Canadian Heart Health Strategy and Action Plan Building a Heart Healthy Canada
February 2009 Members of the CHHS-AP Steering Committee
Eldon R. Smith (Chair) Lyall Higginson Carmen R. Connolly (Director) Trevor Hodge Heather Arthur Carol Jillings Pierre Boyle Darwin Labarthe Sally Brown Peter Liu Norm Campbell David MacLean Karen Chad Anne McFarlane Jean Davignon Kelly McQuillen Jacques de Champlain John Millar Naranjan Dhalla Nancy Poirier Catherine Donovan Wayne Putnam Anne Ferguson Jeff Reading Peter Glynn Ruth Redden Jeremy Grimshaw Brian Rodrigues Antoine Hakim Jack Tu
Secretariat
Odette McNeely Letter from the Chair
February 2009
The Honourable Leona Aglukkaq Minister of Health House of Commons Ottawa, Ontario K1A 0A6
Dear Minister Aglukkaq,
As Chair of the Canadian Heart Health Strategy and Action Plan Steering Committee, it is my privilege to submit our final Strategy document, Building a Heart Healthy Canada, and its companion Action Plan.
As the leading cause of death and hospitalizations among Canadians, cardiovascular disease is a huge health burden, and, at an annual cost of more than $22 billion, treating those who suffer from it is a major strain on our economy and governments. Fortunately, as this Strategy explains, we have a major opportunity to prevent premature cardiovascular disease, and, for those who do develop heart disease and stroke, there are means to markedly limit personal suffering. Importantly, doing what we know to prevent cardiovascular disease will also impact favourably on other chronic diseases that share common risk factors.
The Government of Canada requested this Strategy in October 2006, and our 29-member Steering Committee worked diligently to propose six key recommendations to make Canada a heart healthy nation. We have involved over 100 expert volunteers and consulted with over 1500 stakeholders to ensure that our Strategy is comprehensive, practical and sensitive to regional differences.
We believe that Building a Heart Healthy Canada, and its companion Action Plan, can serve as a pan-Canadian road map for partners to tackle heart disease and stroke. We encourage the Government of Canada to lead the way by adopting this Strategy as the basis for investment in Canada’s heart health – an investment that will yield significant financial and health benefits year after year.
Respectfully submitted,
Eldon R. Smith, oc, md, frcpc Chair, Canadian Heart Health Strategy and Action Plan ii / Building a Heart Healthy Canada Acknowledgements
The Canadian Heart Health Strategy and Action Plan (CHHS-AP) was developed over a two- year period from fall 2006 to fall 2008 as an independent, stakeholder-driven process under the leadership of the CHHS-AP Steering Committee. The work of the Steering Committee could not have been completed without the efforts and support of many individuals and organizations from across the country. The Chair and members of the Steering Committee wish to express their profound appreciation to the more than 1500 individuals who contributed to the development of the CHHS-AP, including: • Theme Working Group Co-Chairs: nneA McFarlane, Andy Wielgosz, John Millar, Roy Cameron, Norm Campbell, Jean-Pierre Després, Jeff Reading, Richard Jock, Peter Glynn, William Ghali, Heather Arthur and Richard Lewanczuk • Theme Working Group members: Theme Working Group 1 Theme Working Group 2 Theme Working Group 3
Kim Barker Lorne Clearsky Sonia Anand Charlyn Black Jane Farquharson Jean-Luc Bigras Trevor Hodge John Frank Jacques de Champlain Merril Knudtson Lars Hallstrom Naranjan Dhalla Doug Manuel Dexter Harvey Jacques Genest Frank Silver Andrew Hazlewood Gaston Godin Anna Svendsen Richard Massé Stewart Harris Larry Svenson Karen Philp Peter Jones Mark Tremblay Kim Raine Chantal LeCouteur-Morais Michael Wolfson Bruce Reeder Lawrence A. Leiter Paula Stewart Kenneth Ross G.B. John Mancini Jack Tu Brian McCrindle Mary McKenna Andrew Pipe Robert Ross
Acknowledgements / iii Theme Working Group 4 Theme Working Group 5 Theme Working Group 6
Laura Arbour David Alter Mark Bayley Treena Delormier Rob Beanlands Patricia Caldwell Lyall Higginson Sally Brown Martin Fortin James Irvine Anne Ferguson George Heckman Malcolm King Gordon Gubitz Jonathan Howlett Nathan Matthew Andreas Laupacis Louise Morrin Sharon Rudderham John Maxted Ruth Redden Stanley Vollant Blair O’Neill Judith Shamian Kue Young Louise Pilote Neville Suskin David B. Ross Anne Sales Claudia Sanmartin Heather Sherrard Chris Simpson
• the writer of the Strategy document, Jean Bacon; the writers who assisted the Theme Working Groups: Pattie Reed, Stephanie Lawrence, Peter Smith, Peggy Edwards, Anwar Merchant, Susan Swanson, Andrew Kmetic, Kim Scott and Diana Daghofer; and fact checkers: Christine LeGrand and Lynne Moffatt • the three lead organizations: the Heart and Stroke Foundation of Canada; the Canadian Cardiovascular Society; and the Canadian Institutes of Health Research – Institute of Circulatory and Respiratory Health, and the members of their staff who provided support to the CHHS-AP Management Group: Louise Marcus, Stephen Samis and Fiona Webster (until September 2007). Valuable input was also provided by the CEOs of the provincial Heart and Stroke Foundations • the Public Health Agency of Canada, which funded the development of the Strategy, and the Agency staff who acted as resource people during the development of the Strategy • members of the Integration and Partnership Committee: Catherine Donovan, Kelly McQuillen, Wayne Putnam, Bonnie Hostrawser and Peter Sargious • other federal government departments and national agencies, including Health Canada, Statistics Canada, the Canadian Institute for Health Information, Canada Health Infoway and the Canadian Institutes of Health Research • the provincial and territorial Deputy Ministers of Health and their officials • members of the Federal/Provincial/Territorial Expert Group on Chronic Disease and Injury Prevention and Control, and Population Health Promotion Expert Group • representatives from many national, provincial/territorial and regional/local non-governmental organizations, professional bodies and industry, as well as individual health professionals and citizens who participated in the CHHS-AP’s consultations • representatives of other national chronic disease strategies who met with members of the CHHS-AP Management Group to discuss opportunities for synergy and collaboration, including the Canadian Stroke Strategy, the Canadian Diabetes Strategy, the Canadian Partnership Against Cancer, the National Lung Health Framework and the Mental Health Commission • and a very special thanks to Senator Wilbert Keon for his support throughout the process.
iv / Building a Heart Healthy Canada Table of Contents
Executive Summary 1 1 Time to Act ...... 2 Developing the Strategy ...... 3 Vision ...... 3 Targets ...... 4 Recommendations ...... 5 1/ Create Heart Healthy Environments ...... 5 A/ Socio-economic Determinants of Health ...... 5 B/ Environmental Factors ...... 7 2/ Help Canadians Lead Healthier Lives ...... 8 3/ End the CV Health Crisis Among Aboriginal/Indigenous Peoples ...... 4/ Continue the Reform of Health Services – Provide Integrated, 9 Patient-Centred Cardiovascular Care ...... 10 5/ Build the Knowledge Infrastructure to Enhance Prevention and Care ...... 12 6/ Develop the Right Service Providers With the Right Education and Skills ...... 12 Partnerships to Move From Plan to Action ......
Background 13 13 Developing the Canadian Heart Health Strategy and Action Plan ...... 13 Establishing a Framework ...... 15 Understanding the Issues 15 Considering Diverse Points of View ...... 16 Looking Beyond “Heart Health” ...... 17 Implementing the CHHS-AP: From Plan to Action 18 CV Diseases: Canada’s Number One Public Health Threat 20 The Economic Impact ...... 22 What Are CV Diseases? ...... 22 What Causes CV Diseases? ...... 23 Who Is Affected? ......
Table of Contents / v 24 What Are the Risk Factors for CV Diseases? ...... 24 Genes ...... 25 Environment ...... 25 Behaviour ...... 26 A Snapshot of CV Risk in Canada ...... 27 CV Diseases: Canada’s Number One Health Opportunity ...... 29 By Acting Now – We Can Build a Heart Healthy Canada ...... 29 Our Strategy ......
1/ Create Heart Healthy Environments 31 32 Key Messages 32 Inequities Threaten Our Health ...... 33 Not All Canadians Can Afford Healthy Foods ...... 34 How Healthy Is Our Food Supply? 34 Many Processed Foods in Canada Contain Too Much Trans and Saturated Fat and Salt ...... 35 Loss of Traditional Diets Leads to Obesity and Health Problems ...... 35 Marketing Affects Food Choices ...... 36 Food Labels are Confusing ...... 36 How Healthy Are Our Physical Environments? ...... 36 The Way Our Communities Are Built Affects Health ...... 37 School, Workplace and Home Environments Influence Health ...... 39 Are Our Environments Smoke-Free? ...... 41 Health Is More Than Health Care 42 Recommendations ......
2/ Help Canadians Lead Healthier Lives 45 46 Key Messages 46 Do Canadians Have the Information They Need to Lead Healthy Lives? 46 Messages About Risk Factors Can be Confusing ...... 47 Information About Self-Care Can Be Hard to Find and Use 48 Many Canadians Do Not Have the Skills to Use Health Information ...... 49 Canadians Need Different Approaches to Health Promotion 50 Few Canadians Are Screened for CV Risk Factors ...... 50 Community Screening Programs Show Promise 51 Setting Priorities for Screening 51 What Is the Potential of Genetic Screening? ...... 52 Recommendations ......
3/ End the CV Health Crisis Among Aboriginal/ Indigenous Peoples 53 54 Diet, Smoking, Sedentary Lifestyle and Other Factors Threaten Health ...... 56 Environments and the Broader Determinants Threaten Health ...... 57 Lack of Screening Threatens Health 58 Lack of Equipment, Technology and Health Care Providers Threatens Health ...... 58 Jurisdictional Disputes Threaten Health ...... 58 Lack of Information Threatens Health 59 Lack of Engagement Threatens Health ...... 59 Recommendations ......
vi / Building a Heart Healthy Canada 4/ Continue the Reform of Health Services – Provide Timely, Integrated Patient-Centred Cardiovascular Care 61 63 How Integrated Is the System Now? ...... 63 Fragmented Services Complicate Patient Care and Affect Outcomes 67 Geography Affects Care 69 Patients Struggle to Navigate the System ...... 70 Patients Are Still Waiting Too Long for Some Services 71 Using Technology to Improve Access and Reduce Inequities ...... 72 Culture and Other Social Factors Affect Care ...... 72 Patients Are Often Passive Recipients of Care ...... 73 Only 20% of Patients Receive Rehabilitation Services ...... 74 Few Cardiac Patients Receive End-of-Life Planning and Care ...... 75 Guidelines Alone Are Not Enough to Change Practice 77 Recommendations ......
5/ Build the Knowledge Infrastructure to Enhance Prevention and Care 79 80 Key Messages ...... 80 What Do We Know About CV Diseases in Canada? ...... 81 Canada Lags Behind Other Countries in CV Disease Information Systems ...... 82 The Role of Cohort Studies in Understanding CV Diseases ...... 83 Canada Does Not Have Performance Measures for Cardiac Care ...... 84 Challenges With Electronic Health Records and Electronic Medical Records ...... 84 Canada Needs Information Systems for Chronic Disease Prevention and Management ...... 85 Canada Needs Information Tools and Systems for Patients ...... 86 Gaps in Research 86 Canada Lags Behind Other Countries in Capitalizing on Research ...... 87 Recommendations ......
6/ Develop the Right Service Providers With the Right Education and Skills 89 89 Canada Lacks Information on the CV Workforce ...... 89 Shortages Threaten reventionP and Care ...... 91 Canada Lags Behind Other Countries in Its Use of Interprofessional Teams ...... 92 Traditional Approaches to Education Will Not Meet Health Needs ...... 92 Incentives Are Needed to Encourage Team Practice 94 Recommendations ......
Conclusion 95 95 Our Targets ...... 97 Leadership and Partnerships
References 99
Table of Contents / vii viii / Building a Heart Healthy Canada Executive Summary
According to the World Health Organization, coronary heart disease and stroke are the number one and number two leading causes of death worldwide, respectively.
By 2030, 23.4 million people will die from heart Nine out of 10 Canadians over age 20 have disease and stroke compared with 11.8 million from at least one risk factor for CV diseases, one-third cancer. (World Health Organization, 2008) Indeed, have three or more risks – and the risks increase as four chronic diseases – heart disease and stroke, we age. One in every 20 Canadians reports being cancer, chronic obstructive lung disease and diabetes diagnosed with a CV disease, but the actual number – now account for 60% of all deaths worldwide and, with undetected heart disease is much higher. by 2020, are expected to account for 73% of deaths (Manuel et al., 2003) CV diseases are a particular and 60% of the global burden of disease. (World problem for Aboriginal/indigenous peoples in Health Organization, 2002) Canada, who develop and die from CV diseases at Canada has a pan-Canadian strategy for cancer twice the rate of the rest of the population. Over prevention and control, a strategy for diabetes the last few years, Canada has seen a dramatic prevention and care and a framework for lung increase in physical inactivity, obesity, diabetes and health. Canada now needs a pan-Canadian strategy hypertension – conditions that lead to CV diseases. for heart disease, stroke and other vascular diseases. Heart disease and stroke are also a significant threat to Canada’s economic well-being. These CV diseases cost Canada over $22 billion a year Time to Act in health care and lost productivity. In terms of Heart disease, stroke and other vascular diseases hospital costs, in 2004/05, three of the top four are Canada’s number one public health threat. most expensive health conditions in Canada were CV diseases; given the expected increase in the Cardiovascular and cerebrovascular diseases (CV disease burden, these costs can only grow. diseases) kill more Canadians each year than any We are faced with a looming epidemic. If we other illness. (Public Health Agency of Canada, do not act now, the situation will only get worse. 2009) Even though more Canadians now survive a heart attack, many go on to develop chronic heart failure, which deprives them of years of quality life.
Executive Summary / 1 The cardiac care system is not as efficient or effec- It is possible to “fix” the problem of CV diseases tive as it should be. Most patients do not have the in Canada, but to do so we need to start now down skills, information or support from their health care the right path. CV diseases do not need to be the providers to be active partners in their own care, and number one problem! We already know how to many find it difficult to move from one level of ser- prevent and treat most CV diseases, and we’re vice or provider to another. Some Canadians are still learning more all the time. But the solutions to CV waiting too long for some cardiac procedures. Too disease lie both within and outside the health care many people with heart failure are being readmit- system. They involve changes in our society – in the ted to hospital, which means they are not receiving way we live and view health – as well as changes in the best follow-up care. There are also inequities in the way we provide care. They require the action and access to cardiac care. The quality and consistency commitment of all levels of government, society, of cardiac services varies considerably across the the health system and Canadians – and they country. Practice does not always reflect the most require a long-term commitment similar to the recent evidence. more than 20 years that our country has devoted Heart disease and stroke are also Canada’s to reducing smoking. number one health opportunity because up to 80% of premature CV diseases are preventable. Unlike Developing the Strategy the situation with some other diseases where the solutions are unclear, the situation with CV diseases The Canadian Heart Health Strategy and Action is that we already have much of the knowledge Plan (CHHS-AP) was developed over a period of required to prevent them but we are not using two years by a Steering Committee of 29 experts, what we know. Moreover, according to a recent led by Dr. Eldon Smith and supported by a small U.S. study, prevention makes economic sense; every secretariat based at the offices of the Heart and $1 invested in effective prevention programs that Stroke Foundation of Canada and the Canadian increase physical activity, improve nutrition and Cardiovascular Society. In the process of develop- reduce smoking – only three of the key risk factors ing the plan, the Chair and Steering Committee for CV diseases – can save $5 in health care costs. consulted with over 1500 people, including Deputy (Trust for America’s Health, 2008) Ministers of Health and other representatives of Investing in CV health now will not only lead federal, provincial and territorial governments, to better health and longer lives for Canadians, it health care organizations and providers, the public, will also improve our productivity and decrease other chronic disease strategies, and the food, health care costs. The cost of not investing now pharmaceutical, medical devices and insurance means more Canadians living with a debilitating industries. The development of the CHHS-AP was disease, more hospitalizations, more deaths and funded by the federal government, but its recom- spiralling health care costs: a future that is unneces- mendations are directed to all levels of government, sary and unacceptable. By preventing CV diseases all parts of Canadian society and all Canadians. and providing more timely, integrated and patient- The strategy looks beyond “heart health.” centred care for those with CV disease, we can give Although Canadians back years of quality life while making this plan is called the Canadian Heart Health our health system more sustainable. Strategy and Action Plan, it goes well beyond what Canadians think of as “heart health.” Heart disease belongs to a family of diseases known as cardiovascular diseases that – along with cerebrovascular disease (stroke) – belong to an even broader group called “vascular diseases.” Vascular diseases affect blood vessels throughout the body, restricting blood flow and damaging organs such
2 / Building a Heart Healthy Canada as the heart through heart attacks or heart failure, Targets or the brain through a stroke. Vascular diseases can also affect the kidneys and legs, and can cause The CHHS-AP sets a number of ambitious dementia and blindness. but achievable targets for prevention and care of The Strategy recognizes the importance of CV diseases. preventing all vascular diseases – regardless of the By 2020: organ affected. For purposes of this document, 1/ the term “CV diseases” is used to describe the full Decrease the annual mortality rate from CV range of cardiac and vascular diseases. Preventing diseases by 25% (from 227/100,000 population CV diseases not only will reduce heart disease and in 2004 to 171/100,000). stroke but also will have a positive impact on other 2/ Decrease the burden of CV diseases in the common chronic illnesses. Aboriginal/indigenous population to the same level as in other Canadians. 3/ a Vision Decrease the prevalence of hypertension in adult Canadians aged 18-74 years by 32% The CHHS-AP Steering Committee believes that (from 22% in 1992 to 15%). we have within our grasp the knowledge and skills b Increase the proportion of adult Canadians to create a much brighter, heart healthy future for with hypertension who are aware of their Canadians – one in which: condition by 64% (from 58% in 1992 Citizens have the knowledge, resources to 95%). and support they need to reduce their risk of CV c diseases and other chronic illnesses, and lead Increase by six-fold the proportion of adult longer, healthier lives. Canadians with hypertension treated to Governments, the health care system, recommended targets (from 12.1% in 1992 the private sector, voluntary and community to 75%). organizations, and individuals work together to 4/ Decrease the risk-adjusted 30-day in-hospital create environments and services that promote mortality rate from heart attacks by 32% and enhance CV health. (from 10.3% to 7%). Patients are active, informed partners in their 5/ own health and care. Interprofessional teams of Decrease the risk-adjusted 30-day in-hospital health care providers have the information, skills mortality rate from stroke by 25% (from 18.2% and tools to promote health, prevent CV diseases, to 13.6%). and provide timely, comprehensive, integrated, 6/ Decrease the age-standardized number of patient-centred care for Canadians with heart hospitalizations per year for treatment of heart and vascular disease. failure by 25% (from 132/100,000 population Canada is recognized around the world as a in 2005/06 to 98/100,000). productive, economically competitive and heart 7/ Decrease the age-standardized number of healthy nation. hospitalizations per year for treatment of acute stroke by 25% (from 95/100,000 population in 2005/06 to 71/100,000). 8/ Have CV risk assessments performed on 90% of Canadians aged 45 years and older within the previous five years. 9/ Work with others to reduce the overall smoking rate by 25%.
Executive Summary / 3 10/ Abnormal levels of blood cholesterol and Recommendations other lipids remain a major risk factor for CV diseases. Unfortunately, no population-based To build a heart healthy Canada, we need a measures of lipids are yet available in Canada, comprehensive approach that addresses not only so a target cannot be set at this time. However, the clinical risks, such as high blood pressure, they are expected soon, and once available a high cholesterol, obesity and diabetes, but also the target can be set. In the meantime, aggressive environments where people live, learn, work and measures to improve this risk factor are play. Supportive environments can make the healthy encouraged as part of the Strategy. choice the easy choice – for all Canadians. To create healthy environments, Canada can and should use 11/ By 2015, achieve the following targets by a combination of education, legislation, regulation working with others who have set these targets: and policy to promote healthy eating and physical • Increase the proportion of Canadian chil- activity, to reduce smoking and to address the dren and adults eating at least five servings underlying “upstream” social inequities that of vegetables and fruit per day by 20%. affect health. • To achieve its vision, the CHHS-AP makes six Increase the proportion of Canadian key recommendations: children and adults who are physically 1/ active by 20%. Create Heart Healthy Environments. 2/ • Decrease the rate of Canadian adults who Help Canadians Lead Healthier Lives. are overweight/obese by 20% and the rate 3/ End the CV Health Crisis Among Aboriginal/ of childhood obesity from 8% to 5%. Indigenous Peoples. 4/ Continue the Reform of Health Services – Provide Integrated, Patient-Centred Economic Analysis Cardiovascular Care. Given the complex relationships among the various 5/ Build the Knowledge Infrastructure to risk factors, the potential for advances in diagnosis Enhance Prevention and Care. and therapies, and the effect of changing care 6/ Develop the Right Service Providers With delivery models, the Steering Committee recognizes the Right Education and Skills. the difficulty in estimating the potential for cost savings as a result of achieving these targets. We are Although the same strategies can be used to continuing to assess various models but believe that collect data on and prevent all vascular diseases, the current estimate of savings of $1 billion per year different skills and services are required to treat each in direct costs and $2 billion per year in indirect vascular disease depending on the organ of the body costs are conservative estimates. This is highlighted affected. Because the causes of many CV diseases by recent studies that estimate direct cost savings are the same but the treatments are different, the of approximately $2 billion per year just from CHHS-AP recommendations for prevention and decreasing average sodium (salt) consumption knowledge infrastructure are designed to help to recommended levels. (Joffres et al., 2007; reduce all CV diseases. The care recommendations, Penz et al., 2008) on the other hand, focus primarily on the diagnosis and treatment of cardiac diseases, including congenital, heart muscle and heart valve diseases. For cerebrovascular diseases, the Heart and Stroke Foundation of Canada and the Canadian Stroke Network have developed the Canadian Stroke Strategy to guide stroke care and rehabilitation, which is now being implemented in many parts of the country.
4 / Building a Heart Healthy Canada 1 / Create Heart Healthy Environments
Supportive environments can make the healthy • reduce poverty choice the easy choice – for all Canadians. To create • improve employment and working conditions healthy environments, Canada can and should use • a combination of education, legislation, regulation reduce food insecurity and policy to promote healthy eating and physical • improve the built environment both to activity, to reduce smoking, and to address the encourage physical activity and to increase underlying “upstream” social inequities that affect access to affordable housing health. Many of the “upstream” determinants of • health require action beyond the health care system improve access to early childhood education and the Canadian Heart Health Strategy and and care Action Plan. Several provincial governments are • improve access to education and implementing whole-of-government approaches literacy training to policy development, but solving problems like • poverty and food insecurity will require significantly improve social supports. more intersectoral leadership and action.
B/ Environmental Factors A/ Socio-economic Determinants of Health 1.1 Improve the nutritional quality of Canada’s food supply and access to healthy foods: Although the focus in the health system tends to • Eliminate processed trans fats in Canada’s food be on behavioural risk factors for CV disease – such supply through regulation as recommended by as poor diet, lack of exercise and smoking – the the Trans Fat Task Force, including replacing CHHS-AP recognizes that these determinants trans fats with healthier alternatives to are in fact greatly influenced by the “upstream” saturated fats. socio-economic determinants of health. We also acknowledge the huge opportunity to prevent CV • Accelerate the work of Health Canada’s and other chronic diseases by addressing these Working Group on Dietary Sodium Reduction broader societal issues. To achieve success in this to drive daily levels of salt intake down area requires broad intersectoral action, leadership to recommended levels and ensure timely and the involvement of all levels of governments, implementation of the Working Group’s using whole-of-government approaches within each recommendations. level of government, working collectively with the • Improve food labelling regulations and other volunteer sector, industry and society in general. processes to make the portion sizes on the The CHHS-AP Steering Committee mandatory nutrition facts panel consistent anticipates the final report of the Standing across similar products and provide clear, Senate Committee on Social Affairs, Science and accurate information about nutritional values, Technology Subcommittee on Population Health including calories, saturated and trans fats, and supports actions to overcome health and sodium (salt), simple sugars, fibre and minerals. societal inequalities, including the actions outlined • in the Chief Public Health Officer’s Report on the State Develop guidelines, with regular monitoring, of Public Health in Canada, 2008 to: for fast food restaurants and food service outlets to post the calorie count per portion for each item at point of purchase.
Executive Summary / 5 • Ban the advertising and marketing of “un- • Provide incentives to employers to implement healthy” foods and beverages to children in all healthy, active living policies and to media based on clear definitions of “healthy” offer employees opportunities for regular foods, and provide incentives to encourage the physical activity. food industry to voluntarily market “healthy” • Provide tax incentives to ensure opportunities foods to children. for children to be more physically active, such • Provide sustainable funding to expand the as offering refundable tax credits to low-income Food Mail Program to more northern and families and exempting the sale of bicycles, isolated communities. helmets and other sports equipment from GST/HST. • Identify best practices for providing healthy foods in schools, and disseminate this information to school boards. 1.3 Reduce exposure to and use of tobacco: • Encourage employers to implement healthy • Enhance community programs that keep food policies in workplaces and to make youth from starting to smoke. healthy foods available to employees. Govern- • Develop regulations to control the sale of ment organizations and hospitals should lead flavoured “cigarillos” and address other tobacco the way by serving only healthy foods. industry measures that attempt to circumvent current tobacco control legislation. 1.2 Create more opportunities for physical activity: • Identify best practices for schools to keep • Increase support for infrastructure develop- children and youth from starting to smoke, and ment that promotes active, healthy living disseminate this information to school boards. (e.g., sidewalks, walking paths, recreation • Support employers to develop tobacco policies centres, parks, bike paths and lanes) by, for and offer smoking cessation programs to em- example, designating a specific portion of ployees, such as improving access to programs the $33 billion Building Canada – Modern and aids that help people become smoke-free. Infrastructure for a Strong Canada plan • (2007-2014) for this purpose. Support successful smoking cessation programs, such as the one developed by the • Promote and showcase Canadian and interna- University of Ottawa Heart Institute, at tional best practices/examples of community other clinical settings in Canada. planning and design that enhance healthy, active living. • Identify best practices for providing daily opportunities for physical activities in schools that will help children meet Health Canada’s physical activity guidelines, and disseminate this information to school boards.
