Challenges That Face California

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Challenges That Face California

• Liana Lianov MD, MPH
• Nan Pheatt, MPH
• April 24, 2003

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Overview

• Burden of disease
• Nationwide challenges
• Californias challenges
• Suggestions for solutions

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Total Burden from Heart DiseaseCalifornia

• Number one cause of death (39 of deaths)
• High death rate (187/100,000) relative to Healthy
  People 2010 target of 166/100,000
• Major cause of disability and poor quality if
  life
• High economic costs health care costs and loss
  of productivity (approximately one tenth of the
  nations cost of 229.9 billion for total heart
  disease and 129.9 for coronary heart disease)

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Expected Rise in Total Burden

• Despite decrease in mortality rates, total
  numbers of deaths from heart disease will rise
  due to
• aging population
• increase in prevalence of certain risk factors
• diabetes increase by 61 1990 to 2000
• obesity increase by 49 1990 to 2000
• Increase in environmental triggers (such as poor
  air quality and stress-- possible triggers for
  heart attacks)

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Burden Complicated by Psychosocial Factors

• Depression and anxiety are under-diagnosed and
  under-treated.
• Yet these conditions are associated with
  coronary heart disease mortality.
• Depression is an independent risk factor for
  death in patients with risk factors for coronary
  heart disease.
• Patients who are depressed post-heart attack have
  greater mortality.

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Challenges Nationwide

• Increase in certain risk factors
• Aging population
• Disparities of special populations
• Public lack of knowledge and confusion
• Delay in public seeking care
• Changing science
• Inadequate health care systems

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Challenges NationwideContinued

• Inadequate data and research
• Human nature
• Unhealthy environment
• Lack of advocacy for heart disease control
• Changing public health priorities
• Limited resources

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Worsening Risk Factor Profile

• Significant rise in obesity and diabetes
• Nearly one fifth of Americans are obese
• 18.7 of Californians were obese in 2000 (up from
  7.4 in 1984)
• Majority of states, including California, have
  greater than 6 diabetes prevalence

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Aging of our Population

• Number over 60 will increase by 112 in 2020
  compared to 1990 nationwide.
• Hospitalizations and deaths due to heart disease
  increase with age.
• Women are impacted, due to their longer average
  survival
• hence even though rates of heart disease are
  lower in women, actual numbers equal men
• 28,937 women vs. 29, 266 men had heart disease
  in 1998 in California.

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Public Confusion

• Lack of knowldege
• Unaware coronary heart disease (CHD) is leading
  cause of death
• Unaware of high risk of long-term disability
• Belief that coronary bypass is a cure
• Lack of recognition of symptoms and the need to
  call 911
• Confusing messages in media
• Diet, e.g. Atkins diet new nutrition pyramid
• Hormone replacement

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Delay in Care

• Increasing out-of-hospital deaths
• Explained in part by delay in seeking care
• Lack of knowledge of signs and symptoms
• Denial
• Worry about out-of-pocket costs
• Embarrassment
• Lack of symptoms

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Changing ScienceChallenge to Health Care
Providers

• What are the risk factors?
• Is C-Reactive Protein a risk factor or a marker?
• When is hormone replacement appropriate?
• What tests should be routine?
• CT scan for coronary artery calcium?
• What is a heart attack?
• Is it inflammation versus blood clot ?(Plaques in
  vessel walls rupture and trigger clotting and
  inflammation.)

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Inadequate Health Care Systems

• Access
• High numbers of uninsured
• Quality
• Few health care settings are fully implementing
  science into practice, such as well-established
  secondary prevention guidelines

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Inadequate Health Care Systems

• Inadequate health care resources, due to high
  numbers of patients with CHD
• Increasing costs due to the need to treat risk
  factors earlier in order to prevent CHD
• Blood pressure
• Cholesterol
• Blood glucose

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Incomplete Data and Research

• No prevalence data--Total number of persons at
  risk for heart disease are difficult to
  obtain--since many are asymptomatic and do not
  seek care
• Limited data on special populations
• Few clinical trials show effective interventions
  to promote health lifestyles, especially in
  special populations
• Few research projects address how to translate
  the science into practice

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Human Nature and Our Environment

• Behavior change to address many of the risk
  factors is difficult to initiate and more
  difficult to maintain.
• Our environment reinforces poor health habits
• Fast food
• Cul-de-sac neighborhoods
• Lack of walking and biking paths

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Other Challenges

• Changing priorities of public policy and
  resources due to terrorism and war
• The challenge of advocacy for heart disease
• Constituency that advocates for resources towards
  heart disease has been less effective than the
  those who advocate for cancer and HIV/AIDS in
  part, this is due to populations having greater
  fear of cancer and HIV.

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California Specific Challenges

• Increasing risk profile
• California dropped from 5th in 1990 to 21st in
  2001 in risk for heart disease based on high
  blood pressure, sedentary lifestyle and obesity
• Diverse population/ethnic disparity/
• many languages
• Large geographic region/geographic disparity

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California Specific ChallengesContinued

• Poor health care quality indicators
• Lack of central database of heart disease
  resources
• Lack of state general funds and limited overall
  resources

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Diversity Challenge

• California African American women have higher
  rates (36) of high blood pressure than any other
  race/gender group
• 4X as many hospital discharges from high blood
  pressure than white women
• 31 of California African American women are
  obese
• California Hispanics have the highest rates of
  diabetes at 10

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Geographic Challenge

• Disparities in heart disease in
• Southern counties Los Angeles, Orange, San
  Bernardino, Riverside
• Central Valley counties Kern, Stanislaus, San
  Joaquin, Sacramento, Sutter, Yuba

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Poor Access and Quality of Care

• 6.2 million Californians uninsured (for some
  period of time in the past year)
• California ranks 44th in cardiovascular care
  quality indicators for MediCare beneficiaries

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Lack of Central Database of Information

• California has a large number of programs and
  services hence public health workers and health
  care providers need
• Clearinghouse of information about who is doing
  what and where
• Inventory of local experts and resources
• Contact list of local referral sources for
  high-risk individuals and patients

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Limited Resources in California

• No state general funds for heart disease programs
• No funds from Centers for Disease Control and
  Prevention dedicated to heart disease
• Funds for heart disease at state health
  department are general prevention funds shared
  with over 20 other programs and have been cut
  recently
• Declining county funds and competing priorities

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Two Levels of Solutions

• Environmental change to promote
  heart-healthy lifestyles
• Schools
• Work sites
• Communities
• Health care organizations
• Education and support for individual behavior
  change

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Specific Solutions

• Public programs at the state and local level
• Programs for high-risk groups, such as African
  Americans
• Information database on the Internet to serve as
  resource for health care workers

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Specific SolutionsContinued

• Systems changes in hospitals and clinics that
  support scientific guidelines
• Research on effective ways to implement the
  science (translational research)
• Wider use of family history tools to identify
  those at high genetic risk for CHD

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Strategies to Implement Solutions

• Legislation
• Partnerships
• Advocacy
• State Plan to Control Heart Disease

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Solutions--What You Can Do

• Advocate for state programs that can educate the
  public, build collaborations with other groups,
  and make systems change
• Advocate for heart-healthy neighborhood design
  and for walking/biking paths
• Advocate for nutrition and physical activity in
  schools and worksites
• Advocate for smoking cessation

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SolutionsWhat You Can Do

• Advocate for systems changes, such as the
  hospital systems changes promoted by the American
  Heart Associations Get With The Guidelines
  program
• Promote calling 911 for signs and symptoms of
  heart attack

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Thank You!

• Llianov_at_dhs.ca.gov
• Npheatt_at_dhs.ca.gov

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