Baltimore, MD - A new survey of outpatients with cardiovascular disease or risk factors has shown that over nine years, until 2006, adherence to evidence-based guidelines for hypertension, hyperlipidemia, and diabetes was suboptimal in Europe and the US [1]. Dr Benjamin A Steinberg (Johns Hopkins School of Medicine, Baltimore, MD) and colleagues report their findings online July 14, 2008 in the American Heart Journal.

The results show that almost half of patients in the US were not at their target for blood pressure or low-density lipoprotein (LDL) cholesterol at the start of the survey in 1998, and in Europe less than one-third of patients were at BP goal and only a minority had their LDL recorded. Only modest improvements were observed by 2006.

What I like about this study is that it is an attempt to determine what happens in real practices . . . not at places like Harvard.

But coauthor Dr Philip Poole-Wilson (Imperial College, London, UK) told heartwire he does not think the news is all gloomy and that the results do show that goals are increasingly being met. "What I like about this study is that it is an attempt to determine what happens in real practices within countries, not at places like Harvard. It's important to establish the facts in a representative population. And, okay, we can say that 55% of people are not getting their LDL cholesterol measured, but the other 45% are, and this may have led to a substantial cholesterol reduction, which is an achievement and likely relates to the fall in cardiovascular mortality seen in many countries."

However, there is always room for improvement, he stresses. The EUROACTION family-based, nurse-led cardiovascular-rehabilitation program, which has just been published, "might be the way forward. It certainly works" and is a good example of a way to successfully improve standards of preventive care, he notes. "If we could pay doctors to run such a system, that might bring about substantial change. I believe in using financial rewards to direct and guide medical services, and I'm not sure doctors are any different from any other group of people when it comes to this. Offering incentives is critical to implementing change."

Steinberg and colleagues explain that there are hardly any data available in cardiac outpatients and few prior studies documenting trends in the achievement of goals. Using the CardioMonitor international outpatient survey, an annual survey of outpatients with cardiovascular disease or risk factors entered by physicians around the world, they tracked 102 318 patients over nine years in the US, the UK, France, Italy, Spain, and Germany, analyzing them for achievement of evidence-based goals for hypertension, hyperlipidemia, and diabetes.

"We observed trends toward improving achievement of clinical goals, as guideline statements became published for each of the respective conditions," they note. "Hypertension and hyperlipidemia goals were increasingly met, yet with still plenty of room for improvement in clinical targets that have been established now for several years.

The most recent progress is not enough, in Europe or in the US.

"Overall, significant proportions (35%-85%) of patients in each of the three disease categories, both in the US and Europe, were not reaching goals, and thus further improvement in adherence to guideline-recommended targets is urgently needed to achieve the posited clinical benefits," they state.

These contemporary data from Europe complement recent similar findings from the Euro Heart Survey and EUROASPIRE projects, they note, and all find that achievement of targets is unacceptably low.

"The proportion of patients not yet achieving their goals represents a cohort of potential strokes, myocardial infarctions, and deaths that could be prevented with currently available therapies. Thus, we currently have the knowledge and the means to significantly improve cardiovascular-disease incidence and outcomes around the world, yet our data demonstrate we are not yet adequately making such modifications. The most recent progress is not enough, in Europe or in the US."

The suboptimal achievement of treatment goals is likely due to several factors, say the researchers, such as poor patient compliance with prescribed therapies, intolerance of medications, lifestyle effects counteracting therapies, physician awareness of conditions, financial burdens of therapy, or perceived lack of benefit of therapy.

Poole-Wilson says that while EUROASPIRE did show that treatment of certain conditions is improving, such as hyperlipidemia and hypertension, "what is missing is an impact on lifestyles, in that obesity rose and people did not seem to be taking more exercise."

He believes that the practice of paying doctors to use drug treatments to lower BP and cholesterol, as is the case in certain countries, is laudable but may lead to them to "ignore other things, such as stopping smoking, exercise, and obesity. I wouldn't want to underestimate the impact of treating hypertension, high cholesterol, and diabetes, but we need systems that can put more emphasis on lifestyle changes."

One of the major problems is the contact time allowed between doctor and patient, he notes. In many countries, this is around eight to 10 minutes, "and it's impossible in this time to get any serious message across or have a serious discussion," he notes.

And although the paper shows that adherence to guideline-recommended therapy was lower in Europe than in the US, Poole-Wilson says, "I'm not sure the US is doing any better. The problem in the States is that there is such a division in the quality of medicine. The poor get almost no care at all, whereas the rich get everything and possibly too much, although there are plenty of isolated systems there where things work better."

Systems including clinics and/or providers dedicated solely to preventive and chronic care—as in the EUROACTION project cited by Poole-Wilson—may help provide more convenient and expedited care for patients, say the researchers.

"These well-known, relatively simple interventions represent potential improvements in population health and must be more effectively implemented, both in the US and Europe," they conclude.