6 / Building a Heart Healthy Canada 2 / Help Canadians Lead Healthier Lives
Canadians’ ability to make healthy choices – to eat • Focus on self-care and make Canadians aware healthy foods, be active, not smoke, and manage of evidence-based guidelines and strategies to their blood pressure, cholesterol and weight – is reduce risk, improve self-care, promote health affected by the information they receive about the and prevent complications at all stages of risk factors that lead to CV diseases, their ability CV diseases. to understand and use that information, their • Link Canadians to community services that motivation to change, and the supports available can help them lead healthier lives, such as to help them, such as screening and follow-up smoking cessation programs, physical activity programs in their communities. programs, dietitian services and support groups. To help Canadians lead healthier lives, • we should: Have the mandate and resources to develop and maintain information tools and links to 2.1 Bring Canada’s major disease organizations related resources. together to: 2.3 Deliver CV risk screening, education • Develop and communicate clear, consistent and follow-up programs in a variety of messages about common risk factors for community settings. These programs should: chronic diseases. • Have strong leadership and accountability, and • Create and launch comprehensive, sustained be part of community/regional care systems. public education/social marketing campaigns • targeted at high-risk populations to prevent Be evidence-based. CV and other chronic diseases, including the • Be delivered by trained providers and/ signs and symptoms of stroke and heart disease, or volunteers. and the actions to take. • Be offered in settings convenient for Cana- • Support the Canadian Public Health Associa- dians, including workplaces, where incentives tion ’s and the Canadian Council on Learning’s should be developed to help employers create work on health literacy. and maintain these programs. • 2.2 Develop and maintain interactive Canadian Target groups at risk. source(s) of authoritative information on • Focus on key CV risk factors, including blood CV health and diseases. pressure and cholesterol levels, weight and waist measurement, smoking, fasting blood The information source(s) should build on sugar, family history, nutritional status and existing initiatives and: physical activity. • Provide up-to-date information on key risk • Ensure that risk profile measurements taken factors, including high blood pressure and during screening are shared with individu- cholesterol, healthy eating, physical activity, als and their primary care providers, and that smoking, obesity and diabetes. individuals have the information they need to • Be supported by interprofessional primary understand their risk profile. care teams who, in turn, will provide more • Refer people who are at risk for appropriate consistent messages to their patients. evidence-based treatments, follow-up services • Include interactive ways for people to identify and supports. and assess their own risks and learn practical • Where possible and practical, use knowledge ways to reduce risk. of genetic variation to identify people with inherited risks for CV diseases.
Executive Summary / 7 3 / End the CV Health Crisis Among Aboriginal/Indigenous Peoples
To end the CV health crisis in Aboriginal/ • Promote promising practices, such as limiting indigenous communities, Aboriginal/indigenous tobacco sales to minors, removing unhealthy peoples and communities must be actively engaged in food from schools and providing opportunities developing their own CV health solutions and plans. for regular physical activity. At the same time, Aboriginal/indigenous peoples • Ensure approaches to CV disease prevention and communities must be an integral part of the and care that respect traditional knowledge, Canadian Heart Health Strategy and Action Plan. Aboriginal/indigenous values and individual/ All the CHHS-AP recommendations apply community readiness. to all Canadians, including Aboriginal/indigenous peoples. In addition, Aboriginal/indigenous leaders should work with their communities, governments Help Aboriginal/indigenous Peoples Lead and non-governmental organizations to develop Healthier Lives: a multi-year action plan to engage Aboriginal/ • Adopt a life course approach to risk reduction indigenous communities and identify culturally with a focus on early life. appropriate ways to reduce risk, improve care, • respond to urgent needs, and address social and Work with other chronic disease strategies/ health inequities. organizations, such as cancer, diabetes, lung and stroke, to develop comprehensive prevention 3.1 Develop a multi-year action plan to meet programs for Aboriginal/indigenous peoples. the CV needs of Aboriginal/indigenous peoples and communities using a partnership approach Continue the Reform of Health Services – Provide involving Aboriginal/indigenous organizations; Integrated, Patient-Centred Cardiovascular Care: federal, provincial, territorial and municipal • governments; Aboriginal/indigenous Ensure a continuum of care between commu- communities; and non-governmental nity-based and regional health authorities. organizations. • Provide the same standard of CV care available to other Canadians. 3.2 Create a national Aboriginal/indigenous • Improve access to care by making effective centre (or network of centres) for chronic use of interprofessional teams – which should disease prevention and management to include nurse practitioners, dietitians, and coordinate the implementation of the action primary care and specialist physicians all linked plan. Together, the centre and the plan will: together – employing cardiovascular disease management algorithms, community and home care services and telehealth/e-medicine Create Heart Healthy Aboriginal/ technologies. indigenous Communities: • Engage community institutions and build Build the Knowledge Infrastructure to Enhance community capacity in prevention interven- Prevention and Care: tions – particularly those related to tobacco • reduction, school-based nutrition, fitness/sports Oversample Aboriginal/indigenous peoples and recreation. in periodic versions of the Canadian Health Measures Survey, and include Métis and Inuit in the First Nations Regional Health Survey. • Advance the development and application of First Nations-, Inuit- and Métis-controlled databases that link with national databases.
8 / Building a Heart Healthy Canada • Establish an accurate, current database of Develop the Right Service Providers With the evidence-informed chronic disease interven- Right Education and Skills: tions as a means of tracking and sharing • Strengthen the Aboriginal/indigenous health best practices. workforce by providing chronic disease inter- • Improve screening, surveillance and monitoring vention training, intercommunity mentoring systems within Aboriginal/indigenous health and exchange, more bursaries, and more seats service agencies by ensuring that all clinical, in medical and nursing faculties, and by ex- research, survey and federally managed data tending regional Heart and Stroke Foundation are available locally. outreach and support. • Support intervention and evaluation studies, • Improve the cultural competency of non- particularly on food security and multi- Aboriginal/indigenous health service providers component interventions. by providing residency incentives in the North, by rotating visiting specialists to rural, remote • Fund research on interventions that address and isolated areas, and by incorporating cultural individuals and communities in context and that competency education and practical models/ reflect Canadian Institutes of Health Research approaches for working with Aboriginal/ guidelines and other recommended research indigenous peoples into professional practices for working with Aboriginal/ training curricula. indigenous communities.
4 / Continue the Reform of Health Services – Provide Integrated, Patient-Centred Cardiovascular Care
• To provide more integrated, patient-centred Document and disseminate best practices in services, health care systems in Canada must make patient partnerships, self-care and patient- some fundamental changes in the way they organize centred care, and in organizing and delivering and provide cardiac care. They must make effective patient-centred care. use of people, technology and other resources to address inequities, and adopt models of care – such 4.2 Improve access to high-quality, appropriate, as the chronic disease prevention and management coordinated specialized cardiovascular model and the regional integrated networks of care, including diagnostics, acute care, specialized cardiac care – that will make the system cardiac rehabilitation and end-of-life planning more efficient and effective. and care: • 4.1 Accelerate the implementation of chronic Provide incentives for the continued disease prevention and management as development of regional integrated networks the preferred model for delivering most of specialized cardiovascular care. cardiovascular care in Canada: • Establish triage systems that will ensure that those in greatest need are seen first. • Accelerate the development and training of • interprofessional primary care teams with new Implement and monitor a system of evidence- roles and working relationships. based maximum recommended wait times – particularly for consultative services and • Implement process improvements and diagnostic testing. change management.
Executive Summary / 9 • Expand the use of telemedicine technologies 4.3 Establish, maintain, promote and evaluate within and between provinces and territories the use of updated, evidence-based, to provide care as well as patient and provider interprofessional clinical guidelines in education (e.g., telestroke). preventing and managing cardiovascular risk and disease, treatment, rehabilitation and • Incorporate “system navigators” into regional end-of-life planning and care: teams to help patients and their health • information move easily between services Support the ongoing development, implemen- and providers. tation and regular updating of best practice guidelines in the Canadian Stroke Strategy, the • Continue to develop and implement specialty Canadian Hypertension Education Program, clinics within integrated regional networks and the Canadian Cardiovascular Society’s staffed by interprofessional teams to manage Heart Failure Knowledge Translation Program complex cardiovascular conditions such as and guidelines for lipids/cholesterol. heart failure, congenital heart disease, certain • abnormal heart rhythms and chest pain. Create a pan-Canadian task force to develop clinical practice guidelines for end-of-life • Continue to develop rehabilitation programs planning and care for individuals with in underserved regions, and incorporate advanced CV disease. cardiac rehabilitation services into primary • care-based chronic disease prevention and Support the development of user-friendly management programs. self-care guidelines for patients and effective ways for patients to access this information. • Provide support for end-of-life planning • and care information and services, including Create a pan-Canadian initiative to develop episodic support and respite services for a comprehensive set of quality indicators for informal caregivers. CV prevention and care programs – to include recommended monitoring methods.
5 / Build the Knowledge Infrastructure to Enhance Prevention and Care
Accurate, timely information and good ways to 5.1 Gather Canadian data on the prevalence and share it are absolutely essential to health. Canada incidence of CV risk factors, diseases and needs information for patients, providers, managers health inequities in Canada: and government, and information to guide preven- • Provide resources to the Public Health Agency tion, improve care and support research. To close of Canada to expand CV disease surveillance the CV information gap and build the informa- in Canada to include conditions such as heart tion infrastructure to enhance prevention and care, failure, heart attack, stroke, hypertension and Canada should use the following strategies. congenital heart disease. • Provide resources to Health Canada and Statis- tics Canada to co-lead the regular collection of comprehensive, standardized food and nutrient consumption data.
10 / Building a Heart Healthy Canada • Facilitate the linkage of death certificates with 5.3 Improve knowledge to inform CV prevention health services utilization data. and cardiac care: • Provide resources to create a Canadian • Hold a pan-Canadian CV research summit, pre-hospital cardiac arrest registry. involving the Canadian Institutes of Health Research, the Public Health Agency of Canada, • Enhance capacity in Statistics Canada’s bien- the Heart and Stroke Foundation of Canada nial Canadian Health Measures Survey by and the members of the National Alliance of oversampling key target populations such as Provincial Health Research Organizations, to certain ethnic groups (e.g., South Asians), develop a strategic, coordinated CV research Aboriginal/indigenous persons on reserves and agenda to address the future needs of in the Far North, and the elderly. our country. • Work with the Canadian Partnership Against • Establish a network of centres of excellence Cancer to develop and support a Canadian in vascular health to improve our basic cohort study of chronic diseases that includes understanding of both large and small vessel risk factors for CV diseases. diseases, identify promising (bio)markers as • Facilitate the development of pan-Canadian well as new targets for prevention and therapy, data standards for regional CV patient regis- and pursue knowledge translation (clinical tries to improve data quality and allow data to trials) and commercialization. be linked and pooled. • Support the Canadian Institutes of Health Research to fund additional research into 5.2 Support Canada Health Infoway’s efforts genetics/proteomics-based diagnostics, markers to accelerate the development and of prognosis, and tools for personalized implementation of the electronic health prevention and care. record (eHR), the electronic medical • record (eMR), chronic disease prevention Provide more support for population health and management information systems, and research and community intervention research consumer health solution capabilities to evaluate the impact of policies and programs across Canada: on health. • Evaluate the impact of economic policies such • Review the barriers and facilitators to the use as tax incentives to increase physical activity of the eMR in primary care in Canada, and (e.g., the children’s fitness tax credit), and advo- develop an action plan to speed its adoption. cate to enhance incentives that are found to be • Develop effective ways for health information effective and do not increase health inequities. systems to support chronic disease prevention • Support knowledge translation initiatives to and management programs that leverage the help prevention programs and clinical settings eHR and can bridge the gap until the eMR is to translate research findings rapidly into more widely available. practice and to market. • Develop effective ways for patients to access their clinical information. • Develop mechanisms to facilitate the use of clinical information from the eHR and the eMR (while respecting citizen privacy and confidentiality) to support surveillance, system management, policy research and ongoing as- sessment of the effectiveness of Canada’s health care system and disease prevention strategies.
Executive Summary / 11 6 / Develop the Right Service Providers With the Right Education and Skills
To develop the right people to provide CV preven- • Encourage faculties of health sciences to ensure tion and care, Canada must take a more systematic that health education programs teach an inte- approach to workforce planning. In collaboration grated approach to chronic disease prevention, with the federal, provincial and territorial govern- management and care, provide more education ments’ efforts to implement the Pan-Canadian on health promotion and disease prevention, Health Human Resource Strategy, Canada must: and prepare a workforce that can adapt quickly to new knowledge and technologies. 6.1 Strengthen and maintain the CV prevention • Provide incentives for education and care workforce: programs to prepare providers to work in interprofessional teams. • Identify the number and mix of health providers and skills required to meet • Provide incentives for health care providers population needs. to work in interprofessional teams. • Recruit and/or develop people with key • Challenge educational programs to critically skills, including epidemiologists, experts in review the length of their training programs public health/population health, primary care and the impact on efforts to ensure an adequate providers, specialists, informatics professionals, supply and mix of health professionals and social scientists, community planners, program skills to meet Canada’s health needs. evaluators and policy specialists.
Partnerships to Move From Plan to Action
Stopping CV diseases requires leadership from all across sectors, in communities, and in schools, levels of government, using whole-of-government workplaces and our homes – to reduce all the risks approaches. But governments cannot do it alone. that threaten our hearts and our blood vessels. We Partnerships are needed, within and outside must change our environments and social norms. At the health sector, to engage health professionals the same time, our health care systems and health and their organizations, non-governmental care providers must work closely with Canadians organizations, industry, the media and citizens to provide timely, high-quality, integrated, patient- in creating a whole-of-society, whole-of-the- centred prevention services and care. country approach. We have an enormous opportunity to improve To be successful, we must invest resources and the health of Canadians by implementing the efforts “upstream” on activities that will prevent Canadian Heart Health Strategy and Action Plan. CV diseases as well as “downstream” in high- We must take responsibility for our health and quality efficient treatment services for people with the future health of our country, and we must act heart and other vascular diseases. We must work now. There is no time for complacency. CV disease together – within government, across governments, should no longer be number one!
12 / Building a Heart Healthy Canada Background
Developing the Canadian Heart Health Throughout the two-year process of developing Strategy and Action Plan the Strategy, three national organizations – the Heart and Stroke Foundation of Canada, the In May 2005, a private member’s motion, Canadian Cardiovascular Society and the Canadian championed by MP Steven Fletcher, called Institutes of Health Research’s Institute of for Canada to develop national strategies for Circulatory and Respiratory Health – played a lead cancer, mental health and heart disease. The role, providing guidance to the Chair. A three- motion received all-party support in the House person secretariat led by a director and housed of Commons. On October 23, 2006, the federal within the Heart and Stroke Foundation of Canada Minister of Health announced funding, through and the Canadian Cardiovascular Society offices the Public Health Agency of Canada, to develop provided operational support. a pan-Canadian strategy for heart health. The goal? To reduce the growing burden and loss from cardiovascular disease in Canada. Establishing a Framework The task of developing a comprehensive, evidence-informed, stakeholder-driven Canadian The Steering Committee developed a framework Heart Health Strategy and Action Plan (CHHS- to define its vision and guide its work (Figure 1). AP) was given to an expert steering committee, The framework reflects the total spectrum chaired by Dr. Eldon Smith. The 29-member of the “health” system covered by the Strategy Steering Committee consisted of leaders in – from policy to end-of-life planning and care, cardiovascular and cerebrovascular health and and from birth to death. It captures the dynamic disease, population health, health policy, research, relationship between “upstream” health promotion information technology and other relevant and disease prevention activities and “downstream” fields, as well as survivors of cardiovascular diagnostic and care services throughout people’s and cerebrovascular (CV) disease. lives and across all health services. It illustrates that health promotion and disease prevention play an important role at all stages of life and care. It highlights the important role of information, access to services, research and health human resources in a comprehensive strategy.
Background / 13 Figure 1 Framework for a Comprehensive Canadian Heart Health Strategy and Action Plan
The Vision
Favourable Healthy Lower Fewer Less Additional environments behaviours population acute chronic quality life risk events disease years
Interventions Required
Policy and environmental Behaviour Treeaatment change change Prevention, strategies detection, Timely management access Timely access of risk factors to quality to quality (acute) care chronic disease Timely management/rehab access to end Prevention of life care Information and Monitoring Access to Services Research Health Human Resources Outcomes 1 2 3 4 5 Healthier Reduced Added quality Decreased burden of Sustainable population inequities life years cardiovascular disease health system
In the vision of the Steering Committee, health is not solely the responsibility of the health care system: Favourable environments encourage healthy behaviours that, in turn, reduce risk and acute events, and – when combined with timely access to quality health care – lead to more people living longer in good health, a lower burden of disease and a more sustainable health care system.
14 / Building a Heart Healthy Canada Understanding the Issues Considering Diverse Points of View
The Steering Committee established Theme Work- The Steering Committee also established an expert ing Groups, each to focus on one of six key issues: group on consultations and partnerships. Because the provinces, territories and regions play a key role 1/ Strengthening information systems for in public health and health care delivery, the Chair monitoring, management, evaluation and and the Director of the CHHS-AP met collectively policy development and individually with provincial and territorial 2/ Creating environments conducive to Deputy Ministers of Health and other senior cardiovascular health officials, and provided periodic updates on the Strategy’s development to the Federal/Provincial/ 3/ Preventing, detecting and managing risk factors Territorial Chronic Disease and Injury Prevention 4/ Addressing and enhancing Aboriginal/ and Control Expert Group, and the Population indigenous cardiovascular health Health Promotion Expert Group. The Steering 5/ Timely access to quality (acute) care Committee and the Theme Working Groups also and diagnostics had members who could represent provincial/ territorial perspectives. 6/ Timely access to quality chronic disease At the federal level, the Public Health Agency management, rehabilitation services and of Canada, Health Canada, Statistics Canada, end-of-life planning and care. the Canadian Institute for Health Information, Each working group, comprising approximately the Canadian Institutes of Health Research and 12 experts, also considered five cross-cutting Canada Health Infoway provided advice and issues in their deliberations: reducing inequities, guidance, and the last three organizations had addressing Aboriginal/indigenous cardiovascular representatives on the Steering Committee. health, evaluating interventions, expanding the When developing the CHHS-AP, the Chair knowledge base and translating knowledge into and the Steering Committee consulted with action. The Theme Working Groups reviewed the over 1500 stakeholders, including: professional literature and commissioned background papers, so organizations, non-governmental organizations, the as to fully understand the issues, and then prepared food and pharmaceutical industries, the insurance detailed reports for the Steering Committee. These and banking industries, companies that manufacture extremely valuable reports are available on the medical devices and the general public. Seven CHHS-AP website at www.chhs-scsc.ca. focus groups were held across the country with Canadians who offered their views on heart health and heart disease, existing services, and the barriers to and supports for prevention and treatment. The Chair also attended annual conferences, such as the Canadian Public Health Association Annual Conference and the Canadian Cardiovascular Congress, to discuss the key issues. To identify opportunities to integrate with and capitalize on other related national disease strategies, the Chair and the Management Group consulted and worked with the leaders of the Canadian Stroke Strategy, the Canadian Diabetes Strategy, the Canadian Partnership Against Cancer, the Mental Health Commission of Canada and the National Lung Health Framework.
Background / 15 Looking Beyond “Heart Health” Building a Heart Healthy Canada describes a comprehensive, integrated approach to health. Although this plan is called the Canadian Heart It recognizes the importance of preventing all Health Strategy and Action Plan, it goes well vascular diseases – regardless of the organ affected. beyond what Canadians think of as “heart health.” Preventing vascular diseases not only will reduce Heart disease belongs to a family of diseases heart disease and stroke but also will have a positive known as cardiovascular diseases that – along with impact on other common chronic illnesses. For cerebrovascular disease (stroke) – belong to an even purposes of this document, the term “CV diseases” broader group called “vascular diseases.” Vascular is used to describe the full range of cardiac and diseases affect blood vessels throughout the body, vascular diseases (see box). restricting blood flow and damaging organs such Although the same strategies can be used to as the heart through heart attacks or heart failure, collect data on and prevent all vascular diseases, or the brain through a stroke. Vascular diseases different skills and services are required to treat each can also affect the kidneys (causing chronic renal vascular disease depending on the organ of the body failure) and the blood supply to the legs (causing affected. Because the causes of many CV diseases pain when walking, leading to gangrene and are the same but the treatments are different, the amputation). They are also important causes of CHHS-AP recommendations for prevention and dementia and blindness. knowledge infrastructure are designed to help reduce all CV diseases. The care recommendations, on the other hand, focus primarily on the diagnosis and treatment of cardiac diseases, including congenital, heart muscle and heart valve diseases. In the Canadian Heart Health For cerebrovascular diseases, the Heart and Stroke Strategy and Action Plan, the Foundation of Canada and the Canadian Stroke Network have developed the Canadian Stroke term “CV diseases” includes: Strategy to guide stroke care and rehabilitation, which is being implemented in many parts of • cardiovascular (blood vessels of the country. the heart) health and diseases as well as other cardiac conditions (congenital, valvular and heart muscle) • cerebrovascular (blood vessels to the brain) health and diseases • peripheral vascular (aorta and blood vessels to the legs) health and diseases.
16 / Building a Heart Healthy Canada Implementing the CHHS-AP: The CHHS-AP is more than a written plan. It From Plan to Action is a process and a partnership. The Strategy makes the case for leadership and collaboration – both The CHHS-AP consists of three parts: within and outside the health care system – to Part 1 The Canadian Heart Health Strategy is the reduce the burden of CV disease. The success of “what”: it identifies the gaps in CV health now, this strategy depends on the commitment of many describes promising practices that are improving partners, including the federal, provincial and health and care, and recommends solutions. territorial governments, municipal governments, Part 2 regional health bodies, health care providers and The Action Plan is the “who, when, how organizations, non-governmental organizations, the and where”: it describes the concrete steps that private sector and individuals (Figure 2). must be taken to implement the Strategy. The CHHS-AP describes how these partners Part 3 The Business Plan is the “how much”: it can work together to create a heart healthy future sets out the costs to implement each component for Canadians. of the Strategy.
Figure 2 The Canadian Heart Health Strategy and Action Plan
Governments Private Sector, Workplaces, Schools, Health Care System, Communities, Planners and Providers, Non-governmental Other Health Strategies Organizations Individuals
Background / 17 CV Diseases: Canada’s Number One More Canadians now survive a heart attack, Public Health Threat but many go on to develop chronic heart failure, which is now the most common reason for people Each year, CV diseases kill 17 million people over age 65 to be admitted to hospital. (Canadian worldwide (World Health Organization, 2004) and Cardiovascular Society, 2006) The incidence more Canadians than any other illness. In 2004, of heart failure also increases with age, and the they were responsible for one out of every three – Canadian population is aging. or 72,743 – deaths in Canada (Figure 3). (Public Heart disease steals about 4.5 years from Health Agency of Canada, 2009) Canadians’ lives. (Manuel et al., 2003) Because Despite recent progress in reducing the number of CV diseases, Canada is falling behind other of deaths each year from heart disease and stroke, developed countries in life expectancy. (Fang and CV diseases remain Canada’s number one public Millar, 2008) Indeed, it is now predicted that our health threat. children will be the first generation of Canadians The Public Health Agency of Canada ever to have a shorter life expectancy than their estimates that at least 1.6 million Canadians have parents. But Canada is not alone in its struggle with heart disease or are living with the effects of a CV diseases: in 2004, coronary disease and stroke stroke. (Public Health Agency of Canada, 2009) were the first and second leading causes of death Cardiovascular diseases account for 17% of all worldwide, respectively (21.9% of total deaths), and hospitalizations in Canada (Public Health Agency both will increase by 2030 (to 26.3% of the total). of Canada, 2009) compared with 7.6% for cancer. (World Health Organization, 2008) (Foote et al., 2005)
Figure 3 The Leading Causes of Death Number and Percentage of Deaths, Canada, 2004 Diabetes 7,823 (3.5%) Respiratory 19,607 (8.7%) Cardiovascular 72,743 (32.1%) Cancer 66,947 (29.5%) Other 46,485 (20.5%)
Accidents/Poisoning/Violence 8,986 Infectious Diseases (4.0%) 3,993 (1.8%)
Source: Statistics Canada. (2007). Mortality, Summary List of Causes 2004.
18 / Building a Heart Healthy Canada Four chronic diseases – heart disease and stroke, cancer, chronic obstructive pulmonary At least 1.6 million Canadians are disease and diabetes – now account for 60% of living with heart disease or the all deaths worldwide and, by 2020, are expected effects of a stroke. They may not die to account for 73% of deaths and 60% of the as quickly as they would have 10 global burden of disease. (World Health years ago, but they are not able to Organization, 2002) participate as fully in life, and many Alarmingly, a number of risk factors that put are extremely ill. people on the path to CV disease – such as high As the World Health Organization blood pressure (hypertension), high cholesterol said, “Longer life is an empty prize (dyslipidemia), obesity and diabetes – are projected to rise in Canada. Figures 4a and 4b illustrate the trends if those added years are lived and projected increases in diabetes and obesity. in poor health.” (World Health The increase in CV risks and diseases is a Organization, 1998) threat for all Canadians, but it is a full-blown crisis for Aboriginal/indigenous peoples. (First Nations Regional Longitudinal Health Survey, 2007) These trends, combined with the growth and aging of our population (CV diseases increase with age) (Public Health Agency of Canada, 2009), could overwhelm the health care system.
Figure 4a Predicted Age-Specific Diabetes Population in Canada in 2000, 2010 and 2016
350 000
300 000
250 000
200 000
150 000
100 000 Number of individuals
50 000
0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-4445-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80 Age groups (years) 2000 2010 2016
Source: Ohinmaa A., et al. (2004). The projection of prevalence and cost of diabetes in Canada 2000 to 2016. Canadian Journal of Diabetes 28(2):00-00. (available online at: www.diabetes.ca/Files/JohnsonCJDJune2004.pdf).
Background / 19 Figure 4b Prevalence (%) of Obesity (BMI >29) in Canada, Actual and Projected, by Sex, 1970-2010
30
25
20
15
10 Prevalence (%) Prevalence
5
0 1970 1975 1980 1985 1990 1995 2000 2005 2010
Men Actual Men Estimate Women Actual Women Estimate
Data Source: 6 surveys with measured height and weight (age20+), Statistics Canada 1970 – Nutrition Canada Survey; 1978 – Canada Health Survey; 1981 – Canada Fitness Survey; 1988 – Campbell’s Survey on Well-being in Canada; 1992 – Canadian Heart Health Survey; 2004 – Canadian Community Health Survey
Source: Luo W., et al. (2007). The burden of adult obesity in Canada. Chronic Diseases in Canada 27(4):135-144.
