Prevention should be at heart of national cardiac review

Professor of Preventive Cardiology at NUI Galway and Medical and Research Director of the National Institute for Prevention and Cardiovascular Health Prof Bill McEvoy outlines his hopes for the national review of specialist cardiac services

The national review of spe­cialist cardiac services is a welcome initiative in that it aims to ensure the deliv­ery of cardiac healthcare across Ire­land and is meeting the current and projected future healthcare needs of the Irish population. Because these healthcare needs change over time; driven largely by (1) changes in pop­ulation demographics (eg, an ageing population means more heart fail­ure and valve disease); (2) changes in the burden of cardiac risk factors (eg, increases in obesity and diabetes will require more upfront preventive efforts); and (3) changes in medical technology (eg, transcatheter aortic valve implantation is a growing, but costly procedure); intermittent re­views of cardiac services are neces­sary so as to meet the contemporary needs of Irish patients.

Cost

In my view, the major challenge facing the review is economical. In the current fiscal environment, the cost of providing state-of-the-art cardiac care that fully meets the needs of the population will always exceed the budget allocated by gov­ernment. As such, smart econom­ical decisions are necessary and, at times, compromises have to be made. The informed, but fair al­location of these limited financial resources is an ever-present chal­lenge.

Thankfully, the development of a mature and efficient healthcare sys­tem is an iterative process and pri­or reviews of cardiac services have laid a good foundation on which to build the 2019 HSE cardiac services review. For example, prior invest­ments in the treatment of acute cor­onary syndrome mean that the ma­jority of Irish adults with ST eleva­tion myocardial infarction can now proceed to primary percutaneous coronary intervention (PCI) with­in the timeframes recommend­ed by international clinical prac­tice guidelines. This acute aspect of cardiac service delivery has argua­bly been a success story overall and represents a foundation on which to build future cardiac services in the years to come. Accordingly, while acute cardiac services require on­going development and investment, there should be scope in the current services review to increase the fo­cus on both preventing heart dis­ease and the management of chron­ic cardiac disease. With regard to the latter, increased investment in heart failure, cardiac imaging, elec­trophysiology and adult congeni­tal heart disease will be needed to address the burgeoning burden of chronic cardiac disease in the Irish population.

Prevention

Croí and its affiliate, the National Institute of Prevention and Cardio­vascular Health (NIPC), have a par­ticular interest in the former; cardi­ovascular disease prevention. There is no doubt that prevention is an ar­ea that has been relatively under­funded in the past. However, we be­lieve that there is now both an op­portunity and also an urgent need to focus much more on cardiovas­cular disease prevention in the cur­rent cardiac services review. Invest­ing in prevention is also smart mon­ey, as it is well-established that pre­venting heart attacks and strokes is more cost-effective than treating the acute emergencies once they oc­cur, which requires hospitalisation. One need not look far for promi­nent examples of other countries who, based on compelling evidence, have shifted their healthcare budg­etary focus away from acute illness and procedure-based remunera­tion towards a more preventive-orientated fiscal strategy whereby healthcare systems are incentivised to prevent disease.

A focus on prevention is also sup­ported by the evidence. For exam­ple, every 10-unit improvement of systolic blood pressure in the popu­lation translates into approximate­ly 30 per cent fewer heart attacks and strokes and every 1mmol/L improvement in LDL-cholester­ol translates into 22 per cent few­er heart attacks and strokes. Thus, it is much better for the patient and cheaper for society, to control these cardiovascular risk factors than it is to treat the acute illness when it oc­curs. Indeed, as the ancient Chinese proverb goes, “the superior doc­tor prevents sickness, the mediocre doctor attends to impending sick­ness, the inferior doctor treats actu­al sickness”.

Priorities

As such, both Croí and NIPC hope that the following ideas might be considered by, and ultimately implemented in, the ongoing review of cardiac services in 2019:

1. Further investment in es­tablished cardiac rehabilita­tion, which represents an evi­dence-based and highly effec­tive method to improve the sec­ondary prevention of heart at­tack and stroke survivors (ie, reducing their chance of a sec­ond or recurrent event). In our opinion, it is irresponsible, and frankly foolish, for any modern cardiac healthcare service with established primary PCI facili­ties (and thus more heart attack survivors) to not support cardi­ac rehabilitation services ade­quately. Without such services, the HSE should simply consider fitting ‘revolving doors’ in cardi­ac catheterisation labs around the country.
2. Investment in and development of primary cardiovascular dis­ease prevention services. An ev­idence-based, effective and cost-efficient model has already been tested under the auspices of Croí, through the MyACTION programme. This, or a version thereof, could be used as a tem­plate for dissemination outside of the west of Ireland, but would require investment. While the full details of MyACTION are outside the scope of this piece, the programme can be summa­rised as a nurse-coordinated, multidisciplinary, family-based cardiovascular disease preven­tion programme (run over a 16-week period) designed to im­prove standards of CVD preven­tive care among secondary and high-risk primary prevention patients. The programme is de­livered by a multidisciplinary team using motivational inter­viewing and stages-of-change assessment techniques. In three geographically distinct settings, it has demonstrated statistically significant improvements in an­thropometric measures (body mass index, waist circumfer­ence), lifestyle habits (physical activity, healthy diet, smoking cessation), psychosocial indices (anxiety, depression, quality-of-life), and target levels of CVD risk factors (blood pressure, li­pid and glucose levels) at one-year follow-up. It has demon­strated cost-effectiveness. This type of intervention is exactly in-line with Sláintecare’s objec­tives, so let’s get serious about rolling these services out more broadly.
3. We need more mid-level health­care providers (eg, advanced nurse practitioners) to integrate into community settings in or­der to surveil and manage the ever-increasing volume of car­diovascular risk-factors in pa­tients who suffer from chronic disease and who attend health-care services. We agree that ‘every contact matters’, but we need to make prevention a re­ality by supporting busy physi­cians in this effort with mid-lev­el support.
4. Research should target the biggest challenges of society. At present, one of the biggest health-related challenges facing us is the increased prevalence of cardiovascular risk factors (eg, diabetes, hypertension, obesity, sedentary lifestyle, etc). Cardio­vascular risk-factors are not just associated with cardiovascular disease, but rather with a long list of chronic diseases that bur­den our healthcare system, in­cluding cancer. This cannot be over-emphasised. Cardiovascu­lar risk-factors increase the risk for most chronic diseases, heart or elsewhere. Given this major and growing challenge, we need to earmark research funding to the prevention and control of these risk-factors.
5. Sláintecare should be more than just a catchy slogan. For Sláintecare to pay more than just lip service, we need to focus on the ‘Sláinte’ aspect of Sláinte­care, ie, health. Health promo­tion initiatives align with, but do not completely overlap, car­diovascular disease prevention efforts. Both need fiscal support in the upcoming review.
6. Funding for patient empow­erment should also be part of this cardiac services review. A “know your numbers” public awareness campaign has been demonstrated in other juris­dictions to lead to improved preventive lifestyle and med­ical care.