Programa Nacional Para As Doenças Cérebro-Cardiovasculares

Objectives

The National Programme for Cerebrocardiovascular Diseases is a 2017 programme extending planned action to 2020, intended to organise health-system action to prevent cerebro-cardiovascular disease, reduce disability and prolong life.[1][2]Its mission combines population risk reduction, especially control of hypertension, dyslipidaemia and excessive salt intake, with timely and appropriate care for acute myocardial infarction and stroke.[2]

• Reduce premature mortality before age 70 from ischaemic heart disease and cerebrovascular disease.[3][4]
• Reduce in-hospital mortality from acute myocardial infarction to 7%.[3][4]
• Increase primary angioplasty for acute myocardial infarction to 470 per million inhabitants.[3][4]
• Increase stroke reperfusion treatment, including fibrinolysis or endovascular reperfusion, to 1,800 cases annually.[3][4][5]
• Reduce population salt consumption by 3% to 4% annually over four years and establish monitoring of salt content in major food groups.[3][4][5]

The programme addresses ischaemic heart disease, including acute myocardial infarction, and cerebrovascular disease, including ischaemic and haemorrhagic stroke.[3][6]It prioritises continued action on cardiovascular disease because premature mortality below age 70 had worsened despite broader mortality improvements, while sudden deaths from ischaemic heart disease frequently occurred outside hospital.[7][8]

• Strengthen prevention, diagnosis, treatment and rehabilitation across the cardiovascular care pathway.[5][9]
• Improve control of modifiable risk factors, particularly hypertension and dyslipidaemia, through primary health care.[2][4]
• Improve emergency response, pre-hospital performance and referral pathways to reduce deaths before hospital admission.[2][10]
• Expand endovascular stroke therapy and improve the effectiveness of percutaneous coronary intervention centres.[11]
• Support cardiac rehabilitation and scientific research into cardiovascular and cerebrovascular diseases.[11]

The epidemiological rationale includes a progressive decline in deaths from circulatory diseases and a 39% reduction in stroke deaths between 2011 and 2015, alongside a 26% increase in hospital admissions for heart disease.[1][3]Hospital admissions for circulatory disease declined overall, but heart-failure admissions increased by 20.3% compared with 2011; population ageing was expected to increase future demand for resources.[12]

Implementation

Implementation combines national surveillance, prevention, strengthened primary and specialist care, emergency-pathway improvement, service-network development and collaborative action across health institutions and other sectors.[10][4][9]The Directorate-General of Health authors and leads the programme through a director, three deputy directors and a programme team.[1]

• Monitor cerebro-cardiovascular health indicators, using direct access to mortality data through the Death Certificate Information System to identify significant deviations and support corrective measures.[4][5]
• Validate and monitor stroke and cardiology referral networks, including coronary and stroke emergency pathways, through surveys of health units.[10]
• Strengthen use of antithrombotic treatment for atrial fibrillation, including non-vitamin K antagonist oral anticoagulants, and consolidate stroke-unit activity.[7][6]
• Improve recognition of acute myocardial infarction warning signs in primary care and monitor pre-hospital admissions through the National Institute of Medical Emergency.[4][9]
• Review national coverage of endovascular stroke treatment and monitor the number of patients receiving stroke reperfusion therapy and primary angioplasty.[4][11]

Salt reduction is delivered jointly with the National Programme for the Promotion of Healthy Eating through monitoring food salt content, supporting legislation, encouraging agri-food-sector self-regulation, training health professionals and creating a specific intervention for general and family medicine.[5][9]The programme also works with the Ministry of Education, regional health administrations, nutritionists and multidisciplinary teams to promote dietary change and disseminate good practice.[9]

• Use national data from the National Statistics Institute, the Central Administration of the Health System, INFARMED and the National Institute of Medical Emergency for surveillance and programme activity.[10]
• Reform cerebro-cardiovascular clinical standards with the Directorate-General of Health Department of Quality in Health.[10]
• Participate in the European ERA-NET CVD research project with the Foundation for Science and Technology.[10][11]
• Develop a pilot remote interpretation and analysis centre for cardiology diagnostic and therapeutic tests, linking primary care groups with specialised hospital units.[10][9]
• Develop cardiac rehabilitation through an integrated plan for rehabilitation centres, criteria for programmes and monitoring of pilot projects.[11]

Delivery partnerships include primary healthcare services, specialised hospital units, the National Programme for the Promotion of Healthy Eating, the Portuguese Society of Cardiology, the Portuguese Society of Angiology and Vascular Surgery, and other scientific associations.[10][11]Hospital activity data are compiled from National Statistics Institute data and hospital diagnosis-related group records, although 2016 figures were provisional.[13][14]