The Economic Impact Given the expected increase in CV diseases, these costs will grow. Provinces and territories are CV diseases are not just a threat to our health predicted to spend 50% of their budgets on health, – they are a threat to our economic well-being. limiting their ability to invest in other essential In 2000, CV diseases cost Canada at least $22.2 public services, such as education, roads, the billion in direct and indirect costs – second only to environment and social services. musculoskeletal diseases (Figure 5). (Public Health If nothing changes and health care spending Agency of Canada, 2009) continues to increase at its current pace, by 2017/18 In terms of hospital costs, in 2004/05, three – in just 10 years’ time – health care and education of the four most expensive health conditions in could consume up to 100% of the provincial/ Canada were CV diseases. They cost $1.4 billion in territorial budgets as illustrated by projections in hospital in-patient costs alone. (Canadian Institute British Columbia (Figure 6). (Taylor, 2006) for Health Information, 2008)
20 / Building a Heart Healthy Canada Figure 5 Costs Due to Disease* for the Leading 7 Diagnostic Categories, by Direct† and Indirect‡ Costs, Canada 2000
Musculoskeletal diseases Cardiovascular diseases Neuropsychiatric conditions Malignant neoplasms
Injuries
Digestive Diagnostic category diseases Respiratory diseases
0 3 6 9 12 15 18 21 Costs ($billion)
Direct costs Indirect costs
* Based on the total cost of illness of $147.9 billion. Expenditures for care in other institutions and additional direct health expenditures are not included. † Direct costs include hospital, drugs and physicians ‡ Indirect costs include mortality, long-term disability and short-term disability Note: Not all diagnostic categories include short-term disability. The five diagnostic categories including short-term disability costs are musculoskeletal diseases, cardiovascular diseases, neuropsychiatric conditions, digestive diseases and respiratory diseases.
Source: Adapted from Public Health Agency of Canada. (2009). Tracking Heart Disease and Stroke in Canada.
Figure 6 Revenue/Spending Projections in British Columbia
100% Total 100.0% 90% Revenue Growth 3% Education Growth 3% 80% Health Growth 8% 71.3% Balanced Budget 70% Other spending reaches zero by 17/18 60% 53.6%
50% 41.6% 40% Percent 28.4% 30% 27.0% 27.0% 27.0% 20%
10% 16.6% -0.6% 0%
-10% 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18 Year Health Education Other
Current and projected spending on health and the impact on other areas of program spending in British Columbia. Source: Taylor, C. (2006). BC Economic and Fiscal Update www.fin.gov.bc.ca/qrt-rpt/qr06/Q1powerpoint.pdf.
Background / 21 What Are CV Diseases? Everyone is born with healthy arteries, but, over time, the blood vessels can become inflamed, Many Canadians mistakenly think that laden with fat (cholesterol) and scarred, restricting cardiovascular disease is just heart attacks. But CV blood flow and potentially causing blood clots, diseases are a broad group of debilitating and costly which lead to heart attacks, stroke and other conditions that affect almost all parts of the body complications. Atherosclerosis begins early in (Figure 7). life – as early as childhood – but it may not cause symptoms or signs of illness for many years. Despite What Causes CV Diseases? major advances in understanding the cause of atherosclerosis, much remains to be learned about Genetic conditions account for approximately 5% vascular function and disease. to 10% of all CV diseases. (Public Health Agency of Canada, 2009) The most common cause of other CV diseases is atherosclerosis or hardening of the arteries.
Figure 7 What Are CV Diseases?
Dementia Blindness
Stroke
Hypertension Pulmonary Emboli Congestive Heart Failure Coronary Artery Disease Abnormal Heart Rhythms Heart Valve Disease Congenital Heart Disease
Kidney Disease
Aortic Aneurysms
Thrombo-embolic Disease Peripheral Arterial Disease
22 / Building a Heart Healthy Canada Who Is Affected?
The traditional image of the typical Canadian with We are all at risk: nine out of 10 CV disease is an older, overweight, white male. But Canadians over age 20 have at least this view is no longer accurate. CV disease affects one risk factor for cardiovascular Canadians of all ages and backgrounds. And some disease. One in three has three or are at greater risk than others. The face of heart dis- more risk factors. (Public Health ease in Canada now is younger, increasingly female, Agency of Canada, 2009) ethnically diverse, poor and too often Aboriginal or South Asian (Figure 8).
Figure 8 Who Is Affected by CV Disease?
Canadians of Chinese Origin South Asian Women Canadians
African Men Over Canadians Age 75
Poorer, Babies Less Educated Canadians
Young People Aboriginal/ Indigenous Peoples
Background / 23 • About one of every 100 babies in Canada is • Canadians of Chinese origin are more likely to born with congenital heart disease. (Heart and have high blood pressure than Canadians Stroke Foundation of Canada, 2003) of European origin. (Anand et al., 2000) • More young people are overweight or • African Canadians are more likely to obese and have diabetes, high blood pressure have high blood pressure than the general and high cholesterol than in the past. population. (Heart and Stroke Foundation (Shields, 2005) of Ontario, 2008) • Although men are more likely than women to develop heart disease and at a younger age, recently more women than men die each year What Are the Risk Factors from heart disease. (Public Health Agency of for CV Diseases? Canada, 2009) Women with CV disease also have longer stays in hospital and suffer greater Atherosclerosis is most common in people who disability than men. (Pilote, 2007) have high blood pressure (hypertension), high • cholesterol levels or other abnormal blood lipids Heart disease increases with age. One out of (dyslipidemia), are overweight or obese and/or every four men over age 75 has heart disease. have diabetes. (Public Health Agency of Canada, 2009) Hypertension, dyslipidemia, obesity, diabetes • Poorer, less educated Canadians are more and atherosclerosis are caused by a complex likely to develop CV diseases than those interaction of genetic risk factors (inborn, inherited with more education and higher incomes. characteristics), environmental risk factors (lack of (Craig et al., 2005) income and/or education, lack of access to healthy foods or physical activity) and behaviour (unhealthy • Aboriginal/indigenous peoples in Canada are diets, physical inactivity and smoking as well as 1.5 to 2 times more likely to develop heart stress and depression). disease than the general Canadian popula- tion. They are also more likely to have diabetes, hypertension, high cholesterol and a family Genes history of heart disease. (Health Canada, 2001) Genes play a role in CV diseases and in diabetes • South Asian Canadians are more likely to and obesity. Anyone with a family history of high die from a heart attack when they are young blood pressure, high cholesterol levels, obesity or than other Canadians. People native to India, diabetes is at higher risk of developing CV diseases. Pakistan, Bangladesh, Nepal and Sri Lanka People who belong to ethnoracial groups with high die from heart disease five to 10 years earlier rates of CV diseases, such as certain Aboriginal/ than people in other ethnic groups – even indigenous people and South Asians, are also at when they appear to be a healthy weight. higher risk. ( Joshi et al., 2007)
24 / Building a Heart Healthy Canada Social inequities lead to health inequities. For example, children who grow up in poor Canada’s Chief Public Health neighbourhoods have higher body mass index Officer stated: “Health status (BMI) and are more likely to be overweight generally follows a gradient where or obese. (Oliver and Hayes, 2008) Poorer, people with low incomes and less educated individuals are more likely to eat less education are less healthy unhealthy diets, be inactive and smoke than those than those at each subsequently who are better educated and wealthier. (Marmot et higher socio-economic level. al., 1991) The high rate of CV disease among some This gradient in health status Aboriginal/indigenous peoples is the complex result is caused by a combination of of lack of access to healthy foods and to health services (particularly in remote communities); lack environmental factors, including of education and meaningful employment; low lack of access to adequate food and incomes; and poor housing. (Kmetic, 2007) housing, psychosocial stress and behavioural factors such as diet, exercise and smoking.” (Public Behaviour Health Agency of Canada, 2008) The genetic and environmental risks of CV disease are compounded by behaviours such as eating diets high in calories, fat, sodium (salt) and simple sugars, and low in fruits, vegetables, fibre and minerals (i.e., calcium, magnesium, potassium); being physically Environment inactive; and smoking. Canadians’ risk of developing a CV disease and their ability to reduce their risk are profoundly affected by environmental and socio-economic factors, such as education, income, the availability “Four of the most prominent and cost of healthy foods, opportunities for physical chronic diseases – cardiovascular activity, and stress. diseases (CVD), cancer, chronic The environment can interact with people’s genes to make them more vulnerable to CV obstructive pulmonary disease diseases. For example, in societies where healthy and type 2 diabetes – are linked by eating and regular physical activity are the norm, common and preventable biological such as Japan, atherosclerosis is uncommon; risk factors, notably high blood however, when people from these societies move to pressure, high blood cholesterol a country or environment where the norm is to be and overweight, and by related less active and eat less healthy foods, their rates of major behavioural risk factors: CV diseases increase rapidly. (Tremblay et al., 2005) unhealthy diet, physical inactivity and tobacco use. Action to prevent these major chronic diseases should focus on controlling these and other key risk factors in a well- integrated manner.” (World Health Organization, 2002)
Background / 25 A Snapshot of CV Risk in Canada Although fewer Canadians are having heart attacks, strokes or heart failure (Campbell et al., 2006), the risks for CV disease remain unacceptably high, and some are on the rise: • One of every four men and women pressure (Joffres et al., 1997), and in their 30s and 40s derives more nine of 10 Canadians will develop than 35% of their calories from fat. high blood pressure in their (Garriguet, 2004) lifetime. (Campbell et al., 2006) • Approximately six of 10 children • Four out of 10 (36%) adult Canadians aged 13 and younger and five of are overweight (BMI 25-29), and one 10 adults have less than five daily out of four (23%) is obese (BMI ≥30). servings of vegetables and fruit. (Tjepkema, 2007) (Garriguet, 2007) • At least one of every four children • Among Canadians aged 19-70, over in Canada (Shields, 2005) – and 85% of men and 60% of women one of every two Aboriginal have sodium intakes exceeding children on reserves – is the recommended upper limit. overweight or obese. (Garriguet, 2007) (National Aboriginal Health • Almost one in two Canadians organization, 2005) aged 12 and older (48%) is • In 2005, almost 1.8 million adult physically inactive. (Gilmour, 2007). Canadians – 5.5% of the population • Nineteen percent of Canadian – had been diagnosed with diabetes adults (one of every five) and – up from 4.8% in 1998. Diagnosed 15% of youth aged 15-19 years diabetes has grown 70% since smoke. (Health Canada, 2008) the publication of the 1998 Canadian Diabetes Association clinical • Twenty-two percent of Canadians practice guidelines. (Canadian aged 18 and older have high blood Diabetes Association, 2008)
26 / Building a Heart Healthy Canada CV Diseases: Over the past nine years, the Canadian Canada’s Number One Hypertension Education Program has actively Health Opportunity promoted evidence-informed hypertension guidelines and educated health care professionals CV diseases are Canada’s number one health threat, and the public, and progress is being made. but they are also Canada’s number one opportunity According to a recent study by the Heart and to improve health. Why? Stroke Foundation of Ontario (Figure 9), 88% of participants with high blood pressure are aware of • because up to 80% of some CV diseases are their diagnosis, and 66% have their hypertension preventable (Public Health Agency of Canada, treated and controlled. (Leenen et al., 2008) It 2009; Yusuf et al., 2004) remains to be demonstrated that this tremendous • because when CV diseases are detected early progress has also been achieved throughout the and treated vigorously, they can be controlled rest of Canada. and managed • because – unlike diseases such as cancer where the causes and solutions are unclear – we already know how to prevent and treat Prevention makes economic sense. CV diseases. According to a recent analysis At each step along the pathway to CV disease, done in the United States, every $1 it is possible to reduce risk and improve health. We spent on prevention programs that already have examples of how using what we know increase physical activity, improve now can improve health and reduce CV diseases. nutrition and prevent smoking In 1992, almost half of Canadians who had provide a return on investment of $5 high blood pressure were undiagnosed, and only in lower treatment costs. (Trust for 13% had their hypertension treated according to guidelines and were under control. (Joffres America’s Health, 2008) et al., 1997)
Right now, a disease that is largely preventable is costing Canada $22.2 billion a year. (Public Health Agency of Canada, 2009) Although the major risk factors for heart disease and stroke are preventable, we do little to prevent them – and once a person develops these risks, damage can occur and become irreversible.
Background / 27 Figure 9 Trends in Hypertension in Canada
Ontario Survey on the Prevention and Control of Hypertension 2006
19.5%
14.7% 65.7%
Canadian Heart Health Survey 1992: Canada Canadian Heart Health Survey 1992: Ontario
13.2% 12.1%
21.4% 20.8% 65.4% 67.1%
Treated and controlled Treated and not controlled Not treated
Treatment and control of hypertension as determined in 2006 by the Ontario Survey on the Prevalence and Control of Hypertension and in 1992, for Ontario and Canada as a whole, in the Canadian Heart Health Survey (1992 data supplied by Dr. Michel Joffres, Simon Fraser University, personal communication, July 31, 2007). The data are presented as percentage of the population with diagnosed hypertension. Both sets of Ontario data were weighted to the Ontario population, and the national data were weighted to the Canadian population. For consistency of comparison, “treatment” in the Canadian Heart Health Survey refers to drug therapy only.
Source: Leenen, F., et al. (2008). Results of the Ontario Survey on the Prevalence and Control of Hypertension. CMAJ 178(11):1441-1449.
In 2005, a partnership between the Heart and However … Stroke Foundation of Canada and the Canadian … far too few Canadians know how to reduce Stroke Network created the Canadian Stroke Strat- their CV risks, egy to promote evidenced-informed acute care and rehabilitation for stroke patients. Four provinces … far too few Canadians with risks are – Ontario, British Columbia, Alberta and Nova diagnosed early, and Scotia – have funded integrated stroke strategies, … far too few Canadians with CV diseases have and all others have made changes to stroke care that access to timely, comprehensive, evidence-based care. are dramatically increasing the number of people who survive and recover from strokes.
28 / Building a Heart Healthy Canada By Acting Now – We Can Build a The Canadian Heart Health Strategy and Heart Healthy Canada Action Plan is designed to fill that gap and provide the blueprint for building a heart healthy nation. It We have within our grasp the knowledge and skills calls on Canada to invest “upstream” in prevention to create a much brighter, heart healthy future for to help people stay healthy and off the pathway to Canadians – one in which: CV disease as well as “downstream” in high-quality, Citizens have the knowledge, resources effective cardiac care for Canadians who need it. and support they need to reduce their risk of CV And it recommends strategies that are practical and diseases and other chronic illnesses, and lead have the potential to improve CV health and reduce longer, healthier lives. health inequities. Governments, the health care system, Our plan is to: the private sector, voluntary and community organizations, and individuals work together to 1/ Create Heart Healthy Environments. create environments and services that promote 2/ Help Canadians Lead Healthier Lives. and enhance CV health. 3/ Patients are active, informed partners in their End the CV Health Crisis Among Aboriginal/ own health and care. Interprofessional teams of Indigenous Peoples. health care providers have the information, skills 4/ Continue the Reform of Health Services – and tools to promote health, prevent CV diseases, Provide Integrated, Patient-Centred and provide timely, comprehensive, integrated, Cardiovascular Care. patient-centred care for Canadians with heart 5/ and vascular disease. Build the Knowledge Infrastructure to Canada is recognized around the world as a Enhance Prevention and Care. productive, economically competitive and heart 6/ Develop the Right Service Providers healthy nation. With the Right Education and Skills.
Our Strategy
We already have many of the tools and building The end result of investing now in blocks – skills, knowledge and people – that we better prevention and care will be: need to build a heart healthy Canada. Across the • a healthier population country, exciting initiatives are under way. Best practices have been developed, and some are • fewer health inequities being shared and adopted. But too often progress is occurring piecemeal – in some provinces or • more quality life years communities or hospitals or doctors’ offices. • a lower burden of CV diseases Individual champions are leading many creative efforts, but they do not have the support, resources • a more sustainable health or influence to shift the entire system. Although system. Canada has strategies to address the other chronic diseases that are the leading causes of death and burden of illness – diabetes, lung disease and cancer – the country does not have a comprehensive, concerted, Canada-wide approach to reducing CV diseases.
Background / 29 Guiding Principles for the Canadian Heart Health Strategy and Action Plan • Reflects the best available evidence. • Builds on existing strengths and successes. • Recognizes the values and world views of Aboriginal/indigenous people and addresses the historical and contextual factors that affect Aboriginal/indigenous health. • Integrates with other strategies and initiatives. • Is person-centred. • Is culturally appropriate and meets the needs of ethnic groups at high risk. • Is a sound investment. • Is practical, feasible and can be implemented and evaluated. • Will reduce health inequities. • Will lead to improvements in health and quality of life. • Is consistent with the Canada Health Act.
30 / Building a Heart Healthy Canada 1 / Create Heart Healthy Environments
Canadians can do a lot to reduce their risk of CV diseases, but they cannot do it alone. They need supportive environments that make the healthy choices the easy choices.
Our environments – our communities, The changes that have occurred in the way workplaces, schools and homes – have a direct Aboriginal/indigenous peoples live – that is, effect on how active we are, our eating habits, rates more sedentary lives and high calorie foods of obesity, and risks for heart disease and stroke. – are largely due to environmental changes, (Heart and Stroke Foundation of Canada, 2007a) including acculturation, urbanization and the Our food supply, the way our communities are “Westernization” of Aboriginal diet, culture and designed and built, and our exposure to tobacco ways of life. (Kmetic, 2007) can all affect our health. Canada already knows from its experience with For example, when less nutritious foods are the Federal Tobacco Control Strategy that changing cheaper, more readily available and more actively the environment can change behaviour and reduce marketed than healthy foods, it is harder for risk. Over the past 20 years, federal, provincial, Canadians to make the healthy choice. When territorial and municipal governments have used people have access to information about nutrition, a combination of public education about the risks they are more likely to make healthy choices. of smoking, taxation, legislation (to limit tobacco (Health Canada, 1996; World Health Organization, advertising, prohibit smoking in public places and 2003) When people live in communities with few stop the sale of tobacco to minors), enforcement, shops and services close by, they are more likely and counselling from health professionals to help to be overweight or obese than people who live people stop smoking. The result? Smoking rates in walkable neighbourhoods. When communities and exposure to second-hand smoke have dropped have few parks or recreation facilities, it is harder dramatically. Most workplaces and public places for people to be physically active. (Sanitch, 2003; in Canada are now smoke-free. In the five years Butterworth, 2000) between 2000 and 2005, the number of Canadians who smoked fell by 23%. (Health Canada, 2000; Health Canada, 2007b)
Create Heart Healthy Environments / 31 The same type of comprehensive approach must now be used to improve the quality of our Key Messages food supply, build communities that promote physical activity and create opportunities for Our environments – our healthy, active living at school, work and home. communities, workplaces, schools and homes – have a direct effect on how active we are, our eating Inequities Threaten Our Health habits, rates of obesity, and risks for In its efforts to create healthy environments, heart disease and stroke. the health system has traditionally focused on Canadians’ risk of developing a CV strategies that influence specific behaviours, such disease and their ability to reduce as diet, exercise and smoking, but the CHHS-AP their risk are profoundly affected recognizes that what Canadians eat, how active they are and whether they smoke is greatly influenced by socio-economic factors, such as by underlying, “upstream” socio-economic education and income, and Canada determinants of health, such as income, education should take steps to overcome and employment. Poorer, less educated Canadians health and social inequities. are more likely to be obese and less physically active, Regulations as well as guidelines to consume fewer fruits and vegetables, and to smoke more than Canadians with higher incomes. and incentives for industry are (Craig et al., 2005) needed to improve the quality of our As the Chief Public Health Officer said in his food, reduce the amount of trans 2008 report, “Health inequalities are fundamentally and saturated fats, sugar and salt societal inequalities that we can overcome through in processed foods, improve food public policy, and individual and collective action.” labelling and encourage marketing (Public Health Agency of Canada, 2008) of healthy foods. A number of jurisdictions are already taking steps to reduce social and health disparities. For Communities should be planned and example, Quebec, Manitoba, Newfoundland and built to encourage Canadians to be Labrador, Nova Scotia and Ontario are developing more physically active. Information poverty reduction strategies. These strategies aim and examples of best practices to raise the standard of living for low wage earners would help schools, workplaces and and provide services to help people succeed in the families promote physical activity. workforce, such as training and literacy programs, affordable housing, early learning and child care New programs and supports are services and social supports. A number of Ontario needed to reduce tobacco use – municipalities are now part of the 25 in 5: Network particularly in youth. for Poverty Reduction, whose goal is to reduce poverty in Ontario by 25% in five years and by Creating healthy environments 50% in 10 years. requires a whole-of-government To help address gender inequities, in 2007 the approach. All ministries should Heart and Stroke Foundation of Canada introduced be involved. the evidence-based Heart Truth campaign to Canada, which is designed to help women understand their heart disease risks, reduce their risk factors and be more active in their own health and care. (Heart Truth website, 2008)
32 / Building a Heart Healthy Canada In 2005, the federal, provincial and territorial Not All Canadians Can Afford Ministers of Health approved the Integrated Healthy Foods Pan-Canadian Healthy Living Strategy. Its goals are to improve overall health outcomes and to To reduce CV risks, all Canadians need healthy, reduce health disparities, using a population health reasonably priced foods. In 2004, just over 9.9% approach. The Strategy is focusing first on healthy (1.1 million) of households in Canada experienced eating and physical activity, and their relationship problems accessing enough safe, nutritious food to to healthy weights. meet their dietary needs and lead active, healthy But more must be done now to create lives. Canadian households most likely to have environments that will help improve health and problems obtaining healthy foods are those with reduce the burden of CV diseases. lower incomes or whose main source of income is The Subcommittee on Population Health social assistance; off-reserve Aboriginal households; of the Standing Senate Committee on Social households that do not own their own dwelling; Affairs, Science and Technology, Chaired by and households with children headed by a lone Senator Wilbert Keon, is currently examining female parent. (Health Canada, 2007a) the broad determinants that influence the health Access to healthy foods is a particular problem of Canadians. Its December 2008 report will in the North, but Canada has already successfully identify actions the federal government can take to used pricing strategies and incentives to improve implement a population health approach, which will food security in remote communities. For example, address the range of factors that influence health. the Food Mail Program makes healthy foods As the Standing Senate Committee on Social available and promotes healthy eating by reducing Affairs, Science and Technology Subcommittee the postage rate for shipping nutritious perishable on Population Health noted in its fourth report, a foods to remote communities in northern Canada. coordinated, population health approach requires In 2007, the program was able to lower the cost intersectoral action – coordination among different of food in all communities that participated government departments, collaboration among (i.e., $196 to $347 per week for the average food all levels of government and the participation of basket compared with $246 to $766 without the different stakeholders from non-governmental program), equalize food costs among communities organizations, industry and communities. (Standing and increase the variety of fresh foods available. Senate Committee on Social Affairs, Science and Without the program, the cost of foods would Technology, 2008b) be higher than the household income in all but a few homes. (Cundill, 2007) At the current time, about 140 communities in three territories and six provinces are eligible for the Food Mail Program, but only about 80 are using it. (F. Hill, personal The concept of population health communication, July 23, 2008) was elaborated in Canada in 1974 The cost and availability of healthy food is not with the Lalonde report; it then just an issue in the North. In other parts of Canada, evolved from a focus on improving there are surprising differences in people’s access overall health status to an emphasis to a supermarket. For example, Canadians living in on reducing health disparities. some high-need and low-income neighbourhoods Health Canada has played a key in Edmonton do not have a supermarket within role in promoting population easy walking distance. (Smoyer-Tomic et al., 2006) health at the federal level and has officially adopted a population health framework for its programs and initiatives. (Standing Senate Committee on Social Affairs, Science and Technology, 2008a)
Create Heart Healthy Environments / 33 How Healthy Is Our Food Supply? It is possible for countries to reduce the Many Processed Foods in Canada Contain amount of trans fats and sodium (salt) in foods and improve the quality of their food supply. In 2004, Too Much Trans and Saturated Fat and Salt Denmark became the first country to regulate an The quality of the food we eat is key to keeping our upper limit on the percentage of processed trans fats blood vessels and hearts healthy. How nutritious is in food. (Health Canada, 2006) Recently, several our food now? jurisdictions, including New York City, have banned the use of artificial trans fats in foods. Finland successfully used a combination of public education and legislation to encourage its food industry to label any foods with more than a certain level of On a given day, one out of every four sodium and its restaurant industry to use less salt. adults and children in Canada eats The result? A 20% decrease in sodium in the food or drinks something in a fast food supply as producers reformulated their products outlet. (Garriguet, 2007) to avoid the “high salt content” label and a 40% decrease in sodium intake. (Laatikainen et al., 2005) Canada has already taken some steps to reduce the trans fats and sodium (salt) in foods. For example: Canadians are eating more processed and • In June 2006, Canada’s Trans Fat Task Force, prepared foods, and these foods tend to be high in co-chaired by Health Canada and the calories, saturated and trans fats, sodium (salt) and Heart and Stroke Foundation of Canada, simple sugars, and low in fibre and minerals. As recommended federal regulation to virtually a result, one in four men and women in their 30s eliminate processed trans fats in foods. The and 40s derives more than 35% of their calories federal government accepted the trans fat levels from fat, which puts them at risk of obesity and recommended by the Task Force but is cur- CV disease. (Garriguet, 2004) According to the rently using a voluntary approach combined Heart and Stroke Foundation of Canada, trans fats with public monitoring, reserving the right to in processed foods are responsible for an estimated regulate in two years if the food industry has 3000 needless cardiac deaths each year in Canada not made changes. In the absence of federal (estimate based on Harvard Public Health data). regulations, some municipalities in Canada (Heart and Stroke Foundation of Canada, 2007b) have introduced regulations to ban trans fats. Canadian adults also consume about double • In October 2007, Health Canada created the recommended amount of sodium (salt) each the multi-stakeholder Working Group on day (3500 mg instead of the 1200 to 2300 mg Dietary Sodium Reduction to advise the recommended by the Institute of Medicine in the federal government on processes and timelines United States), which leads to high blood pressure to meet the targets for sodium consumption and higher risk of CV diseases. (Campbell recommended to Health Canada by the et al., 2006) Institute of Medicine in the United States. • In 2007, Campbell Company Canada received Blood Pressure Canada’s Certificate of Excellence Award for ongoing leadership in sodium reduction. To meet the Heart and Stroke Foundation’s Health Check™ program nutrient criteria, the company has removed the equivalent of nine million teaspoons of salt from its tomato soup alone over the past five years.
