Current and future cardiovascular disease risk assessment in the European Union: an international comparative study
Cardiovascular disease (CVD) is the leading cause of death in Europe, and European policy priorities are shifting from treatment to prevention to reduce the resulting burden on health services. Risk assessment is central to the primary prevention of CVD. EPIC-CVD is a major European-wide programme designed to develop improved risk assessment tools, including novel genetic and biochemical markers. However, there remains a need to better understand current and future use of evidence-based interventions in practice. The current study was designed to address this issue with respect to European practice by determining what are the most important CVD risk assessment policies and guidelines currently used, establishing how CVD risk assessment is implemented, and ascertaining what the barriers and facilitators are to CVD risk assessment.
Data were collected from an on-line pan-European survey of senior academic, clinical and policy stakeholders from all EU Member States (November 2014 to March 2015). In addition, eight in-depth country case-studies were developed, based on telephone interviews with clinicians, academics and policy makers (May to October 2015). Interviews were supported by targeted literature review both to guide the interview and help interpret findings.
The European Society of Cardiology (ESC) is the main body providing and disseminating guidelines for CVD risk assessment across Europe, and the SCORE risk assessment tool, which is endorsed in these guidelines, is the tool most widely reported in use. However, the implementation of ESC guidelines and the use of CVD risk assessment tools in clinical practice is variable and often low. CVD risk assessment is predominantly, but not exclusively, conducted by primary care doctors, and health system factors, particularly lack of funding and lack of time, are important barriers to risk assessment use. Integrating risk assessment tools into clinical systems and financial incentives may act as facilitators. A clear issue was that any novel risk assessment biomarkers would need to be incorporated in ESC guidelines as the key initial step to translation into clinical practice. Evidence of clinical utility and cost-effectiveness would be required by both policy makers and practitioners for implementation of novel biomarkers, but ethical, legal or regulatory issues appeared of less concern. Findings were consistent across Europe, despite differences in context.
The ESC has a central role in informing practice across Europe, and efforts to improve practice are likely to benefit from being channelled through this organisation. There remain significant barriers to the successful implementation of cardiovascular risk assessment in practice. Despite considerable interest in developing novel biomarkers to optimise cardiovascular risk assessment, it is likely that focusing efforts on increasing the extent of implementation of current approaches will offer the greatest gains in terms of improving primary prevention of cardiovascular disease.