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- Gerald F Fletcher, MD, FACC, Conference Co-Chair
Historical medical recordings as early as 2500 BC referred to the practice of Prevention. References to the importance of prevention are found in the writings of Hippocrates and Osler, thus rendering the prevention concept important and certainly “not new” in the practice of medicine (1). Previous Bethesda Conferences 11 (1980) (2) and 27 (1995) (3) addressed Prevention of Cardiovascular Diseases; however, to date, Preventive Cardiology has yet to establish an appropriately strong position in the overall care of patients with cardiovascular disease (CVD).
“Bethesda Conference 33—Preventive Cardiology: How Can We Do Better?” evolved to address specific issues and provide precise recommendations to better implement the prevention of CVD, which is the number one cause of death and disability in the U.S. today. Five task forces of writers and participants with various expertise provided in-depth reports on numerous aspects of preventive cardiology. The following paragraphs cite salient points extracted and paraphrased from each task force.
The first task force addresses in finite detail the magnitude of the overall problem and the opportunities and challenges involved. Cardiovascular disease (CVD) is the leading cause of death and disability; it is increasing in prevalence in many regions of the world; and it includes all ethnic, racial, and gender groups. Risk factors that predispose to CVD have been identified, the modification or alteration of which can result in a significant decrease in morbidity and mortality for CVD. Risk factor categories now addressed are genetic (e.g., abnormal lipids), second level (e.g., endothelial dysfunction), and acute (e.g., plaque rupture perhaps related to nicotine). Obesity and diabetes are emerging as major risks and are increasing in prevalence in America. Primordial prevention (or prevention of risk factors) is being emphasized. These strategies address proper exercise and diet and should focus on early school years. A public health approach to CVD prevention is needed and may require public policy changes and aggressive marketing to the public. An ongoing perceived problem is that “sick care” may not mix well with preventive care.
The second task force considers the cost of prevention: can we afford it; can we afford not to do it? As emphasized, prevention guidelines should reflect economic impacts and value from a societal perspective. As such, a society with limited resources should determine which interventions have the most value. Cost-effectiveness analysis is the most often used approach for economic evaluation of a medical or health care strategy. In concert with this and a “fixed” monetary allocation for health, policy makers want the greatest return on their investment. For example, studies of smoking cessation intervention suggest that cost per year of life saved is small compared with other interventions. In addition, assuming that sedentary behavior increases the risk of CVD by 1.9-fold, $6.4 billion would be saved if all of America began to walk regularly. The prevention of death from one disease may not be a valuable outcome if overall life expectancy is not changed because of another significant illness. An obstacle in an investment in prevention is the public expectation that such an investment should pay for itself.
The third task force discusses “Getting Results: Who, Where, and How?” This component encourages the proposition that physician encounters with patients be broadened to include non-physician personnel and community resources. A combination of community programs, medical referrals and therapy, and mass media for screening and treatment will decrease risk factor levels and CVD. Industries have been supportive of prevention when and if their interests are in accord with national and local organizational guidelines to change knowledge, attitudes, beliefs, and behavior. Community programs involve three models: clinical, public health, and health promotion. Momentum and sustained interventions are crucial to the success with community programs. Case management is effective and involves a nurse in the clinical setting to coordinate the determination of the risk with the treatment plan to reduce risk. In this setting, the guidelines should include outcome assessment and quality assurance. Barriers to implementation of preventive cardiology in medical settings include economics, lack of interest in the patient, and lack of skill and/or motivation of the provider.
The fourth task force addresses adherence issues and behavioral changes and how to achieve a long-term solution. Evidence is presented supporting the involvement of other health care professionals (especially nurses) in treatment plans to improve effectiveness of preventive interventions and increase overall adherence. Brief provider intervention can have a positive effect on adherence. A critical time to target adherence strategies is the early phase of treatment, realizing that poor adherence is higher in those with three or more comorbidities. Awareness of how people reason is important in adherence. Consideration of the stages of change—pre-contemplation, contemplation, preparation, action, and maintenance—which reflect steps of any behavioral intervention process is important in the process. Another important theoretical approach is the social cognitive theoretical model. Ecological frameworks recognize that human behavior is influenced by intrapersonal, interpersonal, institutional, and community factors as well as public policy.
The fifth task force discusses the role of the cardiovascular (CV) specialist in prevention—trainee to champion. Substantial data confirms that prevention is not taught in most medical schools and less than one-third of CV specialty training programs have formal preventive cardiology. Limited time, lack of curriculum integration, lack of trainee interest, and the focus on critical care are all barriers. A solution is to build prevention-related objectives into global medical curriculum reform with associated faculty development activity. Both cognitive and applied systems training are needed to prepare specialists to establish prevention programs. One problem is that CV specialists typically address the chief complaint and often leave prevention to the primary referral. Cardiovascular specialists must address primary prevention and risk factor control and should use a team approach. Physician advice is especially helpful with diet and exercise. Use of evidence-based prompts and alerts can help guide adherence. In addition, health care system changes and informatics can be valuable in the process. A CV specialist should be a “champion” for prevention. Ideally, such a specialist should have clinical training with a Masters in public health and/or expertise in outcomes research.
In summary, the five task forces have addressed the major concerns in preventive cardiology. The recommendations and in-depth consensus discussions that follow will provide the reader with a thorough understanding of the issues that prevail today in this vastly important domain of health care.
- American College of Cardiology Foundation
- Strauss M.D.
- Pasternak R.C.,
- Grundy S.M.,
- Levy D.,
- Thompson P.D.