Phytosterols have been shown to be effective in reducing serum cholesterol levels in numerous human clinical studies and regular consumption is recommended as part of therapeutic lifestyle changes aimed at reducing low density lipoprotein (LDL-C) in the treatment of hyperlipidaemia, a risk factor for cardiovascular disease. Fat based spreads have been shown to be a very successful vehicle for delivery of plant sterols, readily accepted by consumers and efficacious in reducing cholesterol levels. Alfa One™ Rice Bran Oil (RBO) spread is a new product entering into the market place. It is derived from rice bran oil and contains high levels of unsaponifiable material rich in phytosterols, triterpene alcohols, ferulic acid esters ([gamma]-oryzanol) and vitamin E isomers. As such it may have the potential to lower serum cholesterol levels when consumed on a daily basis. In order to establish the effectiveness of Alfa One™ Rice Bran Oil (RBO) spread compared with Flora pro-activ® margarine, a well established brand of plant sterol margarine already proven to lower cholesterol, a randomised double blind cross-over human clinical trial over 12 weeks was conducted. The study was divided into two treatment arms. The first arm of the study was to determine whether Alfa One™ RBO spread (containing 1.5% plant sterols) could lower total and LDL cholesterol levels to a greater extent than standard Flora margarine (containing no plant sterols) or Flora Pro-activ® margarine (containing 8% plant sterols). The second study arm tested the proposition that daily consumption of Alfa One™ Rice Bran Oil (RBO) spread in conjunction with rice bran oil (containing 0.5% plant sterols) would lower total and LDL cholesterol to a greater extent than Alfa One™ RBO spread in isolation and more than Flora margarine in conjunction with sunflower oil. Eighty mildly hypercholesterolaemic individuals (total cholesterol [greater than or equal to] 5 mmol/L and [less than or equal to] 7.5 mmol/L) were recruited and randomised into two groups of forty. Participants were asked to continue with their normal dietary pattern but to replace any margarine/butter/fat consumption with the trial products. One group of 40 were then assigned to the first treatment arm of the study (margarine-only group) and were randomised to consume 20 g (4 teaspoons) Alfa One™ RBO spread daily for 4 weeks, or 20 g Flora margarine daily for 4 weeks, or 20 Flora pro-activ® daily for 4 weeks. Phytosterol levels delivered in these amounts were: RBO margarine: 118mg phytosterol and 14 mg [gamma]-oryzanol; Flora proactiv® 1600 mg phytosterol; Flora margarine 0mg phytosterol. The second group of 40 were allocated to the second arm of the trial (margarine and oil group) and consumed 20 g Alfa One™ RBO spread and 30 ml rice bran oil (RBO) daily for 4 weeks, or 20 g Flora margarine and 30 ml sunflower oil daily for 4 weeks, or 20 g Alfa One™ RBO spread daily for 4 weeks, changing treatment at the end of each 4-week period. Phytosterol amounts delivered in these amounts were: RBO margarine: 118 mg phytosterol and 14 mg [gamma] oryzanol; RBO 222mg mg phytosterol, 150 mg [gamma] oryzanol. Each participant consumed all three treatments in a random order over a 12 week period. At baseline and following each 4 week intervention period, measurements were made of weight and blood pressure. Venous blood samples were collected for analysis of total cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), total cholesterol: HDL-C, triglycerides and plasma phytosterols. Three-day diet records from each individual were also collected for analysis of normal dietary intake. Results showed that compared to a standard Flora margarine, Alfa One™ RBO spread significantly reduced total cholesterol by 2.2% (P=0.045), total cholesterol:HDL by 4.1% (P=0.005) and LDL-C by 3.5% (P=0.016), but was not as effective overall as Flora Pro-activ® which reduced total cholesterol by 4.4% (P=0.001), total cholesterol:HDL by 3.4% (P=0.014) and LDL-C by 5.6% (P=0.001). Consumption of Flora margarine alone produced no significant decrease from baseline figures in any of the cholesterol parameters measured. Surprisingly, in group two, the addition of rice bran oil to the Alfa One™ RBO spread produced no differences in cholesterol levels. The reason for this unexpected result is being explored further. These results confirm that Alfa One™ RBO spread is effective in lowering serum cholesterol levels when consumed as part of a normal diet. Studies have shown that a 1% reduction in LDL-C can equate to a 2% decrease in coronary heart disease (CHD) risk thus suggesting that the 3.5% reduction demonstrated by Alfa One™ RBO spread in this study could be effective in reducing CHD risk as much as 6% in a mildly hypercholesterolaemic population.

