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Cardiovascular health in Australia: Current state and future directions
Cardiovascular Health In Australia: Current State And Future Directions Andrew M. Tonkin, MD, FRACP,~ Adrian E. Bauman, FXD, FAPPHM,~ Stan Bennett, ~HD,~ Annette J. Dobson, PHD,~ Graeme J. Hankey, MD, FRACP,~ Ian T. Ring, FAPPHM 6 INational Heart Foundation of Australia, Xlniversity of New South Wales, 3Australian Institute of Health and Welfare, 4University of Newcastle, 5Royal Perth Hospital and University of Western Australia, 6James Cook University on behalf of the National Health Priority Committee’s Expert Advisory Group on Heart, Stroke and Vascular Disease
Adopting new approaches that build on existing activities was the recommendation of The National Health Priority Areas Report on cardiovascular health, released on 4th August 1999. The report, prepared biennially for Australian Health Ministers, presented the following key recommendations for further improving the cardiovascular health of Australians: establishing a long-term national focus on heart disease; coordinating primary prevention programs across Australia; establishing a national mechanism for the production of better practice guidelines; broadening the focus of cardiovascular disease programs to give more emphasis to stroke; addressing issues of inequalities of health status among disadvantaged groups; and expanding the activities of the National Centre for Monitoring Cardiovascular Disease to allow for future strategic planning. (Asia Pacific Heart J 1999;8(3):183-187) Introduction
Direct healthcare costs for cardiovascular disease were estimated at $3.7 billion in 1993-94,3 which was 12% of total direct healthcare costs in Australia that year. Hospital expenditure accounted for 41% of the costs for cardiovascular disease, pharmaceutical costs for a further 20%, and expenditure on nursing homes and medical services each accounted for about 15%. Expenditure on prevention and screening amounted to only 0.3% of the total cost of cardiovascular disease.
The recent release of The National Health Priority Areas Report on cardiovascular health 1 details the current state of cardiovascular health in Australia. The report is one of a series of biennial reports to Australian Health Ministers on each National Health Priority Area: cardiovascular health, cancer control, mental health, injury prevention and control, and diabetes mellitus. The report describes trends in risk factors and disease (Table 1) over recent decades and estimates the value of different opportunities for improving future cardiovascular health. It contains messages which may be valuable to countries in which the associated burden of cardiovascular disease is increasing.
Table 1. Summary of trends in cardiovascularrisk factor prevalenceand diseases. Favourable trend
Current Size of the Problem Cardiovascular disease is the largest cause of premature death, and death overall, in Australia, accounting for 42% of all deaths in 1996. It is also responsible for much ill-health and disability. Of cardiovascular conditions, coronary heart disease is the major cause of death in those aged less than 70 years, and stroke is the leading cause of chronic disability. In 1996-97, 8% of all hospital separations listed a cardiovascular disease as the principal diagnosis. In 1990-9 1, cardiovascular conditions were the second most frequently managed problems in general practice, after respiratory problems, accounting for 12.5% of the total.*
183
Smoking rates in adults Blood pressure levels Contribution of saturated fat to total energy intake Coronary heart disease death rates Stroke death rates
Little or no change
Smoking rates in adolescents Participation in physical activity
Unfavourable trend
Prevalence of overweight or obesity
Insufficient data
Cholesterol levels Incidence of heart attack or stroke Disability rates
No national data
Time to hospital from symptom onset Use of rehabilitation programs Angioplasty or bypass surgery outcomes Case fatality rates
Asia Pacific Heart .I 1999;8(3)
Tonkin, Bauman,Bennett,Dobson,Hankey,Ring Cardiovascular health in Australia
Deaths per 100,000 population
190
All causes
19!70
1954
1458
1962
1966
1970
1974 Year
1978
1982
Note:
Age standardised to the Australian population at 30 June 1991.
Source;
AIHW National Mortality Database.
1986
19%
1994
19%
Fig. 1. Trends in heart, stroke and vascular disease mortality among females, Australia, 1950-1996. $ (millions)
Pharmaceutical Hospital-admitted patient 4co -.
O-24 Source:
25-34
3544
45-54 Age group (years)
55544
Mathers & Penm (1999).
Fig. 2. Costs of heart, stroke and vascular disease healthcare, Australia, 1993-1994.
