USAPI NCD Core Monitoring and Surveillance Framework: 2016 Status 60th PIHOA Executive Board Meeting August 30 – September 1, 2016 Honolulu, Hawaii Dr. Andre Mark Durand, PIHOA Dr. Haley Cash, CDC Contractor/PIHOA

PIHOA Resolution #41-7 “Recognizing the importance of improving the region’s surveillance system to promote early detection and response to disease” (March, 2006) PIHOA Resolution #48-01 “Declaring a regional state of health emergency due to the epidemic of non-communicable diseases in the United States-Affiliated Pacific islands” (April, 2010) PIHOA Endorsement of Regional Epi Unit Board Meeting Minutes (March, 2015)

3. Surveillance also needs to be “Systematic” 3. Surveillance also needs to be “Systematic”. If consistent methods and definitions are not used then the data points that come out of surveys, vital stats and so forth cannot be used to see trends, which is all-important for charting progress and showing impact of interventions. This is what USAPI NCD Core Monitoring and Surveillance Framework and Data Dictionary is for.

USAPI NCD Core Indicator Scorecard Surveillance Indicators 2010-16 Tobacco Alcohol ↑BMI Diseases (adult) Deaths (30-69 years) Cigs- youth Cigs- adult Chew- Youth Chew- adult Youth Adult HTN DM ↑Cholesterol All Cause Cardiovascular Cancer Diabetes Chronic Lung Jurisdiction A ↓ N ↑ Jurisdiction C Jurisdiction D Jurisdiction E Jurisdiction F Jurisdiction G Jurisdiction H Jurisdiction I Jurisdiction J Overall, evidence shows situation is getting worse rather than better. Still Lots of data gaps, but getting better (some gaps take sequential community-based surveys to rectify and may take several years to accomplish If we look down each column we can see which issues are getting better and getting worse. Notice that good progress is being made on youth smoking and drinking, but we are loosing ground for youth chewing and overweight/obesity. Death rates look like they are getting worse, but could actually be that reporting is more complete. If we “disqualify” death rates, then the talley is: 12 items improved; 13 worse; 21 no change; 53 not enough data Of 144 measurements: 14 = Improved, 32 = Worse, 37 = No change 61 = Not enough data

Key Points: # of items with not sufficient information is decreasing as rapid HS surveys, and hybrid surveys are being put in place (and as more work is being done to get vital stats data in shape and analyzed). We would like to get the gray “not sufficient info” items down to 0 to get clearest possible picture. Number of “improved” items has not changed, while number with no change and number worse have both increased.

Key Points: Death rate data are most complete; Adult risk and disease prevalence (which depend on doing regular community based surveys) are still very incomplete. Being sure that you have (and stick to) and NCD monitoring & surveillance plan and greater roll-out of hybrid surveys will help with this. A lot of the youth items are still incomplete. This should be very easy to address through greater roll-out of rapid HS surveys (for those not already doing YRBS) More youth risk factors are improving than deteriorating; contrary to what we see in adults and deaths. 3. Also note that deaths are “following indicators” i.e. in response to good policy, youth risks will change most quickly, followed by adult risk factors then adult disease prevalence, and finally after a lag by death rates. This is for policy measures. For improvement of clinical care, we can have an immediate impact on death rates. So findings here suggest that we are making better progress on policy front than we are on clinical care front. This evidence supports prioritizing improvement of clinical health information systems so that effective preventive services coverage of target populations can be improved.

USAPI NCD Monitoring & Surveillance Scorecard, 2016 Functional NCD M&S Plan NCD Policy Mapping Done Good Quality Annual NCD Profiles Jurisdiction A Partly done Yes No Jurisdiction B Jurisdiction C Jurisdiction D Jurisdiction E Jurisdiction F Jurisdiction G Jurisdiction H Jurisdiction I Jurisdiction J Here is a scorecard for needed elements for NCD M&S. Without planning, it is unlikely that the regular, consistently obtained data needed to determine core risk, disease and mortality indicators can be obtained. Most of our jurisdictions have made good progress but still have more work to do. A few jurisdictions have not really started developing M&S plans. It is deceptively difficult to develop a good M&S plan. There are quite a few important technical considerations. It is very important to develop a consensus among the various PH programs around what core surveillance will be done in your jurisdiction. You should be concerned with this. NCD Policy Mapping can be done with respect to the USAPI NCD Policy Commitment Package and the WHO “Best Buys”. Since policies are the most potent actions we can take vs. NCDs it is important that each jurisdiction develop a policy agenda, then monitor progress in putting the policies into effect. Annual NCD profiles combine NCD surveillance indicators and policy mapping, showing what are the trends in the epidemic, whether the best practice policies have been implemented and are working, and what remains to be done. A=CNMI B=FSM C=Chuuk D=Kosrae E=Pohnpei F=Yap G=Guam H=Palau I=RMI J= Am Samoa

2015 2016 Here is a comparison of NCD M&S elements per jurisdiction, in August 2015 vs August, 2016. You can see more green, less red and yellow as progress is made A=CNMI B=FSM C=Chuuk D=Kosrae E=Pohnpei F=Yap G=Guam H=Palau I=RMI J= Am Samoa

USAPI NCD Surveillance, Data Inputs 2016 NCD Deaths Analysis Up-to-Date Community Based Surveys Up-to-date Youth Surveys NCD Clinical Quality Indicators * Jurisdiction A Yes Planning Jurisdiction B Partly No Jurisdiction C Jurisdiction D Jurisdiction E Jurisdiction F Jurisdiction G Jurisdiction H Jurisdiction I Jurisdiction J Key Messages: This one is about data availability (rather than the organization of NCD M&S) by jurisdiction. Need regular data collection and analysis to do core NCD surveillance. -According to the (PIHOA Board-endorsed) USAPI NCD M&S Framework this includes: analysis of vital stats for NCD cause-specific mortality rates, regular community-based surveys (at least every 5 years) to determine NCD risk and disease prevalence for adults, regular high school surveys to get risk factor prevalence for youth. An additional desirable data input is for tracking of NCD clinical quality indicators in primary care settings. Examples of these indicators are the CHC UDS Measures and the Chronic Care Model indicators, both of which are in limited use in the USAPI. The UDS indicators are required in the CHC program and are currently being monitored once/year manually in all of the CHCs across the USAPI, but systems have not been set up yet to capture them across the public sector primary care clinics on a routine basis, often enough (monthly or quarterly) to use for driving improvement. Guam DPHSS/CHC, Pohnpei CHC and Saipan CHCC/CHC are working toward this with their EHRs, Kosrae is working toward this with a blended paper based- encounter database system, and Palau is planning to do this for BP control of hypertensives (in their Million Hearts project). There is a major opportunity to prevent secondary complications of NCDs by putting these monitoring systems in place. A=CNMI B=FSM C=Chuuk D=Kosrae E=Pohnpei F=Yap G=Guam H=Palau I=RMI J= Am Samoa * Routine reporting in primary care clinics in public sector

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