Development of a Participatory Cardiovascular Disease Risk Screening Model to Reduce the Incidence of Cardiovascular Events among Hypertensive Patients

Abstract

Background: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide and in Thailand. Despite being preventable through early detection and lifestyle modification, a retrospective review from 2019 to 2021 revealed a declining trend in CVD risk screening among hypertensive patients from 96.27% to 91.06%. Concurrently, the proportion of patients categorized as high or very high-risk (CVD Risk Levels 4–5) increased from 0.24% to 0.65%. The incidence of stroke and coronary artery disease remains concerning. These findings highlight the need for a more engaging and sustainable risk assessment model.

Objective: To reduce the incidence of cardiovascular disease

Methods: Phase 1: Clearly defined the roles of staff, screened for CVD Risk in every case, held a meeting to determine guidelines for recording CVD Risk data in the program, and provided training to leaders and chronic patients. Phase 2: Improve appointment cards to add CVD Risk data, organize intensive group activities for patients at CVD Risk levels 4-5, and coordinate with the EMS team to provide knowledge. Phase 3: Organizing annual proactive complication screening activities, creating a CVD Risk assessment tool, increasing communication channels by recording CVD Risk data in HOSxP notes, and providing knowledge via the LINE group channel.

Results: Following implementation, CVD Risk screening coverage increased to 89.70% among hypertensive patients. The incidence of stroke declined to 0.98%. The incidence of coronary artery disease decreased to 3.69%, continuing a downward trend from previous years.