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