Implementation of the 4th Joint Societies’ Task Force Guidelines on Cardiovascular Disease Prevention in Clinical Practice. Evaluating implementation across 13 European countries. Main report
The Guidelines of the 4th Joint Societies Task Force on Cardiovascular Disease Prevention in Clinical Practice (4th JTF)* were issued in 2007, summarising and evaluating available evidence on reducing the incidence of atherosclerotic events arising from coronary heart disease, cerebrovascular disease and peripheral arterial disease. The purpose of the guidelines is to assist physicians in selecting the best strategies for managing cardiovascular disease. They are an important agreed protocol across countries and professionals that have the ultimate aim of improving outcomes from the disease. The value of these guidelines depends on the extent to which they are used by physicians in daily practice. Introducing the guidelines, the 4th JTF authors stressed that ‘implementation programmes for new guidelines form an important component of the dissemination of knowledge’.1
Transferring guidelines from paper into practice has proven to be frustrating for the many who endeavour to standardise the management of cardiovascular disease across Europe. The EUROASPIRE I, II and III surveys, which audited the practice of preventive cardiology in patients with coronary heart disease over a decade, illustrated that patients were not being managed to the standards set by the ESC guidelines and that limited attention was given to prevention in patients with established heart disease. Evidence of the need for more effective lifestyle management was compelling: blood pressure management remained stubbornly unchanged, and lipid targets were not achieved in almost half of patients. Other studies report disappointing levels of guideline observance among physicians; they are often unaware of recommendations given in guidelines and, even when they are, many fail to consistently apply them in treating patients.2-3 Commonly cited barriers to guideline adherence among physicians include lack of time during consultations, financial constraints and lack of confidence in patients’ motivation to comply. Physicians also find that guideline documents are difficult to translate into practice.
To address the gap between publication of guidelines and their use in practice, the ESC at a European level organises presentations at conferences for its member national societies and key opinion leaders. It works at a political level to promote the prevention agenda and to directly influence EU health policy, leading, for example, to the EU Commission endorsement of the European Heart Health Charter. However, such efforts must be paralleled by concerted strategies at a national level to realise implementation in the front line. The 4th JTF urged national societies to develop implementation programmes, starting with the translation of guidelines to the local language and their adaptation to the national context. It recommended that the guidelines issued by the 4th JTF be regarded as a framework from which national guidance ‘to suit local political, economic, social, and medical circumstances’ would be developed. The recalibration of the SCORE risk assessment charts to reflect mortality and risk factor distributions in individual countries as part of this adaptation was emphasised.
The 4th JTF saw as vital the establishment a multidisciplinary alliance of experts from national professional organisations to oversee the adaptation and to drive implementation. It was necessary that alliances would have the support of national health authorities and work with other sectors such as the medical education and business communities to advance their aims.
Other recommendations included:
An information and education programme aimed at practising doctors that would include an audit of practices and feedback. The development of supplementary materials to the guidelines, specifically electronic versions for use in hand-held devices, such as PDAs, and of A4 sheet versions of risk algorithms and treatment recommendations.
A population health approach addressing lifestyle risk factors in general.
A public information campaign explaining the concept of multiple risk assessment and treatment and intervention thresholds, as well as describing how risk can be reduced.