Canadian Heart Health Strategy and Action Plan

Objectives

The Canadian Heart Health Strategy and Action Plan seeks to reduce the burden, mortality and inequities associated with cardiovascular disease through a life-course, whole-system approach spanning health promotion, prevention, diagnosis, treatment, rehabilitation and end-of-life care.[1][2]It addresses cardiovascular, cerebrovascular and peripheral vascular disease while recognising that many preventive measures also benefit other chronic conditions.[3]

• Create heart-healthy environments by improving food quality, food access, labelling, calorie information, school and workplace food provision, active-living infrastructure, tobacco control and public awareness.[1][4][5][6][7][8]
• Enable healthier lives by strengthening health literacy, authoritative health information, risk assessment, community screening, self-care support, physical activity and smoking cessation.[1][9][10][11]
• Reduce cardiovascular inequities by developing a multi-year action plan and a national centre or network for chronic disease prevention and management with Aboriginal and Indigenous peoples and communities.[1][12][13]
• Reform services to deliver timely, integrated and patient-centred care through interprofessional primary care, regional specialist networks, telemedicine, rehabilitation, end-of-life care, evidence-based wait times and clinical guidelines.[1][14][15][16][17]
• Build knowledge infrastructure through registries, surveillance, linked administrative data, nutrition and population surveys, electronic records, research, knowledge translation and workforce development.[1][11][18][19][20][21]
• Achieve by 2020 a 25% reduction in annual cardiovascular mortality, reduced disparities for Aboriginal and Indigenous populations, improved hypertension prevention and management, lower heart attack and stroke mortality, fewer heart-failure and acute-stroke hospitalisations, cardiovascular risk assessment for 90% of people aged 45 and over, and a 25% reduction in smoking.[22]

The plan also aims to improve diet, physical activity and obesity indicators, strengthen patient participation and self-care, and ensure that people receive coordinated, high-quality care within recommended waiting times.[23][22][15][24]Its cross-cutting priorities are equity, Aboriginal and Indigenous cardiovascular health, evaluation, knowledge generation and knowledge translation into practice.[2]

Implementation

Implementation is designed as a pan-Canadian, whole-of-government and whole-of-society effort combining upstream prevention with downstream investment in integrated, patient-centred services.[3]The Strategy identifies needs and promising solutions, the Action Plan assigns responsibility, timing and delivery arrangements, and a Business Plan is intended to set out implementation costs.[23]

• Coordinate action across federal, provincial, territorial, municipal and regional health bodies, with health professionals, researchers, charities, non-governmental organisations, industry, schools, workplaces, communities, media and the public.[2][3]
• Align cardiovascular action with the Canadian Stroke Strategy, Canadian Diabetes Strategy, Canadian Partnership Against Cancer, Mental Health Commission of Canada and National Lung Health Framework.[2][3]
• Establish a dedicated secretariat within the federal health portfolio and an Implementation Coordinating Council of up to 15 experts, public representatives and ex officio senior federal and provincial or territorial members.[4][25]
• Advise the federal Minister of Health on committed-fund allocation or reallocation, partnerships, implementation progress and corrective action, and publish an annual written report.[25]
• Assign operational activities to named leads and partners, specifying desired outcomes, indicators, timelines and facilitating organisations; planning assumed a start in April 2009, seven years of delivery and impact assessment in 2020.[4]

The strategy was developed by a 29-member expert Steering Committee, supported by a three-person secretariat, with guidance from the Canadian Cardiovascular Society, the Heart and Stroke Foundation of Canada, and the Canadian Institutes of Health Research Institute of Circulatory and Respiratory Health.[1]Development drew on six Theme Working Groups, literature reviews, commissioned papers, consultation with more than 1,500 stakeholders and seven national focus groups.[2]

Delivery mechanisms include regulation and guidance on trans fats, sodium, food labelling, calorie posting and food marketing to children; best-practice inventories and incentives for schools, workplaces and clinical settings; sustainable Food Mail Programme expansion; and infrastructure support for active living.[26][5][27][28][6][29][30]Health Canada, the Public Health Agency of Canada, Statistics Canada, Canada Health Infoway, the Canadian Institute for Health Information, the Canadian Institutes of Health Research and specialised professional and charitable organisations hold major implementation roles across these actions.[2][18][19][31]

Health-service reform is to use incentive funding, collaborative networks, training, innovation support, information systems and dissemination of effective practices.[14][15][32]It includes regional integrated specialist care, interprofessional primary care teams, telemedicine and telestroke, cardiac rehabilitation in underserved areas, end-of-life support, updated clinical guidelines, and patient access to clinical information while respecting privacy and confidentiality.[14][24][16][17][33][31]

