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Preventing cardiovascular disease in primary care

By Dr David Molony, GP, Mallow, Co Cork - 25th Mar 2019

Dr David Molony documents the success of Heartwatch in primary care to date but bemoans the lack of investment in the programme, which is no longer recruiting patients

Heartwatch is the National Programme in General Practice for the Secondary Prevention of Cardiovascular Disease (CVD) in Ireland, as patients with established cardiovascular disease have a high risk of subsequent CVD events, including myocardial infarction (MI), stroke, and death.

In Ireland, CVD accounts for 35 per cent of all deaths and 20 per cent of premature deaths in those under 65 years of age.

Heartwatch was set up in 2003, as a pilot programme, to provide chronic disease management and secondary prevention of a defined population who had previous MI, coronary artery bypass grafting (CABG), or percutaneous transluminal coronary angioplasty (PTCA) in 20 per cent of GP practices. Only in the HSE midlands area, were diabetic patients included in the programme, ie, 20 per cent of doctors nationally were involved but all of those doctors enrolled in the Midlands Diabetes Care Programme were included.

The aim of the programme was to reduce morbidity and mortality from cardiovascular disease in post-cardiac event patients, to study risk factors and therapeutic interventions over time, to examine the patient processes in implementing the processes of referral and retention, and to record the incidence of cardiovascular events in the patients participating in the programme. The programme was based on the second European Joint Task Force recommendations for secondary cardiac prevention.

The gathering of data is a fundamental aspect of this programme and this was overseen by a large national infrastructure with a National Steering Committee (NSC), an Independent National Data Centre (INDC) that received practice data and distributed quality, anonymised data reports appropriately, and a Data Management Committee (DMC), which oversaw the INDC and reported to the NSC, and a National Programme Centre (NPC) to implement the programme). The GP practices involved were supported by GP co-ordinators and nurse facilitators.

Initially, data was collected through an interim software commissioned for the programme but the accredited GP software suppliers in Ireland developed integrated in-house software solutions, allowing GPs to use their practice software to link with the INDC, etc. Data management was reviewed and independently reported with ongoing learning and improvement in quality of data.


The Heartwatch programme was a success from the very start, in that it brought together most of the medical bodies involved in general practice to deliver a patient care study and preventive programme, namely HSE (Health Boards initially), Department of Health and Children, ICGP, IMO and the Irish Heart Foundation. This process followed best international advice that post-cardiac event care should take place in GP primary care and be measured to best international standards of the time, as up to this time, post-cardiac event management and rehabilitation took place in the hospital setting.

This model was designed on the basis of the need to move chronic care into the community and would have been in keeping with the Primary Care Strategy, launched two years previously (2001). The basis of this model comes from Wagner et al, who developed and described the chronic care model (CCM) in the mid-90s. CCM was to enable better care for patients with chronic conditions and comprises six key elements to promote high-quality care in healthcare settings and target populations. The primary goal of the CCM is healthier patients, more satisfied healthcare providers and cost savings.

Six predominant aspects of the CCM include:

Self-management support — promoting patient autonomy in their care plan, linking patients to appropriate community resources, use of evidence-based programmes to provide emotional support, in addition to strategies for living with chronic conditions.

Clinical information systems — effective data management of patient files can improve patient care (ie, providing timely reminders for appointments and tests or other services that may be required). Data management can also facilitate performance monitoring and quality improvement strategies.

Delivery system redesign — incorporating a multidisciplinary approach, where tasks could be delegated/shared with other members of the team (ie, pharmacists, practice nurses, external agencies) in terms of patient follow-up, support for self-management and behaviour change.

Decision support — utilisation of evidence-based guidelines in practice, information-sharing and patient participation in the use of evidence-based guidelines in addition to liaison with specialists in the field.

Healthcare organisation — effective leadership, leadership support where changes have been implemented within an organisation for quality improvement purposes. Communication and inter-agency collaboration between healthcare workers across services may break down barriers that patients often encounter during their trajectory of care.

Community resources — collaboration between clinicians and external agencies, encouraging patients to utilise appropriate community-based resources.

Learning curve

For the practices, there was a significant learning curve to get the programme up-and-running and excellent support was given by GP co-ordinators and nurse facilitators. New organisation in practices was developed, large amounts of information and patient support material had to be managed, patients identified, registers organised, detailed information collected from patients and relayed to the INDC. Some of the personal lessons learned on this pathway in providing a chronic disease programme now seem very obvious and simple, but need to be repeated.

To deliver a sustainable programme for any group of people, you must first:

Identify the patients.

Set up a register of the patients.

Set up a recall system for the patients.

One person in the practice must have primary responsibility for each programme.

That person must review and follow-up defaulters monthly.

The GPs and practice nurses were provided with a useful and detailed handbook to explain the log in and operation of Heartwatch and this had to be followed to the letter, or payment would not be forthcoming. This was to ensure quality and consistency of data but was indeed a learning curve.

How it works

The process is straightforward enough, with initial detailed registration with all the boxes being filled and then maintenance of four visits to the GP annually, following the protocol screens, and compulsory fields (see copy attached forms). This has been a learning curve for each clinician entering data, either a nurse or doctor, and these fields are to follow all major risk factors for deterioration.

The data is loaded by the GP practice monthly (for the programme but only three-monthly for individual patients), sent directly to the INDC (based in ICGP headquarters, Lincoln House, Dublin) where the data is independently and confidentially stored and only anonymised data can be used by certified agencies. When the data is verified, sanction for payment is sent to the PCRS and this is returned to GP practices as a separate payment on ‘pink sheets’. Unfortunately, this payment was severely hit by FEMPI and is still paid at the reduced rate, from €50 to €39.18. Over 90 per cent of data is returned electronically, reflecting the state of computerisation of general practice in Ireland over many years.