Trends in Mortality and Risk Factor Prevalence
Groups at Higher Risk
Cardiovascular mortality rates have more than halved over recent decades, among both males and females (Fig. 1). This decline is more rapid than for non-cardiovascular mortality. Despite this decline, however, rates remain high compared with other developed countries,4 indicating the potential for further lowering the death rate from cardiovascular disease in Australia. In particular, mortality rates for coronary heart disease are more than 5 times those of Japan and several times those of France and Southern Europe. National Heart Foundation Risk Factor Prevalence Surveys in 1980, 1983 and 1989 and the 1995 Australian Bureau of Statistics National Health Survey show favourable trends in a number of the major cardiovascular risk factors. These include decreased smoking rates in adults, falling blood pressure levels and a lower contribution of saturated fat to total energy intake. However, there has been little or no change in smoking rates in adolescents, nor participation in physical activity. Of particular concern is the increasing prevalence of overweight and obesity.
There is a clear gradient of increasing agestandardised death rates with increasing socio-economic disadvantage, with people from the most socioeconomically disadvantaged group being almost twice as likely to die from cardiovascular disease as those from the least socio-economically disadvantaged group. This difference existed throughout the 1970s and 198Os, and has persisted into the 1990~5 Smoking is almost twice as common among disadvantaged people. Excessive alcohol consumption, physical inactivity, obesity and high blood pressure are also more prevalent in lower than in higher socio-economic groups. Indigenous Australians die from cardiovascular disease at twice the rate of non-indigenous Australians. The most striking difference is in mortality from rheumatic heart disease, which is 11 times higher in indigenous males and 7 times higher in indigenous females than in the general population, and is among the highest in the world. Rates of smoking, high-risk alcohol use and diabetes in indigenous Australians are more than twice those in the non-indigenous population. Obesity and physical
184
Asia
PacificHeartJ 1999;8(3)
Tonkin,Bauman,Bennett,Dobson,Hankey,Ring Cardiovascular health in Australia
Number of patients (‘000s) 1,cJoo 900 Kc 7co 600 5!n 400 cm 203 100 0 19% Source:
2016 66-75year olds
ziTx?6
19%
2016 75+ year olds
2Yx
Kelly (1997).
Fig. 3. Projectednumbersof older patientswith certain heart, stroke and vascular conditions,Australia.
inactivity are also known to be more prevalent indigenous people.
Integrated Approaches to Prevention and Treatment
in
Overall, it is estimated 1 that 41% of deaths and 38% of non-fatal events for coronary heart disease could be prevented through better application of existing knowledge. It is also clear that the impact of stroke can be reduced, mainly by primary prevention, and also by effective management of stroke and secondary prevention. l
Mortality from cardiovascular disease, other than rheumatic heart disease, is marginally higher in rural and remote areas than in urban areas. The major issues for remote populations relate to access to services rather than health differentials. Clustering of risk factors also increases the risk of cardiovascular disease. 80% of adult Australians have 1 modifiable cardiovascular risk factor, while 10% have 3 or more modifiable risk factors.6 An example of this clustering is the “metabolic” syndrome which includes glucose intolerance, dyslipidaemia, hypertension and abdominal adiposity, which greatly increases the risk of both cardiovascular disease and diabetes.
Scope of Prevention There is immense potential to improve cardiovascular health, because the disease is largely preventable. In addition, because the behavioural and physiological risk factors for cardiovascular disease often also play a role in the development of other common non-communicable diseases including diabetes and some cancers, an increased investment in prevention is likely to have a broader impact on overall population health.
Importance of Ageing of the Population Despite the downward trends in death rates, the burden of cardiovascular disease is likely to rise. This is because of an ageing population caused by the shift of “baby boomers” to beyond middle-age, and to decreases in acute myocardial infarction case-fatality rates in younger age groups.
To be most effective, prevention needs a combination of legislative, educational and economic approaches. The reduction of tobacco smoking, for example, has been largely due to just such an approach. There are many opportunities available to decrease smoking further, and promote physical activity, good nutrition, the reduction of overweight and obesity and the successful management of risk factors. It is now recognised that, although the health sector should take the lead in preventive actions, more lasting effects will result if it forms long-term partnerships and alliances with other sectors.Work is in progress at Commonwealth, State/Territory and regional levels to establish such partnerships and develop a National primary prevention Strategy to integrate programs on physical activity, diet, tobacco and alcohol, and target the major chronic noncommunicable diseases.
