David R MacLean MD Professor & Director Institute for Health Research & Education Simon Fraser University A Case for Integrated Chronic Disease Prevention.

David R MacLean MDProfessor & Director

Institute for Health Research & EducationSimon Fraser University

A Case for Integrated Chronic Disease Prevention

A Case for Integrated Chronic Disease Prevention

• The Challenge of Chronic Disease

• Barriers to Achieving Better Health

• Action for the Future

Total Number of Deaths: 215,669Cardiovascular (ICD-9 390-459); Respiratory (ICD-9 460-519); Diabetes (ICD-9 250); Cancer (ICD-9 140-239); Infectious Diseases (ICD-9 001-139); Accidents/Poisonings/Violence (ICD-9 E800-E999)

Source: Statistics Canada, 1997

All Cardiovascular

Disease(79,457)

36%

Leading Causes of Death - Canada, 1997

Indirect and Direct Costs of Illness Canada, 1993

Indirect Costs54.3 %

$ 85 Billion

Direct Costs45.7 %

$72 Billion

$ Billions

Total $ 157 Billion

SOURCE: Canadian Institute for Health Information

Total Health Expenditure By Use Of Funds

Canada, 1997

SOURCE: Canadian Institute for Health Information

HOSPITALS

Direct Costs in $ billions

Total: $78 billion

DRUGS

PHYSICIANS

OTHER PROFESSIONAL

S

OTHERINSTITUTIONS

CAPITALL

OTHER HEALTH SPENDING

$25 (31%) $11

(15%)$11

(14%)

$10 (13%)

$8 (10%)

$2 (3%)

$11 (14%)

Total Indirect Costs of Illness Canada, 1993

Mortality

$29 (34%)

Long-term Disability$38 (21%)

Short-term Disability$17.5 (21%)

$ Billions

Total $ 85 Billion

SOURCE: Canadian Institute for Health Information

Association Between Self Reported Health Status and Health Care Costs

Excellent Health

52%

Fair Health 37%

Poor

11%

Self Reported Health Status

Health Care Costs

Crude rates of hospitalizations per 100,000 population for all cardiovascular disease by age group and sex, Canada, 1996/97.

0

5000

10000

15000

20000

35-44 45-54 55-64 65-74 75-84 85+

Age Group

Rat

e pe

r 10

0,00

0

Source: Hospital Morbidity Database, Canadian Institute for Health Information

Figure 3-1 Proportion of adults who report having heart problems by age group and sex, Canada, 1996/97.

1 25

11

22

41

48

1722

4

0

10

20

30

40

50

35-44 45-54 55-64 65-74 75+ All(35+)

Age Group

Per

cen

t

WomenMen

Source: Statistics Canada, National Population Health Survey, 1996/97.

Figure 3-2 Proportion of First Nations and Inuit adults who report having heart problems by age group and sex, Canada, 1997.

2 36

11

24

30

8

2 3 5

14

24

44

9

0

10

20

30

40

50

15-24 25-34 35-44 45-54 55-64 65+ All

Age Group

Per

cent

WomenMen

Source: Assembly of First Nations, National Steering Committee, First Nations and Inuit Regional Health Survey 1997.

Proportion of population aged 35 to 64 with self-reported heart disease who have chronic pain, activity restriction, disability, or unemployment, Canada, 1996/97.

0 10 20 30 40 50 60 70

Not Employed because ofIllness (or Disability)

One or More DisabilityDays in Past 2 Weeks

Activity Restriction

Chronic Pain orDiscomfort

Percent

Women

Men

Source: Statistics Canada, NPHS, 1996/97

0

100

200

300

400

500

600

700

1969 1974 1979 1984 1989 1994

Ra

te p

er 1

00

,00

0

Cardiovascular Disease Ischemic Heart Disease

Cerebrovascular Disease Acute MI

Age-standardized mortality rate per 100,000 women, Canada, 1969-1997.

Age-standardized to 1991 Canadian Population

Source: Laboratory Centre for Disease Control; Statistics Canada

0

100

200

300

400

500

600

700

1969 1974 1979 1984 1989 1994

Rat

e pe

r 10

0,00

0

Cardiovascular Disease Ischemic Heart Disease

Cerebrovascular Disease Acute MI

Age-standardized mortality rate per 100,000 men, Canada, 1969-1997.

