WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 27 th Session of WHO South-East Asia Advisory Committee on Health Research 15-18 April 2002, Dhaka, Bangladesh SEA/ACHR/27/12 9 April 2002 Agenda Item 2.4 Health Research in Cardio-Vascular Diseases RESEARCH PRIORITIES ON CVD MANAGEMENT IN SEAR COUNTRIES WITH SPECIAL FOCUS ON HEALTH SYSTEMS RESEARCH Table of Contents 1. INTRODUCTION .................................................................................................. 3 2. HEALTH RESEARCH PRIORITIES................................................................................ 3 2.1 For Primary and Secondary Prevention ................................................................... 3 2.2 Economic Research .......................................................................................... 4 3. CONCLUSION .................................................................................................... 5 1. INTRODUCTION According to World Health Report 2001, cardiovascular diseases (cardiac and cerebrovascular diseases) are amongst the major causes of death in SEAR countries, accounting for 37% of total deaths. By the year 2020, the burden of disease globally in terms of DALYs lost is going to increase especially of ischaemic heart diseases and cerebrovascular disease. Cardiovascular disease (CVD) epidemic is rapidly increasing in middle and low income countries, and thus, preventive measures of these diseases should be given top priority without any further delay. Even if preventive measures are undertaken, the CVD will continue to remain a major health problem in the foreseeable future, as it is affecting the lower strata of society who can hardly afford to get treatment with high cost. It is imperative to give serious consideration to find out ways and means of low cost management of CVD in primary and secondary health care settings. Some health research in CVD in the area of disease management had been ongoing in most countries of the Region. Most of these are focusing on the tertiary care and the substantial proportions of them are sponsored by medicine industry and pharmaceutical companies. Recently, there is some interest in health systems research in order to find out the most cost effective ways of providing CVD prevention and management at the country level. It is an emerging trend. To achieve this, WHO emphasizes that policy makers and health researchers need to shift the research in expensive tertiary care to thyat of primary and secondary prevention through community based interventions. 2. HEALTH RESEARCH PRIORITIES 2.1 For Primary and Secondary Prevention Intervention for prevention and management of CVD at primary and secondary level, of the health care system are most cost effective for reducing mortality and morbidity due to CVD. Health research on these community based intervention will improve the prevention of the health system. In designing these researches, one should take into account the feasibility, cost and utility of the outcomes including sustainability. The following areas are identified as priority research for CVD prevention and control: (1) Qualitative research on Awareness of CVD: community perception and perception of providers; (2) Operational research on situational analysis of type and quality of cardiovascular care being provided at the community level from different sources, such as physicians, nurses, CHWs, informal health workers. Special emphasis should be given to practice patterns in primary and secondary health centres in management of coronary heart disease, transient ischaemic attacks (TIA), stroke, hypertension, rheumatic fever and rheumatic heart disease, congestive heart failure, cardiomyopathies, (ischaemic and idiopathic) and cor pulmonale. (3) Operational researches on identification of the most cost-effective ways of managing the CVD programmes, especially capacity building; (4) Health Research to identify low cost, safe and effective generic drugs and appropriate technologies and also to develop cost-effective clinical algorithms for primary and secondary care; (5) Evaluation of cost-effectiveness of tobacco cessation programmes aimed at changing the behaviour of current smokers; (6) Field pilot studies for investigating CVD prevention and Control as part of national health care delivery system 2.2 Economic Research Researches on most cost-effective ways of cardiac rehabilitation – physical, mental and social should be promoted. Research on best ways of health education and promoting self-care especially in diseases like heart failure, hypertension, and diabetes should be encouraged. Data on the economic burden caused by CVD are not available in the Region. Health economics research should be supported to find out socio-economic consequences of morbidity and mortality due to CVD. The costs of providing cardiovascular management services should be also studied. Research should identify strategies and measures to reduce the cost without compromising quality of services. Traditional medicine practitioners in many countries of our Region are providing health care services and they have a lot faith of the local population for generations. This potential capacity of health care providers may be utilized after adequate training for capacity building for providing care at primary and secondary levels. Initially it should be tried as a pilot project under close supervision. If successful, it can be adopted at the national level. Some research on the efficacy and safety of traditional medicine is being conducted in some countries of the Region. Research on combined use of traditional and modern medicine can also be conducted in some selected subjects. So national governments and health research councils should form a high level scientific and ethical committee to: (1) identify the priorities of research on traditional medicine for the management of cardiovascular diseases at primary and secondary levels; (2) to monitor the research projects; and (3) to scientifically evaluate the results. For achieving greater success in lifestyle modifications, behavioural research followed by appropriate interventions should be designed and their efficacy evaluated. The efficacy of easily available low cost nutra-pharmaceuticals like regular use of Isofgoal for lowering cholesterol, flexseed (which is loaded with fibre lignans and omega 3 fatty acids) should be scientifically assessed for effectiveness for reducing coronary and cerebrovascular diseases and their recurrences. There have been a few published as well as grey literature report of reversal of coronary heart disease by lifestyle interventions and yoga but most of these are based on the findings of small studies. As this will be most cost-effective method in our part of the world large well designed and controlled study to prove this hypothesis is recommended. 