Primary Care Strength Linked to Prevention Programs for Cardiovascular Disease

April 2, 2009
Jan van Lieshout, MD

,
Michel Wensing, PhD

,
Stephen M. Campbell, PhD

,
Richard Grol, PhD

Volume 15, Issue 4

An observational study of 42 successful programs to improve primary care management of cardiovascular risk showed the impact of a strong primary care system.

Objective:

Primary care plays a central role in the prevention and management of cardiovascular disease. We expected that countries with strong primary care systems would have programs to improve management of disease, but wondered how they dealt with lifestyle interventions delivered in primary care.

Study Design:

Observational comparative study.

Methods:

Using country coordinators and key informants, we collected information on 42 programs to improve cardiovascular risk management in 11 countries (Austria, Belgium, Finland, France, Germany, Israel, the Netherlands, Spain, Slovenia, Switzerland, the United Kingdom).

Results:

Most (95%) of the improvement programs were targeted at health professionals; 86% of these provided education. Evaluation was part of all programs. In countries with a strong primary care system, 63% of the programs focused exclusively on disease management, 29% on lifestyle interventions, and 8% on both. In countries with a weak primary care system, 22% of the programs focused on disease management and 78% on lifestyle improvement.

Conclusions:

Our findings suggest that a strong primary care system is likely to make efforts to improve disease management, but not necessarily efforts to improve delivery of lifestyle interventions. This may be a missed opportunity, given the potential of primary care to influence lifestyle.

(Am J Manag Care. 2009;15(4):255-262)

Primary care plays a central role in prevention and management of cardiovascular diseases. We describe an observational comparative study of 42 successful programs to improve primary care management of cardiovascular risk in 11 countries and analyzed program features in relation to whether the primary care systems were weak or strong. This study showed that:

  • A weak primary care system may need strengthening to implement disease management programs.
  • A strong primary care system seems beneficial for disease management programs but not for lifestyle improvement programs.
  • Policy makers should consider how to create conditions for delivering preventive lifestyle services in a strong primary care system.

A growing body of evidence on prevention and treatment of cardiovascular disease (CVD) has resulted in large numbers of recommendations for cardiovascular risk management (eg, guidelines developed by the American Heart Association and the European Society of Cardiology). Despite these recommendations, CVD remains an important cause of mortality and morbidity in industrialized countries.1 The risk factors for CVD are the same all over the world.2 The age-standardized CVD mortality rate per 100,000 population in the United States is 188.3 In Europe the mortality rate is 354 per 100,000 population, with marked differences between countries. In Eastern European countries rates are higher (eg, 688 in the Russian Federation), whereas rates in Western European countries are comparable to those in the United States (eg, United Kingdom, 182; Germany, 211; and France with a very low mortality rate of 118). Mortality rates remain high partly because of unfavorable lifestyles and partly because not all patients receive effective and recommended treatment.4-11

see

Boxed List 1

All developed countries have large-scale programs to improve prevention and management of CVD, but the content and focus of these programs vary substantially. For instance, some programs focus on improving the management of chronic care for patients with established CVD, including lifestyle change and pharmaceutical treatment. These programs generally are called disease management programs. Other programs focus on lifestyle improvement for patients or the public in general, irrespective of the presence of CVD or risk factors as hypertension. Primary care plays a crucial role in both the prevention and management of CVD. Primary care presents opportunities for disease prevention and health promotion as well as early detection of problems; it is a bridge between personal healthcare and patients’ families and communities.12 However, different countries’ healthcare systems vary with respect to the strength and integration of their primary care systems.13 In some systems (eg, the United Kingdom, the Netherlands), a primary care physician is the first point of contact for health problems for patients who register with a practice, and this physician coordinates access to other care providers through gate keeping. Conversely, in other systems (eg, Germany, the United States) the primary care physician is not a gatekeeper and patients are not listed in a practice ().