Community participation is a key feature of major global health declarations and a fundamental principle of health strategies in Aotearoa New Zealand. However, the frequency with which it is espoused belies the complexities associated with its practical application. Engaging communities in primary health care programmes designed to improve their health has been identified as a major challenge. This study’s objective was to explore community members’ perspectives of participation within a health development programme. The programme chosen aimed to increase the fruit and vegetable intake of targeted population groups, including M ori, Pacific peoples, and low income earners. A qualitative instrumental case study approach was adopted to examine the programme and investigate what influenced, constrained, and sustained community participation. Data collection included fieldwork over an eighteen-month period. Two programme projects were selected as the study foci: a communityled project involving distributions of thousands of free heritage variety plants; and, instigated by health services, a project establishing community gardens. These projects provided markedly different pictures of participation occurring within the same programme. The plant distributions had widespread appeal, while the community garden faltered. Community participation fitted within a description of ‘focused social action’. Participation was motivated by needs, values, and interests. While some were personal and family based, the programme also became an imagined vehicle for addressing wider health, social justice, and environmental sustainability goals. Ongoing challenges related to defining targeted communities and groups, varying degrees and types of participation, and different perspectives of participation, especially as health sector staff worked from an equity mandate and community members spoke of equality. Programme groups established as mechanisms to foster community participation had contradictory effects, engaging some as advisors, while failing to reach communities targeted for the programme. The complexities of health sector bureaucracy both enabled and constrained the programme and community participation. This thesis provides an in-depth examination of the complexities of community participation in action, the contradictory effects of contexts enveloping programmes, and the resolve of community members. It increases our understandings of how community members perceive health programmes and community participation, which are critical factors in improving population health.

The significance of risk is growing in many Western societies, a phenomenon linked to increasing individualism, personal choice, and outcome uncertainty in multiple spheres of life. Despite being healthier and more physically protected from harm than any previous society, a serious concern for safety and risk control is emerging as a defining characteristic of modern social life. Within the context of a risk-averse society, this thesis investigates the nature and relevance of risk in natural resource recreation and tourism settings. Millions of people every day visit national parks and other protected areas around the world in which natural hazards inhere. Many visitors fail to recognise these hazards, creating moral, legal, and ethical issues for natural resource managers. People travel to national parks anticipating a degree of adventure, to escape routines, and to witness the grandeur of nature. Ironically, the very qualities that attract people to natural areas may also put them at risk. Managers of natural resource tourism and recreation areas in New Zealand are confronted with a paradox born out of visitor demand for nature experiences, a legal obligation to facilitate free access, and a growing social emphasis on health and safety. In particular, this study assesses the risk perceptions of visitors to the Fox and Franz Josef glaciers, popular tourist attractions on the West Coast of New Zealand's South Island, and explores the risk perceptions and beliefs of resource management agency staff. The study also investigates the issue of risk communication at these two sites, and the degree to which existing hazard messages are successful at encouraging appropriate visitor behaviour. Pictorial hazard warning signs are introduced to the sites and their effectiveness evaluated. The findings show that many visitors (especially international visitors) have relatively poor awareness of natural hazards, and behave in ways which potentially compromise physical safety. It is argued that perceptions and behaviour are a consequence of diverse individual and situational factors including limited knowledge of the sites, beliefs about management, poor comprehension of hazard warning signs, and freedom from the normative constraints of everyday life. In contrast to visitors, managers at the glacier sites consider the risks to be significant, and, potentially, severe. It is argued that managers' perceptions of risk are influenced by several important social and site-specific factors, including their own experiences of hazards at the glaciers, perceived legal and moral obligations, the organisational culture, and impressions of high societal expectation concerning safety. The situation is further complicated by the freedom of access principle in national parks, and increasing tourist demand for nature-based experiences. These factors governed beliefs about the subject of risk. This study identifies several dimensions of risk in nature-based recreation and tourism settings. Visitors are at risk of personal accident or injury at certain tourism attractions. Awareness of hazards is limited, visitor behaviour compromises safety, and existing communication strategies are only partially effective. Risk is also apparent in the agency responsible for management of outdoor recreation areas. Site managers perceive a risk in their failure to prevent visitors from harm, whereas senior managers identify risk as primarily financial, legal, and political. Collectively, these factors demonstrate that the phenomenon of risk is increasingly important in the tourism and recreation context, and has the potential to influence significantly both management and experience of protected natural areas in New Zealand.