More than 2.2 million Australians in 1993-94 were aged 65 years or more. They were 12% of the population, but accounted for over two-thirds of the cardiovascular healthcare costs (Fig. 2). Over 50% of these people were reported to have some form of cardiovascular disease. Over the next 30 years, the ageing of the population is expected to lead to an approximate 2-fold increase in the prevalence of conditions such as coronary heart disease, stroke, heart failure and hypertension7 (Fig. 3) and their treatment with drugs and other medical interventions will place increasing pressure on the healthcare system. To reduce this impact, more emphasis will be needed on preventing and reducing disability and improving quality of life in this age group.
Secondary prevention and rehabilitation Perhaps the greatest gains for coronary heart disease outcomes can be achieved through aggressive secondary
185
Tonkin, Bauman, Bennett, Dobson, Hankey, Ring Cardiovascular health in Australia
Asia Pacific Heart J 1999;8(3)
(healthcare cards);
prevention involving appropriate use of coronary bypass surgery and angioplasty, drug treatment and lifestyle changes.1 Similarly, drug treatment and lifestyle changes would have a major impact on recurrent strokes.1
l
l
Treatment Treatment advances such as reperfusion therapy for acute coronary syndromes, proven therapies for secondary prevention and better techniques for revascularisation have all contributed to improved outcomes for patients.
l
Despite continuing advances in the management of cardiovascular disease, in many areas there is wide variation in practice. The development and endorsement of guidelines to encourage evidence-based practice are being continued by the Commonwealth, with the involvement of specialist colleges and non-government organisations. An appropriate structure for the regular review, dissemination and implementation of these guidelines is essential. At present, little is known about their impact on use rates, health outcomes or costs.
Coordinating primary prevention across major health issues. Effective national action in these areas will require coordination across different program areas, consistent health messages and adequate funding. Establishing a national mechanism for development, review and implementation of better practice guidelines. To ensure optimal uptake, a nationally coordinated process to ensure that regularly updated systematic reviews and guidelines are available should be linked to local planning and quality improvement processes for implementation.
Monitoring and Information Management Monitoring disease trends and differentials, and applying technology to improve information management, are increasingly used to address issues in cardiovascular health. The National Centre for Monitoring Cardiovascular Disease, at the Australian Institute of Health and Welfare, is developing an integrated information system that will cover major aspects of prevention, management and mortality for individual cardiovascular conditions, as well as monitoring differences between population groups. There is an urgent need for a national risk factor prevalence survey, which involves taking a blood sample from participants in association with the collection of relevant dietary information.
Ensuring that any national focus on heart, stroke and vascular disease includes a specific focus on stroke. Stroke has received less emphasis and funding than coronary heart disease. Any national program for cardiovascular disease should address additional stroke-related issues across the continuum of care. Tackling the underlying causes of inequalities in health among, in particular, the indigenous population. A key aim of public policy in the next millennium must be to design cross-sectoral interventions that improve the health of disadvantaged people and reduce gaps in healthcare.
More generally, a range of evolving technologies is being explored, including: further
evaluation
of portable
medical
use of information technology to facilitate education of health professionals working in remote regions.
Establishing a secure long-term national focus on cardiovascular disease from which policies and activities can emanate. National approaches exist for other National Health Priority Areas, and major achievements have occurred with other national programs such as HIV control and screening for cervical cancer. A similar multi-disciplinary approach would help to coordinate the prevention and guide the management of cardiovascular disease.
Practice Guidelines
l
to improve
Given the size of the health burden, and the extent of knowledge on which to base further endeavours, there is great potential to improve the overall health of a population through changes in cardiovascular health. Achieving this potential requires new approaches which build on existing activities. In Australia, there is still a great challenge to achieve adequate funding for prevention and treatment, and integration of effort and long-term strategic planning. These are addressed in the following priority areas for cardiovascular health identified in the NHPA report:
In stroke treatment, it has been found that acute inpatient care in dedicated units by a multidisciplinary stroke service reduces the odds of death and dependency after stroke by nearly 30%.* However, there are currently insufficient stroke units to meet national needs.
unique patient identifiers to facilitate record linkage;
further development of telemedicine access to clinical expertise; and
Key Recommendations of NHPA Report’
Epidemiological shifts are changing the nature of treatment for cardiovascular disease. For example, in coronary heart disease, unstable angina has overtaken acute myocardial infarction as the major acute coronary syndrome seen in hospitals. This has implications for cardiology units and chest pain units in emergency departments, with greater numbers of less intensively nursed but monitored cardiac beds being required.
