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Significant advances in cardiovascular care, developed over the past three decades, are now routine treatment for people with heart disease—for example, primary angioplasty for acute ST elevation myocardial infarction is available to over 70% of the UK population, resynchronisation and defibrillator pacing devices are options for those with advanced heart failure, and drug therapies such as statins for secondary prevention have made significant impacts in reducing cardiovascular mortality in the past 50 years. Today, patients with cardiovascular disease can expect a better quality of life and greater longevity than those treated previously. However, much of the improvement in cardiovascular outcome (almost half) is due to strenuous anti-smoking public health campaigns and parallel regulatory changes, resulting in a 69% and 50% reduction in smoking prevalence in men and women, respectively, between 1959 and 2009.1 Although there is much to celebrate in the world of cardiology, cardiovascular disease remains the leading cause of death worldwide, with death rates expected to increase to 23.3 million annually by 2030, half of these deaths occurring prematurely in those under the age of 65.2 Despite advances and improvements in understanding the causes of disease, it is clear that neither treatments nor preventive strategies always reach their target populations: overuse of treatment is harmful and contributes to wastage, whereas underuse of preventive interventions means that cheaper more effective routes to better outcomes are missed. Doctors have a pivotal role in reversing this pattern of care.
Overuse is seen in all branches of medicine, not just cardiovascular care. The estimated cost of inappropriate care in the USA in 2011 was US$226 billion. Higher spending is linked to more frequent specialist consultations, diagnostic tests, and minor procedures, but this does not necessarily provide benefit. People living in areas of high Medicare spend have neither better health outcomes nor greater …