CVD Prevention in Primary Care CVD Guidelines Symposium Wednesday 3 rd Novemeber 2010 Dr John Cox FRCPI FRCGP

Introduction “Vascular diseases, of which cardiovascular disease is the most common, account for over 40% of all deaths and 37% of deaths under 65 years in Ireland. Within cardiovascular disease, ischaemic heart disease is by far the most common, accounting for approximately 25% of all deaths.” “Vascular diseases, of which cardiovascular disease is the most common, account for over 40% of all deaths and 37% of deaths under 65 years in Ireland. Within cardiovascular disease, ischaemic heart disease is by far the most common, accounting for approximately 25% of all deaths.” Central Statistics Office

HEARTWATCH  The National Programme in General Practice for the Secondary Prevention of Cardiovascular Disease in Ireland  Commenced in 2003  Protocols based on ESC guidelines (1998)

HEARTWATCH targets  Maintain blood pressure below 140/90 mmHg in all patients in the programme  Total cholesterol consistently below 5 mmol/l and LDLc below 3 mmol/l  No smoking

HEARTWATCH -recruitment

HEARTWATCH - Results Bennett K, Jennings S et al. Eur J Cardiovasc Prev Rehabil Dec;15(6):651-6

HEARTWATCH - Learnings  A secondary prevention programme in primary care in Ireland can work  The value of the practice nurse in implementing a chronic disease management programme  Patient enthusiasm for a disease mangement programme

SLÁN 2007   29% reported being current smokers   6 in 10 respondents had high blood pressure. Of these, about 6 in 10 were not on medication for blood pressure. Of those on medication, about 7 in 10 were not controlled   Over three-quarters of the sample had raised cholesterol, with most not on cholesterol- lowering medication. One-third of those treated with medication for cholesterol were not controlled. Morgan K et al, 2008

Guidelines on risk assessment The Irish College of General Practitioners formally endorsed the 2007 European guidelines on cardiovascular disease (CVD) prevention in clinical practice for the assessment of cardiovascular risk in the Summer of 2009

Use of risk scoring In a survey of US family physicians where >90% screened adults for hyperlipidemia-   85% were aware of the National Cholesterol Education Program guidelines   only 13% had read them carefully   only 17% usually or always used a CHD risk calculator Eaton CB, et al J Am Board Fam Med 2006; 19:46–53

Use of risk scoring In a survey of 26 German general practitioners that evaluated the primary prevention of CVD –   75% used a high-risk strategy in primary prevention   50% admitted to not using guidelines   70% did not use risk calculators. Oriol-Zerbe C, et al Eur J Gen Pract 2007; 13:27–34

What can be done? In a survey conducted by the European Society of Cardiology in six European countries the following suggestions were made were proposed to improve implementation -   development of clear, easy to use and simpler guidelines (prompted = 46%; unprompted = 23%)   greater financial incentives (unprompted = 24%) Graham IM, et al Eur J Cardiovasc Prev Rehabil 2006;13:839–45

U K experience The Quality and Outcomes Framework (QOF) scheme links primary care income with the achievement of specific evidence based targets in healthcare -   In 2009, a new QOF payment was introduced for primary prevention risk scoring of patients on the hypertension registry. [ carecontracting/QOF]

U K experience A UK government-sponsored initiative entitled ‘Putting Prevention First’ was introduced that involves local primary care organizations introducing vascular risk assessment and management programs for all people between 40 and 74 years of age over a 5-year period. [

Computerization   In a study conducted in New Zealand, system improvements in primary care practice software were highly successful, increasing the CVD risk assessment screening rate from 4.7% to 53.5% over 12 months (N= 6570). Sinclair G, Kerr A. N Z Med J 2006; 119:U2312

Computerization Integration of a web-based decision support system (PREDICT–CVD) with primary care electronic medical record software improved CVD risk documentation 4-fold in a primary care practice of 3564 patients in New Zealand. Wells S, et al. Eur J Cardiovasc Prev Rehabil 2008;15:173–8

Implementation of primary prevention guidelines  Articles in Forum the journal published by the ICGP  Publication of The SCORE risk chart in the ICGP Yearbook and Diary  Presentation on HeartScore for GPs attending the ICGP 4 th Annual Summer School at Lyrath Hotel in June 2010

Conclusion  Prevention of CVD is an important component of the General Practitioner’s work  The General Practitioner in ideally situated to carry out this task  A closer working relationship between General Practitioners and those responsible for producing guidelines in this area will help us all

 Thank you !