Barriers to Cardio Vascular Disease Prevention

Tuesday, 16 February 2010 00:00

Numerous barriers to CVD prevention and management remain to be conquered, both in the individual patient and in the at-risk population as a whole.

Multiple barriers to better Cardio Vascular Disease prevention are evident. They can be represented by:
-Difficulty in making an accurate CVD risk estimation. This is key methodological barrier to CVD prevention. There is the difficulty in making an accurate CVD risk estimation in clinical settings, particularly in the high-risk patient population.
-Limitations of CVD risk prediction tools such as underutilization of current CVD risk calculators, especially in primary care (only 13% of physicians always use risk charts to assess a patient’s risk of developing CHD) (Int J Clin Pract 2002; 56 (9): 638-644). Risk calculators tend to be too complicated for a busy practice.
Lack of public awareness of cholesterol as a CHD risk factor. This represents a barrier which is resisting to the many tentative to decrease it. Citizens underestimate the risk because hypercholesterolemia seldom is producing apparent symptoms. Doctors are not always dedicating enough attention to primary prevention and are sometime under pressure to keep the (prescription) budget under limits. Authorities are not investing in primary prevention and in some countries are limiting the use of statins.
-Failure to implement guidelines on CVD prevention. An additional barrier is a failure to implement guideline recommendations on lipid management and CVD prevention effectively (Atherosclerosis 2008; 196 (2): 532-541). The most recent survey (EUROASPIRE III) (http://www.lorenzinifoundation.org/download/HealthPolicyIssues.pdf) also suggests that primary-prevention patients are under treated to an even greater extent than coronary patients as well as not adhering to lifestyles that promote CV health.
-Low rates of adherence with lipid-lowering therapy. Many patients who begin statin therapy have low rates of adherence and, thus, experience no or limited CV benefit attributable to effective lipid lowering (JAMA 2002; 288 (4): 462-467).
Failure in coordination relationships in the typical health care scenario of three providers organizations as hospitals, GPs and health district organizations, involving multiple caregivers and patients and their family members.

Failures in continuity of care represent further barriers source
Continuity of care represent an area where failure in coordination relationships among health providers, patient and their families represent barriers that impede the transfer of medical proposed protocols to the individual treatment at home.
Several critical domains of care coordination exist:
-Among providers (general practitioners (GPs) and specialists; GPs and emergency departments; GPs and hospital-based physicians; GPs and health districts plans; physicians and source of diagnostic data; physicians and regulatory requirements)
-Between providers and patients and their families (GPs and patients and their families; hospitals and patients and their families; health districts, municipalities and patients and their families) (NEJM 2008; 358 (10): 1064-1071).

Strategies to Overcome Barriers
A number of incentives and implementation strategies have been shown to improve outcomes in CVD prevention, including government endorsement of guidelines, targeted financial incentives, structured care, audit and feedback, and educational activities.
-A policy to contain the costs of CVD treatment, instead to focus on the increasing implementation of new technologies in the approach to events, is focusing on the cost of medical prevention. That is the result of a sylos approach to the ecomomic evaluation of diseases. The structural separation between the costs of a bed in hospital, and the cost of the use of a drug in the out-patients sector, is producing a misunderstanding of the global evaluation of costs, and bias in the adopted policies of health costs governing. The introduction of statins led to increased interest in economic aspects of lipid-lowering therapy. Since statins were perceived as effective but potentially very costly, a need existed to assess the economic consequences of this class of drug. The objective of an economic evaluation is to assess the cost per unit of health gained for an intervention, and this can be achieved in two ways: a) within the trial setting, often estimating the cost of an event avoided; and b) using a model to predict the long-term outcome, estimating the cost per life-year or quality adjusted life year (QALY) gained. A clear cost-effectiveness pattern emerges in terms of prevention – the higher the absolute risk in the population, the more cost-effective statin therapy becomes, given similar relative risk reductions. The availability of generic statins thus impacts the interpretation of previously performed health economic studies. The re-analysis of the earlier statin trials using generic prices now universally report savings rather than having to pay for a given unit of health. (Atherosclerosis Supplements 2009; 10: 3-21)
-Potential incentives to improve outcomes in CVD prevention are under consideration. Targeted financial incentives can improve CVD risk management in primary care, as evidenced by the introduction of the Quality Outcomes Framework (QOF) in the UK in 2004. This scheme involves relating performance with pay; 25% of the income in the primary care setting comes from a complex set of initiatives in chronic disease management, practice organization, patient experience, and additional services. Over half of the clinical indicators relate to vascular disease. Evidence of the impact of systematic quality improvement initiatives on quality of care in the National Health Service (NHS) comes from longitudinal cohort studies. Substantial improvements were seen in quality of care for three major chronic diseases (CHD, asthma, and type 2 diabetes) between 1998 and 2003 (BMJ 2005; 331 (7525):1121).
-Treating high-risk patients intensively and expanding patient base to be treated, are under consideration to better optimize the treatment with statin and increase the cost-effectiveness and benefits of lowering LDL-C. Treating high-risk patients more intensively could be achieved either by up-titrating the statin doses or by adding ezetimibe. Accordingly, this would result in the following additional effects on LDL-C levels: a) a 6 to 9% education for up-titrating statin (according National Institute for Health and Clinical Excellence (NICE) guidance BMJ 2008; 336: 1246-48; b) A 23% decrease over 5 years (according to a 2007 meta-analysis of the cholesterol-lowering effect of ezetimibe added to ongoing statin therapy) (Curr Med Res Opin 2007; 23 (8):2009-2026); and c) a1 mmol/L reduction in LDL-C reduces non-fatal MI and CHD death by 23% over 5 years, according to a meta-analysis of clinical trials (Lancet 2005; 366 (9493): 1267-1278). The cost of statin treatment fell following the introduction of generics. Reinterpretation of previously published cost-effectiveness data indicate that statin therapy would be cost saving in the studied risk groups. If freed-up resources were used to treat more intensively, studies indicate that ezetimibe would provide good value. The cost-effectiveness of expanding the number of treated patients is largely unknown. The optimum trade-off between more intensive management compared with an expanded patient base needs to be investigated more fully.
-Suggested ways to improve implementation of CVD prevention guidelines: a) Harmonize guidelines and focus on common areas of consensus rather than state-of-the-art science b) Remove the boundary between primary and secondary prevention and focus on total (global) risk c) Help policy makers understand the different components of CVD; d) Include professional societies from different specialties in guideline development/implementation to increase ownership e) Increase nurse involvement, especially during the first 6 months after initiating statin therapy.
- Suggested ways to improve Continuity of care across all settings and over the natural history of disease: a)  Shared responsibility among university hospital, municipality, and primary care and focusing on comprehensive, patient-centered approach involving integration, cooperation, collaboration, and effective communication; b) Evidence-based clinical practices across multiple disciplines to improve the quality and cost-effectiveness of care for patients with chronic conditions (elderly and frailly patients); c) Patient assessment using biomarkers (especially in heart failure); d) Electronic referral, referral agreements, and efficiency in information exchange among specialists; e) Video discharge conference to increase the effectiveness and quality of the discharge procedure by connecting the patient, patient’s relatives, staff from the university hospital, primary care, and representatives from the municipality.

February 16, 2010


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