l
increasing the use of computerised clinical records in general practice;
Continuing and expanding the activities of the National Centre for Monitoring Cardiovascular
records
186
Asia Pacific Heart J 1999;8(3)
Tonkin, Bauman, Bennett, Dobson, Hankey, Ring Cardiovascular health in Australia
Disease. Regular collections of survey data on risk factors, including lifestyle and biomedicalrisk factors of public healthsignificance,are neededto help direct and evaluatepreventiveand treatmentactivities.
size of middle-aged and elderly age groups, among whom non-communicable diseasesare most likely to develop. Population shifts from rural areas to urban environments, coupled with economic well-being, are exposing large numbersof people to a more “Western” lifestyle. However, the fact that behaviourscan have an impact across a number of risk factor areasand indeed, diseasestates(cardiovasculardiseases,diabetesand some cancers),emphasisesthe needfor coordinatedpreventive
What Are the Broader Messages? Cardiovasculardiseaseis increasingrapidly in Asian populationsfor a number of reasons.Decreasedfertility and mortality rates are leadingto increasesin the relative
Bennett SA. Socioeconomic inequalities in coronary heart disease and stroke mortality among Australian men, 1979-1993. International Journal of Epidemiology 1996;25:266-75. Australian Institute of Health and Welfare. Heart, stroke and vascular diseases, Australian facts. Canberra: AIHW Cat No CVD 7. Australian Institute of Health and Welfare and the Heart Foundation of Australia (Cardiovascular Disease Series No. lo), 1999. Kelly DT. Our future society. A global challenge. Circulation 1997;95:2459-64. Stroke Unit Trialists’ Collaboration. How do stroke units improve patient outcomes: A collaborative systematic review of the randomized trials. Stroke 1997;28:2139-44.
References 1. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare. National health priority areas report: Cardiovascular health 1998. Canberra: AIHW Cat No PHE 9. HEALTH and AIHW, 1999. 2. Bridges-Webb C, Britt H, Miles DA, et al. Morbidity and treatment in general practice in Australia, 1990-1991. Medical Journal of Australia 1992;157(Special Supplement):Sl-S56. 3. Mathers C, Penm R. Health system costs of cardiovascular disease and diabetes in Australia, 1993-94. Canberra: AIHW Cat No HWE 11. Australian Institute of Health and Welfare, 1999. 4. de Looper M, Bhatia K. International health - how Australia compares. Canberra: AIHW Cat No PHE 5. Australian Institute of Health and Welfare, 1998.
187
Adopting new approaches that build on existing activities was the recommendation of The National Health Priority Areas Report on cardiovascular health, released on 4th August 1999. The report, prepared biennially for Australian Health Ministers, presented the following key recommendations for further improving the cardiovascular health of Australians: establishing a long-term national focus on heart disease; coordinating primary prevention programs across Australia; establishing a national mechanism for the production of better practice guidelines; broadening the focus of cardiovascular disease programs to give more emphasis to stroke; addressing issues of inequalities of health status among disadvantaged groups; and expanding the activities of the National Centre for Monitoring Cardiovascular Disease to allow for future strategic planning. (Asia Pacific Heart J 1999;8(3):183-187) Introduction
Direct healthcare costs for cardiovascular disease were estimated at $3.7 billion in 1993-94,3 which was 12% of total direct healthcare costs in Australia that year. Hospital expenditure accounted for 41% of the costs for cardiovascular disease, pharmaceutical costs for a further 20%, and expenditure on nursing homes and medical services each accounted for about 15%. Expenditure on prevention and screening amounted to only 0.3% of the total cost of cardiovascular disease.
The recent release of The National Health Priority Areas Report on cardiovascular health 1 details the current state of cardiovascular health in Australia. The report is one of a series of biennial reports to Australian Health Ministers on each National Health Priority Area: cardiovascular health, cancer control, mental health, injury prevention and control, and diabetes mellitus. The report describes trends in risk factors and disease (Table 1) over recent decades and estimates the value of different opportunities for improving future cardiovascular health. It contains messages which may be valuable to countries in which the associated burden of cardiovascular disease is increasing.
