDPREVENT, the national audit. Laura is Director of Digital Partnerhips at Health Innovation Yorkshire & Humber. Matt and Laura now lead the ongoing development and scaling of CVDACTION through Into-Action.Health.

The CVDACTION Impact Model, Powering the Prevention Shift, was commissioned by Into-Action.Health with independent grant funding from AstraZeneca. AstraZeneca had no involvement in the conception or development. The CVDACTION Impact Model was built independently by Economics By Design and Get The Data Limited.

The CVDACTION Impact Model shows that within 3 years of Step Change improvement in uptake of 4 treatments (Blood pressure, cholesterol, RAASi and SGLT2i) across England there would be 57,000 heart attacks, strokes, heart failure admissions and end stage kidney disease.

In addition to £1.1 billion savings in health and social care, there would £1.2 billion increase in wider economic productivity  - with fewer serious, life changing illnesses forcing patients and their carers to leave the workforce. The modelling does not include the reduction in welfare benefits and increase in taxation that would follow.

3 elements of cost are included in the CVDACTION Impact Model: the increase in medicine uptake (the lionshare of the costs); the CVDACTION licence fee; and the cost of providing structured support for primary care teams to adapt pathways to optimise at scale (at £0.25 per head of population). Even accounting for these costs, ICBs break even within 12 months of Step Change.

​The CVDACTION Impact Model shows that achieving a realistic Step Change improvement in 4 NICE recommended but underused treatments would provide a return  on investment of £14 for every £1 invested within 3 years. From an NHS perspective alone, ICBs would be cost neutral within 12 months.

The CVDACTION Demonstrator programme was run across 10 Primary Care Networks in London covering a population of 600,000 people. Over a 6 month period, 2,200 people with hypertension or cardiovascular disease had their blood pressure newly treated to target, or were newly started on lipid lowering therapy - significant Step Change numbers. CVDACTION was enthusiastically welcomed by primary care clinicians who regarded it not as a new demand when they have no capacity but as a support to work differently. The demonstrator was evaluated by UCLPartners.

The CVDACTION Impact Model and individual headline reports are available for every ICB and Cluster in England.

The CVDACTION Impact Model shows the Size of the Prize for CVD prevention. A realistic Step Change improvement in uptake of 4 NICE recommended but underused treatments (blood pressure, cholesterol, SGLT2i and RAASi) across England, would result every year in 20,000 fewer heart attacks, stokes and episodes of heart failure and kidney failure , generating £700,000 in savings for the NHS, social care and the wider economy.