NHS Health Check - Queen Mary University of London-March-2016.pdfP 4 NHS HEALTH CHECK SUMMARY GUIDELINE 1. Introduction TheNHS Health Check programme is a mandatory public health service

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Key messages

• Assessvascularriskforalleligiblepeopleaged40-74years.

• Prioritisetheassessmentofpeoplewith10yrCVDrisk≥20%.

• Assessriskofdevelopingdiabetes.

• ProvidehealthylifestyleadviceforallpeopleattendingtheNHSHealthChecktoimproveandmaintainahealthydietandphysicalactivity.Referthoserequiringsupport.

• Advisesmokerstoquitandattendcessationsupportservices.

• Manage≥20%CVDriskandco-morbidities,includinghighdiabetesrisk.

• Checkpulseregularityage≥65years

• Increaseawarenessofdementiainpeopleage≥65years

• RemembertorecordinvitesforNHSHealthChecks.

SUMMARY GUIDELINES

ISBN 978-1-910195-15-4

NHS Health Check

Aim of the guideline

TheaimistoimproveattendanceatNHSHealthChecksandmanageCVDanddiabetesrisktoreduceheartattacks,strokes,chronickidneydiseaseanddiabetesandimprovequalityoflife.

MARCH 2016

Contents

Introduction and background 4

Eligible population and QRisk 5

Invitations, blood tests & assessment 6

Advice and risk communication 7

Managing abnormal risk factors 8

Alcohol units and diabetes diagnosis 9

Dietary advice and physical activity 10

Explaining risk 11

References 11

About the guidance

ThisisaguidetobestpracticeanddoesnotoverridedeliveryrequirementssetoutinlocalservicespecificationsineachCCGwhichmaydifferslightly.ForexamplepulseregularitychecksarenotdoneinallCCGsandtheCVDriskthresholdfortestingcholesterolmaydiffer.

ThisdocumentwasauthoredbyJohnRobsonwiththehelpofMikeFitchett,LuiseDawson,MichaelJones,JayneTaylor,SimonReidandHilaryGuite.

AnyqueriesregardingthisdocumentshouldbeaddressedtoCEGatihse-ceg-admin@qmul.ac.uk58TurnerStLondonE12ABTel:02078822553

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P 4 NHS HEALTH CHECK SUMMARY GUIDELINE

1. Introduction

TheNHSHealthCheckprogrammeisamandatorypublichealthservicewhichisoverseenbytheLocalAuthority.Itisanationalvascularriskassessmentandmanagementprogrammeforpeopleaged40-74years,toreducecardiovasculardisease(CVD).Itdoesnotincludepeoplewithpre-existingCVD,diabetesorthosealreadyonstatins.

TheaimoftheNHSHealthCheckistoimprovehealthoutcomesandthequalityoflifeamongstlocalresidents.ItidentifiespeopleatanearlystageofvascularchangeandprovidesopportunitiestohelpthemreducetheirfutureriskofCVDandprematuremortality.

TheNHSHealthCheckisafacetofaceconsultationwhichisofferedevery5yearstothosewhoareeligible.Inadditiontoreferralformedicalmanagementofidentifiedrisksandco-morbidities,theNHSCheckincludesadviceonlifestyle,referraltolocallifestyleinterventionsandinpeopleover65years,informationtopromotedementiaawareness.

ThislocalguidanceshouldbeconsideredtogetherwiththenationalguidanceonNHSHealthCheckswhichisavailableathttp://www.nhshealthcheck.nhs.uk/Servicespecificationsmaydifferbetweenlocalitiesandthisguidancemayneedtobeadaptedtolocalpolicies.

BACKGROUND

ThisguidanceusesprimarycareasthemainsettingtodelivertheNHSHealthCheckprogramme.Otherapproaches-socialmarketing,pharmacies,occupationalorcommunityinitiatives-maybecomplementary.

It is recommended to prioritise people aged 40–74 years who are at highest CVD risk (20% or more CVD risk). However,this doesnotprecludeopportunisticassessmentanditisexpectedthatoverthe5yearlycyclealleligiblepeopleatallrisks,willbeinvitedtoparticipate.

