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Professor of Preventive Cardiology at NUI Galway and Medical and Research Director of the National Institute for Prevention and Cardiovascular Health Prof Bill McEvoy outlines his hopes for the national review of specialist cardiac services
The national review of specialist cardiac services is a welcome initiative in that it aims to ensure the delivery of cardiac healthcare across Ireland and is meeting the current and projected future healthcare needs of the Irish population. Because these healthcare needs change over time; driven largely by (1) changes in population demographics (eg, an ageing population means more heart failure and valve disease); (2) changes in the burden of cardiac risk factors (eg, increases in obesity and diabetes will require more upfront preventive efforts); and (3) changes in medical technology (eg, transcatheter aortic valve implantation is a growing, but costly procedure); intermittent reviews of cardiac services are necessary so as to meet the contemporary needs of Irish patients.
In my view, the major challenge facing the review is economical. In the current fiscal environment, the cost of providing state-of-the-art cardiac care that fully meets the needs of the population will always exceed the budget allocated by government. As such, smart economical decisions are necessary and, at times, compromises have to be made. The informed, but fair allocation of these limited financial resources is an ever-present challenge.
Thankfully, the development of a mature and efficient healthcare system is an iterative process and prior reviews of cardiac services have laid a good foundation on which to build the 2019 HSE cardiac services review. For example, prior investments in the treatment of acute coronary syndrome mean that the majority of Irish adults with ST elevation myocardial infarction can now proceed to primary percutaneous coronary intervention (PCI) within the timeframes recommended by international clinical practice guidelines. This acute aspect of cardiac service delivery has arguably been a success story overall and represents a foundation on which to build future cardiac services in the years to come. Accordingly, while acute cardiac services require ongoing development and investment, there should be scope in the current services review to increase the focus on both preventing heart disease and the management of chronic cardiac disease. With regard to the latter, increased investment in heart failure, cardiac imaging, electrophysiology and adult congenital heart disease will be needed to address the burgeoning burden of chronic cardiac disease in the Irish population.
Croí and its affiliate, the National Institute of Prevention and Cardiovascular Health (NIPC), have a particular interest in the former; cardiovascular disease prevention. There is no doubt that prevention is an area that has been relatively underfunded in the past. However, we believe that there is now both an opportunity and also an urgent need to focus much more on cardiovascular disease prevention in the current cardiac services review. Investing in prevention is also smart money, as it is well-established that preventing heart attacks and strokes is more cost-effective than treating the acute emergencies once they occur, which requires hospitalisation. One need not look far for prominent examples of other countries who, based on compelling evidence, have shifted their healthcare budgetary focus away from acute illness and procedure-based remuneration towards a more preventive-orientated fiscal strategy whereby healthcare systems are incentivised to prevent disease.
A focus on prevention is also supported by the evidence. For example, every 10-unit improvement of systolic blood pressure in the population translates into approximately 30 per cent fewer heart attacks and strokes and every 1mmol/L improvement in LDL-cholesterol translates into 22 per cent fewer heart attacks and strokes. Thus, it is much better for the patient and cheaper for society, to control these cardiovascular risk factors than it is to treat the acute illness when it occurs. Indeed, as the ancient Chinese proverb goes, “the superior doctor prevents sickness, the mediocre doctor attends to impending sickness, the inferior doctor treats actual sickness”.
As such, both Croí and NIPC hope that the following ideas might be considered by, and ultimately implemented in, the ongoing review of cardiac services in 2019:
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