National Cardiovascular Health Policy 2010 – 2019

Objectives

Changing Cardiovascular Health provides Ireland’s 2010-2019 national framework for preventing, detecting and treating cardiovascular disease, including stroke and peripheral arterial disease, through an integrated, quality-assured, life-course approach.[1]Its vision is to protect and promote cardiovascular health as a national resource, manage cardiovascular disease as a chronic condition, and help make Ireland healthier for all citizens by 2020.[2][3]

• Reduce cardiovascular disease burden, premature death and inequalities through combined population-wide prevention, high-risk interventions, and primary, secondary and tertiary prevention.[4][5]
• Improve health behaviours by supporting healthy weight, nutritious diets, physical activity, lower salt intake, smoking cessation and responsible alcohol consumption.[6][7]
• Restore adult weight distribution towards 1999 levels by 2019, increasing healthy weight from 38% to 43% and reducing obesity from 23% to 18%; improve children’s healthy weight from 78% to 84% while reducing overweight and obesity.[8]
• Increase regular physical activity by 2019 from 55% to 66% among adults and from 41% to 49% among children, and reduce adult salt consumption to no more than 6 grams daily within the policy period.[9][10]
• Reduce smoking prevalence from 29% to 19% and smoking initiation from 31% to 21% by 2019, while reducing per-capita alcohol consumption to 9 litres annually.[11][12]
• Strengthen risk assessment, early detection and structured primary care for people with established disease, diabetes, hypertension, atrial fibrillation, heart failure, peripheral arterial disease and other high-risk conditions.[13][14]
• Provide evidence-based acute cardiac and stroke care, including rapid reperfusion for myocardial infarction, emergency stroke thrombolysis, specialist networks, rehabilitation, continuing care and palliative care.[15][16][17]
• Ensure equitable, patient-centred access to prevention, treatment, rehabilitation and support regardless of age, location, income, gender, education or transport barriers.[18][19][20]
• Develop a national quality framework founded on effectiveness, safety, timeliness, efficiency, patient-centredness and equitable access, supported by standards, guidelines, workforce development, information systems, research and health technology assessment.[21][22]

Implementation

Delivery combines intersectoral prevention with integrated care networks linking communities, primary care, hospitals, emergency services, rehabilitation and voluntary organisations.[23][4]The Department of Health and Children provides policy leadership, while the Health Service Executive leads most service implementation through national service plans, care networks and primary care teams.[24][25]

• Coordinate health-improvement action across Government, reporting regularly through the Cabinet Committee on Health, and engage education, transport, planning, agriculture, sport, food industry, media, private-sector and community partners.[26][27]
• Deliver phased public awareness campaigns on cardiovascular risk factors, warning signs and urgent responses to heart attack, stroke, transient ischaemic attack, heart failure and peripheral arterial disease, reinforced through general practices and pharmacies with voluntary agencies.[28][29]
• Adopt the 2007 European Society of Cardiology Clinical Practice Guidelines, develop national and primary-care protocols, and use multidisciplinary shared-care pathways for prevention, chronic disease management and self-management support.[30][31]
• Organise acute cardiac care through population-based networks of General Cardiac Centres and Comprehensive Cardiac Centres, with primary percutaneous coronary intervention delivered within 120 minutes of first medical contact where feasible and timely thrombolysis otherwise.[32][33]
• Establish stroke units in hospitals admitting acute stroke patients and organise General Stroke Centres and Comprehensive Stroke Centres to provide same-day transient ischaemic attack assessment, 24-hour thrombolysis, diagnostics, vascular services, rehabilitation and telemedicine where needed.[34][35][36]
• Develop community-based heart-failure, anticoagulation and rehabilitation services, using specialist nurses, multidisciplinary teams, shared information systems, tele-monitoring, early supported discharge and coordinated hospital-community care.[37][38][39][40]
• Integrate workforce planning with service planning, education and training; undertake network-level staffing gap analyses and support consultant leadership, specialist nursing, allied health, technical, clerical and community liaison roles.[41][42][43]
• Establish a Cardiovascular Policy Monitoring Group to meet twice yearly, produce annual progress reporting, identify implementation barriers and conduct a major mid-term review in 2014.[21]
• Build a comprehensive cardiovascular information system with interoperable records, a unique patient identifier, compatible registers, minimum datasets, annual reporting, national audits and repeated adult and child population surveys.[44][45][46]
• Use research and health technology assessment to evaluate clinical and cost-effectiveness, prioritise investments and inform future policy, with national research priorities coordinated by the Health Research Board.[2][47]
• Implement early actions principally through service reorganisation, existing initiatives and current resources during economic constraints; longer-term resource needs are to be addressed through national service plans, but no quantified overall policy budget is specified.[48][49]

