David R MacLean MD Professor & Director Institute for Health Research & Education Simon Fraser University 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: 215,669 Cardiovascular (ICD ); Respiratory (ICD ); Diabetes (ICD-9 250); Cancer (ICD ); Infectious Diseases (ICD ); Accidents/Poisonings/Violence (ICD-9 E800-E999) Source: Statistics Canada, 1997 All Cardiovascula r Disease (79,457) 36% Leading Causes of Death - Canada, 1997

Indirect and Direct Costs of Illness Canada, 1993 $ 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 PROFESSIONALS OTHER INSTITUTIONS CAPITAL L OTHER HEALTH SPENDING $25 (31%) $11 (15%) $11 (14%) $10 (13%) $8 (10%) $2 (3%) $11 (14%)

Total Indirect Costs of Illness Canada, 1993 $ 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. Source: Hospital Morbidity Database, Canadian Institute for Health Information

Figure 3-1Proportion of adults who report having heart problems by age group and sex, Canada, 1996/97. Source:Statistics Canada, National Population Health Survey, 1996/97.

Figure 3-2Proportion of First Nations and Inuit adults who report having heart problems by age group and sex, Canada, 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. Source: Statistics Canada, NPHS, 1996/97

Age-standardized mortality rate per 100,000 women, Canada, Age-standardized to 1991 Canadian Population Source:Laboratory Centre for Disease Control; Statistics Canada

Age-standardized mortality rate per 100,000 men, Canada, Age-standardized to 1991 Canadian population Source:Laboratory Centre for Disease Control; Statistics Canada

Source:LCDC, Health Canada, unpublished work Number of cardiovascular disease deaths by sex, actual and projected, Canada,

Source: LCDC, Health Canada Number of hospitalizations for cardiovascular disease, actual and projected by sex, Canada,

Source: LCDC, Health Canada Number of hospitalizations for ischemic heart disease, by sex, actual and projected, Canada,

Number of hospitalizations for cerebrovascular disease, actual and projected by sex, Canada, Source:LCDC, Health Canada

Cancer Mortality Trends for Selected Sites in Canadian Males Cancer Bureau, LCDC, Health Canada

Trends in Cancer Incidence for Selected Sites in Canadian Males Cancer Bureau, LCDC, Health Canada

Cancer Mortality Trends for Selected Sites in Canadian Females Cancer Bureau, LCDC, Health Canada

Trends in Cancer Incidence for Selected Sites in Canadian Females Cancer Bureau, LCDC, Health Canada

Prevalence Of Self Reported Diabetes in Canada By Sex MacLean et al Canadian Heart Health SurveysAge 18 to 74 years

Prevalence of Self Reported Diabetes in Canada by Age and Sex MacLean et al Canadian Heart Health Surveys

Prevalence of Self Reported Diabetes in Canada by Age of Diagnosis and Sex MacLean et al Canadian Heart Health Surveys

Educational Achievement by Diabetes Status in Canadian Males MacLean et al, Canadian Heart Health Survey Elementary : yrs Some Secondary : yrs Secondary Completed: yrs University: 16 yrs or more

Educational Achievement by Diabetes Status in Canadian Females MacLean et al, Canadian Heart Health Survey Elementary : yrs Some Secondary : yrs Secondary Completed: yrs University: 16 yrs or more

Self Reported Diabetes Status by Age Group In Canada MacLean et al Canadian Heart Health Surveys

Prevalence of Modifiable CVD Risk Factors by Self Reported Diabetes Status in Canada MacLean et al Canadian Heart Health Surveys

Distribution of Modifiable CVD Risk Factors by Self Reported Diabetes Status in Canada 3 MacLean et al Canadian Heart Health Surveys

Proportion of youth aged years who smoke cigarettes daily by sex, Canada, /97. Source:Statistics Canada, catalogues , vol 7, no. 3; ; Canadians and smoking: An update. Health and Welfare Canada, General Social Survey, Statistics Canada, Survey on Smoking in Canada, Cycle 3, National Population Health Survey, Statistics Canada, 1996/97.

Prevalence of Daily Smoking Among Canadian Youth Aged Years by Province Source: Statistics Canada

Nova Scotia Adult Smoking Rates (15+) Compared to Manitoba Source: Statistics Canada, Population Health Reports,

Awareness, treatment, and control of hypertension in Canada The Canadian Heart Health Surveys Joffres et al

Proportion of adults who are physically inactive by province, Canada, 1996/97. Source:Statistics Canada, National Population Health Survey, Cycle 2, 1996/97

Proportion of adults who are overweight by province, Canada, 1996/97. Source:Statistics Canada, National Population Health Survey, Cycle 2, 1996/97

Prevalence of Obesity Among U.S. Adults BRFSS, %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

INGREDIENT

Commonality Of Risk Factors Smoking Unhealthy diet Overweight Sedentary lifestyle Alcohol abuse Psychosocial stress RISK FACTORS Cardiovascular disease Cancer Diabetes Chronic respiratory conditions Mental ill-health MAJOR CHRONIC DISEASES

Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged years from 1969 to Mortality per population

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

Life Expectance at Birth in Canada Source: Statistics Canada

Getting Older Population Aged 65 and Over As a Percentage of Population 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

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 …