Bridging science and health policy in cardiovascular disease: focus on lipid management: A Report from a Session held during the 7th International Symposium on Multiple Risk Factors in Cardiovascular Diseases: Prevention and Intervention – Health Policy, in Venice, Italy, on 25 October, 2008

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Abstract

In Europe, cardiovascular disease (CVD) represents the main cause of morbidity and mortality, costing countries € 190 billion yearly (2006). CVD prevention remains unsatisfactory across Europe largely due to poor control of CVD risk factors (RFs), growing incidence of obesity and diabetes, and sedentary lifestyle/poor dietary habits. Hypercholesterolaemia is a proven CVD RF, and LDL-C lowering slows atherosclerotic progression and reduces major coronary events. Lipid-lowering therapy is cost-effective, and intensive treatment of high-risk patients further improves cost effectiveness. In Italy, models indicate that improved cholesterol management translates into potential yearly savings of € 2.9–4 billion. Identifying and eliminating legislative and administrative barriers is essential to providing optimal lipid care to high-risk patients. Public health and government policy can influence clinical practice rapidly, and guideline endorsement via national health policy may reduce the CVD burden and change physician and patient behaviour. Action to reduce CVD burden should ideally include the integration of strategies to lower the incidence of major CV events, improvement in total CV risk estimation, database monitoring of CVD trends, and development of population educational initiatives on CVD prevention. Failure to bridge the gap between science and health policy, particularly in relation to lipid management, could result in missed opportunities to reverse the burgeoning epidemic of CVD in Europe.

Introduction

[Volpe M.]

Despite remarkable progress in our understanding of the causes, diagnosis, and management of cardiovascular disease (CVD), strategies to prevent this potentially devastating condition remain largely unsatisfactory throughout the European Union (EU). Although variations in secular trends exist across Europe, the large and increasing incidence of CVD is largely due to poor control of traditional CVD risk factors (such as hypertension and hypercholesterolaemia), the growing incidence of obesity and diabetes in adults and young people, and the sedentary lifestyle and poor dietary habits of modern society.

The progressive and marked increase in the incidence of CVD is a matter of intense and growing concern among many regulators and professionals involved in maintaining and promoting public health. Current health care systems dedicated to acute CVD care (such as coronary care, stroke, and rehabilitation units, intensive care units (ICUs), and specialised outpatient clinics) could quickly become overwhelmed by the growing number of patients requiring prolonged intensive care and assistance. Indeed, disease projections and demographic trends in the European region combined with the routine difficulties admitting patients to ICUs suggest that the health care system may already be imperilled in some countries. In Italy, for example, about half of patients experiencing sudden cardiac arrest (SCA) or acute myocardial infarction (MI) are treated outside of ICUs. In light of these trends, sustaining the advance of medical assistance in terms of the economic costs of drugs, therapeutic devices, diagnostic and interventional technologies, and follow-up programmes will be challenging.

[Wood D.]

It is clear that, in the absence of effective CVD health policy, robust medical evidence and physician expertise do not necessarily translate into high standards of preventive care. In recent years, therefore, European physicians have become more actively engaged in CVD health policy development, as evidenced by the development of the Joint European Societies Prevention Guidelines [1, 2, 3, 4 and the creation of the European Heart Health Charter (EHHC) [5] launched in Brussels on 12 June, 2007. While acknowledging and respecting individual country autonomy, EHHC advocates a unified approach to CV health, promoting the translation, adaptation, and dissemination of CVD prevention guidelines. In particular, the EHHC called for establishment of national strategies for the detection and management of patients at high risk of CVD and the prevention and care of those with established CVD. The overall objective is to bridge the treatment gap between what is recommended and what is achieved in daily practice regarding CVD prevention.

To help support the increasing activities of the EU and national parliaments with respect to CVD health policy (particularly as it relates to lipids), a panel of European experts in CVD management, economics, and health policy, convened at an international symposium on Bridging Science and Health Policy in Cardiovascular Disease: Focus on Lipid Management, in Venice, Italy, on October 25, 2008, to review and discuss the following issues:

  • The clinical and socioeconomic impact of CVD in the EU

  • The impact of lipid-lowering strategies (particularly LDL-C reduction) on CVD outcomes

  • Targeted “high-risk” versus population approaches to reduce CVD risk

  • The cost-effectiveness of lipid-lowering strategies and their potential role in improving long-term financial health care sustainability

  • The barriers and incentives to CVD prevention

  • Overcoming barriers to proper lipid management and implementing strategies to improve CVD prevention: the Italian experience.

