Question	Answer
n      Information for patients
	What is the QRisk CVD score?	n      QRisk is a new cardiovascular disease (CVD) risk score which is designed to identify people at high risk of developing CVD who need to be recalled and assessed in more detail to reduce their risk of developing CVD. n      The QRisk score estimates the risk of a person developing CVD over the next 10 years n      QRisk has been specifically developed by doctors and academics for use in the UK. n      The research underpinning QRisk was published in July 2007 in the British Medical Journal and in January 2008 in Heart journal. n      The research was done using the QResearch anonymised medical research database which consists of the electronic health records of over 10 million patients registered with 550 general practices using the EMIS clinical computer system of whom 2 million contributed to the QRisk dataset. n      All medical decisions relating to the QRisk score need to be taken by a patient in consultation with their doctor. The authors, University of Nottingham and EMIS accept no responsibility for clinical use or misuse of the score.
	What is cardiovascular disease?	n      Cardiovascular disease is a term used by doctors to refer to a collection of diseases such as:             Stroke             Transient ischaemic attack             Myocardial infarction or heart attacks             Angina
	What does 10 year risk of cardiovascular disease mean and why is it important?	n      10 year risk of cardiovascular disease means the risk of someone developing cardiovascular disease over the next ten years. n      If someone has a 10 year QRisk score of 20% then in a crowd of 100 people like them, on average 20 people would get cardiovascular disease over the next 10 years. Or put another way, they have a ‘one in five’ chance of getting cardiovascular disease over the next 10 years. n      If you have a QRisk score of 20% or more then you are considered to be at high risk of developing cardiovascular disease and need to have advice or treatment to reduce your risk. You should contact your doctor for further advice.
	How can I work out my risk?	n      You can use the QRisk not in blue web calculator to estimate your risk. n      Note though that this is just an estimate and that if you do not know some of the information needed for the calculator (like your blood pressure) then it will substitute population average values for someone of your age and sex so the result is just a guide. n      If you are concerned about estimated risk then you can see a doctor or nurse for a full risk assessment. n      Your doctor will have a way of identifying who needs to be assessed based on information already present in your electronic health record and may contact you if you need a review.
	What is body mass index and how is it measured?	n      Body mass index is a number calculated from your height and weight. n      It is the weight in kilograms divided by the height in metres squared. n      Conventionally a person is considered to be obese if they have a body mass index over 30 kg/m2
	What does ‘family history of premature coronary heart disease in a first degree relative mean’?	n      You have a positive family history if you have a mother, father, brother or sister who has had a heart attack or ‘angina’ under the age of 60. n      If you have a positive family history it will give you an increased risk so it is even more important that you try to have a healthy lifestyle ie don’t smoke or aren’t overweight, do exercise etc.
	Which people can have a QRisk cardiovascular score calculated?	n      You can use QRisk if you are aged between 35 and 74 years unless you:               Have had a heart attack, angina or stroke, heart failure or peripheral vascular disease (poor circulation)             Are currently prescribed medicines to lower your cholesterol (statins)             Have diabetes
	I have diabetes – why can’t I use QRisk to calculate my risk?	n      If you already have diabetes you automatically will have a high risk of cardiovascular disease and should already be under your doctor’s care to help this.
	I live in the UK and I am from a black or ethnic group. Can I use the QRisk calculator?	n      Yes you can use QRisk although you need to be cautious. QRisk has been developed on over a million people of all backgrounds and a wide mix of ethnic groups living in the UK and we think it will apply to the majority of people although its accuracy in specific ethnic groups has not yet been tested. n      If you are a South Asian man originating from the Indian sub-continent, then according to previous research, your risk might be a bit higher than the calculator shows, and so you should contact your doctor if you are concerned. n      More research is underway to work out more specific risks for people in different ethnic groups and we will update QRisk in due course if we find this is better.
	Why does the score need a postcode?	n      Cardiovascular risk varies according to where people live and the score takes account of this for us.
	I am over 75 years, why isn’t QRisk suitable for someone of my age?	n      Most people over the age of 75 years have a risk score of more than 20% and so the QRisk score isn’t terribly useful at identifying high risk patients once they get to 75 years.
