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: info@psyma-international.comwebsite: 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