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MEDiterranean studies of Cardiovascular disease and Hyperglycaemia: Analytical Modelling of Population Socio-economic transitions

Periodic Report Summary 3 - MEDCHAMPS (Mediterranean studies of cardiovascular disease and hyperglycaemia: analytical modelling of population socio-economic transitions)

Project context and objectives:

Non-communicable diseases (NCDs), particularly cardiovascular diseases (CVDs) and diabetes, are increasing dramatically in many low- and middle-income countries. The main aim of MEDCHAMPS was to be able to make recommendations about the policy initiatives, both within and outside the health sector, likely to be the most effective and cost effective in reducing the burden of CVD and diabetes mortality and morbidity in 4 eastern Mediterranean / northern Africa countries (occupied Palestinian territories (oPt), Syria, Tunisia, Turkey). MEDCHAMPS used a mixed-method approach to identify these potential policy initiatives. We combined quantitative epidemiological modelling and economic evaluation, with situation and context analysis, to derive policy options and implementation plans in each country.

Epidemiological modelling (impact coronary heart disease (CHD) mortality model): We collected epidemiological risk-factor data to populate quantitative models of CHD mortality and diabetes prevalence. Key findings were a rise in body mass index (BMI) of 1 - 2 kg / m2 over the previous 15 years; with diabetes prevalence increasing by 40 - 50 % in men and women in all four countries. Smoking prevalence were high in men, and persisting in Syria but decreasing in Tunisia, oPt, and Turkey. Age adjusted CHD mortality rates rose by 20 % in Tunisia and by 65 % in Syria, and fell by 12 % in oPt and 17 % in Turkey. Most of the trend could be explained by changes in major risk factors, particularly cholesterol levels, blood pressure, diabetes and BMI.

Situation and context analysis: Work package (WP5) undertook a situation analysis of current CVD and diabetes policy in the four partner countries and analysed the contexts in which health systems manage CVD and diabetes in these countries, at a regional and sub-regional level. Three distinct 'levels' of data collection were carried out: documentary analysis, key informant interviews and clinic fieldwork. There is a formal recognition about the increased burden of NCDs in the partner countries, but none had developed a comprehensive, multi-sectoral, well-defined policy.

The health management system was found to be highly centralised in all the partner countries and there was a lack of coordination between different departments. There is a major lack of information on CVD and diabetes in all the four countries, as well as a shortage of skilled and specialist health personnel to manage these NCDs. While the degree varies between countries, our research shows that awareness regarding the risks of NCDs amongst patients is patchy and incomplete everywhere. At the same time, health facilities and treatment processes were generally experienced by patients as unfriendly (though this was much less the case in oPt), with widespread complaints about the time given by health staff to explain the causes and consequences of their condition, and the reasons for the steps stipulated to manage it.

Policy options were short listed by the research team based on results from the quantitative epidemiological modelling and situation / context analyses. Country-specific policies were then selected by each country team and evaluated by key stakeholders (5 - 7) based on predefined criteria; 5 policies for each country were identified as top priority and action plans were drafted. Three policies to reduce population dietary salt intake were chosen for economic evaluation: a health promotion campaign, labelling of food packaging and mandatory reduction of salt content in processed food. All policies were evaluated separately and in combination. The costs of implementing each of the policies were estimated using a combination of existing evidence from comparable policies and expert opinion. The total cost of implementing the policy and the associated health care costs were calculated and compared against the current baseline (i.e. no policy). In all countries the majority of the evaluated policies were cost saving.

Project results:

Data entry, model analyses and validation in Palestine, Syria, Tunisia and Turkey: The key work tasks were to enter data into parallel country models and then to validate data entry by explicit comparison of model results with observed data or other estimates. Progress towards these outcomes has been excellent for the CHD impact model and diabetes models in each of the four settings, with many papers now published / submitted.

CHD impact model: This has now been populated with data from each of the four MEDCHAMPS partner countries (Tunisia, Syria, oPt, Turkey). It was also validated against observed data and the agreement has been good in all four settings. Three manuscripts have already been published (oPt, Syria, Tunisia) and one submitted (Turkey). The overall results of the CHD impact model across the four countries were presented in a draft paper which is currently in being re-submitted. An abstract detailing the work was submitted to the World Congress of Cardiology in 2011.

Diabetes model: has been populated with Palestinian, Tunisian and Syrian data. It was also validated against country estimates and other estimates (e.g. global burden of disease, and IDF Diabetes Atlas data). The outline of a paper presenting diabetes model results has been drafted, and is being finalised. Key country manuscripts are also now completed and most will be published in the IJPH supplement in 2013.

National situation analyses: After the completion and the delivery of WP5 deliverables (report) to the EU in March 2011, the work in this WP focused on dissemination of findings, scientific writing and publications. Two manuscripts were drafted, one of which was presented in the Palestinian Health Alliance writing clinic which was held in Birzeit University in March 2011. The abstract of the same manuscript was published online in the Lancet.

