Orientación Técnica Programa De Salud Cardiovascular

Objectives

Chile’s Cardiovascular Health Programme (PSCV) is a primary-health-care-based framework within the family- and community-oriented Integrated Health Care Model. It seeks to standardise health-network actions, reduce cardiovascular morbidity and premature mortality, prevent recurrent events and complications, and improve quality of life through person-centred, continuous care.[1][2][3]It covers people aged 15 years and over with cardiovascular risk factors or established cardiovascular disease, while providing administrative guidance for programme managers.[2]

• Reduce cardiovascular risk by identifying, diagnosing, treating and controlling hypertension, type 2 diabetes, dyslipidaemia, smoking and chronic kidney disease, using global cardiovascular-risk assessment rather than managing major risk factors in isolation.[2][3][4]
• Promote healthy lifestyles, including healthy eating, physical activity, weight management, reduced salt, sugar and unhealthy-fat intake, moderate alcohol consumption and tobacco cessation.[3][5][6]
• Prevent complications and recurrent events through secondary prevention, early chronic kidney disease detection, diabetic-foot care, retinal assessment, medication adherence and post-discharge follow-up.[3][7][8][9]
• Strengthen self-management, shared decisions and family support by respecting individuals’ beliefs, preferences, values, family circumstances and lifestyles.[10][11][12]
• Improve population prevention through the Vida Sana Programme, a community-based interdisciplinary intervention intended to reduce unhealthy diet, physical inactivity, overweight and obesity among National Health Fund beneficiaries.[13][14]
• Provide timely, dignified, respectful and non-discriminatory care, with understandable information on health status, treatment options and prognosis to support informed decisions.[1]

Implementation

Implementation is organised through integrated health-service networks led by primary care, combining risk stratification, multidisciplinary clinical management, prevention, referral pathways and systematic follow-up.[2][10][15]The approach links national stewardship, health-service coordination, municipal delivery and local team management, while allowing protocols and capacity to be adapted to territorial conditions and available resources.[15][16][17]

• Identify risk factors at preventive examinations, routine consultations, emergency contacts and other encounters with the health system, then enrol eligible people with established cardiovascular disease, confirmed hypertension, type 2 diabetes, qualifying dyslipidaemia or smoking at age 55 years or over.[3][18][19]Use the Adult Preventive Medical Examination and Older Person’s Preventive Medical Examination to support early detection.[3]
• Stratify 10-year coronary risk using Framingham tables adapted to Chile, and tailor treatment targets and follow-up intervals to cardiovascular risk, age, frailty, comorbidity and clinical status.[2][20][10][21]
• Deliver care through multidisciplinary primary-care teams including doctors, nurses, dietitians, nursing technicians and, where available, pharmacists, psychologists, physiotherapists, social workers, podiatry technicians and physical-activity professionals.[10][11][22]Assign PSCV coordinators protected administrative time to organise, supervise and support programme activity.[23]
• Use a compensation phase to achieve clinical targets, followed by maintenance for controlled conditions; provide individual counselling, family sessions, healthy-lifestyle education, medicine-adherence support and self-management workshops for patients and families.[20][24][10][25]
• Integrate mental-health, respiratory, nutrition, Vida Sana and pharmacy services, including depression screening for people with diabetes or cardiovascular disease, collaborative care for identified symptoms, smoking-cessation support and pharmaceutical follow-up for people with polypharmacy, poor adherence or clinical instability.[19][10][26][27]
• Maintain referral and counter-referral across primary, secondary and tertiary care, supported where appropriate by telemedicine.[28][7]Notify primary care following hospital discharge for acute myocardial infarction or stroke so that follow-up occurs within seven days, and reconcile medicines during transitions between care settings.[7]
• Provide retinal assessment for people with diabetes through comprehensive ophthalmological examination or retinal photography, using primary-care ophthalmology units and tele-ophthalmology where available.[8][29]Manage diabetic-foot risk through risk-based education, footwear support, repeat assessment and specialist referral when indicated.[5]
• Support access and continuity by extending cardiovascular appointment hours beyond standard daytime schedules, using appointment-management and reminder systems, auditing contact data, recalling people who miss follow-up and maintaining formal rescue procedures before removal from registers.[30][28][31][32]
• Ensure medicine availability through the Pharmacy Fund and Health Service Pharmacy and Therapeutics Committees, which guide medicine selection, stock and use.[33]Maintain a critical medicine stock sufficient for two months across the network and provide free medicines and supplies for specified diabetes, hypertension, dyslipidaemia and advanced diabetic-foot-ulcer care.[33][28]
• Train personnel in programme procedures, electronic records, notifications, referral protocols and accurate blood-pressure measurement, using validated calibrated upper-arm devices and standardised technique.[34][35][36]
• Govern delivery through the Ministry of Health, the Undersecretariat of Public Health, Regional Ministerial Health Secretariats, the Undersecretariat of Healthcare Networks, 29 Health Services, municipal health directorates and establishment directors.[12][37][15][17]Health-service and local coordinators are expected to maintain action plans, assess coverage and access gaps, convene technical meetings, oversee referral standards and coordinate training.[16][38][39]
• Monitor coverage, enrolment, effective hypertension and diabetes control, severe uncontrolled disease, retinal examination, diabetic-foot outcomes, renal-function assessment and preventive examination coverage.[9]Record attendances, entries, exits and populations under care through monthly statistical records, retaining auditable documentation of rescue and voluntary withdrawal activities.[40][31][41]Use clinical audits and constructive, time-bound performance feedback to address therapeutic inertia and improve team performance.[42][30]
• Review programme objectives and targets monthly, quarterly, six-monthly and annually at local level, with regional evaluations conducted twice yearly and annually.[16][38][39]The source provides no consolidated programme budget, quantified resource allocation or funding-gap assessment.[43][44]

