Guidelines for the prevention of cardiovascular disease in Ireland the way forward 3 November 2010

European 4

th

Joint Task Force Guidelines on CVD prevention in Clinical Practice:

Targets, implementation and 5 th Joint Task Force Guidelines 2012 Ian Graham Chairman JTF4, European Prevention Implementation Committee and IHF Council on CVD Prevention

Objectives of today’s meeting

1. Summarise current and future European CVD prevention Guidelines and implementation strategy (IG) 2. Summarise the role of the National Co-ordinator in the implementation process (SJ) 3. Guidelines in the context of National Policy (H McG) 4. The role of primary care (JC) 5. The role of the nurse (NF) 6. WORKSHOPS 6.1 Perceived roles in implementation 6.2 Moving towards an integrated national strategy 6.3 Defining synergies and complementarity 6.4 Input into one page Irish Guideline 6.5 Suggestions for the 5 th Joint Task Force

Outline

• Objectives of meeting • General background • 4

th Joint Task Force European Guidelines on CVD prevention

• 5

th Joint Guidelines

• Implementation- some principles • European Prevention Implementation

Committee Action Plan

• Relations with the National Coordinators

for CVD prevention

General Background

European Prevention implementation is complex- many players are involved 1. The EU- vital but no legislative framework 2. Individual Departments of Health- like their independence 3. ESC 4. EACPR 5. National Cardiac and other specialist and GP societies 6. Nurses and allied health professional, European and National 7. Educators- 1 st 2 nd & 3 rd level 8. Industry- Pharma, Food, Exercise, Neutral It’s like herding cats!

No data < 30 30-50 50-70 70-100 100-150 150-200 > 200 Age standardised CHD mortality rates (under 65) in men & women

The European Heart Health Charter and the Guidelines on cardiovascular disease prevention

• The European Heart Health Charter advocates the

development prevent CVD and implementation of comprehensive health strategies, measures and policies at European, national, regional, and local level that promote cardiovascular health and

• The Joint CVD prevention guidelines aim to assist

physicians and other health professionals to fulfil their role in this endeavour, particularly with regard to achieving effective preventive measures in day-to-day clinical practice

• They reflect the consensus arising from a multi-

disciplinary partnership between the major European professional bodies represented

Implementation of CVD guidelines

1.Knowledge of JTF4 guidelines and what is likely in JTF5 2.The gap between recommendations and clinical practice 3.Barriers to implementation 4.Strategies to improve implementation

Guidelines on Prevention

Research

SCORE,HeartScore Evidence based reviews

Guidelines

94,98,03,07,12 EuroAspire E-SURF

Audit Implementation

PIC Nat. Co-ord EuroAction

European Guidelines on CVD Prevention

Fourth Joint European Societies’ Task Force on cardiovascular disease prevention in clinical practice

Ian M Graham Chairman JTF4

JTF4 on CVD PREVENTION

CONTENTS

1. Introduction 2. Scope of the problem; past and future 3. Prevention strategies and policy issues 4. How to evaluate scientific evidence 5. Priorities, total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drug therapy 20. Implementation strategies

What are the PRIORITIES for CVD prevention in clinical practice ?

1. Patients with established atherosclerotic CVD 2. Asymptomatic individuals who are at risk of CVD because of SCORE 10-year risk of CVD death) associated with end-organ damage increased 2.1 Multiple risk factors resulting in raised total CVD risk (≥5% 2.2 Diabetes type 2 and type 1 with microalbuminuria 2.3 Markedly increased single risk factors especially if 3 Close relatives of subjects with premature atherosclerotic CVD or of those at particularly high risk

0 3 5 140 5 3 0

People who stay healthy tend to have certain characteristics:

0 3

No tobacco Walk 3 km daily, or 30 mins any moderate activity

5

Portions of fruit and vegetables a day

140 5

Blood pressure less than 140 mm Hg systolic

130

Total blood cholesterol <5mmol/l

4.5, 4 3 0

LDL cholesterol <3 mmol/l

2.5, 2

Avoidance of overweight and diabetes

JTF5 on CVD Prevention

• Much shorter and more succinct • More explicit evidence base- ESC grading vs. GRADE • New approaches to risk estimation total events, risk age • Targets similar- 1.8 mmol/l for LDL cholesterol?

