Cardiovascular Health Improvement Action Plan for 2013-2015

Objectives

Latvia’s Cardiovascular Health Improvement Action Plan for 2013-2015 is a short-term policy instrument supporting the Public Health Strategy for 2011-2017. Its main goal is to reduce cardiovascular-disease mortality by limiting the harmful health effects of risk factors, thereby contributing to longer healthy life expectancy, better health and prevention of premature death.[1][2][3]

• Reduce modifiable risks, particularly tobacco use, unhealthy diet, physical inactivity, obesity, harmful alcohol use, high blood pressure, raised cholesterol, impaired glucose regulation and psychosocial stress.[4][5][6]
• Promote healthier behaviour throughout the life course, including smoking cessation, physical activity, healthy body weight, higher fruit and vegetable consumption, and lower salt and saturated-fat intake.[7]
• Strengthen prevention and early identification of cardiovascular risk among children, adolescents and adults, with enhanced screening for 11-year-old children, men aged 45 and over, and women aged 50 and over.[8][9]
• Improve the quality, continuity and accessibility of cardiovascular care across primary, secondary, inpatient and tertiary levels, including diagnosis, treatment, rehabilitation, reimbursable medicines and care for congenital heart disease.[10][9][11]
• Improve disease monitoring, patient information systems, cause-of-death data quality, databases and research to support planning and assessment.[10][12][13]

The plan responds to a substantial national burden: cardiovascular diseases accounted for 55% of deaths in Latvia in 2011, including approximately 15,700 deaths, and the 2010 standardised cardiovascular mortality rate was 478 per 100,000 inhabitants, compared with a European Union average of 222.[2][14]The strategic problem analysis identifies widespread preventable risks, high premature mortality, insufficient prevention and treatment capacity, constrained access and quality of resources, weak patient flows, limited early-risk assessment in primary care and inadequate targeted screening.[3]

Its results framework focuses on reducing premature cardiovascular mortality among people under 64 years, including sex-specific mortality and potential years of life lost. It also includes behavioural and risk-factor indicators for smoking, obesity, childhood overweight and sufficient physical activity, alongside preventive testing, dietary behaviour, hospital length of stay and in-patient case fatality.[3][15][16]

Implementation

Implementation combines population prevention, primary-care-led risk assessment, specialist and hospital treatment, service reorganisation, medicines access, surveillance and research. Delivery is intended through state institutions, the Ministry of Health, the National Health Service, the Centre for Disease Prevention and Control, healthcare providers, general practitioners, municipalities, professional associations, universities and research bodies.[17][18][19]

• Use public communication, educational materials and practitioner training to improve awareness of cardiovascular risks, healthy eating, physical activity, heart-attack symptoms, youth tobacco use and passive-smoking exposure.[18][20]
• Embed annual state-financed preventive examinations in general-practitioner care, using general practitioners as care coordinators and enabling nurses and physician assistants to undertake examinations, patient education, prevention follow-up and care coordination.[17]
• Conduct annual cardiovascular screening through preventive examinations or general-practitioner visits, using the SCORE risk assessment for adults and specified laboratory-testing and follow-up algorithms.[9]
• Develop guidance, information materials and proposed legal amendments for age-specific cardiovascular examinations, additional risk measurements, possible high-risk diagnostic coding, and the participation of pharmacies and laboratories in prevention and testing.[21][22][23]
• Organise secondary-level Cardiology Patients Care Offices within existing regional centres, polyclinics and hospitals to provide specialist diagnostics, consultations, treatment advice and follow-up after general-practitioner referral.[24][25]
• Improve communication and referral pathways between primary, secondary and tertiary care, decentralise outpatient provision where appropriate, concentrate hospital services, and reduce unnecessary duplication between regional cardiologists and cardiology centres.[9][26]
• Concentrate tertiary cardiovascular care in four national centres from 2014: P. Stradiņš Clinical University Hospital, the Gaiļezers clinic of Riga East Clinical University Hospital, Daugavpils Regional Hospital and Liepāja Regional Hospital.[27]
• Expand timely reperfusion and primary percutaneous coronary intervention, reduce waits for relevant interventions and surgery, strengthen cardiac surgery capacity, and make multidisciplinary cardiac rehabilitation accessible after myocardial infarction and revascularisation.[11][28][29]
• Introduce mandatory newborn pulse-oximetry screening, support antenatal detection of congenital heart disease in high-risk pregnancies, and improve care pathways for congenital cardiac conditions.[26][27][28]
• Maintain access to reimbursable cardiovascular medicines, generally reimbursed at 75% from state-budget resources for the least expensive equivalent product, while allowing higher reimbursement levels for some diagnoses.[30]

Monitoring relies on e-health development, healthcare-service data, mortality and cause-of-death registers, repeated population studies and targeted research. Planned actions include improving exchange of medical-record information, analysing morbidity and diagnostic errors, assessing cardiac-surgery monitoring, and enabling more effective use of acute coronary and cerebrovascular syndrome register data.[12][25]The Centre for Disease Prevention and Control is assigned recurring surveys of school-aged health behaviour, youth tobacco use, children’s anthropometric characteristics and school environments, and health behaviour and functional capability among older people.[31][32]

