Effectiveness and Cost-Effectiveness of Case Management in Advanced Heart Failure Patients Attended in Primary Care: A Systematic Review and Meta-Analysis.

AIMS: Nurse-led case management (CM) may improve quality of life (QoL) for advanced heart failure (HF) patients. No systematic review (SR), however, has summarized its effectiveness/cost-effectiveness. We aimed to evaluate the effect of such programs in primary care settings in advanced HF patients. We examined and summarized evidence on QoL, mortality, hospitalization, self-care, and cost-effectiveness. METHODS AND RESULTS: The MEDLINE, CINAHL, Embase, Clinical Trials, WHO, Registry of International Clinical Trials, and Central Cochrane were searched up to March 2022. The Consensus Health Economic Criteria instrument to assess risk-of-bias in economic evaluations, Cochrane risk-of-bias 2 for clinical trials, and an adaptation of Robins-I for quasi-experimental and cohort studies were employed. Results from nurse-led CM programs did not reduce mortality (RR 0.78, 95% CI 0.53 to 1.15; participants = 1345; studies = 6; I2 = 47%). They decreased HF hospitalizations (HR 0.79, 95% CI 0.68 to 0.91; participants = 1989; studies = 8; I2 = 0%) and all-cause ones (HR 0.73, 95% CI 0.60 to 0.89; participants = 1012; studies = 5; I2 = 36%). QoL improved in medium-term follow-up (SMD 0.18, 95% CI 0.05 to 0.32; participants = 1228; studies = 8; I2 = 28%), and self-care was not statistically significant improved (SMD 0.66, 95% CI -0.84 to 2.17; participants = 450; studies = 3; I2 = 97%). A wide variety of costs ranging from USD 4975 to EUR 27,538 was observed. The intervention was cost-effective at ≤EUR 60,000/QALY. CONCLUSIONS: Nurse-led CM reduces all-cause hospital admissions and HF hospitalizations but not all-cause mortality. QoL improved at medium-term follow-up. Such programs could be cost-effective in high-income countries.

Update on cardiovascular prevention in clinical practice: A position paper of the European Association of Preventive Cardiology of the European Society of Cardiology.

European guidelines on cardiovascular prevention in clinical practice were first published in 1994 and have been regularly updated, most recently in 2016, by the Sixth European Joint Task Force. Given the amount of new information that has become available since then, components from the task force and experts from the European Association of Preventive Cardiology of the European Society of Cardiology were invited to provide a summary and critical review of the most important new studies and evidence since the latest guidelines were published. The structure of the document follows that of the previous document and has six parts: Introduction (epidemiology and cost effectiveness); Cardiovascular risk; How to intervene at the population level; How to intervene at the individual level; Disease-specific interventions; and Settings: where to intervene? In fact, in keeping with the guidelines, greater emphasis has been put on a population-based approach and on disease-specific interventions, avoiding re-interpretation of information already and previously considered. Finally, the presence of several gaps in the knowledge is highlighted.

Main messages for primary care from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice.

In 2016, a new version of the European Guidelines on Cardiovascular Prevention was released, representing a partnership between the European Association for Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology (ESC) and nine European societies, including Wonca-Europe. The ESC guidelines underscore the importance of a lifetime approach to cardiovascular (CV) risk since both CV risk and prevention are dynamic and continuous as patients' age and/or accumulate co-morbidities. Healthy people of all ages should be encouraged to adopt a healthy lifestyle, as well as improved lifestyle and reduced risk factor levels are paramount in patients at increased risk of developing cardiovascular disease (CVD) and in those with established CVD. Healthcare professionals, and especially general practitioners, play an important role in helping patients achieve this and should set a personal example of healthy lifestyle behaviour. The ESC guidelines are based on 'to do' and 'not to do' messages. Of note, what remains uncertain is stated at the end of each dedicated chapter, confirming that guidelines are not absolute rules, and should be interpreted in the light of the healthcare worker's knowledge and experience, patient preferences and the local social, cultural and economic situation.

Towards new recommendations to reduce the burden of alcohol-induced hypertension in the European Union.

