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Vascular screening plans in chaos as DH looks to QRISK

By Nigel Praities

The national rollout of vascular screening has been plunged into confusion after the Department of Health initiated moves for an eleventh-hour change in risk score.

Ministers have instructed NICE to look again at the evidence on cardiovascular risk scoring after an internal report favoured use of the UK-based QRISK rather than the Framingham charts.

The institute has been told to consider data from a DH-funded validation of QRISK by the University of Oxford, which sources say provides a ‘very favourable review' compared with Framingham.

The referral piles enormous pressure on NICE to recommend Framingham be replaced with QRISK – a return to the draft recommendation it controversially reversed last year, citing a lack of evidence.

Supporters of QRISK warmly welcomed the move, but the switch also risks causing huge disruption to the national rollout of screening, due to begin in April and be completed by 2011.

Many local schemes are already up and running or in late stages of development, and all use Framingham.

Oxfordshire PCT began a LES for 12 pilot practices in deprived areas this month, using a Framingham-based web tool to identify and prioritise patients requiring screening.

Dr Christine A'Court, a GP in Carterton, Oxfordshire, and CHD lead at Oxfordshire PCT, told Pulse: ‘To switch you would have to check the ones you have seen already, see the additional ones, and agonise over those that didn't appear on the QRISK list but did on Framingham.

‘This would be worrying and confusing for patients and GPs.'

Dr Rajai Ahmad, consultant cardiologist and part of the project team for a spearhead screening programme in Sandwell, West Midlands, said using QRISK would require a complete overhaul.

‘For us it would be very difficult. There are some things such as ethnicity and deprivation scores that are not collected routinely in general practice and we would not be able to generate our prioritisation lists,' he said.

But Professor Mike Kirby, professor of health and human sciences at the University of Hertfordshire and a GP in Radlett, said Government heart tsar Professor Roger Boyle was strongly backing a switch to QRISK: ‘He is very keen on QRISK. But we need to have a clear message for the whole country so that we all go the same way.'

Dr Matt Kearney, a GP in Runcorn, Cheshire, and a public health practitioner at Knowsley PCT, said QRISK had many advantages and that his trust was already geared up to switch to it through its screening LES.

‘As soon as software is made available we would welcome switching to QRISK,' he said.

How the risk scores compare

FRAMINGHAM
Based on… a cohort study of affluent white patients in Boston, US
Advantages… familiar to GPs and its flaws are well-known and can be adjusted for
Disadvantages… underestimates risk in people with diabetes, South Asian men and the most socially deprived, so could worsen health inequalities
Supporters… NICE (so far) and Joint British Societies guidelines

QRISK
Based on… patient records from the UK primary care database, QRESEARCH
Advantages… can be remodelled over time and incorporates measures of socioeconomic deprivation and ethnicity
Disadvantages… is not currently available on GP systems and practices may not have all the information required to use it
Supporters… Department of Health and several top epidemiologists

Ministers tell NICE to think again on risk scoring after DH report favours QRISK over Framingham (pictured) Ministers tell NICE to think again on risk scoring after DH report favours QRISK over Framingham (pictured)

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