34 / Building a Heart Healthy Canada Loss of Traditional Diets Leads to Canada has made some progress in limiting Obesity and Health Problems the advertising of unhealthy foods to children. In 2007, the industry members of Concerned Some of the obesity and health problems in Children’s Advertisers – working with the Food Aboriginal/indigenous communities have been and Consumer Products of Canada and Advertising linked to the loss of their traditional diets. To give Standards Canada – agreed that at least 50% of more Inuit access to traditional foods, the Nunavut their advertising to children on television would be Harvesters Support Program project (cost-shared for “healthy” food products. In 2008, the national by Nunavut Tungavik Incorporated and the report by Canada’s Advisor on Healthy Children government of the Northwest Territories) gives and Youth recommended a ban on advertising funding to a small number of full-time hunters of junk food on programs targeted to children to help cover the costs of equipment, fuel and under 12. (Leitch, 2007) The Chronic Disease supplies. The food they harvest is available in local Prevention Alliance of Canada, an alliance of 10 communities, allowing more Inuit to eat traditional national organizations working together to develop diets. (Indian and Northern Affairs Canada, integrated policies and programs for maintaining 2006) A similar program in northern Quebec, the health and preventing chronic disease, held a Inuit Hunting, Fishing and Trapping Support national consensus conference in March 2008 and Program (administered by the Kativik Regional developed a position statement recommending a Government and supported by the Quebec ban on the advertising of unhealthy foods government), provides funding for equipment, to children. purchases harvested food and distributes it free of charge to those who cannot hunt or fish. (Kativik Regional Government, 2007) The program encourages the Inuit way of life and guarantees communities a supply of traditional foods, which In 2006, 44 food companies in the are higher in protein and lower in fat than most United States spent over $1.6 billion meats from southern Canada. (Royal Commission to market food and beverages on Aboriginal Peoples, 1996) Seal and whale are to children and adolescents. excellent sources of omega-3 fatty acids, which (Federal Trade Commission, help reduce the risk of CV illnesses. (Statistics 2008) A significant proportion of Canada, 2001) that advertising also appears on television screens and in-store Marketing Affects Food Choices displays in Canada.
Some companies actively market unhealthy foods – particularly to children. (Federal Trade Commission, 2008) This advertising affects attitudes toward food and food choices. Numerous jurisdictions, including Sweden, Norway, Austria, Belgium, Luxembourg, Greece, Italy, Finland, Germany, Denmark, the United Kingdom and Australia, have developed regulations that limit advertising and marketing of products to young children. Quebec is the only province in Canada to have introduced similar legislation.
Create Heart Healthy Environments / 35 Food Labels are Confusing The opportunities that Canadians have to be physically active are affected by: Even when Canadians want to eat nutritious foods, they often do not have enough information • the way our communities are designed and to make healthy choices. Although Canada is an built, and how safe we think they are international leader in mandatory food labelling • the environments where we spend most of our on packaged foods, only 61% of women and 52% time: our homes, schools and workplaces. of men “always or usually” read the nutrition facts panel on product labels (Canadian Council of Food and Nutrition, 2008), and those who do often find the information confusing. One of the main weaknesses in Canada’s nutrition facts panel is that Almost one out of every two there is no standard serving size. For example, “one” Canadians aged 12 and older (48%) serving on the label for packaged bagels may be is physically inactive – down from one bagel, half a bagel, a quarter of a bagel or 100 57% in 1996, but still unacceptably grams of a bagel. This lack of standardization makes high. (Public Health Agency of it difficult for consumers to compare the nutritional Canada, 2009) quality of similar food products. At the current time, mandatory nutrition labelling applies only to packaged foods in Canada. Some restaurants voluntarily label items on their menus. For example, eight Canadian restaurant The Way Our Communities Are Built chains now use the Heart and Stroke Foundation’s Affects Health Health Check™ logo to identify “healthier” items on their menus. However, information about the People who live in moderate to high density nutrition content of food served in restaurants and communities and in more walkable neighbourhoods fast food outlets is still uncommon. make more trips on foot and bicycle, spend less Within the last few months, New York City, time driving, are more likely to meet recommended San Francisco and the state of California passed levels of physical activity and are less likely to be laws requiring chain restaurants to list information overweight and obese than those living in rural about the calories – and, in San Francisco, saturated areas or low density communities with few shops, fat, carbohydrates and sodium – in the food they services and other amenities close by. (Sanitch, serve at point of purchase. 2003; Ontario College of Family Physicians, 2005; Butterworth, 2000; Heart and Stroke Foundation How Healthy Are Our of Canada, 2005; Frank et al., 2004) Safety is also an issue. According to a Canadian Fitness and Physical Environments? Lifestyle Research Institute report, safety concerns keep one in five Canadians from walking or Health Canada published physical activity bicycling. (Canadian Fitness and Lifestyle Research guidelines for adults in 1998, for older adults in Institute, 1999) 1999 and for children and youth in 2002. These guidelines describe the amount of time everyone should spend being active each day in order to be healthy. However, only 10% of Canadian children and youth (Active Healthy Kids Canada, 2008), and fewer than 50% of Canadian adults are physically active. (Public Health Agency of Canada, 2009)
36 / Building a Heart Healthy Canada • Several efforts are already under way in Canada more dense urban development, with a mix to promote healthy and safe built environments. For of houses, stores and businesses example, the Centre for Sustainable Transportation • roads and pathways that encourage walking in Winnipeg is working with some provinces to and cycling adapt and implement child- and youth-friendly • land use and transport planning guidelines more easily accessible, safe and affordable including: Ontario, Nova Scotia, British Columbia, public transit services Alberta, Saskatchewan and Manitoba. The • more parks and recreation facilities, including guidelines are designed to encourage kids to spend bike lanes and paths less time in cars and more time walking and cycling. • attractive, well-lit streets, where pedestrians and cyclists feel safe. In Canada, there are several examples of new The child- and youth-friendly communities that are trying to promote physical guidelines developed by the Centre activity as well as other aspects of health, including for Sustainable Transportation Garrison Woods in Calgary, Dockside Green in Victoria and Simon Fraser University’s UniverCity. suggest that municipalities: The Dockside Green development in Victoria • Involve children and youth is being monitored for its impact on a range of in planning. environmental, social and economic indicators, including the percentage of residents who are • Identify where children and overweight or obese, self-perceived general health, youth want and need to go and and resident use of indoor and outdoor public space provide ways of getting there and facilities. This information should be used to by foot or bicycle. help create more heart healthy environments and communities. • Ensure pedestrian routes used by children are as safe as possible. School, Workplace and Home Environments Influence Health • Provide separate bicycle paths. • Make the transit system safe, Canadians spend a significant portion of their lives welcoming and affordable at school, work and home – often in sedentary activities. However, these settings can play a key for children. role in creating supportive environments. It is • Post and enforce much lower particularly important to develop work and school speed limits. (Kids on the Move environments that encourage active living because website, 2005) the gap between Canadians’ average level of physical activity and the level needed to prevent obesity is so large that leisure-time physical activity alone is unlikely to be enough to reduce obesity. In 2005, as part of the Integrated Pan- Canadian Healthy Living Strategy, Canada’s Health Smart Growth, a broad-based movement that Ministers made a commitment to develop school advocates for change in the way cities are designed nutrition standards and healthy eating programs. and built, encourages land use practices that reduce Eight of 10 provinces now have nutrition criteria urban sprawl and create more livable communi- for schools in place, but the criteria are inconsistent ties – where people can walk to schools, stores and and fall short of the standards set by the Institute of activities, instead of having to drive. The types of Medicine in the United States. (Centre for Science changes that will improve heart health include: in the Public Interest [Canada], 2007)
Create Heart Healthy Environments / 37 Schools are also providing more opportunities Policies that limit the amount of unhealthy for physical activity. Almost all elementary and food sold in schools and promote active living middle school students in Canada take at least can improve young people’s diets and help them one physical education class per week. In contrast, establish healthy eating and exercise habits early a significantly lower percentage of high school in life. School-based initiatives need rigorous students take at least one class per week. (Canadian evaluation to help identify best practices. Fitness and Lifestyle Research Institute, 2006) Workplaces should also actively promote health – either by providing more opportunities for physical activity and healthy eating, or by rewarding employees who adopt healthy behaviours. For Just over half of Canadian schools example, Scotiabank has implemented an initiative whereby all employees who do not smoke pay less allow students to use their indoor for their insurance and their health benefits. facilities for physical activity At home, parents can create family outside of school hours. environments that encourage their children to be (Canadian Fitness and Lifestyle physically active and reduce the amount of time Research Institute, 2006) they spend in front of computer and television screens. To help families be more active, it is important to reduce barriers, such as the cost of buying equipment or participating in an organized sport. The federal government has already taken In the Annapolis Valley in Nova Scotia, steps to encourage physical activity by making the parents, teachers, school boards, public health, cost of children participating in organized sports tax industry, government and researchers are deductible; however, the impact of this policy has collaborating to provide more nutritious food in not yet been assessed. school. Activities include wellness fairs for students and parents, a playground games handbook developed by students, an interdisciplinary unit on healthy eating and physical activity for Many children in Canada spend middle school students, opening the school gym four to six hours in front of a screen after school for students to use, and offering a each weekday. (Active Healthy Kids nutritious, low cost recess/lunch program for all Canada, 2008) students. Students in schools that participated in the Annapolis Valley Health Promoting School Project had lower rates of overweight and obesity, and ate more fruits and vegetables than students in other schools. The program, which is funded by the government of Nova Scotia, is now available province-wide. (Annapolis Valley Regional School Board, 2008)
38 / Building a Heart Healthy Canada Are Our Environments Smoke-Free?
Despite the progress that Canada has made in One of every five (19%) Canadian reducing smoking and exposure to second-hand adults and one of every seven (15%) smoke, tobacco use is still a key risk factor for CV youth aged 15 to 19 are current diseases. In fact, over the past two to three years, smokers. (Health Canada, 2008) Canada’s efforts to reduce smoking have stalled, especially among teenagers and men between the ages of 20 and 44 (Figure 10a and 10b). In 2007, 15% of Canadians between the ages of 15 and 19 were current smokers (Figure 10c). (Health Canada, 2008) More young women are now smoking newer tobacco products, such as flavoured cigarillos. (Physicians for a Smoke-Free Canada, 2008)
Figure 10a Smoking Trends in Canada 1965-2007: Canadians Aged 15+
60
50
40
Percent 30
20
10
0 1965 1975 1985 1995 2005 2007 Men Women
Data Source: Physicians for a Smoke-Free Canada. (2008). www.smoke-free.ca/eng_home/2008-media/2008-news-release-background/Cigarillo-Q&A.pdf.
Create Heart Healthy Environments / 39 Figure 10b Smoking Trends in Canada 1965-2007: Canadians Aged 20-24 and 25-44
70
60
50
40
Percent 30
20
10
0 1965 1975 1985 1995 2005 2007
Men Aged 20-24 Women Aged 20-24 Men Aged 25-44 Women Aged 25-44
Data Source: Physicians for a Smoke-Free Canada. (2008). www.smoke-free.ca/eng_home/2008-media/2008-news-release-background/Cigarillo-Q&A.pdf.
Figure 10c Smoking Trends in Canada 1965-2007: Canadians Aged 15-19
60
50
40
Percent 30
20
10
0 1965 1975 1985 1995 2005 2007 Boys Girls
Data Source: Physicians for a Smoke-Free Canada. (2008). www.smoke-free.ca/eng_home/2008-media/2008-news-release-background/Cigarillo-Q&A.pdf.
40 / Building a Heart Healthy Canada New strategies are needed to discourage One of the barriers for Canadians who want smoking, and to counter industry efforts to develop to stop smoking is the cost of smoking cessation and market products that are attractive to youth programs and aids. (Zawrtailo, 2008) To create a and circumvent current tobacco control legislation. more supportive environment, governments and Workplaces can play an active role by making their the health care system can help remove or reduce grounds and facilities smoke-free, offering smoking this barrier by including smoking cessation aids cessation programs and providing incentives that in provincial health plans – particularly for low- encourage employees to stop smoking. income Canadians. Quebec is the only province In 2003, when Capital District Health to currently offer this type of incentive. Authority in Nova Scotia implemented its 100% smoke-free policy on all sites, the employer also introduced “To Be Tobacco Free,” a best practice Health Is More Than Health Care tobacco intervention program for employees, physicians and volunteers. Facilitators with The health care system and ministries of health addictions training use a combination of ongoing cannot create healthy environments on their own. peer support, adult education, motivational They need the active support of other ministries, interviewing techniques and pharmacological aids including transportation to improve public transit to help people stop smoking. In 2004/05, 1900 and create more roads with bike lanes, education people participated in the program, 33% remained to shape school policies, and finance to develop smoke-free six months after the intervention, and tax policies and incentives. 44% were smoking less and still trying to stop. A number of jurisdictions are using a “whole- ( Jolemore and Steeves, 2006) of-government” approach to create healthy Hospital-based smoking cessation programs environments. For example, ActNow BC is a cross-government health promotion initiative can be highly effective in helping patients become to improve health by reducing risk factors, smoke-free because people who have had a heart which recognizes that population health goes far attack or have been diagnosed with another CV beyond the responsibility of a single ministry or disease may be motivated to change their lifestyle. a single environment. ActNow BC involves 20 The University of Ottawa Heart Institute has provincial ministries, and is led by the Minister developed a smoking cessation program for patients, of Healthy Living and Sport and supported by an which consists of consultation, intervention, ActNow Assistant Deputy Minister’s committee. information, follow-up and feedback. About 44% Representatives from each provincial ministry of the almost 1500 in-patients who participate in sit on the committee and meet monthly to share the program each year remain smoke-free for six information and develop strategies. ActNow months or longer. Twelve other hospitals in the BC’s aim is to have British Columbia lead North region are now replicating the program and using America in healthy living and physical fitness. The it to assist all smoking patients, not just those initiative has set fairly aggressive provincial goals with heart disease. The Ottawa model is also being for physical activity, healthy eating, weight, tobacco used in River Valley Health in New Brunswick use and alcohol use during pregnancy. ActNow BC and the Vancouver Coastal Health Authority in supports schools, employers, local governments and British Columbia. As the Heart Institute notes, communities to develop and promote programs having smoke-free facilities and grounds (i.e., a that make “healthy choices easy choices for all supportive environment) made it more important British Columbians.” for hospitals to offer sensitive, responsive and successful programs to assist smokers. (Champlain Cardiovascular Disease Prevention Network, 2007; Reid et al., 2006)
Create Heart Healthy Environments / 41 Quebec has also launched a government action plan to promote healthy lifestyles and prevent weight-related problems. The Quebec government Lessons Learned has allocated $20 million a year for 10 years from tobacco taxes to support collaborative projects that Efforts to create supportive promote healthy lifestyles. In Quebec, all ministries environments are most effective and agencies are also required to consult with the when they: Ministry of Health and Social Services about any • are part of a comprehensive laws or regulations they are developing that could have an impact on health. strategy that includes social Successful programs in Europe use both a marketing, legislation/ whole-of-government approach and a whole- regulation, individual education of-community approach. For example, Ensemble, and the advice of health care prévenons l’obésité des enfants (Together, let’s prevent professionals obesity in children), a program in France, has the support of professional associations, the association • involve all parts of society – of mayors of France, and six federal ministries, community, the private sector, including those responsible for health, youth, the health care system and sport, towns, agriculture and food, and business. government The program mobilizes communities – parents, • reach people in all the settings teachers, schools, doctors, stores, and national and local governments – to reduce obesity in children where they live, learn, work between the ages of 5 and 12 and to improve and play family nutrition. Towns organize activities that • aim to reduce inequities in risk, promote a balanced diet and recreational exercise, education, literacy or income. such as school breakfast programs, safe routes for walking to school, sports activities, organized physical activity at playtime, presentations by local producers about healthy foods and opportunities to try and taste new foods. (Westley, 2007; Watson, 2007) Children are weighed and measured each Recommendations year in school. Overweight or at-risk children are Supportive environments can make the healthy encouraged to see a doctor, and they and their choice the easy choice – for all Canadians. To create families receive personal coaching about diet and healthy environments, Canada can and should use physical activity. a combination of education, legislation, regulation Whole-of-government approaches have the and policy to promote healthy eating and physical potential to identify other government policies that activity, to reduce smoking, and to address the have a negative impact on health or create health underlying “upstream” social inequities that affect inequities. They also are able to ensure that any new health. Many of the “upstream” determinants of policies and programs reduce rather than increase health require action beyond the health care system social and health inequities. and the Canadian Heart Health Strategy and Action Plan. Several provincial governments are implementing whole-of-government approaches to policy development, but solving problems like poverty and food insecurity will require significantly more intersectoral leadership and action.
42 / Building a Heart Healthy Canada A/ Socio-economic Determinants B/ Environmental Factors of Health 1.1 Improve the nutritional quality of Canada’s food supply and access to healthy foods: Although the focus in the health system tends to be on behavioural risk factors for CV disease – such • Eliminate processed trans fats in Canada’s as poor diet, lack of exercise and smoking – the food supply through regulation as CHHS-AP recognizes that these determinants recommended by the Trans Fat Task Force, are in fact greatly influenced by the “upstream” including replacing trans fats with healthier socio-economic determinants of health. We also alternatives to saturated fats. acknowledge the huge opportunity to prevent CV • and other chronic diseases by addressing these Accelerate the work of Health Canada’s broader societal issues. To achieve success in this Working Group on Dietary Sodium area requires broad intersectoral action, leadership Reduction to drive daily levels of sodium and the involvement of all levels of governments, (salt) intake down to recommended levels and using whole-of-government approaches within each ensure timely implementation of the Working level of government, working collectively with the Group’s recommendations. volunteer sector, industry and society in general. • Improve food labelling regulations and other The CHHS-AP Steering Committee processes to make the portion sizes on the anticipates the final report of the Standing mandatory nutrition facts panel consistent Senate Committee on Social Affairs, Science and across similar products and provide clear, Technology Subcommittee on Population Health accurate information about nutritional values, and supports actions to overcome health and including calories, saturated and trans fats, societal inequalities, including the actions outlined sodium (salt), simple sugars, fibre and minerals. in the Chief Public Health Officer’s Report on the State • of Public Health in Canada, 2008 to: Develop guidelines, with regular monitoring, for fast food restaurants and food service • reduce poverty outlets to post the calorie count per portion • improve employment and working conditions for each item at point of purchase. • • reduce food insecurity Ban the advertising and marketing of “un- healthy” foods and beverages to children in all • improve the built environment both to media based on clear definitions of “healthy” encourage physical activity and to increase foods, and provide incentives to encourage the access to affordable housing food industry to voluntarily market “healthy” • improve access to early childhood education foods to children. and care • Provide sustainable funding to expand the • improve access to education and Food Mail Program to more northern and literacy training isolated communities. • • improve social supports. Identify best practices for providing healthy foods in schools, and disseminate this information to school boards. • Encourage employers to implement healthy food policies in workplaces and to make healthy foods available to employees. Govern- ment organizations and hospitals should lead the way by serving only healthy foods.
Create Heart Healthy Environments / 43 1.2 Create more opportunities for physical activity: 1.3 Reduce exposure to and use of tobacco:
• Increase support for infrastructure development • Enhance community programs that keep that promotes active, healthy living (e.g., youth from starting to smoke. sidewalks, walking paths, recreation centres, • Develop regulations to control the sale of parks, bike paths and lanes) by, for example, flavoured “cigarillos” and address other tobacco designating a specific portion of the $33 billion industry measures that attempt to circumvent Building Canada – Modern Infrastructure current tobacco control legislation. for a Strong Canada plan (2007-2014) for • this purpose. Identify best practices for schools to keep children and youth from starting to smoke, and • Promote and showcase Canadian and disseminate this information to school boards. international best practices/examples of • community planning and design that enhance Support employers to develop tobacco healthy, active living. policies and offer smoking cessation programs to employees, such as improving access to • Identify best practices for providing daily programs and aids that help people become opportunities for physical activities in schools smoke-free. that will help children meet Health Canada’s • physical activity guidelines, and disseminate Support successful smoking cessation this information to school boards. programs, such as the one developed by the University of Ottawa Heart Institute, at other • Provide incentives to employers to implement clinical settings in Canada. healthy, active living policies and to offer employees opportunities for regular physical activity. • Provide tax incentives to ensure opportunities for children to be more physically active, such as offering refundable tax credits to low-income families and exempting the sale of bicycles, helmets and other sports equipment from GST/HST.
44 / Building a Heart Healthy Canada 2 / Help Canadians Lead Healthier Lives
Healthy environments will provide the foundation to help all Canadians lead healthier lives.
However, even in healthy environments, Some of the information may be confusing. Many Canadians’ ability to make healthy choices – to eat Canadians – particularly older Canadians – are healthy foods, be active, not smoke, and manage not “health literate”: they do not have the skills to their blood pressure, cholesterol and weight – is sort through various health messages, understand affected by the information they receive, their them and then use that information to improve ability to understand and use that information, their their health. (Statistics Canada, 2003) Despite the motivation to change and the supports available to amount of information available about CV diseases, help them. many Canadians do not realize they are at risk or Health information is currently available from how serious the risks are. For example: many sources, including government publications • Although 60% to 70% of Canadians with heart and websites, brochures, media campaigns disease had high cholesterol before they were sponsored by pharmaceutical or other companies, diagnosed, many did not know their cholesterol brochures in doctor’s offices, health charity websites, levels – even though there is strong evidence newspaper and magazine articles, the Internet, that managing cholesterol can save lives. individual blogs, and radio and television reports. (Shepherd et al., 1995) • Heart disease and stroke is the leading cause of death for women, but only 13% of women know this. (Heart Truth website, 2008) About 12% of working-age Most women still consider CV disease a Canadians and 85% of Canadians man’s disease. aged 65 and older do not have the • health literacy skills they need to Few parents think their own children are over- weight. (Canadian Medical Association, 2006) understand health information and make informed decisions. (Statistics Canada, 2003)
Help Canadians Lead Healthier Lives / 45 When people do not think they are at risk, they Do Canadians Have the Information are less likely to take steps to protect their health. They Need to Lead Healthy Lives? To be able to lead healthier lives, Canadians Messages About Risk Factors need to know their risk and have accurate Can be Confusing information, education, skills and support. To build a heart healthy nation, Canada needs more Many of the risk factors that cause CV diseases effective ways to communicate information about also contribute to diabetes, kidney disease, cancer, CV health and risks, and to promote and provide dementia and other chronic illnesses, so many regular screening of blood pressure, cholesterol different chronic disease organizations and and other lipid levels, blood sugar, weight and strategies are talking about the importance of abdominal obesity. healthy eating and physical activity. In some cases – such as advice about alcohol consumption or the benefits of certain medications – the information conflicts. To ensure that Canadians receive accurate Key Messages health information, the key chronic disease Canadians need accurate, authoritative organizations should be working together – information on CV health as well as pooling their expertise, human resources and influence – to develop and communicate clear, education, skills and support to help them consistent messages about common risk factors. lead healthier lives. Some promising collaborative work is already Information about CV risks is currently under way. For example, in 2003, the Heart and available from many sources but can Stroke Foundation of Canada, the Canadian be contradictory. Cancer Society, the Canadian Diabetes Association, the Canadian Council for Tobacco Control, the Chronic disease organizations should Coalition for Active Living and the Dietitians work together to develop consistent of Canada established the Chronic Disease messages about shared risk factors and Prevention Alliance of Canada (CDPAC), a effective public education and social network of organizations working together to marketing campaigns. develop integrated chronic disease policies and programs. CDPAC is now an alliance of 10 national Canada should make health literacy a organizations linked to a network of provincial and priority, so Canadians will have the skills territorial organizations. to assess and use health information. The CHHS-AP supports these collaborative efforts – which have the potential to enhance Interactive tools will help Canadians the individual efforts of different disease groups be more aware of their risks and more – and encourages the different disease strategies involved in their own health and care. to go farther. Social marketing and awareness campaigns should target the general public as well Canadians should be screened regularly as individuals at high risk, such as Aboriginal/ for early signs of CV risk factors. indigenous peoples, Asians, blacks, seniors, women Screening programs should be provided over age 50, people who have more than one risk in different settings in the community. factor for CV diseases and people with low incomes.
46 / Building a Heart Healthy Canada Sustained public education and social market- ing campaigns should provide: Promising Practices in Public • culturally and age-appropriate information Education and Social Marketing • information in a variety of languages and formats Based on experience with the • Federal Tobacco Control Strategy practical advice and tools that will help people and other initiatives, effective make healthy choices, such as signs at the point of sale in grocery stores and restaurants public education and social • marketing campaigns should: information on how to access screening and monitoring programs. • Focus on positive messages and results that can be achieved. • Include population-based Information About Self-Care Can Be Hard to information aimed at the general Find and Use public as well as targeted Informed Canadians can be their own primary care programs designed to meet the provider but – to manage their health – Canadians needs of those at high risk of who have already been diagnosed with a CV disease cardiovascular disease. or a risk factor (e.g., high blood pressure or high • Communicate messages that cholesterol) need accurate, trustworthy information. In fact, information can be an incentive for people are consistent with other health to take a more active role in their own health strategies, in order to reduce and care. confusion and enhance their The Internet is an increasingly important impact. tool for sharing health information – one that has • Be interactive and involve the potential to reduce the disparities between urban and rural areas in accessing information. the people they are trying to Approximately 70% of Canadians use the Internet reach – both to engage them in now, and this percentage will increase. (Canadian their own care and to ensure Radio and Television Commission, 2007) Canada the education messages are should take advantage of the full potential of culturally appropriate. Internet technology, while ensuring that those Canadians who do not have easy access to the • Involve the non-health as Internet are still able to receive accurate health well as the health sectors in information. delivering the messages. When developing Internet information, • Provide information and support Canada should create interactive ways for people to in all settings where people live, obtain information on CV diseases, such as online risk assessments and tips on how to stay active and work, learn and play. track their fitness goals. Information sites should • Provide incentives. also provide places where patients can communicate with others facing the same issues, such as online • Match interventions with communities, health forums and blogs. communities’ and individuals’ readiness for change. • Be long-term, multi-year strategies that recognize the time and political will required to change behaviour.
