FAQs

General program

PHASES — Preventing Heart Attack and Stroke Events through Surveillance — is an initiative focused on reducing the burden of cardiovascular disease in Queensland by leveraging Primary Sense a clinical decision support tool that uses general practice data to give patients the right care at the right time. Its core goal is to identify people at the highest risk of heart attacks and strokes early, so that healthcare providers can intervene sooner and manage risk factors more effectively. This proactive approach, aims to improve patient outcomes and contribute to better cardiovascular health across the state.

Primary Sense provides real-time clinical insights from practice data, enabling both opportunistic and systematic patient recalls for practices who use Best Practice (BP) and Medical Director (MD). These insights help guide targeted interventions for managing cardiovascular risk.

If your practice doesn’t have access to Primary Sense (because you don’t use the Best Practice or Medical Director clinical systems), you can still participate in PHASES. Contact your local PHN or the PHASES team [email protected] to explore alternative approaches and express your interest.

NB. For practices using Best Practice or Medical Director who do not have Primary Sense installed, reach out to your local PHN for assistance on installation and training. Primary Sense is fully funded, so General Practices do not incur any out-of-pocket expenses.

Primary Care providers across Queensland, including general practices, allied health professionals, Royal Flying Doctor Service, Aboriginal Medical Services and other Aboriginal Community Controlled Health Organisations. Cardiology Specialists within Queensland who see referred patients at risk are encouraged to participate. Participation is voluntary and supported by the PHN engagement teams.

There are benefits to patients, primary care providers and the broader healthcare system including:

  • Improved patient outcomes through early intervention.
  • Access to cardiovascular risk assessment tools.
  • More targeted treatment by identifying individuals at the highest risk of CVD.
  • Contribution to a statewide initiative for cardiovascular health.

Implementation and support

Because CVD remains a leading cause of death and disability. Up to 80% of events are preventable and early intervention in general practice prevents hospitalisation and acute events.

Focus on high-risk groups first (including those who have established CVD), as they will benefit most from early intervention. Then target patients with sufficient risk factor data but not recorded risk score. Next, patients who are on the right medications but not meeting targets.

Consider the following ways:
  • Use opportunistic prompts during routine visits
  • Flag risk and schedule follow-up rather than overload the consultation.
  • Embed prevention into existing health assessments and reviews.
Involve the whole practice team e.g., practice nurse to top and tail consultations: complete AusCVD risk assessments; support patients to set goals and provide lifestyle education.
For people with Low risk as measured using the AusCVDRisk calculator (<5%):
  • Lifestyle advice
  • Review in approx. 5 years
For people with Intermediate risk as measured using the AusCVDRisk calculator (5% to <10%):
  • Lifestyle + consider pharmacotherapy
  • Review within 2 years
For people with High risk as measured using the AusCVDRisk calculator ( ≥ 10%):
  • Guideline-based therapy (lipid lowering/antihypertensive/anticoagulant)
  • Chronic disease management plan + frequent follow-up

CVD prevention is lifelong management, and many patients discontinue therapy over time. Ongoing review ensures sustained risk reduction. 

Use brief interventions. Apply motivational interviewing and set realistic, patient-driven goals in consultation with patients. 

Yes – MBS supports heart health checks; chronic disease management plans and nurse-led care and follow-ups.

Firstly, managing prevention alone (e.g. GP only) instead of involving the whole practice team. Secondly, not recording risk scores in data fields. Finally, not planning/scheduling follow-ups and treating prevention as a one-off activity.

They can identify eligible patients at the time of booking or reviewing appointments. Consider flagging recalls and any overdue health checks. Schedule appropriate appointment lengths and maintain accurate patient details.

Recalls bring high-risk patients back into care and ensure follow-up is completed. They also empower patients to manage their own risk through regular review and ongoing conversations with the practice team.

Run Primary Sense Reports and identify high risk cohorts. Review patient records and identify missing data early. Engage patients in prevention conversations and reinforce follow-up and care plans.

Useful reports rely on coded data fields. Notes captured in free text are not captured. Poor coding can lead to missed opportunities to intervene in CVD early.

