Cardiovascular Disease Prevention in Lebanon: Are we making progress?

Transcription

1 Cardiovascular Disease Prevention in Lebanon: Are we making progress? Samer Jabbour, MD, MPH Departments of Medicine and Epidemiology & Population Health Faculties of Medicine & Health Sciences American University of Beirut Outline How important is the burden of CVD in Lebanon? What is being done to reduce (control/prevent) the burden of CVD? Are the current strategies effective? What are barriers and opportunities? What is the way forward?

2 CVD Prevention in Lebanon How important is the burden of CVD in Lebanon? What is being done to reduce (control/prevent) the burden of CVD? Are the current strategies effective? What are barriers and opportunities? What is the way forward? Author (year) Abou-Daoud KT (1967) Zurayk H, Faour M & Awn S (1984) Ministry of Social Affairs (1995) Nuwayhid I, Sibai A, Adib S. & Shaar KH (1997) Ministry of Public Health (1999) Sibai A, Fletcher A, Hills M, Campbell O (2001) Sibai A, Nuwayhid I, Beydoun M & Chaaya M (2002) Study Population/ Methodology The 1966 death certificates of the city of Beirut were reviewed and analyzed. A cross-sectional survey of 2752 households in Beirut in Number and causes of deaths in the 2 years prior to the study recorded. The Population and Household Survey (PHS). Around 70,000 households representative of all districts and geographical areas of the country Age and causes of deaths were elicited. A follow-up study conducted in , of 2752 households in Beirut originally interviewed in A total of 1641 households were visited. Number of and causes of deaths over the last 10 years recorded. National Household Health Expenditures and Utilization Survey (NHHEUS). A total of 6544 households representative of the whole of Lebanon. The questionnaire inquired about the number and causes of deaths in the household over the last 12 months. Data covered 32,648 individuals. A follow-up mortality study conducted in 1993 of individuals who were aged 50 years and over in the Beirut-1983 survey. Utilizing a verbal autopsy interview schedule, the next-of-kin of the deceased was interviewed regarding the circumstances and cause of death. A 20% sample of death certificates registered in the Vital Registration System of the city of Beirut covering the years 1974, 1984, 1994, 1997 and 1998 were reviewed and analyzed. The years were selected to represent pre- during and post-war period.

3 Ten-year all-cause and cardiovascular mortality rates among men and women aged > 50 years by age groups All-cause mortality rates per 1000 person-years Age (years) Men Women CVD mortality rates per 1000 person-years Age (years) Sibai AM J Epi Comm Health 2001 Trends in causes of deaths among the Lebanese population, over three decades: Cause of death Beirut Beirut Beirut Beirut Beirut Lebanon Communicable disease* Non-communicable diseases Cardiovascular diseases Neoplasms Other NCDs** Old age & ill-defined Accidents and Injuries Total number of deaths 2, ,092 15,585

4 Proportionate mortality ratios for both males and females by age groups utilizing two different sources of data: Vital registration system and population-based data. Age at death Vital Registration System Beirut, Population and Housing Survey Lebanon, 1995 Males Females Total Males Females Total Total number of deaths ,452 Prevalence of major diseases by sex in Lebanon (in weighted %) Diseases (by major categories) Certain infectious and parasitic diseases Neoplasms Diseases of the blood, blood-forming organs and disorders of the immune system Endocrine, nutritional and metabolic diseases Mental and behavioral disorders Diseases of the nervous system Diseases of the eye and adnexa Diseases of the ear and mastoid process Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system and connective tissue Diseases of the genitourinary system Symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified Others Source: NHHEUS, Males Sex Females Total

5 Most prevalent diseases by sex in Lebanon (in weighted %). Thyroid problems Diabetes Migraine Hypertension Cardiac problems Asthma Digestive ulcers Rheumatoid arthritis Back pain Kidney problems Disease* Abnormal levels of lipoproteins Cataract/Glaucoma Males Sex *Only diseases that exceed 450 cases are listed. Source: NHHEUS, 1999 Females Total Prevalence of most frequently reported health problems by sex (in weighted %) Health Problems* Sex Males Females Total Depression Anxiety Insomnia Eye problems Dizziness Ear problems Cold Allergy Toothache Constipation Joints problems Back pain Cough Shortness of breath Stomach ache Problems in urination Headaches Loss of appetite *Only diseases that exceed 1700 cases are listed. Source: NHHEUS, 1999