2.3 Research on Telemedicince The increasing incidence of CVD and rising costs on the face of limited health care resources and facilities especially at the peripheral level will deprive large segments of population from essential care. Rapidly developing low cost information technology offers the potential use of telemedicine in cardiology in increasing efficient access to care even in remote areas. Advantages to be gained from these developments are an enhancement in the quality of care that can be delivered locally and regionally and the continued relevant education of health care professionals. Pilot projects can be done in a few selected districts of the Region where PHC facilities are adequately functioning. Availability of telemedicine facilities should be identified for efficacy and suitability of ECG transmission by fax and/or online transmission of ECG and telemedicine for guiding the management of CVD at primary level. Efficacy of the system should be judged in connection with telediagnosis, teleconsultation and teletraining including training of the trainers. One should not be too ambitious and should start in a modest but efficient manner and develop gradually. It has got the potentiality of ultimately being very cost effective intervention in providing high visibility efficient care. 3. CONCLUSION The results of health researches carried out in developed countries may not be fully applicable in the context of the Region. The research capability for prevention and control of CVD within the Member Countries needs to be strengthened and the regional collaborative researches should be encouraged. This will not only enhance the utility of the research but also improve the capacity of less developed countries of the Region. It will also help in networking of research organizations and institutions of the Member Countries. CVD has great socio-economic consequences because of prolonged morbidity and high cost of medical care. The resources spent on health researches in this direction could help in policy formulation and prevention, control and management of cardiovascular diseases.
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 27 th Session of WHO South-East Asia Advisory Committee on Health Research 15-18 April 2002, Dhaka, Bangladesh SEA/ACHR/27/12 9 April 2002 Agenda Item 2.4 Health Research in Cardio-Vascular Diseases RESEARCH PRIORITIES ON CVD MANAGEMENT IN SEAR COUNTRIES WITH SPECIAL FOCUS ON HEALTH SYSTEMS RESEARCH Table of Contents 1. INTRODUCTION .................................................................................................. 3 2. HEALTH RESEARCH PRIORITIES................................................................................ 3 2.1 For Primary and Secondary Prevention ................................................................... 3 2.2 Economic Research .......................................................................................... 4 3. CONCLUSION .................................................................................................... 5 1. INTRODUCTION According to World Health Report 2001, cardiovascular diseases (cardiac and cerebrovascular diseases) are amongst the major causes of death in SEAR countries, accounting for 37% of total deaths. By the year 2020, the burden of disease globally in terms of DALYs lost is going to increase especially of ischaemic heart diseases and cerebrovascular disease. Cardiovascular disease (CVD) epidemic is rapidly increasing in middle and low income countries, and thus, preventive measures of these diseases should be given top priority without any further delay. Even if preventive measures are undertaken, the CVD will continue to remain a major health problem in the foreseeable future, as it is affecting the lower strata of society who can hardly afford to get treatment with high cost. It is imperative to give serious consideration to find out ways and means of low cost management of CVD in primary and secondary health care settings. Some health research in CVD in the area of disease management had been ongoing in most countries of the Region. Most of these are focusing on the tertiary care and the substantial proportions of them are sponsored by medicine industry and pharmaceutical companies. Recently, there is some interest in health systems research in order to find out the most cost effective ways of providing CVD prevention and management at the country level. It is an emerging trend. To achieve this, WHO emphasizes that policy makers and health researchers need to shift the research in expensive tertiary care to thyat of primary and secondary prevention through community based interventions. 