Value of Primordial and Primary Prevention for Cardiovascular Disease

A Policy Statement From the American Heart Association

William S. Weintraub, et al, Circulation. 2011;124:967-990

The process of atherosclerosis may begin in youth and continue for decades, leading to both nonfatal and fatal cardiovascular events, including myocardial infarction, stroke, and sudden death. With primordial and primary prevention, cardiovascular disease is largely preventable. Clinical trial evidence has shown convincingly that pharmacological treatment of risk factors can prevent events. The data are less definitive but also highly suggestive that appropriate public policy and lifestyle interventions aimed at eliminating tobacco use, limiting salt consumption, encouraging physical exercise, and improving diet can prevent events. There has been concern about whether efforts aimed at primordial and primary prevention provide value (ie, whether such interventions are worth what we pay for them). Although questions about the value of therapeutics for acute disease may be addressed by cost-effectiveness analysis, the long time frames involved in evaluating preventive interventions make cost-effectiveness analysis difficult and necessarily flawed. Nonetheless, cost-effectiveness analyses reviewed in this policy statement largely suggest that public policy, community efforts, and pharmacological intervention are all likely to be cost-effective and often cost saving compared with common benchmarks. The high direct medical care and indirect costs of cardiovascular disease—approaching $450 billion a year in 2010 and projected to rise to over $1 trillion a year by 2030—make this a critical medical and societal issue. Prevention of cardiovascular disease will also provide great value in developing a healthier, more productive society.

Rationale for Life-Course Approach to Primordial and Primary Prevention

Disturbing trends for chronic disease and conditions like obesity and diabetes mellitus are emerging in which the incidence rates not only are increasing but also are affecting people at an earlier age. These trends highlight the important need for primordial and primary prevention across the lifespan. Prevention efforts targeted at one point during the life course may have a lasting impact later in life or even from one generation to the next.

The Economic Burden of Cardiovascular Disease and Potential to Reduce Cost

Despite the fall in overall mortality, the prevalence of disease is expected to increase, largely as a result of the aging of the population. This troubling scenario is not inevitable; most CVD is preventable or at least can be delayed until old age with less chronic morbidity, with the potential for fewerevents, less disability, and even lower costs.

Challenges in Determining the Cost-Effectiveness of Primordial and Primary Prevention

Cardiovascular disease remains a serious medical problem that can be associated with death and disability on one hand
and considerable resource use on the other. Clinical efficacy remains the primary driver for the use of any service. Once
efficacy is established and despite its many limitations, cost-effectiveness analysis has an important role in assessing
value. Properly applied, cost-effectiveness analysis not only offers a ratio and its distribution but also renders explicit the
assumptions underlying the analysis (ie, costs of therapy,disease outcomes, and complications), thus helping patients
and society evaluate the choices they make. However, in the evaluation of the value of primordial and primary prevention,
formal cost-effectiveness analysis may not be realistic and may fail to evaluate value properly.

Evidence Base for the Value of Cardiovascular Disease Prevention: Societal Change

The Cost-Effectiveness/Value of Prevention:The Impact of Environment and Policy Change

The conceptual basis for implementing primordial and primary prevention is an environmental model that maintains that an individual’s behavior is influenced by his or her surrounding physical, social, and cultural environments. To bridge the evidence gap and to provide a framework for informed decision making, it will be important to promote effective policy evaluation, optimal research design in real-world settings, and common outcome measures to assess the true value and economic impact of change and to incorporate individuals’ broader perspective of well-being.

Evidence Base for the Value of Cardiovascular Disease Prevention:Behavior Change

As models suggest, the willingness for individuals to change their lifestyle behaviors is affected by a number of factors such as the different stages of readiness, perceived threat or susceptibility of developing a health condition, concerns
about the seriousness of the preventable condition, perceived benefits of changing behavior, and cues to action that might come from social networks and their surrounding environment. This section outlines the cost-effectiveness of primordial and primary prevention concerning environment and policy change that affects behavior in the areas of tobacco use, physical activity, diet, and obesity.

Evidence Base for the Value of Cardiovascular Disease Prevention:Behavior Change

As models suggest, the willingness for individuals to change their lifestyle behaviors is affected by a number of factors such as the different stages of readiness, perceived threat or susceptibility of developing a health condition, concerns
about the seriousness of the preventable condition, perceived benefits of changing behavior, and cues to action that might come from social networks and their surrounding environment. This section outlines the cost-effectiveness of primordial
and primary prevention concerning environment and policy change that affects behavior in the areas of tobacco use, physical activity, diet, and obesity.

Evidence Base for the Value of Cardiovascular Disease Prevention:Therapeutic Areas

Several diseases and chronic health states are associated with CVD risk: diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. This section focuses on the cost-effectiveness of primary prevention in the clinical environment or community setting that is therapeutic in nature to initiate behavior change or to prevent the onset of chronic disease.

Future Research Directions

By several indexes, healthcare expenditures continue to rise at the fastest rate in our history. According to a recent projection, total healthcare spending will approximate $4 trillion in 2015, or 20% of the gross domestic product,corresponding to $1 of every $5 spent in the United States. This growth in healthcare spending is clearly not sustainable,making cost-effective prevention of disease a national priority. Future research in prevention should routinely include economic studies.

Potential areas include the following:

• Serial assessment of participants in behavioral or multicomponent trials to confirm maintenance of the treatment effect and to assess longer-term outcomes
• Evaluation of the role of technology in facilitating and supporting lifestyle change interventions
• Assessment of motivational interviewing and related behavior-change techniques, including the impact of motivational interviewing strategies delivered in primary care settings
• Clarification of the independent and additive benefits of lifestyle modification on cardioprotective pharmacotherapies and vice versa
• Evaluation of the effects of moderate versus vigorous physical activity, with specific reference to the associated benefits, risks, and long-term compliance
• Evaluation of the advantages and limitations of selected environments to deliver primordial and primary preventive interventions, including the home, community, worksite,school, and healthcare system
• Clarification of the impact of excise taxes on the consumption/ use of unhealthy foods, sugary beverages, and tobacco products
•  Testing of the thesis that we are initiating treatment of hypercholesterolemia (and other risk factors) too late in life, particularly among adolescents and young adults with high lifetime risk, clarifying the potential benefits, harms, and costs of initiating lifestyle modification interventions,drug therapy, or both early in life
• Research on the role of genetic testing in developing more personalized approaches to prevention
• Methodological research on better approaches to evaluatingvalue of preventive services
  

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