CVD Control Programs: CVD Control Programs: Preventive StrategiesPreventive Strategies
Sunita DodaniSunita DodaniDepartment of EpidemiologyDepartment of Epidemiology
University of PittsburghUniversity of Pittsburgh
Presentation overviewPresentation overview Burden Of CVDs And Health Burden Of CVDs And Health
Expenditures in developing countriesExpenditures in developing countries Constraints For CVD Prevention In Constraints For CVD Prevention In
Developing CountriesDeveloping Countries Barriers to Implementation of Barriers to Implementation of
Preventive ServicesPreventive Services Prevention StrategiesPrevention Strategies CVD Control ProgramsCVD Control Programs Population based & high risk approachPopulation based & high risk approach
CVD identified as the primary NCD CVD identified as the primary NCD throughout the developing world and throughout the developing world and inflicting major economic and human costs.inflicting major economic and human costs.
One of the main reasons are the One of the main reasons are the epidemiologic transition.epidemiologic transition.
The observed ethnic diversity in the CVD The observed ethnic diversity in the CVD and risk factors profile in South Asian and risk factors profile in South Asian Immigrant studies makes this population Immigrant studies makes this population high-risk. high-risk.
A paucity of cause-specific mortality data A paucity of cause-specific mortality data and epidemiologic studies is a major and epidemiologic studies is a major impediment to the estimation of the impediment to the estimation of the absolute and relative death toll of CVD.absolute and relative death toll of CVD.
Need to establish appropriate research Need to establish appropriate research studies, increase research capacity and studies, increase research capacity and preventive cardiology programs. preventive cardiology programs.
Potential For PreventionPotential For Prevention
CVD risk factors: large potential for preventionCVD risk factors: large potential for prevention
Nonmodifiable RF:Age, Sex, FM history of CVD
Behavioral RF:Smoking, Unhealthy diet
Sedentary Lifestyles
Socioeconomic & culturaldeterminants
Early life Characteristics
* Modifiable
Physiological RF:•Hypertension•Cholesterol•Diabetes•Obesity
Endpoints:Heart Disease
StrokeVascular Disease
Cancer
Burden Of Disease And Health Burden Of Disease And Health Expenditures Of Industrialized Expenditures Of Industrialized And Developing Countries The ’90/10 And Developing Countries The ’90/10
Disequilibrium’Disequilibrium’
0
20
40
60
80
100
120
EME All Other
Per
cen
t DALYs
HealthExpenditure
EME= established market economy
Burden Of CVDs And Health Burden Of CVDs And Health ExpendituresExpenditures
The mismatch between healthcare The mismatch between healthcare needs and resources is widened.needs and resources is widened.
An expanded list of health An expanded list of health conditions calls for policy maker’s conditions calls for policy maker’s attention and public health action.attention and public health action.
Policy has to prioritize on the basis Policy has to prioritize on the basis of disease burdens, cost-of disease burdens, cost-effectiveness and equity.effectiveness and equity.
The rising burdens of CVD The rising burdens of CVD exemplify the high costs and the exemplify the high costs and the adverse effects on development adverse effects on development that would result from mid-life that would result from mid-life death and disability. death and disability.
