Go for targeted screening
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2866 (Published 28 May 2010) Cite this as: BMJ 2010;340:c2866
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Dear Editor,
Akosah et al (1) presented the cardiovascular risk stratification for
202 patients with acute myocardial infarction (men <55 years old;
women <65 years old): 12% high risk, 18% intermediate risk and 70% low
risk. Approximately 75% of those patients with myocardial infarction if
risk stratified before the event would not have qualified for treatment
with statins. In addition, Ford et al (2) in their study concluded that
most cardiovascular events occur in misclassified people and in men with
average risk score.
In conclusion, cardiovascular risk stratification in patients at
intermediate risk of developing cardiovascular diseases should not only be
based on the results of cardiovascular risk charts, but on the combined
used of carotid ultrasound in patients <50 years old, and coronary
calcium scoring in patients > 50 years old. Both carotid ultrasound and
calcium scoring would help to re-classify patients at intermediate risk in
high or low risk groups. Statin therapy in reclassified patients at high
risk would significantly reduce CVD morbidity and mortality.
1. Akosah et al. J Am Coll Cardiol 2003; May 7: 41 (9): 1475-79
2. Ford es et al. J Am Coll Cardiol 2004; 43: 1791-96
Competing interests:
None declared
Competing interests: No competing interests
Really shocking
Whilst I might agree that targeting risk will be more cost-effective
( depending on many factors, most especially the specificity and
sensitivity of the screening test ), I was shocked that Burden would , in
the 'Heart of Birmingham', add to the burdens of the deserving , but
poorly-served !
"Therefore, a combined targeted strategy based on these findings
would screen only patients registered with practices able to provide
assured high quality care and men over 50"
This may well be more cost effective. And cheaper - only 10 864 of
the 48 774 unassessed people would need screening, Burden states. But
only because those patients NOT registered in high-quality practices are
further excluded from the care they presumably need.
Who measures 'practice quality' ? A very great deal of research has
shown that 'quality ' is fairly easy to achieve in leafy surburbs and
Shire England.. but much tougher in the most needy areas. Why don't we
just exclude the poor and needy from the Health Service altogether, like
say, the USA ??
Burden adds immorally and unnecessarily to the Inverse-Care Law (1)
Reference:
Lancet. 1971 Feb 27;1(7696):405-12. The inverse care law. Hart JT.
http://www.sochealth.co.uk/history/inversecare.htm
Competing interests:
I am a GP, and think I practice high quality
Competing interests: No competing interests