NICEguidance2014recommendsriskassessmentusingQRisk2.Thiscanbeusedforages30-84yearsbutisrelevanttothe40-74yearagegroupfortheNHSHealthCheck.

NICEalsorecommendsstatintreatmentinpeoplewith10yearCVDriskof10%ormoreasstatinsreduceCVDeventsatthislevelofrisk.(Infactthereisgoodevidenceofbenefitevenlowerat5-7.5%10yearCVDrisk(AmericanACC/AHAGuidance2013).

About8%ofthepopulationisat20%ormoreCVDriskand30%ofthepopulationisat10%ormoreCVDrisk.It is doubtful that given current resources, primary care can systematically deal with everyone at 10% or more risk and a more feasible strategy is to maintain the current treatment priority at 20% but include those at 10% or more risk who have obvious major additional risks including

• extreme obesity BMI 40 or more

• positive FH of MI in 1st degree relatives under 60 yrs

• pre-diabetes

Decisionstorecommendstatinsinthisgroupatintermediateriskshouldbemadeonanindividualbasis.Patientswhodowishtotakestatinsata10%thresholdshouldbesupportedtodoso.SomeCCGsareactivelysupportingannualreviewforthisgroupofpatientswhohavea10-19%CVDrisk.

Treatment at high CVD risk

CVDrisk20%ormore:lifestyleadviceandrecommendatorvastatin20mg(andanti-hypertensiveswhereappropriate).

CVDrisk10%ormore:BMI>40,positiveFHorpre-diabetes:treatasabove

CVDrisk10%ormorewithoutothermajorriskfactors:supportpatientpreferenceforabovetreatment

Atorvastatin20mgisrecommendedfornewpatientsathighCVDrisk.Peoplealreadyonsimvastatin40mgcanremainonthisifpreferred.

See CEG guidance on statins on website (end of document).


Co-morbidity

Obesity,raisedbloodpressure,renaldisease,diabetes,pre-diabetesandfamilialhypercholesterolaemiawillalsobeidentifiedbyvascularassessmentrequiringappropriatemanagement.GuidanceforthetreatmentoftheseconditionsisavailablefromNICE(Seebibliographyattheendofthisdocument).

AlcoholisanimportantriskfactorforcardiovasculardiseaseandiscoveredintheAlcoholLocalServicecontracts.

Casefindingforatrialfibrillationusingpulseregularitychecksinpeople65yearsandoverisbeingincludedinlocalCCGs.

Older ages - 75 years or more

AlthoughoutsidetheagerangefortheNHSHealthCheck,almosteveryoneaged75yearsisathighrisk,wihaCVDriskof20%ormore.Thosepeoplenotalreadyonstatinsshouldberecommendedtostartthem.

NICErecommendsconsiderationofstatintreatmentinolderpeople.Allpeopleage75yearsormoreshouldbeconsideredfortreatmentwithatorvastatin20mg(exceptthosewithcontraindications).Treatingtheseolderpeoplewouldhaveconsiderablymoreimpactthatextendingtheagerangetoyoungerpeopleunder40years.Recommendingtreatmentwithstatinsensuresthatolderpeoplealsohaveaccesstothiseffectivemedicaltreatmentandavoidsdiscrimination.

Dementia

Dementiaawarenessisincludedforpeopleaged65yearsorover.Thisshouldincludesignpostingtothememoryclinicifappropriate.

NHS Health Check eligible population

PeoplewiththefollowingconditionsareexcludedfromtheNHSHealthCheckprogrammebecausetheyarealreadymanagedaspartofrecognisedtreatmentprogrammes.

PeoplewithIHD,CKD,TIA/stroke,PAD,familialhypercholesterolaemia,diabetes,heartfailure,atrialfibrillation,hypertension.

Peoplealreadyonstatins,

Peopleat20%ormoreonthehighCVDriskregister.

PeoplewhohavealreadyhadanNHSCheckwithin5years.

QRisk assessment

TheQRISK2assessmentisrecommendedbecause:

Itisanaccurateandequitablemethodtoidentifypeoplewhowillbenefitfromtreatment.

