ICGP AGM
Forum
CVD prevention must
start in general practice
In this year’s AGM Foundation Lecture, Prof Andrew Murphy was
scathing about the lack of State commitment to tackling heart
disease through primary care. Niall Hunter reports
This country’s approach to the management of cardiovascular disease has been ‘uncoordinated, chaotic and
inchoate’, according to Dr Andrew Murphy, professor of
general practice at NUI Galway. Delivering the Foundation
Lecture at the ICGP AGM, Prof Murphy gave a withering
insight into the lack of commitment over the years by health
authorities and governments into effective cardiovascular
morbidity and mortality prevention, citing the ‘freezing’ of
the successful Heartwatch secondary prevention scheme in
recent years. Comparing the State’s approach to cardiovascular disease prevention with that of cancer care, he said
there was a very strong evidence base from more than 30
years of research which showed that heart prevention programmes worked, and should be supported.
He said the single greatest contributor to the reduction
in mortality from CVD in recent years had been secondary
prevention in general practice. A study from his department,
published recently in the American Heart Journal1 pointed
to the success of Heartwatch in reducing morbidity and mortality. Comparing Heartwatch with non-Heartwatch patients,
it was found that the former had a mortality rate of 5% after
four years while the latter had a death rate of 14%.
Under Heartwatch, 20% of practices around the country
took part in a prevention programme for patients with established heart conditions in which GPs and practice nurses
actively monitor and provide tailored lifestyle, smoking cessation and dietary advice, as well as drug treatment.
However, Prof Murphy pointed out that the funding for
this programme has been frozen and it had never been
expanded to more practices around the country.
He said while Heartwatch had not been perfect and needed
some tweaking, its results had added to the large body of evidence that secondary prevention in general practice works.
Changes that could be effected in Heartwatch included a
revision of the visit schedule, with a maximum number of
visits, and integration with hospital cardiac rehab.
Andrew Murphy said it was simply not true to state that
there was no money for this type of programme to be
expanded nationally. He said the money was there but it
was being spent elsewhere, and hard choices had to be
made in funding screening and prevention programmes.
Prof Murphy compared the Heartwatch results with recent
controversial UK review conclusions2 on the effectiveness
of population breast cancer screening. This found that
for every 2,000 women invited for breast screening over
a 10-year period, one will have her life prolonged and 10
healthy women who would not have been diagnosed if there
had not been screening, will be treated unnecessarily.
In addition, the research
found that more than 200
women will experience
important psychological distress for many months due
to false positive findings.
It was concluded that it
was unclear whether breast
screening does more good
than harm. So in comparison, while breast screening,
according to this study, will
Prof Andrew Murphy
lead to one from every 2,000
women having their life prolonged, 160 out of 2,000 people
taking part in Heartwatch will have their life prolonged.
Prof Murphy stressed that he was not advocating abandoning breast screening in Ireland in favour of cardiovascular
prevention programmes, and he believed BreastCheck to
be an excellent programme. However, when comparing programmes such as Heartwatch to breast screening, there was
a strong evidential base for funding heart disease prevention programmes.
While it was anticipated that the HSE Clinical Programmes would progress towards this goal, Prof Murphy was
concerned that this would simply lead to excellent guidelines being developed with no overall change in policy. He
said there was a need for transparent allocation of unified
budgets based on national health priorities.
He added that until there is a single national budget for
management of cardiovascular disease in a defined population, general practice will continue to be on the ‘hind
tit’ from a resource perspective. He felt moving resources
from hospitals to GP practices will be a ‘game-breaker’ for
chronic disease management in Ireland. In his address he
also called for the HRB’s health services and population
research to be incorporated into policy-making.
Prof Murphy also called for greater cooperation and
collaboration between the ICGP and the Association of
University Departments of General Practice (AUDGPI), of
which he is secretary. Such a collaboration, he said, would
have exceptional potential and would be to the benefit of
Irish patients.
References
1. McGrath ER, Glynn LG, Murphy AW, O’Conghaile A, Canavan M, Reid C,
Moloney B, O’Donnell MJ. Preventing cardiovascular deaths in primary care:
Role of a national risk factor management program. American Heart Journal,
2012; 163(4): 714-9
2. Jørgensen KJ, Keen JD, Gøtzsche PC. Is mammographic screening
justifiable considering its substantial overdiagnosis rate and minor effect on
mortality? Radiology 2011; 260: 621-627
FORUM June 2012 17
Foundation lecture-NH/AH 1
01/06/2012 12:22:32