1. Guidelines for the prevention of cardiovascular disease in Ireland- the way forward 3 November 2010 European 4 th Joint Task Force Guidelines on CVD prevention in Clinical Practice: Targets, implementation and 5 th Joint Task Force Guidelines 2012 Ian Graham Chairman JTF4, European Prevention Implementation Committee and IHF Council on CVD Prevention

2. Objectives of today’s meeting 1.Summarise current and future European CVD prevention Guidelines and implementation strategy (IG) 2.Summarise the role of the National Co-ordinator in the implementation process (SJ) 3.Guidelines in the context of National Policy (H McG) 4.The role of primary care (JC) 5.The role of the nurse (NF) 6.WORKSHOPS- 6.1 Perceived roles in implementation 6.2 Moving towards an integrated national strategy 6.3 Defining synergies and complementarity 6.4 Input into one page Irish Guideline 6.5 Suggestions for the 5 th Joint Task Force

3. Outline Objectives of meeting General background 4 th Joint Task Force European Guidelines on CVD prevention 5 th Joint Guidelines Implementation- some principles European Prevention Implementation Committee Action Plan Relations with the National Coordinators for CVD prevention

4. General Background

5. European Prevention implementation is complex- many players are involved 1.The EU- vital but no legislative framework 2.Individual Departments of Health- like their independence 3.ESC 4.EACPR 5.National Cardiac and other specialist and GP societies 6.Nurses and allied health professional, European and National 7.Educators- 1 st 2 nd & 3 rd level 8.Industry- Pharma, Food, Exercise, Neutral It’s like herding cats!

6. No data < 30 30-50 50-70 70-100 100-150 150-200 > 200 Age standardised CHD mortality rates (under 65) in men & women

7. The European Heart Health Charter and the Guidelines on cardiovascular disease prevention The European Heart Health Charter advocates the development and implementation of comprehensive health strategies, measures and policies at European, national, regional, and local level that promote cardiovascular health and prevent CVD The Joint CVD prevention guidelines aim to assist physicians and other health professionals to fulfil their role in this endeavour, particularly with regard to achieving effective preventive measures in day-to-day clinical practice They reflect the consensus arising from a multi- disciplinary partnership between the major European professional bodies represented

8. Implementation of CVD guidelines 1.Knowledge of JTF4 guidelines and what is likely in JTF5 2.The gap between recommendations and clinical practice 3.Barriers to implementation 4.Strategies to improve implementation

9. Implementation Guidelines Audit Guidelines on Prevention Research SCORE,HeartScore Evidence based reviews EuroAspireE-SURF PIC Nat. Co-ord EuroAction 94,98,03,07,12

10. European Guidelines on CVD Prevention Fourth Joint European Societies’ Task Force on cardiovascular disease prevention in clinical practice Ian M Graham Chairman JTF4

13. JTF4 on CVD PREVENTION CONTENTS 1. Introduction 2. Scope of the problem; past and future 3. Prevention strategies and policy issues 4. How to evaluate scientific evidence 5. Priorities, total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drug therapy 20. Implementation strategies

14. What are the PRIORITIES for CVD prevention in clinical practice ? 1.Patients with established atherosclerotic CVD 2.Asymptomatic individuals who are at increased risk of CVD because of 2.1 Multiple risk factors resulting in raised total CVD risk (≥5% SCORE 10-year risk of CVD death) 2.2 Diabetes type 2 and type 1 with microalbuminuria 2.3 Markedly increased single risk factors especially if associated with end-organ damage 3Close relatives of subjects with premature atherosclerotic CVD or of those at particularly high risk

15. 0 3 5 140 5 3 0 People who stay healthy tend to have certain characteristics: 0 No tobacco 3 Walk 3 km daily, or 30 mins any moderate activity 5 Portions of fruit and vegetables a day 140 Blood pressure less than 140 mm Hg systolic 130 5 Total blood cholesterol <5mmol/l 4.5, 4 3 LDL cholesterol <3 mmol/l 2.5, 2 0 Avoidance of overweight and diabetes