Wherevaluesaremissing,QRISK2usesestimatednumericalvaluesbasedonage-specificpopulationaveragesforcholesterol,weightandbloodpressure,

Peopleestimatedtobeat≥20%riskorpeoplewhohavenodataatall,shouldbeprioritisedforanNHSCheck.

Alleligiblepeopleshouldbeinvitedduringthe5yearcycle.

QRISK website: http://www.qrisk.org/

NHS Health Check training

TheNHShealthCheckisusuallycarriedoutbytrainedHealthCareAssistantsorhealthprofessionalsbasedingeneralpracticebutmaybecarriedoutbytrainedstaffinothersettings.


Invitations: high risk priority

Prioritisingriskisamoreefficientwayofgettingthemosthighriskpeopleassessed.

Theeasiestwaytodothisistoinviteoldestpeoplefirstandthenworkdownthelisttoyoungerages.AlternativelythehighestriskpatientscanbecalledfirstusingQRisk,againworkingdownthelisttolowest.Todothis........

• UsetheEMISbatchprocessortoestimateCVDQRiskineveryoneage40-74years.

• Rankpeopleandinvitehighestriskfirstie.≥20%risk

• Runbatchprocessorannuallytokeepituptodate.

Other priority groups may include

• PatientswithQDiabetesscore>20%.

• PatientswithaSeriousMentalIllness(SMI)orLearningDisability

• Peoplewithoutrecordsofbloodpresure

Recording Invitations

Usearangeofmethodstocontactindividuals(phone/letter/email/opportunistic)

The invitation MUST be recorded on the NHS Health Check template.

PublicHealthEnglandusesrecordofinvitationforitsuptakefiguresonwhichtheLocalAuthorityisassessed.

NHS Health Check

Explanation:

• ReasonsfortheNHSHealthCheckassessment,itsbenefitsandconsequences

• Causesofandopportunitiestopreventheartattacks,strokesanddiabetes

OpportunitiesforHealthyLifestylesupport

• WillusuallytaketwovisitsinpeoplewithCVDriskgreaterthan10%,becausetheyrequireabloodtest.

Blood tests

• FASTINGbloodsampleareNOTgenerallyrequired.

NICEGuidance2014statesthatafastingsampleisNOTrequiredforcholesterol,HDLcholesterolandHbA1cdoesnotrequirefasting.

• FullliverfunctiontestsLFTsareNOTrequired

AsingleALTtestisallthatisnecessaryifassessingbeforestatintreatmentandnotagainunlessclinicallyindicated.

Inpatientsknowntohaveliverdiseaseorwhoareknowntobeathighrisk(eg.alcoholexcess,HepatitisBorC),fullLFTsarenecessary.InthesepeopleNICEadvisestestingbeforestartingstatins,within6monthsandat12monthsandnotagainunlessclinicallyindicated.

• Peopleunder10%CVDriskwithnootherriskfactorsdonotneedabloodtestandasinglevisitwillusuallysuffice

Assessing CVD and diabetes risk

Assessment• Age,Gender,Ethnicity

• Smokingstatus

• Familyhistoryofischaemicheartdiseaseinafirstdegreerelative(mother/father/brotherorsister)under60years.Thisshouldberecordedifeither negative or positive

• BodyMassIndex

• BloodpressuremeasurementIf≥140/90mmHgrepeat3timesanduselastvalue

• Alcoholscreening(AUDIT-C)

• Physicalactivityassessment:inactive,moderatelyinactive,moderatelyactiveoractive(GPPAQ)

• Age≥65years.Pulsecheck-regularorirregular

• Age≥65years.Informaboutdementia

• Cancerscreeningadvice(breast,bowelandcervical)

• RandomtotalcholesterolandHDLcholesterolbloodtest(onlyusefulinpeopleover10%CVDrisk,positiveFHorhyperglycaemicstates.Inpeopleunder5%CVDriskcholesteroltestingconfersnoadvantageasitdoesnotinfluencemanagement). Note that PHE advises testing in everyone.

Otherbloodtestswilldependonrisksfound-seepage8.


Follow-up of CVD risk

• ThosewhoarebelowQRisk10%shouldbeinformedthattheirnextNHSHealthCheckwillbeduein5yearstime.