Monitoring & Evaluation

The programme establishes a multi-level monitoring and accountability system that combines individual clinical follow-up, routine service statistics, performance feedback, indicator reporting, network oversight and local evaluation. It aims to monitor enrolment, risk stratification, treatment control, complications, continuity of care and service performance across primary, secondary and tertiary care.[9][14][15][38]

• Monitor cardiovascular risk through global risk categorisation, Framingham-based 10-year coronary-risk estimation adapted for Chile, and individualised follow-up plans.[2][41][21]
• Assess hypertension through standardised repeated blood-pressure measurements, including additional visits after an abnormal reading, ambulatory monitoring where indicated, bilateral-arm assessment and documented measurement technique.[45][36][46]
• Confirm or exclude hypertension and diabetes within the 45-day Explicit Health Guarantees Regime period, using appropriate blood-pressure, glucose and oral glucose-tolerance testing.[47]
• Review treatment response against cardiovascular-risk-adjusted targets for blood pressure, glycated haemoglobin and low-density lipoprotein cholesterol.[20][24]
• Schedule routine follow-up according to cardiovascular risk, at three-month intervals for high risk, six-month intervals for moderate risk and every 6–12 months for low risk.[10]
• Reassess glycated haemoglobin three months after diabetes medication or insulin adjustment, and reassess lipid profiles 6–8 weeks after starting or changing statin or fibrate treatment.[48]
• Assess medication adherence throughout follow-up, including use of the four-question Morisky-Green-Levine test during the compensation phase.[24][49]
• Monitor clinical deterioration, adverse drug reactions, treatment adherence, target-organ damage, hospitalisations and complications including diabetic foot disease, kidney disease and retinopathy.[50][51]
• Screen people with diabetes or cardiovascular disease for depression using the Chile-validated Patient Health Questionnaire-9, and incorporate mental-health assessment into comprehensive care.[10][49]
• Repeat diabetic-foot risk assessments according to risk category, from annual review for low risk to every one to three months for the highest-risk group.[5]
• Ensure retinal assessment for people with diabetes through ophthalmological examination or retinal photography, with normal examinations repeated every two years.[8][29]

Routine reporting is centred on standardised monthly statistical records submitted to the Department of Health Statistics and Information. Establishments report attendances, populations under care, programme entries and exits, and information used for management, programme-compliance indicators and health decision-making.[14][40][31]People with multiple cardiovascular conditions are counted as one person within the integrated-care framework, rather than as multiple programme enrolments.[40][41]