16. JTF5 on CVD Prevention Much shorter and more succinct More explicit evidence base- ESC grading vs. GRADE New approaches to risk estimation- total events, risk age Targets similar- 1.8 mmol/l for LDL cholesterol? There is time to influence them! Will be launched at Europrevent Dublin, 3-5 May 2012

17. How big is the gap between recommendations and practice? Has there been an improvement over time?

18. BMI Smoking Obesity Diabetes Use of BP meds Total Chol BP control All countries

19. Utility of Guidelines Guidelines alone are good for the vanity of the authors and bad for rain forests; they are a waste of time without a defined implementation strategy Hence the Prevention Implementation Committee and other implementation efforts

20. “Said is not heard, heard is not understood, understood is not agreed upon, agreed is not applied, applied is not at all maintained.” Konrad Lorenz, 1903-1969 [Thank you, Ulrich Keil]

21. Barriers to implementation Pearson 1996; European Guidelines 4th Joint Task Force 2007 Patient (Person) Physician Health Care Settings Community/Society

22. Barriers to implementation REACT study, Hobbs FDR, Erhardt L, Family Practice 2002 ESC CRT Market research survey, Graham I, EJCPR 2006 Lack of patient compliance Lack of time Lack of budget Lack of clarity (complicated, confusing, too much information) Guidelines too general (do not fit my patient) Unhelpful government health policies (assistance, remuneration, patient education)

23. SUMMARY: Key factors to increase usage of guidelines Simple, clear, credible national guidelines Sufficient time Facilitatory government policy: -Defined prevention strategy -Reimbursement for health professionals -public awareness and education from school on Multidisciplinary implementation strategy- with teeth

24. CVD Prevention Implementation An adapted structure for the future

25. The EUROPEAN PREVENTION IMPLEMENTATION COMMITTEE Terms of Reference The ESC has delegated the implementation of the European Guidelines on CVD Prevention to the European Association Cardiovascular Prevention and Rehabilitation. Its Cardiovascular Prevention Implementation Committee fulfils that function. Its role is to help to close the gap between science and practice for both in hospital and in primary care

26. PREVENTION IMPLEMENTATION COMMITTEE Membership Co-Chairs: Ian Graham & Pantaleo Giannuzzi Members Prof Pantaleo Gianuzzi, EACPR President Prof David Wood, EACPR Past-President Prof Lars Ryden, recent Chair of the ESC European Affairs Committee Prof Richard Hobbs, Chair Council on Cardiovascular Primary Care Susanne Logstrup, EHN Muriel Mioulet, ESC External Affairs Director Sophie Squarta, ESC Head of Department for CVD Prevention Sections representatives Cardiac rehabilitation -Hannah McGee Epidemiology & Public Health -Johan De Sutter Exercise Physiology -Martin Halle Prevention & Health Policy -Diego Vanuzzo Sports Cardiology -Dorian Dugmore Sducation Committee - Lale Tokgozoglu

27. Prevention Implementation Committee Action Plan

28. PREVENTION IMPLEMENTATION COMMITTEE ACTIVITIES 1.Core activities 2.Define strategies to assist in Guideline implementation 3.Activities with the National Co- ordinators for CVD prevention

29. PIC – Suggested Core activities- Benchmarking – H. McGee Health Economic models – D. Wood & G. De Backer Industry projects – M. Halle & D. Dugmore Audit – E-SURF- Ian Graham Implementation research Political lobbying – L. Rydén “How to” manual – P. Giannuzzi Lay communications- Joep Perk (Apoteket), Lay Score/HeartScore

30. Strategies to improve implementation Sophie Squarta, Lars Ryden, Ian Graham

31. Implementation strategies: European level 1.Publication of Guidelines in relevant journals 2.The Prevention Toolkit, comprising the Guidelines (paper and electronic), a slidekit and HeartScore stand alone 3.A defined dissemination strategy 4.Implementation Committees/Groups: Prevention Implementation Committee; Joint Prevention Committee; National Coordinators 5. Presentations at international conferences of the participating societies 6. Directly influencing EU health policy- for example through the Luxembourg Declaration and the European Health Charter- the product of a partnership between the EU, WHO, ESC and EHN

