5 YEARS OF POSITIVE PATIENT OUTCOMES A Report Prepared by the National Institute for Preventive Cardiology

Transcription

1 5 YEARS OF POSITIVE PATIENT OUTCOMES A Report Prepared by the National Institute for Preventive Cardiology

2 Croí MyAction is an exemplar for cardiovascular disease (CVD) prevention, and not just in Ireland but across Europe and more widely. This community based programme unites secondary and primary prevention by addressing total cardiovascular risk for both patients and their families. The Croí Heart and Stroke Centre is a new and imaginative way of delivering preventive care rather than the traditional hospital or general practice setting. Although focussed on patients with any form of atherosclerotic disease, and those at high multifactorial risk of developing CVD, this unique service model will eventually embrace patients with other non-communicable diseases requiring support to achieve a healthier lifestyle. Croí MyAction has become the vanguard for excellence in preventive care in Ireland. Professor David Wood President Elect World Heart Federation Professor of Cardiovascular Medicine Imperial College, London This 5 year report provides important long term data on the efficacy of Croí MyAction. It demonstrates how this innovative lifestyle and medical risk factor management programme impacts positively on behaviour and individual risk for at least 1 year after completion. Importantly results extend into family members and significant others demonstrating there is an impact beyond the patient. These positive outcomes will have significant long term benefits not only for individuals at risk of cardiovascular disease, but will also help to reduce the incidence of other chronic conditions such as cancer, diabetes, and chronic obstructive pulmonary disease. Outcome driven programmes such as Croí MyAction have the potential to significantly reduce the morbidity and mortality associated with these chronic conditions, the major cause of death in Ireland today. Dr Jim Crowley Consultant Cardiologist, University Hospital Galway Research & Medical Officer, Croí 2

3 Contents An NIPC Publication. NIPC Foreword 4 Executive Summary 5 Introduction 6 Chapter 1 What is Croí MyAction? 7 Chapter 2 Five Years in What has been achieved? 10 Chapter 3 What do the results mean? 16 Chapter 4 Informing the Transformation of 20 Preventive Care in Ireland Chapter 5 Key Recommendations 24 References 26 Appendix 1 30 Appendix 2 31 Appendix 3 32 Appendix 4 33 Acknowledgments 34

4 Foreword Neil Johnson Chief Executive, Croí Jenni Jones Executive Director, NIPC The scientific evidence for CVD prevention is compelling. It shows that managing risk factors through lifestyle intervention and cardioprotective drug management can considerably reduce cardiovascular morbidity and mortality. However, results of risk factor management in patients with coronary heart disease and at high multifactorial risk in the European Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE) surveys evidence that CVD prevention in routine clinical practice has remained inadequate over the past decade. Translating guidelines into effective patient care in the real-world of clinical practice is challenging - resulting in a need to invest in strategies that measurably improve outcomes for people with, or at risk of, cardiovascular disease. Croí is a registered Irish charity, dedicated to fighting heart disease and stroke and is strongly committed to prevention. In 2009, Croí commissioned the MyAction programme an evidence-based preventive cardiology programme, developed by Imperial College London. MyAction is an innovative, nurse-led, multidisciplinary programme, which manages cardiovascular disease as a single family of diseases and integrates secondary and primary prevention in one community-based service. This report communicates the achievements in patient outcomes, and also importantly their families, since this flagship programme commenced. The outcomes demonstrate that it is possible to implement national and international clinical guidelines and achieve the lifestyle, medical and therapeutic targets associated with reduced cardiovascular events and improved health outcomes. In recognising the opportunities to bridge the implementation gap for prevention and control of cardiovascular diseases, Croí and the National University of Ireland Galway (NUIG) combined research, teaching, and clinical expertise and launched a Masters and Postgraduate Diploma in Preventive Cardiology in September 2013, with the MyAction programme contributing to a growing research output. In 2014, marking a milestone for cardiovascular disease prevention in Ireland, Croí and NUIG further collaborated to create the country s first National Institute for Preventive Cardiology (NIPC). Its aim is to drive research, education and innovation in the prevention of heart disease, stroke, diabetes and obesity. The Institute, based in Croí s Heart and Stroke centre in Galway, will develop relationships and partnerships with policy makers and health practitioners in preventive care in Ireland and around the world. It is developing new teaching and training opportunities for health care professionals working with individuals and communities to bring about behaviour and lifestyle changes. This 5-year report of patient outcomes demonstrates that Croí MyAction is delivering a unique evidence-based service model that is effectively implementing best-practice in achieving CVD prevention guidelines and represents an efficient use of resources. In Ireland there is a real opportunity to transform the design, delivery and outcome of cardiovascular prevention and rehabilitation care by adopting the Croí MyAction model. 4

