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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.
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.
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”.
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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.