534
Editorials
3 Kraemer HC, Kupfer DJ. Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry 2006; 59: 990–6. 4 Ellis PD. Effect Size Matters: How Reporting and Interpreting Effect Sizes Can Improve your Publication Prospects and Change the World! MadMethods, KingsPress.org, 2012.
5 Ellis PD. The Essential Guide to Effect Sizes: Statistical Power, Meta-Analysis, and the Interpretation of Research Results. New York: Cambridge University Press, 2010. 6 Furukawa TA, Leucht S. How to obtain NNT from Cohen’s d: comparison of two methods. PLoS ONE 2011; 6: e19070.
Disclosures No disclosures relevant to the subject of this editorial other than a reasonably healthy obsession with number needed to treat. doi: 10.1111/ijcp.12435
EDITORIAL
Evidence-based screening to prevent and control cardiovascular disease worldwide
Evidence based CVD prevention
Despite emerging trends for mortality in developed countries, cardiovascular disease (CVD) remains the major cause of premature death in Europe with most clinical events caused by complications of atherosclerosis (1). Even well-known cardiologists have experienced sudden cardiac deaths below the age of 65. These include RW Campbell, JM Isner, PA Poole-Wilson, H Drexler, and recently the paediatric cardiologist from Hannover, A Wessels. These events underline what has been emphasised 15 years ago by the MONICA study, that two-thirds of patients die outside the hospital and therefore there is a requirement to concentrate on primary and secondary prevention. A recent study using data pooled from 18 US cohort studies, including 257,384 participants reported that among the total population aged 55 years, only ~3% of subjects were optimally managed for all key CVD risk factors (2). In the NHANES III population, < 7.5% of the population met six or more of the seven cardiovascular health metrics (i.e. not smoking, being physically active, being normal weight, blood pressure, glucose and total cholesterol levels, eating an healthy diet) which were recently published by the American Heart Association for CVD prevention (3). Similar findings have been described in Europe. The EUROASPIRE III economic project emphasised the economical and societal value of optimising CVD prevention, with an average cost-effective ratio per quality-adjusted life (Qualy) years up to £10,752 in data from eight countries (4). The total economic cost for CVD per year to the EU, including healthcare cost as well as cost for medications, informal care, plus lost opportunity and productivity cost, is spiking at more than 196 billion Euro per year (Euro 196 billion is more than the annual budget of the EU (5).
Heads of States and Governments made commitments to the prevention and control of non-communicable diseases (NCDs) in the political declaration from the UN High-level meeting on NCDs in September 2011. World Health Organization (WHO) member states have agreed an NCD target of a 25% reduction by 2025 regarding the probability of dying from NCDs. The main goal should be the identification of people at high risk of developing a CVD event through evidencebased preventative programmes (6). The UK National Screening Committee (Department of Health-UK, DOH-UK) is now supporting evidence-based preventative programmes and private GPs have been contacted by the UK-NSC regarding recommendations to advise their patients to undergo only evidence-based screenings. The UK-NSC who advises Ministers and the NHS about all aspects of screening and supports implementation of screening programmes, the British Medical Association and the Academy of Medical Royal Colleges, have recently expressed concern about the potential harms of general healthcare screening. They concluded that many direct-to-consumer tests are unreliable, and it is impossible for people to distinguish between those that may be useful and those that have no value or may even be harmful (7). The UK-NSC recommends that NHS professionals should offer screening only if there is evidence that, overall, the benefits of screening outweigh the potential harms. Thus, screening should not be offered in the absence of known evidence (7). Healthcare companies, including BMI Healthcare, BUPA, and Nuffield Healthcare, were found to offer general screening tests with no known benefits (7). This caused unnecessary worry to patients, resulted in higher insurance premiums, produced inadequate information and increased the number of referrals to ª 2014 John Wiley & Sons Ltd Int J Clin Pract, May 2014, 68, 5, 533–535
Editorials
NHS GPs. These conclusions were expressed by an expert panel (including members of the UK-NSC) that assessed the findings and reports of screening Programmes offered by the above named companies (7). According to an investigation by Which? Private health checks have been found not to follow international guidelines supporting evidence based prevention (7). Their researchers made undercover visits to six healthcare companies and found that the risks involved with health MOTs – such as the possibility of further tests which could be painful or risky, and potential false alarms – were not always explained (7). People in the UK spend an estimated £100 m on health screening each year in the private sector (7). Doing nothing is going to cost the world $47 trillion in the next 25 years, including $500 billion a year in low- and middle-income countries, where 80% of deaths from CVD now occur. In contrast, estimates by the WHO of how much it will cost to implement various measures they have recommended vary between just $11 billion and $13 billion a year. The WHO has now identified a core set of 10 low-