5 Executive Summary Croí has developed nationally recognised expertise in cardiovascular disease prevention, through the delivery of the European Society of Cardiology (ESC) endorsed MyAction Programme. The Croí MyAction Programme is a gold standard intensive risk factor management and lifestyle modification programme driven by specific protocols designed to achieve the latest ESC Guidelines. MyAction targets high-risk individuals - i.e. those at high risk of heart attack, stroke, and diabetes - with a week intervention and 1-year follow-up. Established in 2009, this flagship community-based prevention model has reached over 1,100 individuals. Year on year this nurse-led, multidisciplinary programme has achieved outstanding and measurable improvements in cardiovascular health which have been widely published, including the European Journal of Preventive Cardiology 1 and the British Journal of Cardiology. 2 This report provides a 5-year summary of the key programme outcomes since its inception in What has been achieved over a 5-year period? Outcome Impact on CVD Risk Smoking quit rate of 51% 50% reduction in CVD events 3 Greater adherence to the cardio-protective Mediterranean Diet, with an increase in 4.5 units being observed Increase in physical activity targets from 13% to 52% 9% reduction in total mortality, CVD mortality and cancer % reduction in cardiovascular events 5 Improved aerobic fitness of 1.5 MET s 15-25% reduction in all-cause mortality 6,7,8 Increase in achievement of blood pressure targets from 55% to 73%, with a mean reduction of 8.6 mmhg (systolic) and 3.7 mmhg (diastolic) being observed Increase in achievement of cholesterol targets from 39% to 70%, with a mean reduction in Total Cholesterol of 0.73mmol/L and LDL Cholesterol of 0.62mmol/L being observed 20% reduction in risk of CHD 9 35% reduction in risk of Stroke 9 15% reduction in CVD mortality and non-fatal myocardial infarction 10 CVD, cardiovascular disease; CHD, coronary heart disease; MET, metabolic equivalent 5

6 Introduction Cardiovascular Disease (CVD) is the number one cause of death in Ireland 90% of CVD is preventable through risk factor modification Croí MyAction is the only cardiovascular prevention programme of its kind in Ireland Cardiovascular Disease (CVD) is the single most common cause of death in Ireland, accounting for one third of all deaths. It presents a huge burden on the economy through healthcare costs, loss of productivity and disability. It is well established that up to 90% of CVD is preventable through modification of risk factors such as smoking, high blood pressure, high cholesterol, physical inactivity, and obesity 11. In response to the high levels of these risk factors in the Irish population, Croí established the provision of MyAction as the first cardiovascular prevention programme of its kind to be offered in Ireland. MyAction aims to: Provide an evidence based, high quality prevention programme which will reduce cardiovascular risk factors such as cholesterol, blood pressure, smoking and central obesity in those most at risk. Demonstrate the effectiveness of applying an integrated approach to cardiovascular health management in a community-based setting. The MyAction model was developed by Imperial College London and has its strong evidence base in the EUROACTION study, 12 which demonstrated that an intensive nurse-led programme can achieve effective and substantial lowering of CVD risk factors in high risk groups of patients compared with usual care. This programme has been shown to be clinically effective, cost effective and cost saving. An economic analysis of the MyAction programe in the UK shows that every 1 invested in MyAction generates on average 6 in benefits over the lifetime of the patient. 13 Following a successful business case submission, a funding commitment for the delivery of a Croí MyAction pilot programme for 3-years was received from Galway Primary Community and Continuing Care - HSE West. However, due to budget constraints this funding was discontinued early in year 2, and since that time the programme has been funded entirely by Croí through its fundraising activities and philanthropic support. This report provides a summary of the programmes recruitment activity, patient characteristics and clinical outcomes, both short and long term from June 2009 to January Outcome data are presented for each time point for participants who attended both the Initial Assessment (IA) and End of Programme Assessment (EOP) and for participants that attended both the IA and the 1-Year Follow-up Assessment (1-YR). 6

7 Chapter 1 What is Croí MyAction? Nurse-led multidisciplinary programme Family-based intervention Integrated care approach Outcome focused Community-based setting Holistic approach Centred around behaviour change Promotes self-management Croí MyAction is a week intensive cardiovascular disease prevention programme. The key components are: lifestyle modification (smoking cessation, healthy food choices, and physical activity); medical risk factor management (blood pressure, lipids, and glucose); and the prescription of cardioprotective medication where appropriate. The programme is co-ordinated by a multidisciplinary team (MDT) which includes a nurse specialist, dietitian, physiotherapist/exercise specialist supported by a physician. High-risk individuals: Systematic Coronary Risk Evaluation (SCORE) 5% 14, type-2 diabetes, stroke/transient Ischemic Attack (TIA) are referred to the programme through a series of pathways which include general practice and hospital departments such as cardiology, stroke, and endocrinology. An important principle of the programme is involvement of the partner, as risk factors cluster in families due to shared lifestyles such as smoking and poor diet, and healthy lifestyle change is easier to achieve if the family changes together. At Initial Assessment (IA), patients and partners are seen as couples, but individually assessed by each MDT member for: Smoking habit (smoking history, nicotine dependency, breath CO); diet (diet history, food habit questionnaire, and Mediterranean Diet Score); weight and height, Body Mass Index (BMI), and waist circumference; physical activity levels (7-day physical activity recall) and functional capacity (Chester Step Test); psychosocial measures (anxiety, depression and quality of life); blood pressure (BP), fasting lipids, and glucose; and use of cardioprotective medications. This assessment identifies the couple s priorities and needs to reduce their cardiovascular risk, as well as exploring beliefs, barriers, and motivators to change with the use of motivational interviewing and goal setting as behaviour change strategies. The 16-week programme includes individualised follow-up, a weekly educational workshop and a supervised exercise session. There is also a weekly MDT meeting to review lifestyle, risk factor and therapeutic goals including medication prescription as appropriate. The programme is flexible, offering individuals the choice of attending during the day or in the evening. The care pathway of participants is shown in Figure 1. Given the 5-year duration of this report, and to ensure consistency in reporting, outcomes are based on the primary endpoints for lifestyle, risk factor, and therapeutic goals as recommended by the ESC 2007 Prevention Guidelines. 14 The current service aligns to the ESC 2012 Prevention Guidelines, upon which future outcome reports will be based. 15 7

