FLETCHER
ET AL., 33RD BETHESDA CONFERENCE: Preventive Cardiology: How Can
We Do Better?
J Am Coll Cardiol 2002;40:4:579-651
BETHESDA
CONFERENCE REPORT
33rd Bethesda Conference: Preventive Cardiology: How Can We Do Better?
Gerald
F. Fletcher, MD, FACC, Conference Co-Chair
Introduction
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.
References
1. Strauss
MD. Familiar Medical Quotations. 1st edition. Boston, MA: Little,
Brown and Company, 1968:1.
2.
Eleventh Bethesda conference: prevention of coronary heart disease.
September 27-28, 1980, Bethesda, Maryland. Am J Cardiol 1981;47:
713-76.
3. Pasternak
RC, Grundy SM, Levy D, Thompson PD. 27th Bethesda conference: matching
the intensity of risk factor management with the hazard for coronary
disease events. Task Force 3. Spectrum of risk factors for coronary
heart disease. J Am Coll Cardiol 1996;27:978-90.
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