Is the NHS ‘Heart Age Test’ too much medicine?

Bonner, Carissa; McKinn, Shannon; McCaffrey, Kirsten; Glasziou, Paul; Irwig, Les; Doust, Jenny; Jansen, Jesse; Bell, Katy J.L.

doi:10.3399/bjgp19x706349

Cited by 6 publications

(5 citation statements)

References 14 publications

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“…Heart age calculators can work well as a marketing tool to get attention and direct consumers to appropriate clinical assessments or lifestyle change, 93 but caution is needed to ensure they are not used to nudge low-risk people toward medications and tests that they are unlikely to benefit from in the short term. 94 A registered trial (ACTRN12620000806965) will soon test the effect of adding heart age to a cardiovascular disease prevention decision aid for the first time, to investigate how it affects decision making.…”

Section: Time-based Risk Formatsmentioning

confidence: 99%

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

et al. 2021

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Background Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids. Methods Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team. Results Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy. Discussion Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental “nudging” toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

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Section: Time-based Risk Formatsmentioning

confidence: 99%

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

et al. 2021

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“…It is intended not primarily as a guide to decisions about drug initiation, but rather as a way of allowing an individual to understand the lifetime risk'. Heart age was not designed to guide clinical decisions, 42,82 but our data support its use in health check as a means of promoting patient understanding of CVD risk and a useful prompt for patients to consider lifestyle changes. 42,81 Event-free survival age Practitioners' description of the average age to which patients could be expected to survive free from a CVD event was often unclear and sometimes incorrect, which illustrated a lack of understanding of event-free survival.…”

Section: Heart Agementioning

confidence: 81%

Cardiovascular disease risk communication in NHS Health Checks using QRISK®2 and JBS3 risk calculators: the RICO qualitative and quantitative study

Gidlow

Ellis

Cowap

et al. 2021

Health Technol Assess

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Background The NHS Health Check is a national cardiovascular disease prevention programme. There is a lack of evidence on how health checks are conducted, how cardiovascular disease risk is communicated to foster risk-reducing intentions or behaviour, and the impact on communication of using different cardiovascular disease risk calculators. Objectives RIsk COmmunication in Health Check (RICO) study aimed to explore practitioner and patient understanding of cardiovascular disease risk, the associated advice or treatment offered by the practitioner, and the response of the patients in health checks supported by either the QRISK®2 or the JBS3 lifetime risk calculator. Design This was a qualitative study with quantitative process evaluation. Setting Twelve general practices in the West Midlands of England, stratified on deprivation of the local area (bottom 50% vs. top 50%), and with matched pairs randomly allocated to use QRISK2 or JBS3 during health checks. Participants A total of 173 patients eligible for NHS Health Check and 15 practitioners. Interventions The health check was delivered using either the QRISK2 10-year risk calculator (usual practice) or the JBS3 lifetime risk calculator, with heart age, event-free survival age and risk score manipulation (intervention). Results Video-recorded health checks were analysed quantitatively (n = 173; JBS3, n = 100; QRISK2, n = 73) and qualitatively (n = 128; n = 64 per group), and video-stimulated recall interviews were undertaken with 40 patients and 15 practitioners, with 10 in-depth case studies. The duration of the health check varied (6.8–38 minutes), but most health checks were short (60% lasting < 20 minutes), with little cardiovascular disease risk discussion (average < 2 minutes). The use of JBS3 was associated with more cardiovascular disease risk discussion and fewer practitioner-dominated consultations than the use of QRISK2. Heart age and visual representations of risk, as used in JBS3, appeared to be better understood by patients than 10-year risk (QRISK2) and, as a result, the use of JBS3 was more likely to lead to discussion of risk factors and their management. Event-free survival age was not well understood by practitioners or patients. However, a lack of effective cardiovascular disease risk discussion in both groups increased the likelihood of a maladaptive coping response (i.e. no risk-reducing behaviour change). In both groups, practitioners often missed opportunities to check patient understanding and to tailor information on cardiovascular disease risk and its management during health checks, confirming apparent practitioner verbal dominance. Limitations The main limitations were under-recruitment in some general practices and the resulting imbalance between groups. Conclusions Communication of cardiovascular disease risk during health checks was brief, particularly when using QRISK2. Patient understanding of and responses to cardiovascular disease risk information were limited. Practitioners need to better engage patients in discussion of and action-planning for their cardiovascular disease risk to reduce misunderstandings. The use of heart age, visual representation of risk and risk score manipulation was generally seen to be a useful way of doing this. Future work could focus on more fundamental issues of practitioner training and time allocation within health check consultations. Trial registration Current Controlled Trials ISRCTN10443908. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 50. See the NIHR Journals Library website for further project information.