Previous studies on quality improvement of CVD management did not consider the organization and strength of primary care.14-19 However, evidence on chronic care management suggests that healthcare systems with a strong primary care orientation provide more comprehensive chronic care services than systems with a weaker primary care orientation.20 Moreover, high-income countries with stronger primary care systems generally achieve better health outcomes.21 Although the “primary care-ness” model of Starfield et al looks at associations between primary care-ness and outcomes, it does not take into account wider health outcome determinants (eg, quality of services), nor does it attribute better outcomes to specific elements of the system rather than the system as a whole.22

Though primary care focuses on patients (in contrast to disease-focused secondary care), health system features in countries with a strong primary care orientation especially favor efforts to improve disease management. So we hypothesized that in these countries, efforts to improve cardiovascular care would predominantly focus on disease management, aligned to activities already being done. In addition, we wondered what efforts were being made to improve lifestyle interventions for patients without CVD in countries with either a strong or a weak primary care orientation.

This article describes and compares large-scale programs to improve cardiovascular risk management in primary care in 11 countries across Europe and Israel. The Characteristics of healthcare systems with a strong or weak primary care orientation are shown in Boxed List 1. Such differences across Europe and the United States provide an opportunity to learn from the experiences of different countries.

Our intention was to identify commonly shared features of successful programs for improving cardiovascular risk management and prevention, and to assess differences in these programs’ content and focus. In addition, we considered whether the focus of these programs was related to the strength of primary care.

METHODS

Design and Sample

The EPA-Cardiovascular project was conducted as part of the TOPAS-EUROPE Association, founded in January 2005, in collaboration with and funded by the Bertelsmann Foundation.23,24 The aim of this international project is to help improve cardiovascular risk management and prevention in primary care, for instance, by identifying successful programs to improve CVD prevention and management in the participating countries. These countries were Austria, Belgium, Finland, France, Germany, Israel, the Netherlands, Slovenia, Spain (especially Catalonia), Switzerland, and the United Kingdom.

This is a descriptive observational study of existing programs. We asked project partners from each participating country to identify and describe all large-scale cardiovascular risk management improvement programs in their country with the help of national key persons from different disciplines (health policy, research, and primary care) who had expertise on improvement programs. Each country’s representative also was asked to provide information on additional regional or local projects. A maximum of 5 programs per country were included. As the goal was to learn from best practice, all programs had to have a positive evaluation, at least by preliminary results.

Measures

Boxed List 2

The project partners used a standardized form to provide information on program features (). A preliminary report with program information was discussed with

all country coordinators and adapted where needed. They checked and approved the final results regarding completeness and accuracy.

We dichotomized the countries into those with a strong or weak primary care system. We used the classification published by Macinko et al for the countries analyzed in this article.22 For the other countries we used information on the organization of care in general practice that was relevant for delivery of preventive services. The countries were scored on 4 items (patients on practice list, physician-led patient recall allowed, systematic monitoring of risk factors, primary care involved in preventive activities) and judged strong scoring to be 3-4 and weak scoring to be 0-2. Country coordinators provided the necessary information.

Data Analysis

Boxed List 2. W

Two researchers (JvL, MW) independently assessed the program features shown inhen there was disagreement, consensus was reached by discussion after repeated inspection of the program descriptions. Researchers were not blinded to the program name or country because of knowledge of many of the programs.

Programs incorporating both disease management and lifestyle improvement were classified as either lifestyle improvement or disease management when a clear major focus was apparent. When both aspects were of great importance, this feature was scored as “both lifestyle interventions and disease management.”

Data analysis was descriptive, as the low numbers did not allow for statistical analysis. Features shared by more than 80% of the programs were considered to be commonly shared. The comparative analysis focused on the strength of primary care (weak vs strong). We used SPSS 14 (SPSS Inc, Chicago, IL) for cross-tabulation to identify potential associations between program features and strength of primary care, considering that a 20% difference indicated potential relevance.

RESULTS

eAppendix Table

A total of 47 programs from 11 countries were identified. We included 42 programs; they are listed in the (available at www.ajmc.com). Excluded programs were small scale or missed an intervention. Countries with a strong primary care focus were Finland, Israel, the Netherlands, Slovenia, Spain, and the United Kingdom. Countries with a weak primary care focus were Austria, Belgium, France, Germany, and Switzerland.

Table

The provides descriptive program information. Features shared by the programs included interventions targeted at professionals (95%), interventions aimed at education and motivation (86%), and inclusion of an evaluation (100%). A small majority of projects (62%) were targeted at the public and patients as well as at healthcare professionals.