BACKGROUND: Hazardous and harmful alcohol use and high blood pressure are central risk factors related to premature non-communicable disease (NCD) mortality worldwide. A reduction in the prevalence of both risk factors has been suggested as a route to reach the global NCD targets. This study aims to highlight that screening and interventions for hypertension and hazardous and harmful alcohol use in primary healthcare can contribute substantially to achieving the NCD targets. METHODS: A consensus conference based on systematic reviews, meta-analyses, clinical guidelines, experimental studies, and statistical modelling which had been presented and discussed in five preparatory meetings, was undertaken. Specifically, we modelled changes in blood pressure distributions and potential lives saved for the five largest European countries if screening and appropriate intervention rates in primary healthcare settings were increased. Recommendations to handle alcohol-induced hypertension in primary healthcare settings were derived at the conference, and their degree of evidence was graded. RESULTS: Screening and appropriate interventions for hazardous alcohol use and use disorders could lower blood pressure levels, but there is a lack in implementing these measures in European primary healthcare. Recommendations included (1) an increase in screening for hypertension (evidence grade: high), (2) an increase in screening and brief advice on hazardous and harmful drinking for people with newly detected hypertension by physicians, nurses, and other healthcare professionals (evidence grade: high), (3) the conduct of clinical management of less severe alcohol use disorders for incident people with hypertension in primary healthcare (evidence grade: moderate), and (4) screening for alcohol use in hypertension that is not well controlled (evidence grade: moderate). The first three measures were estimated to result in a decreased hypertension prevalence and hundreds of saved lives annually in the examined countries. CONCLUSIONS: The implementation of the outlined recommendations could contribute to reducing the burden associated with hypertension and hazardous and harmful alcohol use and thus to achievement of the NCD targets. Implementation should be conducted in controlled settings with evaluation, including, but not limited to, economic evaluation.

Association Between Improvement in Cardiovascular Risk Profile and Changes in Sickness Absence: Results of the ICARIA Study.

INTRODUCTION AND OBJECTIVES: The purpose of this study was to investigate whether changes in cardiovascular risk (CVR) are associated with the length and cost of sickness absence. METHODS: A prospective cohort of 179 186 participants was evaluated. Each participant's CVR (SCORE) was assessed on 2 consecutive medical examinations, approximately 1 year apart (365 ± 90 days). Cardiovascular risk was categorized as < 4% or ≥ 4%, and participants were divided into 4 groups according to changes in their risk between the 2 assessments. After the second CVR estimate, a 1-year follow-up was carried out to assess sickness absence. Differences between the 4 groups in terms of the total count of sickness absence days during the follow-up period were tested using Poisson regression models. RESULTS: After adjustment for covariates, participants who showed an improvement in CVR had a lower count of sickness absence days compared with both those who showed a worsening in risk and those who remained stable at ≥ 4% (RR, 0.91; 95%CI, 0.84-0.98). In comparison with participants whose CVR did not improve, more of the participants whose risk did improve had quit smoking (+17.2%; P < .001), and had controlled their blood pressure (+26.0%, P < .001), total cholesterol (+9.3%; P < .001), low-density lipoprotein cholesterol (+14.9%; P < .001), and triglyceride levels (+14.6%; P < .001). CONCLUSIONS: Our results suggest that an improvement in CVR profile is accompanied by a decrease in sickness absence during a 1-year follow-up.

[Clinical consequences of using the new cardiovascular risk tables SCORE OP in patients aged over 65 years]. / Consecuencias clínicas de la utilización de las nuevas tablas de riesgo cardiovascular SCORE OP para pacientes mayores de 65 años.

BACKGROUND AND OBJECTIVE: Estimating cardiovascular risk with SCORE is not recommended in persons over 65 years. SCORE investigators have recently published specific tables for older people (SCORE Older Persons [SCORE OP]). The aim of this study is to assess the impact of using SCORE OP tables on a Spanish population aged over 64 years, and compare it with the use of SCORE in patients aged 65-69 years. PATIENTS AND METHOD: Cross-sectional study carried out in 2 urban primary health care centres. Individuals between 65 and 85 years old without diabetes or established cardiovascular diseases were included. Cardiovascular risk using SCORE and the new SCORE OP tables for low risk countries was calculated. RESULTS: Cardiovascular risk was estimated in 3,425 patients. Mean values of the original SCORE and SCORE OP were 4.08 and 3.83, respectively in the group of patients aged 65-69 years old (n=974, 22.44%) (P< .001). The percentage of patients at high or very high risk was 25.46% and 22.90% with the original SCORE and the SCORE OP, respectively (P<.001). Using the original SCORE, 16.43% of the total patients should potentially be treated with lipid lowering drugs, while using the SCORE OP, 13.45% of the patients aged 65-69 years should potentially be treated. Using SCORE OP in patients older than 69 years, 61.49% patients should potentially be treated with lipid lowering drugs. CONCLUSIONS: SCORE OP identifies fewer patients at high or very high risk than the original SCORE, therefore, its utilization would imply treating fewer patients of this age with lipid lowering drugs.

[Ischaemic heart disease]. / Cardiopatía isquémica.

