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Guidelines for the prevention of cardiovascular disease in Ireland- the way forward 3 November 2010 European 4 th Joint Task Force Guidelines on CVD prevention in Clinical Practice: Targets, implementation and 5 th Joint Task Force Guidelines 2012. Ian Graham - PowerPoint PPT PresentationTRANSCRIPT
Guidelines for the prevention of cardiovascular disease in Ireland-
the way forward3 November 2010
European 4th Joint Task Force Guidelines on CVD prevention in
Clinical Practice: Targets, implementation and 5th Joint Task Force Guidelines 2012
Ian Graham Chairman JTF4, European Prevention Implementation Committee and IHF
Council on CVD Prevention
Objectives of today’s meeting
1. Summarise current and future European CVD prevention Guidelines and implementation strategy (IG)
2. Summarise the role of the National Co-ordinator in the implementation process (SJ)
3. Guidelines in the context of National Policy (H McG)4. The role of primary care (JC)5. The role of the nurse (NF)
6. WORKSHOPS- 6.1 Perceived roles in implementation 6.2 Moving towards an integrated national strategy 6.3 Defining synergies and complementarity6.4 Input into one page Irish Guideline 6.5 Suggestions for the 5th Joint Task Force
Outline
• Objectives of meeting• General background• 4th Joint Task Force European Guidelines
on CVD prevention• 5th Joint Guidelines• Implementation- some principles• European Prevention Implementation
Committee Action Plan• Relations with the National Coordinators
for CVD prevention
General Background
European Prevention implementation is complex- many players are involved
1. The EU- vital but no legislative framework2. Individual Departments of Health- like
their independence3. ESC4. EACPR5. National Cardiac and other specialist and
GP societies6. Nurses and allied health professional,
European and National7. Educators- 1st 2nd & 3rd level8. Industry- Pharma, Food, Exercise, Neutral It’s like herding cats!
No data< 3030-5050-7070-100100-150150-200> 200
Age standardised CHD mortality rates (under 65) in men & women
The European Heart Health Charter and the Guidelines on cardiovascular
disease prevention
• The European Heart Health Charter advocates the development and implementation of comprehensive health strategies, measures and policies at European, national, regional, and local level that promote cardiovascular health and prevent CVD
• The Joint CVD prevention guidelines aim to assist physicians and other health professionals to fulfil their role in this endeavour, particularly with regard to achieving effective preventive measures in day-to-day clinical practice
• They reflect the consensus arising from a multi-disciplinary partnership between the major European professional bodies represented
Implementation of CVD guidelines
1.Knowledge of JTF4 guidelines and what is likely in JTF5
2.The gap between recommendations and clinical practice
3.Barriers to implementation4.Strategies to improve
implementation
ImplementationImplementation
GuidelinesGuidelines
AuditAudit
Guidelines on PreventionGuidelines on Prevention
ResearchResearchSCORE,HeartScoreSCORE,HeartScoreEvidence based reviewsEvidence based reviews
EuroAspireEuroAspireE-SURFE-SURF
PICPICNat. Co-ordNat. Co-ordEuroActionEuroAction
94,98,03,07,1294,98,03,07,12
European Guidelines on CVD Prevention
Fourth Joint European Societies’ Task Force on cardiovascular disease prevention in clinical
practice
Ian M Graham Chairman JTF4
JTF4 on CVD PREVENTION
CONTENTS
1. Introduction2. Scope of the problem;
past and future3. Prevention strategies
and policy issues4. How to evaluate
scientific evidence5. Priorities, total risk
estimation and objectives
6. Behaviour change and behavioural risk factors
7. Smoking8. Nutrition, overweight
and obesity9. Physical activity10. Blood pressure
11. Plasma lipids12. Diabetes and metabolic
syndrome13. Psychosocial factors14. Inflammation markers
and haemostatic factors15. Genetic factors16. New imaging methods
to detect asymptomatic individuals at high risk
17. Gender issues: CVD in women
18. Renal impairment as a risk factor in CVD
19. Cardioprotective drug therapy
20. Implementation strategies
What are the PRIORITIES for CVD prevention in clinical practice?
