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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 patient satisfaction than those living in lower spending areas.3 Jack Wennberg concludes that an imbalance exists between ‘the overuse of the health care delivery system in the provision of supply-sensitive care, and the underuse of the public health system in addressing the determinants of population health’. But this is not just a ‘North American problem’. The National Health Service (NHS) atlas of variation reveals similar patterns of variation in medical and surgical interventions to those in the USA, but they are less extreme in absolute terms: unnecessary investigations and treatments cost the NHS at least £2.4 billion annually.
The cost of overuse in cardiology is particularly high because of the high incidence of cardiac disease and the increasing use of expensive procedures and devices. Unnecessary stenting for stable coronary artery disease has been said to cost the US healthcare system US$2.4 billion, a figure that may be significantly underestimated. Despite robust guidance on the use of percutaneous coronary intervention (PCI)4 for stable coronary disease in 2010, a 10-fold variation was noted across 152 primary care trusts.5 Such financial wastage may be better spent on medical therapy clinics for these patients, run by cardiologists, to optimise medication and select the right patients for potential intervention. More recently, the use of intra-aortic balloon pumps in the treatment of the sickest patients with acute myocardial infarction—those with cardiogenic shock—has shown a similar pattern: despite decades of use, a recent meta-analysis revealed no lasting benefit.6 The average cost of the machine is about £40 000, with individual pumps costing £800. With close to 140 000 patients a year worldwide receiving treatment with this technology, the overall costs add up to a significant proportion of the resources. Injudicious use of this technology not only wastes resources but also puts patients at risk of harm—for example, prolonged arterial cannulation risks limb ischaemia, renal failure and stroke. Similarly, the use of thrombectomy catheters during primary angioplasty (costing the NHS at least £2 million annually),7 and now shown to increase periprocedural risk of stroke, has not been shown to reduce the risk of recurrent myocardial infarction, death or shock.8 Such trials do not conclusively point to lack of benefit, but that the population who may stand to benefit is extremely small and is not necessarily reflected in those randomised, or in real life practice.
Understanding the causes of overuse is essential if the right patients are to receive the right treatments and to ensure the most effective use of our limited resources. Several factors may explain overuse, but, at its heart, lie the quality and integrity of research, how it is managed, and how it is used to inform patients of their choices. Some of these arguments are well rehearsed. Published results are more likely to be ‘positive’; studies that show no benefit are less likely to be published.9 Despite campaigns for transparency and detailed declarations of conflicts of interest linking authors and manufacturers, companies clearly have a vested interest in positive research outcomes concerning their products.10 Often, however, funding of large-scale randomised trials would be very difficult without financial input from manufacturers, but we must insist on transparency in the research–manufacturer interface. There may be a more important systemic weakness in the quality of some of the research evidence for high-risk cardiovascular devices: many clinical studies that influence Food and Drug Administration (FDA) approval when finally published show ‘clinically relevant discrepancies’ with FDA approval paperwork, including changed primary end points.11
Much of the demand for medical care is determined by the physician, and so doctors have responsibility for reducing overuse. Routine coronary angioplasty for those with stable coronary artery disease receiving optimal medical treatment does not offer prognostic benefit, although it will reduce symptoms for a period of time.12 Even so, one study revealed that 88% of patients undergoing angioplasty believed that it would prevent myocardial infarction, suggesting a disconnect between the patient, the doctor and the evidence.13 Chris Ham, Chief Executive of the King's Fund, has said ‘many doctors aspire to excellence in diagnosing disease. Far fewer unfortunately aspire to the same standards of excellence in diagnosing what patients want’.5 Patients are less likely to choose PCI as a first-line strategy over medical therapy when fully informed about the benefits and risks. In the USA, using conservative estimates, this would save at least US$864 million per year in healthcare costs, and possibly much more.14 Overtreatment offers only unnecessary risk; shared decision making, starting with the physician investing time in a fully informed, evidence-based consent process, is essential. Such a process must not be seen as an adjunct to a procedure but part of the duty of care to that patient.
With 80% of cardiovascular disease attributable to lifestyle, preventive cardiology with public health and educational campaigns is essential to reduce the burden of cardiovascular disease further; there is simply not enough support to help patients change their lifestyle.15 Great steps in reducing cardiovascular mortality were made by reducing smoking. Today's cardiovascular health challenge is to reduce the increasing prevalence of type 2 diabetes and obesity. Insulin resistance may be the single most important determinant of coronary artery disease. In young adults, preventing insulin resistance could prevent 42% of myocardial infarctions, a larger reduction than correcting hypertension (36%), high-density lipoprotein cholesterol (31%), body mass index (21%) or low-density lipoprotein cholesterol (16%).16 However, making lifestyle choices is often difficult. Patients need to be informed, empowered and supported to help make these changes to their lifestyle. This requires more than just providing information during consultations. It requires organised public health campaigns and joint working across primary, community and specialist care. Change in lifestyle is also essential for those with established cardiovascular disease. Introduction of a ‘Mediterranean diet’ immediately after a myocardial infarction has been shown to reduce mortality; for every 30 patients adopting an American Heart Association ‘low fat’ diet, one life is saved after 4 years.17
Patients often need help to introduce beneficial levels of exercise into their life. However, preventive activities for individuals such as 1:1 personal advice and health education achieve a consistently smaller health impact than regulation of smoking, limitation of the use of trans-fats, and minimum alcohol pricing. For example, within 1 year of the introduction of legislation to ensure that public places are smoke free, a 17% reduction in admissions for myocardial infarction was noted.18 Policy-based interventions reach the whole population and are not dependent on the responses of individuals. This is not an ‘either or’ but a ‘both and’ situation. Doctors have a role in supporting both health-related legislation and their patients to change their lifestyle in any way they can. Today, technology, including phone apps that measure the number of steps taken a day but also ensuring better understanding of and adherence to medications, may provide a very useful tool to educate and empower individual patients to maximise health benefits.
Furthermore, as the population ages, demands for healthcare will increase substantially if those later years are accompanied by chronic disease. A Lancet analysis found that, if rising life expectancy in the European Union means years of good health, then health expenditure caused by an ageing population, health expenditure is only expected to increase by 0.7% of gross domestic produce by 2060.19 Doctors have a pivotal role in ensuring the sustainability of healthcare systems. This is not about a ‘new breed of doctor’ or a challenge that is for the ‘next generation’; this is a responsibility for all doctors today. The duties of a doctor—loyalty, compassion, a commitment to patient well-being and safety—should be supplemented with a responsibility to ensure the best use of our resources for care, with the focus on minimising unnecessary use. Understanding evidence, explaining risks to patients and helping them make the right choice is a duty of all doctors. Duty to the individual patient should be supplemented with a duty to the population. This is not something that can be achieved by doctors working in isolation, but by doctors and other clinical professionals who work in a population—specialists and generalists and population experts and health service managers, coming together, working together and working differently.
Clinicians need to take on a broader population perspective: cardiologists should be responsible not just for the patients who happen to be admitted to the hospital but also for the ‘cardiovascular health’ of the people of that locality. Individual care should be personalised and, with shared decision making, take into account patients’ values and wishes. Payments should reflect population responsibilities and not items of care. Adopting a new set of seven principles (box 1) at the heart of medical practice would benefit both individual patients and populations.20
Value Getting the right patients to the right resources
Outcomes Getting the right outcomes for the right patients
Waste Getting the right outcomes with the least waste
Sustainability Doing the right things to protect resources for future generations
Equity Ensuring fairness and justice
Supporting all patients, not just those referred Creating population-based, integrative systems
Health promotion Preventing disease and promoting health and well-being.