Canadian Heart Health Strategy and Action Plan

Objectives

The Canadian Heart Health Strategy and Action Plan aims to reduce the growing burden, mortality, disability and economic loss associated with cardiovascular disease in Canada through a comprehensive, life-course approach to health promotion, prevention, diagnosis, treatment, rehabilitation and end-of-life care.[1][2][3]Its mission is to stimulate coordinated action towards a heart-healthy Canada, combining healthier environments, prevention, high-quality treatment and integrated patient-centred care.[3]The vision includes informed citizens, active patient participation, skilled interprofessional teams, and collaboration between governments, organisations and communities.[4]

• Create heart-healthy environments by addressing social, economic and environmental determinants of cardiovascular health through broad intersectoral action.[1][5][6]
• Improve diet and physical activity by eliminating processed trans fats, reducing dietary sodium, strengthening food labelling, promoting healthy food in schools and workplaces, and supporting active-living infrastructure and community design.[6][7][8][9]
• Reduce tobacco use by preventing initiation among children and young people, strengthening tobacco regulation, supporting smoking cessation and promoting workplace tobacco policies.[10][11][12]
• Enhance health literacy, public education, self-care and cardiovascular risk assessment, including authoritative health information and community-based screening, education and follow-up.[13][14][15][16]
• Address cardiovascular inequities by developing a multi-year action plan and a national centre, or network of centres, for chronic disease prevention and management for Aboriginal and Indigenous peoples and communities.[17][18]
• Improve prevention and care through interprofessional primary care, quality improvement, patient-centred care, specialised regional networks, timely diagnostics and consultations, telemedicine, rehabilitation and end-of-life services.[18][19][20][21][22][23]
• Build knowledge infrastructure through clinical guidelines, quality indicators, surveillance, patient registries, linked health data, electronic records, population health research and cardiovascular research capacity.[24][25][26][27][28][29][30][31]
• Strengthen the cardiovascular workforce by identifying required provider skills and mix, improving education and curricula, and advancing interprofessional practice, informatics, epidemiology, public health and evaluation capability.[32]

By 2020, headline ambitions include reducing annual cardiovascular mortality by 25%, narrowing the cardiovascular disease burden among Aboriginal and Indigenous populations to that of other Canadians, reducing adult hypertension prevalence by 32%, increasing hypertension awareness to 95%, and increasing treatment to recommended targets from 12.1% to 75%.[33]Additional targets cover risk-adjusted hospital mortality, heart-failure and stroke hospitalisations, cardiovascular risk assessment, smoking, diet, physical activity and adult and childhood obesity.[33]

Implementation

The plan is a pan-Canadian road map requiring leadership across all levels of government and partnerships spanning health services, public health, research, industry, communities, voluntary organisations, patients and the public.[34][2][3][4]It combines upstream action on environments, social norms, schools, workplaces and communities with downstream action for timely, efficient, integrated and patient-centred prevention and care.[3]The Strategy identifies gaps, promising practices and solutions; the Action Plan sets out who should act, when, how and where; and a Business Plan is intended to cost each Strategy component.[4]

• Establish a dedicated federal health-portfolio secretariat, located in either the Public Health Agency of Canada or Health Canada, to oversee implementation.[5][35]
• Create an Implementation Coordinating Council of up to 15 experts to advise the federal Minister of Health on fund allocation and reallocation, partnership development, implementation progress and corrective action.[5][35]
• Report annually to the Minister and the public through a written report, with more frequent interaction when required.[35]
• Coordinate federal organisations including the Public Health Agency of Canada, Health Canada, Statistics Canada, the Canadian Institute for Health Information, the Canadian Institutes of Health Research and Canada Health Infoway.[2]
• Work with provinces, territories, municipalities, regional health bodies, school boards, employers, professional organisations, charities, Indigenous organisations, researchers, communities and relevant private-sector partners.[34][2][7][17][32]
• Use expert groups, best-practice inventories, incentive funding, regulations, guidelines, data standards, information systems, public communications and research programmes to support adoption and scale-up.[6][16][19][25][28][36]

Development was supported by a 29-member expert Steering Committee, a three-person secretariat and six Theme Working Groups that reviewed evidence, commissioned background papers and prepared detailed reports.[1][2]Consultation involved provincial and territorial officials, professional and non-governmental organisations, industry, the public, more than 1,500 stakeholders and seven national focus groups.[34][2]The plan also sought integration with national strategies for stroke, diabetes, cancer, mental health and lung health.[2][3]

