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Targeting high-risk ‘more cost effective’ than universal CVD screening

BMJ 2010; Advance online publication

Using electronic patient records to select high-risk individuals to be screened for cardiovascular disease (CVD) would be just as effective but cheaper to run than the UK government’s current plan to invite all untreated adults aged 40–74 years for screening, suggests a study published in the British Medical Journal.

Under the Department of Health’s national vascular screening program, all adults aged between 40 and 74 years free of diagnosed CVD, diabetes, and hypertension would be invited to their surgery for CVD risk assessment and follow-up if necessary. It is estimated the approach has the potential to prevent 9500 myocardial infarctions and strokes each year, at an annual cost of £250 million.

To estimate the relative population impact of this and alternative approaches, Simon Griffin (MRC Epidemiology Unit, Addenbrooke’s Hospital, Cambridge, UK) and colleagues studied data for around 17,000 participants in the EPIC (European Prospective Investigation of Cancer)-Norfolk study, who were free from CVD and diabetes at the start of the study.

The researchers applied seven different screening strategies to the data that would involve inviting for screening all: 40–74-year-olds; 50–74-year-olds; overweight individuals; those at high risk based on the self-report Finnish diabetes risk score questionnaire; and those in the top 20%, 40%, or 60% of the risk distribution according to the Cambridge diabetes risk score, as identified by their electronic records.

There were 1362 CVD events during 183,586 person-years of follow-up in the study.
Analysis indicated that, based on the UK population in mid-2007, 26,789 new CV events could be prevented each year if all the adults aged 40–74 years were invited for a vascular risk assessment, while 25,134 new cases would be prevented if only the 60% who were at high risk according to the Cambridge risk score were invited.

A similar number of events - 25,016 - could also be prevented by only inviting those aged 50–74 years to be screened.

Using the Finnish diabetes risk score questionnaire or overweight cut-off points for risk prestratification was less effective than the other strategies, however.

"A universal screening program for CVD might prevent an important number of new CV events in a population, but it may be unrealistic to implement in increasingly resource constrained health systems," write Griffin and co-authors.

"Policy makers have to decide on the balance between the number of people needed to screen or treat and the number of cases that can be prevented in the population."

In an accompanying editorial, Tom Marshall (University of Birmingham, UK) agreed with the authors, noting that the study may have overestimated the number of people treated under a universal strategy, which is unlikely to be fully implemented.

Simple ideas can be big ideas, according to Marshall, and when compared with universal screening in the UK, targeted case finding for cardiovascular prevention is the obvious and sensible choice.

Read the abstract

MedWire ( is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2010