Strength of Primary Care

Differences between programs in countries with a strong versus a weak position of primary care are shown in the Table also. Most programs (63%) in countries with a strong focus on disease management were exclusively focused on improving the management of CVD or risk. Additionally, another 2 programs had a disease management character that also had a clear goal of preventing the target disease (diabetes, coronary heart disease); this goal was being pursued through implementation of lifestyle improvement for the general public.

In contrast, in countries with a weak primary care system most programs (78%) were focused on lifestyle interventions. Of the 4 disease management programs in countries with weak primary care orientations, 3 were diabetes programs.

In countries with a strong primary care system, the 7 improvement programs with an exclusive focus on lifestyle were all more or less initiated by public health organizations outside primary care practices. In countries with a weak primary care system, however, 8 of the 14 programs on lifestyle improvement were oriented to general practice, whereas only 6 programs were initiated by public health organizations.

An example of a program that focuses on lifestyle improvement in a country with a weak primary care system is the Checkup 35—Health Examination (Gesundheitsuntersuchung) in Germany (see Boxed Example 1). Boxed Example 2 presents the primary care disease management aspects of the National Service Framework on Coronary Heart Disease as an example of a program run in the United Kingdom, which has a strong position on primary care. Lifestyle improvement also is a focus in this program, including primary preventive activities for the public. Disease management aspects in primary and secondary care were important in the first years of the program and have been evaluated positively.

Compared with programs in countries that have a weak primary care system, programs in countries that have a strong primary care system were more frequently focused on CVD exclusively (71% vs 44%) and were more likely to be nationwide (54% vs 28%). In countries with a weak primary care system, programs were targeted at the community more often (78% vs 58%). There were no differences between programs in financial incentives, regulations, professional involvement, guidance, and aim at organizational changes.

DISCUSSION

In countries with stronger primary care—orientated systems, successful improvement programs were focused more frequently on patients with established CVD, while in the other countries most programs focused on improving the delivery of lifestyle interventions to the general population. Stronger primary care was associated with initiatives designed to improve disease management, but less with the improvement of lifestyle interventions irrespective of CVD or risk factors. Cardiovascular prevention ideally consists of both lifestyle improvement and disease management. Considering the importance of primary care in CVD prevention, countries with a strong primary care system should make extra effort to implement lifestyle improvement programs. In healthcare systems with a weak primary care orientation (Germany, France, and the United States for most patients), primary care should be strengthened to provide greater opportunities for disease management improvement programs. Of course, the relationship between the organization of the healthcare system and cardiovascular mortality is complex. Strength of primary care is just one factor, which is shown by the low cardiovascular mortality rate in France, which has a weak primary care system.

The included programs all are targeted at professionals, emphasize an educational/motivational approach, and have a formal process of evaluation integrated in the program. We included only successful programs and therefore cannot determine whether these features also can be components of unsuccessful programs. Successful programs do generally have these features. Only a few programs included financial incentives or regulations, without distinction between the countries with strong or weak primary care systems. Therefore, we cannot conclude from our findings that financial incentives are important facilitators in improvement programs.

Strengths and Limitations

To dichotomize countries according to their primary care focus, we used published classification results from Macinko et al.22 For countries not in that analysis (Austria, Israel, and Slovenia), we used information from our country coordinators. These criteria applied to the countries in the article by Macinko et al gave the same classification, indicating appropriateness.

The international sample of programs to improve cardiovascular risk management brought together in this study is unique. We used systematic methods to guarantee data integrity (eg, inclusion of several informants per country with repeated checking of their information). Analysis was not blinded because of familiarity with many of the programs,

but 2 authors assessed features independently. Nevertheless, the study may suffer from inclusion bias and incompleteness. We purposefully sampled successful programs, although actual outcome data were not always available or mixed. Lifestyle improvement programs may especially suffer from this bias, as it may be harder to find positive evaluations. But disease management programs with positive evaluations did not prevent lifestyle programs from being included, as most countries did not supply information on the maximum of 5 programs.

Another type of selection bias in our sample was that all included countries have relatively low cardiovascular mortality, below the European average. In consequence, the findings may not generalize to areas or patient groups with a higher mortality rate. However, the countries included and the United States have mortality rates in the same range.

There is no bias associated with country size: both the strong and weak primary care groups contain large and small countries. Furthermore, both groups contain about even numbers of countries and programs.

