Cardiovascular Health Improvement Action Plan for 2013-2015

Objectives

Latvia’s Cardiovascular Health Improvement Action Plan for 2013 to 2015, issued under Cabinet of Ministers Order No. 359 and developed within the Public Health Strategy for 2011–2017, seeks to reduce deaths from cardiovascular diseases by limiting the harmful health effects of risk factors.[1][2][3]It responds to cardiovascular disease as the leading cause of death, responsible for 55% of deaths and 15.7 thousand deaths in 2011, including a substantial share among people under 64.[2][4]

• Reduce premature mortality, morbidity, disability and preventable cardiovascular burden, particularly through healthier behaviour, risk-factor reduction and timely treatment.[2][5][3]
• Promote cardiovascular prevention and address smoking, unhealthy diet, physical inactivity, alcohol consumption, obesity, high blood pressure, high cholesterol, diabetes and psychosocial stress.[5][3]
• Improve the quality, accessibility and efficiency of cardiovascular healthcare services across primary, secondary and tertiary care.[3][6]
• Improve access to prevention and healthcare resources, including screening, diagnostics, medicines, rehabilitation and specialised treatment.[3][7]
• Strengthen monitoring, assessment, databases, e-health and research on cardiovascular disease and its risk factors.[8][9][3]

The Plan aligns cardiovascular action with national development planning, Latvia 2030, local-authority health-promotion guidance, European Union priorities and World Health Organization approaches to non-communicable disease prevention.[10][6]Its prevention strategy promotes the markers of good cardiovascular health, including non-smoking, healthy body weight, physical activity, balanced nutrition, healthy blood pressure and cholesterol, and avoidance of diabetes and cardiovascular disease.[5]It also prioritises prevention among children and adolescents, recognising early risk factors and the need to reduce future cardiovascular complications.[11][12]

Specific result targets for 2015 include reducing cardiovascular mortality among men under 64 from 242.9 per 100,000 in 2011 to 225, and among women under 64 from 85.1 to 65.7.[3]The Plan also aims to reduce potential years of life lost, stabilise or reduce smoking and obesity, increase physical activity and preventive checks, improve dietary habits, shorten hospital stays and reduce in-patient case fatality.[3][13][7]

Implementation

Implementation combines population prevention, primary-care risk assessment, coordinated referrals, specialist diagnostics and treatment, rehabilitation, medicines access, service reorganisation and strengthened health intelligence.[14][15][9][3]The Ministry of Health developed the Plan and coordinates measures with the National Health Service, Centre for Disease Prevention and Control, Latvian Association of Cardiology, healthcare providers, municipalities, professional associations and other institutions assigned to individual actions.[2][16][17]

• Deliver health-information and behaviour-change campaigns on cardiovascular risks, healthy eating, physical activity, smoking cessation, personal health checks and recognition of myocardial infarction, stenocardia and stroke symptoms.[11][18][16]
• Provide annual state-financed preventive examinations for people registered with general practitioners, including weight, blood-pressure and pulse measurement and relevant clinical assessment.[19]
• Screen children aged 11, women aged 50, 55 and 60, and men aged 45, 50, 55 and 60 for cardiovascular risk through family doctor practices, using prescribed clinical and laboratory algorithms.[15][20][21]
• Position general practitioners as care coordinators, supported by nurses and physician assistants who educate patients, monitor prevention, coordinate chronic-disease care and link health and social services.[19]
• Establish Cardiology Patients Care Offices within existing infrastructure to provide secondary-level diagnostics, consultations, treatment recommendations, feedback to general practitioners and follow-up where needed.[22][23]
• Improve patient flows between general practitioners, cardiologists, hospitals and emergency services, while concentrating tertiary cardiovascular care in four national healthcare centres from 2014.[15][24]
• Expand timely acute and tertiary interventions, including primary percutaneous coronary intervention, cardiac surgery, advanced medical technologies and multidisciplinary cardiological rehabilitation.[25][26][27][28]
• Support access to reimbursable cardiovascular medicines, for which the state reimbursement rate is stated as 75%, while applying the least-expensive equivalent medicine principle.[29]

Operational governance includes working groups, legislative amendments, methodological guidance, submissions to the Cabinet of Ministers, publication of materials through institutional websites, professional training and delivery deadlines generally set for 30 December in 2013, 2014 or 2015.[16][20][30]The Plan envisages training 30 cardiologists and 30 cardiology nurses, establishing 30 cardiology patient treatment centres, and strengthening functional diagnostics capacity.[17][31][32]

Monitoring uses mortality, premature mortality, risk-factor prevalence, preventive-check uptake, hospital length of stay, case fatality, service queues, procedure volumes and screening outputs.[3][7][27]Data sources include the Centre for Disease Prevention and Control, National Health Service information systems, cause-of-death records, the World Health Organization Health for All database and population surveys such as FINBALT.[4][33][9]E-health and improved registers are intended to enable unique-patient incidence and prevalence analysis, although existing aggregated data and the absence of a dedicated cardiovascular patient register limit morbidity measurement.[9][34]

Financing combines annual State Budget appropriations with specified additional requirements.[16][27]The Plan identifies additional financing of 399,783 Latvian lats for prevention and monitoring activities, including 259,783 Latvian lats in 2014 and 140,000 Latvian lats in 2015.[18]It also identifies 497,454 Latvian lats annually from 2015 for cardiovascular screening, 993,802 Latvian lats annually from 2015 to expand tertiary services, and 92,747 Latvian lats annually for cardiology patient treatment centres after offsetting existing programme financing.[21][28][17]