Abstract Background Cardiovascular disease (CVD) has an enormous impact on the lives and health of New Zealanders. There is substantial epidemiological evidence that supports identifying people at high risk of CVD and treating them with lifestyle and drug-based interventions. If fully implemented, this targeted high risk approach could reduce future CVD events by over 50%. Recent studies have shown that a formal CVD risk assessment to the systematically identify high risk patients is rarely done in routine New Zealand general practice and audits of CVD risk management have shown large evidence-practice gaps. The CVD risk prediction score recommended by New Zealand guidelines for identifying high CVD risk patients was derived from the US Framingham Heart Study using data collected between the 1960s and 1980s. This score has only modest prediction accuracy and there are particular concerns about it’s validity for New Zealand sub-populations such as high risk ethnic groups or people with diabetes. Aims The overall aims of this thesis were to investigate the potential of a computerised decision support system (CDSS) to improve the assessment and management of CVD risk in New Zealand general practice while simultaneously developing a sustainable cohort study that could be used for validating and improving CVD risk prediction scores and related research. Methods An environmental scan of the New Zealand health care setting’s readiness to support a CDSS was conducted .The epidemiological evidence was reviewed to assess the effect of decision support systems on the quality of health care and the types and functionality of systems most likely to be successful. This was followed by a focused systematic review of randomised trials evaluating the impact of CDSS on CVD risk assessment and management practices and patient CVD outcomes in primary care. A web-based CDSS (PREDICT) was collaboratively developed. This rules-based provider-initiated system with audit and feedback and referral functionalities was fully integrated with general practice electronic medical records in a number of primary health organisations (PHOs). The evidence-based content was derived from national CVD and diabetes guidelines. When clinicians used PREDICT at the time of a consultation, treatment recommendations tailored to the patient’s CVD and diabetes risk profile were delivered to support decision-making within seconds. Simultaneously, the patient’s CVD risk profiles were securely stored on a central server. With PHO permission, anonymised patient data were linked via encrypted patient National Health Index numbers to national death and hospitalisation data. Three analytical studies using these data are described in this thesis. The first evaluated changes in GP risk assessment practice following implementation of PREDICT; the second investigated patterns of use of the CDSS by GPs and practice nurses; and the third describes the emerging PREDICT cohort and a preliminary validation of risk prediction scores. Results Given the rapid development of organised primary care since the 1990’s, the high degree of general practice computerisation and the New Zealand policy (health, informatics, privacy) environment, the introduction of a CDSS into the primary care setting was deemed feasible. The evidence for the impact of CDSS in general has been moderately favourable in terms of improving desired practice. Of the randomised trials of CDSS for assessing or managing CVD risk, about two-thirds reported improvements in provider processes and two-fifths reported some improvements in intermediate patient outcomes. No adverse effects were reported. Since 2002, the PREDICT CDSS has been implemented progressively in PHOs within Northland and the three Auckland regional District Health Board catchments, covering a population of 1.5 million. A before-after audit conducted in three large PHOs showed that CVD risk documentation increased four fold after the implementation of PREDICT. To date, the PREDICT dataset includes around 63,000 risk assessments conducted on a cohort of over 48,000 people by over 1000 general practitioners and practice nurses. This cohort has been followed from baseline for a median of 2.12 years. During that time 2655 people died or were hospitalised with a CVD event. Analyses showed that the original Framingham risk score was reasonably well calibrated overall but underestimated risk in high risk ethnic groups. Discrimination was only modest (AUC 0.701). An adjusted Framingham score, recommended