Help Canadians Lead Healthier Lives / 47 There are some good interactive forms of CV information already available, such as: Low health literacy is associated • the Heart and Stroke Foundation of Ontario’s with poor health. The situation in web-based Heart&Stroke Blood Pressure Canada is critical. (Rootman and Action Plan™ and the Heart&Stroke Risk Gordon-El-Bihbety, 2008) Assessment™, which allow people to track their blood pressure and other health risks and provide individual, personalized advice on how to improve health • Blood Pressure Canada’s website, Health literacy is key to helping Canadians www.hypertension.ca/bpc, which provides find and judge information. In January 2008, updated information for patients and health a health literacy symposium sponsored by the care providers on blood pressure management. Canadian Public Health Association Expert Panel There are also some message boards and blogs on Health Literacy recommended priorities for a where Canadians can “talk” with others trying to nationwide health literacy strategy (Rootman and reduce their CV risks and be more active in their Gordon-El-Bihbety, 2008): own self-care; however, these online communities • Make literacy – and health literacy – a are not as well developed for CV diseases as they national priority. are for other diseases, such as breast cancer. • Many Canadians continue to turn to their Make health and education sensitive primary care providers for information or to and responsive to language, culture and confirm what they have learned on the Internet. health literacy. Primary care providers can play a valuable role in • Develop programs that help populations at directing patients to accurate, authoritative sources risk make better use of health services. of information on CV diseases and in encouraging • them to use that information to be active partners Encourage health practitioners to be agents in their own care. of change. • Develop an integrated, comprehensive strategy that addresses the needs and concerns of First Many Canadians Do Not Have the Skills Nations, Inuit and Métis people. to Use Health Information It is important that efforts to improve health For campaigns and information to be effective, literacy work for everyone and do not increase Canadians must have the health literacy skills to be inequities between those who have easy access to able to use health information to make informed information and services and those who do not. decisions. When Canadians look for health Schools can play an important role in health literacy information online using search engines such as by developing stronger health curricula. Google, they often find it difficult to know how One of the most effective ways to improve accurate the information is. Is the source biased? health literacy – particularly among people Is the site trying to market a product? diagnosed with a CV disease – is to develop user-friendly versions of evidence-based clinical guidelines. This type of information helps patients become aware of the care they should be receiving and talk to their providers about their care. For example, the Canadian Hypertension Education Program has published a public version of the blood pressure guidelines, and the Canadian Stroke Strategy is developing a public version of the Canadian Best Practice Recommendations for Stroke Care. Another way to improve health literacy is to give individuals easy access to their own health records and test results.
48 / Building a Heart Healthy Canada Canadians Need Different Approaches to Health Promotion A life course approach recognizes The health care system has traditionally used a risk that life experiences – particularly factor approach to promote health, focusing on a in the early years – affect habits and particular risk, such as smoking or obesity, and then choices later in life, and it focuses developing information and education programs on promoting health at critical that target that risk. This approach can work well with CV diseases – particularly when education life stages, such as improving about risk factors is combined with screening fetal nutrition and birth weights; programs that give people concrete information promoting a healthy diet and about their own personal risks as well as ways to physical activity in the early years reduce them. to avoid childhood obesity; giving With some populations at high risk, a life children information and skills course approach – combined with a risk factor at the age when many first start approach – may be a more effective way to reduce smoking so they will remain smoke- risk (Figure 11). Life course epidemiology is a free; developing programs that particularly promising practice in Aboriginal/ keep adolescents physically active; indigenous communities. Targeting maternal and child health not only leads to better birth outcomes and measuring adolescent blood but also helps mothers make adjustments in their pressure. At each age and stage of lives at a time when they are most amenable life, people receive the information, to change. With smoking and poor diet well skills and supports they need to entrenched in many Aboriginal/indigenous make healthy choices. (World communities, (Cooke et al., 2004) the development Health Organization, 2005) of healthy habits early in life is key, and early intervention is the best use of limited resources. (Hecmann, 2006)
Figure 11 A Life Course Approach to Chronic Diseases
FETAL INFANCY LIFE AND CHILDHOOD ADOLESCENCE ADULT LIFE
Accumulation of Chronic Disease Risk Development of chronic diseases of chronic Development
Age
Source: World Health Organization. (2005). “Preventing Chronic Disease, A Vital Investment”.
Help Canadians Lead Healthier Lives / 49 When developing prevention programs, However, every effort must be made to Canada should use both a risk factor and a life ensure that: course approach, helping children establish healthy • Community-based screening is done properly. lifestyles early and targeting Canadians at key stages • of life when their risks of cardiovascular disease Participants are given their results and know are high. what they mean. • People receive appropriate, high-quality follow- Few Canadians Are Screened for up and treatment. CV Risk Factors Several effective screening programs already operate in community settings across Canada. People are more likely to change eating habits For example, the Calgary Fire Department offers or be more active when they know they have regular blood pressure measurements for the public, a problem. Regular screening for risk factors with the screening done by firefighters. helps detect problems early, when they can be Preschoolers in Ontario are now being screened managed with changes in diet or exercise or with for healthy eating using the Nutrition Screening medication – rather than after complications have Tool for Every Preschooler (NutriSTEP™), developed. Various clinical practice guidelines developed by dietitian researchers at the Sudbury contain recommendations for regular screening of and District Health Unit in collaboration with diet, level of activity, obesity (i.e., body mass index, the Canadian Institutes of Health Research. The waist circumference) and blood pressure, as well as questionnaire assesses preschoolers’ eating habits blood glucose, cholesterol and triglyceride levels. and comes with a tool kit that parents can use to Yet relatively few Canadians – given that 90% have improve their child’s nutrition. NutriSTEP™ – an at least one risk factor for CV diseases – are being example of a life course approach to promoting monitored. When screening is done, it is not always health – is a requirement of the new Ontario Public done well or consistently. Health Standards and is being promoted across the The lack of risk factor screening and province. The Ministry of Health Promotion plans monitoring may be due, in part, to the large number to monitor results. of Canadians – more than four million, including Industry can also offer employees effective 240,000 who have a chronic disease – who do not screening programs for common risk factors as well have a family doctor. (Statistics Canada, 2008) as programs to improve diet, weight management About 80% of this group report that they use and health knowledge. For example, in Project walk-in clinics or emergency departments when Impact, 2700 employees from eight Halifax they need care; however, this means that they are companies were screened in the workplace for CV unlikely to receive the regular screening that would risk factors, such as smoking, obesity, blood pressure, help detect high blood pressure or cholesterol at an cholesterol and physical activity. Over 60% had at early stage. least two modifiable risk factors, and 566 agreed to participate in a three-month Health and Wellness Program. The control group received information Community Screening Programs about their risk factors, while the intervention Show Promise group received heart health education sessions, individualized exercise programs, nutrition analysis Risk factor screening has traditionally occurred in and counselling, a smoking cessation program and a doctor’s offices, but it can also take place at other stress management program. All participants – even sites in the community, including pharmacies, those who just received information – had a drop in schools, fire stations and workplaces – where their risk, which reinforces that just knowing about programs can reach more people. In fact, having one’s risks has value. However, those who received trained volunteers take some measurements, such information, counselling and other programs had a as blood pressure, outside the primary care setting greater reduction in risk. According to the sponsors (i.e., in surroundings familiar to participants) can of the project (Atlantic Blue Cross Care, Aventis result in more accurate readings. (Kaczorowski et al., 2008)
50 / Building a Heart Healthy Canada What Is the Potential of Genetic Screening? Pharma and the Atlantic Health and Wellness Institute), the results translate into one cardiac Molecular genetics holds great promise for event avoided for every 100 participants and one transforming cardiovascular care in the 21st century, stroke avoided for every 500 participants over a and it has the potential to improve diagnosis and 10-year time period. (C. LeCouteur-Morais, treatment. (Robin et al., 2007) Genetic testing is personal communication, November 28, 2007) already being used to diagnose many single-gene Workplace screening programs are in the diseases and, in the near future, may be able to best interest of employers in that they help ensure determine whether an individual is genetically a healthy workforce and decrease absenteeism. susceptible to common CV risk factors. Genetic (Renaud et al., 2008) However, more positive testing can also be used to detect genetic variations incentives for employers are clearly required. that may affect how people respond to treatment. (Bennett et al., 2007; Kajinami et al., 2004) Setting Priorities for Screening Thirty-seven countries are currently involved in a global systematic genetic screening program, Risk of CV diseases increases with age, and Canada called “Make Early Diagnosis to Prevent Early has an aging population. Indeed, the number Death” (MEDPED), for dominant familial of Canadians over the age of 65 is expected to hypercholesterolemia (FH), a lethal treatable – but double within the next 15 years. This means difficult to diagnose – disease that affects one of that seniors should be a target group for CV every 250 people in Quebec and one of every 500 education and screening programs. For example, in other Canadian provinces. The Netherlands has some communities have designed programs for an ongoing nationwide family-based FH molecular older adults, such as the Cardiovascular Health screening program, which has resulted in better Awareness Program in Ontario (Kaczorowski et al., treatment for high-risk patients, better adherence to 2008) and the Airdrie Community Hypertension treatment, a lower risk of cardiovascular events and Awareness and Management Program in Alberta. better access to life and disability insurance (Leren ( Jones et al., 2008) In these initiatives, local et al., 2008; Homsma et al., 2008), and it has proven pharmacies hold screening and education sessions, to be cost-effective. (Wonderling et al., 2004) where seniors are assessed for their cardiovascular Canada has been a leader in genetic screening risk. Trained volunteers take each person’s blood in the cancer field, initiating successful breast cancer pressure and complete a cardiovascular risk profile. prevention programs that include genetic screening Participants are given a copy of their risk profile, for BRCA1/2 gene mutations. (Oros et al., 2006; as well as information about how to reduce their Simard et al., 2007) These programs should be a risks. Results are recorded in a database and sent to model for other diseases, including CV diseases. the person’s primary care provider and pharmacist. Within the next half-generation, we will have the Seniors, physicians and pharmacists can also access technology to support routine genetic screening test results online. In addition to individual patient for at least some cardiovascular disorders. There reports, physicians receive a confidential report is much still to be learned, but this “personalized” comparing the proportion of their patients with approach to diagnosis, risk stratification and high blood pressure with those of other practices. optimal treatment is extraordinarily exciting for This report allows physicians to see whether they our future. are doing as good a job as their peers in helping patients manage blood pressure. Priority should also be given to other populations with high rates of CV diseases, such as Aboriginal/indigenous peoples, South Asians and African Canadians. In a life course approach, priority would also be given to screening adolescents according to recommended guidelines to identify risk factors early in life.
Help Canadians Lead Healthier Lives / 51 Recommendations • Focus on self-care and make Canadians aware of evidence-based guidelines and strategies to Canadians’ ability to make healthy choices – to eat reduce risk, improve self-care, promote health healthy foods, be active, not smoke, and manage and prevent complications at all stages of their blood pressure, cholesterol and weight – is CV diseases. affected by the information they receive about the • risk factors that lead to CV diseases, their ability Link Canadians to community services that to understand and use that information, their can help them lead healthier lives, such as motivation to change, and the supports available smoking cessation programs, physical activity to help them, such as screening and follow-up programs, dietitian services and support groups. programs in their communities. • Have the mandate and resources to develop To help Canadians lead healthier lives, and maintain information tools and links to we should: related resources. 2.1 Bring Canada’s major disease organizations together to: 2.3 Deliver CV risk screening, education and follow-up programs in a variety of community • Develop and communicate clear, consistent settings. These programs should: messages about common risk factors for • chronic diseases. Have strong leadership and accountability, and • be part of community/regional care systems. Create and launch comprehensive, sustained • public education/social marketing campaigns Be evidence-based. targeted at high-risk populations to prevent • Be delivered by trained providers and/or CV and other chronic diseases, including the volunteers. signs and symptoms of stroke and heart disease, • and the actions to take. Be offered in settings convenient for Cana- dians, including workplaces, where incentives • Support the Canadian Public Health Associa- should be developed to help employers create tion’s and the Canadian Council on Learning’s and maintain these programs. work on health literacy. • Target groups at risk. 2.2 Develop and maintain interactive Canadian • Focus on key CV risk factors, including blood source(s) of authoritative information on pressure and cholesterol levels, weight and CV health and diseases. waist measurement, smoking, fasting blood sugar, family history, nutritional status and The information source(s) should build on physical activity. existing initiatives and: • Ensure that risk profile measurements taken • Provide up-to-date information on key risk during screening are shared with individu- factors, including high blood pressure and als and their primary care providers, and that cholesterol, healthy eating, physical activity, individuals have the information they need to smoking, obesity and diabetes. understand their risk profile. • Be supported by interprofessional primary care • Refer people who are at risk for appropriate teams who, in turn, will provide more consistent evidence-based treatments, follow-up services messages to their patients. and supports. • Include interactive ways for people to identify • Where possible and practical, use knowledge and assess their own risks and learn practical of genetic variation to identify people with ways to reduce risk. inherited risks for CV diseases.
52 / Building a Heart Healthy Canada 3 / End the CV Health Crisis Among Aboriginal/ Indigenous Peoples
CV diseases are a serious problem for Canadians, but a full-blown crisis for Aboriginal/indigenous peoples. While Canadians as a whole enjoy a level of health that is among the highest in the world, the health picture for many Aboriginal/indigenous peoples in Canada is much bleaker.
Although not all Aboriginal/indigenous peoples There is little information available specifically and communities are at high risk of heart disease on Inuit and Métis health, but, based on traditional and stroke, Aboriginal/indigenous peoples have a measures such as body mass index, the Inuit – higher prevalence of CV and other chronic diseases particularly Inuit women – are at higher risk from such as diabetes, cancer and arthritis/rheumatism overweight and obesity than other populations. than Canadians in general (Figure 12). (National (Young, 2007) Two in five Métis people are Aboriginal Health Organization, 1997) From 1984 physically inactive, one in three is overweight, one to 1995, the hospitalization rate for ischemic heart in five is obese and one in three is a daily smoker. disease in First Nations communities in Ontario (Public Health Agency of Canada, 2009) more than doubled (from 76 to 186 per 10,000 people) while hospitalization rates for the rest of the province declined. (Shah et al., 2000; Harris et al., 2002) In 1991, 31% of First Nations adults The Constitution of Canada reported having a chronic health problem; by 2002/2003, 63.7% reported at least one long-term recognizes three groups of health condition. (National Aboriginal Health Aboriginal peoples: Indians Organization, 2005) (or First Nations), Inuit and Métis. These three separate peoples have unique heritages, languages and cultural practices.
End the CV Health Crisis Among Aboriginal/Indigenous Peoples / 53 Figure 12 Prevalence of Heart Disease and Risk Factors of First Nations Compared to General Canadian Adult Population (%)
Physical 78.7 Inactivity 46.9 Smoking 58.8 19.0 Overweight 37.0 33.0 Obesity 31.2 15.0 High Blood 20.4 Pressure 16.4 Diabetes 19.7 5.2 7.6 Heart Disease 5.6
0 10 20 30 40 50 60 70 80
First Nations Regional Longitudinal Health Survey Canadian Community Health Survey (RHS) 2002/03 (CCHS) 2003
Diet, Smoking, Sedentary Lifestyle and Other Factors Threaten Health About 60% of Aboriginal/indigenous The CV health of Aboriginal/indigenous peoples people smoke compared with is threatened by smoking, substance use, sedentary 22% of the general population of lifestyles and poor diet. Of these risk factors, poor Canada. (National Aboriginal Health diet is the most complex because it is related to Organization, 2005) the changing tastes of a new generation (i.e., Westernized diets), the high cost and lack of access to healthy foods (i.e., food insecurity) and less access to traditional foods because of climate change and harvesting costs. Social and economic If nothing is done to address the heart health factors also affect health. For example, the health crisis in Aboriginal/indigenous communities, the problems of many Inuit are compounded by situation will become much worse – simply because overcrowded housing, low levels of education of demographics. The Aboriginal population in and income, prevailing mental health issues Canada is growing much faster than the rest of the (e.g., guilt, hopelessness, low self-esteem, population (Figures 13a and 13b). If we do not act substance use/abuse, suicidal ideation and now, both the well-being of Aboriginal/indigenous poor coping skills). (S. Carriere, personal peoples and the sustainability of health care systems communication, December 18, 2007) across the country will be threatened.
54 / Building a Heart Healthy Canada Figure 13a Population Projections for Aboriginal and Canadian Populations
35537.6 33909.7 35000 32547.2
30000
25000
20000
15000
10000 Population in Thousands in Population 5000 1169.5 1282.8 1431.8 0 2006 2011 2017 Aboriginal* Canada**
Data Sources: *Statistics Canada. (2005). Projections of the Aboriginal Populations, Canada, Provinces and Territories: 2001-2017. **Statistics Canada. (2005). Population Projections for Canada, Provinces and Territories: 2005-2031.
Figure 13b Projected Growth for Aboriginal and Canadian Populations
25
20
15
Percent 10
5
0 2006 2011 2017 Aboriginal* Canada**
Data Sources: *Statistics Canada. (2005). Projections of the Aboriginal Populations, Canada, Provinces and Territories: 2001-2017. **Statistics Canada. (2005). Population Projections for Canada, Provinces and Territories: 2005-2031.
End the CV Health Crisis Among Aboriginal/Indigenous Peoples / 55 While CV disease is a crisis for many Aboriginal/indigenous peoples vary widely Aboriginal/indigenous peoples, there is hope. Many in their cultural strength and history, community Aboriginal/indigenous communities – in Canada, infrastructure, economic opportunity, language and in the United States and internationally – are group identity. Because of this diversity, health and actively developing and implementing programs healing efforts must be designed to meet the needs and services to reduce CV diseases and improve of different communities. Strategies to reduce CV treatment. If we use what we already know and diseases and improve treatment for Aboriginal/ build on the strengths of Aboriginal/indigenous indigenous peoples must take into account those communities, we can prevent disease and avoid living in Aboriginal/indigenous communities as the health problems and costs. well as the more than 50% of the population that To end the CV crisis among Aboriginal/ live away from their home communities. Solutions indigenous peoples, Canada must engage must meet the needs of both urban and rural/ Aboriginal/indigenous communities in developing remote communities. their own heart health solutions, support Most CV diseases begin in childhood, and comprehensive health promotion programs that habits formed early can affect health throughout life. address the health and social factors that put Risk accumulates over time and increases with age. people at risk, improve screening programs, provide However, it is possible to delay illness and deaths integrated treatment services, and develop the from chronic diseases by intervening early. (World information to guide prevention and care programs. Health Organization, 2005) A life course approach – targeting people at critical stages in their lives – may be an effective way to enhance health. Environments and the Broader For example, in response to a plea for Determinants Threaten Health community Elders to address the diabetes epidemic, doctors at the Kateri Memorial Hospital In Aboriginal communities health is conceived less collaborated with dietitians, researchers and as a personal matter than as a harmonious order in school officials to develop the Kahnawake Schools which the person is integrated in an encompassing Diabetes Prevention Program. The goal is to reduce social, temporal, spiritual and non-empirical diabetes by reducing obesity and high fat/high environment. (Ootoova et al., 2001) As a natural calorie diets and increasing physical activity. The by-product of respectful balance and harmony in program consists of three components: children in the universe, “health” or the good life unfolds from grades 1 to 6 learn about nutrition, fitness, diabetes, broader social and environmental order. the human body and healthy lifestyles at school; No matter how well designed and effective parents and caregivers receive a home support clinical and programmatic efforts are in the short program on nutrition, physical activity and health term, environmental factors have enormous power lifestyles; and the community is involved through a to override gains, prompting many to view the local advisory board. The program started as a three- individual in context as the only appropriate focus year pilot in the mid-1990s, which demonstrated of intervention and analysis. (Kirmayer et al., 2003; that this intervention did have an effect on eating Willms, 2005) habits: participants drank less pop and ate fewer Efforts to solve the CV disease crisis among high fat foods. Local universities are now involved, Aboriginal/indigenous peoples must focus not and the program trains service providers from solely on individual health behaviours but also other communities to deliver similar multi-faceted on the environment and policies that influence prevention programs to all community school individual behaviour – including equitable access children. (Paradis, 2005) to primary care and other health services. Lifestyle The Aboriginal HeartSmart Kids™ program modification campaigns, such as smoking cessation developed by the Heart and Stroke Foundation programs, have not been as successful with is designed to reach children early by integrating Aboriginal/indigenous peoples as with Canadians culturally sensitive information about heart health in general. This is largely because they focus only into the curriculum. Educators in 177 of 241 on individual risk factors and do not address the communities with a First Nations band have been broader socio-economic determinants of health or trained to use the program, and most parts of the the need for healthy environments. curriculum are well used. Among teachers who have used the program, 83% find it excellent or good in cultural sensitivity.
56 / Building a Heart Healthy Canada Lack of Screening Threatens Health In Australia, the New South Wales Aboriginal Vascular Health Program organized a series Despite high rates of cardiovascular disease and of demonstration projects to address diabetes, other illnesses, many Aboriginal/indigenous peoples circulatory diseases and renal disease by offering lack access to services – particularly screening and risk assessment, early intervention and health monitoring for chronic disease and basic physician promotion and/or by improving coordination of services. Because they are not tested and diagnosed, existing services and collaboration among service many do not receive treatment or rehabilitation providers. The Program used activities that are not until they are close to death. traditionally part of more targeted heart health efforts, including building the capacity of local teams by providing support, education, training and resources; developing partnerships; using Although First Nations living culturally appropriate teaching methods guided by on-reserve are at a higher risk of community members; and creating local ownership. mortality from acute myocardial More than 1000 Aboriginal people were screened. infarction (72.7 per 100,000 The success was attributed to the fact that projects compared with 52.1 per 100,000 for were flexible enough to meet local needs, engaged the community in collaborative ways and provided all Canadians), they are less likely responsive, hands-on support. (New South Wales than Canadians in general to receive Department of Health, 2004) routine early testing for heart disease risk, such as cholesterol testing. (National Aboriginal Health Organization, 2005) Promising Practices Effective interventions for Aboriginal/indigenous people share the following features. They: Screening, treating and monitoring people for risk factors for CV diseases is an effective way to • are developed through reduce risk. For example, the Alaska Inuit Diabetes partnerships and collaboration Prevention Project screened participants for a with Aboriginal/indigenous number of risk factors, including blood pressure, communities cholesterol levels and glucose tolerance. One group received a four-year intervention that included • use a team approach a counselling session and yearly mailings about • create capacity within healthy diet and exercise. They were specifically encouraged to eat more foods with omega-3 fatty Aboriginal/indigenous acids and to avoid foods with palmitic acid, a communities to promote health common saturated fat. When they were screened • use a life course approach again after the intervention, participants had lower levels of cholesterol, fasting glucose and blood • focus on specific risk factors pressure than members of another group who • provide more equitable access received just the yearly mailings. (Ebbesson to care et al., 2005) • are culturally appropriate • match the needs and readiness of the people/communities involved.
End the CV Health Crisis Among Aboriginal/Indigenous Peoples / 57 Lack of Equipment, Technology and Lack of Information Threatens Health Health Care Providers Threatens Health Information is key to improving Aboriginal/ Even when Aboriginal/indigenous peoples are indigenous health, but there have been few diagnosed and receive treatment, they often do not systematic efforts to gather data on the CV health have the same access to care as most Canadians and risks of Aboriginal/indigenous peoples – and – particularly if they live in remote and isolated most of the information that does exist is for First communities. While telehealth and e-medicine can Nations populations rather than Inuit or Métis. help, Aboriginal/indigenous peoples need better There is very little information that specifically access to cardiac life support, specialists and other, addresses CV disease treatment or management in often simple diagnostic equipment (e.g., x-ray, Canadian Aboriginal/indigenous communities or electrocardiogram) in their communities. how acute, rehabilitative or end-of-life planning (Cooke et al., 2004) and care is provided. Aboriginal/indigenous There is also a shortage of Aboriginal/ communities need more specific local, regional and indigenous health care providers. Efforts are under national data on First Nations, Métis and Inuit way to recruit Aboriginal/indigenous people to peoples so they can develop unique strategies for health careers, and progress is being made, but each group. More directed research is required there are still relatively few Aboriginal/indigenous to understand the distinct health needs of First providers. More must be done to ensure that Nations, Inuit and Métis peoples, to engage and Aboriginal/indigenous peoples receive culturally support the community and to develop effective competent care from interprofessional primary interventions that have cultural integrity. care teams. Some individual efforts are under way to collect information, but they are not systematic. For example, the BRAID study, co-funded by the Jurisdictional Disputes Aboriginal Diabetes Initiative and the University Threaten Health of Alberta, was designed to collect information on diabetes and metabolic syndrome (i.e., abdominal The capacity to end the heart health crisis in obesity, abnormal blood fats, high blood pressure Aboriginal/indigenous communities is also affected and glucose intolerance) on people in a First by jurisdictional issues. The federal government Nations community in Northern Alberta. (Kaler et is responsible for health care services provided al., 2006) A research team collected blood pressure, in Aboriginal/indigenous communities, while fasting glucose and body mass index measurements the provinces and territories are responsible for as well as family history on almost 300 people health care services that Aboriginal/indigenous over age 6 who had not previously been diagnosed peoples receive in hospitals and outside their home with diabetes. About 50% of the adults and 40% communities. The provinces and territories also fund of the children and adolescents had metabolic some services provided in Aboriginal/indigenous syndrome, a condition associated with a high communities. Disputes between jurisdictions incidence of CV diseases. Rates of obesity, pre- can delay services and cause severe hardship – as diabetes and metabolic syndrome were particularly in the case of Jordan Anderson, a First Nations high in participants who were aged 18 or older. All child who died in a Winnipeg hospital instead of participants were offered follow-up services by a with his family in his home community because nurse, dietitian or physician. the governments could not agree on how to share his medical care costs. (In 2007, the Government of Canada passed Jordan’s Principle, a resolution establishing a “child first” principle for resolving jurisdictional disputes.)