	My score is greater than 20% using the web calculator. What things can I do myself to reduce my chances of getting heart disease?	n      If your QRisk is more than 20% then you should speak to your doctor. n      You can do things yourself to lower your risk. n      The biggest thing you can do is to stop smoking if you smoke (your doctor can help you with this). n      Take regular exercise (need more detail). n      Try to Lose weight if you are overweight (body mass index is > 25kg/m2). n      Your doctor might advise you to take medication to lower your blood pressure or lower your cholesterol levels.
	My score is between 10% and 20%, what should I do?	n      You risk is below the threshold for needing medical treatment but you can still help lower your risk by doing the things above. n      Your score will rise as you get older so you could measure it again in a couple of years time to see how it is getting on. n      If you are concerned and want to discuss it or get some help to reduce your risk factors, then make an appointment to see your doctor.
	I am on blood pressure treatment and I notice that my risk is higher than it would be had I not been taking blood pressure treatment. Why is this?	n      Blood pressure treatment lowers your blood pressure and reduces your risk of heart disease and stroke. n      The fact that you are taking blood pressure treatment means that you have already been identified by your doctor as someone needing treatment which automatically puts you in a higher risk group. n      The treatment itself isn’t increasing your risk but is acting as a marker for the fact that your underlying risk is higher.
	I am already taking statins given to me by my doctor. Should I see what my QRisk score is?	n      If you are already on statins then your doctor has already assessed your risk and decided to treat you so you don’t need to do it again. n      You do need to keep your appointments with your GP and keep taking the treatment you have been given.

n      Information for professionals and suppliers
	What is the difference between QRisk and the traditional Framingham score?	The QRisk CVD score contains many of the traditional risk factors included in Framingham (such as age, sex, cholesterol/HDL ratio blood pressure and smoking status) but also contains important additional risk factors: n      Family History of premature coronary heart disease in a first degree relative under the age of 60 n      Deprivation (measured using the Townsend deprivation score) n      Blood Pressure Treatment n      Body Mass Index
	Why was a new CVD risk score needed for the UK when we already have Framingham?	n      Estimates of CVD risk derived from equations are not an exact science but are better than clinical judgment alone for the estimation of CVD risk. n      A number of risk assessment equations are available that estimate cardiovascular risk in individual patients. They have been derived from studies of individuals who have been followed up often for substantial lengths of time. n      Risk assessment equations predict risk best in the type of population from which they were derived. The Framingham equations were derived from North American populations from the 1960s to the 1980s when coronary heart disease (CHD) was at its peak and they overestimate risk in contemporary European populations by around 100% in Southern European populations and by 50% or more in Northern European populations including the UK. n      Conversely, such equations may underestimate risk in populations such as people with diabetes, South Asian men or the most socially deprived who are at higher than average risk. Overall the Framingham risk equation is likely to overestimate risk in the current UK population. n      They may also underestimate risk in people with extreme risk factor levels or other clinical risks not included in the model.
	Why was a measure of socio-economic deprivation included in the QRisk equation?	n      Cardiovascular risk is closely associated with socio-economic status such that people from deprived areas have higher risks. n      Framingham equations do not include socio-economic status and underestimate risk in people who are relatively socially deprived. n      The use of equations that do not include a measure of socio-economic status may exacerbate inequalities in CVD ie the difference between rich and poor.
	What is the Townsend score, what does it measure and why was it used?	n      The Townsend Score is a measure of material deprivation based on where a person lives and obtained using their postcode and includes four variables obtained from census data: unemployment (lack of material resources and insecurity), overcrowding (material living conditions), lack of owner occupied accommodation (a proxy indicator of wealth) and lack of car ownership (a proxy indicator of income). n      This score is considered the best indicator of material deprivation currently available and has been widely used in medical research including a range of studies conducted on the QResearch database.
	How has the QRisk score been validated?	n      The QRisk score was initially validated in a one third sample of the QResearch database by comparing its performance against the traditional   Framingham score which is currently in use in the UK. This research was published in the British Medical Journal in July 2007. n      A second validation study was performed using the THIN database (which is a similar UK research database consisting of the electronic records of patients using a different computer system). This was published in the Heart journal in January 2008. n      An editorial accompanying this study explains that the two main measures by which a risk prediction tool should be judged are calibration and discrimination. Calibration relates to how close the predicted risk is to the observed risk. Discrimination is the ability of the tool to differentiate between people who will have an event and those who will not, over a defined period of time (often five to ten years). n      On both measures and in both studies, the QRisk no hyperlink here score outperformed Framingham indicating that it is likely to be more accurate than Framingham at estimating cardiovascular risk.