1. Patients with established atherosclerotic CVD
2. Asymptomatic individuals who are at increased risk of CVD because of
2.1 Multiple risk factors resulting in raised total CVD risk (≥5% SCORE 10-year risk of CVD death)
2.2 Diabetes type 2 and type 1 with microalbuminuria
2.3 Markedly increased single risk factors especially if associated with end-organ damage
3 Close relatives of subjects with premature atherosclerotic CVD or of those at particularly high risk
0 3 5 140 5 3 0People who stay healthy tend to have
certain characteristics:
0 No tobacco
3 Walk 3 km daily, or 30 mins any moderate activity
5 Portions of fruit and vegetables a day
140 Blood pressure less than 140 mm Hg systolic
1305 Total blood cholesterol <5mmol/l 4.5,
43 LDL cholesterol <3 mmol/l 2.5,
20 Avoidance of overweight and diabetes
JTF5 on CVD Prevention• Much shorter and more succinct• More explicit evidence base- ESC grading vs.
GRADE• New approaches to risk estimation- total
events, risk age• Targets similar- 1.8 mmol/l for LDL
cholesterol?• There is time to influence them!• Will be launched at Europrevent Dublin, 3-5
May 2012
How big is the gap between
recommendations and practice?
Has there been an improvement over
time?
BMI
Smoking
Obesity
Diabetes
Use of BP meds
Total Chol
BP control
All countries
Utility of Guidelines
• Guidelines alone are good for the vanity of the authors and bad for rain forests; they are a waste of time without a defined implementation strategy
• Hence the Prevention Implementation Committee and other implementation efforts
“Said is not heard,heard is not understood,understood is not agreed upon,agreed is not applied,applied is not at all maintained.”
Konrad Lorenz, 1903-1969 [Thank you, Ulrich Keil]
Barriers to implementation
Pearson 1996; European Guidelines 4th Joint Task Force 2007
•Patient (Person)•Physician•Health Care Settings•Community/Society
Barriers to implementation REACT study, Hobbs FDR, Erhardt L, Family Practice
2002 ESC CRT Market research survey, Graham I, EJCPR
2006
• Lack of patient compliance• Lack of time• Lack of budget• Lack of clarity (complicated,
confusing, too much information)• Guidelines too general (do not fit
my patient)• Unhelpful government health
policies (assistance, remuneration, patient education)
SUMMARY:Key factors to increase usage of
guidelines
• Simple, clear, credible national guidelines
• Sufficient time• Facilitatory government policy: -Defined prevention strategy -Reimbursement for health professionals -public awareness and education from
school on• Multidisciplinary implementation
strategy- with teeth
CVD Prevention Implementation
An adapted structurefor the future
The EUROPEAN PREVENTION IMPLEMENTATION COMMITTEE
Terms of Reference
• The ESC has delegated the implementation of the European Guidelines on CVD Prevention to the European Association Cardiovascular Prevention and Rehabilitation. Its Cardiovascular Prevention Implementation Committee fulfils that function.
• Its role is to help to close the gap between science and practice for both in hospital and in primary care
PREVENTION IMPLEMENTATION COMMITTEE Membership
Co-Chairs: Ian Graham & Pantaleo Giannuzzi
Members • Prof Pantaleo Gianuzzi, EACPR President• Prof David Wood, EACPR Past-President • Prof Lars Ryden, recent Chair of the ESC European Affairs Committee • Prof Richard Hobbs, Chair Council on Cardiovascular Primary Care• Susanne Logstrup, EHN• Muriel Mioulet, ESC External Affairs Director • Sophie Squarta, ESC Head of Department for CVD Prevention• Sections representatives
Cardiac rehabilitation - Hannah McGeeEpidemiology & Public Health - Johan De SutterExercise Physiology - Martin HallePrevention & Health Policy - Diego VanuzzoSports Cardiology - Dorian DugmoreSducation Committee - Lale Tokgozoglu
Prevention Implementation Committee Action Plan
PREVENTION IMPLEMENTATION COMMITTEE ACTIVITIES
1. Core activities2. Define strategies to assist in
Guideline implementation3. Activities with the National
Co-ordinators for CVD prevention
PIC – Suggested Core activities-
• Benchmarking – H. McGee• Health Economic models – D. Wood & G.
De Backer• Industry projects – M. Halle & D.