Data reflects the patient risk and collection includes gender, systolic BP, diastolic BP, total cholesterol, LDL, smoking status, exercise (minutes per week of activity), BMI, medication, including groups on aspirin or other antiplatelet drugs, anticoagulant, beta-blocker, statin or other lipid-lowering drugs, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB), especially any changes, smoking habits, outpatient department visits, and diabetic factors if diabetic. Objective risk assessment using Heartscore is carried out at the time to give more objective data of care.

It is expected that as well as recording data, that lifestyle advice be given where necessary and that easy referral to community dieticians, smoking cessation support and access to physical activity officers, etc, would be offered. Patient support leaflets are provided to support the role and give accurate information to the patient. Some consideration has to be given to the literacy level of the patient, taking into account that approximately 10 per cent of the Irish population have low literacy levels.

It is at the lifestyle discussion stage with the patient that knowledge of behaviour modification and brief intervention techniques are useful and prevent confrontation with patients on targets. First, the target must always be apparent to the patient or no change will take place but just mentioning something is bad, ie, smoking, will cause 10 per cent to change, but the majority have to be supported and here the ‘Wheel of Change’ model is a useful guide. Going from one stage to the next is a useful gain and just reassuring the patient and offering support, when they are ready themselves for change, is greatly beneficial.

Using the Wheel of Change, such as in the Smokers Guide, is a useful guide for the doctor or nurse to gauge where the patient is as regards changing their lifestyle in specific areas, but clinicians always have to remember to deal with the patient’s own concerns first, and then only approach the clinical concerns for the patient if appropriate at the time. This is a slow process of informing self-management and supporting the patient on their clinical pathway.

Another aspect which is not measured, but which those of us operating this and other chronic disease illness programmes know, is the importance of the relationships and trust built up in the practices between GPs, practice nurses and practice staff and their patients. The sending of reminders to patients about their visits is a positive reinforcement to the patients that someone is watching and cares about their health and outcomes and we all take pride in delivering a complete service to our patients.

After some time in operation, it is noticeable that a new therapeutic relationship/bond develops between patient and practice team supported by consistency, etc, as in six rules of CCM previously mentioned. This relationship often opens up avenues of further support for the families of Heartwatch patients, as relatives are the most likely to be at risk of developing CVD in the future and the opportunity for education and behaviour change of family members is important.

Further on-the-ground learning with these patients with chronic disease is that they need our support and not criticism when they fail to reach targets and we must have a positive, forward-looking approach always, without blame, and give reassurance that ‘the next visit will be better’, as we cannot do anything about the past.


By 2005, 11,400 Heartwatch patients were recruited by 470 GPs, approximately 24 patients each, rising to 12,358 patients in 2011, 17,399 patients in 2014 having 185,855 consultations, and again to 22,000 patients with over 400,000 consultations by 2016, according to the ICGP.

The 400,000 consultations over the last 15 years of Heartwatch must have contributed significantly to the improvement in cardiovascular disease morbidity and mortality of the Irish population, but imagine what might have been done if the pilot programme had been rolled out nationally to the other 80 per cent of GP practices in the country.

Bennet et al 2008 noted “substantial decreases in several of the risk factors from baseline to the one-year follow-up time point were observed. It showed a statistically significant decrease in systolic and diastolic blood pressure, total and LDL cholesterol, BMI and smoking”. Also, they noted a “statistically significant decrease in HbA1c levels for those with diabetes at one year”. Also noted was an increase in the diagnosis of diabetes from the close monitoring of the programme with 170 additional patients with diabetes at year two.

They also noted a marked increase in appropriate medication prescribing, with more aspirin, statins, ACE and ARBs being used, especially with diabetic patients.

By year two, further substantial decreases in several of the risk factors from baseline were noted, ie, statistically significant further reductions in systolic, diastolic BPs, total and LDL cholesterol, BMI and smoking prevalence. So continuing with the programme meant continuing improvements were seen at year two.

Further, the improvements seen in Heartwatch at this time reflect other international studies, in particular the National Swedish Programme, where the results and gains were very similar, showing that the Irish medical system can achieve as much as our international colleagues, if supported.

Further still in 2011, Fitzpatrick et al showed “studies of cardiac rehabilitation without any follow-up programmes show that over time, patients revert in part to previous lifestyle habits; this primary care-delivered programme (Heartwatch) has shown sustained improvements in major risk factors, particularly smoking, blood pressure and cholesterol, and treatments for CHD. Weight management presents a greater challenge”.

The interactions are also not lost on the families who see the need for care and compliance with both the programme and the prescribed medication. Families can also become more aware of risks to other family members and support siblings and parents, and hopefully subliminally themselves, with an eye on the future.

The physicians also gain from the close working relationships with the practice nurses and having objective risk-assessment tools applied to their patient population, where objective risk assessment often prompts an intervention that might otherwise be missed for some time and this benefit is clearly demonstrated in Heartwatch. Supported systems work for patients and practice staff alike.

What now?

Heartwatch is a study that brings hope and despair, because it demonstrates that Irish practice is at least as good as any other medical system if it is supported. We see equivalent measures to other countries and gains from Heartwatch have been demonstrated clearly and scientifically from at least 2008, yet this successful programme is now no longer recruiting and has had much of the GP resources removed in the last number of years. A conservative figure shows that over 90,000 people at any one time over the last 15 years would have benefitted from this simple but effective programme.

The evidence here reflects all the other chronic disease programmes that could decrease expensive morbidity in our young cardiac and diabetic patients and also death in our national population.

Chronic disease is what we GPs and practice nurses deal with in the main and the Heartwatch programme showed unequivocally that we can do this to best international standards, but we need support, IT and infrastructure to succeed.

References on request

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