Editorial
Importance of a Community-Based Approach to Accelerate Referral to Physicians for Individuals with a High Risk of Cardiovascular Disease
2023 Volume 30 Issue 10 Pages 1315-1316
Details
2023 Volume 30 Issue 10 Pages 1315-1316
See article vol. 30: 1389-1406
In a recent issue of J Atheroscler Thromb, Iso et al. reported that health counseling program for individuals with a high risk of cardiovascular disease (CVD) screened at community sites can accelerate clinic visits in Japan1). Despite some potential issues in the feasibility of implementing this system nationwide, their study provides a valid and practical method for strengthening Japan’s primary health care system.
CVD is a major cause of death and disability in Japan2, 3), and individuals with a high risk of cardiovascular disease must receive early and sustained treatment to prevent the progression of vascular damage4). In 2008, Japan introduced the national Specific Health Checkup (SHC) and Specific Health Guidance (SHG) program to systematically detect and prevent the deterioration of the preclinical cases of hypertension, hyperlipidemia, and hyperglycemia among individuals with visceral obesity. SHCs involve insurance-covered health screenings for residents aged 40–74 years and are designed to identify individuals with or at the risk of metabolic syndrome. These individuals are eligible for SHG counseling and educational sessions aimed at improving lifestyle habits and clinical outcomes. In relation to the development of SHGs, previous studies reported that the development of lifestyle modification programs for individuals with metabolic syndrome has also been developed5).
However, there are some problems with Japan’s current approach for handling individuals with a high risk of CVD under the SHC and SHG program. Specifically, it remains unclear if physician referrals after SHCs lead to actual clinic visits for treatment among such individuals. Furthermore, patients who are being treated for CVD risk factors (e.g., hyperlipidemia and hypertension) are not eligible for SHG interventions. Japan’s national health promotion program “Health Japan 21” has set the prevention of the onset and progression of lifestyle-related diseases as one of its goals6, 7). Therefore, many communities and health insurers require effective programs that encourage high-risk individuals to visit clinics and initiate treatment, but there is a lack of such programs.
The study by Iso et al. was a cluster-randomized trial conducted in 43 Japanese municipalities (21 intervention and 22 usual care)1, 8). The cumulative proportions of post-SHC clinic visits for 12 months were 58.1% in the intervention group versus 44.5% in the usual care group; the probability ratio of clinic visits between the groups was 1.46. The between-group differences between the baseline survey and 1-year survey were −1.50 mmHg for diastolic blood pressure in the hypertension category, −0.30% for HbA1c levels in the diabetes category, and −0.37 mmol/L for low-density lipoprotein–cholesterol (LDL-C) levels in the dyslipidemia category.
The health counseling program employed by Iso et al. was able to accelerate clinic visits for high-risk individuals, which led to significant reductions in blood pressure, HbA1c levels, and LDL-C levels. Accordingly, their approach demonstrates that health counseling following health screening can help control risk factors and prevent lifestyle-related diseases. The standardized health counseling method developed in their study is based on a well-known “health belief model” used extensively by Japanese health professionals such as public health nurses and nutritionists. Therefore, the procedures of health counseling based on this model would be easily accepted by Japanese health professionals.
Nevertheless, the implementation of the health counseling program developed by Iso et al. requires additional human resources and costs, which may be barriers for some municipalities. This approach involves intensive interventions, with 42.1% of initial health counseling provided within 45 days of health checkups and 62.3% of initial health counseling provided through home visits1). Although the 43 municipalities in the study were able to apply this approach, other municipalities and health insurance associations may have difficulties in securing necessary human resources and finances. Therefore, when developing health counseling programs, it is also necessary to consider the establishment of systems and environments that would facilitate clinic visits by high-risk individuals. As shown in the results of Iso et al., a system for recommending early clinic visits after health checkups is essential for improving health outcomes in high-risk individuals. Similarly, a recent study reported that the early promotion of clinic visits using referral letters at the time of health screening significantly increased the number of visits within 6 months of health checkups or untreated hypertensive patients9). Based on the findings of Iso et al.1), future implementation research is needed to optimize a simple health counseling system to accelerate clinic visits for individuals with a high CVD risk.
Iso et al. provides a systematic and evidence-based study that verifies the effectiveness of health counseling program in recommending and accelerating clinic visits for individuals with a high CVD risk using a multiregion cluster randomized trial1). Their results also demonstrate the usefulness of community-based health counseling in accelerating clinic visits within Japan’s unique primary care system. I recommend that this study’s approach be implemented and expanded to other regions in Japan with consideration to its feasibility for each community and health insurer. Further research on programs to accelerate clinic visits for individuals with a high CVD risk through other approaches is also warranted.
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