The impact of provision of a cardiovascular disease risk estimate to practitioners or patients: a systematic review and meta-analysis

The problem

Cardiovascular disease (CVD) is the single largest cause of death worldwide. To focus preventive strategies on those at high risk, CVD risk scores have been incorporated into clinical guidelines and risk management programmes such as Health Checks. Despite this strong advocacy relatively little is known about the benefits and harms of provision of a CVD risk score itself to patients, and whether their use by physicians translates into improved behavioural and clinical outcomes. We aimed to systematically review the impact of providing CVD risk estimates to either practitioners or patients and to address whether provision of the risk score itself, as opposed to provision of a risk score alongside other simultaneous or subsequent interventions, impacts on patient or practitioner behaviour or patients' health.

The approach

As part of a larger systematic review on CVD risk scores, we searched Medline, PubMed, EMBASE, CINAHL, Psychlit and Zetoc from 01/01/2004 to 01/06/2013, and the reference lists of previous systematic reviews on similar topics to identify primary research studies reporting implementation and impact of use of CVD risk scores. Included papers were: (1) primary research published in peer reviewed journals; (2) included participants without a history of CVD; (3) provided a CVD risk score to either physicians or patients; and (4) had the only difference between the intervention and control group (or the only intervention in the case of before-after studies) as the provision of a CVD risk score. Screening of studies for inclusion and data extraction together with quality assessment were completed independently by at least two researchers.

Findings

After duplicates were removed, the initial electronic search identified 9671 papers. After title screening, we screened the abstracts of 196 papers and included 17 studies. Together they showed that provision of risk information to patients improves accuracy of risk perception without decreasing quality of life or increasing anxiety but has little effect on lifestyle. Providing risk information to physicians increases prescribing of lipid lowering and blood pressure medication, with greatest effects in those with CVD risk >20% (RR for change in prescribing 2.13 (1.02-4.63) and 2.38 (1.11-5.10) respectively). Overall there is a trend towards reductions in cholesterol and blood pressure and a statistically significant reduction in modelled CVD risk (-0.39% (-0.71 to -0.07)).

Consequences

In spite of the widespread use of CVD risk scores, few studies have addressed their impact. The small number of heterogeneous studies does, however, suggest that risk information improves perceived risk and prescribing, and there appears to be little evidence that it leads to false reassurance (increased frequency of unhealthy behaviours) or harm (adverse effects on psychological well-being).

Credits

• Juliet Usher-Smith, University Medical Center Utrecht, Utrecht, The Netherlands
• Barbora Silarova, University Medical Center Utrecht, Utrecht, The Netherlands
• Ewoud Schuit
• Simon Griffin, University Medical Center Utrecht, Utrecht, The Netherlands