This article serves as a compilation of the broad range of material presented and discussed during the meeting and summarises the conclusions made.

Section snippets

Global and European burden of CVD

[Volpe M.]

The clinical and socioeconomic impact of CVD is substantial. According to World Health Organisation (WHO) 2004 statistics, CVD represents the number one cause of death worldwide, accounting for 29% of total mortality (Fig. 1) [6]. In Europe, CVD represents the main cause of morbidity, mortality, and hospitalisation [7, 8, 9. CVD is the largest contributor to the European burden of disease in terms of mortality – considerably larger than infectious and parasitic diseases, malignant

Economic burden of CVD

[Volpe M.]

In the US in 2006, the cost of CVD was estimated to be $ 368 billion (two-thirds of the overall in-hospital medical assistance cost); a 25% increase over the next 25 years would result in CVD costs increasing to $ 550 billion [13]. In Italy, the effective gross cost of the intra-hospital phase of acute MI could be around € 6000 per patient (€ 720 million per year); a 25% increase in MI over the next 25 years (without considering the costs related to rehabilitation, leave of absence

Clinical outcome benefits of lowering LDL-C

[Atella V.]

Several key factors contribute to CVD, including age, high blood pressure (BP), smoking, high cholesterol levels, high body mass index (BMI), obesity, and diabetes. The median age in most member states of the EU is now over 30 years (Italy is the highest with 41.6 years). By 2020, 20% of people in Europe will be over 60 years and more than 5% will be over the age of 80 years. Obesity and diabetes are estimated to be 30 million in 2020, with obesity and overweight, in particular,

Targeted “high-risk” versus population approaches to reduce CVD risk

[Critchley J.]

Public policies outside of the health service play a major role in influencing public health, generally by facilitating (or hindering) healthier choices among the population. The role of these population interventions for reducing CVD (primary prevention) compared with targeted “high risk” approaches has been much debated.

Cost-effectiveness of lipid-lowering therapy

[Lindgren P.]

The introduction of statins led to increased interest in economic aspects of lipid-lowering therapy. Since statins were perceived as effective but potentially very costly, a need existed to assess the economic consequences of this class of drug. Initially this was achieved through prediction models (such as using Framingham risk equations) but the completion of end-point trials (starting with the Scandinavian Simvastatin Survival Study (4S)) led to economic evaluations based on

Better lipid-lowering therapy improves long-term financial health care sustainability: a simulation model

[Atella V.]

Despite improvements in drug treatments and medical care over the last 25 years, CVD currently represents a major health care issue in terms of both health and economic aspects and is expected to be a growing concern for the future. Hospitalisation forecasts in Italy (based on Ministry of Health data) show that the number of patients at risk of hospitalisation for CVD due to high cholesterol levels is anticipated to increase by more than 50% over the next 30 years (assuming

Barriers and incentives to CVD prevention

[Hobbs F.D.R.]

This section serves to identify the spectrum of barriers to implementing CVD prevention (including those strategies pertaining to lipid management) as well consider potential incentives to overcome these barriers.

Overcoming barriers to proper lipid management: lessons from Italy

[Vanuzzo D.]

Overcoming barriers to proper lipid management in country-specific health organisations will require revising the legislative and administrative policy objectives at the EU, national, and regional levels. Examples of these new objectives could be: (1) To implement national and regional cholesterol performance measures and incentives for primary care physicians to screen high risk patients and achieve cholesterol target levels in these patients; (2) To identify and eliminate

Strategies and interventions to improve CV prevention: the Italian experience

[Volpe M.]

CVD is expected to have a substantial clinical and socioeconomic impact in Italy in the next few years, potentially threatening the sustainability of the entire national health care system [9]. To enhance the level of attention on interventional strategies for improving CV prevention in Italy, consensus document or White Paper was developed [9].

Speaker Panel discussion

After reviewing the facts about CVD and barriers to achieving widespread improvements in lipid control and CVD prevention, the panel members, under the direction of the meeting co-chairmen (see layout of the Session, page 21), identified and discussed several aspirational and achievable goals or targets that could potentially improve the health of all nations within the EU. These key issues are summarised in Table 7) and described below.

  • Evaluate the economic burden of disease by

Concluding remarks

[Graham I.M.]

The key priorities to improve the health of all nations within the EU with respect to lipid lowering and CVD prevention should include the following:

  • All policy recommendations should fall within the general context of the EHHC.

  • Multidisciplinary implementation groups that include politicians, educators, as well as physicians, need to be convened and empowered.

  • The general public health issues of obesity and fat balance within Europe urgently need addressing.

  • Equity of access of

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