Implementation of QRisk tool for cardiovascular risk management
Submitting InstitutionQueen Mary, University of London
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Economics: Applied Economics
Summary of the impact
QRisk is a statistical model / score derived from routine general
practice (GP) records to calculate an individual's risk of developing
cardiovascular disease (CVD). Queen Mary researchers formed the London arm
of a multi-centre study and were particularly instrumental in testing the
tool in general practice. QRisk targets treatment more effectively than
other scores; it is also more equitable for disadvantaged and minority
ethnic groups and cheaper per event prevented. QRisk is used in the NHS
Health Checks programme covering 20 million people in England and is
available at a keystroke in all GP computer systems in England. It has
contributed to the identification of an additional 2.8 million people in
England at high risk of CVD and their treatment with statins, reducing CVD
deaths and events by an estimated 9,000 per year — about 50,000 to date
since the NHS Checks programme started in 2009.
The epidemic of premature CVD mortality (under 75 years old) peaked in
the 1970s, declining from 250 per 100,000 to 50 per 100,000 in 2010. But
ethnic and socio-economic differences in CVD risk have persisted. It has
been possible for many years to estimate a person's CVD risk, calculated
from paper look-up tables based on Framingham data. In 1997, Dr Robson
(based at Queen Mary throughout) implemented the first UK electronic
version of a CVD risk score (Framingham) on the leading GP computer system
(EMIS), which allowed GPs to use two keystrokes for an `automated' risk
score. However, the Framingham score was derived from research undertaken
in the 1970/80s in one small, relatively affluent and largely white US
town. Framingham score substantially overestimates overall UK CVD risk and
underestimates this risk in South Asian and socially disadvantaged people.
Inaccurate estimates lead to poorly targeted interventions, including
lifetime statin treatment, and impact on equitable provision and outcomes.
The Framingham score targets 3 million people in England for preventive
therapy while QRisk targets 2 million more accurately. QRisk identifies
300,000 people who would miss out on treatment if CVD risk were calculated
with Framingham score, many of whom are South Asians and / or in
socio-economically disadvantaged groups.
QRisk: In 2004-08, the NICE guideline development group CG67,
chaired by Dr Robson, reviewed risk scores including Framingham, and
identified the need to develop more contemporary scores that included
minority ethnic groups, social disadvantage and family history of
premature CVD . In 2007, Dr Robson worked with Prof Hippisley-Cox's
team in Nottingham to develop QRisk [2-4]. This was the first use of
routine GP records for risk prediction and the first to include socio-
economic status. The tool was validated in an internal subset and an
independent external dataset. QRisk reallocates treatment assignment in
1/3 of those who would previously have been identified at high risk (1.3
million individuals), impacting significantly on individuals, equity and
Validation: An international statistical and epidemiological panel
commissioned by NICE including Peto (Oxford) and Jackson (New Zealand)
recommended use of QRisk to the NICE guideline group. Despite this, the
group initially failed to reach agreement on QRisk. In 2008, a third
independent validation, carried out by Collins and Altman at DOH's
request, confirmed the methods, validation and superiority of QRisk
compared to the historically popular Framingham score [6,7]. In 2008, a
refined version of the score, QRisk2, was accepted as a major improvement
and the first independently validated score to include ethnic group. An
updated version was developed in 2010  and externally validated in 2012
Updating: To avoid overestimation, the QRisk score equation is
regularly updated and modified using accessible real-time GP data —
important to maintain accurate prediction given continuing changes in
population behaviour (smoking/diet) and falling trends in CVD risk. It
also allows periodic statistical refinements to the score (eg addition of
new components, revisions in the weightings assigned to each component).
In contrast, the Framingham score, based on an historical cohort, has led
to major inaccuracy in contemporary European populations.
The team that developed QRisk included the following academics:
Prof J Hippisley-Cox (U of Nottingham). Director QResearch clinical
database. QRisk team leader
Dr J Robson (QMUL). Academic GP and health services researcher
Dr P Brindle (Avon Primary Care Research Collaborative). General
C Coupland Y Vinogradova (U of Nottingham). Statisticians
Prof A Sheikh, University of Edinburgh. Academic GP and health services
Dr Robson [a] chaired the NICE guideline group that originally identified
the need to improve risk tools for general practice; [b] tested existing
tools in GP computer systems in east London as a preliminary phase to the
QRisk research; [c] helped develop and validate QRisk; [d] provided unique
input to the QRisk team as a GP academic with specific expertise in the
installation and implementation of computerised risk scores in the
community-based clinical setting across a socio- economically deprived
district; and [e] played an active role in implementing QRisk locally (to
demonstrate real-world feasibility) and nationally (through the EMIS user
group and otherwise). Funding was from local NHS trusts, Queen Mary, and
Universities of Nottingham and Edinburgh.