8 Chapter 1 Figure 1. Care Pathway Dietitian (1hr) Current eating habits Modified Mediterranean Diet Score (questionnaire and food atlas) BMI and Waist Circumference Food diary Initial Assessment Nurse Specialist (1hr) Past medical history Smoking status Psychosocial history (HADS, EQ-VAS, HRQoL) Blood pressure (average of 2 readings with an automated device, validated by 24hr monitor if indicated) Fasting blood lipids and glucose Stages of Change Assessment Motivational Interviewing Goal Setting Personal Record Card Exercise Specialist/ Physiotherapist (1hr) 7 day activity recall Barriers to excercise Exercise preferences Functional capacity test CST, calculation of estimated METmax 7 day pedometer Intervention (16 Weeks) Weekly exercise class and educational workshops which include; What is CVD, Risk factors for CHD and Stroke, Healthy Eating and Alcohol, Healthy Eating and Weight Management, Physical Activity, Stress Management, Food Labels, Maintaining Change, Cardiac Medications Serial BP, weight, lipid and glycaemia measurements with continued goal setting Weekly MDT meetings Targeted and protocol driven pharmacotherapy to supplement lifestyle changes. As per initial assessment EOP Assessment As per initial assessment 1 YR Assessment 8 HADS, hospital anxiety and depression scale; EQ-VAS, euroqol visual analogue scale; HR QoL, health related quality of life; CST, chester step test; MET, metabolic equivalent; CVD, cardiovascular disease; CHD, coronary heart disease; BP, blood pressure

9 5 YEARS OF POSITIVE PATIEN T OUTCOMES Patient Quote I learned I was able to do more exercise than what I thought was possible or safe for me to do. I just wouldn t have pushed myself because I was uncertain. The exercise caters to all levels in the group, and allows us to work in a group to our personal best. Ann Davey 9

10 Chapter 2 Five Years in What has been achieved? High programme uptake and retention rates. Figure 2. Croí MyAction Programme Uptake, Retention and Follow-up at 1-Year Since Croí MyAction commenced in 2009 over 1,194 patients have been referred, with 71% (n=846) of these patients being eligible for the programme. The programme employs specific evidence-based interventions that are known to increase uptake and retention, and as a result these rates have remained consistently high over the five-year period. As Croí MyAction is an ongoing programme, outcome data are presented for those who completed the 16-week programme. As of January patients were invited to attend EOP of which 77% attended (n=530), and 455 were invited to attend 1-YR of which 86% attended (n=391) (see Figure 2). The programme only accepts patients at highest cardiovascular risk, those who are at low to moderate risk and do not meet the inclusion criteria (n=348) are sign-posted to other Croí health and lifestyle programmes. Referrals n=1,194 n=846 (71% of all referrals) Eligible for Programme Referrals n=746 (88% of all eligible referrals) Attended Initial Assessment Agreed to Enrol in the Programme Attended End of Programme Assessment Attended 1 Year Follow-up Assessment n=741 (99% of all who attended initial assessment) n= 530 (77% of 691 invited to attend) n=391 (86% of 455 invited to attend) 10

11 Chapter 2 Five Years in What has been achieved? To help facilitate behaviour change and promote programme adherence, every member of the MyAction MDT is trained in the use of Motivational Interviewing (MI) techniques. Irene Gibson, MyAction Nurse-Lead & Programme Manager Successful recruitment of high risk individuals. Croí MyAction is successfully recruiting patients at high cardiovascular risk as outlined in Figure 3. These patients presented with multiple cardiovascular risk factors (see Table 1), endorsing the programmes multidisciplinary specialist approach in tackling smoking, diet, physical activity, psychological and medical risk factors, within families all in one setting. Seventy percent of patients were referred to the programme by general practitioners, with the remainder from hospital departments. Measurable improvements in medical & lifestyle risk factor management and psychosocial health. The programme is having an impact on risk factor reductions, lifestyle and behaviour modifications, not only in the short term but also in the longer term. Results indicate that patients and their partners are sustaining improvements made at EOP (16 weeks) at 1-YR (see Appendices 1-4). This is particularly significant as long-term maintenance of lifestyle modifications is key to the success of any prevention programme. Increase in cardioprotective medications. While the emphasis of the programme is on lifestyle modification, cardioprotective medications are prescribed where appropriate in accordance with a protocol. Prescription of all cardioprotective medications with the exception of beta-blockers, increased significantly during the programme (see Figure 4). 11

12 Chapter 2 Figure 3. 59% Diagnosis of Patients at Initial Assessment 22% 5% 14% High CVD Risk CVA/TIA Coronary Type 2 Diabetes 12

