A logical approach to planning health care services in relation to need Dr Christopher A Birt University of Liverpool

Transcription

1 EUREGIO III A logical approach to planning health care services in relation to need Dr Christopher A Birt University of Liverpool

2 PURPOSE OF A HEALTH SERVICE To utilise resources allocated to the health sector in such a way as to raise, most effectively, the health status of the whole population, taking full account of its known health problems and particular health needs.

3 DEMOGRAPHIC CHARACTERISTICS OF POPULATION Knowing the population: Size and distribution Age structure / old people and children Social class distribution Ethnic mix Inequalities of wealth Gender balance

4 EXAMPLE: NAIRN AND EAST KILBRIDE Nairn: Retirement town, elderly population Low SMR from CVD and cancer Low fertility rate East Kilbride: New town, married couples and families High SMR from CVD and cancer High fertility rate

5 SO THE SERVICES REQUIRED ARE: Nairn needs home-based care of the elderly, treatment services for CVD and cancer and terminal care facilities East Kilbride needs excellent maternity and child care services, population prevention of CVD and cancer and accident & emergency services

6 MEDICAL CARE OVER A CENTURY 1900: Treatment for acute episodes of infectious diseases, Old public health: sanitation, clean water, removing overcrowding. 2010: Chronic diseases: primary prevention, secondary prevention, treatment of acute episodes, rehabilitation. New public health: addressing the major determinants of health.

7 THE MAIN CONDITIONS ARE KNOWN Main conditions in Europe Cardiovascular diseases Neuropsychiatric disorders Cancer Digestive diseases Respiratory diseases Diabetes mellitus Musculoskeletal diseases Sense organ disorders Other NCDs Total Disease burden (DALYs) 23% 20% 11% 5% 4% 1% 4% 4% 5% 77% Deaths 52% 3% 19% 4% 4% 1% 0% 0% 2% 85%

8 CVD causes more >50% of all deaths in Europe Cardiovascular mortality (up to 65 years) in the WHO European Region Last available data <= 300 <= 240 <= 180 <= No data SDR per and is a main contributor to the almost 20 year difference in life expectancy across Europe

9 International comparisons CHD death rates in 2004, men & women aged World Health Organization (2004)

10 200 SDR, ischaemic heart disease, 0-64 per Belgium Finland Hungary Italy Latvia Poland Slovakia Spain United Kingdom

11 IMPACT CHD POLICY MODEL Original Aims To explain falls in CHD mortality in recent decades in some countries and & rises in others Subsequent Aims To predict future trends in CVD mortality To compare policy options for reducing CVD NEJM 2007; 356: 2388.

12 Explaining the fall in coronary heart disease deaths in England & Wales ? ,230 fewer deaths in Unal, Critchley & Capewell Circulation (9) 1101

13 Explaining the fall in coronary heart disease deaths in England & Wales ,230 fewer deaths in 2000 Risk Factors worse +13% Obesity (increase) +3.5% Diabetes (increase) +4.8% Physical activity (less) +4.4% Risk Factors better -71% Smoking -41% Cholesterol -9% Population BP fall -9% Deprivation -3% Other factors -8% Treatments -42% AMI treatments -8% Secondary prevention -11% Heart failure -12% Angina:CABG & PTCA -4% Angina: Aspirin etc -5% Hypertension therapies -3% 1981 Unal, Critchley & Capewell 2000 Circulation (9) 1101

14 IMPACT model: CHD mortality RISE in Beijing In 1999: 1820 Extra deaths attributable to risk factor changes Cholesterol 77% Diabetes 19% BMI 4% Smoking 1% 370 Fewer deaths by treatments AMI treatments 41% Hypertension 24% Secondary prevention 11% Heart failure 10% Aspirin for Angina 10% 1984 Critchley, Capewell et al Circulation : Angina:CABG & PTCA 2%

15 IMPACT model: CHD mortality fall in Finland Risk Factors-71% Cholesterol - 53% Smoking - 11% Blood pressure - 7% 375 fewer deaths in 1997 Treatments-24% AMI treatments - 4% Secondary prevention - 8% Heart failure -2% Angina:CABG & PTCA -8% Angina: Aspirin etc -2% Other Factors -5% Laatikainen et al Am J Epid

16 INTERHEART Study nine potentially modifiable risk factors account for over 90% of the risk of an initial acute myocardial infarction Population attributable risk fractions Smok ing H ypertension Lipids (ApoB/A1 ratio) Abdom obesity Diabetes F ruit & Veg Alcohol Exercise Psychosocial Other Salim Yusuf et al. Effect of potentially Capewellmodifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). Lancet Sept 2004