References to the research
1. NICE Guidance CG67. Cooper A, Nherera L, Calvert N, O'Flynn N,
Turnbull N, Robson J, et al. Clinical guidelines and evidence
review for lipid modification, cardiovascular risk assessment and the
primary and secondary prevention of cardiovascular disease. NCCP. London:
Royal College of General Practitioners; 2008.
2. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M,
Brindle P. Derivation and validation of QRISK, a new cardiovascular
disease risk score for the United Kingdom: prospective open cohort study.
3. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Brindle
P. Performance of the QRISK cardiovascular risk prediction algorithm in an
independent UK sample of patients from general practice: a validation
study. Heart 2008; 94: 34-9.
4. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas
R, Sheikh A, et al. Predicting cardiovascular risk in England and Wales:
prospective derivation and validation of QRISK2. BMJ
5. Hippisley-Cox J, Coupland C, Robson J, Brindle P. Derivation,
validation, and evaluation of a new QRISK model to estimate lifetime risk
of cardiovascular disease: cohort study using QResearch database. BMJ
2010; 341: c6624.
Independent validation studies on QRISK by external experts
6. Collins GS, Altman DG. An independent external validation and
evaluation of QRISK cardiovascular risk prediction: a prospective open
cohort study. BMJ 2009; 339: b2584.
7. Collins GS, Altman DG. An independent and external validation of
QRISK2 cardiovascular disease risk score: a prospective open cohort study.
BMJ 2010; 340: c2442.
8. Collins GS, Altman DG. Predicting the 10-year risk of cardiovascular
disease in the United Kingdom: independent and external validation of an
updated version of QRISK2. BMJ 2012; 344: e4181.
Details of the impact
QRisk had an impact in five areas: implementation and use of QRisk in UK
primary care (GP surgeries and pharmacies); direct uptake and use by the
public and patient organisations; informing policy on NHS Health Checks;
informing methodological work on risk score development and validation;
and inspiring further research on the use of QRisk-type scores for other
chronic conditions. We consider these in turn below.
4a: Implementation and routine use of QRisk in UK primary care
The success of QRisk has depended both on its robust scientific basis and
on intensive efforts on the implementation of the score in front-line
general practice. The effort included:
- Dr Robson worked with the GP system supplier EMIS to ensure that the
risk score was fully integrated in GP computer software to give a
`one-click' QRisk calculation covering 55% of the English population.
- An accessible website (www.qrisk.org)
including a user-friendly risk calculator aimed at both health
professionals and the public. The website currently receives ~25,000
visits per month (around 2 million visits to date).
- Dr Robson advised the DH and a London-wide team on QRisk
implementation. Locally in east London, he was a member of the North
East London Cardiac Network Board, CVD lead for Tower Hamlets PCT and
advisor to other local PCTs in east London.
Using QRisk rather than Framingham as the risk score on GP computer
systems is more equitable for the needs of high risk ethnic minorities,
the socially disadvantaged and is estimated it will prevent 3,000 more CVD
events in five years in those at high risk in England because QRisk
identifies a risk group that is on average, at higher risk than that those
identified by Framingham. In people found to be at high CVD risk, events
will be further reduced by targeting treatment for high blood pressure and
earlier identification of diabetes.
Dr Robson collaborated with Prof Hippisley-Cox to design the QRisk
calculator and website and worked with EMIS, the largest UK computer
supplier to integrate QRisk in their electronic record using minimal
additional data and no duplicated entry. This was complex, requiring
automated on- line real-time connection to a remote `cloud' calculator,
which returns the score to the GP record within milliseconds in a seamless
electronic tool for busy clinicians and their patients in the consulting
room. An app is now available. The new QRisk-lifetime score was presented
by the Joint British Societies to replace the previous Framingham score as
their preferred risk engine .
QRisk has now been implemented by all GP system suppliers in England and
Wales. Other system suppliers use QRisk in community and pharmacy contexts
including Oskis, Wellpoint (kiosk/pharmacies), Telehealth
(kiosk/pharmacies), Cumbria Mental Health Trust, Informatica, Health
Diagnostics and Health Smart. These pharmacy and other community schemes
use QRisk as part of the NHS Health Checks programme (see below).
By 2011 the NHS Health Checks programme had identified 2.8 million people
at high CVD risk who have been started on statins — most of whom are
likely to have been identified with QRisk (as EMIS covers 60% of GP
practices and QRisk is implemented on all other major computer systems) —
though some will have been identified with Framingham. As statins reduce
CVD events by 25% and the average risk of those identified is around 10%,
it is estimated that this programme is preventing 9,000 CVD deaths or
events every year — about 50,000 since the programme started in 2009. This
is a major public health achievement .