• There is time to influence them!

• Will be launched at Europrevent Dublin, 3-5 May 2012

How big is the gap between recommendations and practice? Has there been an improvement over time?

Total Chol Use of BP meds BP control All countries Diabetes Obesity BMI Smoking

Utility of Guidelines

• Guidelines alone are good for the

vanity of the authors and bad for rain forests; they are a waste of time without a defined implementation strategy

• Hence the

Prevention Implementation Committee and other implementation efforts

“Said is not heard, heard is not understood, understood is not agreed upon, agreed is not applied, applied is not at all maintained.” Konrad Lorenz, 1903-1969 [Thank you, Ulrich Keil]

Barriers to implementation

Pearson 1996; European Guidelines 4th Joint Task Force 2007

•Patient (Person) •Physician •Health Care Settings •Community/Society

Barriers to implementation REACT study, Hobbs FDR, Erhardt L, Family Practice 2002 ESC CRT Market research survey, Graham I, EJCPR 2006

• Lack of patient compliance • Lack of time • Lack of budget • Lack of clarity (complicated, confusing, too

much information)

• Guidelines too general (do not fit my

patient)

• Unhelpful government health policies

(assistance, remuneration, patient education)

SUMMARY: Key factors to increase usage of guidelines

• Simple, clear, credible national guidelines • Sufficient time • Facilitatory government policy:

-Defined prevention strategy -Reimbursement for health professionals -public awareness and education from school on

• Multidisciplinary implementation strategy-

with teeth

CVD Prevention Implementation

An adapted structure for the future

The EUROPEAN PREVENTION IMPLEMENTATION COMMITTEE Terms of Reference

• • The ESC has delegated the implementation of the European Guidelines on CVD Prevention to the European Association Cardiovascular Prevention and Rehabilitation. Its Cardiovascular Prevention Implementation Committee fulfils that function. Its role is to help to close the gap between science and practice for both in hospital and in primary care

• • • • • • • •

PREVENTION IMPLEMENTATION COMMITTEE Membership

Co-Chairs: Ian Graham & Pantaleo Giannuzzi

Members

Prof Pantaleo Gianuzzi, EACPR President Prof David Wood, EACPR Past-President Prof Lars Ryden, recent Chair of the ESC European Affairs Committee Prof Richard Hobbs, Chair Council on Cardiovascular Primary Care Susanne Logstrup, EHN Muriel Mioulet, ESC External Affairs Director Sophie Squarta, ESC Head of Department for CVD Prevention

Sections representatives

Cardiac rehabilitation Epidemiology & Public Health Exercise Physiology Prevention & Health Policy Sports Cardiology Sducation Committee Hannah McGee Johan De Sutter Martin Halle Diego Vanuzzo Dorian Dugmore Lale Tokgozoglu

Prevention Implementation Committee Action Plan

PREVENTION IMPLEMENTATION COMMITTEE ACTIVITIES 1. Core activities 2. Define strategies to assist in Guideline implementation 3. Activities with the National Co ordinators for CVD prevention

PIC – Suggested Core activities-

• Benchmarking

– H. McGee

• Health Economic models

Backer – D. Wood & G. De

• Industry projects

– M. Halle & D. Dugmore

• Audit

– E-SURF- Ian Graham

• Implementation research • Political lobbying

– L. Rydén

• “How to” manual

– P. Giannuzzi

• Lay communications-

Score/HeartScore Joep Perk (Apoteket), Lay

Strategies to improve implementation

Sophie Squarta, Lars Ryden, Ian Graham

Implementation strategies: European level 1. Publication of Guidelines in relevant journals 2. The Prevention Toolkit HeartScore stand alone , comprising the Guidelines (paper and electronic), a slidekit and 3. A defined dissemination strategy 4. Implementation Committees/Groups: Committee; National Coordinators Prevention Implementation Committee; Joint Prevention 5. Presentations at international conferences the participating societies of 6. Directly influencing EU health policy for example through the Luxembourg Declaration and the European Health Charter- the product of a partnership between the EU, WHO, ESC and EHN