13 Chapter 2 Table 1. Baseline Characteristics of Patients and Partners Gender Patients (n=746) % Male % Female Smoking % of Current Smokers Diet Mean Mediterranean Diet Score (optimal score 9) % Fruit & Vegetable NOT at target- 5 portions/day Physical Activity % NOT achieving targets ( 5x/week 30 minutes) Anthropometrics %BMI 25kg/m² (overweight) %BMI 30kg/ m² (obese) % Waist Circumference NOT at target, Male 94cm & Females 80cm Psychosocial Risk Factors % with raised Anxiety levels 8 (normal level 0-7) % with raised Depression levels 8 (normal level 0-7) Blood Pressure % BP NOT to target (>140/90mmHg for high risk individuals & >130/80mmHg for coronary/ diabetes) Cholesterol % Cholesterol NOT to target (TC >5mmol/L & LDL >3mmol/Lfor high risk individuals and TC >4.5mmol/L & LDL >2.5mmol/L for coronary/diabetes) Partners (n=378) 13

14 Chapter 2 Figure 4. Change in Cardioprotective Medications Between IA and EOP for Patients and Partners IA Initial Assessment EOP End of Programme Assessment Percentage Antiplatelet Therapy Statins ACE Inhibitors Cardioprotective Medications Beta Blockers Calcium Channel Blockers Patients IA Patients EOP Partners IA Partners EOP 14

15 Patient Quote We have a new lease on life. Not only have we both lost weight and increased our fitness, but we have also become more confident and sociable. We look forward to going for our daily walk and meeting people. The support of the health team reassured us along the way and kept us on our toes. Brothers Albert and Robert O Reilly

16 Chapter 3 What do the results mean? 16

17 Chapter 3 What do the results mean? This chapter will highlight how the outcomes of Croí MyAction are directly impacting on the cardiovascular health of patients (see Appendix 1-4) Making a difference through lifestyle change... pivotal to CVD prevention Smoking The prevalence of smoking among patients (20%) is consistent with the national average of 21%. 16 The uptake of smokers on the Croí MyAction programme is significant considering smokers are less likely to uptake on prevention initiatives. Croí MyAction is successfully helping people quit smoking, achieving a quit rate of 42% at EOP, which increases to 51% at 1-YR. This quit rate exceeds the targets set by specialist smoking cessation services, of 35% at 4-weeks. 17 This significantly high quit rate can be attributed to the programme s strong emphasis on providing specialist smoking cessation support through behavioural counselling, pharmacotherapy and motivation. There was a significant reduction from IA to EOP in partners who smoked. Stopping smoking is the single most beneficial change one can make in terms of reducing their risk of heart disease, cancer, and death - with nonsmokers living on average 10-years longer than smokers. 18 Weight and Shape There is a high prevalence of obesity in the Croí MyAction population of patients (69%) and partners (48%) compared to the estimated prevalence of obesity in the general adult population of 24%. 19 It is well recognised that weight loss impacts positively on cardiovascular health through reducing fasting blood glucose levels, blood pressure, and cholesterol levels. 20 There was a significant reduction in weight by an average of 3.7kg and waist circumference by 4.9cm in men and 4.4cm in women at EOP. Abdominal obesity is increasingly recognised as a major risk factor for CVD, 21 with an increase of 1cm in waist circumference being associated with a 2% increase in risk of future CVD. 22 Croí MyAction is delivering to NICE best practice guidelines for weight loss 23 resulting in successful maintenance of weight loss at 1-YR among both patients and their partners. 17

18 Chapter 3 What do the results mean? Diet The Mediterranean Diet has been recommended as the first line dietary advice in the protection against cardiovascular disease 15 and is a key lifestyle target in the Croí MyAction programme. There was an increase in the Mediterranean Diet Score of 3.6 units in patients and 3.7 units in partners attending both IA and EOP, which is of great significance considering that an increase of just 1.5 units has been shown to be associated with a 30% relative risk reduction in CVD events. 24 This increase in Mediterranean Diet Score observed during the programme was also successfully maintained at 1-YR. Physical Activity and Fitness Physical activity levels at baseline were extremely low with only 12% of patients and 19% of partners achieving the recommended physical activity targets of 30-minutes of moderate aerobic activity 5-days per week. By the end of programme however, six in ten patients were achieving this target with a similar increase seen in partners. Achieving this level of physical activity has been shown to be associated with at least a 20-30% reduction in cardiovascular events, even if physical activity levels are increased late in life. 5 Importantly, these self-reported increases were accompanied by objective evidence of increased functional capacity of 1.6 and 1.3 estimated MET maximum for patients and partners respectively. For every MET increase, there is an associated 8-17% reduction in all cause mortality. 6,7,8 Improving mental well-being...a holistic approach to CVD prevention Anxiety, Depression, Quality of Life and Social Support It is increasingly recognised that a healthy diet, regular physical activity, and participation in group-based activities can have a positive effect on quality of life and symptoms of anxiety and depression This was clearly observed in the Croí MyAction programme with a significant reduction in those displaying raised anxiety and depression levels as determined by the Hospital Anxiety and Depression Scale (HADS) from 32% to 23% for anxiety and 19% to 7% for depression. This is particularly important as many studies have linked hostility, 29, 30, 31 depression, and cardiovascular death. 18