32. Implementation strategies: TOOLS 1.Guidelines: full text/ summary/pocket/one page/posters 2.HeartSore: The electronic, interactive risk estimation and guideline tool. On line and stand- alone, downloadable and on CD 3.The new Guideline Learning Tool- on-line interactive case-based learning 4.The e-toolkit: Guidelines, slides, HeartScore 5.E-SURF, the new and simplified risk factor audit

33. Implementation strategies: National level 1.Adapt the European Guidelines to suit the local culture 2.Formation of a multidisciplinary implementation group: professional bodies, medical and other health professionals, basic scientists, educators, business people, politicians. Needs to be more than merely advisory: should inform and shape health policy 3. Multi-faceted communications using all available media to doctors, medical and para-medical students, and ultimately all adults and children, including schools

34. Forming a multidisciplinary implementation group Process- The ESC asks National Cardiac Societies to nominate a National Co-ordinator to develop and lead the multidisciplinary implementation group which will develop- National adaptation of guidelines if required Partnerships between politicians, health professionals, educators and business A defined communication strategy An evaluation strategy BUT it must have teeth. This requires high level political representation if it is not to be a talking-shop. Indeed… This process has been variably successful. It is now proposed that there should be two national co-ordinators- one a cardiologist and one from the Department of Health/ Health Service Executive

35. Forming a multidisciplinary implementation group -IRELAND 1. IHF Council on CVD prevention established to facilitate the process 2.(Chair IG) 3.National Co-ordinators Siobhan Jennings and Mahon Varma 4.Project manager Bridget Claffrey 5.Workplan established including meetings with all stakeholders and this meeting 6.Aim to showcase Ireland as an exemplar of the development of an implementation strategy 7.Presentation to the ESC European Summit on CVD prevention, Nice 30 Nov 2010

36. SUMMARY Objectives of meeting defined General background 4 th Joint Task Force European Guidelines on CVD prevention 5 th Joint Guidelines Implementation- some principles European Prevention Implementation Committee Action Plan Relations with the National Coordinators for CVD prevention The strategy for Ireland

37. Thank you

38. Relations with the National Coordinators for CVD Prevention

39. PIC and the National Co-ordinators Promotion of joint co-ordinators in each country representing Cardiology and the Department of Health Contribute to benchmarking by updating the Mapping document Individualised strategic advice to countries Workshops especially for developing countries Contribution and use of the “How to” manual Advice to and from the Joint Prevention Alliance Possibly to act as national co-ordinators for the pan- European audit

40. PIC, JPA and National Co-ordinators- Likely most effective actions? 1.Driving National alliances 2.Simpler Guideline materials 3.How-to manual 4.Benchmarking and audit 5.Lobbying EU policy

41. Discussion of JPA and PIC

42. PIC and Joint Prevention Alliance 1.It is suggested to reflect the importance of the JPC by re-naming it the Joint Prevention Alliance 2.The partnership- JTF4/5 members- remains the same 3.The JPA will decide its own workplan: Encourage Joint Guidelines dissemination by the partner bodies Promote and co-ordinate Alliance events and workshops at specialist conferences Provide information on networks within countries to aid in the co-ordination of implementation Advise the PIC in all of its activities Advise on & promote the “how-to” manual Assist in development of guideline learning tool Specific topics for lobbying

43. PIC – Suggested Core activities- to be prioritised Benchmarking – H. McGee –“ Call for Action” mapping document – EuroAspire III – Psyma survey report – Powerhouse Health Consumer report – EuroHeart WP5 Health Economic models – D. Wood & G. De Backer Demonstration projects – M. Halle & D. Dugmore Audit – Epidemiology & Public Health section Implementation research Political lobbying – L. Rydén “How to” manual – I. Graham & P. Giannuzzi Lay communications- Joep Perk (Apoteket), Lay Score/HeartScore

44. JTF4 Guidelines on CVD Prevention in Clinical Practice 1. INTRODUCTION

45. JTF IV Guidelineson prevention of CVD FORMAT Full text- far too long!- treat as a resource document. Summary boxes from the pocket guidelines to make navigation easier Summary- still far too long! Pocket guidelines- better, more accessible Single page handout- summarizes the key points The challenge- to keep the key points in the health professional’s mind- and on his/her desk!