Knowledge infrastructure is to be strengthened through cohort research, registry standards, cardiovascular surveillance, regular nutrition data, death-certificate linkage, a pre-hospital cardiac-arrest registry, enhanced surveys of high-risk populations, electronic health and medical records, and coordinated research agendas.[11][34][35][18][36][37][20]Progress is to be monitored using activity, uptake, service-access, behavioural, disease, mortality, hospitalisation and cost indicators, generally with milestones to 2020.[22][4][21]Many actions identify qualitative resource needs, including new investment, enhancement or leveraging of existing resources, but the supplied material does not provide a consolidated quantified budget.[4][21][25]

Monitoring & Evaluation

The plan uses a long-term performance framework, linking implementation milestones from 2009 onwards to population and service outcomes targeted mainly for 2020. It combines prevention, food environments, physical activity, tobacco control, care integration, health information, research, surveillance and workforce development.[22][4][21]

• Measure national outcomes through cardiovascular mortality, hypertension prevalence and management, heart attack and stroke mortality, heart-failure and acute-stroke hospitalisations, cardiovascular risk-assessment coverage, smoking, diet, physical activity and obesity.[22]
• Monitor delivery of food, activity and tobacco actions through regulatory milestones, programme uptake, compliance, availability and quality of healthy food, active-living opportunities, smoking rates and obesity outcomes.[26][5][30][38]
• Track access, quality and efficiency of care through uptake of patient self-care support, specialised-care networks, telemedicine, rehabilitation, end-of-life services, interprofessional teams, wait-time information systems, hospitalisations and health-care costs.[15][32][24][16][17]

Information and surveillance mechanisms include chronic-disease cohort research, common registry standards, expanded cardiovascular surveillance, repeated nutrition and high-risk-population data collection, linked mortality and health-service data, a pre-hospital cardiac-arrest registry, and electronic health-record systems.[11][34][35][18][36][37][31]These mechanisms are intended to support regular prevalence and incidence reporting, policy development, service management, research and assessment of prevention and care strategies.[35][36][31]

Evaluation extends to research translation and policy effects. It includes monitoring biomarker and population-health research, assessment of tax incentives and physical-activity policies, and tracking whether evidence is translated into prevention and clinical practice.[39][40][41]The plan also assigns indicators, lead organisations and timelines to health-literacy, community screening, Aboriginal and Indigenous cardiovascular action, and workforce initiatives.[9][10][12][21]

Accountability is principally embedded in designated leads, partner organisations, implementation milestones and monitoring of uptake and outcomes.[4][16][19]A proposed Implementation Coordinating Council would advise the federal Minister of Health, assess progress, recommend course corrections and publish an annual written report.[25]The extracts do not provide a single consolidated evaluation methodology, common reporting format, independent evaluation body, enforcement mechanism or comprehensive surveillance governance framework.[15][35][37][20]

Costing & Financing

The plan presents mainly qualitative resource implications rather than a consolidated costed budget. Its Business Plan is intended to set out implementation costs, while activities are categorised as requiring no additional cost, enhancement or reallocation of existing resources, new investment, and, in many cases, opportunities to leverage partner resources.[23][4]

• Record annual cardiovascular-disease treatment costs of more than 22 billion dollars, although the currency is not specified in the supplied material.[42]
• Estimate potential annual savings of 1 billion dollars in direct costs and 2 billion dollars in indirect costs from achieving the targets, while noting uncertainty and possible conservatism in these estimates.[4]
• Estimate approximately 2 billion dollars in annual direct savings from reducing average sodium consumption to recommended levels.[4]
• Refer to the 33 billion Canadian dollar Building Canada infrastructure plan for 2007 to 2014, from which a portion was proposed for active-living infrastructure; no allocation amount is specified.[29]

New investment is identified for a wide range of delivery activities, including community screening, Aboriginal and Indigenous cardiovascular action, primary-care teams, patient-centred care, specialised networks, telemedicine, rehabilitation, end-of-life care, self-care tools, cohort research, nutrition data collection, cardiac-arrest registries and vascular research nodes.[10][13][14][15][16][11][18][36][43]Enhancements apply particularly to clinical guidelines, registries, surveillance, linked data, surveys, electronic information systems, workforce development, research translation and policy evaluation.[33][34][35][36][37][19][21][41]

Some actions are described as requiring no additional cost, including food-labelling measures, child food-marketing controls, tobacco regulation and certain infrastructure activities.[5][28][30][38]The source refers to committed-fund allocation or reallocation, sustainable funding for the Food Mail Program, and funding for coordination, advisory groups and secretariat functions, but does not specify a total budget, financing shares, funding sources, funding gap, unit costs or detailed economic assumptions.[28][44][45][25]