19 Chapter 3 What do the results mean? Managing medical risk factors...vital to preventing CVD events Blood Pressure Only 50% of patients were achieving optimal blood pressure targets at IA and this is in line with recent surveys of hypertension control. 25 However, this had increased significantly to 79% of patients by EOP with a mean reduction of 8.6/3.7mmHg being observed for systolic and diastolic blood pressure respectively. Research would suggest that this decrease is linked to a 20% reduction in risk of CHD and a 35% reduction in risk of stroke. 6 While there was slight regression of the number of patients and partners achieving targets at 1-YR, the results were still significant. The improved management of hypertension can be attributed to a combination of lifestyle modification and increased prescribing of anti-hypertensive agents in accordance with ESC Hypertension Guidelines. 26 Total and LDL Cholesterol Less than one in two patients (45%) were achieving the recommended cholesterol targets at IA, but this increased to nearly three in four patients (73%) at EOP, with a mean reduction in total cholesterol of 0.73 mmol/l and LDL of 0.62 mmol/l being observed. These reductions are associated with a 15% reduction in CVD mortality and non-fatal myocardial infarction 10 and most importantly are being maintained at 1-YR. Diabetes Over a fifth of all patients recruited to Croí MyAction, have type 2 diabetes. Consistent with the very high levels of BMI of the Croí MyAction population, 5% of patients and 2% of partners with no known history of diabetes, were subsequently diagnosed with diabetes or impaired glucose tolerance at IA. Glycaemic control improved significantly amongst all patients with type-2 diabetes, with an almost doubling in those achieving a HbA1c target,48mmol/l (28% to 55%) at 1-YR. 19

20 Chapter 4 Informing the Transformation of Preventive Care in Ireland Contributing to a Healthier Ireland for the Future Partnership and cross sectional work Empowering people and communities Reforming preventive healthcare delivery in Ireland Providing robust research and evidence Ongoing monitoring and evaluation Croí MyAction is the first cardiovascular prevention programme of its kind in Ireland and is delivering to the recommendations of the National Cardiovascular Health Strategy. 32 The programme s success is due to its unique principles and protocols which align to the Healthy Ireland framework for improved health and wellbeing. 33 With five years of robust clinical evidence, the findings of the Croí MyAction programme have translated into a number of proposals which have been presented to the HSE (Health Service Executive) Department of Health, Minister for Health and other agencies with the aim of influencing and shaping National governance and policy around the delivery of CVD prevention. Partnership and cross sectional work is exemplified in the Croí MyAction programme at a number of levels. The programme is a collaboration between the voluntary sector Croí, and an academic institution - Imperial College London, and through its unique integrated approach to prevention, is working in partnership with key stakeholders including, general practice, hospital departments, and community groups. It is actively empowering people and communities through its individualised approach to behavioural change to lifestyle modification. It is family-centred, actively involving patients partners and other family members. By locating the programme in the heart of the community it is more accessible to those who most need it, removing the barrier of having to attend the doctor s clinic or hospital. Croí MyAction is reforming how preventive healthcare is being delivered in Ireland. The programme provides an evidence-based service model that is effectively implementing best-practice in achieving CVD prevention and rehabilitation guidelines and represents an efficient use of resources. The programme is nurse-led, an approach which is known to be effective in the prevention and management of CVD. 34 Croí MyAction provides robust research and evidence for investment in preventive cardiovascular care. To date outcomes have been widely disseminated at multiple National, European and International health care professional conferences with over thirty oral/poster presentations being made. The outcomes of the programme were published in the British Journal of Cardiology (2013) 2 and the European Journal of Preventive Cardiology (2014) 1. The programme has also been part of a Health Research Board study, providing an intervention to women with a previous history of gestational diabetes, the outcomes of which are currently awaiting publication. Through ongoing monitoring, reporting and evaluation, Croí MyAction is addressing the challenges of translating best practice evidencebased guidelines into everyday clinical practice. The programme s outcome-driven approach has led to the development of other community-based programmes which are addressing the increasing adverse lifestyle trends of obesity, physical inactivity, and type-2 diabetes, which the Irish population are facing. 20

21 Patient Quote MyAction taught me I am in control and responsible for MY body. My success in achieving and managing weight loss was that my motivation changed from trying to fit into a certain dress size to achieving lasting weight loss for my health. There s no going back. Teresa Gilmore 21

22 Chapter 4 Informing the Transformation of Preventive Care in Ireland Bridging the Implementation Service Gap Croí MyAction demonstrates that it is possible to implement the ESC prevention guidelines into everyday clinical practice. However in order for this to be accomplished on a wider scale it is important to build the capacity of health care professionals through ongoing education, training and research. In aspiring to achieve this, Croí have formed a unique academic collaboration with the National University of Ireland, Galway through the establishment of postgraduate courses and the National Institute for Preventive Cardiology (NIPC). The postgraduate studies include a Masters and Postgraduate Diploma in Preventive Cardiology and is one of only two such programmes available in Europe. The course graduated its first class of students in November 2014 and aims to produce a generation of scholars with an expertise in CVD prevention. The Croí MyAction programme provides the rich learning environment for the applied clinical component of this programme. The NIPC was launched by Croí as an affiliate of NUI Galway in November The mission of the Institute is to provide leadership through discovery, training and applied programmes to prevent and control cardiovascular disease for all, promote healthier living, raise standards of preventive cardiology practice, and prepare leaders to advance preventive healthcare in Ireland. Dr James J Browne, President NUI Galway pictured with Jenni Jones, Executive Director NIPC The NIPC aims to: Produce a new generation of scholars and leaders in cardiovascular health and disease prevention. Address priority health needs by driving cardiovascular research in disease prevention and rehabilitation. Develop and test innovative models of preventive care and service delivery. Engage with policy makers and health practitioners to strive for excellence in preventive healthcare. Enable patient advocacy and empowerment. 22