Implementation strategies: TOOLS 1. Guidelines: full text/ summary/pocket/one page/posters 2. HeartSore: The electronic, interactive risk estimation and guideline tool. On line and stand alone, downloadable and on CD 3. The new Guideline Learning Tool interactive case-based learning on-line 4. The e-toolkit : Guidelines, slides, HeartScore 5. E-SURF , the new and simplified risk factor audit

Implementation strategies: National level 1.Adapt the European Guidelines to suit the local culture 2.Formation of a multidisciplinary implementation group : professional bodies, medical and other health professionals, basic scientists, educators, business people, politicians. Needs to be more than merely advisory: should inform and shape health policy 3. Multi-faceted communications using all available media to doctors, medical and para-medical students, and ultimately all adults and children, including schools

Forming a multidisciplinary implementation group Process-

• The ESC asks National Cardiac Societies to nominate a

National Co-ordinator to develop and lead the multidisciplinary implementation group which will develop-

• National adaptation of guidelines if required • Partnerships between politicians, health professionals,

educators and business

• A defined communication strategy • An evaluation strategy • BUT it must have teeth. This requires high level political

representation if it is not to be a talking-shop. Indeed…

• This process has been variably successful. It is now proposed

that there should be two national co-ordinators- one a cardiologist and one from the Department of Health/ Health Service Executive

Forming a multidisciplinary implementation group -IRELAND 1. IHF Council on CVD prevention established to facilitate the process 2. (Chair IG) 3. National Co-ordinators Siobhan Jennings and Mahon Varma 4. Project manager Bridget Claffrey 5. Workplan established including meetings with all stakeholders and this meeting 6. Aim to showcase Ireland as an exemplar of the development of an implementation strategy 7. Presentation to the ESC European Summit on CVD prevention, Nice 30 Nov 2010

SUMMARY

• Objectives of meeting defined • General background • 4

th Joint Task Force European Guidelines on CVD prevention

• 5

th Joint Guidelines

• Implementation- some principles • European Prevention Implementation

Committee Action Plan

• Relations with the National Coordinators

for CVD prevention

• The strategy for Ireland

Thank you

Relations with the National Coordinators for CVD Prevention

PIC and the National Co-ordinators

• Promotion of joint co-ordinators in each

country representing Cardiology and the Department of Health

• Contribute to benchmarking by updating

the Mapping document

• Individualised strategic advice to countries • Workshops especially for developing

countries

• Contribution and use of the “How to”

manual

• Advice to and from the Joint Prevention

Alliance

• Possibly to act as national co-ordinators for

the pan- European audit

PIC, JPA and National Co-ordinators Likely most effective actions?

1. Driving National alliances 2. Simpler Guideline materials 3. How-to manual 4. Benchmarking and audit 5. Lobbying EU policy

Discussion of JPA and PIC

PIC and Joint Prevention Alliance 1.

• • • • • •

2.

3.

•

It is suggested to reflect the importance of the JPC by re-naming it the Joint Prevention Alliance The partnership- JTF4/5 members- remains the same The JPA will decide its own workplan: Encourage Joint Guidelines dissemination by the partner bodies Promote and co-ordinate Alliance events and workshops at specialist conferences Provide information on networks within countries to aid in the co-ordination of implementation Advise the PIC in all of its activities Advise on & promote the “how-to” manual Assist in development of guideline learning tool Specific topics for lobbying

PIC – Suggested Core activities-

to be prioritised

• Benchmarking

– H. McGee

– – – – – “

Call for Action” mapping document EuroAspire III Psyma survey report Powerhouse Health Consumer report EuroHeart WP5

• Health Economic models • Demonstration projects

– D. Wood & G. De Backer – M. Halle & D. Dugmore

• Audit

– Epidemiology & Public Health section

• Implementation research • Political lobbying

– L. Rydén

• “How to” manual

– I. Graham & P. Giannuzzi

• Lay communications-

Joep Perk (Apoteket), Lay Score/HeartScore

JTF4 Guidelines on CVD Prevention in Clinical Practice

1. INTRODUCTION

JTF IV Guidelineson prevention of CVD FORMAT

• Full text-

easier far too long!- treat as a resource document. Summary boxes from the pocket guidelines to make navigation

• Summary-

still far too long!

