Preventive care - Chronic Disease Management in primary care: a population perspective Rod Jackson University of Auckland New Zealand (22/11/8) Key causes of preventable deaths in New Zealand In a population of 1, New Zealanders, every year there will be about: 1 coronary & stroke deaths 1 diabetic death 1 breast cancer death 1 prostate cancer death 1 suicide every year 1 road traffic death (1 cervical cancer death every 5 years) NZHIS annual mortality statistics Burden of disease in NZ: IHD Stroke CORD Diabetes Depression Asthma Anxiety Lung cancer Road traffic Colorectal ca Dementia Breast ca Suicide/self harm LRTI Osteoarthritis Hearing disorders Prostate ca Substance Burden of dise Due to disease and injury outcome (No. DALYs/1) 1 2 3 4 5 6 7 8 Peripheral arterial Lymphoma/myeloma Martin Tobias MoH 23 Vascular disease management 1
The main causes of CHD & stroke smoking* Burden of disease in NZ: 8 Due to risk factors (No. deaths) 5 1 15 2 25 3 35 4 45 5 Tobacco Cholesterol high blood cholesterol / saturated fat diet* Blood pressure Body mass index Physical inactivity Microbes (infection) Inadequate F&V intake Diabetes high blood pressure* * these 3 factors explain most events in populations Alcohol Violence Other injury hazards Road traffic crashes Radiation (ultraviolet) Sexual behaviours Illicit drug use Martin Tobias MoH 23 4 Smoking prevalence in NZ: 1976-24 P e r c e n t 6 Smoking prevalence in NZ by ethnicity P e r c e n t 35 5 3 % 25 2 4 % 3 15 2 1 5 1976 19811983 19841985 19861987 19881989 1991991 19921993 1994199519961997 19981999 221 222324 Y e a r year 1 M_o r i Pacific peoples European/Other 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 Y e a r year Blood cholesterol & CHD death CHD PSC. Lancet 27; 37: 1829 39 2
CHD: A. HDL; B. non-hdl; & C. TC/HDL Trends in TC/HDL ratio in Auckland 1982-23 CHD PSC. Lancet 27; 37: 1829 39 Metcalf et al. NZMJ 26 Blood pressure & IHD Type 2 Diabetes is not a disease! 4. Total stroke 4. Total ischaemic heart disease 4. Cardiovascular death Hazard ratio & 95% CI 2. 1. 2. 1. 2. 1..5 4.5 5. 5.5 6. 6.5 7. 7.5.5.5 4.5 5. 5.5 6. 6.5 7. 7.5 4.5 5. 5.5 6. 6.5 7. 7.5 Usual fasting glucose (mmol/l) PSC. Lancet 22; 36: 193 132 Asia Pacific Cohort Studies Collaboration. Diabetes Care 24;27:2836-42 The average NZder is overweight Everyone is getting fatter The optimal BMI Metcalf et al. NZMJ 17 November 26, Vol 119 No 1245. URL: http://www.nzma.org.nz/journal/119-1245/238 Metcalf et al. Auckland studies (unpublished) 3
CHD mortality trends in 35-69 year-old New Zealanders 195-25 www.mortrends.org Stroke mortality trends in 35-69 year-old New Zealanders 195-25 Contribution of changes in risk factors to trends in CHD in New Zealand www.mortrends.org Tobias et al. ANZJPH 28;32: 117-25 Estimated trends in systolic blood pressure by sex, New Zealand: 198-24; standardised for age (35-64 years) Estimated trends in blood cholesterol by sex, New Zealand: 198-24; standardised for age (35-64 years) 4
Estimated trends in tobacco smoking by sex, New Zealand: 198-24; standardised for age (35-64 years) Estimated contribution of risk factor changes to CHD trends by sex, New Zealand: 198-24; standardised for age (35-64 years) 22% 31% 2% 73% 15% 35% 39% 87% Trends in systolic blood pressure in normal, overweight & obese Aucklanders NZ & Japan: CHD mortality 35-69 yrs Metcalf et al. unpublished 28 www.mortrends.org Annual deaths per 5, people 4 35 3 25 2 15 1 Annual deaths from IHD per 5, 5-64 yrs: 195-23 Australia men NZ men 5 195 196 197 198 199 2 Year 5
Please put out that cigarette, grandpa Offer brief advice and NRT to all smokers every time you see them! Ashley Bloomfield MoH 28 Source: Jamrozik K, Dobson A, Tobacco Control, August 1999 Advise all patients to eat less SF Per capita availability of butter 23 Sources of saturated fat in New Zealand diet 1.9 kg/person per yr 3.2 kg/person per yr http://faostat.fao.org/ Eat less salt Aspirin + Statin + BP drugs = > 5% CVD Aspirin Statin ACEI ± Diuretic ± BB ± CCB 6
Benefit of treatment is directly proportional to the pre-treatment risk Difficult to estimate risk in your head Absolute CVD risk by SBP ± other risk factors Usage of CVD risk charts by GPs in NZ: 1999-2; after 6 yrs of risk-based guidelines n= 5 (RR =83%) Never 6% < once per month 39% About once per month 24% > twice per month 31% Jackson et al. Lancet 25. 365:434-4 Arroll. N Z Fam Physician. 22;117:177-183 Percentage on combined BP & lipid lowering medication by 5 year absolute CV risk: 2-3 6 5 % on BP & C medication 4 3 2 1 2 21 22 23 CV 1 history 2% 2 15 3 - <2% 1 4 - <15% 5 5 - <1% <5% 6 Risk 7 not estimable Unpublished data Risk could only be estimated on 1/3 patients Impact of electronic decision support in 1 o care % documented 16% 14% 12% 1% 8% 6% 4% 2% % Documentation of 5yr absolute CVD risk pre Prompt Audit time period post Prompt CVD risk nonmaori CVD risk Maori Wells S et al. Eur J Cardiovasc Prev Rehab 28;15:173-8 7
Framingham predicted versus observed CVD event rates in NZ primary care (35-74 yrs) OBSERVED (Cumulative incidence (%) of CVD event in 5 years (95%CI)) 3 25 2 15 1 5 Framingham Performance: Threshold Discrimination Event rates by risk category 1% 13% 9% 7% 8% 1% 53% 7% 6% Hx CVD 15+% 5% 1-<15% 4% 11% <1% 7% 3% 11% 2% 24% 1% 5 1 15 2 25 3 PREDICTED (Framingham score, 5-year risk, %) Preliminary analyses on PREDICT patient population, personal communication Sue Wells 28 % % of total people (n=44842) % of total events (n=2314) Preliminary analyses on PREDICT patient population, personal communication Sue Wells 28 8