• ThosewithCVDrisk20%ormoreorthosewithabnormalriskfactorsorco-morbiditiesshouldmakeanappointmenttoseeaGPorPNforfurthermanagement.

• Practicesshouldmakearrangementstoannuallyreviewpeopleat10%-19%CVDriskinLocalAuthoritieswhichsupportthisreview.

Lifestyle advice

ThepracticewillprovidehealthylifestyleadvicetoALLpatientsafteranNHSHealthCheckonhowtomaintain/improvetheirvascularhealthanddirectpatientstolocalserviceswhichsupportthis.

Thepracticewillprovideatailoredpackageofinterventionsandreferralwhereapproriateforpatientswithidentifiedriskfactorsincludingarrangmentsforannualfollow-up.

• CVDriskscore≥20%(codeashighCVDriskontemplate)

• highriskofdiabetes

The practice should record on the template if the offer of a statin is declined or contraindicated.

• smoker• physicalinactivity• BMI≥30or27.5inSouthAsians.• AlcoholAuditCscore≥8

adviceandreferralontotheappropriatelocalserviceorcarepathway

LocalAuthorityservicesforhealthyeating,weightmanagementandphysicalactivityinclude

• Smokingcessationservice• Alcoholsupportservices• Localadviceservices–(LAwebsite)• Pre-diabetesservices

Communication of risk

StaffdeliveringtheNHSHealthCheckshouldbetrainedincommunicating,capturingandrecordingtheriskscoreandresults,andunderstandthevariablesusedbytheriskenginetocalculatetheriskscore.

Ageisthemainfactordeterminingrisk.Menareathigherriskthanwomen.Ofthefactorswecandosomethingabout,smokingisthemostimportantanddoublesrisk.Hypertensionisthenextmostimportantriskfactor.

Inpeoplewithapositivefamilyhistoryinafirstdegreerelativeunderage60yearsthisequivalenttotheriskofsmoking.Peoplewithpositivefamilyhistoriesshouldbeinvestigatedandmanymoreshouldbetreatedwithstatins.

BeingphysicallyactiveprotectspeopleagainstCVD-evenwalkingamoderateamounthelps.

TheresultsoftheNHSHealthCheckshouldbeexplainedtoeachpatient.Thisshouldbeface-to-faceandtailoredtoeachindividualtomaximisepatientunderstanding.

Comminicating risk, staff should:

• communicateriskineveryday,jargon-freelanguagesothatindividualsunderstandtheirlevelofriskandwhatchangestheycanmaketoreducetheirrisk

• usebehaviourchangetechniques(suchasmotivationalinterviewing)todeliverappropriatelifestyleadviceandhowitcanreducetheirrisk

• createatwo-waydialoguetoexploreindividualvaluesandbeliefstofacilitateaclient-centredrisk-reductionplan

• givepeopleadequatetimetoaskquestionsandobtainfurtherinformationabouttheirriskandresults

• CommissionersandprovidersshouldconsiderdevelopmentofappropriatewritteninformationforattendeestotakeawaywiththemfromtheNHSHealthCheck

• Thiswritteninformationshouldincludepersonalisedfeedbackexplainingthat...

• Forsmokers,stoppingsmokingisthesinglemostimportantwaytoreduceCVDrisk

• Informationontheirpersonalrisksandwhatthesemean:CVDriskscore,BMI,cholesterollevel,bloodpressure,AUDITCandanyreferralsontolifestyleorclinicalservices

• Theimportanceofchangesindietandphysicalactivityandavailablesupportservices


Abnormal risk factors

Peoplefoundtohavetheabnormalriskfactorslistedbelowwillusuallyrequiretwovisits.ThisisbecauseserumtotalandHDLcholesterolresultswilloftennotbeavailableuntilthesecondvisitandalsobecausethetimeavailableinasinglevisitisnotalwayssufficienttoallowafullexplanationofidentifiedriskfactorsandnecessaryadvice,actionsandreferrals.

Additional blood tests include

Ifbloodpressure≥140/90mmHg(3readings)orifCVDrisk≥20%,

Bloods required:HbA1c,ALT, eGFR and referral to GP.