58 / Building a Heart Healthy Canada In the United States, efforts have been made Recommendations to collect much more extensive information 3.1 Develop a multi-year action plan to meet the on a larger, more diverse group of Aboriginal/ CV needs of Aboriginal/indigenous peoples indigenous peoples. The Strong Heart Study is and communities using a partnership approach a longitudinal analysis of cardiovascular disease involving Aboriginal/indigenous organizations; in American Indian communities: the largest federal, provincial, territorial and municipal epidemiological study of American Indians ever governments; Aboriginal/indigenous undertaken. (Center for American Indian Health communities; and non-governmental Research, 2008) Over 4500 people from 13 tribes organizations. and communities in three geographic areas in the United States are participating. The five-phase study 3.2 Create a national Aboriginal/indigenous looks at mortality rates among people aged 35 to centre (or network of centres) for chronic 74, findings from clinical examinations (i.e., risk disease prevention and management to factors) and the role of genetics. It includes a family coordinate the implementation of the action study to help identify genes that might contribute plan. Together, the centre and the plan will: to risk. The study has constructed a genetic map and is doing a genome scan to analyze changes in Create Heart Healthy Aboriginal/ risk. In addition to increasing knowledge about the indigenous Communities: risks of cardiovascular disease, the study may lead to new therapeutic and prevention strategies for • Engage community institutions and build Aboriginal/indigenous peoples. community capacity in prevention interven- tions – particularly those related to tobacco reduction, school-based nutrition, fitness/ Lack of Engagement Threatens Health sports and recreation. • To end the CV health crisis in Aboriginal/ Promote promising practices, such as limiting indigenous communities, Aboriginal/indigenous tobacco sales to minors, removing unhealthy peoples and communities must be actively engaged food from schools and providing opportunities in developing their own CV health solutions and for regular physical activity. plans. At the same time, Aboriginal/indigenous • Ensure approaches to CV disease prevention peoples and communities must be an integral part and care that respect traditional knowledge, of the Canadian Heart Health Strategy and Aboriginal/indigenous values and individual/ Action Plan. community readiness. All the recommendations in this report apply to all Canadians, including Aboriginal/indigenous peoples. In addition, Aboriginal/indigenous leaders Help Aboriginal/indigenous Peoples Lead should work with their communities, governments Healthier Lives: and non-governmental organizations to develop • Adopt a life course approach to risk reduction a multi-year action plan to engage Aboriginal/ with a focus on early life. indigenous communities and identify culturally • appropriate ways to reduce risk, improve care, Work with other chronic disease strategies/ respond to urgent needs, and address social and organizations, such as cancer, diabetes, lung and health inequities. stroke, to develop comprehensive prevention programs for Aboriginal/indigenous peoples.
End the CV Health Crisis Among Aboriginal/Indigenous Peoples / 59 Continue the Reform of Health Services: Provide Develop the Right Service Providers With Integrated, Patient-Centred Cardiovascular Care: the Right Education and Skills: • Ensure a continuum of care between commu- • Strengthen the Aboriginal/indigenous health nity-based and regional health authorities. workforce by providing chronic disease intervention training, intercommunity • Provide the same standard of CV care available mentoring and exchange, more bursaries, and to other Canadians. more seats in medical and nursing faculties, • Improve access to care by making effective and by extending regional Heart and Stroke use of interprofessional teams – which should Foundation outreach and support. include nurse practitioners, dietitians, and • Improve the cultural competency of non- primary care and specialist physicians all linked Aboriginal/indigenous health service providers together – employing cardiovascular disease by providing residency incentives in the North, management algorithms, community and by rotating visiting specialists to rural, remote home care services and telehealth/ and isolated areas, and by incorporating cultural e-medicine technologies. competency education and practical models/ approaches for working with Aboriginal/ Build the Knowledge Infrastructure to indigenous peoples into professional Enhance Prevention and Care: training curricula. • Oversample Aboriginal/indigenous peoples in periodic versions of the Canadian Health Measures Survey, and include Métis and Inuit in the First Nations Regional Health Survey. • Advance the development and application of First Nations-, Inuit- and Métis-controlled databases that link with national databases. • Establish an accurate, current database of evidence-informed chronic disease interventions as a means of tracking and sharing best practices. • Improve screening, surveillance and monitoring systems within Aboriginal/indigenous health service agencies by ensuring that all clinical, research, survey and federally managed data are available locally. • Support intervention and evaluation studies, particularly on food security and multi- component interventions. • Fund research on interventions that address individuals and communities in context and that reflect Canadian Institutes of Health Research guidelines and other recommended research practices for working with Aboriginal/ indigenous communities.
60 / Building a Heart Healthy Canada 4 / Continue the Reform of Health Services – Provide Timely, Integrated Patient-Centred Cardiovascular Care
A great deal of CV disease can be prevented, but once disease and its complications have developed, they usually cannot be cured. CV diseases are chronic, deteriorating conditions that people have to manage and endure for the rest of their lives. To enjoy the best possible quality of life, they need timely, integrated, patient-centred care.
Given the large number of Canadians who are likely to develop CV diseases over the next 10 to 20 An integrated, patient-centred years, they will also need efficient care. If the system does not become more efficient and effective, it will system: be overwhelmed by the demand for care and the • communicates and shares cost of that care. information among the primary As noted earlier, this chapter focuses primarily care team, the regional network on cardiovascular disease and the care of people and the patient with heart disease; however, the directions (such as improving access to care, establishing effective • helps patients make the regional networks and the use of evidence-based transition between different guidelines) are consistent with the approaches providers and different levels recommended for treating other chronic diseases of care and, in particular, with the Canadian Stroke Strategy. • ensures high-quality, evidence- informed care in all settings and sites • supports patients as active partners in their own health and care.
Continue the Reform of Health Services / 61 The Building Blocks for Integrated, Patient-Centred Care Patient-centred cardiac care consists of the following key elements: Self-Care. Individuals and their families are partners in their own health and care. They have easy access to information and services that help them to monitor their health (e.g., weight, blood pressure, cholesterol, abdominal obesity, eating habits and physical activity); improve their eating and exercise habits; and take medications prescribed by a care provider regularly. They know their own risk factors, have access to their health records and are involved in the decisions about their care. They have “voice, choice and representation.” Team-Based Primary Care. Primary care practitioners (i.e., family physicians, nurse practitioners, nurses, pharmacists, dietitians, exercise specialists and social workers) work in teams to provide information and support to help their patients stay healthy; monitor their patients to detect any risk signs early; and engage patients at risk in their own care, giving them information and support to help them manage their risk and/or prescribing medications to help patients manage or reduce their risks (e.g., stop smoking, lower blood pressure and/or cholesterol, or lose weight). Emergency Care. People who suffer a heart attack have access to immediate emergency services with care on site and during transport to a hospital that has the people and equipment to provide the right care in a timely manner. Specialized Care. Teams of specialists, including cardiologists, cardiac surgeons, nurses, pharmacists, diagnostic technicians, rehabilitation professionals, geneticists and researchers who are based in regional centres and are part of a regional network, provide a range of timely diagnostic, medical and surgical interventions. Rehabilitation Services. Patients recovering from a heart attack, stroke, cardiac surgery or congestive heart failure receive the exercise, active living aids, dietary counselling and other services that help them recover quickly to their maximum capacity, adopt a healthier lifestyle and prevent another occurrence. Home/Community Care. Patients who need help after they leave hospital to recover from surgery or manage conditions such as heart failure or stroke receive home care services in their community and are helped to reintegrate back into their community. End-of-Life Planning and Care. Patients with life-threatening heart conditions receive information and support with end-of-life planning and care early in the course of their disease. Providers communicate effectively with patients and their families about their prognosis and the advantages and disadvantages of different treatments.
62 / Building a Heart Healthy Canada How Integrated Is the System Now?
In an integrated, patient-centred system, all Chan, a 38-year-old man who cardiovascular services have to work well together. recently had a cardiac procedure, Canadians need to be able to move easily from one was referred back to his primary cardiac care service to another, and their care should care practitioner for ongoing be seamless. monitoring and care. However, Although Canadians generally receive excellent his primary care doctor had cardiac care and jurisdictions across Canada are no information on the tests working to develop more integrated systems (e.g., reforming primary care services, developing or procedures performed, the interprofessional primary care teams, establishing medications Chan received in regional networks of specialized cardiac services), hospital or his recommended there continue to be gaps and weaknesses in the treatment plan. Some of the advice way services are organized and delivered. Chan received from his primary care doctor contradicted the specialist’s Fragmented Services Complicate instructions, so he was confused about his ongoing care. Patient Care and Affect Outcomes
Cardiac care services continue to be fragmented. The problem of fragmented services is not unique to cardiovascular disease. It is an issue for all chronic diseases. People with chronic diseases require ongoing comprehensive care and Earl, a man in his early sixties management. The problem is even worse for Canadians who with diabetes who lives in a small have other chronic diseases as well as heart disease community in northern Alberta, was because services are often organized in disease- recently diagnosed with cardiac specific silos. disease and referred to a specialist in Edmonton. Before his condition was fully diagnosed and treated, he made at least six trips to the cardiac centre in the city several hundred miles away – each one to spend only a short time with a different specialist or technician. He also had to make two other trips to see specialists about his diabetes. For each trip, his son had to take time off work to drive him. Earl is confused about his overall care, and he and his family have lost several weeks of work time and income.
Continue the Reform of Health Services / 63 A number of jurisdictions are beginning to (Wagner, 1998), which illustrates the need for use a chronic disease prevention and management various components of the health system to work model to provide more integrated, patient-centred together and with community resources to provide care. Many are adapting the Chronic Care Model care. In this model, productive interactions between originally developed by Wagner (Figure 14) informed patients and a proactive care team lead to better health outcomes.
Figure 14 Chronic Care Model
HEALTH SYSTEM COMMUNITY Health Care Self- Organizations Clinical Resources Management Information and Policies Support System Delivery Decision System Design Support
Informed, Prepared, Productive Empowered Interactions Proactive Patient Practice Team
Improved Outcomes
Source: Wagner, E.H. (1998). Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice; 1:2-4.
64 / Building a Heart Healthy Canada The CHHS-AP Steering Committee has adapted the Wagner model to include an A chronic disease prevention emphasis on chronic disease prevention as well as management (Figure 15). Chronic disease and management program is prevention and management is about relationships particularly well suited for patients between patients and the interprofessional primary/ with complex, long-term illnesses chronic care team, between the primary care team such as heart disease and for the and specialized regional networks that provide growing number of Canadians who episodic acute care, and between the health care have more than one chronic disease system and the community. In a chronic disease (e.g., heart disease and diabetes). prevention and management program, all parts of the health care system would work together – using clinical information systems to help them provide timely, responsive, patient-centred care.
Figure 15 Chronic Disease Prevention and Management for CV Diseases
COMMUNITY HEALTH SYSTEM Healthy Primary Health Care by Interprofessional Teams Public Policy
Healthy Screening Prevention Care Environments– Schools, Workplaces, etc. Self-Management Home Rehabilitation Supports Care Access to Health Information Clinical Information Screening Systems Programs Home Care
Continue the Reform of Health Services / 65 The Chronic Disease Prevention and Management Program in Brief In a chronic disease prevention and management program: • Canadians with heart disease or at risk for cardiovascular disease are identified as early as possible and offered interventions tailored to their needs (e.g., education, monitoring, medication and case management). • Patients and their caregivers are actively involved and receive the information, skills and support to take more responsibility for self-care. • Interprofessional primary care teams – made up of a mix of health professionals, including physicians, nurse practitioners, nurses, dietitians, pharmacists, physiotherapists, exercise specialists – support self-care, provide continuity of care and work in partnership with patients to maintain health and/or manage disease. • The interprofessional teams provide coordinated care and make effective use of all providers’ skills. Care is provided by the most appropriate provider, in the most appropriate setting. Patients are referred to the “right” member of the primary care team and, if necessary, to the “right” specialty service. • Specialists provide advice, co-manage patients, provide episodic care and support primary care teams. • Transitions of care are highly organized. When patients have to move between levels of care, they understand their own role and the role of each provider. Patients and providers receive appropriate information, and the services are in place to allow patients to move easily through the system (e.g., acute care, home care and cardiac rehabilitation services). • Information systems are used to help patients and providers share information, to guide care and to support surveillance and evaluation. • The patient’s health and care are continually monitored, and the data are used to assess and improve quality of care and outcomes. Feedback is provided to patients, practitioners and the system. The chronic disease prevention and management program also includes the types of actions that governments and communities can take to create supportive environments and healthy public policies. While primary and specialized care providers focus on providing patient-centred monitoring, education, care and treatment, public health practitioners and others in the community focus on reducing social and environmental risks to heart health. The model brings together health promotion, prevention and care, and involves a partnership among individuals and families, communities and health professionals.
66 / Building a Heart Healthy Canada According to organizations in the United Geography Affects Care States, Europe and Canada that use a chronic disease prevention and management model of care, Where people live matters. The quality and this approach has a measurable impact on both consistency of cardiac services varies across the health and the cost of care: country, and treatment and outcomes differ depending on where people go for care. Timely • In the eight-country EuroAction Project, access to services – particularly specialized cardiac 888 patients and 225 partners participated care – continues to be a problem for Canadians, in a one-year comprehensive, family-based especially those who live in rural and remote areas. heart disease prevention and management To help reduce geographic and other inequities program delivered by interprofessional teams in access to care, most parts of Canada and many made up of cardiovascular prevention nurses, other jurisdictions have developed or are developing dietitians, physiotherapists, cardiologists and regional integrated networks of specialized cardiac general practitioners. The program had a care. These networks plan for some or all of the measurable impact on diet, exercise and use of cardiac services in their geographic area rather than evidence-based medications: 78% of patients in just one hospital, and they focus on making the met the European targets for eating fruits and best use of skills and resources. vegetables compared with 39% who received usual care; 50% achieved physical activity targets compared with 22%; and 58% had their blood pressure controlled compared with 41%. People participating in the program were also For patients with acute heart more likely to adhere to prescribed preventive problems, speed and experience medications, such as statin medication. matter: patients with ST-segment (Wood, 2006) elevation myocardial infarction • In a trial of the chronic disease prevention who receive primary percutaneous and management model with two million coronary intervention within 90 people, the Florida Agency for Health Care minutes at centres that perform a Administration (Medicaid) reported that 48% high volume of these procedures of participants experienced a drop in blood have better health outcomes. pressure, the prevalence of class III and IV (Jacobs et al., 2007) However, few heart failure dropped by 45%, hospitalizations centres – particularly those in were down 22%, and the average length of stay smaller communities – can provide dropped by 51%. Hospital payments were also the procedure within the 90 minutes down 70%. (Pfizer Health Solutions Inc., 2004) recommended by the American Several provinces, including British Columbia, College of Cardiology and the Alberta, Ontario, Quebec and Nova Scotia, are Canadian Cardiovascular Society. implementing the chronic disease prevention and management strategies for at least some diseases. To meet the needs of patients at risk and those with cardiovascular disease, this process should be accelerated and should include all provinces and territories.
Continue the Reform of Health Services / 67 Treatments for heart attacks and heart the region. These programs are very effective failure can be performed in several different sites in reducing hospitalizations and emergency throughout the region, while more specialized department visits, improving quality of life and treatment and procedures, such as angiography controlling costs. This approach can work well and cardiac surgery, are performed in a limited in a shared care model with primary care teams. number of high volume sites. Other conditions, Unfortunately, some clinics do not receive adequate including those requiring complicated risk factor funding to achieve optimal efficiency. management (like familial hypercholesterolemia, In an integrated regional network, a centralized cardiomyopathies, rhythm abnormalities and triage system assures that all patients receive congenital heart disease), are managed in appropriate care within an appropriate length specialized, multidisciplinary clinics throughout of time (Figure 16).
Figure 16 Integrated Regional Network for Specialized Cardiac Care
Chronic Disease Prevention and Management Emergency Services Primary Health Care Triage
Consultations Diagnostic Specialized Testing Therapies
Specialized Clinics of Interprofessional Teams Other Heart Failure/ Transplants Abnormal Rehabilitation Rhythms & Congenital Program Devices Heart Disease
Back to Primary Care Team
68 / Building a Heart Healthy Canada All parts of the network work together to agreements with its 18 member hospitals and ensure that people are assessed, referred and established interprofessional committees of transported quickly to the best site for their care. clinicians, nurses, administrators and ministry They develop processes and procedures that ensure officials to identify opportunities for quality timely care. improvements. As a result, between 1994 and 2000, deaths during or after bypass surgery dropped 32%. (Rachlis, 2004)
Patients who have a heart attack Patients Struggle to Navigate because of a blocked artery to the the System heart muscle need to have their blood flow re-established as quickly Despite the progress that has been made in as possible. Minutes of delay result developing integrated regional networks for some in more damage to the heart muscle. specialized cardiac care, patients continue to find it difficult – and sometimes costly – to navigate the system. The cardiac care system should learn from the cancer care system’s experience in helping patients connect with the services they need when they need them. For example, the Libin Cardiovascular Institute Quebec, Nova Scotia and Alberta are now and the Calgary Health Region have a program using patient/system navigators to help improve to ensure rapid access to re-perfusion therapy the quality and consistency of care for cancer for patients suffering a heart attack. Emergency patients. The navigators ensure that patients are service providers record an electrocardiogram on referred appropriately, their care is coordinated all patients with acute chest pain that is suspected and all the professionals involved in their care to be heart-related and transmit it electronically have the information they need. These navigators to the on-call interventional cardiologist. Patients also help patients who live in rural and remote with an acutely blocked artery are then directed areas to coordinate their appointments, so they to the appropriate hospital, where they bypass can make fewer visits to regional centres, and to admitting and emergency and go directly to access services such as telephone support and the catheterization laboratory for immediate telemonitoring, instead of driving long distances angioplasty and stenting as needed. According to receive a test result. In cancer programs that use to data from the Canadian Institute for Health navigators, health professionals are now working Information, for the past four years Calgary has more collaboratively with less duplication of had the lowest mortality rate for heart attack services, and patients are better prepared for the victims in Canada. different levels of care they receive. (Corporate The New Brunswick Heart Centre has Research Associates, 2004) developed a comprehensive triaging process for Alberta has recently added system navigators patients who need cardiology interventions: to their regional cardiac care teams with the goal of gathering all clinical information on a patient at facilitating transitions in patient care and making the outset and triaging all referrals using objective the system more efficient. This innovative approach rating tools. (Doucet, 2007) should be replicated in other regions across the Integrated regional networks can have a country (Figure 17). positive impact on both timeliness and quality of care. For example, to improve the quality of key procedures provided at different sites, the Cardiac Care Network of Ontario negotiated accountability
Continue the Reform of Health Services / 69 Figure 17 Cardiovascular Care: The Working Model
Triage Chronic Disease Prevention and Patients Specialized Management and Cardiac Information Services Primary Health Care
System Navigation
Patients Are Still Waiting Too Long catheterization (from 75% to 85%). The Cardiac for Some Services Care Network also reported a 50% reduction in the regional variation of wait times. The Network Over the past four to five years, the federal and was able to achieve this progress by establishing a provincial/territorial governments have invested system of: significant resources into cutting wait times for • cardiovascular procedures, and there has been triaging patients based on an urgency rating progress in cardiac bypass surgery. (Health Council scale developed by an expert committee of Canada, 2007) However, surgery is only one • monitoring patients to identify any changes component of care. Consultations and diagnostic in their status procedures are equally important steps in a patient’s • journey through the cardiac care system, and wait developing efficient processes to transfer times for these services should also be reduced. patients to specialty centres for procedures and The Quebec Cardiology Network has to move them back to community facilities as established a “medically acceptable waiting time” soon as feasible for all cardiac procedures as well as a provincial • using regional cardiac care coordinators to system to monitor all patients waiting for a help patients navigate the system. procedure. The network carefully monitors access and productivity, and uses this information to make Using a national panel of experts, the Canadian recommendations to the Quebec government to Cardiovascular Society has developed a series ensure that all patients receive timely care. of wait time benchmarks for the continuum of Between 2004 and 2006, the Cardiac Care cardiovascular services, from access to a specialist Network of Ontario increased the proportion of through access to heart failure clinics. These patients who received care within maximum wait medically acceptable wait time benchmarks are time guidelines for all procedures, including elective being used by a number of institutions across the cardiac bypass surgery (from 86% to 98%), urgent country to help improve patients’ access to care. cardiac surgery (from 79% to 86%) and urgent
70 / Building a Heart Healthy Canada Patients log on each morning to enter their weight for the day and answer questions about how they The Veterans Affairs hospitals in the are feeling. They can then see graphs that show United States were able to improve them how they are doing. If there is a problem, the quality of care dramatically the nurse at the Heart Function Clinic will call. by integrating services, improving The BCATPR is now incorporating the patient’s teamwork, introducing performance primary care team. If there is a problem, the nurses measurement and reporting, will triage the patient and alert his or her primary making effective use of information care provider, who can then use the system to obtain technology, and realigning payment a “quick cardiology consult” by email if needed. policies. (Jha et al., 2007) With this “shared care” model, patients in areas with no specialist support can still be connected to a team that can provide advice and support to the primary care providers. The BCATPR believes this technology will help patients avoid re-hospitalizations as well as long trips to urban The concept of wait times currently being centres to see specialists. It will also improve the applied to cardiac procedures should also be applied dissemination of guideline-based care to primary to other aspects of care where timing affects care providers. outcomes, such as how early statins are given after The BCATPR has also developed a virtual an acute coronary syndrome and how quickly cardiac rehabilitation program. Patients complete patients with heart failure are evaluated and treated. an online assessment form about their medical This approach will require more consistent use of and lifestyle history and then receive education risk scores to determine which patients should be sessions using Flash technology, weekly tasks such admitted, transferred or treated as outpatients. as measuring and entering blood pressure and body weight, peer support chat groups (to mimic Using Technology to Improve Access in-class peer support), exercise heart rate uploads and scheduled chat sessions with the nurse, dietitian and Reduce Inequities and exercise specialist. When they log in, patients are automatically directed to the list of tasks they Technology can be a valuable tool in reducing need to complete for that week of their program. inequities, providing more patient-centred care and The patient’s primary care provider can view his or engaging patients in their own care. For example, her heart rates in order to monitor progress, and digital images from diagnostic tests can now be the nurse will contact the primary care provider transmitted electronically, and viewed off site, if there is any change in the patient’s symptoms reducing the need for patients and providers to or interventions. Patients liked the program and travel. Other promising technologies such as self- achieved a 75% increase in their exercise capacity, as management tools, telemonitoring and structured compared with another group receiving usual care. telephone support (Clark et al., 2007) can help The University of Ottawa Heart Institute patients and the care team detect problems early. has a home monitoring system that uses patients’ These technologies have the potential to greatly phone lines to transmit vital signs, weight, improve care for patients in rural and remote electrocardiogram and other information to communities, who may not even have to leave an advanced practice nurse. The system can be home to be diagnosed or monitored. customized to meet the needs of specific patients The virtual Heart Function Clinic (vHFC) and to provide assistance with self-care. It tracks is an interactive website developed by the British data and identifies problems, so patients can receive Columbia Alliance on Telehealth Policy and care at home instead of having to be readmitted Research (BCATPR), a research team that focuses to hospital. on developing telehealth services in the area of cardiovascular disease to improve routine care for patients in rural and remote communities.
Continue the Reform of Health Services / 71 Culture and Other Social Factors and adherence to their medication. Together, the Affect Care practices outperformed the state averages for blood pressure and cholesterol control by 20 percentage Vulnerable populations – including people who points. (Johnson et al., 2008) are socially and/or economically disadvantaged or In the Chronic Disease Self-Management members of specific ethnic populations – often Program, a collaborative project developed by have difficulty accessing the full range of cardiac Stanford University and the Northern California screening, diagnosis and care. Kaiser Permanente Medical Care Program now in As noted earlier, many Aboriginal/indigenous use in the Yukon and British Columbia, patients communities do not have access to culturally are trained to lead groups of people with chronic sensitive care or to specialized care and essential diseases. (Johnson et al., 2008) The program, which equipment, such as defibrillators and oxygen is similar to the “buddy” model used in many therapy, routinely available in other communities. Aboriginal/indigenous communities, is based on Aboriginal/indigenous peoples need special the assumption that people with chronic disease attention to ensure that they receive the same share similar concerns and problems, and can teach standards of care and access to cardiac services as disease management skills (e.g., how to develop an other Canadians. Strategies to reduce cardiovascular exercise program, healthy eating, problem solving, disease and improve treatment for Aboriginal/ how to use medication, and how to communicate indigenous peoples must take into account those with family, friends and health care providers) living in Aboriginal/indigenous communities as as effectively, if not more effectively, than health well as the more than 50% of the population that professionals. In randomized controlled trials in live away from their home communities. To ensure the United States and Canada, participants in the that models of care fully recognize the unique needs Chronic Disease Self-Management Program had of Aboriginal/indigenous populations, Aboriginal/ fewer hospitalizations and fewer emergency room indigenous people and their leaders must be and outpatient visits. They were more successful in engaged in planning and delivering their care. changing behaviour and maintaining the changes over time than those in the control group. Patients Are Often Passive Recipients of Care
Self-care and informed, involved patients are key Families play a key role in to preventing and managing heart disease, yet – in chronic disease prevention and most settings – patients continue to be passive management. For an individual recipients of care. to change smoking, eating and In a chronic disease prevention and exercise habits, his or her family management program, patients are full partners in must be supportive. When the their care. They receive information and training in techniques such as goal setting, action planning and EuroAction Project actively problem solving that help them play a major role in involved patients’ partners in the maintaining their health. They are also involved in cardiovascular disease prevention planning their care and treatment. program, 77% of the partners In the ideal patient-centred model, patients achieved European targets for also have a voice in designing the organization’s eating fruits and vegetables programs and services. For example, the 13 compared with 54% of the partners practices involved in the California Diabetes and of people receiving usual care. Cardiovascular Care Collaborative redesigned the (Johnson et al., 2008) way they delivered care to meet patients’ needs by making patient information available at the point of care, offering group visits, scheduling planned care visits, screening patients for depression and following up with patients on their action plans
72 / Building a Heart Healthy Canada Only 20% of Patients Receive The recent Cardiac Rehabilitation Pilot rojectP Rehabilitation Services funded by the Ontario government demonstrated that rehabilitation services can be organized Specialized cardiac rehabilitation programs provide and delivered in ways that make evidence-based up to six months of exercise, dietary counselling care accessible to more people. The 24 sites that and other therapies for people recovering from a participated in the project were able to serve 60% heart attack, coronary artery bypass surgery or other more people in a year. The program cost about acute event. These highly cost-effective services $1,500 per person – considerably less than the can reduce cardiac deaths by 20% to 25% (Taylor, $8,000 to $10,000 to treat myocardial infarction 2006) and should be available to all patients who or the $10,000 to $20,000 per person for coronary can benefit. However, highly specialized cardiac artery bypass graft surgery – and participants’ risk rehabilitation programs are usually based in regional profiles improved substantially over the six-month centres and are not available in all communities. As program. (Suskin et al., 2002) a result, only about 20% of the patients who could The pilot sites achieved these outcomes benefit receive rehabilitation services. (Suskin et al., by offering a standard program across all sites 2002; Arthur et al., 2004) and by pushing services and expertise out into different settings in the community. While the intensive, supervised exercise program cannot be offered everywhere, many other aspects of cardiac Cardiac rehabilitation is a rehabilitation can be integrated into the chronic systematic program that includes disease prevention and management services offered comprehensive targeted by interprofessional primary care teams. In fact, monitored home-based exercise programs are as cardiovascular risk factor effective as supervised exercise for low-risk patients. therapies, behaviour modification (Arthur et al., 2002; Jolly et al., 2006; Jolly strategies designed to improve et al., 2008) long-term lifestyle and adherence Other jurisdictions, such as the United to medication, and therapeutic Kingdom, Finland and Australia, have adopted physical activity – primarily for strategies to make cardiac rehabilitation available people recovering from heart to more patients in a variety of settings – including attack and coronary artery bypass primary care settings, community settings and surgery. The programs, which are workplaces. Cardiac rehabilitation guidelines can and should be adapted for use in other settings. delivered by interprofessional In Canada, regional cardiac rehabilitation teams including physicians, nurses, facilities should serve as resource centres, providing exercise specialists, dietitians, rehabilitation services directly for patients with social workers and others, help complex needs (e.g., patients with congenital heart patients make changes that will disease or heart failure) and supporting the primary lead to healthier lifestyles over the care, chronic disease prevention and management long term and will prevent another teams to provide evidence-based cardiac heart attack or acute incident. rehabilitation services for other patients.
