Review of evidence for the alignment of guidelines on Aboriginal and Torres Strait Islander absolute cardiovascular disease risk: A report prepared for the Australian Government Department of Health

Policy context: Cardiovascular disease (CVD) is highly preventable. CVD continues to be the largest contributor to mortality within the Aboriginal and Torres Strait Islander population and rates of CVD are disproportionately higher within the Australian Aboriginal and Torres Strait Islander population compared to the non-Indigenous population. Improving uptake of current evidence based solutions such as the absolute risk approach to CVD within the Aboriginal and Torres Strait Islander population is important to address this disparity. Although there are several tools available supporting an absolute CVD risk approach, clinical uptake is limited due to a number of factors including an outdated continued reliance on the ‘single risk factor’ approach to prevention, diagnosis and treatment of CVD. A major barrier to uptake is inconsistent messages in the current clinical practice guidelines. Key messages: There are three main guidelines on the absolute CVD risk approach for Aboriginal and Torres Strait Islander peoples in Australia: The NVDPA Guidelines for the Management of Absolute Cardiovascular Disease Risk; The Central Australian Rural Practitioners Association Standard Treatment Manual; and the RACGP National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. There is considerable alignment between the existing guidelines, including the need for an absolute risk approach, conditions conferring automatic high risk, use of the Framingham risk equation as the basis of calculating absolute risk, and the need to treat people at a greater than 15% risk of a primary CVD event over the next five years. The guidelines diverge materially in relation to four recommendations: 1) the age at which to commence absolute CVD risk assessment; 2) whether or not calculated risk scores should be adjusted upward by 5%; 3) how often CVD risk should be assessed; and 4) treatment targets for blood pressure. Available evidence indicates that CVD events and high absolute CVD risk occurs earlier in Aboriginal and Torres Strait Islander peoples, and that prevention of CVD should also start early. The proportion of Aboriginal and Torres Strait Islander peoples at high absolute CVD risk at the ages of 18-34 years broadly corresponds to the proportion at high risk among the general population aged 45-54 years. Limited evidence suggests that the current risk scores are likely to underestimate risk in Aboriginal and Torres Strait Islander peoples. Specific data on the extent of underestimation and alternative validated risk scores in this population are lacking. There is no primary data on adjusting risk scores upwards by 5% in Aboriginal and Torres Strait Islander people. Frequency of CVD risk assessment should be based on initial level of risk but the optimal interval for risk reassessment at each level of risk is not clear. There is general agreement between the guidelines to lower blood pressure as tolerated but there are inconsistencies in the exact blood pressure target. Evidence suggests that reductions in systolic blood pressure result in proportional reductions in CVD events and all-cause mortality. CVD guidelines could be kept up to date by adopting a ‘living’ guidelines model, but consideration needs to be given to how to identify relevant updated evidence and how to integrate the updates into electronic decision support tools.This research was supported by a grant from the Australian Government Department of Health

Framework para el desarrollo y entrenamiento de sistemas de indeferencia difusa siguiendo métodos de desarrollo dirigido por modelos

224 p.Este trabajo de tesis doctoral presenta un modelo independiente de la computación de un Diagnóstico Diferencial (DD), así como un modelo independiente de la plataforma de un Sistema de Inferencia Difusa. Se han utilizado los Métodos de Desarrollo Dirigido por Modelos (MDDM) en la concepción de los modelos, los cuales, además de facilitar la definición de los modelos, ofrecen herramientas para la realización de transformaciones entre ellos. Así, en el presente trabajo también se exponen las transformaciones entre los modelos de DD y SID y las transformaciones para la generación automática de SID expresados en lenguajes concretos a partir de los modelos de SID independientes de la plataforma. Los SID dependientes de la plataforma pueden ser incluidos en el formalismo de representación de Guías Clínicas Informatizadas (GCI) Aide. Así mismo, en la tesis también se incluye una descripción de las herramientas que facilitan la definición de modelos de DD y SID, así como la generación automática de SID en lenguajes concretos utilizables en distintos motores de razonamiento. Es de reseñar la adición de un módulo de aprendizaje automático mediante un Algoritmo Genético que permite adaptar algunas características de los modelos de SID a los datos reales de entrenamiento. Las herramientas y modelos se han validado en dos ámbitos. Por un lado, se han utilizado en el cribado neonatal, una prueba diagnóstica dirigida a la identificación presintomática de enfermedades graves con el fin de tratarlas precozmente y así prevenir y minimizar minusvalías neurológicas, orgánicas y psíquicas. Por otro lado, se han utilizado en el diagnóstico de la hiperamonemia, una Enfermedad Rara que se debe tratar de forma urgente para evitar graves secuelas neurológicas e incluso la muerte. En ambos casos, los SID creados se han integrado en unas GCI para ser evaluados