Embedding CVD risk screening in routine care

5 minute read

Improve CVD risk screening for your eligible patients through this quality improvement activity.

Improve CVD risk screening for your eligible patients through one of the largest quality improvement activities in Australian general practice.

Coronary heart disease remains the leading cause of death in Australia.1

The Australian Guidelines for the Management of Absolute Cardiovascular Disease Risk recommend regular cardiovascular disease (CVD) risk factor screening for adults aged 45 to 74 years (30 years for Aboriginal and/or Torres Strait Islander Peoples) without a history of CVD.2 Yet, adherence to CVD prevention guidelines in Australia remains suboptimal,3 creating an urgent need to explore how we can routinely embed CVD risk screening in primary care.

Learning from international experiences

Over the last 2 decades, the introduction of more accurate mechanisms for assessing CVD risk has shifted our focus to targeted screening and treatment of high-risk groups.

Dedicated cardiovascular and diabetes screening programs, such as those launched in New Zealand and UK have provided useful lessons for the Australian context. New Zealand’s national CVD and diabetes screening program reached 90% of eligible patients with a risk assessment thanks to good clinical leadership, primary care sector buy-in and financial incentives.4    

The NHS Health Check program in the UK is another example of large scale, systematic implementation of chronic disease screening which was enabled by clinical decision support and integration of risk screening tools across electronic primary care records.5

Taking steps to embed regular CVD risk screening in Australia

Although Australia currently does not have a national CVD risk screening program, we are making great progress towards embedding regular CVD screening activities into routine care. With the introduction of Medicare MBS items 699 and 177, the Heart Health Check enables and incentivises health professionals to conduct best practice CVD risk factor screening, assessment, and management for eligible Australians. Since the introduction of the MBS item numbers in April 2019, there have been over 263,000 Heart Health Check items claimed.6

In 2019, Practice Incentive Program Quality Improvement (PIP QI) Measures were introduced to support general practices in undertaking quality improvement activities as a means of improving patient outcomes.

Recently published data from the first year of the PIP QI Measures, suggest that less than 50% of eligible Australians had the four risk factors recorded to enable absolute CVD risk assessment. These risk factors include tobacco smoking status, diabetes type or HbA1c result or fasting glucose tests, blood pressure and lipid levels.7

To address this and further explore what a national CVD risk screening program might look like in Australia, the Heart Foundation piloted a national Heart Health Check Recall program in 2021. The program utilised novel SMS technologies to recall eligible Australians for a Heart Health Check via a personalised invitation from their general practice.

Over 150 practices participated in the pilot, reaching over 42,500 eligible Australians. In the evaluation survey, 100% agreed that SMS recall worked well to bring patients back in. Findings from this initial phase will be published in a peer-reviewed journal later this year.

Hear from Dr Michael Futter and the team at Providence Medical Belmont (NSW) as they share their experience taking part in the Heart Health Check Recall Pilot.

Express interest in the 2022 National Heart Health Check Recall Program

Building on the success of the pilot, the Heart Foundation is offering 200 practices the opportunity to be part of the program in 2022, which aims to increase the proportion of eligible Australians booking in for a Heart Health Check.

Known as Text to Detect, this next phase will support targeted identification and management of CVD risk via an innovative SMS recall system developed by Healthily. Text to Detect will be the largest quality improvement program of its kind in Australian primary care.

Places are limited, so get in quick!

This program is delivered in partnership with Healthily and the activity is funded by the Commonwealth Department of Health, as part of the Public Health and Chronic Disease program.


  1. Australian Bureau of Statistics. Causes of Death, Australia. 2021. Accessed 7 March 2022. https://www.abs.gov.au/statistics/health/causes-death/causes-death-australia/2020#australia-s-leading-causes-of-death-2020
  2. JW Agostino, D Wong, E Paige et al. Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement. Med J Aust 2020; 212 (9): 422-427. doi: 10.5694/mja2.50529
  3. CM Hespe, A Campain, R Webster et al. Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed. Med J Aust. 2020;213(7):327-328. doi: 10.5694/mja2.50756.
  4. Ministry of Health. More Hearts and Diabetes Checks Evaluation. 2016. Accessed 7 March 2022. https://thehub.swa.govt.nz/resources/more-heart-and-diabetes-checks-evaluation/
  5. Public Health England. NHS Heart Health Check: stocktake and action plan.  2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/675590/NHS_Health_Check_stocktake_and_action_plan.pdf [PDF]
  6. Australian Government. Services Australia. MBS data report. 2021. Accessed 7 March 2022.  http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp
  7. Australian Institute of Health and Welfare. Practice Incentives Program Quality Improvement Measures: National report on the first year of data 2020-21. 2021. Accessed 7 March 2022. https://www.aihw.gov.au/reports/primary-health-care/pipqi-measures-national-report-2020-21/contents/about

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