PI 20 - CVD risk assessment factors

Proportion of regular clients who have had the necessary risk factors assessed to enable cardiovascular disease (CVD) assessment


Proportion of Indigenous regular clients with no known cardiovascular disease (CVD), assessed aged 35 to 74, with information available to calculate their absolute CVD risk.


  • User may select between AIHW's definition of Regular Client (attended the OATSIH-funded primary health care service at least 3 times in 2 years), or Communicare's Current Patient status.
  • Patients must be recorded as Aboriginal or Torres Strait Islander or both.
  • Patients must have a sex and date of birth.
  • Patients must have the following recorded in the previous 24 months:
    • Smoking status (reference qualifier with system code of SMO or SMP).
    • Systolic blood pressure (numeric qualifier with system code of BPS).
    • Either total cholesterol and HDL (numeric qualifiers with system codes of CHO and HDL) or cholesterol/HDL level (numeric qualifier with system code of CHR).
    • For more information about qualifier system codes, see Qualifier codes.
Table 1. NKPI PI 20
Element Description
Communicare reports
  • Report > National KPI > PI20 CVD Risk Factors
  • Report > National KPI > PI20 CVD Risk Factors Patients
Numerator All defined measures must have been recorded in the previous two years.
Denominator Regular, Indigenous patients aged 35 years and under 75 years old at the end of the report period without a CVD diagnosis.

For more information about condition codes, see Condition codes reference.

Additional data recording considerations
Note: some patients will not have all the measures recorded, but will still have an absolute CV risk recorded for indicator PI 21. This may be a data entry issue or may relate to some patients who can have a high risk inferred due to age and other conditions. For example, over 60 years with diabetes and microalbuminuria.