17 Changes in diet PS ratio predicted a 24% drop in CHD mortality Dietary PS Ratio (polyunsaturated : saturated fat ratio) & CHD mortality in Poland (1990 onwards) superimposed on fat ratio /CHD risk in Nurses' Health Study (NHS) Zatonski & Willett. BMJ

18 SDR, ischaemic heart disease, 0-64 per 10,000 Hungary Czech Republic PolandPoland Source: WHO/Europe, European HFA Database January 2009

19 Potential changes in CHD mortality in England & Wales between 2000 and 2010 IF risk factors a) continue recent trends b) additional reductions already achieved elsewhere Unal et al J Clin Epid Capewell

20 LEVELS OF HEALTH INTERVENTION Primary Prevention Secondary Prevention Tertiary Care Rehabilitation Long Term Care Terminal Care

21 CORONARY HEART DISEASE Primary prevention: avoidance of tobacco and saturated fat Secondary prevention: risk factors raised serum LDL cholesterol, blood pressure Treatment: for acute episodes (medication and surgery) Rehabilitation: after acute attacks and surgery; medication for tertiary prevention Long term care: not usually relevant Terminal care: needed for some cases of heart failure

22 CORONARY HEART DISEASE Primary prevention will consist of two components of health promotion: health education, e.g. to create a nutritionally informed population health protection, to provide healthy food choices available at cheap prices (e.g. by reform of the CAP)

23 THE PREVENTION PARADOX A large number of people at a small risk may give rise to more cases than a small number of people who are at a high risk

24 24

25 BUILDING HEALTHIER HEARTS: IRELAND S CARDIOVASCULAR HEALTH STRATEGY Launched 1999 and addresses: The common aspects of prevention Treatment Rehabilitation of patients with coronary heart disease Overall aims To detect those at high risk To reduce the risk factor profile in the general population To deal effectively with those who have clinical disease To ensure the best survival and quality of life outcome for those who recover from an acute attack

26 80 SDR, trachea/bronchus/lung cancer, 0-64 per , male Belgium Finland Hungary Italy Latvia Poland Slovakia Spain United Kingdom

27 30 SDR, trachea/bronchus/lung cancer, 0-64 per , female Belgium Finland Hungary Italy Latvia Poland Slovakia Spain United Kingdom

28 LUNG CANCER Primary prevention: avoidance of tobacco Secondary prevention: not relevant (screening criteria not satisfied) Treatment: surgery, radiotherapy, chemotherapy usually palliative Rehabilitation: after surgery and other treatments Long term care: not relevant Terminal care: a major component of treatment for this condition

29 INEQUALITIES WITHIN COUNTRIES Socio-economic determinants Distribution of risk factors Burden of disease Access to health services Coping capacity

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31 Policy Levels for Improving Health

32 IRELAND: NEW NATIONAL HEALTH STRATEGY Guiding principles Equity People-centredness Quality Accountability Funding Goals Developing human Better health for everyone resources Fair access Organizational reform Responsive and appropriate Information care delivery High performance Six frameworks for change Strengthening primary care Reform of acute hospital system

33 HEALTH STRATEGY DEVELOPMENT IDENTIFY TOP 10 HEALTH CHALLENGES For each, identify ideal mix of: Primary prevention Secondary prevention Therapy Rehabilitation Long term care Terminal care Then plan services required for this mix

34 TOP 10 ARE LIKELY TO INCLUDE: CVD: population prevention, high risk prevention, treatment, rehabilitation Obesity and diabetes: prevention and lifetime care Cancer: prevention, treatment, terminal care Alcohol and drugs: prevention, treatment, rehabilitation Ageing population: osteoporosis, accidents, care in the community

35 CAPITAL INVESTMENT FOR HEALTH SERVICES IN EUROPE On basis of plan for services: What type of primary care centres are needed, for which services? What types of hospitals / treatment centres are required? Centralised or disseminated? Emergency separated from planned care? Hospitals for rare conditions and superspecialties? What other supporting capital investment is required? Primary prevention initiatives? Rehabilitation centres? Terminal care?

36 RC56 COMPREHENSIVE AND BALANCED Upstream approach Health promotion Disease prevention Spanning the continuum Health-oriented health services Determinants Risk factors Diseases Comprehensive approach: Population-level prevention programmes Targeting high risk individuals Improved quality and coverage of care Systematic reduction of inequalities

37 THANKS FOR YOUR ATTENTION! Any questions? Let`s discuss!

38 ADDRESSING PREVENTION & POLICY ISSUES How can we: Explain falls in CHD mortality? Integrate treatment trends and risk factor trends? Simultaneously consider vast amounts of data? Quantify benefits from treatments and risk factors? Build a model! BUILD A MODEL...!