Monitoring & Evaluation

The Plan combines outcome monitoring, service-performance measurement, routine surveillance, research and implementation-output tracking to reduce cardiovascular mortality and risk factors between 2013 and 2015. It sets reference values and 2015 targets for mortality, risk-factor prevalence, preventive behaviour, hospital use and in-patient outcomes, but the supplied material does not describe one consolidated evaluation methodology or regular plan-wide reporting cycle.[3][13][7]

• Monitor premature cardiovascular mortality among men and women under 64 years, potential years of life lost, smoking, obesity, physical activity, diet, and uptake of blood-pressure, cholesterol and blood-glucose checks.[3][13][7]
• Measure progress towards reducing male cardiovascular mortality under 64 from 242.9 per 100,000 in 2011 to 225 in 2015, and female mortality from 85.1 to 65.7.[3]
• Track potential years of life lost due to cardiovascular disease, with 2015 targets of 1,930 for men and 600 for women, compared with 2,392 and 736 respectively in 2011.[3]
• Assess hospital performance through average cardiovascular hospital stay, hospital stay among patients aged 18 to 59, and in-patient case fatality; stated 2015 targets are 6.5 hospital days, 58 days for the specified age group, and 6.5% case fatality.[7]
• Use mortality data from the Centre for Disease Prevention and Control, healthcare statistical reports, National Health Service medical-information-system data, the World Health Organization Health for All database, and causes-of-death registers.[4][9]
• Recognise limitations in morbidity surveillance: existing data are aggregated, cannot identify unique patients across institutions, principally cover state-budget-financed services and approved diagnoses, and cannot reliably estimate incidence or prevalence without a dedicated cardiovascular patient register.[9]
• Strengthen e-health data exchange, develop a computerised record for cardiac-surgery patients, enable access to acute coronary and cerebrovascular syndrome register data, and engage specialists and researchers in analysing morbidity and possible misdiagnosis.[9][34]
• Continue population research through FINBALT health monitoring, Health Behaviour in School-aged Children, the Global Youth Tobacco Survey, and studies of anthropometric measures and substance use.[34]
• Conduct ongoing quality-control investigations of death certificates by comparing certification with Cabinet requirements and available medical records, supporting more reliable causes-of-death data.[35]
• Use annual preventive examinations, annual cardiovascular screening for specified age groups, SCORE cardiovascular risk assessment for adults, and general-practitioner quality evaluation to support routine prevention and care quality.[19][15]
• Track implementation through measure deadlines, submitted legislative proposals, reports, guidance, working groups, published materials, screenings and training outputs.[16][20][30][36][37][21]
• Assess campaign delivery through reach of at least 1,000,000 people and a post-campaign poll of at least 1,000 respondents for myocardial infarction, stenocardia and stroke awareness.[16]
• Monitor specialised-service performance through treatment queues, congenital-heart-disease diagnosis, time from first medical contact to reperfusion, technology approvals, tariff development, and additional tertiary-service recipients.[38][24][27][39][28]
• Use creation of 30 cardiology care facilities, training of 30 cardiologists and 30 cardiology nurses, and assessment of the acute coronary register as implementation indicators.[31][32]

Costing & Financing

Financing combines annual State Budget appropriations, identified additional requirements and state reimbursement of medicines. The Plan identifies additional financing of 399,783 Latvian lats for prevention and monitoring actions, while several service-expansion and screening measures require recurrent funding from 2015 onwards. The supplied material does not provide a single consolidated programme budget, comprehensive funding-gap analysis, resource-mobilisation strategy or economic assumptions.[18][36][37][21][27][39][28][17]

• Allocate 82,872 Latvian lats for cardiovascular prevention and risk-factor reduction, including public campaigns, practitioner guidance and patient information, and 316,911 Latvian lats for monitoring and health and epidemiological research.[18]
• Plan total additional financing of 399,783 Latvian lats, including 259,783 Latvian lats in 2014 and 140,000 Latvian lats in 2015.[18]
• Provide approximately 10,000 Latvian lats of additional 2014 State Budget funding for the public-information campaign on recognising myocardial infarction, stenocardia and stroke.[16]
• Provide 3,000 Latvian lats of additional 2014 State Budget funding for family-doctor methodological materials and 497,454 Latvian lats from 2015 and each subsequent year for cardiovascular screening, including 17,824 Latvian lats for laboratory examinations for children.[37][21]
• Fund acute coronary reperfusion activity during 2013 to 2015 within annual State Budget appropriations, and fund technology assessment, tariff development and regulatory amendments through the relevant 2014 and 2015 State Budget appropriations.[27][40][41]
• Provide 993,802 Latvian lats in additional state-budget financing from 2015 onwards to expand tertiary services, covering coronary diagnostic and intervention services and invasive correction of heart defects in adults.[28][42]
• Require 92,747 Latvian lats of additional state-budget financing from 2015 onwards for cardiology patient treatment centres after offsetting planned existing cardiology programme financing.[17]
• Reimburse cardiovascular medicines through the state system at 75%, while diagnosis-dependent medicine reimbursement rates may be 100%, 75% or 50%; patients choosing a more expensive equivalent pay the difference.[29]
• Record 14 million Latvian lats in reimbursable medicine expenditure for cardiovascular patients in 2010, representing 19.5% of total reimbursable medicine expenditure and 4 million Latvian lats less than in 2008.[43]
• Note that reducing reimbursable-medicine financing may reduce medicine use and increase hospitalisation, treatment costs, sickness-related costs and foregone tax revenue.[43][22]
• Identify preventive examinations for patients registered with a general practitioner as state-financed, while outpatient secondary-care consultations without a general-practitioner referral are paid services.[19][15]