David R MacLean MD

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

• The Challenge of Chronic Disease
• Barriers to Achieving Better Health
• Action for the Future

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Leading Causes of Death - Canada, 1997
All Cardiovascular Disease(79,457)36
Total Number of Deaths 215,669 Cardiovascular
(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
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Indirect and Direct Costs of Illness Canada, 1993
Billions
Total 157 Billion
SOURCE Canadian Institute for Health Information
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Total Health Expenditure By Use Of Funds Canada,
1997
Direct Costs in billions
HOSPITALS
DRUGS
25 (31)
11 (15)
OTHER HEALTH SPENDING
11 (14)
11 (14)
2 (3)
PHYSICIANS
8 (10)
10 (13)
CAPITALL
OTHER INSTITUTIONS
OTHER PROFESSIONALS
Total 78 billion
SOURCE Canadian Institute for Health Information
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Total Indirect Costs of Illness Canada, 1993
Billions
Total 85 Billion
SOURCE Canadian Institute for Health Information
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Association Between Self Reported Health Status
and Health Care Costs
Health Care Costs
Poor 11
Fair Health 37
Excellent Health 52
Self Reported Health Status
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Crude rates of hospitalizations per 100,000
population for all cardiovascular disease by age
group and sex, Canada, 1996/97.
Source Hospital Morbidity Database, Canadian
Institute for Health Information
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Figure 3-1 Proportion of adults who report having
heart problems by age group and sex, Canada,
1996/97.
Source Statistics Canada, National Population
Health Survey, 1996/97.
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Figure 3-2 Proportion of First Nations and Inuit
adults who report having heart problems by age
group and sex, Canada, 1997.
Source Assembly of First Nations, National
Steering Committee, First Nations and Inuit
Regional Health Survey 1997.
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Proportion of population aged 35 to 64 with
self-reported heart disease who have chronic
pain, activity restriction, disability, or
unemployment, Canada, 1996/97.
Source Statistics Canada, NPHS, 1996/97
13
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
14
Age-standardized mortality rate per 100,000 men,
Canada, 1969-1997.
Age-standardized to 1991 Canadian population
Source Laboratory Centre for Disease Control
Statistics Canada
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Number of cardiovascular disease deaths by sex,
actual and projected, Canada, 1950-2016.
Source LCDC, Health Canada, unpublished work
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Number of hospitalizations for cardiovascular
disease, actual and projected by sex, Canada,
1971-2016.
Source LCDC, Health Canada
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Number of hospitalizations for ischemic heart
disease, by sex, actual and projected, Canada,
1971-2016.
Source LCDC, Health Canada
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Number of hospitalizations for cerebrovascular
disease, actual and projected by sex, Canada,
1971-2016.
SourceLCDC, Health Canada
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Cancer Mortality Trends for Selected Sites in
Canadian Males
Cancer Bureau, LCDC, Health Canada
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Trends in Cancer Incidence for Selected Sites in
Canadian Males
Cancer Bureau, LCDC, Health Canada
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Cancer Mortality Trends for Selected Sites in
Canadian Females
Cancer Bureau, LCDC, Health Canada
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Trends in Cancer Incidence for Selected Sites in
Canadian Females
Cancer Bureau, LCDC, Health Canada
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Prevalence Of Self Reported Diabetes in Canada By
Sex
MacLean et al Canadian Heart Health Surveys
Age 18 to 74 years
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Prevalence of Self Reported Diabetes in Canada by
Age and Sex
MacLean et al Canadian Heart Health Surveys
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Prevalence of Self Reported Diabetes in Canada by
Age of Diagnosis and Sex
MacLean et al Canadian Heart Health Surveys
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Educational Achievement by Diabetes Status in
Canadian Males
Elementary 0 - 6 yrs Some Secondary 7 - 11
yrs Secondary Completed 12 -15 yrs University
16 yrs or more
MacLean et al, Canadian Heart Health Survey
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Educational Achievement by Diabetes Status in
Canadian Females
Elementary 0 - 6 yrs Some Secondary 7 - 11
yrs Secondary Completed 12 -15 yrs University
16 yrs or more
MacLean et al, Canadian Heart Health Survey
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Self Reported Diabetes Status by Age Group In
Canada
MacLean et al Canadian Heart Health Surveys
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Prevalence of Modifiable CVD Risk Factors by Self
Reported Diabetes Status in Canada
MacLean et al Canadian Heart Health Surveys
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Distribution of Modifiable CVD Risk Factors by
Self Reported Diabetes Status in Canada3
MacLean et al Canadian Heart Health Surveys
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Proportion of youth aged 15-19 years who smoke
cigarettes daily by sex, Canada, 1977-1996/97.
Source Statistics Canada, catalogues 91-002, vol
7, no. 3 91-51291-213. 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.
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Prevalence of Daily Smoking Among Canadian Youth
Aged 15 - 17 Years by Province
Source Statistics Canada
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Nova Scotia Adult Smoking Rates (15) Compared to
Manitoba
Source Statistics Canada, Population Health
Reports, 1985 - 1999
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Awareness, treatment, and control of
hypertension in Canada
The Canadian Heart Health Surveys
Joffres et al
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Proportion of adults who are physically inactive
by province, Canada, 1996/97.
Source Statistics Canada, National Population
Health Survey, Cycle 2, 1996/97
36
Proportion of adults who are overweight by
province, Canada, 1996/97.
Source Statistics Canada, National Population
Health Survey, Cycle 2, 1996/97
37
Prevalence of Obesity Among U.S. AdultsBRFSS,
1998
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Prevalence of Diabetes Among Adults in the U.S.
BRFSS 1999
Source Mokdad et al., Diabetes Care 2001
Feb24(2)412
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INGREDIENT
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Commonality Of Risk Factors


RISK FACTORS
MAJOR CHRONIC DISEASES
Cardiovascular disease
Smoking
Unhealthy diet
Cancer
Diabetes
Overweight
Sedentary lifestyle
Chronic respiratory conditions
Alcohol abuse
Psychosocial stress
Mental ill-health
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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
43
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
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Life Expectance at Birth in Canada
Source Statistics Canada
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Getting OlderPopulation Aged 65 and Over As a
Percentage of Population 20 - 64
Source The Canada Pension Plan Fifteenth
Statutory Actuarial Report
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A Case for Integrated Chronic Disease Prevention

• The Challenge of Chronic Disease
• Barriers to Achieving Better Health
• Agenda for Future Action

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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

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Barriers to Achieving Better Health (cont)

• 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

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Barriers to Achieving Better Health (cont)

• 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

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A Case for Integrated Chronic Disease Prevention

• The Challenge of Chronic Disease
• Barriers to Achieving Better Health
• Agenda for Future Action

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Need to Develop Appropriate

• Systems
• Products
• Resources
• Leadership

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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

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Systems (cont)

• 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

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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

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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

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Leadership

• Need to foster the development of champions at
  all levels
• Need to enhance the capacity of the health
  systems governance structures
• Need to market chronic disease prevention and
  health promotion at all levels
• Need to create demand for preventive services

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Functions Common To Population Health
ApproachesTo Prevention And Control Of Major
Chronic Diseases

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

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The Need for Economic Capacity

• 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 --- gt use
  existing assets

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Conclusions
Major 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