Developing policy options: We have shortlisted policy options which appear most practical, feasible and cost effective for each of the 4 Mediterranean partners, based on integrating results from the qualitative situation analyses (WP5) and the quantitative epidemiological modelling (WP4). A mixed methods framework for integration was developed and shared, and used to identify the policy options most likely to be effective and cost effective in each of the four partner countries. These were shared with key stakeholders in each country setting who were asked to rank the policy options, based on a framework developed and validated previously by the World Health Organisation (WHO). Based on these stakeholder ratings, we developed implementation plans for selected policies. We also assessed the cost effectiveness of several policies (singly or in combination) to reduce salt intake at a population level. Detailed costing methodologies were developed including tools and data sheets to ensure a consistent methodology across countries. Data sources included expert opinion, field visits, the CHD model results, and literature review. Three policies to reduce population dietary salt intake were chosen for economic evaluation: a health promotion campaign, labelling of food packaging and mandatory reduction of salt content in processed food. All three of these policy options were evaluated separately and in combination. The costs of implementing each of the policies were estimated using a combination of existing evidence from comparable policies and expert opinion. The total cost of implementing the policy and the associated health care costs were calculated and compared against the current baseline (i.e. no policy). In all countries the majority of the evaluated policies were cost saving compared with the baseline. The combination of all three policies together resulted in estimated cost savings of: USD 235 000 000 and 6 455 life years gained (LYG) in Tunisia; USD 39 000 000 and 31 674 LYG in Syria; USD 6 000 000 and 2 682 LYG in Palestine and USD 1 300 000 000 and 378 439 LYG in Turkey.

Potential impact:

Results from epidemiological modelling: Age adjusted CHD mortality rates rose by 20 % in Tunisia and by 65 % in Syria. The adverse trends in risk factors explained approximately 98% of the observed mortality rise in Tunisia and more than 80% of the increase in Syria. These mortality rises occurred in spite of treatments which annually prevented or postponed approximately 450 CHD deaths in Tunisia and 2 150 deaths in Syria. CHD mortality rates fell by 12 % in oPt and by 17 % in Turkey. In oPt risk factor changes explained more than 65 % of the overall mortality fall with treatments accounting for approximately 30 %. In Turkey, risk factor improvements explained approximately 60 % of the overall mortality fall with treatments accounting for the remaining 40 %.

Diabetes prevalence trends (in Turkey). The prevalence estimated by the model was 7.5 % in 1997, increasing to 16 % in 2010, the available year for validation. Comparisons of the model estimates with the observed prevalence from surveys showed a close fit. The observed prevalence of diabetes mellitus in Turkey in 2010 was 14.9 % (13.6 % in men and 16.1 % in women) and the estimated values by the model were 16.1 % (14.9 % in men and 17.1 % in women). The forecasted prevalence for 2025 was 31 % (28 % in men and 35 % in women). Similar results were obtained for the other 4 countries.

Results from national situation analysis: There is a formal recognition about the increased burden of NCDs in the partner countries. However, they are placed differentially in terms of planning and managing this emerging situation. While Turkey and Tunisia have developed some policies and strategies concerning CVD and diabetes, Syria is lagging well behind. Despite the unique political context, oPt is making good progress. However, it is also apparent that none of these countries has developed a comprehensive, multi-sectoral, well-defined policy to deal with NCDs.

The health management system was found to be highly centralised in all the partner countries and there is a lack of coordination between different departments. There is a major lack of information on CVD and diabetes in all the four countries, as well as a shortage of skilled and specialist health personnel to manage these NCDs. Although the supply of medicine and equipment did not appear as a key problem, there is evidence of unequal distribution between regions, as well as between urban and rural areas. While the degree varies between countries, our research shows that awareness regarding the risks of NCDs among patients is patchy and incomplete everywhere. At the same time, health facilities and treatment processes were generally experienced by patients as unfriendly, with widespread complaints about the time given by health staff to explain the causes and consequences of their condition, and the reasons for the steps stipulated to manage it.

Results from policy option appraisal: Policies were short listed by the research team based on results from the quantitative epidemiological modelling and situation / context analyses. Country specific policies were then selected by each country team and evaluated by key stakeholders (5 - 7) based on predefined criteria; 5 policies for each country were identified as top priority. Three policies to reduce population dietary salt intake were chosen for economic evaluation: a health promotion campaign, labelling of food packaging and mandatory reduction of salt content in processed food. All policies were evaluated separately and in combination. The costs of implementing each of the policies were estimated using a combination of existing evidence from comparable policies and expert opinion. The total cost of implementing the policy and the associated health care costs were calculated and compared against the current baseline (i.e. no policy). In all countries the majority of the evaluated policies were cost saving.

List of websites: http://research.ncl.ac.uk/medchamps/index.html