46. JTF4 on CVD Prevention in Clinical Practice 3. PREVENTION STRATEGIES AND POLICY ISSUES

47. WHO report on the Prevention of CHD (and hence CVD) defined three components to preventive strategy: 1. Population 2. High risk 3. Secondary prevention The prevention paradox- high risk individuals gain most from preventive measures- but most CVD deaths come from subjects with only mildly increased risk because they are so numerous The three strategies should be complementary, not competitive Policy is defined further in the Osaka declaration

48. JTF4 on CVD Prevention in Clinical Practice 5. PRIORITIES, TOTAL RISK ESTIMATION AND OBJECTIVES

49. JTF4 on CVD Prevention in Clinical Practice 20. IMPLEMENTATION STRATEGIES

50. Report from the EACPR EuroPRevent Congress

51. EUROASPIRE- Surveys of patients with proven CHD EASP I: 1995-1996. 9 countries EASP II: 1999-2000. 15 countries EASP III: 2005-2007. 22 countries 6 months after first CABG, PCI, or ACS without prior CABG or PCI Considerable potential to improve risk factor control:

52. Implementation- barriers & strategies. Review of current knowledge Luxembourg Declaration, Heart Health Charter, Prevention Summit & consequent Call for Action EAS III US Task Force 8 JTF4 REACT & ESC Surveys Powerhouse Survey Mapping document questionnaire to National Co- ordinators Heart Health Charter Questionnaire* *Results awaited

53. Barriers to implementation

54. Barriers to implementation- Google Scholar “Cardiovascular guidelines; implementation”: 7600 refs “Cardiovascular guidelines; barriers to implementation”: 2720 refs Very repetitive! Strategies to improve implementation tend to be verbose, woolly and based on little evidence

55. Barriers to the implementation of guidelines on CVD prevention Task force 8. Organization of Preventive Cardiology Service. Pearson TA, McBride PE, Miller NH, Smith S. JACC 1996; 27: 1039-47 European Guidelines on CVD Prevention in Clinical Practice. Fourth Joint Task Force Eur J of Cardiovascular Prevention and Rehabilitation 2007;14:suppl 2; E1-E40 and S1- S113

56. Barriers to implementation- 1: PATIENT (PERSON!) Social, educational and cultural factors Consequent lack of knowledge and motivation Consequent lack of skills to make a life plan Time and financial constraints Unclear, complex advice and polypharmacy Consequent difficulty in compliance Unwillingness to ask for help from physician Lack of access to care

57. Barriers to implementation- 2: PHYSICIAN Acute problem (disease)-based focus Negative or neutral feedback on prevention Time constraints Lack of incentives, incl. reimbursement Lack of training- knowledge & skills Lack of specialist- generalist communication Guidelines - difficult to interpret; too complex; lack of perceived legitimacy

58. Barriers to implementation- 3: HEALTH CARE SETTING (hospitals, practices etc) Acute care priority Lack of resources and facilities Lack of systems for preventive services Time and economic constraints Poor communications between specialty and primary care providers Lack of policies and standards

59. Barriers to implementation 4: COMMUNITY/SOCIETY Political failure of health planning strategy- Educational policy- Schools, universities, hospitals, adult education Activity, nutrition and tobacco policy Apportionment of budget/taxes between prevention and treatment services- hospitals get votes Effective multidisciplinary prevention planning and implementation group Morbidity & mortality registers Risk factor surveys Physician re-imbursement for prevention

60. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) Survey Hobbs FDR, Erhardt L Family Practice 2002; 19: 596-604

