Risk-I: Exploring Risk-Identification to Prevent Cardiovascular Disease - an Institutional Ethnography

Identifying individuals who may be ‘at risk’ of disease has become increasingly prominent in healthcare policy. As the demographic of disease becomes dominated by so-called ‘lifestyle’ related conditions, many of these diseases are seen as preventable.

In the UK, screening for cardiovascular risk is achieved through the NHS Health Check and opportunistically in routine primary care consultations. It hinges around a computerised tool which calculates risk based on risk factors such as: age; diabetes; blood cholesterol; blood pressure; weight; ethnicity; and address. Efforts in preventative care are focused on increasing uptake of screening - through which individuals are presented with information on how likely they are to have a heart attack or stroke over the following 10 years. This is calculated as a numerical probability, and may also be represented visually. The assumption is that this information will trigger them into altering their lifestyle, or taking medication to modify their risk.

People’s experience of being targeted for risk identification may not reflect the ideology of preventative care. Many healthcare professionals working in primary healthcare are concerned that strict adherence to clinical guidelines may harm, rather than benefit, individual patients through side-effects of medication, or harms from being labelled as being ‘at risk’. As risk thresholds are reduced, there may be increasing uncertainty about the balance of benefits and harms, and a greater role for shared decision-making between patient and practitioner. Uncertainty is particularly acute in cardiovascular risk identification, where guideline-based care is largely based on surrogate outcomes, rather than on outcomes which have more relevance to patients – such as morbidity or mortality.

This study, using institutional ethnographic methods, investigates problematics around preventative care from the standpoint of people who are the target of screening for risk.