Continue the Reform of Health Services / 73 Few Cardiac Patients Receive End-of-Life Planning and Care Promising Practices Many people with advanced heart failure do not in Cardiac Rehabilitation receive services that could help them and their families make informed decisions about their care at For cardiovascular rehabilitation to the end of life. have the greatest positive impact: The lack of end-of-life planning and care in CV disease is mainly due to the uncertainty about • Rehabilitation must be recognized when someone with heart disease is nearing the as an integral part of cardiac care. end of life and the fact that the CV care system is • Patients should be engaged as early focused on prolonging life. When “cure” is the goal, as possible during their disease so important conversations about quality of life and they can reap the greatest benefits end-of-life planning and care often do not happen. Although the pathway from heart disease from rehabilitation. to death is not as predictable as it is for diseases • Providers should take a patient- like cancer, heart disease is still a life-threatening centred approach, designing each illness: 50% of people diagnosed with heart failure patient’s rehabilitation program to die within five years. Yet most patients with heart meet the patient’s needs while failure are not offered end-of-life planning and care. This is an issue because as many as 60% of the still being consistent with best people who die with heart failure will die suddenly practice guidelines. and would benefit from the opportunity to discuss • Programs should be developed and plan for the end of life. to meet the needs of adults with Patients with heart failure who do not congenital heart disease and for die suddenly will deteriorate over time, even though their disease trajectory may be highly elderly patients with heart failure. variable. They will often experience symptoms • Special efforts must be made to not classically attributed to heart failure, such as ensure that patients who have pain, falls, cognitive problems, mood and anxiety not traditionally been referred symptoms, loss of function, sleep disturbances for rehabilitation have access to and anorexia, and they could benefit from the symptom management approach used in end-of- these services. life care. (Caldwell et al., 2007; U.K. Department • Patients’ families should be of Health, 2000; McPherson et al., 2006) involved so they can help the According to research, patients would prefer more patient and themselves adopt a communication about end-of-life planning and healthy lifestyle. more opportunities for decision making earlier in the course of their disease. (Caldwell et al., 2007; • Workplaces should be involved in Selman et al., 2007) rehabilitation in order to support Few guidelines for cardiac care include end-of- the patient’s return to work if at life planning and care. Even when they do – such all possible. as the United Kingdom guidelines that call for good communication regarding “prognosis and • Programs should have access to living with uncertainty” (U.K. National Institute for tools such as care algorithms, Clinical Excellence, 2003) – patients and their care point-of-care electronic decision providers often do not recall receiving information support, and training. about their condition or being involved in the decision-making process. (Murray et al., 2002) • A surveillance system should be established to monitor system- and patient-level outcomes.
74 / Building a Heart Healthy Canada The 2006 Canadian Cardiovascular Society To meet the end-of-life needs of people with Recommendations on the Diagnosis and heart disease: Management of Heart Failure included advanced • The system needs to develop interprofessional medical directives, wishes for resuscitative strategies and ethical guidelines for providing care, substitute decision makers, ethical issues culturally appropriate end-of-life planning and opportunities for patients to re-evaluate and care. their preferences as their condition changes. • (Arnold et al., 2006) However, uptake of these Health care providers need specialized training recommendations must be broader to change in how to talk with patients and families about the system. end-of-life planning and care, and how to en- To provide patient-centred care, the cardiac sure their discussions are culturally appropriate. care system needs a better understanding of when, • The cardiac care system should develop more how and where patients should receive end-of-life effective ways to help patients with advanced planning and care. The system also needs more heart failure identify symptoms that could be information on existing end-of-life care services managed through appropriate pain manage- and their capacity to meet the unique end-of- ment and other palliative care services. life planning and care needs of people with heart disease, which are quite different from the needs of cancer patients usually referred to palliative care programs (in 2007, about 90% of people who Guidelines Alone Are Not Enough to received end-of-life care were cancer patients). Change Practice While some lessons can be learned from Ideally, every Canadian diagnosed with a particular the palliative care programs used in cancer care, heart disease or risk should receive the most these models are not appropriate for people with effective, up-to-date treatment. Health care cardiovascular disease, particularly those with providers should follow clinical guidelines that are heart failure. More research is required to identify developed based on research evidence. However, best practices in end-of-life planning and care experience over the past 20 years shows that just for people with cardiovascular disease, to assess developing clinical guidelines is not enough to the effectiveness of symptom identification and influence practice; other efforts are required to management in patients with advanced heart actually translate research knowledge into failure, and to develop strategies and techniques clinical care. to talk to patients about disease progression and symptom management. A better understanding of the impact of demographic, geographic, ethnocultural and other variables on end-of-life care will also help improve counselling and match Improvements in the treatment patients to interventions. A broad-based Canadian and control of hypertension are multidisciplinary end-of-life research working associated with a significant group has been formed, funded by the Canadian decline in deaths from stroke and Institutes of Health Research, to examine critical heart failure, a 50% decrease in the end-of-life issues for cardiac and respiratory patients, but work will be required to translate rate of deaths from heart attacks findings into practice. and a drop in hospitalization rates. (Campbell et al., 2006)
Continue the Reform of Health Services / 75 The Canadian Hypertension Education services are being monitored to see whether they Program, a made-in-Canada knowledge are meeting set benchmarks for quality care, and translation program, has demonstrated the research is being funded to improve both care and benefits of a more organized and active approach health care delivery. The Canadian Stroke Strategy to developing and promoting the use of clinical has also established performance indicators that guidelines. In that program, experts in CV will be used to measure the timeliness, quality care meet annually to review the research and and consistency of stroke care across the country update the recommendations on how best to and the extent to which the guidelines are being diagnose and manage hypertension. Teams of followed in practice settings. Over the past three health care professionals then translate the expert years, Ontario reports an increase in the number recommendations into practical tools and simple of patients receiving evidence-based treatment consistent messages about how to treat patients for ischemic stroke. (Stroke Evaluation Advisory with hypertension. The tools and messages Committee, 2007) are disseminated widely to physicians, nurses, In 2006 the Canadian Cardiovascular Society pharmacists and other health care professionals. adopted an innovative “closed-loop” model of A large group of volunteers helps to evaluate the clinical practice guideline development on the impact of the program. This process of evaluating diagnosis and management of heart failure to the impact of the hypertension recommendations translate guidelines into practice. In the spirit is coordinated with federal and provincial of collaborative development of timely, practical government programs and has resulted in a and effective guidelines, this model incorporates comprehensive system of assessing hypertension ongoing end-user and stakeholder input and management in Canada. This process has helped evaluation to drive the next iteration of guidelines to identify where the guidelines are working and and their dissemination to each audience. The not working and facilitates ongoing improvement annual update process assures continuous in the development of the recommendations. In quality improvement in this important area the nine years that the Canadian Hypertension of disease management. Education Program has been in place, the quality Initiatives such as the Canadian Hypertension and consistency of hypertension care has improved Education Program, the Canadian Stroke Strategy dramatically. The program involves collaboration Best Practice Guidelines and the Canadian among government, health care professionals and Cardiovascular Society’s Heart Failure Knowledge scientific organizations, and it could be a model Translation Program should continue to be funded for efforts to manage other risk factors for and developed, and the same comprehensive heart disease. approach should be used to promote evidence- The Canadian Stroke Strategy, a partnership based practice in other key areas of cardiovascular between the Canadian Stroke Network and the disease prevention and care, including management Heart and Stroke Foundation, is using a similar of dyslipidemia, congenital heart disease, coronary comprehensive approach to close the gap between artery disease and heart rhythm abnormalities. evidence and practice, and ensure that all Canadians In addition, there is a need for a comprehensive have access to integrated, high-quality stroke set of quality indicators for the common cardiac prevention, care and rehabilitation. Canadian Best conditions – which can be monitored and regularly Practice Recommendations for Stroke Care were reported. The Safer Healthcare Now initiative has released in 2006 and widely disseminated (and are adopted a set of quality indicators for acute heart now being updated). Providers are being educated attack and implemented systems to collect the about the guidelines, public education campaigns necessary data to monitor change over time. are making Canadians more aware of the signs and (Safer Healthcare Now, 2008) This approach needs symptoms of stroke and how to respond, stroke to be developed and adopted for other conditions such as heart failure, certain arrhythmias and cardiac surgery.
76 / Building a Heart Healthy Canada Recommendations 4.2 Improve access to high-quality, appropriate, coordinated specialized cardiovascular care, To provide more integrated, patient-centred and including diagnostics, acute care, cardiac efficient services, health care systems in Canada rehabilitation and end-of-life planning must make some fundamental changes in the way and care: they organize and provide cardiac care. They must • make effective use of people, technology and other Provide incentives for the continued devel- resources to address inequities. opment of regional integrated networks of There is no “one size fits all” model for specialized cardiovascular care. providing cardiac care. The best way to organize • Establish triage systems that will ensure that cardiac services depends on geography and on the those in greatest need are seen first. needs of the population being served (i.e., age, • ethnicity and risk factors). However, chronic disease Implement and monitor a system of evidence- prevention and management programs combined based maximum recommended wait times with integrated regional networks of specialized – particularly for consultative services and cardiac care hold the greatest promise to improve diagnostic testing. access and make the best use of resources and skills. • Expand the use of telemedicine technologies To fulfill their promise, integrated regional within and between provinces and territories networks must continue to find better ways to tri- to provide care as well as patient and provider age patients, provide timely care, manage wait times education (e.g., telestroke). and improve patients’ ability to self-manage their • conditions when they have to wait for care. Signifi- Incorporate “system navigators” into cant investment needs to be made to encourage the regional teams to help patients and their health care delivery system to be innovative. health information move easily between services and providers. 4.1 Accelerate the implementation of chronic • Continue to develop and implement specialty disease prevention and management as clinics within integrated regional networks the preferred model for delivering most staffed by interprofessional teams to manage cardiovascular care in Canada: complex cardiovascular conditions such as heart failure, congenital heart disease, certain • Accelerate the development and training of abnormal heart rhythms and chest pain. interprofessional primary care teams with new • roles and working relationships. Continue to develop rehabilitation programs in underserved regions, and • Implement process improvements and incorporate cardiac rehabilitation services change management. into primary care-based chronic disease • Document and disseminate best practices in prevention and management programs. patient partnerships, self-care and patient- • Provide support for end-of-life planning centred care and in organizing and delivering and care information and services, including patient-centred care. episodic support and respite services for informal caregivers.
Continue the Reform of Health Services / 77 4.3 Establish, maintain, promote and evaluate the use of updated, evidence-based, interprofessional clinical guidelines in preventing and managing cardiovascular risk and disease, treatment, rehabilitation and end-of-life planning and care:
• Support the ongoing development, implemen- tation and regular updating of best practice guidelines in the Canadian Stroke Strategy, the Canadian Hypertension Education Program, and the Canadian Cardiovascular Society’s Heart Failure Knowledge Translation Program and guidelines for lipids/cholesterol. • Create a pan-Canadian task force to develop clinical practice guidelines for end-of-life plan- ning and care for individuals with advanced CV disease. • Support the development of user-friendly self- care guidelines for patients and effective ways for patients to access this information. • Create a pan-Canadian initiative to develop a comprehensive set of quality indicators for CV prevention and care programs – to include recommended monitoring methods.
78 / Building a Heart Healthy Canada 5 / Build the Knowledge Infrastructure to Enhance Prevention and Care
Knowledge is as important to CV health as the heart is to the circulation of blood. Information is key to preventing CV diseases and reducing illness.
Patients need information to manage their Health Canada, “Understanding Canadian health and make informed decisions. Providers trends in tobacco use [was] vital to the effective need information to develop programs and services, development, implementation and evaluation of work well with other providers, and improve tobacco control strategies, policies and programs.” practice and quality of care. Managers and health (Health Canada, 2007b) administrators need information to plan, develop To build a heart healthy nation, Canada needs budgets, administer programs and evaluate progress. accurate, timely information on CV risks, diseases Governments need information to know where and treatments – and fast, easy ways to share to invest resources. And, the entire field needs that information with researchers, policy makers, knowledge and research to guide prevention providers and the public. Where do we stand now? strategies and develop better treatments for What information do we have? What’s missing? the future. How effective are our information systems? Information can help drive change. For example, the information infrastructure built to support the tobacco strategy was able to provide data on smoking patterns, consumer attitudes Without better data, those and behaviours, industry practices, the impact of smoking on health, and the impact of prevention responsible for health care efforts on smoking. The Federal Tobacco Control renewal are working in the dark. Strategy used this information to persuade policy (Health Council of Canada, 2007) makers, providers and the public to adopt policies and regulations to discourage smoking and to invest in prevention programs. According to
Build the Knowledge Infrastructure to Enhance Prevention and Care / 79 What Do We Know About CV Diseases in Canada? Key Messages As a nation, we currently do not know how many Information is key to preventing and reducing citizens suffer a heart attack each year. We have illness and deaths from CV diseases. some information on the number of people who have been diagnosed with certain CV diseases To develop a robust national surveillance and on the health care services they receive. For system for CV diseases, Canada needs more example, hospitals and health authorities have effective ways to collect information on information on hospital stays, emergency visits, risk factors, prevalence and incidence, and home care and other services. Ministries of health treatment outcomes. know the insured services each person in each province or territory has received. The Canadian Although provinces and territories have Institute for Health Information has some administrative databases and a number of information from all provinces and territories on all groups and organizations have developed CV hospital stays but has information from only some disease patient registries, the information provinces and territories on other services, such as collected is based on different data home care and mental health services. Statistics definitions, making it difficult to share, Canada collects data on mortality rates by cause pool or compare information. of death but cannot link that information to the health services people received or use it to improve Canada is a world leader in electronic treatment and reduce deaths due to CV diseases. health records, but it still lags behind other Several provinces have developed cardiac countries in its use of electronic medical registries – including the Cardiac Care Network records in physician offices. of Ontario, Improving Cardiovascular Outcomes in Nova Scotia (ICONS), the Alberta Provincial In implementing CV information systems, Project for Outcome Assessment in Coronary every effort must be made to safeguard Heart Diseases (APPROACH), the BC Cardiac the privacy and confidentiality of Registry and the Quebec Cardiac Registry. The health information. Canadian Stroke Network has also established a stroke registry. As a result, Canada has become Chronic disease prevention and management a world leader in linking these registries with information systems are not yet in provincial health services/administrative databases widespread use, but they have the potential and using this information to monitor key to significantly improve CV health and care. conditions and improve care. Despite these innovative information Patient information systems will help patients initiatives, there are glaring gaps in our knowledge play a more active role in their own health of CV diseases and the associated risk factors. Most and care, and have the potential to contribute of the registries were developed by researchers to better health outcomes at lower cost. to answer questions about a certain condition or To capitalize on the dollars invested each outcome, or by clinicians to support clinical care. Canadians become part of a registry only when they year in research and attract more research reach the stage where they experience an event such funding, Canada needs a CV research plan as angiography, surgery or hospitalization, so the that will provide knowledge to improve data do not provide a complete picture. prevention and care. Canada has the potential to contribute to worldwide efforts to prevent and manage CV diseases, but it must do more to move new knowledge into practice and to market.
80 / Building a Heart Healthy Canada To reduce the burden of CV disease, Canada Although the current surveillance system has needs a more robust pan-Canadian disease sur- a fair amount of information on CV diseases, it veillance system that can provide reliable, timely, lacks key data on heart failure, heart attack, stroke comparable data on: and congenital heart disease. For example, we know how many Canadians suffer a heart attack and are • the prevalence and incidence of CV risk factors admitted to hospital, but we do not know how • the prevalence and incidence of CV diseases many have a heart attack and die before reaching a hospital. • the prevalence and incidence of CV diseases Steps are being taken to close these in Aboriginal/indigenous people and in other information gaps. The Canadian government ethnocultural groups where there is a paucity has committed to funding the Canadian Health of information Measures Survey: a biennial survey that will • access to services (i.e., Who is receiving care? measure the weight, waist circumference, fitness Is the care appropriate? Is it timely? Are there level, blood pressure, cholesterol and other physical any geographic, financial or other barriers?) measures of CV health of 5000 citizens. The survey • rates of treatment and control will help monitor the prevalence of CV risk factors in the population and develop targeted prevention • patterns of care and trends in the use of drugs, and education programs. However, the survey as devices, information technology, and surgical it is currently planned will not provide enough and medical interventions information on certain populations at high risk for • patient outcomes after treatment CV diseases, such as Aboriginal/indigenous peoples, • South Asians or the elderly. With additional causes and location of death. resources, the Canadian Health Measures Survey could periodically oversample these populations, which would provide valuable information on their Canada Lags Behind Other Countries in risks and lead to more effective programs CV Disease Information Systems and services for these communities. Although Canada has a number of valuable Canada’s current surveillance system relies on varied CV disease patient registries, each registry was sources of data, such as self-reported surveys, rather developed independently using different data than routinely measuring common risk factors for definitions and standards, so it is not easy to pool or CV diseases, including blood pressure, cholesterol link information from different jurisdictions. When and other lipid levels, weight, eating habits and jurisdictions can pool their data, they can create a physical activity. Because many Canadians do better picture of CV diseases across the country. For not know that they have high blood pressure or example, what are the risk factors? Which diseases abnormal cholesterol levels, self-reported surveys are most common? What treatments do people consistently understate the number of people at receive? What are their health outcomes? Do the risk for CV disease. There is also no consistent risks, diseases, treatments and/or outcomes vary in mechanism for gathering information about the different parts of the country? When researchers, food Canadians eat and their consumption patterns. health planners and clinicians can access data The Canadian Community Health Survey gathers from across the country, they can make better some data on food and nutrition, but the last use of the information to compare the impact of comprehensive survey of Canadians’ consumption different treatments; assess the cost-effectiveness patterns was reported in 2004. (Statistics of investments in new pharmaceuticals, tests and Canada, 2004) procedures; and develop more effective prevention programs and therapies.
Build the Knowledge Infrastructure to Enhance Prevention and Care / 81 Some work is already under way that may Although imperfect, this type of surveillance is an provide a model for linking data on CV diseases. economical way to enhance the amount and quality The Longitudinal Health and Administrative of information available to monitor CV diseases Data (LHAD) Initiative – a partnership among in Canada until more comprehensive data sets provincial and territorial ministries of health and are developed through electronic health records, Statistics Canada, the Canadian Institute for electronic medical records and chronic disease Health Information, the Canadian Council of prevention and management information systems. Cancer Registries and the Vital Statistics Council for Canada – is working to link provincial and territorial administrative data with Statistics The Role of Cohort Studies in Canada population health survey data, the births Understanding CV Diseases and deaths databases, and the Canadian Cancer Registry. CV researchers may be able to use the One of the most effective ways to understand LHAD data sets to examine the role of modifiable CV diseases is to follow a cohort or representative risk factors in the first hospitalization for selected group of Canadians over a long period of time – at CV diseases across provinces, taking into account least 20 years – to see who develops heart disease both socio-demographic characteristics (e.g., or stroke and why. Cohort studies can identify household income) and co-morbidities (e.g., high factors that affect both risk and resilience. They blood pressure). can help researchers understand the potential When developing strategies to link databases, impact of recent social and cultural changes, governments, organizations and researchers such as the increases in obesity and diabetes, the must address issues of data quality, privacy and decrease in smoking and changes in eating habits, ownership, the timeliness of data, and the capacity on Canadians’ CV health. They also provide a for analysis – as well as mechanisms for health means to assess the effect of clinical and social system planners, researchers and evaluation interventions such as controlling hypertension specialists to access, link and pool anonymized or reducing the amount of sodium in processed health data at little or no cost. They must also make foods. For example, the Framingham Heart Study, every effort to ensure that CV databases address the a U.S. cohort study, demonstrated the importance information needs of disadvantaged populations, of controlling hypertension in reducing stroke, including Aboriginal/indigenous people, different heart attacks and heart failure; it also helped ethnocultural groups, poorer Canadians and identify individuals at greatest risk of cardiovascular Canadians who do not have a family physician. disease. For the past 50 years, Canada has relied on In an effort to build a stronger national disease the Framingham Heart Study to make educated surveillance system, the Public Health Agency assumptions about CV risks in Canada, but, given of Canada has developed a diabetes surveillance the growing differences between the Canadian system that links hospitalization data, provincial and U.S. populations, this approach is no longer health administrative data and survey results, adequate. In fact, the Framingham cohort is no and the Agency plans to do the same for stroke longer representative of the U.S. population, much and hypertension. The same approach could also less the Canadian population. be used for coronary disease, heart failure and The Canadian Partnership Against Cancer, congenital heart disease, among other conditions. which is funded by the federal government, is in the process of establishing a large national cohort study that plans to follow 300,000 Canadians over 20 to 30 years to obtain a more complete picture of their health and habits, including what they eat and how much they exercise, as well as environmental variables. Canada could profit greatly from enhancing the national cancer cohort study to include more about CV and other chronic disease risks.
82 / Building a Heart Healthy Canada Canada Does Not Have Performance In fact, Safer Healthcare Now is using the Measures for Cardiac Care CCORT indicators as part of its initiative to improve care for acute myocardial infarction. Information is key to improving the quality of CV The program includes a “getting started kit” and care. Measurable quality indicators are needed to measurement worksheets for different aspects provide the legitimate data that hospitals and other of care. health care settings need to shape care. Although In the Enhanced Feedback for Effective performance measures have been established for Cardiac Treatment (EFFECT) study, the first stroke care in Canada, the cardiac care system has randomized trial to determine whether public yet to agree on common clinical quality indicators, cardiac report cards in Ontario improve the quality how to measure them or how to report the results of cardiac care for patients in Ontario hospitals, to providers, funders and the public. the Institute for Clinical Evaluative Sciences broke new ground by publicly releasing the performance of Ontario hospitals on indicators such as “door-to- needle” time for thrombolytic therapy. The research Measuring quality is critical to showed that more than 400 lives could be saved improving care and ensuring the each year in Ontario (1200 nationally) if hospitals sustainability of the health care used evidence-based medical therapies with all eligible patients. (Tu et al., 2004; Tu et al., 2005) system. (Rachlis, 2004)
The Canadian Stroke Strategy has The Canadian Cardiovascular Outcomes developed performance measures Research Team (CCORT), a pan-Canadian and a performance measurement research team of more than 30 cardiovascular manual to accompany the Canadian researchers from five provinces (Nova Scotia, Best Practice Recommendations Quebec, Ontario, Alberta and British Columbia), for Stroke Care, and it is working is working to measure and improve the quality of to establish specific benchmarks. cardiac care delivered in Canada. In partnership Also, the Canadian Stroke Network with the Canadian Cardiovascular Society, CCORT has partnered with Accreditation developed the first Canadian quality indicators for acute myocardial infarction and congestive heart Canada to develop a stroke program failure, and recommended national benchmarks for accreditation process, the first high-quality care for all Canadian hospitals and disease-specific accreditation cardiovascular practitioners. (Tran et al., 2003; Lee process in Canada. et al., 2003) CCORT investigators also led the development of Canadian quality indicators for bypass surgery and angioplasty, using large, national population-based databases from Statistics Canada and the Canadian Institute for Health Information Efforts by researchers to set benchmarks, and linking large population-based provincial measure quality and report results should be clinical registries to other administrative databases. supported and expanded to include “upstream” (Lee et al., 2003; King et al., 2004; Bhatia et al., benchmarks for preventing CV diseases and 2006) This important work could be the basis for enhancing self-care as well as “downstream” comprehensive quality indicators and the systems benchmarks for improving clinical care. to monitor them.