Dugmore• Audit – E-SURF- Ian Graham• Implementation research • Political lobbying – L. Rydén• “How to” manual – P. Giannuzzi• Lay communications- Joep Perk
(Apoteket), Lay Score/HeartScore
Strategies to improve implementation
Sophie Squarta, Lars Ryden,Ian Graham
Implementation strategies: European level
1. Publication of Guidelines in relevant journals
2. The Prevention Toolkit, comprising the Guidelines (paper and electronic), a slidekit and HeartScore stand alone
3. A defined dissemination strategy4. Implementation Committees/Groups:
Prevention Implementation Committee; Joint Prevention Committee; National Coordinators
5. Presentations at international conferences of the participating societies
6. Directly influencing EU health policy- for example through the Luxembourg Declaration and the European Health Charter- the product of a partnership between the EU, WHO, ESC and EHN
Implementation strategies: TOOLS
1. Guidelines: full text/ summary/pocket/one page/posters
2. HeartSore: The electronic, interactive risk estimation and guideline tool. On line and stand-alone, downloadable and on CD
3. The new Guideline Learning Tool- on-line interactive case-based learning
4. The e-toolkit: Guidelines, slides, HeartScore
5. E-SURF, the new and simplified risk factor audit
Implementation strategies: National level
1.Adapt the European Guidelines to suit the local culture
2.Formation of a multidisciplinary implementation group: professional bodies, medical and other health professionals, basic scientists, educators, business people, politicians. Needs to be more than merely advisory: should inform and shape health policy
3. Multi-faceted communications using all available media to doctors, medical and para-medical students, and ultimately all adults and children, including schools
Forming a multidisciplinary implementation group
Process-• The ESC asks National Cardiac Societies to
nominate a National Co-ordinator to develop and lead the multidisciplinary implementation group which will develop-
• National adaptation of guidelines if required• Partnerships between politicians, health
professionals, educators and business• A defined communication strategy• An evaluation strategy• BUT it must have teeth. This requires high level
political representation if it is not to be a talking-shop. Indeed…
• This process has been variably successful. It is now proposed that there should be two national co-ordinators- one a cardiologist and one from the Department of Health/ Health Service Executive
Forming a multidisciplinary implementation group
-IRELAND
1. IHF Council on CVD prevention established to facilitate the process
2. (Chair IG)3. National Co-ordinators Siobhan Jennings
and Mahon Varma4. Project manager Bridget Claffrey5. Workplan established including meetings
with all stakeholders and this meeting6. Aim to showcase Ireland as an exemplar
of the development of an implementation strategy
7. Presentation to the ESC European Summit on CVD prevention, Nice 30 Nov 2010
SUMMARY• Objectives of meeting defined• General background• 4th Joint Task Force European Guidelines on
CVD prevention• 5th Joint Guidelines• Implementation- some principles• European Prevention Implementation
Committee Action Plan• Relations with the National Coordinators for
CVD prevention• The strategy for Ireland
Thank you
Relations with the National Coordinators for CVD Prevention
PIC and the National Co-ordinators
• Promotion of joint co-ordinators in each country representing Cardiology and the Department of Health
• Contribute to benchmarking by updating the Mapping document
• Individualised strategic advice to countries• Workshops especially for developing
countries• Contribution and use of the “How to”
manual• Advice to and from the Joint Prevention
Alliance• Possibly to act as national co-ordinators
for the pan- European audit
PIC, JPA and National Co-ordinators- Likely most effective
actions?
1. Driving National alliances2. Simpler Guideline materials3. How-to manual4. Benchmarking and audit5. Lobbying EU policy
Discussion of JPA and PIC
PIC and Joint Prevention Alliance
1. It is suggested to reflect the importance of the JPC by re-naming it the Joint Prevention Alliance
2. The partnership- JTF4/5 members- remains the same
3. The JPA will decide its own workplan:• Encourage Joint Guidelines dissemination
by the partner bodies• Promote and co-ordinate Alliance events
and workshops at specialist conferences• Provide information on networks within
countries to aid in the co-ordination of implementation
• Advise the PIC in all of its activities• Advise on & promote the “how-to” manual• Assist in development of guideline learning
tool• Specific topics for lobbying
PIC – Suggested Core activities- to be prioritised
• Benchmarking – H. McGee– “Call for Action” mapping document– EuroAspire III– Psyma survey report– Powerhouse Health Consumer report– EuroHeart WP5
• Health Economic models – D. Wood & G. De Backer
• Demonstration projects – M. Halle & D. Dugmore
• Audit – Epidemiology & Public Health section• Implementation research • Political lobbying – L. Rydén• “How to” manual – I. Graham & P. Giannuzzi• Lay communications- Joep Perk (Apoteket),
Lay Score/HeartScore
JTF4 Guidelines on CVD Prevention in Clinical
Practice
1. INTRODUCTION
JTF IV Guidelineson prevention of CVD
FORMAT• Full text- far too long!- treat as a
resource document. Summary boxes from the pocket guidelines to make navigation easier
• Summary- still far too long!• Pocket guidelines- better, more
accessible• Single page handout- summarizes
the key points
• The challenge- to keep the key points in the health professional’s mind- and on his/her desk!