by the New Zealand Guideline Group (NZGG) overestimated 5-year event rates by around 4-7%, in effect lowering the threshold for drug therapy to about 10% 5-year predicted CVD risk. The NZGG adjusted score (AUC 0.676) was less discriminating than the Framingham score and over-adjusted for high risk ethnic groups. For the cohort aged 30-74 years, the NZGG-recommended CVD risk management strategy identified almost half of the population as eligible for lifestyle management +/- drug therapy and this group generated 82% of all CVD events. In contrast the original Framingham score classified less than one-third of the cohort as eligible for individualised management and this group generated 71% of the events that occurred during follow-up. Implications This research project has demonstrated that a CDSS tool can be successfully implemented on a large scale in New Zealand general practice. It has assisted practitioners to improve the assessment and management of CVD at the time of patient consultation. Simultaneously, PREDICT has cost-effectively generated one of the largest cohorts of Māori and non-Māori ever assembled in New Zealand. As the cohort grows, new CVD risk prediction scores will be able to be developed for many New Zealand sub-populations. It will also provide clinicians and policy makers with the information needed to determine the trade-offs between the resources required to manage increasing proportions of the populations and the likely impact of management on preventing CVD events.

Abstract Background Cardiovascular disease (CVD) has an enormous impact on the lives and health of New Zealanders. There is substantial epidemiological evidence that supports identifying people at high risk of CVD and treating them with lifestyle and drug-based interventions. If fully implemented, this targeted high risk approach could reduce future CVD events by over 50%. Recent studies have shown that a formal CVD risk assessment to the systematically identify high risk patients is rarely done in routine New Zealand general practice and audits of CVD risk management have shown large evidence-practice gaps. The CVD risk prediction score recommended by New Zealand guidelines for identifying high CVD risk patients was derived from the US Framingham Heart Study using data collected between the 1960s and 1980s. This score has only modest prediction accuracy and there are particular concerns about it’s validity for New Zealand sub-populations such as high risk ethnic groups or people with diabetes. Aims The overall aims of this thesis were to investigate the potential of a computerised decision support system (CDSS) to improve the assessment and management of CVD risk in New Zealand general practice while simultaneously developing a sustainable cohort study that could be used for validating and improving CVD risk prediction scores and related research. Methods An environmental scan of the New Zealand health care setting’s readiness to support a CDSS was conducted .The epidemiological evidence was reviewed to assess the effect of decision support systems on the quality of health care and the types and functionality of systems most likely to be successful. This was followed by a focused systematic review of randomised trials evaluating the impact of CDSS on CVD risk assessment and management practices and patient CVD outcomes in primary care. A web-based CDSS (PREDICT) was collaboratively developed. This rules-based provider-initiated system with audit and feedback and referral functionalities was fully integrated with general practice electronic medical records in a number of primary health organisations (PHOs). The evidence-based content was derived from national CVD and diabetes guidelines. When clinicians used PREDICT at the time of a consultation, treatment recommendations tailored to the patient’s CVD and diabetes risk profile were delivered to support decision-making within seconds. Simultaneously, the patient’s CVD risk profiles were securely stored on a central server. With PHO permission, anonymised patient data were linked via encrypted patient National Health Index numbers to national death and hospitalisation data. Three analytical studies using these data are described in this thesis. The first evaluated changes in GP risk assessment practice following implementation of PREDICT; the second investigated patterns of use of the CDSS by GPs and practice nurses; and the third describes the emerging PREDICT cohort and a preliminary validation of risk prediction scores. Results