References 1 Perk J, De Backer BG, Gohlke H et al. European guidelines on CVD prevention in clinical practice. Eur Heart J 2012; 33: 1635–701. 2 Berry J, Dyer A, Cai X et al. Lifetime risk of CVD. N Engl J Med 2012; 366: 321–9. 3 Yang Q, Cogswell ME, Flanders WD et al. Trends in cardiovascular health metrics and associations with all cause and CVD mortality among US adults. JAMA 2012; 307: 1273–83. 4 De Smedt SD, Kotseva K, Wood D et al. Cost effectiveness of optimizing prevention in patients with
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, May 2014, 68, 5, 533–535
535
cost strategies called ‘best buys’ to address NCDs, including, for example, a 25% relative reduction in prevalence of hypertension, 30% relative reduction in mean population intake of salt and a 30% relative reduction in prevalence of tobacco smoking (8). In conclusion, the UK-NSC agrees that there are a number of accepted principles of screening that the NHS professionals should adhere to: only offer screening if there is proven evidence that, overall, the benefits of screening outweigh the potential arms. This means that screening and preventative programmes should not be offered in the absence of known evidence provided by international scientific guidelines published by international scientific medical societies. F. De Lorenzo Cardiovascular Disease Prevention & Lipid Clinic, Hammersmith Hospital NHS Foundation Trust, London, UK Email: [email protected]
coronary heart disease: the Euroaspire III health economic project. Eur Heart J 2012; 33: 2865–72. 5 Wood S. Best targets, biggest hurdles in Europe’s war on CVD. Heartwire Conference News, April 18, 2013. 6 Smith SC Jr, Collins A, Ferrari R et al. Our time: a call to save preventable death from CVD. Eur Heart J 2012; 33(23): 2243–8. 7 De Lorenzo F. Many private screening tests have no known benefit. BMJ 2012; 345: e8365.
8 Smith SC Jr, Collins A, Ferrari R et al. Our time: a call to save preventable death from cardiovascular disease (heart disease and stroke). Circulation 2012; 126(23): 2769–75.
Disclosure None. doi: 10.1111/ijcp.12381
Editorials
3 Kraemer HC, Kupfer DJ. Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry 2006; 59: 990–6. 4 Ellis PD. Effect Size Matters: How Reporting and Interpreting Effect Sizes Can Improve your Publication Prospects and Change the World! MadMethods, KingsPress.org, 2012.
5 Ellis PD. The Essential Guide to Effect Sizes: Statistical Power, Meta-Analysis, and the Interpretation of Research Results. New York: Cambridge University Press, 2010. 6 Furukawa TA, Leucht S. How to obtain NNT from Cohen’s d: comparison of two methods. PLoS ONE 2011; 6: e19070.
Disclosures No disclosures relevant to the subject of this editorial other than a reasonably healthy obsession with number needed to treat. doi: 10.1111/ijcp.12435
EDITORIAL
Evidence-based screening to prevent and control cardiovascular disease worldwide
Evidence based CVD prevention
Despite emerging trends for mortality in developed countries, cardiovascular disease (CVD) remains the major cause of premature death in Europe with most clinical events caused by complications of atherosclerosis (1). Even well-known cardiologists have experienced sudden cardiac deaths below the age of 65. These include RW Campbell, JM Isner, PA Poole-Wilson, H Drexler, and recently the paediatric cardiologist from Hannover, A Wessels. These events underline what has been emphasised 15 years ago by the MONICA study, that two-thirds of patients die outside the hospital and therefore there is a requirement to concentrate on primary and secondary prevention. A recent study using data pooled from 18 US cohort studies, including 257,384 participants reported that among the total population aged 55 years, only ~3% of subjects were optimally managed for all key CVD risk factors (2). In the NHANES III population, < 7.5% of the population met six or more of the seven cardiovascular health metrics (i.e. not smoking, being physically active, being normal weight, blood pressure, glucose and total cholesterol levels, eating an healthy diet) which were recently published by the American Heart Association for CVD prevention (3). Similar findings have been described in Europe. The EUROASPIRE III economic project emphasised the economical and societal value of optimising CVD prevention, with an average cost-effective ratio per quality-adjusted life (Qualy) years up to £10,752 in data from eight countries (4). The total economic cost for CVD per year to the EU, including healthcare cost as well as cost for medications, informal care, plus lost opportunity and productivity cost, is spiking at more than 196 billion Euro per year (Euro 196 billion is more than the annual budget of the EU (5).