Table 1. Summary of trends in cardiovascularrisk factor prevalenceand diseases. Favourable trend
Current Size of the Problem Cardiovascular disease is the largest cause of premature death, and death overall, in Australia, accounting for 42% of all deaths in 1996. It is also responsible for much ill-health and disability. Of cardiovascular conditions, coronary heart disease is the major cause of death in those aged less than 70 years, and stroke is the leading cause of chronic disability. In 1996-97, 8% of all hospital separations listed a cardiovascular disease as the principal diagnosis. In 1990-9 1, cardiovascular conditions were the second most frequently managed problems in general practice, after respiratory problems, accounting for 12.5% of the total.*
183
Smoking rates in adults Blood pressure levels Contribution of saturated fat to total energy intake Coronary heart disease death rates Stroke death rates
Little or no change
Smoking rates in adolescents Participation in physical activity
Unfavourable trend
Prevalence of overweight or obesity
Insufficient data
Cholesterol levels Incidence of heart attack or stroke Disability rates
No national data
Time to hospital from symptom onset Use of rehabilitation programs Angioplasty or bypass surgery outcomes Case fatality rates
Asia Pacific Heart .I 1999;8(3)
Tonkin, Bauman,Bennett,Dobson,Hankey,Ring Cardiovascular health in Australia
Deaths per 100,000 population
190
All causes
19!70
1954
1458
1962
1966
1970
1974 Year
1978
1982
Note:
Age standardised to the Australian population at 30 June 1991.
Source;
AIHW National Mortality Database.
1986
19%
1994
19%
Fig. 1. Trends in heart, stroke and vascular disease mortality among females, Australia, 1950-1996. $ (millions)
Pharmaceutical Hospital-admitted patient 4co -.
O-24 Source:
25-34
3544
45-54 Age group (years)
55544
Mathers & Penm (1999).
Fig. 2. Costs of heart, stroke and vascular disease healthcare, Australia, 1993-1994.
Trends in Mortality and Risk Factor Prevalence
Groups at Higher Risk
Cardiovascular mortality rates have more than halved over recent decades, among both males and females (Fig. 1). This decline is more rapid than for non-cardiovascular mortality. Despite this decline, however, rates remain high compared with other developed countries,4 indicating the potential for further lowering the death rate from cardiovascular disease in Australia. In particular, mortality rates for coronary heart disease are more than 5 times those of Japan and several times those of France and Southern Europe. National Heart Foundation Risk Factor Prevalence Surveys in 1980, 1983 and 1989 and the 1995 Australian Bureau of Statistics National Health Survey show favourable trends in a number of the major cardiovascular risk factors. These include decreased smoking rates in adults, falling blood pressure levels and a lower contribution of saturated fat to total energy intake. However, there has been little or no change in smoking rates in adolescents, nor participation in physical activity. Of particular concern is the increasing prevalence of overweight and obesity.
There is a clear gradient of increasing agestandardised death rates with increasing socio-economic disadvantage, with people from the most socioeconomically disadvantaged group being almost twice as likely to die from cardiovascular disease as those from the least socio-economically disadvantaged group. This difference existed throughout the 1970s and 198Os, and has persisted into the 1990~5 Smoking is almost twice as common among disadvantaged people. Excessive alcohol consumption, physical inactivity, obesity and high blood pressure are also more prevalent in lower than in higher socio-economic groups. Indigenous Australians die from cardiovascular disease at twice the rate of non-indigenous Australians. The most striking difference is in mortality from rheumatic heart disease, which is 11 times higher in indigenous males and 7 times higher in indigenous females than in the general population, and is among the highest in the world. Rates of smoking, high-risk alcohol use and diabetes in indigenous Australians are more than twice those in the non-indigenous population. Obesity and physical
184
Asia
PacificHeartJ 1999;8(3)
Tonkin,Bauman,Bennett,Dobson,Hankey,Ring Cardiovascular health in Australia
Number of patients (‘000s) 1,cJoo 900 Kc 7co 600 5!n 400 cm 203 100 0 19% Source:
2016 66-75year olds
ziTx?6
19%
2016 75+ year olds
2Yx
Kelly (1997).
Fig. 3. Projectednumbersof older patientswith certain heart, stroke and vascular conditions,Australia.
inactivity are also known to be more prevalent indigenous people.