	Where patients are on antihypertensive treatment, should a pre-treatment blood pressure be used when calculating their risk?	n      No. QRisk has been designed such that if a patient is taking antihypertensive medication then their current blood pressure on treatment can be used rather than a pre-treatment value.
	What is the difference between an ‘estimated’ QRisk CVD score and an ‘actual’ QRisk CVD score?	n      In EMIS the actual QRisk CVD score can be calculated where all values needed to calculate the score are available in the patient’s electronic health record. n      In EMIS the estimated QRisk score is a CVD score which has been calculated using the data recorded in the patient’s electronic health record but also using reference values based on the patient’s age and sex where some data are missing. n      For example, if a patient is a 55 year old male and has all the data for calculating a QRisk score in his ‘e’ health record except a systolic blood pressure, then the system will select a default value from a reference table for males aged 55 years. n      An actual QRisk score is one which has been calculated using the patient’s actual recorded data with all the risk factor values available within a clinical consultation with the patient present. It doesn’t have to be done within a consultation.  An automatically calculated score with all the risk factor information would still be the ‘actual’ QRisk score. It will not be based on estimated default values.
	I am a clinician and have a patient with a QRisk score of just under 20% - what should I do?	n      If the risk estimate is marginally below the threshold, clinical judgement should be used to determine whether further treatment of risk factors should be offered (for example, South Asian males).
	Why is it important to measure HDL cholesterol in order to get the best estimate of CVD risk?	n      It is the ratio of total cholesterol to HDL cholesterol that is the best predictor of risk, better than either total cholesterol or HDL cholesterol alone. n      Someone with a total cholesterol of 7.5mmols/l and an HDL cholesterol of 1.8mmols/l has a ratio of 4.2 which is associated with a considerably lower risk than someone with a total cholesterol of 5.8mmols/l and an HDL of 0.8 (ratio 7.2)
	What about other factors which may increase CVD risk but are either not included in the 'score' or fully accounted for?	n      There are other factors which can increase CVD risk which are not directly accounted for in the QRisk algorithm. n      These include, for example, alcohol excess, very heavy smoking, poor diet, lack of exercise and extreme obesity. These factors will all tend to increase risk of cardiovascular disease. n      There is a strong relationship between deprivation and CVD risk, and so the inclusion of deprivation in the QRisk algorithm will take account of this to some extent.
	Has NICE now recommended QRisk?	n      QRisk has been provisionally recommended by NICE and this recommendation is currently the subject of a second consultation which closes in the first week of March 2008. NICE considered the emerging evidence which suggested that QRisk gives a better estimation of risk in the general population of England and Wales than the Framingham score. n      The Nice Guideline Development Group reviewed this evidence in detail and has revised its recommendations on cardiovascular risk assessment in its review document. NICE also commissioned expert reviews of QRisk and these are given on the NICE website.
	When will QRisk be available for use in clinical practice nationally?	n      We are waiting for NICE to finalise its guidance before releasing QRisk.
	Will the QRisk CVD algorithm be updated and change over time?	n      QRisk is a dynamic risk factor score developed from live anonymised electronic health records recorded by thousands of family doctors in the UK. We know that the characteristics of the population change over time and this will affect the equation itself. For example, the incidence of heart disease itself has fallen over the last 30 years, blood pressure has fallen, obesity is rising, smoking patterns have changed. n      QRisk will therefore be updated periodically in order to reflect these population changes and also to take advantage of the continual improvements in the quality of electronic health records and the latest evidence regarding new or additional risk factors.
	When will QRisk next be updated?	n      We expect that the next release of QRisk will be available in 2009 or 2010.
	I am a GP and use EMIS clinical computer system. Will QRisk be available in the clinical system?	n      EMIS are developing software which will enable all practices to generate a list of high risk patients for primary prevention in ‘population manager’ based on the new QRisk equation. n      This software will flag patients according to what assessments and interventions are needed so that the appropriate patients can be recalled.