Given the rapid development of organised primary care since the 1990’s, the high degree of general practice computerisation and the New Zealand policy (health, informatics, privacy) environment, the introduction of a CDSS into the primary care setting was deemed feasible. The evidence for the impact of CDSS in general has been moderately favourable in terms of improving desired practice. Of the randomised trials of CDSS for assessing or managing CVD risk, about two-thirds reported improvements in provider processes and two-fifths reported some improvements in intermediate patient outcomes. No adverse effects were reported. Since 2002, the PREDICT CDSS has been implemented progressively in PHOs within Northland and the three Auckland regional District Health Board catchments, covering a population of 1.5 million. A before-after audit conducted in three large PHOs showed that CVD risk documentation increased four fold after the implementation of PREDICT. To date, the PREDICT dataset includes around 63,000 risk assessments conducted on a cohort of over 48,000 people by over 1000 general practitioners and practice nurses. This cohort has been followed from baseline for a median of 2.12 years. During that time 2655 people died or were hospitalised with a CVD event. Analyses showed that the original Framingham risk score was reasonably well calibrated overall but underestimated risk in high risk ethnic groups. Discrimination was only modest (AUC 0.701). An adjusted Framingham score, recommended by the New Zealand Guideline Group (NZGG) overestimated 5-year event rates by around 4-7%, in effect lowering the threshold for drug therapy to about 10% 5-year predicted CVD risk. The NZGG adjusted score (AUC 0.676) was less discriminating than the Framingham score and over-adjusted for high risk ethnic groups. For the cohort aged 30-74 years, the NZGG-recommended CVD risk management strategy identified almost half of the population as eligible for lifestyle management +/- drug therapy and this group generated 82% of all CVD events. In contrast the original Framingham score classified less than one-third of the cohort as eligible for individualised management and this group generated 71% of the events that occurred during follow-up. Implications This research project has demonstrated that a CDSS tool can be successfully implemented on a large scale in New Zealand general practice. It has assisted practitioners to improve the assessment and management of CVD at the time of patient consultation. Simultaneously, PREDICT has cost-effectively generated one of the largest cohorts of Māori and non-Māori ever assembled in New Zealand. As the cohort grows, new CVD risk prediction scores will be able to be developed for many New Zealand sub-populations. It will also provide clinicians and policy makers with the information needed to determine the trade-offs between the resources required to manage increasing proportions of the populations and the likely impact of management on preventing CVD events.

Abstract Background Cardiovascular disease (CVD) has an enormous impact on the lives and health of New Zealanders. There is substantial epidemiological evidence that supports identifying people at high risk of CVD and treating them with lifestyle and drug-based interventions. If fully implemented, this targeted high risk approach could reduce future CVD events by over 50%. Recent studies have shown that a formal CVD risk assessment to the systematically identify high risk patients is rarely done in routine New Zealand general practice and audits of CVD risk management have shown large evidence-practice gaps. The CVD risk prediction score recommended by New Zealand guidelines for identifying high CVD risk patients was derived from the US Framingham Heart Study using data collected between the 1960s and 1980s. This score has only modest prediction accuracy and there are particular concerns about it’s validity for New Zealand sub-populations such as high risk ethnic groups or people with diabetes. Aims The overall aims of this thesis were to investigate the potential of a computerised decision support system (CDSS) to improve the assessment and management of CVD risk in New Zealand general practice while simultaneously developing a sustainable cohort study that could be used for validating and improving CVD risk prediction scores and related research. Methods An environmental scan of the New Zealand health care setting’s readiness to support a CDSS was conducted .The epidemiological evidence