Integrated Approaches to Prevention and Treatment
in
Overall, it is estimated 1 that 41% of deaths and 38% of non-fatal events for coronary heart disease could be prevented through better application of existing knowledge. It is also clear that the impact of stroke can be reduced, mainly by primary prevention, and also by effective management of stroke and secondary prevention. l
Mortality from cardiovascular disease, other than rheumatic heart disease, is marginally higher in rural and remote areas than in urban areas. The major issues for remote populations relate to access to services rather than health differentials. Clustering of risk factors also increases the risk of cardiovascular disease. 80% of adult Australians have 1 modifiable cardiovascular risk factor, while 10% have 3 or more modifiable risk factors.6 An example of this clustering is the “metabolic” syndrome which includes glucose intolerance, dyslipidaemia, hypertension and abdominal adiposity, which greatly increases the risk of both cardiovascular disease and diabetes.
Scope of Prevention There is immense potential to improve cardiovascular health, because the disease is largely preventable. In addition, because the behavioural and physiological risk factors for cardiovascular disease often also play a role in the development of other common non-communicable diseases including diabetes and some cancers, an increased investment in prevention is likely to have a broader impact on overall population health.
Importance of Ageing of the Population Despite the downward trends in death rates, the burden of cardiovascular disease is likely to rise. This is because of an ageing population caused by the shift of “baby boomers” to beyond middle-age, and to decreases in acute myocardial infarction case-fatality rates in younger age groups.
To be most effective, prevention needs a combination of legislative, educational and economic approaches. The reduction of tobacco smoking, for example, has been largely due to just such an approach. There are many opportunities available to decrease smoking further, and promote physical activity, good nutrition, the reduction of overweight and obesity and the successful management of risk factors. It is now recognised that, although the health sector should take the lead in preventive actions, more lasting effects will result if it forms long-term partnerships and alliances with other sectors.Work is in progress at Commonwealth, State/Territory and regional levels to establish such partnerships and develop a National primary prevention Strategy to integrate programs on physical activity, diet, tobacco and alcohol, and target the major chronic noncommunicable diseases.
More than 2.2 million Australians in 1993-94 were aged 65 years or more. They were 12% of the population, but accounted for over two-thirds of the cardiovascular healthcare costs (Fig. 2). Over 50% of these people were reported to have some form of cardiovascular disease. Over the next 30 years, the ageing of the population is expected to lead to an approximate 2-fold increase in the prevalence of conditions such as coronary heart disease, stroke, heart failure and hypertension7 (Fig. 3) and their treatment with drugs and other medical interventions will place increasing pressure on the healthcare system. To reduce this impact, more emphasis will be needed on preventing and reducing disability and improving quality of life in this age group.
Secondary prevention and rehabilitation Perhaps the greatest gains for coronary heart disease outcomes can be achieved through aggressive secondary
185
Tonkin, Bauman, Bennett, Dobson, Hankey, Ring Cardiovascular health in Australia
Asia Pacific Heart J 1999;8(3)
(healthcare cards);
prevention involving appropriate use of coronary bypass surgery and angioplasty, drug treatment and lifestyle changes.1 Similarly, drug treatment and lifestyle changes would have a major impact on recurrent strokes.1
l
l
Treatment Treatment advances such as reperfusion therapy for acute coronary syndromes, proven therapies for secondary prevention and better techniques for revascularisation have all contributed to improved outcomes for patients.
l
Despite continuing advances in the management of cardiovascular disease, in many areas there is wide variation in practice. The development and endorsement of guidelines to encourage evidence-based practice are being continued by the Commonwealth, with the involvement of specialist colleges and non-government organisations. An appropriate structure for the regular review, dissemination and implementation of these guidelines is essential. At present, little is known about their impact on use rates, health outcomes or costs.
Coordinating primary prevention across major health issues. Effective national action in these areas will require coordination across different program areas, consistent health messages and adequate funding. Establishing a national mechanism for development, review and implementation of better practice guidelines. To ensure optimal uptake, a nationally coordinated process to ensure that regularly updated systematic reviews and guidelines are available should be linked to local planning and quality improvement processes for implementation.
Monitoring and Information Management Monitoring disease trends and differentials, and applying technology to improve information management, are increasingly used to address issues in cardiovascular health. The National Centre for Monitoring Cardiovascular Disease, at the Australian Institute of Health and Welfare, is developing an integrated information system that will cover major aspects of prevention, management and mortality for individual cardiovascular conditions, as well as monitoring differences between population groups. There is an urgent need for a national risk factor prevalence survey, which involves taking a blood sample from participants in association with the collection of relevant dietary information.
