Improving the prevention and management of chronic conditions

Impact and scale of the issue

Chronic diseases such as cardiovascular diseases, cancer, diabetes and chronic respiratory disease, represent a leading threat to human health and development.

These four non-communicable diseases are the world's biggest killers, causing an estimated 35 million deaths each year. This is 60% of all death globally, with 80% of those occurring in low and middle-income countries. Total deaths from non-communicable diseases are projected to increase by a further 17% over the next 10 years.

  • Chronic disease accounts for more than 80% of the burden of disease and injury in Australia.
  • About 70% of the total burden of disease in Australia and almost 78% of all deaths have been attributed to just seven conditions.
  • Cardiovascular disease is the leading cause of death for both males and females, despite a marked drop in death rates since the late 1960s.
  • In 2001, about one in five Australians had cardiovascular problems and around 1.1 million have a disability as a result.
  • Cancer ranks second as an overall cause of death and it now causes more deaths among middle aged Australians than cardiovascular disease.
  • Lung cancer caused most cancer deaths in Australia in 2002, ranking first in males and a close second to breast cancer in females.
  • Diabetes prevalence has more than doubled over the past two decades and is estimated to affect around one million Australian adults. Type 2 diabetes is predicted to have the largest increase of the chronic diseases by 2020.
  • Asthma affects about 14% of children and 10% of adults.
  • In 2001, it was estimated that more than 6 million Australians (3 in every 10) were affected by arthritis and other musculoskeletal conditions. These cause more disability than any other medical condition, affecting about 34% of all people with a disability (NHPAC 2006).

The rise in prevalence of chronic disease is relatively recent. This change can be attributed to a range of factors, and in particular:

  • demographic changes as people live longer
  • lifestyle changes which have increased exposure to risk factors for chronic disease (NHPAC 2006).

In Tasmania, like the rest of Australia, chronic disease is responsible for a significant proportion of reported illness, disability and mortality. Table 2 illustrates the top ten causes of death in Tasmania, the vast majority of which are chronic diseases (DHHS 2008d).

Table 1: Top Ten Causes of Death in Tasmania, 2001-05

Rank

Disease

Average No of deaths per year

% of all deaths

1

Cancers

1128

28.8

2

Ischaemic heart diseases

724

18.5

3

Cerebrovascular diseases

305

7.8

4

Injury and poisoning

251

6.4

5

Chronic lower respiratory diseases

215

5.5

6

Other forms of heart disease

196

5.0

7

Diabetes mellitus

137

3.5

8

Diseases of arteries, arterioles and capillaries

94

2.4

9

Organic, including symptomatic, mental disorders

74

1.9

10

Renal failure

59

1.5

 

All other causes of death

733

18.7

  • The Tasmanian population as a whole tends to have poorer health status than other state and territory populations.
  • Compared to other states and territories, Tasmania has the second highest death rate for cancers, circulatory diseases and accidents.
  • A higher proportion of Tasmanians report a long-term health condition than the national average (79% compared with 76.7%).

Chronic diseases, and particularly their long-term nature, pose special challenges for the health system. People with chronic disease use health services and medicines frequently and over extended periods. They often develop complex conditions associated with co-morbidities, including mental health problems such as depression (NHPAC 2006).

Chronic diseases are the leading cause of disability in the community and are associated with high use of services, from a range of settings including hospital, home and community and through the public, private and non-government sectors (NHPAC 2006).

Chronic disease is estimated to be responsible for more than two thirds of all health system expenditure that can be allocated to disease. Diabetes and heart disease alone cost the health system more than $6 billion per annum(NHPAC 2006).

It is anticipated that the burden of disease associated with chronic disease will continue to rise in future years and that health systems will struggle to cope. This will be acutely felt in Tasmania, given our lower socio-economic status, our higher risk factor profile (see table 2) which predisposes towards diseases such as Type 2 Diabetes, and our ageing population.

  • Tasmania is now the oldest population of all states and territories with the highest proportion of people aged 65 years and over.
  • The prevalence of chronic disease and associated need for health services is known to increase significantly within older age groups, particularly after the age of 65 (Borowski et al 2007).

It is widely recognised that many chronic diseases share common risks and protective factors - those things that influence occurrence, degree and duration of chronic disease.