In the year 2011, cardiovascular diseases were responsible of 31.2% of total deaths in Spain. The absolute number of cases of acute coronary syndrome in this year will be approximately 115,752 cases (95%CI: 114,822-116,687). The prevalence of stable angina in the population aged 25-74 years is 2.6% in men and 3.5% in women. Cardiovascular diseases were in the year 2011 the first cause of hospitalizations representing 14.1% of the total hospitalizations. Diagnose of ischaemic heart disease and acute myocardial infarction were responsible of 110,950 and 50,064 hospitalizations, respectively. In the year 2003, the hospitalization rate was 314 while in the year 2011 was 237 per 100,000, a reduction of 24.4%. The average cost of hospitalization due to ischaemic heart disease in 1997 was 3,093.7euros while in the year 2011 was 7,028.71euros. Cardiovascular mortality rates have decreased from 2007 to 2011, showing a relative reduction of 7% in women and 8% in men. With regard to myocardial infarction, it was observed a relative reduction of 17% in men and 20% in women. According to EUROASPIREIII survey done in 8,966 patients with ischaemic heart disease in Europe, 17% of patients were still smokers, 35% were obese, 56% has uncontrolled blood pressure, 51% has raised blood cholesterol and 25% were diabetics. With regard to drugs utilisation, 91% were treated with antiplatelets agents, 80% with beta blockers, 71% with ACE inhibitors/ARBs.

Lipid treatment assessment project 2: a multinational survey to evaluate the proportion of patients achieving low-density lipoprotein cholesterol goals.

BACKGROUND: Information about physicians' adherence to cholesterol management guidelines remains scant. The present survey updates our knowledge of lipid management worldwide. METHODS AND RESULTS: Lipid levels were determined at enrollment in dyslipidemic adult patients on stable lipid-lowering therapy in 9 countries. The primary end point was the success rate, defined as the proportion of patients achieving appropriate low-density lipoprotein cholesterol (LDL-C) goals for their given risk. The mean age of the 9955 evaluable patients was 62+/-12 years; 54% were male. Coronary disease and diabetes mellitus had been diagnosed in 30% and 31%, respectively, and 14% were current smokers. Current treatment consisted of a statin in 75%. The proportion of patients achieving LDL-C goals according to relevant national guidelines ranged from 47% to 84% across countries. In low-, moderate-, and high-risk groups, mean LDL-C was 119, 109, and 91 mg/dL and mean high-density lipoprotein cholesterol was 62, 49, and 50 mg/dL, respectively. The success rate for LDL-C goal achievement was 86% in low-, 74% in moderate-, and 67% in high-risk patients (73% overall). However, among coronary heart disease patients with > or =2 risk factors, only 30% attained the optional LDL-C goal of <70 mg/dL. In the entire cohort, high-density lipoprotein cholesterol was <40 mg/dL in 19%, 40 to 60 mg/dL in 55%, and >60 mg/dL in 26% of patients. CONCLUSIONS: Although there is room for improvement, particularly in very-high-risk patients, these results indicate that lipid-lowering therapy is being applied much more successfully than it was a decade ago.

Health-related quality of life in unselected outpatients with heart failure across Spain in two different health care levels. Magnitude and determinants of impairment: the INCA study.

AIMS: To assess health-related quality of life (HRQL) in Spanish outpatients with chronic heart failure (CHF). METHODS: Cross-sectional study carried out in a sample of CHF patients (echocardiography was performed in all of them) followed either in Primary Care (PC) centres or Cardiology outpatient clinics throughout Spain. HRQL was evaluated using the EuroQol 5D (EQ-5D) and Minnesota Living with Heart Failure (MLWHF) Questionnaire. RESULTS: The study subjects were 2161 CHF patients (1412 PC; 749 Cardiology). Patients were older and had more severe disease in PC than in Cardiology settings. Their HRQL scores were likewise worse. After adjusting for clinical variables, the differences in global and physical MLWHF disappeared, but persisted to a smaller degree in EQ-5D and mental MLWHF. HRQL was worse than in a representative sample of the Spanish population and in other chronic conditions such as rheumatoid arthritis or type 2 diabetes, being only comparable to severe chronic obstructive pulmonary disease (COPD). CONCLUSION: All domains of HRQL were significantly impaired in CHF patients. Differences found in HRQL between PC and Cardiology should possibly be attributed to a large extent to the different clinical characteristics of the patients attended. In spite of the differences between EQ-5D and MLWHF, our results suggest that both questionnaires adequately reflect the severity of the disease.

[Health economic evaluation of low-dose acetylsalicylic acid in the primary prevention of cardiovascular disease]. / Evaluación económica del tratamiento con ácido acetilsalicílico en dosis bajas en la prevención primaria de enfermedades cardiovasculares.