23 Patient Quote I am successfully keeping my cholesterol under control by learning to make better food choices. For me one of the key insights was in learning to read food labels and track the amount of sugar and salt in the foods I was eating. It s about getting the basics right. Sally Fullard 23

24 Chapter 5 Key Recommendations Consistent with global trends it is predicted that by 2020 the incidence of type-2 diabetes and cardiovascular diseases are expected to rise by 20-30% in Ireland. 33 Therefore it is imperative that preventive actions are put in place to tackle CVD. 1. Manage CVD as a single family of diseases. Croí MyAction demonstrates the effectiveness of applying an integrated approach to CVD prevention. Health service planners should therefore consider Croí MyAction as a template for a national demonstration model which could integrate the care of all those at high CVD risk (multiple risk factors, vascular disease, heart disease, TIA and type-2 diabetes). 2. Promote healthy lifestyle as a focus of CVD preventive efforts. Recognising that cardiovascular risk is driven by poor dietary habits, physical inactivity and smoking, the focus of preventive efforts should be on promoting healthy lifestyle habits to address total cardiovascular risk. This requires the wider expertise of a team of multidisciplinary health care professionals including nursing, dietetics, physical activity, medicine and psychology. 3. Train health care providers to address complex lifestyle behaviours. Addressing and managing complex lifestyle behaviours require expertise. Health care professionals should be trained and equipped with the skills to apply effective behavioural strategies in improving self efficacy, promoting self management and enhancing motivation. 4. Deliver community-based CVD prevention programmes. CVD prevention programmes should be delivered in community settings that adopt flexible approaches in allowing easy access to those most at risk, particularly vulnerable and deprived groups. This approach has proven to be very successful in the MyAction programme as demonstrated by the high uptake and retention rates. 5. Promote early diagnosis and access to treatment for those at risk of CVD. Despite the global acceleration of CVD, many patients go undiagnosed and untreated. There is compelling evidence to show that even among those with established disease there are treatment gaps. 25 There is a need to examine the wider role of other health care professionals such as pharmacists, nurses and patients organisations in the early identification of individuals at risk and to support general practice in ensuring that these patients are managed appropriately. 6. Implement data monitoring and auditing of CVD risk factors on a national level. Croí MyAction reports across a wide spectrum of CVD health outcomes. However there is a real need to develop intelligence in relation to data monitoring and auditing of CVD risk factor prevalence and management across the island of Ireland. Not only will this help assess progress in terms of achievement of best practice guideline for prevention, it will also help inform future policies and strategies in CVD prevention. 7. Undertake a formal economic analysis of Croí MyAction. While an economic analysis of the MyAction programme in the UK has shown the programme to be cost effective, a formal economic analysis of Croí MyAction is required. 24

25 5 YEARS OF POSITIVE PATIEN T OUTCOMES Patient Quote Following my stroke I was determined to regain my mobility and with hard work I am so happy to realise how well I have done. Having my wife Monica on the programme with me meant she was also aware of the amount of activity I was capable of doing and could encourage me to keep going. Pat and Monica O Leary 25

26 References 1. Gibson I, Flaherty G, Cormican S, Jones J, Kerins C, Walsh AM, Costello C, Windle J, Connolly S, Crowley J. Translating guidelines to practice: findings from a multidisciplinary preventive cardiology programme in the west of Ireland. European Journal of Preventive Cardiology. 2014;21(3): Gibson I, Crowley J, Jones J, Kerins C, Walsh AM, Costello C, Windle J, Flaherty G. Delivering the MyAction programme in different populations: Galway, Republic of Ireland. British Journal of Cardiology. 2013; 20(supplement 3):S15-S Critchley J, Capewell,S. Smoking Cessation for the secondary prevention of coronary heart disease. Cochrane Database of Systematic Reviews CD Sofi F, Cesari F, Abbate R, Gensini GF, Casini, A. Adherence to Mediterranean diet and health status: meta-analysis. British Medical Journal. 2008; 337: a, Byberg L, Melhus H, Gedeborg R, Sundstrom J, Ahlbom A, Zethelius B, et al. Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort. British Medical Journal. 2009;338:b Myers J, Kaykha A, George S, Abella J, Zaheer N, Lear S, et al. Fitness versus physical activity patterns in predicting mortality in men. American Journal of Medicine. 2004; 15; 117(12): Dorn, J., Naughton, J., Imamura, D. & Trevisan, M. Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP). Circulation. 1999; 100 (17), Gulati, M., et al. Exercise capacity and the risk of death in women: the St James Women Take Heart Project. Circulation. 2003; 108(13): Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. British Medical Journal. 2009;338:b, Baigent C, Blackwell L, Emberson J, Holland LE, Reith C, Bhala N, Peto R, Barnes EH, Keech A, Simes J, Collins R. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. The Lancet. 2010;376: Yusuf PS, Haweeken S, Oˆ unpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case control study. The Lancet 2004; 364: Wood D, Kotseva K, Connolly S, Jennings C, Mead A, Jones J, et al. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. The Lancet. 2008;371:

