Table 2

Critical factors and 33 final delivery indicators (no shading) for which a national dataset can be applied and delivery enablers (shading) for which there is no national dataset but which may be ascertained/explored locally

Critical factor	Final delivery indicator/delivery enabler
1 Access to integrated care records for CVD	1a Access for complete MDT to patient integrated care record
2 Effective processes for inviting for CVD review in primary care	2a Total proportion of NHS Health Checks taken up vs those offered to eligible population
3 Effectiveness of CVD reviews in primary care	3a Proportion of identified patients with AF
	3b Proportion of patients identified with CHD
	3c Proportion of patients identified with HF
	3d Proportion of patients identified with hypertension
4 Effective treatment of identified patients with CVD	4a Percentage of patients with confirmed diagnosis of HF who have been optimised on medication
	4b Percentage of adult patients with CVD on lipid-lowering medication
	4c Percentage of NICE-identified at-risk patients who smoke offered support and treatment
5 Patients with AF are appropriately managed on anticoagulant	5a Percentage of patients diagnosed with AF currently treated with anticoagulation drug therapy
6 Processes in place to enable prescription of DOAC at diagnosis for patients with AF	6a DOAC can be initiated in primary care
	6b Ratio of prescribed DOAC per identified patients with AF
7 Identification of people with familial hypercholesterolaemia	7a Ratio of actual vs estimated patients with familial hypercholesterolaemia
8 At-risk patients with CHD are appropriately treated with aspirin or alternative agent	8a Percentage of patients with CHD appropriately treated with aspirin or alternative agent
9 Access to local practice pharmacists for CHD management	9 a Practice pharmacists per 1000 patients with CHD
10 Access to appropriate HF diagnostics	10a Percentage of patients with confirmed diagnosis of HF
	10b Proportion of general practices that have policy for actively using NT-proBNP in primary care for diagnosis of HF
	10c Proportion of general practices that have access to community echocardiography
11 Access to local specialist HF nurses	11a Specialist HF nurses per 1000 HF patients
12 Appropriate provision of cardiac rehabilitation services	12a* Proportion of patients with guideline indication for CR starting treatment
12 Appropriate provision of cardiac rehabilitation services	12b* Proportion of female patients with guideline indication for CR starting treatment
13 Appropriate access to cardiac rehabilitation services	13 a* Proportion of ethnic minority patients with guideline indication for CR starting treatment
13 Appropriate access to cardiac rehabilitation services	13b* Local CR services are personalised to patient availability—out-of-hours/virtual/alternative sites
14 Cardiac rehabilitation is resourced appropriately	14a* Average waiting time for starting CR therapy
15 Processes for actively managing CVD review invitations	15a Proportion of general practices with out-of-working-hours appointments available for NHS Health Checks and/or CVD reviews
16 Delivering CVD review management	16a CVD reviews offered by other providers such as community teams and community pharmacy
17 Identifying CVD review patients	17a Proportion of general practices actively using case identification tools as part of electronic patient record for CVD risk management
18 Ability to identify patients with AF	18a Proportion of general practices that have access to ECG machine
	18b Average waiting time for access to ambulatory rhythm monitoring for paroxysmal AF
	18c Average waiting time for access to TTE
19 Availability of familial hypercholesterolaemia service	19a ICS or PCN plan for identifying and referring patient with suspected familial hypercholesterolaemia for genomic testing
20 There is confidence in awareness and diagnosis of HF	20a PCN with breathlessness diagnostic pathway
21 There are sufficient community defibrillators for ICS demographics	21a ICS plan for provision of community defibrillators

The denominators and numerators for the final delivery indicators and enablers are available in online supplemental table D.
*Requires access to data from the NACR, which was inaccessible to the study team.
AF, atrial fibrillation; CHD, coronary heart disease; CR, cardiac rehabilitation; CVD, cardiovascular disease; DOAC, direct-acting oral anticoagulant; ECG, electrocardiography; HF, heart failure; ICS, integrated care system; LTP, long-term plan; MDT, multidisciplinary team; NACR, National Audit of Cardiac Rehabilitation; NHS, National Health Service; NICE, National Institute for Health and Care Excellence; NT-proBNP, N-terminal pro-brain natriuretic peptide; PCN, primary care network; TTE, transthoracic echocardiography.