Constraints For CVD Prevention Constraints For CVD Prevention In Developing CountriesIn Developing Countries
Limited recognition and available data on Limited recognition and available data on CVDCVD
Lack of commitmentLack of commitment Prevention not taken seriously (market Prevention not taken seriously (market
pressure favoring therapy)pressure favoring therapy) Stroke/ CHD considered as diseases for Stroke/ CHD considered as diseases for
specialists to treatspecialists to treat Health care needs not addressed Health care needs not addressed
“prospectively” by existing health system“prospectively” by existing health system Costs are rising and resources are dwindlingCosts are rising and resources are dwindling
Barriers To Achieving CVD ReductionBarriers To Achieving CVD Reduction Agencies Involved in PreventionAgencies Involved in PreventionGovernmentGovernment very bureaucratic very bureaucratic slow and ineffective slow and ineffective failure to influence policesfailure to influence policesCardiac societies and foundationsCardiac societies and foundations effectiveness in reaching out to the public effectiveness in reaching out to the public
through the media through the media Community and societal barriersCommunity and societal barriers strong health beliefs and lack of strong health beliefs and lack of
awareness, education and knowledge awareness, education and knowledge
Barriers to Achieving CVD Barriers to Achieving CVD ReductionReduction
Medical Education SystemMedical Education System Focused towards secondary & tertiary Focused towards secondary & tertiary
care than Public health and preventioncare than Public health and prevention In- adequate training of medical In- adequate training of medical
professionals in research methodsprofessionals in research methods Communication skills: knowledge Communication skills: knowledge
deficit in most providers deficit in most providers Providers attitudes about prevention Providers attitudes about prevention
Barriers to Implementation of Barriers to Implementation of Preventive ServicesPreventive Services
Health Care SystemsHealth Care Systems– Acute care priorityAcute care priority– Lack of resourcesLack of resources– Lack of systems for Lack of systems for
preventive servicespreventive services– Time and economic Time and economic
restraintsrestraints– Lack of policies and Lack of policies and
standardsstandards
Community/Community/Society/ Society/ patientspatients– Lack of motivationLack of motivation– Cultural factorsCultural factors– Social factorsSocial factors– Lack of knowledgeLack of knowledge
Barriers to Implementation of Barriers to Implementation of Preventive ServicesPreventive Services
Physician LevelPhysician Level– Problem-based focusProblem-based focus– Little positive feedbackLittle positive feedback– TimeTime– Lack of trainingLack of training
Poor knowledgePoor knowledgeLack of skillsLack of skillsPerceived low efficacyPerceived low efficacy
– Lack of specialist-generalist Lack of specialist-generalist communicationcommunication
Preventive Cardiology Programs: Preventive Cardiology Programs: How Can We Do Better?How Can We Do Better?
Development of strategies for the Development of strategies for the prevention of cardiovascular disease prevention of cardiovascular disease (CVD) presents an important policy (CVD) presents an important policy question for society question for society
Do the benefits of these programs justify Do the benefits of these programs justify the investment? the investment?
Substantial costs …affordable ?Substantial costs …affordable ? How limited health care resources should How limited health care resources should
be allocated to these activities?be allocated to these activities? Will it cover the majority who are at risk?Will it cover the majority who are at risk? Who will benefit the most?Who will benefit the most? What are the best approaches ?What are the best approaches ?
CVD Control ProgramsCVD Control ProgramsThe essential components of any CVD control The essential components of any CVD control
program would be:program would be: Establishment of efficient systems for Establishment of efficient systems for
estimation of CVD-related burden and its estimation of CVD-related burden and its secular trends.secular trends.
Estimation of the levels of established CVD risk Estimation of the levels of established CVD risk factors in representative population samples factors in representative population samples to help identify risk factors that require to help identify risk factors that require immediate intervention.immediate intervention.
Evaluation of emerging risk factorsEvaluation of emerging risk factors Development of a health policy that will Development of a health policy that will
integrate population-based measures for CVD integrate population-based measures for CVD risk modification and cost-effective case risk modification and cost-effective case management strategies for high risk group. management strategies for high risk group.
Prevention StrategiesPrevention StrategiesStrategic GoalsStrategic Goals
1.1. Build a nationwide Cardiovascular Build a nationwide Cardiovascular Disease Prevention and Control ProgramDisease Prevention and Control Program
2.2. Eliminate health disparities among Eliminate health disparities among priority populationspriority populations
3.3. Create a national surveillance system Create a national surveillance system for CVD for CVD
44..Develop research capacity and skills by Develop research capacity and skills by training the training the trainerstrainers
5.5.Support applied researchSupport applied research
Prevention StrategiesPrevention StrategiesThree types of prevention are advocated by WHOThree types of prevention are advocated by WHO
PrimordialPrimordial: prevention of appearance of : prevention of appearance of risk factorsrisk factors
e.g In the case of CAD and hypertensione.g In the case of CAD and hypertension
PrimaryPrimary: control of risk factors of CVD: control of risk factors of CVDe.g. Hypertension, smoking etce.g. Hypertension, smoking etc
&&
SecondarySecondary: control of CVD to control : control of CVD to control complications and further deteriorationcomplications and further deterioration
e.g. RHD, MI or Anginae.g. RHD, MI or Angina
CVD Control ProgramsCVD Control Programs All of these require a strengthening of policy-All of these require a strengthening of policy-
relevant research that can support and relevant research that can support and evaluate CVD control programs in the evaluate CVD control programs in the developing countries. developing countries.
