What is CVDACTION?

 

CVDACTION is a smart platform that takes real time primary care data and shines a spotlight on the gaps, opportunities and inequalities in the management of cardiovascular-kidney-metabolic (CVKM) conditions.

 

These include high blood pressure, high cholesterol, chronic kidney disease, diabetes, non-diabetic hyperglycaemia, atrial fibrillation, heart failure and obesity.

 

CVDACTION systematically identifies every patient with one or more of these conditions who is not on NICE recommended treatment.

 

Our simple dashboards display the gaps in coding, diagnosis, monitoring, treatment initiation and treatment optimisation. They provide a holistic, proactive view, integrating co-morbidities and targeting health inequalities.

  

 

CVDACTION is designed for simplicity, making it easy to prioritise, with numbers to fit to workflow and to optimise within capacity.

 

CVDACTION is different from other digital tools

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Digital tools are in widespread use in primary care and many provide useful insights, help standardise care with templates and protocols, monitor targets and contracts, and support clinical decision making. But there are some fundamental gaps:

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• Widespread reliance on single indicator searches that serve narrow QOF targets but don't address the multiple risk factors that most patients have, and don’t focus on the interventions with greatest impact.

• Searches that generate lists of patients requiring action, but without the pathways or capacity to absorb the work.

• Software that adds electronic alerts to flag patients who need attention but which get lost in the blur of other flags there is no time to act on.

• Population health management platforms that tell you everything you might need to know about your population, but are too complex for busy clinicians to navigate and make use of.

 

The real-world challenge in primary care is not the data, but having the capacity and ways of working to act on the data.

 

CVDACTION has been designed to address this challenge.

 

 Why do we need CVDACTION now?

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CVD is very preventable, but large numbers of people with cardiovascular-kidney-metabolic (CVKM) conditions (like high blood pressure, high cholesterol, diabetes and kidney disease) are not on recommended preventive treatments.

 

• 1 in 3 people with hypertension do not have their blood pressure well controlled

• 1 in 6 people at risk of a second heart attack or stroke are not taking life-saving statins

• three quarters of people with chronic kidney disease, diabetes and heart failure do not receive critical medicines.

 

Step change improvement in these treatments has been set as a national priority in the Cardiovascular Disease Modern Service Framework. Every Integrated Care Board in the country will be expected to deliver on this as the national Mission to reduce deaths from CVD by a quarter in ten years will not be delivered without such a step change in the treatment of these CVKM conditions.

 

But it's important to recognise that optimal care is hard to deliver in real world primary care:​

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• Complexity, multiple conditions and time pressure are the norm in primary care consultations

• High risk CVKM conditions are often asymptomatic with no alert to warn the patient they need more treatment

• There is limited prioritisation in the QOF recall system - it is not designed to systematically detect patients who are under-treated.

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To achieve a step change in care and outcomes, real-world solutions need to address these real-world challenges.

 

CVDACTION has been designed for this purpose.

  

The CVDACTION Demonstrator Programme

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In a demonstrator programme, delivered with financial support from NHS England (London), CVDACTION was deployed across 10 Primary Care Networks in London, covering a population of 600,000​.  In addition to the CVDACTION data platform, sites received structured support for workforce and pathway transformation provided by the three London Health Innovation Networks.

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The evaluation found that CVDACTION:​

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• Delivered step change improvement with 2,200 patients having blood pressure and cholesterol optimised

• Was accepted well by primary care teams as a more efficient way of working rather than as a new demand

• Stimulated local leadership in pathway transformation and in action on health inequalities

• Increased staff satisfaction

 

“I got my hands on the dashboard and was totally blown away … Clinically speaking, the dashboard will be a massive game changer and totally unlike any other tools currently available.”

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Dr Farwa Hasan, Clinical Director Primary Care Network