JTF4 on CVD Prevention in Clinical Practice
3. PREVENTION STRATEGIES AND POLICY ISSUES
WHO report on the Prevention of CHD (and hence CVD) defined three
components to preventive strategy:
1. Population2. High risk3. Secondary prevention
• The prevention paradox- high risk individuals gain most from preventive measures- but most CVD deaths come from subjects with only mildly increased risk because they are so numerous
• The three strategies should be complementary, not competitive
• Policy is defined further in the Osaka declaration
JTF4 on CVD Prevention in Clinical Practice
5. PRIORITIES, TOTAL RISK
ESTIMATION AND OBJECTIVES
JTF4 on CVD Prevention in Clinical Practice
20. IMPLEMENTATION
STRATEGIES
Report from the EACPR EuroPRevent Congress
EUROASPIRE- Surveys of patients with proven CHD
• EASP I: 1995-1996. 9 countries• EASP II: 1999-2000. 15 countries• EASP III: 2005-2007. 22 countries
• 6 months after first CABG, PCI, or ACS without prior CABG or PCI
• Considerable potential to improve risk factor control:
Implementation- barriers & strategies. Review of current
knowledge• Luxembourg Declaration, Heart Health
Charter, Prevention Summit & consequent Call for Action
• EAS III• US Task Force 8• JTF4• REACT & ESC Surveys• Powerhouse Survey• Mapping document questionnaire to
National Co-ordinators• Heart Health Charter Questionnaire*
*Results awaited
Barriers to implementation
Barriers to implementation-Google Scholar
• “Cardiovascular guidelines; implementation”: 7600 refs
• “Cardiovascular guidelines; barriers to implementation”: 2720 refs
• Very repetitive!• Strategies to improve
implementation tend to be verbose, woolly and based on little evidence
Barriers to the implementation of guidelines
on CVD prevention
• Task force 8. Organization of Preventive Cardiology Service. Pearson TA, McBride PE, Miller NH, Smith S. JACC 1996; 27: 1039-47
• European Guidelines on CVD Prevention in Clinical Practice. Fourth Joint Task Force Eur J of Cardiovascular Prevention and Rehabilitation 2007;14:suppl 2; E1-E40 and S1-S113
Barriers to implementation- 1: PATIENT (PERSON!)
• Social, educational and cultural factors• Consequent lack of knowledge and
motivation• Consequent lack of skills to make a life plan• Time and financial constraints• Unclear, complex advice and polypharmacy• Consequent difficulty in compliance • Unwillingness to ask for help from physician • Lack of access to care
Barriers to implementation- 2: PHYSICIAN
• Acute problem (disease)-based focus• Negative or neutral feedback on
prevention• Time constraints• Lack of incentives, incl.