IfQDscore≥20%orifObesityBMI≥30(27.5SouthAsian)HbA1c

IfPositiveFHprematureIHDFasting lipid profile

Smoking Stopsmokingadviceandreferraltolocalstopsmokingservice.

Obesity BMI ≥30; 27.5 South Asians

Adviseondietandphysicalactivity.Offerreferraltosupportservices.Seelastpageofguidelineforbasicdietaryadvice.

CVD Risk 20% or more

Addpatienttothehighriskregisterforannualfollowupandexitfromtheprogramme.

Offeratorvastatin20mg(recordifofferdeclined)andlifestyleadvice.

CVD Risk 10-19%RecommendtreatmentasaboveifBMI>40,positiveFH,orpre-diabetes.Ifnomajorriskfactorssupporttreatmentbypatientchoice.Annualfollow-upifsupportedbyCCG.

Hypertension assessment CheckbloodpressureaccordingtoNICEguidanceandlocalpathways.

Chronic Kidney Disease (CKD)

WhereeGFRisbelow60ml/min/1.73m2,managementandassessmentforchronickidneydiseaseisrequiredinlinewiththeNICEguidelineandlocalpathways.

Alcohol risk assessmentAfullAUDITassessmentisindicatedbyanAUDITCscore≥5

IftheindividualmeetsorexceedstheAUDITthresholdof8briefadviceshouldbegiven.Referraltolocalalcoholservicesshouldbeconsideredforindividualsscoring20ormore.(seeNICEpublichealthguideline2010forfurtherdetails)

Familial hypercholesterolemia

PatientswhohaveBOTHatotalcholesterol>7.5mmol/LANDapositiveFHofIHDinafirstdegreerelativeunderage60years,shouldbeassessedforfamilialhypercholesterolemiawithfullfastinglipidprofile,HbA1candthyroidfunctiontest.Ifthesetestsarenotinformative,orinthosewithacholesterolof>9mmol/Lconsiderspecialistreferral.

Type 2 diabetes risk assessment

TheNHSCheckwillalsoestimatetheriskofdevelopingdiabetes(QDiabetes).

CheckHbA1ctodetectpre-diabetesordiabetesforpatientswiththefollowingcriteria:

• QDiabetes20%ormoreorQRisk20%ormore

• BMI≥30(or≥27.5totriggeractioninIndian,Pakistani,Bangladeshi,otherAsianorChinese).

• Abloodpressuresustainedabove140mmHgsystolicor90diastolicmmHg.

ThesepatientsshouldreceiveanHbA1ctestwhichcanbeusedforcasefindingofdiabetesorpre-diabetes.InafewpeopleitmaybenecessarytouseFastingGlucose.

ThereisnonationalconsensusontestingandproceduresdifferinCCGsforpeoplefoundtohaveabnormalHbA1c.SomeCCGsconfirmwithfurtherfastingbloodglucosetests.

See CEG Website: Diagnosing Diabetes CEG 2013:http://www.blizard.qmul.ac.uk/ceg-resource-library/clinical-guidance.html


New co-morbidity

Newlydiagnosedpatientswithdiabetes,hypertension,chronickidneydiseaseorpatientsathigh-riskofaCVDeventwillbeplacedontherespectiveregister.ThesepatientswillexittheNHSCheckprogramme

FurtherreferenceshouldbemadetoNHSHealthCheckBestPracticeGuidance2015foundonthefollowingsitehttp://www.healthcheck.nhs.uk.

Alcohol Units

This is one unit of alcohol…

…andeachoftheseismorethanoneunit


Dietary advice

1. FATSReducetotalfatandsaturatedinthediet-removevisiblewhitefatinmeatandchickenskin.Avoidprocessedmeatssuchassausage,kebabs,mincemeatsandburgerswhichareVERYhighinfats.Avoidtakeawayfastfoodslikefriedchicken,curry,chips,chineseandkebabmealsthatareveryhighinfat.

Useskimmedmilkandlowfatnaturalyoghurt.

Avoidcheese,butterorgheewhicharesolidfat.

Usesunflower,rapeseed,cornoroliveoilspreadsinsteadwhichcontainpolyunsaturatedormonounsaturatedfats.Note:thesespreadsandoilsareashighincaloriesassaturatedfats,butnotsobadfortheheart-soforpeoplewishingtoloseweight,onehastoreduceallfatintakeincludingthese.