Interpretation

What can be learned by national health policy makers? Previous research showed that strong primary care is associated with better chronic care management. 20 Our findings regarding CVD management are consistent with this trend. There are several potential explanations for the lower frequency of programs to improve lifestyle interventions in countries with strong primary care systems. Primary care physicians may feel that lifestyle improvement in healthy individuals is not their responsibility or priority, that it is not effective or cost-effective, or that it is unfeasible as large population groups need to be addressed.25 Disease management may be perceived as more relevant, evidence based, and aligned to priorities. These priorities may relate to the workload within primary care associated with registered patients and to the society burden of established disease. Disease management also may relate to the definition and values of primary care and to how well primary care is integrated within the wider healthcare system. For example, countries with a strong primary care orientation may simultaneously have a strong public health system.

We found that all lifestyle improvement programs in countries with a strong primary care system were launched by public health organizations outside primary care. This fits both with the explanation that primary care is taking care of disease management instead of lifestyle improvement and with the explanation that public health is strongly organized. The implication, paradoxically, is that the full potential of primary care for delivering preventive services is not used in strong primary care systems. This is a missed chance, especially considering trends toward larger practices and more supportive staff in several countries, because these developments increase the ability of primary care to deliver the full spectrum of cardiovascular preventive services and by doing so, to deliver coherent, continuous care. Supported adequately, primary care could deliver lifestyle advice to healthy patients; the advantage over public health interventions would be that these interventions would be tailor-made to individuals, because of familiarity with listed patients.

In countries with a weaker primary care system, implementation of disease management programs requires extra efforts to enhance the delivery of preventive services. Interesting disease management initiatives are being undertaken in Germany and France, with regulations that reinforce the role of the family practitioner in delivering preventive services. In several US programs for improving disease management in primary care, baseline data collection showed marked room for improvement.26-28 There is little information on large programs in primary care that have been evaluated as successful, although small programs show clear results.29 The American Heart Association and the American Stroke Association have a “Get With the Guidelines” program on implementation, but this is based on hospital care.30

What can be learned by program developers? We analyzed the content and focus of improvement programs in 10 European countries and Israel. Because the sample included countries from all over Europe, except Eastern Europe, trends were robust for variations across health systems and cultures. However, the effectiveness of a specific improvement program may not be generalizable to other countries. Implementing a successful program in another country needs a systematic approach, taking the national context into consideration.31 Assessing generalizability to another country needs groups of experts focusing on the professionals, the target population, and the healthcare system. When an intervention is considered effective, the next step is to examine whether the intervention can be implemented, again considering professionals, population, and system. This is acknowledged in both European and US guidelines. In the European guidelines on CVD prevention in clinical practice, only general remarks are made on implementation; national colleges are expected to organize implementation in accordance with local needs.32 The American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation defined core elements of implementation programs.33 It is considered essential to the success of any program that each intervention is performed in concert with the patient’s primary care provider and/or cardiologist, who will supervise and refine interventions. Interventions are adapted and tailored at the patient level, not at the level of the implementation program. The American Heart Association Guide for Improving Cardiovascular Health at the Community Level presents recommendations to achieve their goals.34 The guide provides assistance with cardiovascular prevention on a community level without making recommendations regarding implementation. The American Heart Association Guidelines for Primary Prevention of Cardiovascular Disease and Stroke also make general remarks about implementation for individual patients.35 These guidelines state that implementation needs acceptance and a physician-patient partnership. They provide tools for risk assessment and communication, and for general information.

Optimal prevention and treatment programs require knowledge about both CVD and successful implementation.36 To reduce the burden of CVD, both lifestyle improvement in the general public and disease management improvement for patients with established CVD are mandated. A balanced approach is needed to create comprehensive programs across the risk spectrum.37

CONCLUSIONS

We found that in countries with weaker primary care systems successful cardiovascular preventive programs are more often lifestyle oriented rather than focused on patients with established disease. As such, the infrastructure and culture for successful disease management programs may be missing. The key message may be that before the start of a disease management program, the position of primary care should be strengthened. Several countries with weak primary care systems have been making interesting strides in this direction.