Age-standardized to 1991 Canadian populationSource: Laboratory Centre for Disease Control; Statistics Canada

0

20000

40000

60000

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

Num

ber

Men-Actual Men-Estimate Women-Actual Women-Estimate

Source: LCDC, Health Canada, unpublished work

Number of cardiovascular disease deaths by sex, actual and projected, Canada, 1950-2016.

0

50000

100000

150000

200000

250000

300000

350000

400000

450000

1971 1976 1981 1986 1991 1996 2001 2006 2011 2016

Num

ber

Men-Actual Men-Estimate Women-Actual Women-Estimate

Source: LCDC, Health Canada

Number of hospitalizations for cardiovascular disease, actual and projected by sex, Canada, 1971-2016.

0

50000

100000

150000

200000

250000

1971 1976 1981 1986 1991 1996 2001 2006 2011 2016

Num

ber

Men-Actual Men-Estimate Women-Actual Women-Estimate

Source: LCDC, Health Canada

Number of hospitalizations for ischemic heart disease, by sex, actual and projected, Canada, 1971-2016.

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

1971 1976 1981 1986 1991 1996 2001 2006 2011 2016

Num

ber

Men-Actual Men-Estimate Women-Actual Women-Estimate

Number of hospitalizations for cerebrovascular disease, actual and projected by sex, Canada, 1971-2016.

Source:LCDC, Health Canada

Cancer Mortality Trends for Selected Sites in Canadian Males

020406080

100120140160180200220240260280

Year

Rate per 100,000

All CancersLungProstateColorectalStomach

Cancer Bureau, LCDC, Health Canada

Trends in Cancer Incidence for Selected Sites in Canadian Males

050

100150200250300350400450500550

1971

1974

1977

1980

1983

1986

1989

1992

1995

1998

Year

Rate p

er 100,000

All Cancers

Lung

Prostate

Colorectal

Stomach

Cancer Bureau, LCDC, Health Canada

Cancer Mortality Trends for Selected Sites in Canadian Females

020406080

100120140160180

1971

1974

1977

1980

1983

1986

1989

1992

1995

1998

Year

Rate p

er 100,000

All Cancers

Lung

Breast

Colorectal

Stomach

Cancer Bureau, LCDC, Health Canada

Trends in Cancer Incidence for Selected Sites in Canadian Females

0

50100

150200

250300

350

1971

1974

1977

1980

1983

1986

1989

1992

1995

1998

Year

Rate p

er 100,000

All Cancers

Lung

Breast

Colorectal

Stomach

Cancer Bureau, LCDC, Health Canada

Prevalence Of Self Reported Diabetes in Canada By Sex

4.5%

0

1

2

3

4

5

6

7

8

9

10

%

Males Females Total

MacLean et al Canadian Heart Health Surveys Age 18 to 74 years

Prevalence of Self Reported Diabetes in Canada by Age and Sex

0

2

4

6

8

10

12

14

18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74

Age

Males

Females

MacLean et al Canadian Heart Health Surveys

Prevalence of Self Reported Diabetes in Canada by Age of Diagnosis and Sex

02468

101214161820

Age

%

Male

Female

MacLean et al Canadian Heart Health Surveys

Educational Achievement by Diabetes Status in Canadian Males

0

10

20

30

40

50

%

Ele

men

tary

Som

eS

econ

dar

y

Sec

ond

ary

Com

ple

ted

Un

iver

sity

DiabetesNo Diabetes

MacLean et al, Canadian Heart Health Survey

Elementary : 0 - 6 yrsSome Secondary : 7 - 11 yrsSecondary Completed: 12 -15 yrsUniversity: 16 yrs or more

Educational Achievement by Diabetes Status in Canadian Females

0

10

20

30

40

50

60

%

Ele

men

tary

Som

eS

econ

dar

y

Sec

ond

ary

Com

ple

ted

Un

iver

sity

DiabetesNo Diabetes

MacLean et al, Canadian Heart Health Survey

Elementary : 0 - 6 yrsSome Secondary : 7 - 11 yrsSecondary Completed: 12 -15 yrsUniversity: 16 yrs or more

Self Reported Diabetes Status by Age Group In Canada

Age GroupTreatment Status(%)

18 – 34(n=196)

35 – 64(n=385)