• Pocket guidelines-

better, more accessible

• Single page handout-

points summarizes the key

• The challenge-

the health professional’s mind- and on his/her desk!

to keep the key points in

JTF4 on CVD Prevention in Clinical Practice

3. PREVENTION STRATEGIES AND POLICY ISSUES

WHO report on the Prevention of CHD (and hence CVD) defined three components to preventive strategy: 1. Population 2. High risk 3. Secondary prevention

• The prevention paradox- high risk individuals gain

most from preventive measures- but most CVD deaths come from subjects with only mildly increased risk because they are so numerous

• The three strategies should be complementary, not

competitive

• Policy is defined further in the Osaka declaration

JTF4 on CVD Prevention in Clinical Practice

5. PRIORITIES, TOTAL RISK ESTIMATION AND OBJECTIVES

JTF4 on CVD Prevention in Clinical Practice

20. IMPLEMENTATION STRATEGIES

Report from the EACPR EuroPRevent Congress

EUROASPIRE- Surveys of patients with proven CHD

• EASP I

: 1995-1996. 9 countries

• EASP II

: 1999-2000. 15 countries

• EASP III

: 2005-2007. 22 countries

• 6 months after first CABG, PCI, or ACS

without prior CABG or PCI

• Considerable potential to improve risk

factor control:

Implementation- barriers & strategies. Review of current knowledge

• Luxembourg Declaration, Heart Health Charter,

Prevention Summit & consequent Call for Action

• EAS III • US Task Force 8 • JTF4 • REACT & ESC Surveys • Powerhouse Survey • Mapping document questionnaire to National Co-

ordinators

• Heart Health Charter Questionnaire* *Results awaited

Barriers to implementation

Barriers to implementation Google Scholar

• “Cardiovascular guidelines;

implementation”: 7600 refs

• “Cardiovascular guidelines; barriers

to implementation”: 2720 refs

• Very repetitive! • Strategies to improve implementation

tend to be verbose, woolly and based on little evidence

Barriers to the implementation of guidelines on CVD prevention

• Task force 8. Organization of

Preventive Cardiology Service.

Pearson TA, McBride PE, Miller NH, Smith S. JACC 1996; 27: 1039-47

• European Guidelines on CVD

Prevention in Clinical Practice. Fourth Joint Task Force Eur J of Cardiovascular Prevention and Rehabilitation 2007;14:suppl 2; E1-E40 and S1 S113

Barriers to implementation 1: PATIENT (PERSON!)

• Social, educational and cultural factors • Consequent lack of knowledge and motivation • Consequent lack of skills to make a life plan • Time and financial constraints • Unclear, complex advice and polypharmacy • Consequent difficulty in compliance • Unwillingness to ask for help from physician • Lack of access to care

Barriers to implementation 2: PHYSICIAN

• Acute problem (disease)-based focus • Negative or neutral feedback on

prevention

• Time constraints • Lack of incentives, incl. reimbursement • Lack of training- knowledge & skills • Lack of specialist- generalist

communication

• Guidelines - difficult to interpret; too

complex; lack of perceived legitimacy

Barriers to implementation 3: HEALTH CARE SETTING (hospitals, practices etc)

• Acute care priority • Lack of resources and facilities • Lack of systems for preventive services • Time and economic constraints • Poor communications between specialty

and primary care providers

• Lack of policies and standards

Barriers to implementation 4: COMMUNITY/SOCIETY

• Political failure of health planning

strategy-

• Educational policy- Schools, universities,

hospitals, adult education

• Activity, nutrition and tobacco policy • Apportionment of budget/taxes between

prevention and treatment services- hospitals get votes

• Effective multidisciplinary prevention planning

and implementation group

• Morbidity & mortality registers • Risk factor surveys • Physician re-imbursement for prevention

Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) Survey

• Hobbs FDR, Erhardt L • Family Practice 2002; 19: 596-604

REACT 2002

• Telephone interviews of 754

randomly selected primary care physicians in F, D, I, S, UK

• Most(89%) agreed with & said that

they used guidelines(81%) but only 1/5 believed that they were being implemented

REACT 2002- Barriers to implementation

• Time (38%) • Prescription costs (30%) • Patient compliance (17%)

REACT 2002- Suggestions to improve implementation

• Education for physicians (29%) • Education for patients (25%) • Publicizing or increasing guideline

availability (23%)

• Simpler guidelines (17%) • Clearer guidelines (12%)

Factors Impeding the Practical Implementation of Cardiovascular Prevention

An international market research project in 6 countries: Germany, France, Italy, Spain, the United Kingdom and Poland D F I E - PRESENTATION CHARTS -

Psyma International Medical Marketing Research GmbH Gartenweg 2 90607 Rückersdorf/Nürnberg Germany

phone: +49-911-95 785-0 fax: +49-911-95 785-33 e-mail: [email protected]

website: www.psyma-international.com

This study was commissioned by

European Society of Cardiology (ESC) Cardiovascular Round Table (CRT) Task Force 4

Technical staff at Psyma International

: Alexander Rummel Monica Bach Dr. Britta Meyer-Lutz

Study No: 41057021 December 2002

Factors impeding the implementation of cardiovascular prevention guidelines: findings from a survey conducted by the European Society of Cardiology Graham IM, Stewart M & Hertog M for the Cardiovascular Round Table Task Force .

EJCPR 2006:13; 839-45

• Market research survey • In-depth interviews with 66

cardiologists & 154 primary care physicians (N=220)

• 6 focus groups involving 49 physicians • D,F,I,E,UK,P

Factors impeding implementation

• 25% of physicians didn’t know or couldn’t

explain the term “total” or “global” risk

• Guideline usage varied- 20% (Poland and

France) to >70% (Spain and UK)

• Usage of risk scoring systems varied

widely- 4% in Italy to 43% in UK (Mean 21%)

• National guidelines are preferred to ESC

guidelines (45% vs 4%)

• Perceived problems with guidelines-

impractical, time consuming, not interesting, “guideline fatigue”

Improvements to increase guideline usage

• Simpler, more user-friendly

guidelines with improved content

• Increased patient awareness &

education

• Independent research (credible,

trustworthy)

• Government initiatives (time,

remuneration)

Guidelines for all and their integration into education

• The challenge is to make practical

prevention universally accessible. Medical control of this process may have been excessive

• This implies integration of the messages

from guidelines into schools curricula as well as into undergraduate and postgraduate education

TARGETS TO DEFINE SUCCESS for discussion

• Dissemination of guidelines and toolkit in 100%

European countries

• National co-ordinators in 90% • Evidence of effective national alliances with

defined plan in 66%

• Evidence of agreed guidelines (National or

European) in 80%

• Risk estimation systems used in 80% • National risk factor audits in 66% • Evidence of monitoring systems for CVD mortality

and risk factor trends

Background

• European Guidelines on CVD Prevention • European Heart Health Charter • Call for Action • EACPR and JPC Minutes • EACPR strategic plan • Mapping document • Slide kit • HeartScore • Health Professional Toolkit

Joint Prevention Group EACPR Implementation Committee

Prevention Implementation Committee

Implementing new guidelines into clinical practice

Ian M Graham

Prevention Implementation Committee 1. Summary of JTF4 Guidelines 2. Will JTF5 be different? This will impact on our workplan 3. The gap between recommendations and clinical practice 4. Barriers to implementation 5. Strategies to improve implementation 6. Review of knowledge, gaps in knowledge and survey needs 7. Critical success factors 8. Review of role of National co-ordinators 9. Respective responsibilities of JPC and EACPR prevention implementation committee 10.Pan- European activities 11.Selected individual country activities 12.Workplan and timelines 13.Responsibilities of individual partners