61. REACT 2002 Telephone interviews of 754 randomly selected primary care physicians in F, D, I, S, UK Most(89%) agreed with & said that they used guidelines(81%) but only 1/5 believed that they were being implemented

62. REACT 2002- Barriers to implementation Time (38%) Prescription costs (30%) Patient compliance (17%)

63. REACT 2002- Suggestions to improve implementation Education for physicians (29%) Education for patients (25%) Publicizing or increasing guideline availability (23%) Simpler guidelines (17%) Clearer guidelines (12%)

64. Factors Impeding the Practical Implementation of Cardiovascular Prevention An international market research project in 6 countries: Germany, France, Italy, Spain, the United Kingdom and Poland - PRESENTATION CHARTS - This study was commissioned by European Society of Cardiology (ESC) Cardiovascular Round Table (CRT) Task Force 4 Technical staff at Psyma International: Alexander Rummel Monica Bach Dr. Britta Meyer-Lutz Study No: 41057021 December 2002 Psyma International Medical Marketing Research GmbH Gartenweg 2 90607 Rückersdorf/Nürnberg Germany phone: +49-911-95 785-0 fax: +49-911-95 785-33 e-mail: info@psyma-international.com website: www.psyma-international.com E D F I

65. Factors impeding the implementation of cardiovascular prevention guidelines: findings from a survey conducted by the European Society of Cardiology Graham IM, Stewart M & Hertog M for the Cardiovascular Round Table Task Force. EJCPR 2006:13; 839-45 Market research survey In-depth interviews with 66 cardiologists & 154 primary care physicians (N=220) 6 focus groups involving 49 physicians D,F,I,E,UK,P

66. Factors impeding implementation 25% of physicians didn’t know or couldn’t explain the term “total” or “global” risk Guideline usage varied- 20% (Poland and France) to >70% (Spain and UK) Usage of risk scoring systems varied widely- 4% in Italy to 43% in UK (Mean 21%) National guidelines are preferred to ESC guidelines (45% vs 4%) Perceived problems with guidelines- impractical, time consuming, not interesting, “guideline fatigue”

67. Improvements to increase guideline usage Simpler, more user-friendly guidelines with improved content Increased patient awareness & education Independent research (credible, trustworthy) Government initiatives (time, remuneration)

68. Guidelines for all and their integration into education The challenge is to make practical prevention universally accessible. Medical control of this process may have been excessive This implies integration of the messages from guidelines into schools curricula as well as into undergraduate and postgraduate education

70. TARGETS TO DEFINE SUCCESS- for discussion Dissemination of guidelines and toolkit in 100% European countries National co-ordinators in 90% Evidence of effective national alliances with defined plan in 66% Evidence of agreed guidelines (National or European) in 80% Risk estimation systems used in 80% National risk factor audits in 66% Evidence of monitoring systems for CVD mortality and risk factor trends

71. Background European Guidelines on CVD Prevention European Heart Health Charter Call for Action EACPR and JPC Minutes EACPR strategic plan Mapping document Slide kit HeartScore Health Professional Toolkit

72. Joint Prevention Group EACPR Implementation Committee Prevention Implementation Committee Implementing new guidelines into clinical practice Ian M Graham

73. Prevention Implementation Committee 1.Summary of JTF4 Guidelines 2.Will JTF5 be different? This will impact on our workplan 3.The gap between recommendations and clinical practice 4.Barriers to implementation 5.Strategies to improve implementation 6.Review of knowledge, gaps in knowledge and survey needs 7.Critical success factors 8.Review of role of National co-ordinators 9.Respective responsibilities of JPC and EACPR prevention implementation committee 10.Pan- European activities 11.Selected individual country activities 12.Workplan and timelines 13.Responsibilities of individual partners