Implementation is structured around desired outcomes, activities, indicators, timelines, leads or facilitators and cost implications.[5]The proposed timetable assumes an April 2009 start, seven years of implementation and impact assessment in 2020.[5]Progress measures include mortality, risk-factor prevalence, hospital outcomes, service access, programme uptake, policy implementation, information-system development, research activity and workforce capacity.[33][26][29][32]Many actions are classified as requiring new investment, enhancement of existing resources or leveraging of partner resources; detailed implementation budgets are not specified in the supplied material.[5][35]

Monitoring & Evaluation

The plan establishes a broad monitoring and evaluation architecture spanning population health, service quality, risk factors, information systems, research, workforce development and implementation governance. It combines national outcome targets, action-specific milestones, programme uptake measures and longer-term indicators of health outcomes, service access and health-care costs.[33][5][26][35]

• Track national targets to 2020 for cardiovascular mortality, Aboriginal and Indigenous health equity, hypertension prevalence, awareness and control, hospital mortality and hospitalisations, cardiovascular risk assessment, smoking, diet, physical activity and obesity; selected health-promotion targets are set for 2015.[33]
• Monitor regulatory and environmental actions through milestones for trans-fat regulation, sodium reduction, school and workplace food policies, active-living infrastructure, tobacco control and tax incentives.[6][7][8][9][10]
• Assess prevention and public-information initiatives through uptake of health-literacy strategies, authoritative cardiovascular information tools, community screening, social-marketing campaigns and smoking-cessation programmes.[12][13][14][15][16]
• Measure care-system performance through access to integrated specialised care, self-care support, telemedicine, rehabilitation, end-of-life services, maximum wait times, guideline uptake and health-care costs.[20][21][22][23][25][37]
• Establish a pan-Canadian cardiovascular quality-indicator initiative, implement a monitoring system, promote use and reporting across jurisdictions, report to providers, institutions and the public, and review results to improve care quality.[26]
• Strengthen surveillance through expanded coverage of cardiovascular conditions and risk factors, nutrition data collection, linked administrative and death-certificate data, patient registries, a cardiac-arrest registry, enhanced population surveys and use of electronic clinical information.[27][28][29][38][39][40][30]
• Monitor research and workforce initiatives through resource allocation, funded projects, knowledge translation, clinical application, workforce shortages, training models and provider-mix requirements.[36][31][41][42][43][32]
• Assign implementation oversight to a proposed Implementation Coordinating Council, supported by a federal secretariat, to assess progress, recommend course corrections and provide an annual public written report to the federal Minister of Health.[35]

Many actions specify leads, timelines and indicators, generally from 2009 or 2010 through 2020, but the material does not define a single consolidated surveillance framework, common evaluation methodology, uniform reporting schedule or independent accountability process.[5][15][20][40][32]Population-based lipid measures were unavailable when national targets were set, so no lipid target was established; a future target was anticipated once suitable measures became available.[33]

Costing & Financing

The strategy envisages a Business Plan to cost each component and classifies many actions as requiring no additional cost, enhancement or reallocation of existing resources, or new investment with opportunities to leverage partner resources.[4][5]Detailed implementation budgets, funding sources, funding gaps and resource-mobilisation plans are generally not specified.[4][15][29]

• Recognise an annual cardiovascular disease treatment cost of more than 22 billion dollars and estimate conservative annual savings of 1 billion Canadian dollars in direct costs and 2 billion Canadian dollars in indirect costs if plan targets are achieved.[34][33]
• Estimate approximately 2 billion Canadian dollars in annual direct savings from reducing average sodium consumption to recommended levels, while noting that savings estimates are uncertain because risk factors, diagnostic and treatment advances, and care models interact.[33][5]
• Designate a portion of the 33 billion Canadian-dollar Building Canada infrastructure plan for 2007 to 2014 to support active-living infrastructure; the amount designated is not specified.[8][9]
• Fund or enhance guideline development, quality indicators, surveillance, data systems, electronic medical records, research, workforce development and information access through federal, provincial, territorial, charitable, private-sector and other partnership arrangements where indicated.[25][26][29][44][36][32]
• Provide new investment for several prevention, Indigenous health, community screening, specialised care, telemedicine, rehabilitation, end-of-life, registry and research activities, often alongside leveraging opportunities.[45][16][18][22][27][31]
• Advise on allocation and reallocation of committed implementation funds through the Implementation Coordinating Council, while appropriately resourcing its proposed federal secretariat.[35]

Several regulatory measures, including listed trans-fat and sodium actions and flavoured-cigarillo regulation and compliance monitoring, are classified as requiring no additional cost.[6][10]The plan does not provide quantified budgets for most proposed investments, tax incentives, incentive funds, centre or network establishment, programme delivery, or reporting systems.[16][18][21][26]