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“…Participants questioned the accuracy of the HAT, largely owing to the small amount of information required from which heart age was estimated and the implications of not knowing their blood pressure or cholesterol level to inform this estimate. Concerns that heart age can overestimate CVD risk are well reported [19,27,31,33,34] and have led to calls for caution in its application [17,34]. Nevertheless, most participants stated that they would recommend or already had recommended the HAT to others, would engage with the test again in the future, and would be more likely to take up the offer of an NHS Health Check and self-reported that they had made or intended to make changes to their health behavior (ie, lose weight, be more active, and eat more healthily) or were encouraged and motivated by the test to maintain the changes made to their health behavior.…”

Section: Principal Findings and Comparison With Previous Studiesmentioning

confidence: 99%

“…Despite their popularity, it has been noted that web-based CVD risk calculators (ie, including heart age calculators) produce variable risk estimates, often fail to disclose the models upon which they were based, can result in limited understanding and concern regarding CVD risk, and lead to poor behavioral intentions [13,32]. There is also the risk that heart age calculated based on incomplete data owing to poor user awareness of physiological risk information is also poor [24,27] and can lead to underestimation or overestimation of CVD risk [19,27], doubts about the credibility of the risk calculator [13,33], and unnecessary primary care visits and clinical testing [31,34]. Evaluation of Australia's heart age calculator suggested that it provoked a positive emotional response and led to self-reported health behavior change (ie, improvement in diet, physical activity, and weight loss) and clinical checks for more than half of the survey respondents [31].…”

Section: Introductionmentioning

confidence: 99%

The Impact and Perception of England’s Web-Based Heart Age Test of Cardiovascular Disease Risk: Mixed Methods Study

Riley¹,

Gidlow²,

Fedorowicz³

et al. 2023

JMIR Cardio

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Background It is well documented that individuals struggle to understand cardiovascular disease (CVD) percentage risk scores, which led to the development of heart age as a means of communicating risk. Developed for clinical use, its application in raising public awareness of heart health as part of a self-directed digital test has not been considered previously. Objective This study aimed to understand who accesses England’s heart age test (HAT) and its effect on user perception, knowledge, and understanding of CVD risk; future behavior intentions; and potential engagement with primary care services. Methods There were 3 sources of data: routinely gathered data on all individuals accessing the HAT (February 2015 to June 2020); web-based survey, distributed between January 2021 and March 2021; and interviews with a subsample of survey respondents (February 2021 to March 2021). Data were used to describe the test user population and explore knowledge and understanding of CVD risk, confidence in interpreting and controlling CVD risk, and effect on future behavior intentions and potential engagement with primary care. Interviews were analyzed using reflexive thematic analysis. Results Between February 2015 and June 2020, the HAT was completed approximately 5 million times, with more completions by men (2,682,544/4,898,532, 54.76%), those aged between 50 to 59 years (1,334,195/4,898,532, 27.24%), those from White ethnic background (3,972,293/4,898,532, 81.09%), and those living in the least deprived 20% of areas (707,747/4,898,532, 14.45%). The study concluded with 819 survey responses and 33 semistructured interviews. Participants stated that they understood the meaning of high estimated heart age and self-reported at least some improvement in the understanding and confidence in understanding and controlling CVD risk. Negative emotional responses were provoked among users when estimated heart age did not equate to their previous risk perceptions. The limited information needed to complete it or the production of a result when physiological risk factor information was missing (ie, blood pressure and cholesterol level) led some users to question the credibility of the test. However, most participants who were interviewed mentioned that they would recommend or had already recommended the test to others, would use it again in the future, and would be more likely to take up the offer of a National Health Service Health Check and self-reported that they had made or intended to make changes to their health behavior or felt encouraged to continue to make changes to their health behavior. Conclusions England’s web-based HAT has engaged large number of people in their heart health. Improvements to England’s HAT, noted in this paper, may enhance user satisfaction and prevent confusion. Future studies to understand the long-term benefit of the test on behavioral outcomes are warranted.

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Is the NHS ‘Heart Age Test’ too much medicine?

Cited by 6 publications

References 14 publications

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

Cardiovascular disease risk communication in NHS Health Checks using QRISK®2 and JBS3 risk calculators: the RICO qualitative and quantitative study

The Impact and Perception of England’s Web-Based Heart Age Test of Cardiovascular Disease Risk: Mixed Methods Study

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