Ensuring that any national focus on heart, stroke and vascular disease includes a specific focus on stroke. Stroke has received less emphasis and funding than coronary heart disease. Any national program for cardiovascular disease should address additional stroke-related issues across the continuum of care. Tackling the underlying causes of inequalities in health among, in particular, the indigenous population. A key aim of public policy in the next millennium must be to design cross-sectoral interventions that improve the health of disadvantaged people and reduce gaps in healthcare.
More generally, a range of evolving technologies is being explored, including: further
evaluation
of portable
medical
use of information technology to facilitate education of health professionals working in remote regions.
Establishing a secure long-term national focus on cardiovascular disease from which policies and activities can emanate. National approaches exist for other National Health Priority Areas, and major achievements have occurred with other national programs such as HIV control and screening for cervical cancer. A similar multi-disciplinary approach would help to coordinate the prevention and guide the management of cardiovascular disease.
Practice Guidelines
l
to improve
Given the size of the health burden, and the extent of knowledge on which to base further endeavours, there is great potential to improve the overall health of a population through changes in cardiovascular health. Achieving this potential requires new approaches which build on existing activities. In Australia, there is still a great challenge to achieve adequate funding for prevention and treatment, and integration of effort and long-term strategic planning. These are addressed in the following priority areas for cardiovascular health identified in the NHPA report:
In stroke treatment, it has been found that acute inpatient care in dedicated units by a multidisciplinary stroke service reduces the odds of death and dependency after stroke by nearly 30%.* However, there are currently insufficient stroke units to meet national needs.
unique patient identifiers to facilitate record linkage;
further development of telemedicine access to clinical expertise; and
Key Recommendations of NHPA Report’
Epidemiological shifts are changing the nature of treatment for cardiovascular disease. For example, in coronary heart disease, unstable angina has overtaken acute myocardial infarction as the major acute coronary syndrome seen in hospitals. This has implications for cardiology units and chest pain units in emergency departments, with greater numbers of less intensively nursed but monitored cardiac beds being required.
l
increasing the use of computerised clinical records in general practice;
Continuing and expanding the activities of the National Centre for Monitoring Cardiovascular
records
186
Asia Pacific Heart J 1999;8(3)
Tonkin, Bauman, Bennett, Dobson, Hankey, Ring Cardiovascular health in Australia
Disease. Regular collections of survey data on risk factors, including lifestyle and biomedicalrisk factors of public healthsignificance,are neededto help direct and evaluatepreventiveand treatmentactivities.
size of middle-aged and elderly age groups, among whom non-communicable diseasesare most likely to develop. Population shifts from rural areas to urban environments, coupled with economic well-being, are exposing large numbersof people to a more “Western” lifestyle. However, the fact that behaviourscan have an impact across a number of risk factor areasand indeed, diseasestates(cardiovasculardiseases,diabetesand some cancers),emphasisesthe needfor coordinatedpreventive
What Are the Broader Messages? Cardiovasculardiseaseis increasingrapidly in Asian populationsfor a number of reasons.Decreasedfertility and mortality rates are leadingto increasesin the relative
Bennett SA. Socioeconomic inequalities in coronary heart disease and stroke mortality among Australian men, 1979-1993. International Journal of Epidemiology 1996;25:266-75. Australian Institute of Health and Welfare. Heart, stroke and vascular diseases, Australian facts. Canberra: AIHW Cat No CVD 7. Australian Institute of Health and Welfare and the Heart Foundation of Australia (Cardiovascular Disease Series No. lo), 1999. Kelly DT. Our future society. A global challenge. Circulation 1997;95:2459-64. Stroke Unit Trialists’ Collaboration. How do stroke units improve patient outcomes: A collaborative systematic review of the randomized trials. Stroke 1997;28:2139-44.
References 1. Commonwealth Department of Health and Aged Care and Australian Institute of Health and Welfare. National health priority areas report: Cardiovascular health 1998. Canberra: AIHW Cat No PHE 9. HEALTH and AIHW, 1999. 2. Bridges-Webb C, Britt H, Miles DA, et al. Morbidity and treatment in general practice in Australia, 1990-1991. Medical Journal of Australia 1992;157(Special Supplement):Sl-S56. 3. Mathers C, Penm R. Health system costs of cardiovascular disease and diabetes in Australia, 1993-94. Canberra: AIHW Cat No HWE 11. Australian Institute of Health and Welfare, 1999. 4. de Looper M, Bhatia K. International health - how Australia compares. Canberra: AIHW Cat No PHE 5. Australian Institute of Health and Welfare, 1998.
187