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Derivation and Validation of QRISK, a New Cardiovascular Disease Risk Score for the United Kingdom: Prospective Open Cohort Study

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Derivation and Validation of QRISK, a New Cardiovascular Disease Risk Score for the United Kingdom: Prospective Open Cohort Study RESEARCH BMJ: first published as 10.1136/bmj.39261.471806.55 on 5 July 2007. Downloaded from 8 Bergenstal RM, Gavin III JR. The role of self-monitoring of blood practices and recommendations from the NIH Behavior Change glucose in the care of people with diabetes: report of a global Consortium. Health Psychol 2004;23:443-51. consensus conference. Am J Med 2005;118(9, suppl 1):1-6. 14 Davidson MB, Castellanos M, Kain D, Duran P. The effect of self 9 Gerich JE. Clinicians can help their patients control postprandial monitoring of blood glucose concentrations on glycated hemoglobin hyperglycemia as a means of reducing cardiovascular risk. Diabetes levels in diabetic patients not taking insulin: a blinded, randomized Educator 2006;32:513-22. trial. Am J Med 2005;118:422-5. 10 Farmer A, Wade A, French DP, Goyder E, Kinmonth AL, Neil A. The DiGEM trial protocol—a randomised controlled trial to determine the 15 Guerci B, Drouin P, Grange V, Bougneres P, Fontaine P, Kerlan V, et al. effect on glycaemic control of different strategies of blood glucose Self-monitoring of blood glucose significantly improves metabolic self-monitoring in people with type 2 diabetes [ISRCTN47464659]. control in patients with type 2 diabetes mellitus: the auto- BMC Fam Pract 2005;6:25. surveillance intervention active (ASIA) study. Diabetes Metab 11 Owens DR, Barnett AH, Pickup J, Kerr D, Bushby P, Hicks D, et al. 2003;29:587-94. Blood glucose self-monitoring in type 1 and type 2 diabetes: 16 Schwedes U, Siebolds M, Mertes G. Meal-related structured self- reaching a multi-disciplinary consensus. Diabetes Primary Care monitoring of blood glucose: effect on diabetes control in non- 2004;6:398-402. insulin-treated type 2 diabetic patients. Diabetes Care 12 American Diabetes Association. Standards of medical care in diabetes-2006. Diabetes Care 2006;29(suppl 1):S4-42. 2002;25:1928-32. 13 Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, et al. Enhancing treatment fidelity in health behavior change studies: best Accepted: 13 June 2007 Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study Julia Hippisley-Cox,1 Carol Coupland,1 Yana Vinogradova,1 John Robson,2 Margaret May,3 Peter Brindle4 EDITORIAL by Bonneux ABSTRACT was better calibrated to the UK population than either the Objective To derive a new cardiovascular disease risk Framingham or ASSIGN models. With QRISK 8.5% of 1Tower Building, University Park, score (QRISK) for the United Kingdom and to validate its patients aged 35-74 are at high risk (≥20% risk over Nottingham NG2 7RD performance against the established Framingham 10 years) compared with 13% when using the 2 Centre for Health Sciences, cardiovascular disease algorithm and a newly developed Framingham algorithm and 14% when using ASSIGN. With Queen Mary’s School of Medicine http://www.bmj.com/ and Dentistry, London Scottish score (ASSIGN). QRISK 34% of women and 73% of men aged 64-75 would 3Department of Social Medicine, Design Prospective open cohort study using routinely be at high risk compared with 24% and 86% according to University of Bristol collected data from general practice. the Framingham algorithm. UK estimates for 2005 based 4Avon Primary Care Research Setting UK practices contributing to the QRESEARCH on QRISK give 3.2 million patients aged 35-74 at high risk, Collaborative, Bristol Primary Care database. with the Framingham algorithm predicting 4.7 million and Trust Participants The derivation cohort consisted of 1.28 ASSIGN 5.1 million. Overall, 53 668 patients in the Correspondence to: J Hippisley-Cox julia.hippisley-cox@nottingham. million patients, aged 35-74 years, registered at 318 validation dataset (9% of the total) would be reclassified ac.uk practices between 1 January 1995 and 1 April 2007 and from high to low risk or vice versa using QRISK compared on 30 September 2021 by guest. Protected copyright. who were free of diabetes and existing cardiovascular BMJ 2007;335:136-41 with the Framingham algorithm. doi:10.1136/bmj.39261.471806.55 disease. The validation cohort consisted of 0.61 million Conclusion QRISK performed at least as well as the patients from 160 practices. Framingham model for discrimination and was better Main outcome measures First recorded diagnosis of calibrated to the UK population than either the cardiovascular disease (incident diagnosis between 1 Framingham model or ASSIGN. QRISK is likely to provide January 1995 and 1 April 2007): myocardial infarction, more appropriate risk estimates to help identify high risk coronary heart disease, stroke, and transient ischaemic patients on the