was reviewed to assess the effect of decision support systems on the quality of health care and the types and functionality of systems most likely to be successful. This was followed by a focused systematic review of randomised trials evaluating the impact of CDSS on CVD risk assessment and management practices and patient CVD outcomes in primary care. A web-based CDSS (PREDICT) was collaboratively developed. This rules-based provider-initiated system with audit and feedback and referral functionalities was fully integrated with general practice electronic medical records in a number of primary health organisations (PHOs). The evidence-based content was derived from national CVD and diabetes guidelines. When clinicians used PREDICT at the time of a consultation, treatment recommendations tailored to the patient’s CVD and diabetes risk profile were delivered to support decision-making within seconds. Simultaneously, the patient’s CVD risk profiles were securely stored on a central server. With PHO permission, anonymised patient data were linked via encrypted patient National Health Index numbers to national death and hospitalisation data. Three analytical studies using these data are described in this thesis. The first evaluated changes in GP risk assessment practice following implementation of PREDICT; the second investigated patterns of use of the CDSS by GPs and practice nurses; and the third describes the emerging PREDICT cohort and a preliminary validation of risk prediction scores. Results Given the rapid development of organised primary care since the 1990’s, the high degree of general practice computerisation and the New Zealand policy (health, informatics, privacy) environment, the introduction of a CDSS into the primary care setting was deemed feasible. The evidence for the impact of CDSS in general has been moderately favourable in terms of improving desired practice. Of the randomised trials of CDSS for assessing or managing CVD risk, about two-thirds reported improvements in provider processes and two-fifths reported some improvements in intermediate patient outcomes. No adverse effects were reported. Since 2002, the PREDICT CDSS has been implemented progressively in PHOs within Northland and the three Auckland regional District Health Board catchments, covering a population of 1.5 million. A before-after audit conducted in three large PHOs showed that CVD risk documentation increased four fold after the implementation of PREDICT. To date, the PREDICT dataset includes around 63,000 risk assessments conducted on a cohort of over 48,000 people by over 1000 general practitioners and practice nurses. This cohort has been followed from baseline for a median of 2.12 years. During that time 2655 people died or were hospitalised with a CVD event. Analyses showed that the original Framingham risk score was reasonably well calibrated overall but underestimated risk in high risk ethnic groups. Discrimination was only modest (AUC 0.701). An adjusted Framingham score, recommended by the New Zealand Guideline Group (NZGG) overestimated 5-year event rates by around 4-7%, in effect lowering the threshold for drug therapy to about 10% 5-year predicted CVD risk. The NZGG adjusted score (AUC 0.676) was less discriminating than the Framingham score and over-adjusted for high risk ethnic groups. For the cohort aged 30-74 years, the NZGG-recommended CVD risk management strategy identified almost half of the population as eligible for lifestyle management +/- drug therapy and this group generated 82% of all CVD events. In contrast the original Framingham score classified less than one-third of the cohort as eligible for individualised management and this group generated 71% of the events that occurred during follow-up. Implications This research project has demonstrated that a CDSS tool can be successfully implemented on a large scale in New Zealand general practice. It has assisted practitioners to improve the assessment and management of CVD at the time of patient consultation. Simultaneously, PREDICT has cost-effectively generated one of the largest cohorts of Māori and non-Māori ever assembled in New Zealand. As the cohort grows, new CVD risk prediction scores will be able to be developed for many New Zealand sub-populations. It will also provide clinicians and policy makers with the information needed to determine the trade-offs between the resources required to manage increasing proportions of the populations and the likely impact of management on preventing CVD events.