Monitoring & Evaluation

The policy establishes a national quality, monitoring and accountability architecture for cardiovascular health, combining population surveys, routine data, registries, clinical audit, service-network review, research and health technology assessment.[23][24][25][21][22]

• Establish a Cardiovascular Policy Monitoring Group, comprising Department of Health and Children officials and external experts, to meet twice yearly, review progress, advise on implementation and produce a brief annual progress report.[24][21]
• Complete a major mid-term review in Year 5, reporting in 2014, and use early implementation findings to refine priorities for the second half of the 2010-2019 policy period.[24][48][21]
• Require progress reports from cardiovascular care networks, primary care teams and community-based services, while using the annual National Service Plan as an implementation mechanism between the Department of Health and Children and the Health Service Executive.[24][21]
• Develop evidence-based national standards, clinical guidance, performance indicators, reporting structures and information requirements for cardiovascular services.[24][25][22]
• Implement systematic surveillance using patient-based data, common data standards and a unique patient identifier to analyse mortality, morbidity, risk factors, equity of access, disease prevalence and health-service use.[25][22]
• Develop a comprehensive cardiovascular health information system, interoperable electronic records, minimum cardiovascular datasets and a national cardiovascular disease registry, including priority databases for acute stroke care and thrombolysis.[25][44][45]
• Conduct at least two national adult and child population surveys during the policy’s 10-year lifetime to measure health profiles, inform planning and direct resources.[25][45]
• Commence a routine national audit system from 2010 and undertake annual cardiovascular-network audits covering service volume, quality, patient throughput, adherence to best-practice guidance, workforce, facilities, equipment and information and communications technology.[25][46]
• Use national audit review to identify implementation barriers, share solutions across networks and recommend corrective action.[46]
• Use health technology assessment and research to assess the clinical and cost-effectiveness of medicines, devices, diagnostics, health-promotion interventions and primary-care cardiovascular risk assessment.[2][31][47]

Specific targets support monitoring of population health behaviours, including adult and child weight status, diet, physical activity, salt intake, smoking and alcohol consumption.[50][51][28]Regular reporting to Government through the Cabinet Committee on Health is required for intersectoral health-improvement work, with reductions in cardiovascular-health inequalities used to assess its success.[28][26]

Service-level evaluation includes interim review of public awareness campaigns, formal assessment of primary-care cardiovascular risk ascertainment, evaluation of atrial-fibrillation screening, heart-failure registers and audits, stroke clinical audit, carotid-intervention audit, rehabilitation outcome audit and workforce review.[29][52][53][54][19][55]The document does not consistently specify detailed indicators, reporting frequencies or independent accountability arrangements for every individual clinical recommendation.[53][56][57]

Costing & Financing

The policy recognises cardiovascular disease as a substantial economic and service burden, but provides no total implementation budget, programme allocations, funding formula, quantified national funding gap or costing methodology.[58][24][25]

• Recognise that cardiovascular disease generates healthcare costs, productivity losses and informal-care costs, while Irish direct, productivity and informal-care cost estimates were unavailable.[58][59]
• Note that cardiovascular health accounted for 6% of the Irish healthcare budget, compared with a 10% average across the EU27.[58]
• Record that cardiovascular disease cost the European economy 192 billion euro in 2006, comprising healthcare costs, productivity losses and informal care.[59]
• Seek substantially better analysis of cardiovascular expenditure, investment needs, potential savings and value for money to inform service-planning decisions.[58][59]
• Implement early actions in a severe economic climate with little prospect of immediate additional resources, primarily through alignment with existing strategies, hospital reconfiguration, primary-care development and reorganisation of Health Service Executive resources.[1][49]
• Develop new emergency care models and clinical networks within current resources in the short term, while pursuing later staffing and capital developments subject to resource availability.[16]
• Balance longer-term additional resource requirements against service priorities, potential savings from staff redeployment and resource reorganisation, with further detail intended for future national service plans.[49]
• Invest in workforce development, information and communications technology, information systems, audit, research, health technology assessment, rehabilitation staffing and facilities, emergency capacity and multidisciplinary community services, without monetary valuations.[18][24][3][21]

Several interventions are described as potentially efficient or cost-effective, including structured heart-failure care, emergency stroke thrombolysis, cardiac rehabilitation and organisational change through best-practice pathways; however, no quantified savings or economic assumptions are provided.[38][15][60][35][61]The proposed primary-care risk-assessment study is intended to determine health and cost-effectiveness before wider implementation.[31]