Build the Knowledge Infrastructure to Enhance Prevention and Care / 83 Challenges With Electronic benefits of eHRs, all providers involved in a person’s Health Records and Electronic care must be able to access records online and input Medical Records new information; however, it will likely be 10 years before even 80% of physician offices have eMRs. Electronic health records (eHRs) are essential To speed this process, some provinces, including to integrated, patient-centred care. They store British Columbia, Alberta and Saskatchewan, plan all electronic information about a client’s care – to facilitate the development of eMRs for all their including clinical records, lab results, diagnostic physicians within the next five years. The CHHS- tests, medications, hospital services, immunizations AP strongly supports these initiatives. In the and communicable diseases – in one secure place, meantime, jurisdictions are developing web-based where it can be accessed and used by professionals viewers as part of their eHRs, so practitioners who providing care, while still safeguarding the person’s do not have eMRs can still see the information that privacy. Electronic health records help providers is in their patients’ eHRs, such as lab test results. communicate with one another about a patient’s A third challenge is the concern about the care, access information quickly, reduce medical safety and privacy of the health information errors, and improve quality and productivity. With stored in eMRs and eHRs, and the mechanisms eHRs, providers are able to see the results of all to safeguard confidentiality when data are shared. tests and medications ordered by other providers, Canada Health Infoway is currently working with so they can avoid repeating tests or prescribing all jurisdictions to ensure that the systems will be medications that could lead to drug interactions. able to “talk” to one another, share anonymized At a press of a button, providers can access health data and have in place mechanisms to evidence-based guidelines, which will help them protect the privacy and confidentiality of make informed clinical decisions. individual health records. All provinces and territories, in partnership with Canada Health Infoway, are in the process of developing eHRs. Approximately 50% of Canada Needs Information Systems Canadians will have eHRs by 2010; 100% will have for Chronic Disease Prevention them by 2016. As of 2008, 85% of the pharmacists and Management in Alberta are using the province’s eHR. According to Canada Health Infoway, by 2012, all provinces The chronic disease prevention and management except Ontario will have eHRs in place, and model depends on information systems and tools Ontario will have eHRs for all citizens by 2015. that help providers manage patient care, such When eHRs are fully implemented, they will form as tools to record and monitor key heart health the foundation for a comprehensive information measures (e.g., blood pressure, cholesterol levels, system for CV and other chronic diseases, providing weight and abdominal obesity), reminders, alerts real-time information that can be used to plan and and real-time decision-making tools. Members of assess treatment services. The CHHS-AP fully the primary care team use the system to schedule supports efforts to implement this technology. screening tests and for regular monitoring and Although Canada leads almost all countries follow-up. The information system helps ensure that (except the United Kingdom) in implementing patients with more than one chronic condition, such eHRs, we still face challenges in making the as heart disease and diabetes, receive coordinated, technology work for providers and for patients. For evidence-based care that meets all their needs. example, a relatively small proportion of primary These systems, which must be able to link with care physicians – fewer than one in four in most eHRs, are not yet widely available. As of fall 2008, provinces – use electronic medical records (eMRs) the Calgary Health Region and Capital Health in now to record information about patient care. Alberta were the only regions in Canada to have Canada lags behind Australia, New Zealand and implemented a patient-centred chronic disease many countries in Europe in the development of management system that is fully integrated with eMRs. Most of our primary care practitioners still its eMR and with the patient’s eHR. use paper charts, and that information cannot be integrated easily into eHRs. To reap the maximum
84 / Building a Heart Healthy Canada Canada Needs Information Tools • At Sunnybrook Health Sciences Centre in To- and Systems for Patients ronto, patients can use the MyChart Personal Health Record to see and keep records of their Canadians with cardiovascular disease can do a care, amend family health history (e.g., allergies great deal to manage their own health, but they and medication history), view clinic visit notes, need information about the best ways to do this, request prescription refills, send messages to as well as regular contact with providers to help providers and connect to videos and other in- them stay on track. All Canadians should be able formation. The result has been better informed to access their eHRs and know how to use and patients, fewer phone calls and consultations interpret the information. They should also be able and more efficient workflow. to access other information, self-management tools • and systems to enhance their health, such as links to In the New Brunswick Care@Home program, support groups. patients recovering from heart surgery use home monitoring technology to transmit their health information to clinicians. • The Canadian Stroke Network, as part of It is conceivable that patients will the Canadian Stroke Strategy, has developed soon access their eHR online – the StrokEngine, an online resource for stroke survivors receiving post-acute care services. same way they now access their • bank account. Several provinces are making effective use of telemedicine to provide education and help patients, providers and informal caregivers to manage stroke and heart disease care and rehabilitation. Although the development of information The move toward information systems for systems for patient use is in its infancy, there are a patients will have far-reaching implications. few promising innovative programs in Canada that Canadians will have to be able to connect to the allow patients to view or control their health re- Internet and be knowledgeable enough to use the cords, let them enter information and forward it to technology to find, understand and apply health their providers, and encourage them to use chronic information (i.e., be health literate). Information disease management systems and tools for self-care. systems for patients have the potential to increase For example: health inequities for Canadians who may already be at high risk and who cannot take advantage of the • Grand River Hospital in Waterloo, Ontario, technology. However, they also have the potential to has developed a patient portal, called My reduce health inequities for Canadians who live in CARE Source, that cancer patients can use rural and remote areas by giving them easier access to access their treatment plans, manage their to information and reducing travel time and costs. appointments, monitor side effects and symp- toms, ask their care providers questions, and re-order prescriptions. Patients will eventually be able to use the portal to see lab and diag- nostic results. The hospital expects the portal to result in better outcomes for patients and fewer admissions to hospital for adverse drug events or other complications.
Build the Knowledge Infrastructure to Enhance Prevention and Care / 85 Gaps in Research In terms of prevention research, the focus should be on: The Canadian Institutes of Health Research and • the Heart and Stroke Foundation annually invest the life course approach, including exploring approximately $150 million in CV research in the critical periods in an individual’s life that Canada. Provincial health research organizations, increase his or her risk for CV diseases and philanthropic organizations and the pharmaceutical how CV risks accumulate throughout the and medical devices industry also fund some CV life course research. To obtain the greatest return on research • identifying at-risk populations and detecting investment, Canada needs a CV research plan the early presence of disease in order to be able that will: to implement effective interventions • Enhance our understanding of causes of both • how changes in socio-economic status large and small blood vessel diseases and iden- throughout the life course affect CV outcomes tify novel targets for prevention and therapy. • • the effectiveness of prevention interventions Create better knowledge of the evolving role of (policies and programs) in different populations genetics and proteomics in assessing individual and communities risk and designing personalized prevention and • treatment strategies. the impact on health of legislation developed • by other government departments Support emerging areas of research, such as an- • alyzing cause of death and health care services the economics of prevention and utilization prior to death, the role of end-of-life early intervention. planning and care, the impact of mental health as a co-morbid condition and independent risk factor, Aboriginal/indigenous health, and the Canada Lags Behind Other Countries intersection between income and health. in Capitalizing on Research • Help to develop economic and decision- Canada currently lags behind other countries in its making models that funders and policy ability to capitalize on research. According to the makers can use to evaluate the benefits Conference Board of Canada, Canada depends on of various interventions. other countries for a large majority of the innova- Relatively little research has been done on tive medicines, medical devices and other health effective ways to prevent CV diseases, to detect technology we need. In the 2007 European Innova- and intervene in early disease states, or to improve tion Scoreboard, Canada barely made it into the the organization and delivery of care. Canada ‘Innovation Followers’ group – and it is in danger must provide more support for population health of soon joining countries such as Cyprus, Slovenia and intervention research to evaluate the impact and Spain in the ‘Moderate Innovators’ group. … of policies and programs – including incentives – on health and to study the social, cultural and environmental factors that affect CV health. When it comes to innovation, Canada is a land of great potential. Health and related life sciences and technologies should be areas of strength and competitive advantage for Canada. (Conference Board of Canada, 2008)
86 / Building a Heart Healthy Canada Substantial efforts are needed (and needed now) to Recommendations revitalize Canada’s health innovation system and refuel Canada’s capacity to commercialize health Accurate, timely information and good ways innovations. (Conference Board of Canada, 2008) to share it are absolutely essential to health. Initiatives such as the Industry Canada Networks Canada needs information for patients, providers, of Centres of Excellence program have achieved managers and government, and information some success in translating Canadian discovery into to guide prevention, improve care and support commercial products, but Canada must do more research. To close the CV information gap and to apply new knowledge to the development of build the information infrastructure to enhance new treatments and technologies that will enhance prevention and care, Canada should use the health and contribute to the economy. To build a following strategies. sustainable national competitive advantage based on 5.1 Gather Canadian data on the prevalence and science and technology, the Government of Canada incidence of CV risk factors, diseases and has made a commitment to: health inequities in Canada: • Translate knowledge into practical applications • to improve our wealth, wellness and well-being Provide resources to the Public Health Agency (entrepreneurial advantage). of Canada to expand CV disease surveillance in Canada to include conditions such as heart • Build on our research and engineering failure, heart attack, stroke, hypertension and strengths, generate new ideas and innovations, congenital heart disease. and achieve excellence by global standards • (knowledge advantage). Provide resources to Health Canada and Statis- tics Canada to co-lead the regular collection of • Grow our base of knowledge workers by comprehensive, standardized food and nutrient developing, attracting and retaining the highly consumption data. skilled people we need to thrive in the modern • global economy (people advantage). (Industry Facilitate the linkage of death certificates with Canada, 2007) health services utilization data. • This policy position makes the case for more Provide resources to create a Canadian pre- investment in CV research and researchers, as well hospital cardiac arrest registry. as in the capacity to move new knowledge into • Enhance capacity in Statistics Canada’s bien- practice and new treatments and technologies nial Canadian Health Measures Survey by to market. oversampling key target populations such as certain ethnic groups (e.g., South Asians), Aboriginal/indigenous persons on reserves and in the Far North, and the elderly. Canada already has tremendous • Work with the Canadian Partnership Against strengths – including the drive and Cancer to develop and support a Canadian ingenuity of our people, the relative cohort study of chronic diseases that includes strength of our fiscal position, and risk factors for CV diseases. our strong research base. But, • Facilitate the development of pan-Canadian Canada can and must do more to data standards for regional CV patient regis- turn our ideas into innovations that tries to improve data quality and allow data to provide solutions to environmental, be linked and pooled. health, and other important social challenges, and to improve our economic competitiveness. (Industry Canada, 2007)
Build the Knowledge Infrastructure to Enhance Prevention and Care / 87 5.2 Support Canada Health Infoway’s 5.3 Improve knowledge to inform CV prevention efforts to accelerate the development and and cardiac care: implementation of the electronic health • record (eHR), the electronic medical Hold a pan-Canadian CV research summit, record (eMR), chronic disease prevention involving the Canadian Institutes of Health and management information systems, and Research, the Public Health Agency of Canada, consumer health solution capabilities the Heart and Stroke Foundation of Canada across Canada: and the members of the National Alliance of Provincial Health Research Organizations, to • Review the barriers and facilitators to the use develop a strategic, coordinated pan-Canadian of the eMR in primary care in Canada, and CV research agenda to address the future needs develop an action plan to speed its adoption. of our country. • Develop effective ways for health information • Establish a network of centres of excellence systems to support chronic disease prevention in vascular health to improve our basic and management programs that leverage the understanding of both large and small vessel eHR and can bridge the gap until the eMR is diseases, identify promising (bio)markers as more widely available. well as new targets for prevention and therapy, and pursue knowledge translation (clinical • Develop effective ways for patients to access trials) and commercialization. their clinical information. • Support the Canadian Institutes of Health • Develop mechanisms to facilitate the use of Research to fund additional research into clinical information from the eHR and the genetics/proteomics-based diagnostics, markers eMR (while respecting citizen privacy and of prognosis, and tools for personalized confidentiality) to support surveillance, system prevention and care. management, policy research and ongoing as- sessment of the effectiveness of Canada’s health • Provide more support for population health care system and disease prevention strategies. and intervention research to evaluate the impact of policies and programs on health. • Evaluate the impact of economic policies such as tax incentives to increase physical activity (e.g., the children’s fitness tax credit), and advocate to enhance incentives that are found to be effective and do not increase health inequities. • Support knowledge translation initiatives to help prevention programs and clinical settings to translate research findings rapidly into practice and to market.
88 / Building a Heart Healthy Canada 6 / Develop the Right Service Providers With the Right Education and Skills
To reduce the burden of CV diseases and provide integrated, patient-centred chronic and acute care, Canada will need the right people with the right education and skills.
Canada Lacks Information on Shortages Threaten Prevention the CV Workforce and Care
At the current time, we do not have a clear picture CV prevention and cardiac care services face the of the future need for CV care or the current same human resource issues as the rest of the health capacity of the CV workforce, so it is difficult care system: shortages of family physicians, public to identify, in hard numbers, how many primary health practitioners and other health care providers; care practitioners, dietitians, specialist physicians, the aging of nurses and acute care specialists; the diagnostic imagers and other care providers we small number of Aboriginal/indigenous health will need. professionals; and underutilization of other care Canada needs better information on the providers, such as primary care nurse practitioners, CV workforce, including the number of people who could play a key role in cardiac care. working in the system, workforce trends and an While we do not know exactly how many assessment of the scope of practice for all members health care professionals and workers in other of interprofessional teams. More work must also be disciplines will be required over the next 10 to 20 done to forecast accurately the number and mix of years for CV prevention and cardiac care, we do skills required – now and in the future – to meet the know that over four million Canadians do not have population’s CV prevention and cardiac care needs. a primary care physician. (Statistics Canada, 2008) To provide high-quality CV prevention and cardiac care services, the system is in urgent need of: • epidemiologists and people skilled in informatics who can manage surveillance programs • social scientists to help better understand the social determinants of health
Develop the Right Service Providers With the Right Education and Skills / 89 • public health professionals, community Over the past eight years, jurisdictions planners and policy specialists who can across Canada have taken steps to increase take the lead in population-wide efforts to training positions for professions in short supply. prevent diseases and to reduce the social and The number of physicians – particularly family environmental factors that affect heart health physicians – in practice in Canada has increased, as have the number of nurse practitioners (by 80% • primary care practitioners, including physicians, between 2003 and 2006) and nurses (by 10%, nurses, pharmacists, physiotherapists, dietitians or over 27,000 new nurses). (Canadian Institute and experts in physical activity for Health Information, 2007) The total number • cardiologists and stroke neurologists of training positions for cardiologists across the country also increased over the past five years, • Aboriginal/indigenous health care providers although some jurisdictions have reduced or capped • specialists who are flexible enough to adapt to the number of training places for cardiologists. new needs and technologies Current workforce shortages are exacerbated • program evaluators and policy specialists who by increasing entry-to-practice requirements and can assess the effectiveness of services. longer training programs. Because of the length of training, the full impact of the increases in enrolment will not be felt in the health care system for a number of years. Even with these increases, Canada will need comprehensive recruitment and Canada’s Aboriginal/indigenous retention programs to attract people to careers that population represents 3.6% of the will support CV prevention and cardiac care. Canadian population (2006 Census), Some provinces are trying to mitigate the yet less than 1% of physicians in impact of workforce shortages and increasing Canada are from the Aboriginal/ demand by developing new roles in the health care indigenous population. More must system and making more effective use of other be done to recruit Aboriginal/ providers such as nurse practitioners and physician assistants, among others. indigenous people to health careers and to ensure that all health providers working with Aboriginal/ indigenous peoples have the In Alberta, pharmacists now knowledge and skills to provide have the authority to prescribe culturally sensitive care. medications in certain circumstances, and the system is using nurse practitioners, international medical graduates and physician extenders to be able to provide more care. A randomized trial conducted in Edmonton showed that using community pharmacists and nurses to monitor the blood pressure of people with diabetes led to a significant improvement in blood pressure management. (Tsuyuki et al., 2002)
90 / Building a Heart Healthy Canada Canada Lags Behind Other Countries in Its Use of Interprofessional Teams The success of the Tui’kn Initiative Interprofessional teams are an effective way to was due to: integrate services, compensate for shortages of • encouraging stakeholders to certain professions, such as family physicians, participate when they were and improve care (Institute of Medicine, 2001) – particularly for primary care and prevention/ ready and recognized the need rehabilitation services. However, a recent survey for change of seven member countries of the Organisation • addressing the root causes of for Economic Co-operation and Development limited service access (OECD) showed that Canada makes significantly less use of teams and non-physicians to provide • considering the cultural primary care than other developed countries such context and relevance of health as the United Kingdom, the United States, New interventions. (Hampton, 2006) Zealand, Australia, the Netherlands and Germany. (Schoen et al., 2006) Although some health science faculties are now introducing interprofessional education, most health care providers are still trained in profession- By working closely with Dalhousie University’s specific silos that are highly treatment-focused and medical school, local provincial health authorities give relatively little attention to health promotion and the health directors of the five First Nations and disease prevention. communities, the Initiative was able to replace According to experience in both the United sporadic physician care with mobile primary care States and the United Kingdom, integrating nurses, teams that include nurse practitioners supported pharmacists and other health care providers into by physicians. Six full-time family doctors on the primary care team (i.e., allowing them to work a return-of-service fee schedule participate in to their full scope, providing training and providing collaborative teams and provide a set number of appropriate compensation) can transform primary clinical hours and home visits, in-patient care, care and give patients access to a wider range of support for program development and occasional services. (Campbell et al., 1998) Teams are also a after-hours service. The Initiative includes a mobile good way to redistribute workload and ensure skills blood collection service for smaller, more remote are available where they are most needed. (Health communities, which helps people with the blood Council of Canada, 2005) Allowing practitioners monitoring required for diabetes treatment, and, to work to their full scope can improve work as a result, compliance with monitoring schedules satisfaction, recruitment and retention. (Canadian has soared. The Dalhousie University’s Population Health Services Research Foundation, 2006; Health Research Unit helped train local health Health Canada, 2006) teams to manage health information. An electronic For example, the Tui’kn Initiative, a multi- patient record system was introduced that links community, cross-jurisdictional collaboration, the communities with district hospital-based developed a new model of primary health care for information systems, allowing for more integrated five First Nations communities struggling with high health planning regionally and locally as well as rates of diabetes on the island of Cape Breton in access to decision support tools. Nova Scotia.
Develop the Right Service Providers With the Right Education and Skills / 91 Traditional Approaches to Education Will Not Meet Health Needs Based on the results of the National Health care providers must have the skills to work Medical Council examinations, in teams, to work in partnership with patients and Canada has already demonstrated communities to enhance health, and to continually that the length of medical acquire new skills. The time has come for health training can be shortened without science faculties to better respond to the current measurable negative impact on needs of the health system. They must commit to physician performance. training graduates to work in teams and to solving the problems created by the increasing length of initial training programs. If we are to expect graduates to work effectively in interprofessional teams, they must be trained Incentives Are Needed to Encourage together – or at least have opportunities for training within an interprofesssional team environment. Team Practice Traditional departmental structures should be Incentives shape practice. The way some health replaced with models that reflect evolving care care services are funded (such as by the fee-for- delivery models. Accreditation bodies should service method) does not promote or encourage evaluate specialty designations that are a better interprofessional teams or chronic disease “fit” with the chronic disease prevention and prevention and management. Instead, it continues management model and the shared care model. to reward individual practitioners rather than teams, The CV workforce also faces intense pressure and acute procedures more than health promotion, to continually develop new skills to keep pace with monitoring, education and rehabilitation services. new knowledge and to care for the growing number of Canadians who have two or more chronic diseases – yet there are few opportunities for ongoing training or career laddering. The education system must respond to the need for ongoing Both the federal Primary Health training to help health care providers adapt to new Care Transition Fund and some knowledge and technologies. Shorter initial training provincial primary care team programs combined with regular opportunities for initiatives have offered financial lifelong learning and career laddering may be a incentives to encourage physicians more effective way to prepare the health workforce to participate in teams, but the and meet Canadians’ health needs. three-year federal transition fund may not have been long enough to achieve its goals.
92 / Building a Heart Healthy Canada The traditional fee-for-service funding for British Columbia has used pay for performance medical services recognizes the amount of care to encourage physicians to provide certain provided, but not the quality, comprehensiveness preventive services (e.g., $100 for assessing or timeliness of that care. It does not compensate cardiovascular risk using a series of validated providers for the time it takes to educate patients measures). While pay for performance may be an and families or engage them as partners in their effective tool, it has not yet been well defined or care, or for the time required to work as part of studied and may have unintended consequences. an interprofessional team. As a result, health When care is provided by an interprofessional care professionals have little incentive to work team, it is also difficult to determine which provider collaboratively or give as much attention to should be rewarded for a particular outcome. prevention, early detection of risk factors, and A more effective strategy may be to reward the treatments that prevent or delay crises and enhance integrated regional network for specialized cardiac quality of life. Innovative models are required that care with recognition or additional resources. This provide incentives for all members of primary approach would encourage more teamwork across health care teams. the network and greater accountability to the public Procedure-based funding can be a problem and funders for the quality of care provided by when recommended procedures and the people the network. who perform them change. For example, the shift Whenever possible in both primary care and to less invasive therapies has reduced the demand integrated regional networks for specialized cardiac for certain cardiac surgeries. In a fee-for-service care, funding and other incentives should be used to model, this change could have a direct impact promote and reward high-quality, patient-centred on surgeons’ incomes and the system’s ability to care, teamwork and innovation. Ideally, incentives retain those surgeons. The system needs incentives should reward improved outcomes as well as that adequately support all members of the care the more traditional benchmarks. Examples team and reward evidence-based care. In regional might include: networks of specialized cardiac care where funding • proportion of patients with hypertension or for medical specialities is not based on the fee- high cholesterol who are receiving evidence- for-service method, interdisciplinary teams have based therapies developed to care more effectively for patients with • heart failure, implanted devices, chest pain and percentage of patients adhering to medications abnormal rhythms. Canada has the potential to after discharge develop the right mix of incentives and supports to • percentage of patients participating in and encourage individual health care professionals to completing cardiac rehabilitation work in interprofessional teams. • Some jurisdictions, such as the United smoking cessation rates. Kingdom, New Zealand and Australia, have Rewarding performance requires the introduced “pay-for-performance” incentives development and regular assessment of a system of that reward physicians or hospitals based on their quality indicators for each of the various forms of performance against certain indicators for clinical CV disease. care, preventive care, organizational quality and patient satisfaction, and this approach can be an effective incentive for the “right” care. For example, hospitals that participated in a pay-for-performance program in addition to public reporting of their performance results showed greater improvements in quality than hospitals that had public reporting only – including a 5.2% improvement in the treatment of heart failure. (Lindenauer et al., 2007)
Develop the Right Service Providers With the Right Education and Skills / 93 Recommendations • Encourage faculties of health sciences to ensure that health education programs teach an inte- To develop the right people to provide CV grated approach to chronic disease prevention, prevention and care, Canada must take a more management and care, provide more education systematic approach to workforce planning. In on health promotion and disease prevention, collaboration with the federal, provincial and and prepare a workforce that can adapt quickly territorial governments’ efforts to implement the to new knowledge and technologies. Pan-Canadian Health Human Resource Strategy, • Canada must: Provide incentives for education programs to prepare providers to work 6.1 Strengthen and maintain the in interprofessional teams. CV prevention and care workforce: • Provide incentives for health care providers to work in interprofessional teams. • Identify the number and mix of health • providers and skills required to meet Challenge educational programs to critically population needs. review the length of their training programs • and the impact on efforts to ensure an adequate Recruit and/or develop people with key supply and mix of health professionals and skills, including epidemiologists, experts in skills to meet Canada’s health needs. public health/population health, primary care providers, specialists, informatics professionals, social scientists, community planners, program evaluators and policy specialists.
94 / Building a Heart Healthy Canada Conclusion
CV diseases are Canada’s number one health threat. But, it is no longer acceptable to be number one. CV diseases are also Canada’s number one health opportunity!
Over the past two decades, Canada has made To build a heart healthy Canada, we need a major progress in addressing CV diseases. Our comprehensive approach that addresses not only success in cutting the number of premature deaths the clinical risks, such as high blood pressure, from heart disease and stroke must be applauded. high cholesterol, obesity and diabetes, but also the However, the burden of CV diseases continues to environments where people live, learn, work and grow, and we cannot be complacent. We now face play. We also need to address the socio-economic a potential epidemic of CV diseases across the factors that contribute to health inequities and that country and a CV crisis in Aboriginal/ create a greater burden of CV disease among certain indigenous communities. groups in the population. Fortunately, we have within our grasp the knowledge and skills to create a much brighter, healthier future for Canadians. We know what Our Targets to do and how to do it. This is different from the The Canadian Heart Health Strategy and Action situation with other chronic diseases, where many of Plan supports and endorses targets that Canada the causes and solutions are unclear. To change the has set for healthy eating, physical activity, healthy current trajectory of CV disease, we must sharpen weights, trans fats and sodium in food, and our understanding of the factors that increase risk smoking, as defined in several initiatives; these of cardiovascular disease, look both within and include the Integrated Pan-Canadian Healthy beyond the health system for opportunities to Living Strategy, the Trans Fat Task Force, the improve CV health, and focus on actions that are Working Group on Dietary Sodium Reduction, practical, achievable, affordable, sustainable the Federal Tobacco Control Strategy and the and measurable. Canadian Diabetes Strategy. Provinces and territories, regional health authorities and public health departments have set targets to improve the health of their populations. Some have also established targets to reduce poverty.
Conclusion / 95 The CHHS-AP has identified a number of 6/ Decrease the age-standardized number of ambitious but achievable targets for prevention and hospitalizations per year for treatment of heart care of CV diseases. failure by 25% (from 132/100,000 population By 2020: in 2005/06 to 98/100,000). 7/ Decrease the age-standardized number of 1/ Decrease the annual mortality rate from CV hospitalizations per year for treatment of acute diseases by 25% (from 227/100,000 population stroke by 25% (from 95/100,000 population in in 2004 to 171/100,000). 2005/06 to 71/100,000). 2/ Decrease the burden of CV diseases in the 8/ Have CV risk assessments performed on 90% Aboriginal/indigenous population to the same of Canadians aged 45 years and older within level as in other Canadians. the previous five years. 3/ a Decrease the prevalence of hypertension in 9/ Work with others to reduce the overall adult Canadians aged 18-74 years by 32% smoking rate by 25%. (from 22% in 1992 to 15%). 10/ Abnormal levels of blood cholesterol and b Increase the proportion of adult Canadians other lipids remains a major risk factor for CV with hypertension who are aware of their diseases. Unfortunately, no population-based condition by 64% (from 58% in 1992 to measures of lipids are yet available in Canada, 95%). so a target cannot be set at this time. However, c Increase by six-fold the proportion of adult they are expected soon, and once available a Canadians with hypertension treated to target can be set. In the meantime, aggressive recommended targets (from 12.1% in 1992 measures to improve this risk factor are to 75%). encouraged as part of the Strategy. 4/ Decrease the risk-adjusted 30-day in-hospital 11/ By 2015, achieve the following targets by mortality rate from heart attacks by 32% (from working with others who have set these targets: 10.3% to 7%). • Increase the proportion of Canadian chil- 5/ Decrease the risk-adjusted 30-day in-hospital dren and adults eating at least five servings mortality rate from stroke by 25% (from 18.2% of vegetables and fruit per day by 20%. to 13.6%). • Increase the proportion of Canadian children and adults who are physically active by 20%. • Decrease the rate of Canadian adults who are overweight/obese by 20% and the rate of childhood obesity from 8% to 5%.
96 / Building a Heart Healthy Canada Economic Analysis Leadership and Partnerships
Given the complex relationships among the various Stopping CV diseases requires leadership from all risk factors, the potential for advances in diagnosis levels of government, using whole-of-government and therapies, and the effect of changing care approaches. But, governments cannot do it alone. delivery models, the Steering Committee recognizes Partnerships are needed, within and outside the difficulty in estimating the potential for cost the health sector, to engage health professionals savings as a result of achieving these targets. We are and their organizations, non-governmental continuing to assess various models but believe that organizations, industry, the media and citizens the current estimate of savings of $1 billion per year in creating a whole-of-society, whole-of-the- in direct costs and $2 billion per year in indirect country approach. costs are conservative estimates. This is highlighted To be successful, we must invest resources and by recent studies that estimate direct cost savings efforts “upstream” on activities that will prevent CV of approximately $2 billion per year just from diseases as well as “downstream” in high-quality decreasing average sodium (salt) consumption to efficient treatment services for people with heart recommended levels. (Joffres et al., 2007; Penz and other vascular diseases. We must work together et al., 2008) – within government, across governments, across sectors, in communities, and in schools, workplaces and our homes – to reduce all the risks that threaten our hearts and our blood vessels. We must change our environments and social norms. At the same time, our health systems and health care providers must work closely with Canadians to provide timely, high-quality, integrated, patient-centred prevention services and care. We have an enormous opportunity to improve the health of Canadians by implementing the Canadian Heart Health Strategy and Action Plan. We must take responsibility for our health and the future health of our country, and we must act now. There is no time for complacency.
Conclusion / 97 98 / Building a Heart Healthy Canada References
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