basis of age, sex, and social deprivation. It attacks. Risk factors were age, sex, smoking status, is therefore likely to be a more equitable tool to inform systolic blood pressure, ratio of total serum cholesterol to management decisions and help ensure treatments are high density lipoprotein, body mass index, family history directed towards those most likely to benefit. It includes of coronary heart disease in first degree relative aged less additional variables which improve risk estimates for than 60, area measure of deprivation, and existing patients with a positive family history or those on treatment with antihypertensive agent. antihypertensive treatment. However, since the validation Results A cardiovascular disease risk algorithm (QRISK) was performed in a similar population to the population was developed in the derivation cohort. In the validation from which the algorithm was derived, it potentially has a cohort the observed 10 year risk of a cardiovascular event “home advantage.” Further validation in other populations was 6.60% (95% confidence interval 6.48% to 6.72%) in This article is an abridged version is therefore required. women and 9.28% (9.14% to 9.43%) in men. Overall the of a paper that was published on bmj.com on 5 July 2007. Cite this Framingham algorithm over-predicted cardiovascular version as: BMJ 5 July 2007, doi: disease risk at 10 years by 35%, ASSIGN by 36%, and INTRODUCTION 10.1136/bmj.39261.471806.55 (abridged text, in print: BMJ QRISK by 0.4%. Measures of discrimination tended to be Risk equations for cardiovascular disease derived from 2007;335:136-41). higher for QRISK than for the Framingham algorithm and it the American Framingham cohort study are the most 136 BMJ | 21 JULY 2007 | VOLUME 335 RESEARCH BMJ: first published as 10.1136/bmj.39261.471806.55 on 5 July 2007. Downloaded from widely used in the United Kingdom1 but have major of death data from the Office for National Statistics limitations (see bmj.com). For example, the algorithm enabling sensitivity analyses including certified cause does not include factors such as social deprivation. of death. The UK National Institute for Health and Clinical Excellence has lowered the threshold for primary pre- Practices and cohorts vention with statins from a 10 year cardiovascular dis- We included contributing practices once they had 23 ease risk of 40% to 20%. We refer to a 10 year risk of been using EMIS for at least a year. We randomly allo- 20% or more as high. It is important that this pro- cated two thirds to the derivation dataset (used to gramme includes social deprivation to reduce inequal- derive an equation for estimating cardiovascular risk) ities in cardiovascular disease and to target those at and one third to the validation dataset. greatest risk.4 Scotland has adopted ASSIGN equa- We identified an open cohort of patients aged 35-74, tions that include social deprivation.5 registered with eligible practices during the study per- We derived and validated a new cardiovascular dis- iod 1 January 1995 to 1 April 2007 (see bmj.com for ease risk score for the UK population and compared exclusions). this with the Framingham1 and ASSIGN equations.6 For each patient we determined an entry date to the METHODS analysis, which was the latest of the following: 35th Our prospective cohort study was carried out within a birthday, date of registration with practice, date when large UK primary care population. We used version 14 practice computer system was installed, and start of of QRESEARCH, a validated database containing the study period. We also included patients only when ’ records of 10 million patients from 529 general prac- they had at least one year s complete data in their med- tices using the EMIS computer system. It also contains ical record. area measures of ethnicity and deprivation evaluated at For each patient we determined the right censor date output area on the basis of the 2001 census. The Town- —the earliest date of the dates on which they devel- send score7 is an area measure of material deprivation. oped the outcome of interest, the study ended, date of Most recently QRESEARCH has been linked to cause death, date of deregistration, or date of last upload of Table 1 |Ratio of predicted to observed risks of cardiovascular disease event at 10 years across tenths of estimated risks QRISK Framingham ASSIGN http://www.bmj.com/ Predicted Observed Predicted Observed Predicted Observed Tenth* risk (%) risk (%) Ratio risk (%) risk (%) Ratio risk (%) risk (%) Ratio Women: First 0.71 0.44 1.61 0.59 0.53 1.12 1.31 0.34 3.81 Second 1.06 0.95 1.12 1.17 0.96 1.22 1.83 0.91 2.00 Third 1.49 1.45 1.03 1.95 1.59 1.22 2.41 1.49 1.61 Fourth 2.11 2.11 1 3.02 2.19 1.38 3.18 2.14 1.48 on 30 September 2021 by guest. Protected copyright. Fifth 2.97 3.06 0.97 4.41 3.02 1.46 4.23 3.08 1.37 Sixth 4.22 4.5 0.94 6.15 4.63 1.33 5.76 4.17 1.38 Seventh
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