There are clearly established preventable risk factors for chronic disease which can be broadly grouped into two categories: behavioural and social risk factors, and biomedical risk factors as illustrated in Table 3 (AIHW 2002; NHPAC 2006).

Table 2: Risk Factors for Chronic Disease

Behavioural and social risk factors

Biomedical risk factors

Poor health in early childhood

Tobacco smoking *

Risk and high use alcohol use

Poor diet and nutrition*

Physical inactivity*

Excessive sun exposure

Social isolation

Excess weight*

High blood cholesterol*

High blood pressure*

Genetic factors

Depression

* indicates risk factors common to several major chronic diseases

Table 2 (DHHS 2008l) shows the risk factors - smoking, nutrition, alcohol, physical inactivity and psychosocial stress that are common to many of the major chronic diseases, along with high blood, pressure, excess weight and high blood cholesterol (NHPAC 2006). Nine in ten adult Australians have at least one of these common risk factors, with 54% of males and 45% of females having a combination of two or more. Aboriginal and Torres Strait Islander (ATSI) peoples are at heightened risk according to all of these common risk factors.

Tobacco remains the leading cause of preventable disease and death in Australia and Tasmania.

In 2004/05 Tasmania had the highest rate of current smokers of all state and territories.

Excess alcohol consumption has increased in Tasmania from 11.8% in 2001 to 14.9% in 2004, in comparison to Australia as whole, which has decreased from 13.4% to 12.9%.

Diabetes is increasingly common as a cause of premature mortality, with the Tasmanian age-standardised death rate for Type 2 diabetes in 2005 being 29.1 deaths per 100,000 persons. This is significantly higher than the Australian rate of 16.1 deaths per 100,000 persons.

Degree of health inequality

  • Chronic diseases are most prevalent in more disadvantaged sectors of the population. (Mathers C et al. 1999) In Australia, people from diverse cultural and indigenous backgrounds, socio-economically disadvantaged groups, rural and remote populations and people with disabilities are generally at increased risk of chronic disease.
  • Of particular note is the higher prevalence of chronic disease for Aboriginal and Torres Strait Islander peoples. In 1999-2001, over two-thirds of excess deaths for Aboriginal and Torres Strait Islander peoples were accounted for by diseases of the circulatory system, respiratory system, and endocrine, nutritional and metabolic diseases; self reported diabetes was almost four times as high as for other Australians. (Marmot, M 2005)
  • Living with chronic conditions can reduce family income and prosperity, substantially leading to reduced education and other opportunities for family members.

Evidence that health promotion and prevention action can bring about change

ยทThe Australian Institute of Health and Welfare defines prevention as "action to reduce or eliminate or reduce the onset, causes, complications or recurrence of disease" (AIHW 2008b). Prevention and lifestyle modification can assist the well population, those at risk and those with disease.

A number of the major chronic diseases can be prevented or their onset delayed. Up to 80% of heart disease, stroke and Type 2 diabetes and over a third of cancers could be prevented by eliminating shared risk factors. These are, mainly, tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol.

Some chronic diseases cannot be prevented on the basis of current knowledge, but their progression can be slowed and associated complications reduced (NHPAC 2006).

Social marketing interventions, such as stand-alone media campaigns, are unlikely to influence risk factors such as sedentary behaviour across the whole socio-economic spectrum. Initiatives that improve opportunities for physical activity or reduce level of sedentary behaviour and increase "incidental" activity are likely to have greater long-term success.

Effective strategies for reducing risk factors for non communicable chronic diseases aim at encouraging healthy choices for all and will include actions across the continuum, and need to involve both public and private actors in multiple sectors including agriculture, finance, trade, transport, urban planning, education, and sport. Different settings - for example, schools, workplaces, households and local communities will all require different action.

Surveillance of the four major behavioural risk factors and associated risk factors (including raised blood pressure, raised cholesterol, raised blood glucose and overweight/obesity) is an important component of action to assess prevalence, and monitor progress (NHMRC 2003; ACDPA2004).

The National Chronic Disease Strategy outlines four action areas and four implementation actions to address chronic disease. These include:

Action areas

  • prevention across the continuum
  • early detection and early treatment
  • integration and continuity of prevention and care
  • self-management.