reimbursement• Lack of training- knowledge & skills• Lack of specialist- generalist
communication• Guidelines - difficult to interpret; too
complex; lack of perceived legitimacy
Barriers to implementation- 3: HEALTH CARE SETTING (hospitals, practices etc)
• Acute care priority• Lack of resources and facilities• Lack of systems for preventive
services• Time and economic constraints• Poor communications between
specialty and primary care providers• Lack of policies and standards
Barriers to implementation4: COMMUNITY/SOCIETY
• Political failure of health planning strategy-
• Educational policy- Schools, universities, hospitals, adult education
• Activity, nutrition and tobacco policy• Apportionment of budget/taxes between
prevention and treatment services- hospitals get votes
• Effective multidisciplinary prevention planning and implementation group
• Morbidity & mortality registers• Risk factor surveys• Physician re-imbursement for prevention
Acceptance of guideline recommendations and
perceived implementation of coronary heart disease
prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment
(REACT) Survey• Hobbs FDR, Erhardt L • Family Practice 2002; 19: 596-604
REACT 2002
• Telephone interviews of 754 randomly selected primary care physicians in F, D, I, S, UK
• Most(89%) agreed with & said that they used guidelines(81%) but only 1/5 believed that they were being implemented
REACT 2002- Barriers to implementation
• Time (38%)• Prescription costs (30%)• Patient compliance (17%)
REACT 2002- Suggestions to improve implementation
• Education for physicians (29%)• Education for patients (25%)• Publicizing or increasing
guideline availability (23%)• Simpler guidelines (17%)• Clearer guidelines (12%)
Factors Impeding the Practical Implementationof Cardiovascular Prevention
An international market research project in 6 countries:Germany, France, Italy, Spain, the United Kingdom and Poland
- PRESENTATION CHARTS -
This study was commissioned byEuropean Society of Cardiology (ESC)
Cardiovascular Round Table (CRT)Task Force 4
Technical staff at Psyma International:Alexander Rummel
Monica BachDr. Britta Meyer-Lutz
Study No: 41057021December 2002
Psyma International MedicalMarketing Research GmbHGartenweg 290607 Rückersdorf/NürnbergGermanyphone: +49-911-95 785-0fax: +49-911-95 785-33e-mail: [email protected]: www.psyma-international.com
ED F I
Factors impeding the implementation of cardiovascular prevention
guidelines: findings from a survey conducted by the European Society
of Cardiology
Graham IM, Stewart M & Hertog M for the Cardiovascular Round Table Task Force .
EJCPR 2006:13; 839-45• Market research survey• In-depth interviews with 66
cardiologists & 154 primary care physicians (N=220)
• 6 focus groups involving 49 physicians
• D,F,I,E,UK,P
Factors impeding implementation
• 25% of physicians didn’t know or couldn’t explain the term “total” or “global” risk
• Guideline usage varied- 20% (Poland and France) to >70% (Spain and UK)
• Usage of risk scoring systems varied widely- 4% in Italy to 43% in UK (Mean 21%)
• National guidelines are preferred to ESC guidelines (45% vs 4%)
• Perceived problems with guidelines- impractical, time consuming, not interesting, “guideline fatigue”
Improvements to increase guideline usage
• Simpler, more user-friendly guidelines with improved content
• Increased patient awareness & education
• Independent research (credible, trustworthy)
• Government initiatives (time, remuneration)
Guidelines for all and their integration into education
• The challenge is to make practical prevention universally accessible. Medical control of this process may have been excessive
• This implies integration of the messages from guidelines into schools curricula as well as into undergraduate and postgraduate education
TARGETS TO DEFINE SUCCESS- for discussion
• Dissemination of guidelines and toolkit in 100% European countries
• National co-ordinators in 90% • Evidence of effective national alliances
with defined plan in 66% • Evidence of agreed guidelines (National
or European) in 80%• Risk estimation systems used in 80% • National risk factor audits in 66%• Evidence of monitoring systems for CVD
mortality and risk factor trends
Background• European Guidelines on CVD
Prevention• European Heart Health Charter• Call for Action• EACPR and JPC Minutes• EACPR strategic plan• Mapping document• Slide kit• HeartScore• Health Professional Toolkit
Joint Prevention Group EACPR Implementation Committee
Prevention Implementation Committee
Implementing new guidelines into clinical
practice
Ian M Graham
Prevention Implementation Committee
1. Summary of JTF4 Guidelines2. Will JTF5 be different? This will impact on our workplan3. The gap between recommendations and clinical practice4. Barriers to implementation5. Strategies to improve implementation6. Review of knowledge, gaps in knowledge and survey
needs7. Critical success factors8. Review of role of National co-ordinators9. Respective responsibilities of JPC and EACPR prevention
implementation committee10.Pan- European activities11.Selected individual country activities12.Workplan and timelines13.Responsibilities of individual partners
4th Joint Task Force on Prevention: MEMBERS
• Dan Atar [ESC]• Knut Borch-Johnson
[EASD/IDF Europe]• Gudrun Boysen [EUSI]• Gunilla Burrell [ISBM]• Renata Cifkova [ESH]• Jean Dallongeville• Guy de Backer [ESC]• Shah Ebrahim [ESC]• Bjorn Gjelsvik
[ESGP/FM/Wonca]• Christoff Hermann-
Lingen [ISBM]• Arno W Hoes
[ESGP/FM/Wonca]
• Steve Humpries [ESC]• Mike Knapton [EHN]• Joep Perk [EACPR]• Sylvia G Priori [ESC]• Kalevi Pyorala [ESC]• Zeljko Reiner [EAS]• Luis Ruilope [ESC]• Susana Sans-Mendes [ESC]• Wilma Scholte Op Reimer
[ESC council on CV Nursing]
• Peter Weissberg [EHN]• David Wood [ESC]• John Yarnell [EACPR]• Jose Luis Zamorano
[ESC/CPG]
4th Joint Guidelines on CVD Prevention
SPECIAL PEOPLE,SPECIAL THANKS
INVITED EXPERTS
Marie-Therese Cooney
Alexandra DudinaTony FitzgeraldEdmond Walma
ESC STAFF
Keith McGregorVeronica DeanCatherine DepresSophie Squarta
Why develop a preventive strategy in clinical practice?