65 – 74(n=485)

All(n=1066)

Some Treatment1 59 72 81 72

Insulin 25 21 16 21

Pills 1 27 44 27

Diet 34 43 43 41

Weight Loss 2 9 4 6

Other 9 6 3 6

No Treatment 41 28 19 28 I Individuals may be taking one or more treatments at the same time

MacLean et al Canadian Heart Health Surveys

Prevalence of Modifiable CVD Risk Factors by Self Reported Diabetes Status in Canada

Risk Factor1 Diabetes (%) No Diabetes (%)

Smoking 32 27

Hypercholesterolemia 50 43 *2

Hypertension 26 15 *

Obesity 50 30 *

Sedentary 47 37 *1 Smoking is defined as daily smoking of one or more cigarettes per day Hypercholesterolemia is defined as 5.2 mmol/l Hypertension is defined as 140\90 Mm Hg Obesity is defined as BMI 27 Sedentary is defined as not exercising as least once per week

2 Significant at the 0.05 level

MacLean et al Canadian Heart Health Surveys

Distribution of Modifiable CVD Risk Factors by Self Reported Diabetes Status in Canada3

MacLean et al Canadian Heart Health Surveys

Proportion of youth aged 15-19 years who smoke cigarettes daily by sex, Canada, 1977-1996/97.

41 4138

35

2520 21 23

43 43 41

34

20

12

20 21

0

10

20

30

40

50

1977 1979 1981 1983 1986 1991 1994 1996/97

Per

cent Young

WomenYoungMen

Source: Statistics Canada, catalogues 91-002, vol 7, no. 3; 91-512;91-213. Canadians and smoking: An update. Health and Welfare Canada, 1991. General Social Survey, Statistics Canada, 1991. Survey on Smoking in Canada, Cycle 3, 1994. National Population Health Survey, Statistics Canada, 1996/97.

Prevalence of Daily Smoking Among Canadian Youth Aged 15 - 17 Years by Province

0

5

10

15

20

25

30

%

NF

LD

PE

I

NS

NB

Qu

e

On

t

Man

Sas

k

Alb

BC

Province

Source: Statistics Canada

Nova Scotia Adult Smoking Rates (15+) Compared to Manitoba

1985 1990 1994 1999

10

15

20

25

30

35

40

NS MB

Source: Statistics Canada, Population Health Reports, 1985 - 1999

Awareness, treatment, and control of hypertension in Canada

42

19

23

16

0 5 10 15 20 25 30 35 40 45

Unaware,not treated

Not treated, notcontrolled

Treated and notcontrolled

Treated and controlled

percentage

The Canadian Heart Health Surveys

Joffres et al

Proportion of adults who are physically inactive by province, Canada, 1996/97.

50 50

60 58 5661

6361

68

6157

0

10

20

30

40

50

60

70

BC Alta Sask Man Ont Que NB NS PEI Nfld Can

Per

cent

Source: Statistics Canada, National Population Health Survey, Cycle 2, 1996/97

Proportion of adults who are overweight by province, Canada, 1996/97.

20 20 23 20 19 18 20 19 22 18 19

27 29

3634

28 27

4238 36 39

29

0

10

20

30

40

50

60

70

80

BC Alta Sask Man Ont Que NB NS PEI Nfld Can

Per

cent

Obese

Some excessweight

Source: Statistics Canada, National Population Health Survey, Cycle 2, 1996/97

Prevalence of Obesity Among U.S. AdultsBRFSS, 1998

Prevalence of Obesity Among U.S. AdultsBRFSS, 1998

<10% 10% to 15% >15% N/A

Source: Mokdad et al., Diabetes Care 2001 Feb;24(2):412

4% 4-6% 6% n/a

Prevalence of Diabetes Among Adults in the U.S. BRFSS 1999

American Diet Rural Chinese Diet

Total fat (% of kcal)Dietary fibre (g/day)Soluble carbohydrate (g/day)Calcium (mg/day)Protein (g/day, 70 kg man)Animal protein (% of total protein)Iron (mg/day)Thiamin (mg/day)Retinol (RF/day)Total carotenoids (RE/day)Vitamin C (mg/day)Riboflavin (mg/day)

Energy intake (k-cal/day)

1534

470540

647

342-330

8361401.8

2640

38 - 40 10 -12

2401140

90-9570181.4990429731.9

2360

INGREDIENT

Commonality Of Risk Factors

Smoking

Unhealthy diet

Overweight

Sedentary lifestyle

Alcohol abuse Psychosocial

stress

RISKFACTORS

Cardiovasculardisease

Cancer

Diabetes

Chronicrespiratoryconditions

Mental ill-health

MAJOR CHRONICDISEASES

Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35-64 years from 1969 to 1995.