4b: Uptake and use by the lay public and patient organisations
A key aspect of the QRisk website is that it can be used by an untrained
layperson to calculate their own cardiovascular risk, allowing
self-diagnosis and prompting people to attend their GP or pharmacist for
further investigation and advice. Public dissemination has been extensive
and QRisk is included on a number of websites including Patient UK,
National Prescribing Centre, NHS Health Check and NHS Improvement
websites. It was endorsed by the Director of the British Heart Foundation
and is included in their factsheets. The QRisk website is now being
accessed about 300,000 times a year, including 40,000 visits from outside
4c: Informing policy on NHS health checks
Dr Robson has been an advisor to the Department of Health on NHS Health
Checks and a member of the London NHS Health Checks Implementation Group.
The NICE guideline [1 above], chaired by Dr Robson, provided the
scientific rationale and recommendation that underpinned the 2009 national
NHS Health Checks programme, which offers cardiovascular risk assessment
to all adults aged 40-74 years in England. On publication of NICE guidance
in 2007, the Department of Health endorsed QRisk for CVD risk estimation
in its NHS Checks programme [11,12] and used it to develop the economic
modelling underpinning the NHS Checks programme in 2008 . This
demonstrated that QRisk potentially provided better value than Framingham
for the £200m annual cost of NHS Health Checks . In 2010, NICE revised
their original guidance to support the use of QRisk2 . QRisk
technology integrated into the GP electronic record has been an essential
component of implementation and instrumental to widespread adoption.
4d: Informing methodological work on risk scores
QRisk development has contributed to the discussion on validation and
statistical comparison of models to predict risk, and to debates on
multiple imputation. For example, QRisk was a case study in a workshop
convened by the Foundation for Genomics and Population Health, Cambridge
[15,16]. The debate around the use of routine GP data for predictive
purposes has highlighted the potential of large primary care datasets for
research purposes (eHealth records research capacity and capability MRC
2011). The open source QRisk calculator has been downloaded from the QRisk
website by over 500 separate organisations in the last year and has been
used by a number of UK universities (including SCHARR for the health
economic modelling for NICE), Cambridge and Imperial. QRISK® is
a registered trademark and IP is protected by GNU licences. QRisk has had
an international impact — for example, an American paper on health
economic assessment used QRisk in an Austrian population  and an
American review highlighted the importance of socio-economic data in
predicting individual and population CVD risk .
4e: Promoting development of further risk prediction scores
The principles behind the development of QRisk — using readily available
data items on GP systems to calculate real-time risk scores to inform
treatment decisions with patients and public health planning — have been
applied to other chronic conditions. These include diabetes risk scores
(with Dr Robson QDiabetes 2011 www.qdscore.org)
and cancer, osteoporotic fracture, renal disease and thrombosis risk tools
(Hippisely-Cox J www.QCancer.org).
Prizes, awards and grants
In 2011, Dr Robson received a NICE Shared Learning Award for his work
implementing NICE guidance on cardiovascular disease and the John Perry
Award of the British Computer Society for his work on this topic. In 2011,
he was awarded a two-year NIHR grant to evaluate the NHS Health Checks
programme, which will study the extent to which QRisk has been
implemented. The team is an important component of CHAPTER — the
successful £5m MRC eHealth bid (PI Harry Hemmingway UCL) as the primary
care `arm' of this bid. The team are working to develop data linkage and
to demonstrate the success of a new paradigm in improvement science —
using networks of local practices that have produced a step change in
process and outcomes.
Sources to corroborate the impact
- Spiegelhalter D. JBS-3: The Joint British Societies' revised
guidelines for the prevention of cardiovascular disease. Lecture
given on 8th March 2013 at Royal Society of Medicine, in
which he announced that JBS will adopt QRisk in its new joint guideline.
- van Staa TP. The efficiency of cardiovascular risk assessment: Do the
right patients get statins? Heart 2013; 0: 1-6. doi:
- Department of Health. Putting prevention first: Vascular checks: risk
assessment and management. 'Next steps' guidance for Primary Care
Trusts. London: 2008.
- Department of Health. NHS Health Check: Vascular Risk Assessment and
Management Best Practice Guidance. London, Stationery Office, 2009.
- Department of Health. Vascular Checks Programme. Economic modelling
for vascular checks. London, Stationery Office, 2008.
- NICE. Change to lipid modification guidance CG67 2010: Available from:
- Dent TH. Predicting the risk of coronary heart disease. The use of
conventional risk markers. Atherosclerosis 2010; 213: 345-51.
- Wright C, Dent TH. Quality standards in risk prediction. Cambridge:
PHG Foundation for genmomics and population health. ISBN
- Richter A, Thieda P, Thaler K, Gartlehner G. The impact of inclusion
criteria in health economic assessments. Applied Health Economics
and Health Policy 2011; 9: 139-48.
- Franks P, Tancredi DJ, Winters P, Fiscella K. Including socioeconomic
status in coronary heart disease risk estimation. Annals of Family
Medicine 2010; 8: 447-53.