	I am a GP who uses other clinical computer systems apart from EMIS  - will QRisk be available within my clinical system?	n      QRisk will be available under license to the system suppliers for all clinical computer systems in England and Wales. n      It will be up to the system supplier to decide on whether to implement QRisk within the clinical system or not.
	I am the CHD lead for a PCT and would like to use QRisk in all the practices in my PCT as we have a Locally Enhanced Service. How can I achieve this? What data is available to the practices themselves and to me as a PCT. What training is available?	n      Practices using EMIS will have QRisk incorporated into the clinical system so that they can generate a CVD recall list and establish a CVD primary prevention register. Other computer suppliers may also provide this for their practices. n      In addition, there are third party software companies which have CVD prevention software. A list of approved suppliers which hold a QRisk license will be available. n      EMIS\QResearch may in future provide a PCT level extraction service for EMIS practices subject to governance arrangements, practice consent and costs being met. n      EMIS field staff will be providing training for EMIS practices. n      We expect PCTs and health communities to provide training locally. No other training is being provided by QResearch or EMIS.
	Will QRisk be available free for research and non commercial use?	n      Yes – the QRisk algorithms will be available free of charge for research and non-commercial personal use under a creative commons license. n      There will be an annual license fee for commercial use.
	I am interested in using the QRisk CVD algorithm within my own software, where can I find out more information?	n      We have developed a QRisk software development kit designed to be used by commercial companies who wish to embed QRisk in their applications. n      For further details contact Julia.hippisley-cox@nottinghan.ac.uk
	I am an academic who is currently developing some software with a commercial company which we plan to sell to third parties. I am being paid for my expertise. Can I have a free academic license?	n      No. The arrangements are the same as for a commercial supplier as it is the intended use which is important.
	What is the definition of commercial use?	n      Use for research purposes means use within a specific research project where the output is a research paper intended for publication in a peer reviewed journal. n      Research expressly excludes service delivery and Commercial Use and the benefits derived from such use must not constitute a financial gain.  “Commercial Use” means any purposes which seek to exploit the data for financial gain or any purpose which is likely to place the use of the data in competition with a third party who is seeking to exploit the licensed data.  “Financial Gain” means a benefit accruing where the licensee or any third party used by, or connected to, the licensee receives any revenue or financial credit when using the data.  n      To avoid any doubt, commercial use (or any other use which falls outside the definition of research) will require further direct discussion and a further licence to be obtained.
	As clinical director of a primary care clinical computer system, I have been following the discussions around QRisk. I am keen to review how this scoring system could be integrated within our clinical system. Can you tell me what arrangements are in place for suppliers to have access to the scoring algorithm and supporting data?	We are currently preparing the technical and user documentation which will describe the input variables/search definition and also how to generate the score with the coefficients. In addition, we are also preparing a mini software development kit which has a set of DLL class libraries which will be licensed and will: n      'Fill in' missing values for blood pressure, BMI, cholesterol ratio using age-sex reference data where these values are missing. n      Generate an 'actual' QRisk score given the right input parameters for patients with complete data or an 'estimated' QRisk score where one or more data items are missing. n      The software can then be used in single use mode or batch mode (eg to run against the practice database to generate a recall list).   The package will be available under annual license fee and downloadable. In addition to the above, it is likely to include a choice of the following components: n      The read code and search definition needed to extract the patient level data which needs to be fed into the algorithm. n      A postcode to deprivation mapping table to generate the deprivation score. n      The age-sex reference data for the blood pressure, cholesterol, body mass index. n      Test harness/test set of data. n      A web service definition. n      PCT level CVD calculator to derive estimates of the numbers of patients in a PCT at high risk of CVD, the number likely to need risk factor recording and risk factor modification interventions.   The idea behind this approach is to ensure  n      The QRisk score is implemented as simply and correctly by suppliers as possible as it is fiddly to calculate. n      Also, it is likely that we will need to update the score every couple of years (as per NICE recommendation) so will want to be able to issue updates simply and reliably.
	I have further questions on QRisk which haven’t been answered here – who can I contact?	Please go to http://www.qresearch.org and submit your question online.

This handout is only a guide to using QRisk. No part of this document may be sold, hired, reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording and information storage and retrieval systems for any other purpose than the purchaser’s use without the express written permission of QRisk.