The challenge of CVD control is complex in The challenge of CVD control is complex in settings in which epidemiological data CVD settings in which epidemiological data CVD events as well as population-attributable risk events as well as population-attributable risk CVD risk factors are not readily or reliably CVD risk factors are not readily or reliably available at present. available at present.
Research training and Pubic health knowledge Research training and Pubic health knowledge are an important tool for CVD control in are an important tool for CVD control in
developing countriesdeveloping countries
Research training in PakistanResearch training in Pakistan
There are more than 50 medical There are more than 50 medical universities and collegesuniversities and colleges
Only 2 institutes have accredited Only 2 institutes have accredited public health/ research training public health/ research training programsprograms
There is no school of public healthThere is no school of public health Those trained, majority leavesThose trained, majority leaves Few publications in international Few publications in international
journalsjournals Three journal are indexedThree journal are indexed
CVD Control ProgramsCVD Control ProgramsResearch PrioritiesResearch Priorities Public health action for CVD control Public health action for CVD control
linked to a policy-relevant researchlinked to a policy-relevant research The classic sequence of long-term The classic sequence of long-term
cohort studies followed by cohort studies followed by intervention trials to initially identify intervention trials to initially identify and later modify risk factors will be and later modify risk factors will be time consuming and is likely to be time consuming and is likely to be impeded by financial constraints. impeded by financial constraints.
Public health action cannot afford to Public health action cannot afford to wait that long to initiate wait that long to initiate
interventions.interventions.
CVD Control ProgramsCVD Control ProgramsThe appropriate strategy would be to: The appropriate strategy would be to: (1)(1)Commence control strategies, based on what Commence control strategies, based on what
we can readily extrapolate from the knowledge we can readily extrapolate from the knowledge available from other populations.available from other populations.
(2)(2) Evaluate known and putative risk factors Evaluate known and putative risk factors through cross-sectional studies of populations through cross-sectional studies of populations (ecological comparisons) and case-control (ecological comparisons) and case-control studies, preferably using incident cases of CVDstudies, preferably using incident cases of CVD
(3)(3)Use of South Asian Immigrant study data as a Use of South Asian Immigrant study data as a surrogate to develop preventive programs surrogate to develop preventive programs
From Epidemiological Evidence From Epidemiological Evidence to Prevention Programto Prevention Program
Two complementary strategies that are Two complementary strategies that are advocated for primary prevention are advocated for primary prevention are Population based and High risk strategies Population based and High risk strategies approachapproach
Population based approachPopulation based approach community wide interventions community wide interventions modify behaviormodify behavior influence the distribution of risk factors influence the distribution of risk factors
in a population in a population modest changes in risk factors --modest changes in risk factors --
substantial reduction in the cumulative substantial reduction in the cumulative population risk of CVD in a community population risk of CVD in a community
small benefits to each individual small benefits to each individual
Strategies to prevent CVDsStrategies to prevent CVDs
High risk approachHigh risk approach
identify few who are at high riskidentify few who are at high risk targeted behavioral or targeted behavioral or
pharmacological interventions pharmacological interventions greatest risk reduction in greatest risk reduction in
individualsindividuals
Population and high risk preventive strategiesPopulation and high risk preventive strategies
Original distribution
Population approach
Combined Strategies
High risk approach
Distribution Destiny
Risk Factor
Risk factors
Strategies to prevent CVDsStrategies to prevent CVDs
Primary Prevention
(Limit the number of cases)
Population Strategies
• Public health approach
• Targets Population
High risk Strategies
• Clinical management
• Targets individual
Strategies To Prevent CVDsStrategies To Prevent CVDsPopulation based approach: How to do it?Population based approach: How to do it? Culturally and linguistically appropriate Culturally and linguistically appropriate
and effective community health promotion and effective community health promotion and disease prevention programmes and disease prevention programmes should be encouraged and made available.should be encouraged and made available.
If they already exist they should be If they already exist they should be strengthened and integrated with the strengthened and integrated with the formal health care sector. formal health care sector.
Cardiovascular disease prevention should Cardiovascular disease prevention should be integrated with primary heath care.be integrated with primary heath care.
Cardiovascular health education should be Cardiovascular health education should be integrated with other health promotion integrated with other health promotion initiatives. initiatives.
