MODELING DIFFERENT STRATEGIES TO PREVENT CORONARY HEART-DISEASE IN PRIMARY-CARE

Strategies for prevention of coronary heart disease (CHD) in primary c are need to take into account the number of people who require screeni ng, further assessment, intervention and follow-up (i.e. the patient w orkload generated for the general practitioner) as well as the anticip ated reductions in morbidity and mortality. Risks of CHD for various r isk profiles were estimated from equations produced by the Framingham study. This enabled an estimate of the number of avertable CHD events to be compared against the patient workload implications for the gener al practitioner when different screening and intervention strategies w ere used. The Framingham equations were applied to a population of 572 7 men and women aged 35-64 years of age registered with general practi ces in the south of England. Adopting an unselective approach to scree ning resulted in 14.1% (n = 73) of the 517 CHD events predicted over a 10 year period being averted. A limited screening strategy, involving 25% (n = 1436) of the patients would avert 5.6% (n = 29) of the predi cted CHD events, whilst more extended strategies involving between 37% (n = 2131) and 46% (n = 2660) of the practice population respectively would result in between 6.9% (n = 36) and 9.3% (n = 48) of events bei ng averted. The marginal benefit in averting CHD events decreased as m ore screening criteria were included. Almost all (99%) of the people i dentified by the selective screening strategies would require some for m of intervention, predominantly lifestyle advice. Lowering the systol ic blood pressure by 15 mmHg instead of 10 mmHg was equally effective as a 5% improvement in the overall rate of smoking cessation. The grea test increase in the proportion of CHD events averted resulted from ev en smaller improvements in the effectiveness of lipid-lowering interve ntions. We conclude that this approach is useful in evaluating the pot ential effects of different preventive strategies for CHD in primary c are and, with further refinement, may provide a useful basis for guidi ng clinical practice and planning health care policy.