1.Cardiovascular disease (CVD) is the major cause of premature death in Europe. It is an important cause of disability and contributes substantially to the escalating costs of health care
2.The underlying atherosclerosis develops insidiously over many years and is usually advanced by the time that symptoms occur
3.Death from CVD often occurs suddenly and before medical care is available, so that many therapeutic interventions are either inapplicable or palliative
4.The mass occurrence of CVD relates strongly to lifestyles and to modifiable physiological and biochemical factors
5.Risk factor modifications have been shown to reduce CVD mortality and morbidity, particularly in high risk subjects
CVD Prevention: CHALLENGES
• Inactivity• Obesity• Stroke• Heart failure• Gender and social class
inequalities • Renal failure• Implementation
Fig 1The expected number of CVD deaths at increasing levels of
predicted risk. Illustration of the fact that most events occur in low risk subjects with few deaths among high risk subjects.
0
20
40
60
80
CV
D D
eat
hs (
all c
ohor
ts)
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Predicted Risk (Men aged 50-59 )
10 year risk of fatal CVD in high risk regions of Europe
10 year risk of fatal CVD in low risk regions of Europe
Relative Risk ChartThis chart may used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions
about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication
JTF5 – will it be different?
• Chairperson- Prof Joep Perk• Detailed suggestions to simplify the
process available (IG)• Electronic version of JTF4 available• Single format for submissions
essential• SCORE developments• Will rehabilitation be included? logical
(but political…)• ? Make pocket guidelines the summary • Continue to use figures in main text• One page card critical• Tie more closely to interactive
teaching?
Additional knowledge needed?
• Commissioned surveys on what additional information is needed to inform strategy (by EACPR?)
• Modelling exercises on effects of implementation strategy (by EACPR?)
• Inventories of prevention in different countries to allow benchmarking
• Subsequent development of educational materials
Joint Prevention Group EACPR Implementation Committee
Prevention Implementation Committee
The implementation of current CVD prevention
guidelines
Ian M Graham
PIC CORE ACTIVITIES- to be prioritised
1. BENCHMARKING- Inventory of implementation info + development of strategy: H McG
2. AUDIT- Pan European audit: Epidemiology 3. HEALTH ECONOMIC MODELLING: DW, Gde B4. HOW-TO manual: IG, PG5. DEMONSTATION PROJECTS WITH INDUSTRY:
DD, MH6. IMPLENTATION RESEARCH: tbd7. LOBBYING: LR, European Affairs8. LAY COMUNICATIONS: JP (Apoteket);
SCORE-Lay
Give me a doctor partridge plump,short in the leg and broad in the
rump,an endomorph with gentle hands,who’ll never make absurd demandsthat I abandon all my vices,or pull a long face in a crisis,but with a twinkle in his eye, will tell me that I have to die. -W H Auden
Give me a doctor underweight,computerised and up to date.A businessman who understandsaccountancy and target bands.Who demonstrates sincere
devotionto audit and to health promotion-but when my outlook’s for the
worserefers me to the practice nurse -
MariaCampkin
Report from the EACPR EuroPrevent Congress
Stockholm, May 2009