Strategies To Prevent CVDsStrategies To Prevent CVDsPopulation based approachPopulation based approach Target population-wide lifestyle interventions,Target population-wide lifestyle interventions, Population-wide screening for risk factors Population-wide screening for risk factors Lifestyle advice should center on tobacco cessation, Lifestyle advice should center on tobacco cessation,
weight control, a heart healthy diet, physical activity weight control, a heart healthy diet, physical activity and stress management. e.g. Smart Heart Programand stress management. e.g. Smart Heart Program
Cardiovascular health promotion should be part of Cardiovascular health promotion should be part of the national media strategy. e.g. National Action the national media strategy. e.g. National Action ProgramProgram
Cardiovascular health should be addressed in Cardiovascular health should be addressed in schools as part of the curriculum, e.g. Smart Heart schools as part of the curriculum, e.g. Smart Heart Program Program
Cardiovascular health education should be offered in Cardiovascular health education should be offered in places of religious worship and worksites where places of religious worship and worksites where appropriate. appropriate.
Strategies To Prevent CVDsStrategies To Prevent CVDs
Population based approachPopulation based approach Infrastructure support and local Infrastructure support and local
capacity building for research should be capacity building for research should be prioritized. prioritized.
Train the trainers" approach should be Train the trainers" approach should be adopted for promoting CVD prevention adopted for promoting CVD prevention at the professional level. at the professional level.
Community empowerment through Community empowerment through education (mass and targeted) and education (mass and targeted) and policy change (to provide an enabling policy change (to provide an enabling environment) are essential for health environment) are essential for health promotion. promotion.
Strategies To Prevent CVDsStrategies To Prevent CVDs
Some famous population based Some famous population based programsprograms
1.1. North Karelia Project. North Karelia Project. Puska P 1975Puska P 1975
2.2. Non-communicable disease Non-communicable disease intervention programme in Mauritius. intervention programme in Mauritius.
Dowsen GK Br. Med J. 1995; 311: 1255–9Dowsen GK Br. Med J. 1995; 311: 1255–9
3.3. Five standford city project. Five standford city project. Winkleby Winkleby Am J Public HealthAm J Public Health 86 (1996), pp. 1773– 86 (1996), pp. 1773–
1779.1779.
Strategies To Prevent CVDsStrategies To Prevent CVDsHigh risk approachHigh risk approach Identification of High Risk population from a Identification of High Risk population from a
community ( those with CVD, community ( those with CVD, ≥ ≥ two risk factors two risk factors of CHD, diabetics)of CHD, diabetics)
Cost-effective and customized diagnostic and Cost-effective and customized diagnostic and management algorithms should be developed management algorithms should be developed for the treatment for the treatment
These guidelines should be made widely These guidelines should be made widely available to and adopted by health professionals available to and adopted by health professionals in primary and secondary care settings. in primary and secondary care settings.
The availability of effective and affordable The availability of effective and affordable drugs, devices and procedures should be drugs, devices and procedures should be ensured.ensured.
Referral chains should be established to provide Referral chains should be established to provide effective links between primary, secondary and effective links between primary, secondary and tertiary health care centers whenever required. tertiary health care centers whenever required.
Strategies To Prevent CVDsStrategies To Prevent CVDsHigh risk approachHigh risk approach Physicians in South Asia usually lack support Physicians in South Asia usually lack support
of related health professionals such as of related health professionals such as dietitians as is the norm in the developed dietitians as is the norm in the developed world.world.
A customized risk management curriculum A customized risk management curriculum should be introduced for physicians and should be introduced for physicians and health professionals during the course of health professionals during the course of formal and informal training. formal and informal training.
Specialist opinion should be sought Specialist opinion should be sought whenever essential and feasible. The cut-off whenever essential and feasible. The cut-off points for specialist referral for every risk points for specialist referral for every risk category should be recognized.category should be recognized.