The programme specifies mortality, hospital-death, intervention and salt-content indicators, but the supplied material does not set out a complete reporting timetable, formal evaluation methodology or comprehensive accountability framework.[5][4]No overall programme budget, resource-allocation plan, funding gap or economic assumptions are specified.[10][5][11]

Monitoring & Evaluation

The programme combines outcome monitoring with service-activity tracking to assess progress towards its 2020 cerebro-cardiovascular targets, using mortality, hospital, treatment and dietary-salt indicators.[3][4][5]Available evidence shows declining standardised cardiovascular and cerebrovascular mortality, but worsening premature mortality from ischaemic heart disease and cardiovascular disease in some reviewed periods, supporting continued prioritisation of prevention and acute care.[7][8][6]

• Monitor premature deaths before age 70 from ischaemic heart disease and cerebrovascular disease; hospital mortality from acute myocardial infarction; primary angioplasty activity; stroke reperfusion treatment; and annual reductions in population salt consumption.[3][4][5]
• Track eight specified 2020 indicators: standardised cerebrovascular mortality below age 70, cerebrovascular deaths, standardised ischaemic heart disease mortality below age 70, ischaemic heart disease deaths, hospital deaths from acute myocardial infarction, primary angioplasties, stroke fibrinolysis or endovascular reperfusion, and average salt content in major food groups.[5]
• Use baseline and execution values to follow change, including reductions between 2014 and 2015 in standardised cerebrovascular mortality below age 70 from 10.9 to 10.1 per 100,000 inhabitants, and in standardised ischaemic heart disease mortality below age 70 from 14.9 to 14.4 per 100,000 inhabitants.[5]Annual cerebrovascular deaths fell from 11,296 to 11,271 and ischaemic heart disease deaths from 6,966 to 6,853 over the same period.[5]
• Monitor acute-care performance, with hospital deaths from acute myocardial infarction falling from 1,071 to 1,010, primary angioplasties increasing from 3,641 to 4,220, and stroke fibrinolysis or endovascular reperfusion cases increasing from 1,326 to 1,516 between 2014 and 2015.[5]
• Strengthen surveillance through direct access to mortality data in the SICO mortality-data system, identify significant deviations and enable corrective measures.[5]Mortality data also draw on the National Statistics Institute, while hospital mortality uses Central Administration of the Health System and hospital discharge data.[5]
• Compile mortality rates by age and sex, hospital admissions, deaths, fibrinolysis, primary angioplasty and endovascular stroke-procedure activity.[13][12][14]Mortality reporting uses International Classification of Diseases codes I60-I69 for the broader stroke table and I60-I66 for subsequent data.[13][12]
• Monitor coronary and stroke emergency pathways through health-unit surveys, including stroke-pathway progress and coronary angioplasty performance for acute myocardial infarction.[10]Monitor pre-hospital admissions through the national medical emergency service and assess the referral networks for stroke and cardiology.[10][9]
• Establish a baseline for salt content in major food groups through a wider study under the interministerial healthy-eating strategy, as no baseline or execution value was available.[5]

Hospital activity data for 2016 were provisional and compiled from National Statistics Institute and hospital diagnosis-related group records.[13][14]The supplied material identifies monitoring objectives and data sources but does not specify reporting cycles, a complete indicator-definition framework, formal evaluation methods, or named accountability procedures.[1][10][4][11]

Costing & Financing

Financial information is limited and does not present a costed programme, overall budget, funding gap, resource-mobilisation plan or economic assumptions for the national cerebro-cardiovascular programme.[15][10][5][9][11]The evidence instead reports a reduction in National Health Service pharmaceutical and therapeutic consumption charges alongside increased medicine-package volumes.[15]

• Record National Health Service pharmaceutical and therapeutic consumption charges declining from 336.2 million euros in 2012 to 330.5 million euros in 2016.[15]
• Record pharmaceutical and therapeutic package volumes increasing from 39.9 million in 2012 to 46.5 million in 2016, while the charge per package fell from 8.4 euros to 7.1 euros.[15]
• Recognise that increased medication consumption coincided with a lower overall National Health Service financial burden, although the supplied material does not quantify the broader relationship or attribute savings to particular interventions.[1][3]
• Anticipate that population ageing and the associated projected increase in heart-failure admissions may have important implications for distributing available resources, although no monetary estimate is provided.[12]
• Support research through participation in the European ERA-NET CVD project with the Foundation for Science and Technology, without a stated funding amount, allocation or financing mechanism.[10]

An amount of 336.2 million euros is also displayed in one extract without an identified expenditure category.[10]The more detailed extract identifies the same 2012 amount as National Health Service pharmaceutical and therapeutic consumption charges.[15]No budgets or financing arrangements are specified for salt-reduction work, emergency-pathway monitoring, the remote cardiology-analysis pilot, cardiac rehabilitation pilots, stroke reperfusion expansion or coronary intervention improvements.[5][9][11]