Benchmarking study prompts rethink on next Cardiovascular Disease (CVD) prevention guidelines

Behind the rethink lies a benchmarking study which has tested the penetration and application of the Joint Societies' fourth Guidelines on CVD Prevention and concluded that "substantial progress has been made" in implementing the Guidelines, but that many countries "have struggled with the task".(1) The conclusions were based on interviews with representatives of national organisations active in CVD prevention from each of 13 countries, to reflect "the enablers" and the barriers to the Guidelines' full implementation. The 13 countries were Estonia, France, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Romania, Russia, Spain, Sweden, and the UK.

"Implementation is a key step in the development of all clinical Guidelines," explains Perk. "Without dissemination, Guidelines will remain ineffective and of little more than academic interest. We wanted our next Guidelines to really have an impact, and we were very sensitive to the difficulties many countries have clearly had in applying previous recommendations." The fifth European Guidelines on CVD Prevention will be published in May and have been produced by a joint Task Force of the ESC and eight other European societies.

One of the benchmarking investigators, Dr Karen Morgan from the Royal College of Surgeons in Dublin, Ireland, agrees that the value of the next European Guidelines will depend on how their recommendations are transferred into daily practice - but she acknowledged that progress in disease prevention according to the fourth version of the Guidelines has been varied throughout Europe.(2) "So the challenge for the next edition," says Karen, "is to provide Guidelines which are sufficiently detailed but still short and easily accessible in a number of languages and formats, so as to engage health professionals in their implementation."

The benchmarking interviews and analysis found that ten of the 13 countries had made some use of the fourth Guidelines, which the investigators identified according to three definitions:

1. Adoption as national Guidelines with local adaptation, mainly the adjustment of risk charts to national data (Italy, Poland, Romania, Russia, and Spain)

2. Incorporation into national Guidelines along with Guidelines from other sources (Estonia, Germany, and the Netherlands)

3. Co-existence with national Guidelines developed by the health authorities (France and Sweden).

In Ireland, the Joint CVD Prevention Guidelines were used alongside Guidelines from other sources, while in Norway and the UK other Guidelines altogether were applied. All countries except Ireland and Norway had secured health ministry support for the joint Guidelines.

However, while the framework for implementation of the Guidelines seemed secured, active health authority support was not always apparent. For example, interviewees noted several factors which prevented governments from pursuing their prevention initiatives more vigorously, such as ideological beliefs in personal responsibility for lifestyle, inability to commit funding to support prevention activities, a tacit need to maintain the revenues from taxes on tobacco and alcohol, and the commercial interests of the tobacco, agriculture, and food industries in local economies.

However, there were other everyday barriers too, not least that physicians, faced everyday with managing acute and chronic disease, "undervalued prevention". Many interviewees also said that the Guidelines themselves were simply too dense (more than 100 pages in the full version) for everyday observance - and that risk stratification according to the SCORE system still required more country-specific versions.

So now, as a result of the benchmarking study, which the Task Force has been aware of throughout its duration, the new Guidelines have adopted several suggestions made by the investigators to improve implementation. These, said Perk, include a single-page quick-reference format and making the pocket version freely available. The Task Force has also developed a range of questions for CME credits derived from the new Guidelines.

However, when published in May - in the European Heart Journal - and presented that same month at the EuroPRevent 2012congress in Dublin, the fifth edition of the Guidelines will have a whole new look and feel: just fifty pages and 150 references. "We've taken the study's comments to heart," says Perk. "Implementation is the key to the Guidelines' success, and that's what we're aiming for."

The benchmarking study did, however, find an overall positive attitude towards the concept of uniform prevention Guidelines across Europe, with ready acknowledgement of the need for preventive measures at both the clinical and population levels. Already, the study noted, such Guidelines have had a major impact, and, at the specific level of their development, interviewees were "satisfied with their scope, credibility and evidence base".