6 Reported frequencies of diseases in some health care centers in Lebanon AUB-UHS Malta-Kobyat Malta-Nabatiyeh CATEGORY N % N % N % Accidents Blood disorders Cardiovascular Congenital Dermatology Ear Nose Throat Digestive system diseases Gynecology Infectious diseases Male Genito-Urinary Metabolic disorders Musculoskeletal Neoplasm (Benign) Neoplasm (Malignant) Neurology Not specified Obstetrics Ophthalmology Psychiatric/Behavioral Renal diseases Respiratory diseases Total Medical conditions as reported by MedNet in 1999 Diseases Infectious and parasitic Neoplasms Endocrine, nutritional, metabolic Blood and blood-forming organs Mental disorders Nervous system & sense organs Circulatory system Respiratory system Digestive system Genitourinary system Complications of pregnancy, childbirth and puerperium Skin and subcutaneous tissue Musculoskeletal system and the connective tissue Congenital Anomalies Certain conditions originating in the Perinatal period Symptoms, signs, and ill-defined conditions Injury and poisoning Death Emergency Organ or tissue replacement Any disease TOTAL Frequency 1,781 2, ,592 2,295 3,368 3,501 2,623 3, , ,676 10, ,941

7 Distribution of hospitalized cases by reason Reason* Distribution in % Certain infectious and parasitic diseases 5.5 Neoplasms 2.7 Diseases of blood and disorders involving 1.1 immunity mechanisms Endocrine, nutritional and metabolic diseases 2.4 Mental and behavioral disorders 2.0 Diseases of the nervous system 1.2 Diseases of the eye and adnexa 3.2 Diseases of the ear and mastoid process 1.3 Diseases of the circulatory system 13.2 Diseases of the respiratory system 12.4 Diseases of the digestive system 10.9 Diseases of the skin and subcutaneous tissue 0.8 Diseases of the musculoskeletal system and 5.5 connective tissue Diseases of the genitourinary system 10.0 Pregnancy, childbirth and the puerperium 10.7 Symptoms, signs, and abnormal clinical lab 0.3 findings (not elsewhere classified) Certain conditions originating in the perinatal 14.9 period and congenital malformations Injury, poisoning and certain other external causes 8.1 of morbidity and mortality Factors influencing health status+ contact w. 3.9 health services Number of cases of hospitalization= 100% (non weighted) Number of cases of hospitalization= 100% 3981 (weighted) Hospitals discharge diagnoses Disease Classification Group 1-Communicable, maternal, perinatal and nutritional conditions Maternal conditions Respiratory infections Conditions arising during the perinatal period Infectious and parasitic diseases Nutritional deficiencies Group 2 -Noncommunicable diseases Cardiovascular diseases Genitourinary diseases Digestive diseases Musculoskeletal diseases Malignant neoplasms Endocrine disorders Respiratory diseases Sense organ diseases Diabetes mellitus Congenital anomalies Other neoplasms Skin diseases Oral conditions Group 3-Injuries Unintentional injuries Intentional injuries Frequency

8 CVD Prevention in Lebanon How important is the burden of CVD in Lebanon? What is being done to reduce (control/prevent) the burden of CVD? Are the current strategies effective? What are barriers and opportunities? What is the way forward? CVD Prevention & Control Efforts in Lebanon Clinical interventions Emphasis on prevention? Community-based interventions Availability and coverage? Population-wide interventions Role of Ministry of Public Health and international organizations

9 Clinical interventions for CVD More than XX cardiologists and XX cardiac surgeons High competition for care Plethora of highly specialized cardiac services 23 centers for cardiac surgery Inadequacy of non-physician essential cardiac care staff Nurses, smoking cessation counselors Abundance of imported trade cardiac drugs cheap generic and essential cardiac drugs far less available. Clinical interventions for CVD Old models for cardiac care Little emphasis on the comprehensive vascular model Fragmented, discontinuous care Little involvement by non-physician personnel High quality acute care Over-utilization common Opportunities for prevention commonly missed Poor financing scheme MOPH pays for cardiac interventions for the uninsured (40% of the population) but this is not linked to promotion of prevention or use of locally relevant guidelines Cardiac interventions account for > 60% of MOPH s expenditures on acute care

10 Community-based CVD programs No ongoing community-based programs Important role by NGO Making essential drugs for chronic (including CVD) diseases available in PHC centers Not linked to quality of care or ensuring emphasis on prevention of CVD. A sole community-based study was conducted A research study based on community mobilization in a Beirut neighborhood First community-based intervention study for CVD in the Arab world.