74. 4 th Joint Task Force on Prevention: MEMBERS Dan Atar [ESC] Knut Borch-Johnson [EASD/IDF Europe] Gudrun Boysen [EUSI] Gunilla Burrell [ISBM] Renata Cifkova [ESH] Jean Dallongeville Guy de Backer [ESC] Shah Ebrahim [ESC] Bjorn Gjelsvik [ESGP/FM/Wonca] Christoff Hermann-Lingen [ISBM] Arno W Hoes [ESGP/FM/Wonca] Steve Humpries [ESC] Mike Knapton [EHN] Joep Perk [EACPR] Sylvia G Priori [ESC] Kalevi Pyorala [ESC] Zeljko Reiner [EAS] Luis Ruilope [ESC] Susana Sans-Mendes [ESC] Wilma Scholte Op Reimer [ESC council on CV Nursing] Peter Weissberg [EHN] David Wood [ESC] John Yarnell [EACPR] Jose Luis Zamorano [ESC/CPG]

75. 4 th Joint Guidelines on CVD Prevention SPECIAL PEOPLE, SPECIAL THANKS INVITED EXPERTS Marie-Therese Cooney Alexandra Dudina Tony Fitzgerald Edmond Walma ESC STAFF Keith McGregor Veronica Dean Catherine Depres Sophie Squarta

76. Why develop a preventive strategy in clinical practice? 1.Cardiovascular disease (CVD) is the major cause of premature death in Europe. It is an important cause of disability and contributes substantially to the escalating costs of health care 2.The underlying atherosclerosis develops insidiously over many years and is usually advanced by the time that symptoms occur 3.Death from CVD often occurs suddenly and before medical care is available, so that many therapeutic interventions are either inapplicable or palliative 4.The mass occurrence of CVD relates strongly to lifestyles and to modifiable physiological and biochemical factors 5.Risk factor modifications have been shown to reduce CVD mortality and morbidity, particularly in high risk subjects

77. CVD Prevention: CHALLENGES Inactivity Obesity Stroke Heart failure Gender and social class inequalities Renal failure Implementation

78. Fig 1 The expected number of CVD deaths at increasing levels of predicted risk. Illustration of the fact that most events occur in low risk subjects with few deaths among high risk subjects.

79. 10 year risk of fatal CVD in high risk regions of Europe

80. 10 year risk of fatal CVD in low risk regions of Europe

81. Relative Risk Chart This chart may used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication

82. JTF5 – will it be different? Chairperson- Prof Joep Perk Detailed suggestions to simplify the process available (IG) Electronic version of JTF4 available Single format for submissions essential SCORE developments Will rehabilitation be included? logical (but political…) ? Make pocket guidelines the summary Continue to use figures in main text One page card critical Tie more closely to interactive teaching?

83. Additional knowledge needed? Commissioned surveys on what additional information is needed to inform strategy (by EACPR?) Modelling exercises on effects of implementation strategy (by EACPR?) Inventories of prevention in different countries to allow benchmarking Subsequent development of educational materials

84. Joint Prevention Group EACPR Implementation Committee Prevention Implementation Committee The implementation of current CVD prevention guidelines Ian M Graham

85. PIC CORE ACTIVITIES- to be prioritised 1.BENCHMARKING- Inventory of implementation info + development of strategy: H McG 2.AUDIT- Pan European audit: Epidemiology 3.HEALTH ECONOMIC MODELLING: DW, Gde B 4.HOW-TO manual: IG, PG 5.DEMONSTATION PROJECTS WITH INDUSTRY: DD, MH 6.IMPLENTATION RESEARCH: tbd 7.LOBBYING: LR, European Affairs 8.LAY COMUNICATIONS: JP (Apoteket); SCORE-Lay

86. Give me a doctor partridge plump, short in the leg and broad in the rump, an endomorph with gentle hands, who’ll never make absurd demands that I abandon all my vices, or pull a long face in a crisis, but with a twinkle in his eye, will tell me that I have to die. - W H Auden

87. Give me a doctor underweight, computerised and up to date. A businessman who understands accountancy and target bands. Who demonstrates sincere devotion to audit and to health promotion- but when my outlook’s for the worse refers me to the practice nurse - MariaCampkin

88. Report from the EACPR EuroPrevent Congress Stockholm, May 2009