Quality assurance includes review of cause-of-death certification, examination of 1,000 randomly selected medical certificates, training for approximately 1,000 family doctors in disease coding and death-certificate completion, and recommendations to improve cause-of-death determination.[13]The Ministry of Health is responsible for monitoring implementation results, and the Minister for Health is required to submit an informative report to the Cabinet of Ministers by 1 December 2016.[19]

Implementation is financed through participating institutions’ state-budget allocations and, for relevant measures, European Union funding.[20]The plan identifies total additional financing of Latvian lats 4,744,189 for specified prevention, treatment, access, support and assessment measures, including Latvian lats 559,346 in 2014 and Latvian lats 4,184,843 in 2015 and subsequent years.[20]

Monitoring & Evaluation

The Plan establishes cardiovascular disease monitoring and assessment as one of four action areas, alongside prevention, service quality and access to resources. Its results framework tracks premature cardiovascular mortality among people under 64 years, including sex-specific mortality rates and potential years of life lost, and sets 2015 mortality targets of 225 per 100,000 for men and 65.7 per 100,000 for women.[3]

• Monitor behavioural and risk-factor indicators, including smoking, obesity, overweight among seven-year-olds, physical activity, dietary behaviour, and uptake of blood-pressure, cholesterol and blood-glucose measurement.[3][15][16]
• Track health-service outcomes, including cardiovascular hospital length of stay, inpatient case fatality, waiting lists for planned invasive cardiology, coronary angiography and angioplasty, and volumes of invasive procedures.[27][33][34][16]
• Use the Centre for Disease Prevention and Control Register of Causes of Death, National Health Service treatment data, e-health information and repeated population studies to assess mortality, morbidity, service activity and risk-factor trends.[35][25][12]
• Conduct recurring surveillance studies, including the Health Behaviour in School-aged Children study and Global Youth Tobacco Survey every four years, and the children’s anthropometric and school-environment study every three years.[31][32]
• Improve data quality by reviewing causes of death, auditing medical certificates, training family doctors in disease coding and death-certificate completion, and developing recommendations on correct cause-of-death determination.[13]
• Address information-system limitations, as Latvia lacked a dedicated cardiovascular-patient register and available data were constrained by aggregation, incomplete patient identification across institutions and coverage focused on state-funded services.[25]
• Assess delivery through specified operational outputs, such as completed screening, published guidance, legal amendments, approved tariffs, technology assessments and implementation of pulse oximetry for newborns.[21][28][36]

The Ministry of Health is responsible for monitoring implementation results, and the Minister for Health is required to submit an informative report to the Cabinet of Ministers by 1 December 2016.[19]The supplied material does not set out a consolidated reporting cycle, independent evaluation process or wider accountability framework beyond assigned institutions, deadlines, outputs and the implementation report.[19][28][37]

Costing & Financing

Implementation is financed through state-budget allocations to participating institutions, supplemented by European Union funding for relevant measures.[20]The Plan identifies total additional financing of Latvian lats 4,744,189 for specified preventive, clinical, support and assessment measures, comprising Latvian lats 559,346 in 2014 and Latvian lats 4,184,843 in 2015 and subsequent years.[20]

• Allocate Latvian lats 399,783 for prevention, monitoring and risk-factor reduction, including Latvian lats 82,872 for prevention and Latvian lats 316,911 for monitoring and research.[18]
• Provide further additional financing for primary-level prevention and treatment, secondary and tertiary treatment, screening, reimbursed medicines, cardiac-care access and service capacity.[20]
• Fund recurrent surveillance studies through additional state-budget resources, including studies of school-aged children, youth tobacco use, children’s anthropometric characteristics and the post-working-age population.[31][32]
• Require additional state-budget financing for expanded tertiary services, including increased coronary angiography, and for mandatory newborn pulse oximetry.[28][38]
• Support early-diagnosis, technology-approval and legal-amendment measures within the annual State Budget provisions; pharmacy and laboratory information activities may also use the budgets of relevant professional organisations.[21][23][36]
• Reimburse cardiovascular medicines generally at 75% from state-budget resources, with reimbursement levels of 100%, 75% or 50% determined by diagnosis and patients covering the difference if they choose a more expensive equivalent medicine.[30]
• Record expenditure of Latvian lats 14 million on reimbursable medicines for cardiovascular patients in 2010, representing 19.5% of total reimbursable medicinal-product expenditure; medicine prices were reduced by 5% to 35% from January 2013.[39]

Several actions identify resource needs or potential efficiencies, including reducing duplicate regional and tertiary treatment, expanding cardiology care offices to avoid costly late-stage interventions, and increasing cardiac-surgery capacity.[26][11][24]Apart from the stated allocations and tariffs, the material does not provide a consolidated funding-gap assessment, resource-mobilisation strategy or economic assumptions.[18][20][28]