Implementation actions

  • building workforce capacity
  • developing strategic partnerships
  • enhancing investment and funding opportunities
  • developing infrastructure and information technology support.

Major gains are possible by strategically focussing prevention interventions on the common risk factors that underlie a range of chronic diseases, often called a "clustered" approach (NPHP 2001). Health promotion and risk reduction interventions are relevant across the disease continuum, and not just for healthy people. For example, the benefits of reducing the risk factor of tobacco smoking is evident for people regardless of whether they are currently healthy, at risk of chronic disease or living with chronic disease (NHPAC 2006).

Based on the common risk factors for chronic disease, key actions to prevent chronic disease include:

  • controlling tobacco use
  • promoting healthy diet and good nutrition
  • promoting physical activity
  • reducing harmful use of alcohol.

Examples of directions for prevention outlined in the National Chronic Disease Strategy include:

  • investing in prevention
  • creating healthy environments
  • starting early, which is essential for success
  • promoting health and wellbeing during the early school years
  • raising community awareness and encouraging action
  • focusing on health inequalities
  • reducing risk through health care interactions
  • building the evidence base, tracking progress and monitoring performance.

Opportunities and capacity to address the issue

Given the recent policies and strategies that have been developed to address chronic disease, strategic opportunities exist at both national and state levels. These include:

National

  • National Chronic Disease Strategy 2005
  • Council of Australian Governments' National Reform Agenda
  • National Preventative Health Strategy (in development)
  • he National Primary Health Care Strategy (in development)

Tasmania

  • Future Health: Tasmania's Health Plan 2007
  • Connecting Care: A Chronic Disease Action Framework for Tasmania 2009-13
  • Tasmanian Self Management Framework (to be developed in 2009)

Chronic disease prevention and management is a key priority in Tasmania's Future Health Plan. The following actions to increase prevention, early intervention and self-management activities are outlined in the Primary Health Services Plan:

  • Each health centre to have a role in working with key stakeholders in the local community to design and implement programs to support healthy life conditions and choices and address local causes of illness and injury.
  • Expansion of the range of approaches to chronic disease that are currently being used, including group work and individual approaches, supported by infrastructure and training.
  • Expansion of the number of Health Promotion Coordinators throughout the state, and integration of health promotion approaches across the primary health workforce.
  • Improving e-health infrastructure and support for assessment services and health coaching.
  • Increasing effort in tobacco cessation programs to specifically targeting those most at risk; young women, Aboriginal people and those with mental illness.
  • Identification of chronic disease at risk population groups, with an initial focus on diabetes risk modification and early intervention and support programs.
  • Increasing effort in the promotion of mental health programs; including suicide prevention.
  • Build the skills and capacity of the health workforce in health promotion, illness prevention and self-management through the expansion and evaluation of training programs for different work groups and working with University of Tasmania, other education providers and Population Health Services.
  • Dissemination of nutrition resources for practitioners and development and distribution of improved self-help tools for people at risk or with chronic conditions. (DHHS 2007b)

Connecting Care: A Chronic Disease Action Framework for Tasmania

The DHHS has developed a chronic disease action framework for 2009-2013. This outlines goals, principles and action areas to guide directions for the prevention and management of chronic disease in Tasmania.

KEY ACTION AREAS:

Action Area 1: Promoting healthy lifestyles and environments for individuals and communities across the life course

Action area 2: Supporting the early detection of chronic disease and its risk factors including early intervention and lifestyle and risk factor modification programs

Action Area 3: Integrated management and targeted clinical care for people with chronic disease

Action Area 4: Supporting active patient self-management for people with chronic disease

Action Area 5: Improving communication and coordination between service providers

Action Area 6: Enabling our workforce to support people with chronic disease and their carers/family

Action Area 7: Strengthening monitoring, surveillance, research and evaluation(DHHS 2009b)

Stakeholder support

Department of Economic Development, Tourism and the Arts

Department of Education

Department of Premier and Cabinet

Department of Infrastructure Energy and Resources

Australian Department of Health and Ageing

Local Government Association of Tasmania

Community sector organisations and alliances

University of Tasmania

Menzies Research InstituteBusiness and private enterprises

October 2014