Turning data into action: early insights from the CVDACTION demonstrator programme

Cardiovascular disease is a leading cause of mortality in the UK and a major driver of health inequalities. But it is highly preventable – both through changes to lifestyle and by treatment of the high-risk conditions that can lead to heart attacks and strokes. 

At UCLPartners we’ve been working on actionable data to support primary care teams to both identify and prioritise patients that need support – and then put in place care and support for those individuals.  

Last year, we launched CVDACTION - a smart data tool that identifies exactly which patients have one or more of the six high risk conditions for cardiovascular disease: 

• atrial fibrillation 
• blood pressure 
• cholesterol 
• chronic kidney disease 
• prediabetes 
• diabetes.

CVDACTION also offers a case finder for patients who’ve not yet had a diagnosis of these conditions but may be at risk of them. CVDACTION enables further prioiritisation by enabling stratification by age, ethnicity, deprivation, learning difficulties and serious mental illness. The idea being that the dashboard enables action by offering manageable ‘chunks’ of work. Working in this way promotes a holistic care approach by incorporating multiple risk factors in individual patients, as well as offering the ability to target health inequalities. 

We are trialling CVDACTION in ten PCNs within London and five PCNs outside of London (in Mid and South Essex and West Yorkshire) across a population of around 800,000 people. Our UCLPartners team is actively supporting each of the trial sites and it has been an incredible privilege to work closely with PCNs, ICSs and GP Federation colleagues who are passionate about transforming outcomes for people with CVD. 

We’ll be sharing a formal evaluation around April time, but we wanted to give you a flavour of what we have learnt so far. 

• There is enthusiasm for Patient and Public engagement – we are working with underserved communities to ensure that the pathways put in place don’t widen health inequalities. South London colleagues are actively working to understand why people may be disengaged by healthcare services and why there may be a reluctance to take medicines when needed. 
• The wider workforce has led on implementation in several sites with clinical pharmacists particularly leading the work in calling and re-calling patients. Care coordinators and Health and Wellbeing coaches are also involved in the delivery of care – through patient contact and offering support for behaviour change and self-management.
• The enthusiasm shown for this work from the clinical and operational leads both inspire others and, despite hectic schedules and the daily pressures in primary care, they willingly share their approach with others. 
• Hearing directly from peers is a key part of innovation adoption ranging from clinical staffing solutions to approaches to the technical integration of the CVDACTION dashboard. 
• CVDACTION is being used to bolster existing initiatives tackling CVD prevention – whether this is alignment with tech to support diabetes monitoring or use of existing clinics.