A strong primary healthcare system seems beneficial for improving chronic care management of patients with established CVD but, paradoxically, not for deliverance of lifestyle interventions to the wider population. Such a system (Boxed List 1) offers opportunities for the delivery of lifestyle counseling to relevant target groups. Nevertheless, lifestyle improvement programs are underrepresented, even though research evidence suggests they have a high impact on mortality and morbidity in the population.38-40 Developments in primary care organization (increasing practice size, involvement of supportive staff) increase the feasibility of delivering large-scale lifestyle interventions. Policy makers should consider how to create the necessary conditions for these interventions to happen.

Our survey sample was restricted to improvement programs for CVD. Further research might address the relation between the strength of primary care and implementation programs concerning other conditions such as chronic obstructive pulmonary disease, osteoarthritis, and malignancies.

Author Affiliations: From the Centre for Quality of Care Research (JvL, MW, RG), Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands; and the Division of Community Based Medicine (SMC), University of Manchester, Manchester, United Kingdom.

Funding Source: The study was funded by the Bertelsmann Foundation (http://www.bertelsmann-stiftung.de/cps/rde/xchg/bst/hs.xsl/prj_8519.htm), which had no involvement in the study design or collection, analyses, or interpretation of data.

Author Disclosure: The authors (JvL, MW, SMC, RG) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JvL, MW, SMC, RG); acquisition of data (JvL, SMC); analysis and interpretation of data (JvL, MW, SMC, RG); drafting of the manuscript (JvL, SMC, RG); critical revision of the manuscript for important intellectual content (MW); provision of study materials or patients (SMC); and supervision (MW).

Address correspondence to: Jan van Lieshout, Centre for Quality of Care Research, Radboud University Nijmegen Medical Centre, PO Box 9101, 114 IQ Healthcare, 6500 HB Nijmegen, Netherlands. E-mail: j.vanlieshout@iq.umcn.nl.

1. Petersen S, Peto V, Rayner M, Leal J, Luengo-Fernandez R, Gray A. European Cardiovascular Disease Statistics. 2005 edition. http://www.ehnheart.org/files/statistics%202005-092711A.pdf. Accessed May 14, 2008.

2. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-952.

3. World Health Organization. Health status: mortality. http://www.who.int/whosis/whostat2007_1mortality.pdf. Accessed May 14, 2008.

4. Anderson RE, Brismar K, Ivert T. Only a minority of patients referred for elective coronary artery bypass surgery have risk factors diagnosed and treated according to established guidelines. Diab Vasc Dis Res. 2007;4(2):112-116.

5. Bailey TC, Noirot LA, Blickensderfer A, et al. An intervention to improve secondary prevention of coronary heart disease. Arch Intern Med. 2007;167(6):586-590.

6. Smith EE, Abdullah AR, Amirfarzan H, Schwamm LH. Serum lipid profile on admission for ischemic stroke: failure to meet National Cholesterol Education Program Adult Treatment Panel (NCEP-ATPIII) guidelines. Neurology. 2007;68(9):660-665.

7. Carlhed R, Bojestig M, Wallentin L, et al. Improved adherence to Swedish national guidelines for acute myocardial infarction: the Quality Improvement in Coronary Care (QUICC) study. Am Heart J. 2006;152(6):1175-1181.

8. Scholte op Reimer WJ, Dippel DW, Franke CL, et al. Quality of hospital and outpatient care after stroke or transient ischemic attack: insights from a stroke survey in the Netherlands. Stroke. 2006;37(7):1844-1849.

9. Tanne D, Goldbourt U, Koton S, et al. A national survey of acute cerebrovascular disease in Israel: burden, management, outcome and adherence to guidelines. Isr Med Assoc J. 2006;8(1):3-7.

10. Drechsler K, Dietz R, Klein H, et al. Euro heart failure survey. Medical treatment not in line with current guidelines. Z Kardiol. 2005;94(8):510-515.

11. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645.

12. Donaldson MS, Yordy C, Vanselow N, eds; for the Committee on the Future of Primary Care, Division of Health Care Services. Defining Primary Care: An Interim Report. Washington, DC: National Academy Press; 1994:15-33.

13. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38(33):831-865.

14. Sellers DE, Crawford SL, Bullock K, McKinlay JB. Understanding the variability in the effectiveness of community heart health programs: a meta-analysis. Soc Sci Med. 1997;44(9):1325-1339.