Heads of States and Governments made commitments to the prevention and control of non-communicable diseases (NCDs) in the political declaration from the UN High-level meeting on NCDs in September 2011. World Health Organization (WHO) member states have agreed an NCD target of a 25% reduction by 2025 regarding the probability of dying from NCDs. The main goal should be the identification of people at high risk of developing a CVD event through evidencebased preventative programmes (6). The UK National Screening Committee (Department of Health-UK, DOH-UK) is now supporting evidence-based preventative programmes and private GPs have been contacted by the UK-NSC regarding recommendations to advise their patients to undergo only evidence-based screenings. The UK-NSC who advises Ministers and the NHS about all aspects of screening and supports implementation of screening programmes, the British Medical Association and the Academy of Medical Royal Colleges, have recently expressed concern about the potential harms of general healthcare screening. They concluded that many direct-to-consumer tests are unreliable, and it is impossible for people to distinguish between those that may be useful and those that have no value or may even be harmful (7). The UK-NSC recommends that NHS professionals should offer screening only if there is evidence that, overall, the benefits of screening outweigh the potential harms. Thus, screening should not be offered in the absence of known evidence (7). Healthcare companies, including BMI Healthcare, BUPA, and Nuffield Healthcare, were found to offer general screening tests with no known benefits (7). This caused unnecessary worry to patients, resulted in higher insurance premiums, produced inadequate information and increased the number of referrals to ª 2014 John Wiley & Sons Ltd Int J Clin Pract, May 2014, 68, 5, 533–535
Editorials
NHS GPs. These conclusions were expressed by an expert panel (including members of the UK-NSC) that assessed the findings and reports of screening Programmes offered by the above named companies (7). According to an investigation by Which? Private health checks have been found not to follow international guidelines supporting evidence based prevention (7). Their researchers made undercover visits to six healthcare companies and found that the risks involved with health MOTs – such as the possibility of further tests which could be painful or risky, and potential false alarms – were not always explained (7). People in the UK spend an estimated £100 m on health screening each year in the private sector (7). Doing nothing is going to cost the world $47 trillion in the next 25 years, including $500 billion a year in low- and middle-income countries, where 80% of deaths from CVD now occur. In contrast, estimates by the WHO of how much it will cost to implement various measures they have recommended vary between just $11 billion and $13 billion a year. The WHO has now identified a core set of 10 low-
References 1 Perk J, De Backer BG, Gohlke H et al. European guidelines on CVD prevention in clinical practice. Eur Heart J 2012; 33: 1635–701. 2 Berry J, Dyer A, Cai X et al. Lifetime risk of CVD. N Engl J Med 2012; 366: 321–9. 3 Yang Q, Cogswell ME, Flanders WD et al. Trends in cardiovascular health metrics and associations with all cause and CVD mortality among US adults. JAMA 2012; 307: 1273–83. 4 De Smedt SD, Kotseva K, Wood D et al. Cost effectiveness of optimizing prevention in patients with
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, May 2014, 68, 5, 533–535
535
cost strategies called ‘best buys’ to address NCDs, including, for example, a 25% relative reduction in prevalence of hypertension, 30% relative reduction in mean population intake of salt and a 30% relative reduction in prevalence of tobacco smoking (8). In conclusion, the UK-NSC agrees that there are a number of accepted principles of screening that the NHS professionals should adhere to: only offer screening if there is proven evidence that, overall, the benefits of screening outweigh the potential arms. This means that screening and preventative programmes should not be offered in the absence of known evidence provided by international scientific guidelines published by international scientific medical societies. F. De Lorenzo Cardiovascular Disease Prevention & Lipid Clinic, Hammersmith Hospital NHS Foundation Trust, London, UK Email: [email protected]
coronary heart disease: the Euroaspire III health economic project. Eur Heart J 2012; 33: 2865–72. 5 Wood S. Best targets, biggest hurdles in Europe’s war on CVD. Heartwire Conference News, April 18, 2013. 6 Smith SC Jr, Collins A, Ferrari R et al. Our time: a call to save preventable death from CVD. Eur Heart J 2012; 33(23): 2243–8. 7 De Lorenzo F. Many private screening tests have no known benefit. BMJ 2012; 345: e8365.
8 Smith SC Jr, Collins A, Ferrari R et al. Our time: a call to save preventable death from cardiovascular disease (heart disease and stroke). Circulation 2012; 126(23): 2769–75.
Disclosure None. doi: 10.1111/ijcp.12381
