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In the UK National Health Service (NHS), primary prevention of cardiovascular disease (which encompasses diabetes and renal disease too) is now achieving the status afforded to secondary prevention 10 years ago. The Department of Health vascular risk checks programme1 is welcomed to strategically reduce health inequalities, which are precipitated largely by cardiovascular disease. Cardiovascular morbidity and mortality are, in principle, preventable.2 In 2005 in England, there were 171 021 deaths from circulatory diseases (accounting for 40% of all deaths).3 Additionally, it is responsible for one-fifth of all hospital admissions and incurs an NHS expenditure of £30 billion annually. Therefore, prevention is beneficent not only to the individual but also to the wider economy. The government has recently recommended the introduction of a universal risk assessment and management programme for people aged 40 to 74 years.1 The magnitude of this task must not be underestimated, as a number of challenges will need to be addressed before such a programme can be widely implemented.
Accepting a NHS shift from illness management to health protection requires a paradigm shift in public perception. Widespread publicity and health promotion must accompany cardiovascular prevention strategies, similar to campaigns supporting initiatives such as cervical screening. The voluntary sector may launch and sustain such public campaigns, but the role and responsibility of the NHS as a partner in publicity will require clarification.
With a population aware and engaged with the principles of vascular risk assessment, next comes the issue of whom and how to target risk assessment. In the absence of a UK prospective cohort study, a variety of tools are available for risk assessment. It is neither necessary nor cost-effective to screen the entire population for cardiovascular risk, yet should everyone receive lifestyle risk management advice? Specific population subgroups such as south Asians and socio-economically deprived populations, at increased risk of cardiovascular disease,4–6 must be targeted for population-based prevention strategies. There are several parallels with a screening programme, highlighting the need to consider issues such as collaborative commissioning, call–recall systems, provision of both upstream and downstream services, counselling, etc.
Evidence for the effectiveness and cost-effectiveness of population-based risk assessment and interventions is, in the main, lacking. Where programmes have succeeded, they are often not restricted to healthcare-related interventions alone.7 Those responsible for implementation of vascular risk assessment programmes must rely on indirect evidence from modelling studies.8 Currently recommended is risk assessment in people aged 40 to 74 years. Is the suggested age cut-off of 40 years for access to risk assessment appropriate? In certain ethnic groups such as south Asians, the onset of diabetes or a first myocardial infarction occurs on average 8 years earlier,9 suggesting that earlier targeted screening may be prudent if cost-effective. However, differential modelling for different ethnic groups is lacking. A further major evidence gap is the most appropriate rescreening interval. For implementation, the government’s own cost-effective modelling evaluations have made a number of assumptions including a 75% uptake of such a programme. However, many urban areas have had uptake rates of less than 30% for similar programmes10 and lifestyle change programmes such as smoking cessation have shown a social gradient in uptake,11 suggesting that inequalities may widen without proactive case finding. Awareness of, access to, acceptance of and acquisition of services (including health promotion) are all essential to success. Furthermore, health promotion will need to be tailored to the needs of communities and mainstreamed.
Proactive case finding is essential to reduce health inequalities and complement the vascular risk checks programme. Reduced tobacco use and statin prescribing are appropriate interventions in those at risk. Lower socio-economic groups (where premature cardiovascular disease is three times more prevalent) and first-degree relatives of those with proven, premature cardiovascular disease might be specifically targeted groups to complement the risk-assessment programme.
At primary care level, where the majority of risk assessment and management will be carried out, key challenges exist. First, the infrastructure required to accommodate an extended role for primary care must be identified and resourced appropriately. Second, adequate provision and funding of lifestyle risk management and therapeutic interventions to address increased healthcare needs identified will be required. Third, systematic use of appropriate risk-assessment tools must be utilised efficiently. The existence of disease-specific registers in isolation without integrated risk assessment in many practices is regrettably a missed opportunity. Fourth, comprehensive ethnic coding for all registered patients will enable targeted screening and accurate risk assessment for ethnic groups. Finally, demands placed on primary care by this programme must not be underestimated. In areas where population needs are greatest, support and education will be required.
The government is keen to deliver a vascular risk-assessment programme in a variety of settings including pharmacies and community centres. Highlighting alternative venues may improve awareness, acceptability and uptake of the programme. How should screening occur in pharmacies or by alternative providers? Evidence for effective use of such strategies is lacking, and integration of these services within the NHS is essential. Screening contingent on a single risk factor such as cholesterol is less efficient than screening contingent on age, sex, smoking, ethnicity and blood pressure which might signpost individuals into a systematic risk assessment programme. We should be screening for risk, not cholesterol. One can be high risk with “normal cholesterol.” The ability of non-NHS providers to codeliver the risk assessment programme might be welcomed by the government, but if uncoordinated and with inadequate information technology (IT) available, risks duplication of effort and challenges communication of data between the non-NHS provider and primary care. It is imperative that IT systems be developed to audit uptake and provide reporting frameworks to assess the efficacy of the programme.
As with genetic screening, the impact of cardiovascular risk assessment for the individual on personal matters, such as life assurance, must be considered. Disclosure of a personal risk-assessment score may be mandated by underwriters for those falling within the age strata of screening services. In the absence of accurate epidemiological data for subgroups, is this acceptable?
The long-awaited vascular risk checks programme provides a unique opportunity to harness, guide and endorse the multitude of cardiovascular prevention and screening programmes and projects which exist nationwide. While the endpoint of risk assessment and interventions to reduce risk are the same for each individual, the journey to arrive at such an endpoint will inevitably vary. The challenge for the NHS is to ensure that resources and quality control measures are in place to deliver a comprehensive, non-fragmented programme, while being mindful of the opportunity to rise to the challenges, foresee the risks and reap the benefits such an ambitious programme offers.
Competing interests: KCRP is clinical lead for Staying Healthy and Lead for the CVD Strategy for West Midlands Strategic Health Authority, a member of NICE guideline groups on smoking cessation, chest pain and cardiovascular prevention, a member of the National Heart Forum which focuses on prevention of CVD and a steering group member of the Cardio and Vascular Coalition. RM is a member of NICE guideline groups on Lipid Modification and Familial Hyperlipidaemia. PG is a member of the NICE Guideline group for Lipid Modification and cardiovascular prevention. KK has received funding from Department of Health for a diabetes screening and intervention study, an NIHR diabetes prevention programme grant and advised the UK National Screening Committee on the Vascular Risk Assessment Programme. RC is screening lead for Department of Health West Midlands and co-lead for the CVD Strategy. KCRP, RM, PG and KK are members of the South Asian Health Foundation, which is a stakeholder to several NICE guidelines.
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