Using Classification and Regression Trees (CART) to Identify Prescribing Thresholds for Cardiovascular Disease


Background and Objective

Many guidelines for clinical decisions are hierarchical and nonlinear. Evaluating if these guidelines are used in practice requires methods that can identify such structures and thresholds. Classification and regression trees (CART) were used to analyse prescribing patterns of Australian general practitioners (GPs) for the primary prevention of cardiovascular disease (CVD). Our aim was to identify if GPs use absolute risk (AR) guidelines in favour of individual risk factors to inform their prescribing decisions of lipid-lowering medications.


We employed administrative prescribing information that is linked to patient-level data from a clinical assessment and patient survey (the AusHeart Study), and assessed prescribing of lipid-lowering medications over a 12-month period for patients (n = 1903) who were not using such medications prior to recruitment. CART models were developed to explain prescribing practice. Out-of-sample performance was evaluated using receiver operating characteristic (ROC) curves, and optimised via pruning.


We found that individual risk factors (low-density lipoprotein, diabetes, triglycerides and a history of CVD), GP-estimated rather than Framingham AR, and sociodemographic factors (household income, education) were the predominant drivers of GP prescribing. However, sociodemographic factors and some individual risk factors (triglycerides and CVD history) only become relevant for patients with a particular profile of other risk factors. The ROC area under the curve was 0.63 (95 % confidence interval [CI] 0.60–0.64).


There is little evidence that AR guidelines recommended by the National Heart Foundation and National Vascular Disease Prevention Alliance, or conditional individual risk eligibility guidelines from the Pharmaceutical Benefits Scheme, are adopted in prescribing practice. The hierarchy of conditional relationships between risk factors and socioeconomic factors identified by CART provides new insights into prescribing decisions. Overall, CART is a useful addition to the analyst’s toolkit when investigating healthcare decisions.

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    For example, the American Heart Association (AHA) recommends using a modified Framingham equation [3]. In the UK, the National Institute for Health and Care Excellence (NICE) recommends an absolute CVD risk algorithm known as QRISK2 [4].

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    Prior exposure to medication is not preferred as we would observe risk factors after response to treatment.

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    Similar complications exist in clinical decision making in general [17], and in observed (as well as recommended) prescribing patterns for statins [1, 18, 19].

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    This has been shown to be an optimal method for model selection [29].

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    Bagging or ‘bootstrapped aggregating’ is a method for generating multiple versions of a tree to allow evaluation of predictor stability [31].

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    For example, there is some evidence to suggest that compliance increases with the number of risk factors [45].


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This work was supported by Monash University, the George Institute for Global Health, and the University of Melbourne.

Chris Schilling, Duncan Mortimer, Kim Dalziel, Emma Heeley, John Chalmers and Philip Clarke declare that they have no conflicts of interest.

Author contributions

CS, DM and KD conceptualized this report. All authors had input in developing the approach. CS produced multiple drafts. All authors provided input on the draft report and all read and approved the final report.

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Corresponding author

Correspondence to Chris Schilling.


Appendix 1

See Table 4.

Table 4 Summary of Australian guidelines current during the study period, to inform the prescribing of lipid-lowering medication

Appendix 2

After condensing the data to obtain a single observation per patient, our CART makes no further adjustment for clustering of observations by GP. On average, GPs see eight patients within the dataset (minimum of one patient per GP; maximum of 16). Stability across bagged trees may be overestimated if ‘bags’ of observations are drawn from clustered data. In supplementary analyses, we evaluated stability of the CART in 100 samples drawn using cluster-bootstrap methods [46]. Predictor counts and threshold densities were much the same with the cluster bootstrap as for the simple bootstrap on clustered data described above.

Similarly, while detailed contextual data on each GP was not available, the data did contain a State location variable that identifies the GP’s geographic region. In supplementary analyses, we included this variable within the predictor set, however it did not enter into the preferred CART model shown in Fig. 1.

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Schilling, C., Mortimer, D., Dalziel, K. et al. Using Classification and Regression Trees (CART) to Identify Prescribing Thresholds for Cardiovascular Disease. PharmacoEconomics 34, 195–205 (2016).

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  • Absolute Risk
  • Individual Risk Factor
  • Pharmaceutical Benefit Scheme
  • High Total Cholesterol
  • National Heart Foundation