27 13. Matrix. Cost benefit analysis of MyAction, a cardiac rehabilitation programme for post acute event patients and those patients which have been identified in general practice setting as high risk. In Press; 2014 Available from: com/events/535 [Accessed December 2014]. 14. Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: fourth joint task force of the European society of cardiology [ESC] and other societies on cardiovascular disease prevention in clinical practice. European Heart Journal. 2007; 28: Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren MMW, et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The fifth joint task force of the European society of cardiology and other societies on cardiovascular disease prevention in clinical practice. European Heart Journal. 2012;33, Children DoHa. Tobacco Free Ireland: Report of the Tobacco Policy Review Group. Dublin; National Institute for Health and Clinical Excellence. Smoking Cessation Services. NICE public health guidance 10. Issued February 2008, modified November2013. Available from: (Accessed online December2014) 18. Jha P, Ramasundarahettige C, Landsman V, Rostron B, Thun M, Anderson R, McAfee T, Peto R. 21st-Century hazards of smoking and benefits of cessation in the United States. New England Journal of Medicine. 2013; 368 (4), Irish Nutrition Universities Alliance (IUNA).National Adult Nutrition Survey. Cork: University College Cork; Goldstein DJ. Beneficial health effects of modest weight loss. International Journal of Obesity and Related Metabolic Disorders. 1992;16(6), DeKoning L, Merchant AT, Pogue J, Anand SS. Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies. European Heart Journal. 2007; 28(7), Pischon T, Boeing H, Hoffmann K, Bergmann M, Schulze MB, Overvad K, et al. General and abdominal adiposity and risk of death in Europe. New England Journal of Medicine. 2008; 359(20), National Institute for Health and Clinical Excellence. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults. NICE; Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. The New England Journal of Medicine. 2013; 368(14), Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Keil U. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. European Journal of Cardiovascular Prevention and Rehabilitation. 2009; 16:

28 References 26. European Society of Cardiology ESH/ESC guidelines for the management of arterial hypertension. European Heart Journal. 2013; 34: Conn VS. Depressive symptom outcomes of physical activity interventions: meta-analysis findings. Annals of Behavioural Medicine 2010; 39(2): Conn VS. Anxiety outcomes after physical activity interventions: meta-analysis findings. Nursing Research 2010; 59(3): Kuczmarski MF, Cremer SA, Hotchkiss L, Cotugna N, Evans MK, Zonderman AB. Higher healthy eating index-2005 scores associated with reduced symptoms of depression in an urban population: findings from the healthy aging in neighborhoods of diversity across the life span (HANDLS) study. Journal of the American Dietetic Association. 2010; 110(3): Das S, O Keefe JH. Behavioral cardiology: recognizing and addressing the profound impact of psychosocial stress on cardiovascular health. Current Hypertension Reports 2008; 10(5): Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in cases and controls from 52 countries (the INTERHEART study): case-control study. The Lancet. 2004; 364(9438): Children DoHa. Changing Cardiovascular Health: National Cardiovascular Health Policy Dublin; Children DoHa. Healthy Ireland, A Policy Framework for Improved Health and Wellbeing Dublin; Berra K, Miller NH, Jennings C. Nurse-based models for cardiovascular disease prevention from research to clinical practice. European Journal of Cardiovascular Nursing. 2011;10(SUPPL. 2):S42-S50. 28

29 Patient Quote My level of fitness was transformed. When I started the programme I couldn t walk a mile before being breathless. Now Mona and I walk 3 miles a day and at a greater pace then I believed I could achieve. John and Mona Prendergast 29

30 Appendix 1 Change in Lifestyle Risk Factors and Psychosocial Health between Initial Assessment (IA) and End of Programme (EOP), and between IA and 1 Year Follow-up Assessment (1-YR) for patients. Smoking Patients IA (n=530) Patients EOP (n=530) Patients IA (n=390) Patients 1-YR (n=390) % of Current Smokers (p<0.001) (p<0.001) Diet Mean Mediterranean Diet Score (optimal score 9) % Fruit & Vegetable target- 5 portions/day (p<0.001) (p<0.001) (p<0.001) (p<0.001) % achieving salt target of not adding to food or cooking (p<0.001) (p<0.001) Median Alcohol Units per week 8 4 (p<0.001) 10 6 (p<0.001) Physical Activity % achieving targets ( 5x/week 30 minutes) (p<0.001) (p<0.001) Estimated METs maximum (p<0.001) (p<0.001) Anthropometrics Mean BMI (kg/m 2 ) (p<0.001) (p<0.001) Mean Waist Circumference Men (cm) (p<0.001) (p<0.001) Women (cm) (p<0.001) (p<0.001) % to target (p=0.001) (p=0.02) Psychosocial Risk Factors % with raised anxiety levels 8 (normal level 0-7) (p<0.001) (p=0.001) % with raised depression levels 8 (normal level 0-7) (p<0.001) (p=0.002) BMI, body mass index; MET, metabolic equivalent. 30

