Support is crucial to deliver CVD screening
CVD screening has huge potential - but the support structures must be in place.
We have become accustomed to the new paradigm that heart disease, stroke, diabetes and kidney disease are the product of overlapping risk factors and that from middle age onwards almost all of us will carry a portfolio of cardiovascular risk. Our task is to prevent progression to cardiovascular illness and mortality.
There is now a consensus that something needs to be done. If we don't take on this challenge in primary care, somebody else will.
Initial results from Department of Health modelling work indicate that a programme of vascular checks would prevent 4,000 people a year from developing diabetes and could detect at least 25,000 cases of diabetes and kidney disease. Such a programme would prevent 9,500 heart attacks and strokes every year and save 2,000 lives.
So what needs to be done? Everyone between 40 and 74 will be entitled to a personal assessment under the programme, which will start in 2009/10. The modelling process has estimated the cost will be in the region of £250m a year.
Among people in the age bracket who do not have established cardiovascular disease, CKD, diabetes or hypertension and who are not taking a statin, only 28% have had their cholesterol tested and recorded in the past five years. Over the same time period, 53% have had their BMI measured and recorded, 76% have had their blood pressure taken, 92% have had their smoking status recorded - and just 21% have had all these measurements.
What does this mean for those of us in primary care? For a typical practice serving a population of 5,000 patients, it is estimated that seven individuals will need to be invited for a cardiovascular risk assessment each week in order to cover the population aged 40-74 who are not already on a disease register. Assuming that only 75% of the patients take up the offer, this would mean five extra appointments a week initially - but many of these patients will need structured follow-up.
Screening for pre-diabetes will require careful planning and will increase workload considerably, since an estimated 20% of patients screened may be diagnosed with diabetes, impaired fasting glucose or impaired glucose tolerance and would subsequently require monitoring, lifestyle advice and treatment.
It is absolutely critical to have carefully evaluated pilot sites. Funding will need to be appropriate to the task and education is key to an understanding of risk and how it can be modified. There will be a crucial role for practice nurses, healthcare assistants and data collection clerks, as well as for support services in smoking cessation, weight management and other lifestyle issues such as exercise. The most effective approach would be to have a central screening unit for a cluster of practices with trained nurse prescribers and healthcare assistants delivering the programme cost-effectively.
Professor Mike Kirby, University of Hertfordshire, part-time GP in Radlett, Hertfordshire