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Screening for cardiovascular risk: public health imperative or matter for individual informed choice?http://bmj.com/cgi/content/full/325/7355/78
Primary careScreening for cardiovascular risk: public health imperative or matter for individual informed choice?Theresa M Marteau a Psychology and Genetics Research Group, King's College London, London SE1 9RT, b GP and Primary Care Research Unit, University of Cambridge, Institute of Public Health, Cambridge CB2 2SR Correspondence to: T M Marteau theresa.marteau@kcl.ac.uk The National Screening Committee has recommended a paradigm of informed choice for participants in all screening programmes. Theresa Marteau and Ann Louise Kinmonth examine the potential consequences of applying such a policy to screening for risk of coronary heart disease in primary care Current recommendations for the primary prevention of coronary heart disease
in groups at high risk depend on screening through primary care and
provision of risk related advice or treatment.1
Criticisms of these recommendations highlight the lack of evidence
for the cost effectiveness of multiple risk factor interventions
delivered through primary care. 2
3 We propose that this lack of
effectiveness may, in part, reflect how people are invited for
screening. The public health approach most often used focuses on
maximising participation in screening rather than on informed
participation. We consider here the implications of offering primary
preventive services for cardiovascular disease within a framework of
informed choice.
We searched Medline and PsycINFO databases for systematic literature reviews
relating to informed choice and screening, both in general and in
relation to cardiovascular disease. We also drew on personal
literature collections, stemming from joint long term interests in
risk perception and screening for cardiovascular and other
risks.
A screening procedure is one that is applied to a population to select people at risk of an unfavourable health outcome for further investigation, monitoring, or advice and treatment. A traditional public health approach to screening regards the population benefits of reduced morbidity and mortality as inherent, not to be appraised by individuals before they decide whether or not to participate. In keeping with this, the information accompanying the invitation tends to be brief, emphasising the general health benefits of participation. A policy shift is occurring in the United Kingdom and elsewhere towards informed choice, as laid out by the National Screening Committee: "There is a responsibility to ensure that those who accept an invitation (to screening) do so on the basis of informed choice, and appreciate that in accepting an invitation or participating in a programme to reduce their risk of a disease there is a risk of an adverse outcome".4 This approach recognises the fact that although screening programmes may benefit populations, not all participants will benefit and some will even be harmed by participation. Good examples of an informed choice approach to screening are mainly to be found in situations where the penalty of uninformed screening is seen as unacceptably high. When termination of pregnancy is a possible outcome of antenatal screening, for example, a policy of informed choice is seen as central to individual autonomy and to avoiding eugenic practice.5 Authors concerned about the adverse psychological effects of unrealistic expectations of what cancer screening programmes can deliver have emphasised the importance of informed choice. 6 7 This position is reinforced by increasing litigation associated with the provision of poor quality information to people participating in cancer and prenatal screening programmes.8 Screening for risk of coronary heart disease can be said to differ fundamentally from screening for existing disorders such as Down's syndrome or breast cancer. In the first case screening is based on the probability of a future event, and cardiovascular risk is continuously distributed in the population; in the second case a screening test, of defined precision, splits the population into people likely or unlikely to have an existing condition, and this is then confirmed or excluded by a diagnostic test. Although cardiovascular risk may be continuous, however, judgments on how to manage it are binary. Individual risk status is usually confirmed by duplication of measurement of risk factors such as blood pressure, lipids, and glucose. At specified levels of risk, treatment is offered to individuals in an attempt to avert possible adverse future events. Screening for cardiovascular risk in primary care has also been approached
through "case finding." For example, a patient may be identified as
having hypertension while consulting about a skin infection. However,
qualitative evidence has shown that patients would like choice in
this situation and vary as to whether they are ready for the
associated lifestyle advice.9
Categorising individuals as belonging to high risk groups is associated with
the adverse effects resulting from labelling. For example,
identification of diabetes, hypertension, or hyperlipidaemia creates
demands for clinical monitoring and adherence to drug treatment,
potentially resulting in a life lived in fear of a heart attack or
stroke. Many people do not want to pay these prices for an uncertain
reduction in personal risk.10 However, little
or no debate has taken place about the consequences of shifting
the focus of screening for specified thresholds of cardiovascular
risk from one guided by a population based public health paradigm to
one guided by individual informed choice.
An emerging consensus states that an informed choice or decision has two core characteristics: firstly, it is based on relevant, good quality information; and, secondly, the resulting choice reflects the decision maker's values. This can be viewed in practice as a choice based on relevant knowledge, reflecting an individual's value system, and behaviourally implemented.11 The General Medical Council has produced guidance on the information that should be provided to people offered screening.12 This includes information on the condition for which screening is being offered, as well as information on the likelihood, meaning, and implications of all possible test results. Such guidelines do not, however, tell us how much information should be provided or how it should be presented in order to facilitate choices that are informed.
The national service framework for coronary heart disease and the joint British recommendations on prevention of coronary heart disease propose that all patients with a 10 year absolute risk of a coronary event (non-fatal myocardial infarction or death from coronary heart disease) of over 30% should "be targeted and treated." 1 13 People meeting or exceeding this threshold may be viewed as "screen positive." If such patients take effective drugs for hypercholesterolaemia and high blood pressure they can, as a group, reduce this risk by about 30% over 10 years (estimated from studies over five years). 14 15 This might reduce a 10 year risk of 30% to one of 21%. Thus a patient identified as being at high risk by the screening criteria in the national service framework has about a 9% chance of benefiting (and a 91% chance of not benefiting) from 10 years of treatment. To put this another way, 11 patients at high risk must be treated for 10 years to avoid a coronary event in one of them. How will individual patients respond to different representations of their
predicament? The information could be presented in general terms
Uptake
Emotional impact of screening
Motivation to change behaviour
Impact on equity and population health
The net effect of any population based preventive strategy depends on the
number of people participating, their baseline levels of risk, and
the changes in risk achieved by their actions after testing. Although
a policy of informed choice may reduce the likelihood of the public
health objectives of screening being achieved, it may also increase
the effectiveness of interventions among people who choose to
participate and may prove at least as cost effective as current
efforts. If people are unmotivated to achieve the gains that risk
assessment and subsequent intervention can result in, this would be
another instance of informed patients behaving in ways that are at
odds with prevailing medical opinion, an increasingly recognised
consequence of patient centred care.24 Whatever
the population outcomes, a policy of informed choice could place
primary care back in partnership with patients seeking help to change
their behaviour, as opposed to being faced with a responsibility
for improving the health of the public, regardless of the motivation
of individual patients. Studies are now needed to evaluate the
impact of a policy of informed choice on reducing cardiovascular risk
in high risk populations identified by screening.
We thank Kay Tee Khaw, Simon Griffin, Jon Emery, David French, Susan Michie, and David Armstrong for discussions of earlier drafts of this paper and Nadine Bowen for its preparation.
Editorial by Brindle and Fahey
Funding: TMM is funded by the Wellcome Trust. ALK is supported by NHS Research and Development.
Competing interests: None declared.
(Accepted 11 April 2002)
This article has been cited by other articles:
Rapid Responses:Read all Rapid Responses
Related editorials in BMJ:
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