• Record first enrolments by hypertension, diabetes mellitus, dyslipidaemia, atherosclerotic cardiovascular disease history or smoking status.[40]
• Record exits due to transfer, death, abandonment or documented resignation, and distinguish inactive people, those in abandonment and those recovered after returning to care.[31]
• Maintain people in the chronic-disease guarantee system during prolonged absence unless an applicable exception is documented; activate follow-up or recovery action before removal from the register.[31][32]
• Document recovery actions, voluntary withdrawals and informed consent in auditable records, using digital clinical records where available.[41]
• Track preventive-examination coverage, programme enrolment for hypertension and diabetes, effective coverage among controlled patients, severe uncontrolled blood pressure and glycated haemoglobin, diabetic-foot outcomes, fundus examination and renal-function assessment.[9]

Performance management uses electronic clinical records where possible to generate objective measures of patient control. Examples include the proportion of people with type 2 diabetes achieving glycated haemoglobin below 7% and the proportion of people with hypertension achieving blood pressure below 140/90 mmHg at their latest consultation.[42]Audit and constructive feedback are intended to address therapeutic inertia, with feedback linked to specific, time-bound goals and delivered periodically by a colleague or supervisor.[42][30]

Accountability operates through multidisciplinary clinical meetings, local programme management, municipal administration, Health Service oversight and regional and national coordination. Teams should discuss indicators, complex cases, continuity between care levels, administrative issues and performance, preferably in weekly meetings of at least one hour.[34][42]Local programme coordinators evaluate target achievement monthly, quarterly, six-monthly and annually, report findings to sector meetings, establishment managers and communities, and monitor attendance, referrals and critical operational problems.[38][39]

Health Services are expected to review referral and counter-referral compliance, technically validate monthly statistical submissions, maintain information on coverage and accessibility gaps, and undertake regional programme evaluations twice yearly and annually.[16]Regional authorities also conduct periodic and random inspections of primary-care centres and hospitals, oversee regulatory compliance and track National Health Strategy targets.[37]Continuity mechanisms include hospital-discharge notification for acute myocardial infarction or stroke, enabling primary-care follow-up within seven days, and documented medication reconciliation during care transitions.[7]

Additional operational assurance includes random field visits to verify primary-care opening hours, continuous audits of patient contact data, and complaints mechanisms for unavailable medicines, for which a response and delivery target of 24 working hours is identified.[33][28]While the framework contains substantial clinical, administrative and service indicators, the supplied material does not provide a single consolidated national indicator dictionary, universal reporting timetable, surveillance protocol or independent accountability cycle.[9][16][38]

Costing & Financing

The material identifies resource requirements and several financing-related mechanisms, but does not provide an overall programme budget, costed implementation plan, funding-gap estimate, economic assumptions or quantified resource-allocation formula.[30][15][38]

• Provide medicines and medical supplies free and promptly through the Pharmacy Fund for type 2 diabetes, hypertension, dyslipidaemia and advanced diabetic-foot-ulcer management.[33]
• Maintain a critical medicine stock equivalent to two months of network need and add pharmacy personnel in municipalities with more than 20,000 registered people, without stated monetary values.[28]
• Use Pharmacy Fund resources that supported increased pharmacist staffing in Family Health Centres from 2014 onwards, creating capacity for pharmaceutical care within primary-care teams.[26]
• Allocate protected weekly administrative time for the Cardiovascular Health Programme coordinator, although the resource requirement is not quantified.[23]
• Ensure adequate human and material resources, with staffing and programme coordination aligned to territorial needs, population characteristics and vulnerability.[15][17]
• Consider equipment servicing, maintenance costs and calibration frequency when procuring blood-pressure devices, while recognising that no procurement or maintenance costs are supplied.[35]
• Provide free Ministry of Health information, training resources and smartphone applications relevant to programme implementation, without monetary valuation.[52]

Integrated cardiovascular and mental-health care is described as potentially reducing costs, but no estimate is given.[8]The material also notes the social and economic burden of diabetes, obesity and sedentary behaviour, particularly for economically vulnerable groups, without presenting quantified economic analysis.[53]