15. Parker DR, Assaf AR. Community interventions for cardiovascular disease. Prim Care. 2005;32(4):865-881.

16. Matson-Koffman DM, Brownstein JN, Neiner JA, Greaney ML. A site-specific literature review of policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: what works? Am J Health Prom. 2005;19(3):167-193.

17. Sowden A, Arblaster L, Stead L. Community interventions for preventing smoking in young people. Cochrane Database Syst Rev. 2003;(1):CD001291.

18. EUROASPIRE I and II Group. EuroAction. http://www.escardio.org/Policy/prevention/initiatives/Pages/EuroAction.aspx. Accessed May

14, 2008.

19. Trichopoulou A, Orfanos P, Norat T, et al. Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. BMJ. 2005;330(7498):991.

20. Schmittdiel JA, Shortell SM, Rundall TG, Bodenheimer T, Selby JV. Effect of primary health care orientation on chronic care management. Ann Fam Med. 2006;4(2):117-123.

21. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.

22. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38(3):831-865.

23. Anonymous. www.topaseurope.eu. Accessed March 26, 2009.

24. Volbracht E. Prevention and risk management in primary care. http://www.bertelsmann-stiftung.de/cps/rde/xchg/SID-0A000F14-5E34EB08/bst_engl/hs.xsl/prj_16458_16464.htm. Accessed May 14, 2008.

25. Marshall T, Rouse A. Resource implications and health benefits of primary prevention strategies for cardiovascular diseases in people aged 30 to 74: mathematical modelling study [published correction appears in BMJ. 2002;325(7357):197]. BMJ. 2002;325(7357):197-203.

26. Giese M, Lackland D, Basile J, Egan B. 2003 update on the Hypertension Initiative of South Carolina. Bringing South Carolina from “worst to first” in cardiovascular health. J S C Med Assoc. 2003;99(6):157-161.

27. Goff DC Jr, Gu L, Cantley LK, Parker DG, Cohen SJ. Enhancing the quality of care for patients with coronary heart disease: the design and baseline results of the hastening the effective application of research through technology (HEART) trial. Am J Manag Care. 2002;8(12):1069-1078.

28. Maue SK, Jackson JH 4th, Weiss BA, Rivo ML, Jhaveri V, Lennert B. The hypertension management program: identifying opportunities for improvement. J Clin Hypertens (Greenwich). 2003;5(3 suppl 2):33-40.

29. Litaker D, Mion L, Planavsky L, Kippes C, Mehta N, Frolkis J. Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care. J Interprof Care. 2003;17(3):223-237.

30. American Heart Association. Get With the Guidelines. http://www.americanheart.org/presenter.jhtml?identifier=1165. Accessed May 14, 2008.

31. Cuijpers P, De Graaf I, Bohlmeijer E. Adapting and disseminating effective public health interventions in another country: towards a systematic approach. Eur J Public Health. 2005;15(2):166-169.

32. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease (constituted by representatives of nine societies and by invited experts). European guidelines on cardiovascular disease prevention in clinical practice: full text. Eur J Cardiovasc Prev Rehabil. 2007;14(suppl 2):S1-113.

33. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115(20):2675-2682.

34. Pearson TA, Bazzarre TL, Daniels SR, et al. American Heart Association guide for improving cardiovascular health at the community level: a statement for public health practitioners, healthcare providers, and health policy makers from the American Heart Association Expert Panel on Population and Prevention Science. Circulation. 2003;107(4):645-651.

35. Pearson TA, Blair SN, Daniels SR, et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation. 2002;106(3):388-391.

36. Gaziano TA. Reducing the growing burden of cardiovascular disease in the developing world. Health Aff (Millwood). 2007;26(1):13-24.

37. Pearson TA. The prevention of cardiovascular disease: have we really made progress? A balance of community and medical approaches holds the most promise for preventing CVD. Health Aff (Millwood). 2007;26(1):49-60.

38. Gemmell I, Heller RF, Payne K, Edwards R, Roland M, Durrington P. Potential population impact of the UK government strategy for reducing the burden of coronary heart disease in England: comparing primary and secondary prevention strategies. Qual Saf Health Care. 2006;15(5):339-343.

39. Unal B, Critchley A, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention. BMJ. 2005;331(7517):614-619.

40. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease 1980-2000. N Engl J Med. 2007;356(23):2388-2398.