White Coat, Black Art

Carrot and stick best to prevent heart disease

The failure of the world's largest prevention program against heart disease means it’s time to try a radical new approach.
(Photo by Justin Sullivan/Getty Images)

Heart disease is Canada's number-one killer. Many doctors believe the best way to deal with heart attacks is to try to prevent them.  A new study just published in the Canadian Medical Association Journal documents the failure of a massive prevention program.  

Here's a bit of background.  In 2014, the World Health Organization set the goal of reducing premature deaths from heart disease by 25 per cent.  To try and reach that ambitious goal, many governments set up publicly funded prevention programs.  The UK's Health Check program - run by the National Health Service - is the largest by far of its kind in the world.  Since 2009, the program has offered all adults ages 40 to 74 with no known history of heart disease a heart risk assessment every five years complete with individual recommendations on what to eat, how much to eat, and how much to exercise.  It even advises participants to take cholesterol-lowering drugs.  

Researchers from the School of Public Health in London looked at the health records of more than 138,000 patients age 40 to 74.  Considering the ambitious goals of the program, the results were very disappointing.  For people who attended the program, there was a statistically significant though modest overall reduction in the risk of a heart attack. 

How modest?  For every five thousand people in the UK who attended the Health Check program, one additional heart attack per year was prevented.  That doesn't scream "stunning success."  The program also reached just 21.4% of adults; far fewer than the 75% that experts said was necessary to make the Health Check a success.

The authors cite several possible factors for this rather massive failure.  Doctors and other health professionals may not have been included in the roll out of the program.  Two studies suggest that Health Check may have suffered from poor planning and execution.  Common complaints included lack of flexible appointment locations and times.  One study that recently evaluated Health Check found that people who didn't attend the program weren't told much about it.  A third of those who didn't attend Health Check said they never received an invitation.  

If anyone in Canada is thinking about starting our own version of Health Check, my advice is not to bother. The UK had optimal conditions for Health Check to be successful.  A well-developed system of family medicine or primary care should have been able to implement Health Check across the population.  The widespread use of electronic health records in the UK should have made it easy to reach a large segment of the population. If anything, Canada has fewer family doctors, and fewer doctors who use electronic health records.  The fact that health care in the UK is a national program allowed Health Check to be implemented across the country - something that would be nearly impossible in Canada where health care is a provincial responsibility.

I think it's time for a very different approach.  I would make disease prevention a core academic subject from early childhood to college and university.  I would incentivize evidence-based health literacy and health prevention targets.   For instance, the provinces could charge a levy for those who don't meet health targets and give tax credits to those who do. How about giving people who take tangible steps to reduce their risk of heart disease lower insurance premiums and greater opportunities to gain entrance to post-secondary education programs? 

These ideas might offend those who say it's an individual's choice to pursue a healthy lifestyle or not.  But encouraging them to get healthy does not work.  We have to try something else – or just go on footing an increasingly steep medical bill for carrying on as per usual.



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