At a minimum the following influence risk calculation and eligibility for preventive care:

  • Demographic details: age, gender
  • Smoking status
  • Ethnicity/Aboriginal and Torres Strait Islander status
  • Blood pressure
  • Cholesterol
  • Diabetes

Yes. A quick team huddle at the start of the day can help identify patients needing are plans and allocate tasks. Nurses can check records beforehand and collect any missing information during the visit. Preparing documentation in advance and communicating clearly after the consultation helps keep appointments running smoothly and ensures follow-up bookings are arranged efficiently.

Yes. A kick-off meeting is an effective way to clarify roles, responsibilities, and expectations for all team members involved in a Quality Improvement activity. This meeting doesn’t need to be separate; it can easily be incorporated into an existing team meeting.

Making sure risk factors are completed and recorded in data fields will have the greatest impact because missing or misplaced information (key clinical measurements or test results) can lead to patients being overlooked or not identified because their names will not appear in CVD reports.

Consider dedicating an area in the waiting room to a different health topic each month. When heart health is the focus, practices can use Heart Foundation resources, for example, to raise awareness and prompt conversations.

There are plenty of other worthwhile activities to focus on, including
  • cleaning up inactive patient records
  • updating patient information, and
  • arranging recalls and follow-up appointments for patients with chronic conditions.
After all, the risk factors associated with CVD often overlap with those for other conditions, such as diabetes, so these efforts can have benefits beyond cardiovascular health.

Training and education

There are a range of resources you can access for more information. Visit the PHASES website for:

  • Factsheets CVD risk factors, Primary Sense and the new CVD Report, MBS billing opportunities, HealthPathways
  • Recordings of the webinar series
  • QI Toolkit

You can also contact your local PHN or the PHASES team [email protected] if you would prefer a more tailored education session.

Data and privacy

Primary Sense data is hosted on Primary Health Insights which is a data storage and analytics platform developed collaboratively by PHNs and hosted in Australia.

The platform provides leading edge data security and robust data governance to minimise the risk of data security breaches and unauthorised data management practices.

Data is de-identified and encrypted when it is extracted before it is forwarded to the database. Extracted de-identified data is stored in the Primary Sense Database, which is located in the cloud-based Microsoft Azure, in Australia.

Future developments

Today! Practices can begin using Primary Sense or their clinical system’s reporting tools to identify and manage patients at risk of CVD. Ongoing support, quality improvement resources and regular updates will be provided to help practices embed proactive cardiovascular care into their routine.

We welcome your input! You can share feedback through:

Other

The allied health sector has a vital role in supporting the lifestyle changes that may be recommended to managed CVD risk. To maximise impact, allied health professionals are encouraged to:

  • Proactively connect with general practices in your local area or with practices that frequently refer clients, to discuss how you can support cardiovascular health and improve outcomes.
  • Offer services that enhance the work of general practice. For example, exercise programs, point-of-care lipid profile analysis, blood pressure. Let practices know you are keen to support them.
  • Participate in statewide referral networks and keep up to date with the PHASES project.

Currently the AusCVDRisk calculator is NOT embedded as an application within clinical systems. However, it is possible to launch a web browser to access the AusCVDRisk calculator Australian cardiovascular disease risk calculator | AusCVDRisk.

Work is underway to enable seamless integration – so that fields can be prepopulated and a risk score automatically fed back into the clinical system. This work is separate from the PHASES project and therefore the exact timing of this integration is not currently available.

Currently the logic used in Primary Sense is the Framingham Risk Calculator which provides a more conservative estimate of cardiovascular risk i.e. it will overestimate risk and so there are no safety concerns that high risk patients will be missed. Work is underway to update the Primary Sense with the AusSCVDRisk tool logic.

Funded by the Queensland Health Clinical Research Fellowship, the PHASES Linkage project connects general practice cardiovascular disease (CVD) risk data with hospitalisation and mortality data. This study aims to better understand how CVD risk impacts hospitalisation rates and assess the accuracy of the new CVD risk prediction equation in identifying high-risk individuals within Queensland’s population. 

The project will: 

  • Estimate the number of heart attacks and strokes that could be prevented with improved treatment for high CVD risk. 
  • Identify gaps in CVD prevention to inform future care strategies. 

Running in parallel with the PHASES project, PHASES Linkage highlights the power of data-driven insights to improve cardiovascular outcomes and reduce hospitalisations.