31 Appendix 2 Change in Medical Risk Factor Management between Initial Assessment (IA) and End of Programme (EOP), and between IA and 1 Year Follow-up Assessment (1-YR) for patients. Blood Pressure Patients IA (n=530) Patients EOP (n=530) Patients IA (n=390) Patients 1-YR (n=390) % <140/90mmHg for high risk individuals & <130/80mmHg for coronary/diabetes (p<0.001) (p<0.001) Mean Systolic BP (mmhg) (p<0.001) (p<0.001) Mean Diastolic BP (mmhg) (p<0.001) (p<0.001) Cholesterol % Cholesterol to target (TC <5mmol/L & LDL <3mmol/L (p<0.001) (p<0.001) % Total Cholesterol to target (<5mmol/L) (p<0.001) (p<0.001) % LDL to target (<3mmol/L) (p<0.001) (p<0.001) Mean Total Cholesterol (p<0.001) (p<0.001) Mean LDL Cholesterol (p<0.001) (p<0.001) Diabetes Control % Glucose to target in patients with diabetes (FBG < 6mmol/L) (p=0.002) (p<0.001) Mean HbA1c (mmol/mol) (p<0.001) (p<0.001) % HbA1c to target (<48mmol/mol) (p<0.001) (p<0.001) BP, blood pressure; TC, total cholesterol; LDL, low-density lipoprotein; FBG, fasting blood glucose; HbA1c, glycosylated haemoglobin 31

32 Appendix 3 Change in Lifestyle Risk Factors and Psychosocial Health between Initial Assessment (IA) and End of Programme (EOP), and between IA and 1 Year Follow-up Assessment (1-YR) for partners. Smoking Partners IA (n=258) Partners EOP (n=258) Partners IA (n=185) Partners 1-YR (n=185) % of Current Smokers (p=0.02) (p=0.50) Diet Mean Mediterranean Diet Score (optimal score 9) (p<0.001) (p<0.001) % Fruit & Vegetable. Target- 5 portions/day (p<0.001) (p<0.001) % achieving salt target of not adding to food or cooking (p<0.001) (p<0.001) Median Alcohol Units per week 6 3 (p<0.001) 6 5 (p=0.003) Physical Activity % achieving targets ( 5x/week 30 minutes) (p<0.001) (p<0.001) Estimated METs maximum (p<0.001) (p<0.001) Anthropometrics Mean BMI (kg/m 2 ) (p<0.001) (p<0.001) Mean Waist Circumference Men (cm) (p<0.001) (p<0.001) Women (cm) (p<0.001) (p<0.001) % to target (p<0.001) (p=0.07) Psychosocial Risk Factors % with raised Anxiety levels 8 (normal level 0-7) (p<0.001) (p=0.005) % with raised depression levels 8 (normal level 0-7) (p<0.001) (p=0.002) BMI, body mass index; MET, metabolic equivalent. 32

33 Appendix 4 Change in Medical Risk Factor Management between Initial Assessment (IA) and End of Programme (EOP), and between IA and 1 Year Follow-up Assessment (1-YR) for partners. Blood Pressure Partners IA (n=258) Partners EOP (n=258) Partners IA (n=185) Partners 1-YR (n=185) % <140/90mmHg for high risk individuals & <130/80mmHg for coronary/diabetes (p<0.001) (p<0.001) Mean Systolic BP (mmhg) (p<0.001) (p<0.001) Mean Diastolic BP (mmhg) (p<0.001) (p<0.001) Cholesterol % Cholesterol to target (TC <5mmol/L & LDL <3mmol/L (p<0.001) (p<0.001) % Total Cholesterol to target (<5mmol/L) (p<0.001) (p<0.001) % LDL to target (<3mmol/L) (p<0.001) (p<0.001) Mean Total Cholesterol (p<0.001) (p<0.001) Mean LDL Cholesterol (p<0.001) (p<0.001) Diabetes Control % Glucose to target in partners with diabetes (FBG 6 mmol/l) (p=0.50) (p=0.50) Mean HbA1c (mmol/mol) (p=0.17) (p=0.86) % HbA1c to target (<48mmol/mol) (p=0.50) (p=0.63) BP, blood pressure; TC, total cholesterol; LDL, low-density lipoprotein; FBG, fasting blood glucose; HbA1c, glycosylated haemoglobin 33

34 Acknowledgments We would like to acknowledge the support of: Croí MyAction programme participants and partners Croí MyAction multidisciplinary team: Annie Costelloe, Caroline Costello, Katie Cunningham, Dr. Gerard Flaherty, Irene Gibson, Claire Kerins, Anne Marie Walsh and Jane Windle MyAction, Central Team at Imperial College London: Catriona Jennings, Alison Mead, Jenni Jones, Prof David Wood, Dr. Susan Connolly, Dr. Kornelia Kotseva and Annie Holden Galway PCCC, HSE West who funded the programme for the first 2 years MSD Ireland, who supported the programme through an unconditional educational grant in its initial 3 years

35

36 National Institute for Preventive Cardiology Croí Heart and Stroke Centre Moyola Lane, Newcastle, Galway