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Enhancing Heart Health in Primary Care

Cardiovascular disease (CVD), including heart disease, stroke, and vascular disease, remains the second leading cause of death in Australia, accounting for one in four deaths.1 While CVD is a major health burden, it is largely preventable—modifiable risk factors contribute to 90% of heart attack risk.2 Despite this, over half of Australian adults live with three or more modifiable CVD risk factors.1

In July 2023, updated guidelines introduced a new CVD risk equation tailored to the Australian population, aimed at improving early identification and treatment. Additionally, the Heart Health Check provides a structured approach to assessing CVD risk, with modelling suggesting that 76,500 CVD-related events, including heart attacks, strokes, and deaths, could be prevented over five years with its widespread uptake.3

This QI Toolkit supports primary care providers in enhancing the identification and recording of key CVD risk factors—such as blood pressure, cholesterol, smoking status, and family history—within routine practice. By systematically integrating risk assessment and leveraging tools like the Heart Health Check, general practice can drive better patient outcomes, prevent avoidable CVD events, and ultimately reduce the burden of CVD across Australia.

This QI Toolkit relates to QIM #8, the proportion of eligible regular clients with a record of the necessary risk factors in their GP record for CVD risk assessment.

As of July 2024, the CCQ region reported 61.1% of regular clients aged 45 to 74 years without a CVD diagnosis had the necessary risk factors recorded in their GP record to enable CVD risk assessment, lower than the 62.3% across Queensland but higher than the 58.8% nationally. 

Click image to enlarge.
Source: AIHW (accessed April 2025)

Increase identification of CVD risk and management for people at risk of cardiovascular disease.

To achieve this goal, you can access a range of resources:

  1. HealthPathways: Explore locally tailored approaches for cardiovascular disease. Simply enter “Cardiovascular Risk Assessment” in the search bar to get started.
  2. Review current best practice. CVD Check provides the Australian guideline and calculator for assessing and managing cardiovascular disease risk.
  3. The Heart Foundation is the peak body for heart health and provides a range of useful resources including information on the MBS Heart Health Check.
  4. My Health for Life is a free, evidence-based behaviour change program for people at risk of chronic disease including people with an Absolute CVD score of 15% or greater.

Kickstart your quality improvement activity by bringing together a quality improvement team. Together, you’ll identify the key challenges and come up with innovative solutions, ensuring you all share a clear understanding of the improvement objectives and strategies.

  1. Engage with your Primary Health Coordinator from CCQ; they can offer tailored support, resources and guidance to enhance your QI efforts wherever you are in your QI journey. Your Primary Health Coordinator can support your practice to:
    • Bring a QI team together to decide on an improvement idea
    • Plan, start and finish a QI activity
    • Facilitate QI meetings
    • Create practice-wide systems improvement
  1. Gather data and information. Review current practice data and processes for managing people at risk of and living with CVD.
  2. Identify and discuss any common enablers and barriers to optimal care for people at risk of and living with CVD. Consider using process maps, flow charts or driver diagrams to generate change ideas and improve processes.

What data might you need? You’ll need data to understand the problem and measure your outcomes. We suggest you start with:

  1. Primary Sense can provide insight, detailed reports, and targeted guidance for improving data quality. Note: Primary Sense calculates CV risk using the old Heart Foundation calculator, however a link to the new calculator is available in relevant reports and prompts. The following reports and prompts are available within Primary Sense:
    • Cardiovascular Disease Risk Factors: highlights patients who are at risk of cardiovascular disease.
    • Patients Missing PIPQI Measures: Lists all patients which are missing one or more PIPQI measures. Focus on QIM #8.
    • Due Heart Health Check Assessment Prompt: prompts for an MBS healthy heart check when missing CV risk medication and is more than 12 months since last assessment, if there is one.
    • Missing CV Risk Medication Prompt: prompts for high CV risk where there isn’t a history of CVD and the patient is not on dual therapy.

To achieve your goal, you can consider several possible improvement ideas such as:

  1. Conduct a patient awareness campaign about the importance of cardiovascular risk assessment, encouraging patients to book for a Heart Health Check. This can include waiting room posters, brochures and prompts to complete the Heart Age Calculator while waiting for their appointment. Tip: Heart Week is a national heart health awareness week held in May each year.
  2. Develop a workflow utilising the Primary Sense prompt ‘Due Heart Check Assessment’ to opportunistically book patients in prior to them leaving the practice.
  3. Utilise the Primary Sense report ‘Patients Booked in with Missing PIP QI Measures’ to identify those missing recording of CV risk factors (QIM #8). Develop a workflow that these patients are opportunistically seen by the nurse when presenting for their appointment prior to or after seeing the GP to update their CV risk factors.
  4. Consider practice processes and how to incorporate the new cardiovascular risk calculator into practice processes. Tip: Ensure relevant health assessment templates are updated to use this calculator.
  5. Develop a procedure for offering regular Heart Health Checks utilising the whole practice team including reception, nurses and GPs. Tip: Check out the Heart Foundation Heart Health Check Toolkit for scripts for reception and recall templates as a guide.
  6. Utilise the Primary Sense Cardiovascular Disease Risk Factor report to identify people at high risk of cardiovascular disease and are not currently on dual therapy (anti-lipid and antihypertensives) to recall these patients for further assessment and management as appropriate. As part of this activity, utilise the Primary Sense prompt ‘Missing CV Risk Medication’ to create an opportunistic workflow when patients are already in the practice.

Remember to self-report your QI project as a CPD activity. QI is a great tool for measuring tangible outcomes and demonstrating improvement in patient care!

Share your results with your CCQ practice support team and with your patients. Ensure you document your quality improvement activity to meet PIP QI guidelines and for CPD purposes.

References

  1. Australian Institute of Health and Welfare (2024) Heart, stroke and vascular disease: Australian facts, AIHW, Australian Government, accessed 11 March 2025.
  2. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–952. doi:10.1016/S0140-6736(04)17018-9.
  3. Heart Foundation. About the Heart Health Check Toolkit [Internet]. Melbourne: Heart Foundation; 2024 [cited 2025 Feb 26]. Available from: https://www.heartfoundation.org.au/heart-health-check-toolkit/about-the-toolkit
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