Cardiovascular disease

Prevention of Recurrences of Myocardial Infarction and Stroke Study

The PREMISE programme: country projects


Treatment gap and policies

Treatment gap

Large-scale surveys conducted in high-income countries have demonstrated large gaps between clinical recommendations and treatment. The ASPIRE stud enrolled 2583 coronary disease patients from 24 hospitals in the United Kingdom. Only 25% of smokers received any recommendation to stop smoking. For patients diagnosed with high serum cholesterol, 50% received therapeutic intervention. Among patients who were receiving lipid-lowering drugs, most (57-69%) remained hypercholesterolemic six months following hospitalization for coronary heart disease.

EUROASPIRE extended this research to 10 European countries, and found a similar large gap between clinical recommendations and practice. While these large-scale surveys provide useful information regarding the current standard of care, it is necessary to probe further to understand the factors that inhibit practice of secondary prevention.

Study of the treatment gap in secondary prevention of CVD has predominantly been conducted in developed countries. Due to limited resources for health care workers, coupled with inequitable and inaccessible health care systems, treatment gaps in low and middle income countries are likely to be much worse.

Therefore in order to scale-up secondary prevention of CVDs in low- and middle-income countries, a situational analysis is required 1) to describe the current standard of care for CVD and 2) to gain insights into the various barriers to comprehensive risk reduction.

Health care systems and adherence

Successful management of chronic diseases as opposed to acute infections involve long-term follow-up and care and are closely linked to appropriate health care systems and issues of adherence. Health systems in most countries are not geared to cater to these requirements. Many organizational changes will be required in existing health services to make them more receptive to the needs of those suffering from CVDs.

To achieve optimal outcomes patients suffering from CVD have to have a strong partnership with their families, health care teams and the community. If all members of this partnership - patients, families, health care teams and community - have adequate resources and are suitably informed, motivated and skilled, management of MI and stroke patients can become more effective . WHO has developed a Innovative Care for Chronic Conditions Framework to address these key issues.

In developed countries adherence to longterm therapies is usually only 50% and this figure is much lower in developing countries due to a variety of reasons. Adherence with treatment regimens for CVD, whether pharmacological or non-pharmacological, plays a pivotal role in the success of such regimens and in influencing outcomes.

Policies on drugs for secondary prevention

A substantive part of direct costs of secondary prevention programmes can be attributed to drug costs. As such success of secondary prevention programmes are heavily dependant on national drug policies and the quality, rational use and access to the relevant drugs. WHO has developed an effective strategy to improve access to essential drugs.

The main components of this strategy are rational selection, affordable prices, sustainable financing, and reliable health and supply systems. Key actions recommended for rational selection include: linking treatment guidelines with essential drug lists, regular updating of such lists based on best evidence, and using such lists for supply, reimbursement, and training. For affordable prices, proposed key actions include: encouraging competition, using generics and equity pricing of newer essential drugs.

For sustainable funding, the proposed actions include: increasing public funding for cost-effective drugs, expanding drug benefits in health insurance, and seeking external funding for poorest communities. For reliable health and supply systems, it proposes integrating supply management into health system development, developing efficient mix of public-private-NGO systems, and maintaining quality in distribution channels.

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