4 th Joint Task Force on Prevention: MEMBERS

• Dan Atar [ESC] • Knut Borch-Johnson [EASD/IDF Europe] • Gudrun Boysen [EUSI] • Gunilla Burrell [ISBM] • Renata Cifkova [ESH] • Jean Dallongeville • Guy de Backer [ESC] • Shah Ebrahim [ESC] • Bjorn Gjelsvik [ESGP/FM/Wonca] • Christoff Hermann-Lingen [ISBM] • Arno W Hoes [ESGP/FM/Wonca] • Steve Humpries [ESC] • Mike Knapton [EHN] • Joep Perk [EACPR] • Sylvia G Priori [ESC] • Kalevi Pyorala [ESC] • Zeljko Reiner [EAS] • Luis Ruilope [ESC] • Susana Sans-Mendes [ESC] • Wilma Scholte Op Reimer [ESC council on CV Nursing] • Peter Weissberg [EHN] • David Wood [ESC] • John Yarnell [EACPR] • Jose Luis Zamorano [ESC/CPG]

4

th

Joint Guidelines on CVD Prevention SPECIAL PEOPLE, SPECIAL THANKS

INVITED EXPERTS ESC STAFF Marie-Therese Cooney Alexandra Dudina Tony Fitzgerald Edmond Walma Keith McGregor Veronica Dean Catherine Depres Sophie Squarta

Why develop a preventive strategy in clinical practice?

1.Cardiovascular disease (CVD) is the major cause of premature death in Europe. It is an important cause of disability and contributes substantially to the escalating costs of health care 2.The underlying atherosclerosis develops insidiously over many years and is usually advanced by the time that symptoms occur 3.Death from CVD often occurs suddenly and before medical care is available, so that many therapeutic interventions are either inapplicable or palliative 4.The mass occurrence of CVD relates strongly to lifestyles and to modifiable physiological and biochemical factors 5.Risk factor modifications have been shown to reduce CVD mortality and morbidity, particularly in high risk subjects

CVD Prevention:

CHALLENGES

• Inactivity • Obesity • Stroke • Heart failure • Gender and social class inequalities • Renal failure • Implementation

Fig 1 The expected number of CVD deaths at increasing levels of predicted risk. Illustration of the fact that most events occur in low risk subjects with few deaths among high risk subjects.

80 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Predicted Risk (Men aged 50-59 )

10 year risk of fatal CVD in high risk regions of Europe

10 year risk of fatal CVD in low risk regions of Europe

Relative Risk Chart This chart may used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication

JTF5 – will it be different?

• Chairperson- Prof Joep Perk • Detailed suggestions to simplify the

process available (IG)

• Electronic version of JTF4 available • Single format for submissions essential • SCORE developments • Will rehabilitation be included? logical (but

political…)

• ? Make pocket guidelines the summary • Continue to use figures in main text • One page card critical • Tie more closely to interactive teaching?

Additional knowledge needed?

• Commissioned surveys on what

additional information is needed to inform strategy (by EACPR?)

• Modelling exercises on effects of

implementation strategy (by EACPR?)

• Inventories of prevention in different

countries to allow benchmarking

• Subsequent development of

educational materials

Joint Prevention Group EACPR Implementation Committee

Prevention Implementation Committee

The implementation of current CVD prevention guidelines

Ian M Graham

PIC CORE ACTIVITIES to be prioritised 1. BENCHMARKING- Inventory of implementation info + development of strategy: H McG 2. AUDIT- Pan European audit: Epidemiology 3. HEALTH ECONOMIC MODELLING: DW, Gde B 4. HOW-TO manual: IG, PG 5. DEMONSTATION PROJECTS WITH INDUSTRY: DD, MH 6. IMPLENTATION RESEARCH: tbd 7. LOBBYING: LR, European Affairs 8. LAY COMUNICATIONS: JP (Apoteket); SCORE-Lay

Give me a doctor partridge plump, short in the leg and broad in the rump, an endomorph with gentle hands, who’ll never make absurd demands that I abandon all my vices, or pull a long face in a crisis, but with a twinkle in his eye, will tell me that I have to die. W H Auden

Give me a doctor underweight, computerised and up to date.

A businessman who understands accountancy and target bands.

Who demonstrates sincere devotion to audit and to health promotion but when my outlook’s for the worse refers me to the practice nurse MariaCampkin

Report from the EACPR EuroPrevent Congress Stockholm, May 2009