Public Health Approach Vs. High Risk Public Health Approach Vs. High Risk StrategyStrategy
High-RiskHigh-Risk Benefit for individual largeBenefit for individual large Easy to understand, henceEasy to understand, hence
motivation and rewards for motivation and rewards for
individualsindividuals Needs person’s co-operationNeeds person’s co-operation
LimitationsLimitations Impact on total burden smallImpact on total burden small Often misusedOften misused Costly (screening)Costly (screening) Palliative (does not solve Palliative (does not solve overall problem, ‘rescue’)overall problem, ‘rescue’) Distracts from population Distracts from population
approachesapproaches
Population- basedPopulation- based Radical ( incidence)Radical ( incidence) Potential large benefitsPotential large benefits Cost effective (Policy)Cost effective (Policy) Can target unaware Population Can target unaware Population
LimitationsLimitations Need for mass change is hard to Need for mass change is hard to
communicatecommunicate Interventions other than policiesInterventions other than policies
hard to implementhard to implement Benefit for individual small, weak Benefit for individual small, weak motivation of physicians motivation of physicians Intervention can challenge vestedIntervention can challenge vested
interests/societal normsinterests/societal norms
Strengthening Research Strengthening Research CapacityCapacity
Build Capacity & Skills To Conduct Build Capacity & Skills To Conduct Research ActivitiesResearch Activities
Standardized morbidity data to Standardized morbidity data to estimate CVD burden.estimate CVD burden.
Prevalence data from valid cross-Prevalence data from valid cross-sectional sample surveys of selected sectional sample surveys of selected communitiescommunities
Incidence data from selected cohort Incidence data from selected cohort studies would provide a reasonable studies would provide a reasonable basis for extrapolation. basis for extrapolation.
Develop disease surveillance systemDevelop disease surveillance system Develop CVD registries and data centersDevelop CVD registries and data centers
Strengthening Research Strengthening Research CapacityCapacity
How much research training How much research training required for Health care required for Health care professional to obtain basic professional to obtain basic research skills.research skills.
Basic knowledge of Epidemiology, Basic knowledge of Epidemiology, Biostatistics and Public health Biostatistics and Public health should be core components of post-should be core components of post-graduate education and CME graduate education and CME
training programs for doctorstraining programs for doctors..
Five Essential Five Essential Components Of The Components Of The
Action PlanAction Plan1.1. Taking ActionTaking Action
Putting present knowledge to workPutting present knowledge to work
2.2. Strengthening CapacityStrengthening Capacity Transforming the organization and Transforming the organization and
structure of public health agencies and structure of public health agencies and partnershipspartnerships
3.3. Evaluating ImpactEvaluating Impact Monitoring the Disease Burden, Monitoring the Disease Burden,
measuring progress, and measuring progress, and communicating urgencycommunicating urgency
CDC model, 2003CDC model, 2003
Five Essential Components Five Essential Components Of The Action PlanOf The Action Plan
4.4. Advancing PolicyAdvancing Policy Defining the issues and finding Defining the issues and finding
the needed solutions the needed solutions
5.5. Engaging in (regional and global) Engaging in (regional and global) partnershipspartnerships Multiplying resources and Multiplying resources and
capitalizing on shared capitalizing on shared experienceexperience
Action Framework For A Comprehensive Public Health StrategyTo Prevent Heart Disease And Stroke
Fatal CVD Complications/ Decompensation
Unfavorable Social and Environmental Conditions
Adverse Behavioral Patterns
Major Risk Factors
First Event/ Sudden Death
Disability/ Risk of Recurrence
The Present Reality
Good Quality of Life Until Death
Social and Environmental Conditions Favorable to Health
Behavioral Patterns that Promote Health
Low Population Risk
Few Events/ Only Rare Deaths
Full Functional Capacity/Low Risk of Recurrence
A Vision of the Future
Policy and Environmental Change
Behavior Change
Risk Factor Detection and Control Emergency
Care/Acute CaseManagement
Rehabilitation/ Long-term Case Management
InterventionApproaches
End-of-Life CarePREVENTION
Action Framework For A Comprehensive Public Health StrategyTo Prevent Heart Disease And Stroke
Fatal CVD Complications/ Decompensation
Unfavorable Social and Environmental Conditions
Adverse Behavioral Patterns
Major Risk Factors
First Event/ Sudden Death
Disability/ Risk of Recurrence
The Present Reality
Good Quality of Life Until Death
Social and Environmental Conditions Favorable to Health
Behavioral Patterns that Promote Health
Low Population Risk
Few Events/ Only Rare Deaths
Full Functional Capacity/Low Risk of Recurrence
A Vision of the Future
Policy and Environmental Change
Behavior Change
Risk Factor Detection and Control Emergency
Care/Acute CaseManagement
Rehabilitation/ Long-term Case Management
InterventionApproaches
End-of-Life Care
TREATMENT