2. HEALTH RESEARCH PRIORITIES 2.1 For Primary and Secondary Prevention Intervention for prevention and management of CVD at primary and secondary level, of the health care system are most cost effective for reducing mortality and morbidity due to CVD. Health research on these community based intervention will improve the prevention of the health system. In designing these researches, one should take into account the feasibility, cost and utility of the outcomes including sustainability. The following areas are identified as priority research for CVD prevention and control: (1) Qualitative research on Awareness of CVD: community perception and perception of providers; (2) Operational research on situational analysis of type and quality of cardiovascular care being provided at the community level from different sources, such as physicians, nurses, CHWs, informal health workers. Special emphasis should be given to practice patterns in primary and secondary health centres in management of coronary heart disease, transient ischaemic attacks (TIA), stroke, hypertension, rheumatic fever and rheumatic heart disease, congestive heart failure, cardiomyopathies, (ischaemic and idiopathic) and cor pulmonale. (3) Operational researches on identification of the most cost-effective ways of managing the CVD programmes, especially capacity building; (4) Health Research to identify low cost, safe and effective generic drugs and appropriate technologies and also to develop cost-effective clinical algorithms for primary and secondary care; (5) Evaluation of cost-effectiveness of tobacco cessation programmes aimed at changing the behaviour of current smokers; (6) Field pilot studies for investigating CVD prevention and Control as part of national health care delivery system 2.2 Economic Research Researches on most cost-effective ways of cardiac rehabilitation – physical, mental and social should be promoted. Research on best ways of health education and promoting self-care especially in diseases like heart failure, hypertension, and diabetes should be encouraged. Data on the economic burden caused by CVD are not available in the Region. Health economics research should be supported to find out socio-economic consequences of morbidity and mortality due to CVD. The costs of providing cardiovascular management services should be also studied. Research should identify strategies and measures to reduce the cost without compromising quality of services. Traditional medicine practitioners in many countries of our Region are providing health care services and they have a lot faith of the local population for generations. This potential capacity of health care providers may be utilized after adequate training for capacity building for providing care at primary and secondary levels. Initially it should be tried as a pilot project under close supervision. If successful, it can be adopted at the national level. Some research on the efficacy and safety of traditional medicine is being conducted in some countries of the Region. Research on combined use of traditional and modern medicine can also be conducted in some selected subjects. So national governments and health research councils should form a high level scientific and ethical committee to: (1) identify the priorities of research on traditional medicine for the management of cardiovascular diseases at primary and secondary levels; (2) to monitor the research projects; and (3) to scientifically evaluate the results. For achieving greater success in lifestyle modifications, behavioural research followed by appropriate interventions should be designed and their efficacy evaluated. The efficacy of easily available low cost nutra-pharmaceuticals like regular use of Isofgoal for lowering cholesterol, flexseed (which is loaded with fibre lignans and omega 3 fatty acids) should be scientifically assessed for effectiveness for reducing coronary and cerebrovascular diseases and their recurrences. There have been a few published as well as grey literature report of reversal of coronary heart disease by lifestyle interventions and yoga but most of these are based on the findings of small studies. As this will be most cost-effective method in our part of the world large well designed and controlled study to prove this hypothesis is recommended. 2.3 Research on Telemedicince The increasing incidence of CVD and rising costs on the face of limited health care resources and facilities especially at the peripheral level will deprive large segments of population from essential care. Rapidly developing low cost information technology offers the potential use of telemedicine in cardiology in increasing efficient access to care even in remote areas. Advantages to be gained from these developments are an enhancement in the quality of care that can be delivered locally and regionally and the continued relevant education of health care professionals. Pilot projects can be done in a few selected districts of the Region where PHC facilities are adequately functioning. Availability of telemedicine facilities should be identified for efficacy and suitability of ECG transmission by fax and/or online transmission of ECG and telemedicine for guiding the management of CVD at primary level. Efficacy of the system should be judged in connection with telediagnosis, teleconsultation and teletraining including training of the trainers. One should not be too ambitious and should start in a modest but efficient manner and develop gradually. It has got the potentiality of ultimately being very cost effective intervention in providing high visibility efficient care. 3. CONCLUSION The results of health researches carried out in developed countries may not be fully applicable in the context of the Region. The research capability for prevention and control of CVD within the Member Countries needs to be strengthened and the regional collaborative researches should be encouraged. This will not only enhance the utility of the research but also improve the capacity of less developed countries of the Region. It will also help in networking of research organizations and institutions of the Member Countries. CVD has great socio-economic consequences because of prolonged morbidity and high cost of medical care. The resources spent on health researches in this direction could help in policy formulation and prevention, control and management of cardiovascular diseases.