Avoid‘vegetableoil’whichdoesn’tsaywhatitis-itoftencontainscoconutoilorpalmoilthataresaturatedfats,notgoodfortheheart.

2. SUGARSAvoidsweetdrinksincludingfruitjuiceevenif‘freshlysqueezed’.Alargeglassoffreshsqueezedorangejuicecontainsalmostasmanycalories,(106kcal)ashalfabarofchocolate(115kcal).Aregularcanofcokeorlemonadeis(140kcal).ChocolatebarslikeMarsbars,CadburysorKitKatsaretypicallyabout(240kcal).

Drinkwaterorlowcaloriedrinks.

Fruitjuiceorsweetdrinksofanykindarea‘treat’likesweets.Sweetdrinksandfruitjuicearenotanessentialpartofamealandarenotgoodforchildrenasitalsorotstheirteethifdrunkregularlyandcausesobesity.Smoothiesarealsooftenhighinsugarandcalories.

Foodswithaddedsugarsincludingsweetenedbreakfastcerealsorgranolatypemixesoftenhavealmostasmanycaloriesassweets.Biscuitsandcakesarealsoveryhighinbothfatandsugar.

3. ALCOHOL Excessalcoholisharmfultotheliverandtotheheart.Itisamajorsourceofcaloriesandacauseofobesity.Thereareasmanycaloriesinalargeglassofwine(230kcal)asinachocolatebarandapintofbeeris(180kcal)whichis3/4ofachocolatebar.

4. BETTER FOODS• Eatmoregreenvegetablesandsalads

• Eatfreshfruit-atleast2portionsaday.• Eatmorepulseslikelentils,dhalandbeans• Eatmorefishespeciallyoilyfishlikeherring,mackerel,sardinesandsalmon.

Physical activity

Physicalactivityisveryimportanttoprotectagainstheartdiseaseandstroke.Itisaveryunderratedfactorbutevensmallchangesinphysicalactivityhaveabigeffectonreducingtherisk.Walkingatleasthalfanhouradayisaminimum.Themoreactivityyoudothebetteritisforyourarteries,heartandbrain.Walkingpartofthewaytowork,totheshops,upthestairsordoingmorevigorousactivityateveryopportunityisbeneficialtoyourheart.


20% 1 in 5

10%1 in 10

5% 1 in 20

References• LipidmodificationandCVDrisk http://www.nice.org.uk/guidance/cg181

• Type2diabetes https://www.nice.org.uk/guidance/ng28

• Obesity http://www.nice.org.uk/guidance/cg189

• Hypercholesterolaemia https://www.nice.org.uk/guidance/cg71

• Hypertension http://www.nice.org.uk/guidance/cg127

• CKDguidance http://www.nice.org.uk/guidance/cg182

• Bloodpressuremeasurement http://www.nice.org.uk/guidance/cg127

• DiagnosingDiabetesCEG. http://www.blizard.qmul.ac.uk/ceg-home.html

• StatinguidanceCEGhttp://www.blizard.qmul.ac.uk/ceg-resource-library/clinical-guidance.html

• NHSHealthChecksPHEhttp://www.nhshealthcheck.nhs.uk/

Explaining QRisk and QDiabetes risk.

A high risk is a 20% risk: a 1 in 5 chance of having the condition in 10 years.

A moderately high risk is a 10% risk: a 1 in 10 chance of having the condition in 10 years

A lower risk is less than 5%: less than 1 in 20 chance of having the condition in 10 years.

Risk of death from a motor vehicle accident is 1 in 3000 and for a cyclist 1 in 40,000 in 10 years

Centre for Primary Care and Public HealthBarts and The London School of Medicine and DentistryYvonne Carter Building58 Turner StreetLondon E1 2ABTel: 020 7882 2553 Fax: 020 7882 2522email: [email protected]: http://www.blizard.qmul.ac.uk/ceg-home.html

Documents

NHS Health Check - Queen Mary University of London-March-2016.pdfP 4 NHS HEALTH CHECK SUMMARY GUIDELINE 1. Introduction TheNHS Health Check programme is a mandatory public health service