Abstract Background Cardiovascular disease (CVD) has an enormous impact on the lives and health of New Zealanders. There is substantial epidemiological evidence that supports identifying people at high risk of CVD and treating them with lifestyle and drug-based interventions. If fully implemented, this targeted high risk approach could reduce future CVD events by over 50%. Recent studies have shown that a formal CVD risk assessment to the systematically identify high risk patients is rarely done in routine New Zealand general practice and audits of CVD risk management have shown large evidence-practice gaps. The CVD risk prediction score recommended by New Zealand guidelines for identifying high CVD risk patients was derived from the US Framingham Heart Study using data collected between the 1960s and 1980s. This score has only modest prediction accuracy and there are particular concerns about it’s validity for New Zealand sub-populations such as high risk ethnic groups or people with diabetes. Aims The overall aims of this thesis were to investigate the potential of a computerised decision support system (CDSS) to improve the assessment and management of CVD risk in New Zealand general practice while simultaneously developing a sustainable cohort study that could be used for validating and improving CVD risk prediction scores and related research. Methods An environmental scan of the New Zealand health care setting’s readiness to support a CDSS was conducted .The epidemiological evidence was reviewed to assess the effect of decision support systems on the quality of health care and the types and functionality of systems most likely to be successful. This was followed by a focused systematic review of randomised trials evaluating the impact of CDSS on CVD risk assessment and management practices and patient CVD outcomes in primary care. A web-based CDSS (PREDICT) was collaboratively developed. This rules-based provider-initiated system with audit and feedback and referral functionalities was fully integrated with general practice electronic medical records in a number of primary health organisations (PHOs). The evidence-based content was derived from national CVD and diabetes guidelines. When clinicians used PREDICT at the time of a consultation, treatment recommendations tailored to the patient’s CVD and diabetes risk profile were delivered to support decision-making within seconds. Simultaneously, the patient’s CVD risk profiles were securely stored on a central server. With PHO permission, anonymised patient data were linked via encrypted patient National Health Index numbers to national death and hospitalisation data. Three analytical studies using these data are described in this thesis. The first evaluated changes in GP risk assessment practice following implementation of PREDICT; the second investigated patterns of use of the CDSS by GPs and practice nurses; and the third describes the emerging PREDICT cohort and a preliminary validation of risk prediction scores. Results Given the rapid development of organised primary care since the 1990’s, the high degree of general practice computerisation and the New Zealand policy (health, informatics, privacy) environment, the introduction of a CDSS into the primary care setting was deemed feasible. The evidence for the impact of CDSS in general has been moderately favourable in terms of improving desired practice. Of the randomised trials of CDSS for assessing or managing CVD risk, about two-thirds reported improvements in provider processes and two-fifths reported some improvements in intermediate patient outcomes. No adverse effects were reported. Since 2002, the PREDICT CDSS has been implemented progressively in PHOs within Northland and the three Auckland regional District Health Board catchments, covering a population of 1.5 million. A before-after audit conducted in three large PHOs showed that CVD risk documentation increased four fold after the implementation of PREDICT. To date, the PREDICT dataset includes around 63,000 risk assessments conducted on a cohort of over 48,000 people by over 1000 general practitioners and practice nurses. This cohort has been followed from baseline for a median of 2.12 years. During that time 2655 people died or were hospitalised with a CVD event. Analyses showed that the original Framingham risk score was reasonably well calibrated overall but underestimated risk in high risk ethnic groups. Discrimination was only modest (AUC 0.701). An adjusted Framingham score, recommended by the New Zealand Guideline Group (NZGG) overestimated 5-year event rates by around 4-7%, in effect lowering the threshold for drug therapy to about 10% 5-year predicted CVD risk. The NZGG adjusted score (AUC 0.676) was less discriminating than the Framingham score and over-adjusted for high risk ethnic groups. For the cohort aged 30-74 years, the NZGG-recommended CVD risk management strategy identified almost half of the population as eligible for lifestyle management +/- drug therapy and this group generated 82% of all CVD events. In contrast the original Framingham score classified less than one-third of the cohort as eligible for individualised management and this group generated 71% of the events that occurred during follow-up. Implications This research project has demonstrated that a CDSS tool can be successfully implemented on a large scale in New Zealand general practice. It has assisted practitioners to improve the assessment and management of CVD at the time of patient consultation. Simultaneously, PREDICT has cost-effectively generated one of the largest cohorts of Māori and non-Māori ever assembled in New Zealand. As the cohort grows, new CVD risk prediction scores will be able to be developed for many New Zealand sub-populations. It will also provide clinicians and policy makers with the information needed to determine the trade-offs between the resources required to manage increasing proportions of the populations and the likely impact of management on preventing CVD events.