11 Community partners Housewives Representatives from health centers Shop owners Representatives of NGO s Pharmacy owners School Principals Mokhtar Lay persons Dynamic Process Continuously welcoming new interested members

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13 Interventions Specific interventions for priority targets (smoking, physical activity, nutrition) Antismoking poster campaign Community heart healthy cooking Cross-cutting interventions Community heart health fair Lecture series Fundraising concert Screening day

14 Strengths & limitations Strengths Multidisciplinary and multidimensional Participatory in approach based on community organizing and coalition building Limitations Limited resources limited scope of interventions Too short for assessment of outcomes Long-term sustainability not clear Lessons learned Community- based approach is feasible No community is homogenous All communities are unique:can not duplicate work of past projects Sustainability issues need to be incorporated early on Empowerment is an important outcome Capacity building is an essential component

15 Population-based CVD programs National Non-Communicable Disease Program Established in 1997 Joint MOPH WHO program Focus on CVD, cancer, HTN & diabetes Objectives: Data collection and management Update knowledge and increase awareness Produce guidelines Establish national registries Working Strategy of NCDP Establishment of advisory boards Development of a national plan of action Production of educational material: multiple messages, brochures, posters Production of guidelines Training of trainers for management, awareness and prevention.

16 Working Strategy of NCDP Establishment of specialized centers for care and prevention. Determination of the role of mass media with the national Program. Establishment of a comprehensive and collaborative working team. Strengthen research capabilities Limitations of NCDP Social determinants/political economy of CVD & risk factors not addressed No emphasis on public health, Predominance of biomedical model Weak role of the state after the civil war Little emphasis on policy interventions & regulatory leverage No integration of CVD prevention and control in primary health care No critical mass of staff or resources A national plan of action requires clear vision

17 A COMPREHENSIVE FRAMEWORK FOR CARDIOVASCULAR HEALTH: The progressive development of CVD and opportunities for CVH promotion and CVD prevention The progressive development of CVD (heart disease and stroke) UNFAVORABLE ADVERSE MAJOR FIRST EVENT/ DISABILITY/ LATE SOCIAL AND BEHAVIORAL RISK SUDDEN DEATH RISK OF DEATH ENVIRONMENTAL PATTERNS FACTORS RECURRENCE CONDITIONS WHOLE POPULATION WHOLE POPULATION ESTABLISHED RISK FACTORS: SMOKING, HBP, TC, DM FIRST FATAL OR NON-FATAL EVENTS/YR: MI, STROKE, CHF SURVIVORS >1 YR: MI, STROKE, CHF LATE DEATHS /YR CVD POLICY AND BEHAVIOR RISK FACTOR EMERGENCY REHABILITATION/ END-OF- ENVIRONMENTAL CHANGE DETECTION CARE/ACUTE LONG-TERM CARE LIFE CHANGE AND CONTROL CASE MANAGEMENT CARE Prevention of risk factors in the first place - 0 O Cardiovascular health promotion 1 O 2 O 3 O Cardiovascular disease prevention Palliation INCREASE QUALITY AND YEARS OF HEALTHY LIFE ELIMINATE HEALTH INEQUALITIES GOAL 1 GOAL 2 GOAL 3 GOAL 4 Opportunities for CVH promotion and CVD prevention CVD Prevention in Lebanon How important is the burden of CVD in Lebanon? What is being done to reduce (control/prevent) the burden of CVD? Are the current strategies effective? What are barriers and opportunities? What is the way forward?

18 Facilitators Need to change path! Little progress in decreasing CVD burden despite the increasing investment in cardiac care High cost of care unsustainable Increasing public knowledge about importance of prevention Consumer dissatisfaction / mistrust Pressures on Lebanese government to act for budgetary reasons Need to change path! Barriers Public pressure for change is inadequate and not organized. Powerful medical-industrial industrial complex has little incentives for change. No visionary governmental policy and lack of adequate resources for a big job. Absence of a critical mass of health professionals who can produce change.

19 CVD Prevention in Lebanon How important is the burden of CVD in Lebanon? What is being done to reduce (control/prevent) the burden of CVD? Are the current strategies effective? What are barriers and opportunities? What is the way forward? What is the way forward? Mobilize the public Strengthen public health capacity Develop vision for national action and corresponding strategies that work Engage/provide incentives for the medical profession to change course Monitor progress Cooperate with regional and international partners

20 Summary How important is the burden of CVD in Lebanon? Very important Both mortality and morbidity as well as health care utilization What is being done to reduce (control/prevent) the burden of CVD? High cost clinical care with little emphasis on prevention No community-based interventions Inadequate population-based program Summary Are the current strategies effective? What are barriers and opportunities? No. Facilitaors & barriers identified Identified gaps in current programs What is the way forward? Vision for a national action strategy Mobilization of the public Building public health capacity Cooperation with regional and international partners

21 An ounce of prevention is better than.. Our Grandmothers