Creating initiatives that enhance primordial and primary prevention strategies on a national level would help prevent cardiovascular disease (CVD) before it begins, according to an American Heart Association (AHA) policy statement published online July 25 in Circulation. While costs have often been a deterrent to implementing these types of programs, AHA said imparting community-based changes is a good long-term investment to improve the population’s health.

The direct costs associated with medical care and CVD are expected to rise to more than $1 trillion a year by 2030. “With primordial and primary prevention, cardiovascular disease is largely preventable,” William S. Weintraub, MD, and colleagues from the AHA advocacy coordinating committee wrote. "The data are less definitive but also highly suggestive that appropriate public policy and lifestyle interventions aimed at eliminating tobacco use, limiting salt consumption, encouraging physical exercise and improving diet can prevent events.

“Disturbing trends for chronic disease and conditions like obesity and diabetes mellitus are emerging in which the incidence rates not only are increasing but also are affecting people at an earlier age,” the authors wrote. “These trends highlight the important need for primordial and primary prevention across the lifespan.” For example, deploying smoking cessation programs that are targeted at pregnant women can help improve the health of the mother and also influence the health of the growing fetus.

However, a major barrier to implementing these types of prevention strategies is cost, Weintraub, chief of cardiology at the Christiana Care Health System and director of the Christiana Center for Outcomes Research (CCOR) in Wilmington, Del., told Cardiovascular Business.

Weintraub and colleagues offered that cost-effectiveness analyses can be flawed and that the long time frames involved in evaluating preventive interventions make them difficult to carry out. Additionally, the majority of cost-effectiveness analyses are mathematical models or simulations, according to the authors.

“We know that prevention works,” Weintraub said. “There are lots of clinical trial data suggesting that we can prevent most cardiovascular disease and there are estimates of the 50 percent or so decline in cardiovascular mortality that we have seen over the last 45 years and some two-thirds of that is related to primary or secondary prevention.

“We are interested in primary prevention rather than secondary prevention,” Weintraub said. “We need to focus on patients prior to an event and attempt to prevent cardiovascular risk factors from occurring.”

Each year, chronic disease costs U.S. employers $225.8 billion, or $1,685 per employee, with 71 percent of those costs due to reduced performance at work.

Environmental and policy changes can help to better an individual’s behavior by influencing physical, social and cultural environments to promote a healthier lifestyle. Passing clean indoor air laws, raising tax on tobacco or reducing sodium in foods are some changes that can impact the population and better cardiovascular health. “These population-based strategies are a critical complement to preventive services and treatment programs in which practitioners and patients are working together to foster important individual behavior and lifestyle changes,” the authors wrote.

To deploy some of the strategies above, multiple sectors—communities, work sites, healthcare systems and schools, among others—must work together and understand how environment and policy changes can help prevent CVD and better the CV health of the population. For example, implementing workplace wellness programs can improve employee health and on the community level, creating walking or biking trails can encourage exercise.

Worksite wellness programs would decrease medical costs by $3.27 for every dollar spent on workplace wellness within the first 12 to 18 months, according to the statement.

“A lot of these types of programs will actually save money,” Weintraub said. “Programs working with the state to create financial incentives to get people to not smoke would save money and building walking trails would encourage exercise.”

While Weintraub said the ultimate dollar figure of implementing the aforementioned programs is uncertain, he said that most would save money in the long run.

Examples of programs that could be implemented are listed below:

• School-based initiatives to promote healthy eating and physical activity: These types of programs would equate to $900 to $4,305 per quality adjusted life years (QALYs) saved;
• Building bike and pedestrian trails: For every $1 invested in building these trails, nearly $3 in medical costs would be saved;
• Reducing sodium in the food supply: Reducing population sodium intakes to 1,500 mg/day would result in a $26.2 billion in healthcare savings annually;
• Excise taxes on tobacco: A 40 percent tax-induced cigarette price increase would reduce smoking prevalence to 15.2 percent by 2025 with large gains in cumulative life years (7 million) and QALYs (13 million) and would result in a total cost savings of $682 billion;
• Diabetes screening: Targeted screening for type 2 diabetes based on age and risk was cost-effective. Targeted screening for undiagnosed type 2 diabetes in African Americans between ages 45 and 54 was found to be most cost-effective with an incremental cost-effectiveness ratio of $19,600 per QALY gained relative to no screening; and
• Lifestyle changes in diabetes prevention: Lifestyle changes reduced the incidence of diabetes by 58 percent. In comparison, metformin therapy reduced risk by 31 percent.