Mortality per 100 000

population

Age-adjusted mortality rates of lung cancer in North Karelia and the whole of Finland among males aged 35-64 from 1969 to 1995

Mortality per 100 000

population

Life Expectance at Birth in Canada

50

55

60

65

70

75

80

85

90

1920 1930 1940 1950 1960 1970 1980 1990

Year

AgeCanadaMaleFemale

Source: Statistics Canada

Getting OlderPopulation Aged 65 and Over As a Percentage of Population 20 - 64

19% 21%

34%39% 41% 43%

0

10

20

30

40

50

60

1991 2000 2025 2050 2075 2100

Year

Per

cent

Source: The Canada Pension Plan Fifteenth Statutory Actuarial Report

A Case for Integrated Chronic Disease Prevention

• The Challenge of Chronic Disease

• Barriers to Achieving Better Health

• Agenda for Future Action

Barriers to Achieving Better Health

• In General

– The cause and effect relationship with disease prevention, health promotion is less observable, more subject to the effects of externalities

– Lack of interest on the part of government leadership and generally within health care system with respect to promotion and prevention

– Health policy tends to equate to health care policy

– Lack of capacity to develop chronic disease policies and to follow through with scalable interventions

Barriers to Achieving Better Health (con’t)

• Bureaucratic Issues– Lack of capacity, especially regarding the

development of policies and strategies for promotion and prevention

– Disconnect among organizational units within health systems at all levels. There is a lack of continuity – little corporate memory

– Lack of accountability for outcomes – the bureaucracy concentrates on running good administrative processes

– Lack of attention to sustainable financing for promotion and prevention

Barriers to Achieving Better Health (con’t)

• System Issues

– Constant changes of paradigms

– Disconnect between research and implementation

– Disconnect between specialists groups, primary health care, public health and health promotion systems or structures

A Case for Integrated Chronic Disease Prevention

• The Challenge of Chronic Disease

• Barriers to Achieving Better Health

• Agenda for Future Action

Need to Develop Appropriate

• Systems

• Products

• Resources

• Leadership

Systems

• Public Health (broadly defined)– Needs to assume a mandate and leadership

role in chronic disease prevention and control

– Needs to be restructured with new technical skills and new resources

– Needs to be more collaborative with a community capacity building orientation

Systems (con’t)

• Primary Care– Needs to assume a mandate in chronic

disease prevention– Needs to be more multidisciplinary with

more of a community focus– Need new skills, tools and resources

Products - Policies & Programs • That are practical and feasible from a

management and cost perspective• That deliver the preventive dose• That build capacity and provide appropriate

tools• Operate on the basis of appropriate evidence

and best practice

Resources - People & Money

• Need to move from reliance research funding to appropriate levels operational funding

• Need funding to begin the process of realigning system priorities

• Need new models of program delivery that involve the private and voluntary sectors and other formal sectors such as education and environment

Leadership

• Need to foster the development of champions at all levels

• Need to enhance the capacity of the health system’s governance structures

• Need to market chronic disease prevention and health promotion at all levels

• Need to create demand for preventive services

•Policy development •Advocacy •Marketing •Capacity building •Education – public and professional •Community mobilization •Dissemination/deployment•Resource mobilization •Information technology •Surveillance •Monitoring and evaluation•Research… … …

Functions Common To Population Health Approaches

To Prevention And Control Of Major Chronic Diseases

•Place in the agenda of the health system

•Monetize support for prevention “in principle”

•Arguing the case for financing prevention

… but it is not all about money --- > use existing assets

The Need for Economic Capacity

ConclusionsMajor Challenges

… Infrastructure + Political Will …

-Marketing the Health Vision-Policy Development & Implementation- Intersectoral Action-Financing strategies -Use of existing assets

… in sink with broader social and economic policies

… the problem is not what to do, but how to do it …