INTRODUCTION AND OBJECTIVES: Low-dose aspirin is standard treatment for patients with a history of cardiovascular disease. Its use in primary prevention is more controversial. However, recent studies also support the use of aspirin in high-risk individuals with no history of cardiovascular disease. This study investigated the health economic implications of using low-dose aspirin in the primary prevention of cardiovascular disease in Spain. METHODS: A model was developed to predict the cost-effectiveness of low-dose aspirin in the primary prevention of cardiovascular disease over a period of 10 years. The direct costs used were those of the Spanish National Health Service (NHS). Results were expressed as cost per life-year gained and per quality-adjusted life-year gained. RESULTS: Administering low-dose aspirin to an individual with a 10-year risk of coronary heart disease > or =15% resulted in an average net saving of e 797 (95% CI, e 263-1331) over the 10-year period, with savings starting in the first year. For an annual risk > or =0.24%, this form of treatment would reduce NHS costs. Treating all at-risk individuals in the Spanish population with aspirin would save e 26.5 million from the healthcare budget, starting in the first year. CONCLUSIONS: Administering low-dose aspirin to individuals with a 10-year risk of coronary heart disease > or =15% would result in significant cost savings for the Spanish NHS. Sensitivity analysis confirmed the robustness of these findings.

Prevention and health promotion in clinical practice: the views of general practitioners in Europe.

BACKGROUND: Disease prevention and health promotion are important tasks in the daily practice of all general practitioners (GPs). The objective of this study was to explore the knowledge and attitudes of European GPs in implementing evidence-based health promotion and disease prevention recommendations in primary care, to describe GPs' perceived barriers to implementing these recommendations and to assess how GPs' own health behaviors affect their work with their patients. METHODS: A postal multinational survey was carried out from June to December 2000 in a random sample of GPs listed from national colleges of each country. RESULTS: Eleven European countries participated in the study, giving a total of 2082 GPs. Although GPs believe they should advise preventive and health promotion activities, in practice, they are less likely to do so. About 56.02% of the GPs answered that carrying-out prevention and health promotion activities are difficult. The two most important barriers reported were heavy workload/lack of time and no reimbursement. Associations between personal health behaviour and attitudes to health promotion or activities in prevention were found. GPs who smoked felt less effective in helping patients to reduce tobacco consumption than non-smoking GPs (39.34% versus 48.18%, P < 0.01). GPs who exercised felt that they were more effective in helping patients to practice regular physical exercise than sedentary GPs (59.14% versus 49.70%, P < 0.01). CONCLUSIONS: Significant gaps between GP's knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention in primary care.

[Usefulness of coronary risk assessment using the equation of the Framingham study: a case control study]. / Utilidad de la medición del riesgo coronario a partir de la ecuación del estudio de Framingham: estudio de casos y controles.

BACKGROUND AND OBJECTIVE: During the last decade, recommendations for coronary heart disease prevention have emphasized the need of an assessment of coronary risk. The objective of this study was to assess the usefulness of the Framingham risk function for the estimation of coronary risk in our population, assessing the accuracy of the coronary risk as a diagnostic test (assuming that a coronary risk >20% is a positive diagnosis test of coronary disease). PATIENTS AND METHOD: Prospective case-control study, carried out in a public tertiary hospital. RESULTS: 138 cases were identified and matched, according to age and sex, with 223 controls. The level of risk > or =20% was the one which better classified the patients (70% of patients correctly classified as cases and controls) with an area under the ROC curve of 73.5% (moderate accuracy). Patients with a coronary risk >20% had a six times higher probability of being a case than a control (OR=6.09; 95% CI, 3.30-11.22). CONCLUSIONS: The utilization of the Framingham function for the prediction of coronary disease is a useful method to identify high risk patients. It is recommended to use it in clinical practice until we have our own model derived from populations with a baseline risk similar to ours allowing to predict the risk with higher accuracy.

Dietary advice in clinical practice: the views of general practitioners in Europe.

BACKGROUND: General practitioners (GPs) can promote good nutrition to patients and advise them about desirable dietary practices for specific conditions. OBJECTIVE: The objective was to assess GPs' knowledge and attitudes in implementing preventive and health promotion activities and to describe tools used by European GPs in advising patients about dietary practices. DESIGN: A postal survey was mailed to 1976 GPs from 10 GP national colleges to obtain information about beliefs and attitudes in prevention and health promotion, and an e-mail survey was sent to 15 GPs representing national colleges to obtain information about dietary guidelines. RESULTS: In the postal survey, 45% of GPs reported estimating body mass in clinical practice, and 60% reported advising overweight patients to lose weight. Fifty-eight percent answered that they felt minimally effective or ineffective in helping patients achieve or maintain normal weight. In the e-mail survey, only 4 colleges out of 15 reported that they had published their own dietary tools, although 10 out of 15 answered that GPs use some nutritional/dietary recommendations in the office when seeing patients. Eleven out of 15 answered that both the nurse and the GP advise patients about dietary practices, with 4 answering that GPs were the only ones who advise patients. Only 5 delegates answered that they can refer their patients to trained nutrition specialists. CONCLUSIONS: GPs think that obesity is not easy to handle in practice. Most GPs have dietary tools in the office and think that nurses play an important role in advising patients.