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A GP software system to monitor cardiovascular disease risk and improve treatment

Associate Professor Kim Greaves, Institution: Australian National University

2018 Vanguard Grant

Years funded: 2019-2020


Cardiovascular disease (CVD) is Australia’s biggest killer and consumes 11% of the healthcare budget yet is largely preventable. 11% of the Australian population aged 45-74 years without prior CVD, have a high CVD risk and medications are recommended for these individuals to reduce the chance of heart attack and stroke. However, despite this 75% are untreated or on incomplete treatment, revealing a huge opportunity for CVD prevention.

To be successful in preventing CVD, a surveillance system is needed to monitor the differing levels of CVD risk in the population. This gives essential information on the size of the health problem, whether prevention programs are successful and which communities need the most help. The system should also identify untreated high risk patients so they can be recalled for therapy. Such a surveillance system does not exist in Australia. PenCS is a key provider of population health analytics software to GP networks.

PenCS has the potential to act as a surveillance system for monitoring population CVD risk and identifying untreated high CVD risk patients. However, this ability has not been harnessed or evaluated. Our project will assess PenCS as a surveillance system for monitoring CVD risk levels in the population and its ability to guide recall of untreated high risk patients. If successful, surveillance could be implemented on a larger scale leading to improved healthcare delivery and CVD reduction in Australia.

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