28/03/2011 National Health Monitoring/ Tiina Laatikainen 1

CVD and health monitoring: from information to action

Dr. Tiina Laatikainen

Purpose of health monitoring - case non-communicable diseases (NCD)

Aim of health monitoring is to:

• define disease burden

• identify populations at highest risk

• determine the prevalence of health risks

Data collected is needed to:

• provide ongoing or routine prevalence estimates of NCD risk factors

• track health trends over time

• develop targeted programs, policy and legislation

• evaluate program and policy progress and success

• demonstrate progress in meeting global or national health objectives

Different information needed to build up the health profile of the population

Mortality (life-expectancy)

Morbidity

Risk factors

Health behavior

Nutrition

Use of health services, uptake of interventions

Environmental factors

Quality of life

Different data sources on population level

• Registers:• mortality

• morbidity

• patient registers/records

• Surveys:

– health examination surveys

• health surveys (diseases)

• risk factor surveys

– health interview surveys

• health behavior surveys (behavior, self-reported diseases)

• nutrition surveys

Mortality and disease registers in Finland

Administrative registers:

• Causes of Death register

• Hospital Discharge register

• Cancer register

• Social insurance register: drug reimbursement data

Unique social security numbers enable linkage possibilities

NCD monitoring in THL

Mortality:

• Permission to analyze data from administrative registers

• Causes of death register (Statistics Finland)

100

200

300

400

500

600

700

69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 2000 1 2 3 4

Year

North Karelia

All Finland

per 100 000

Decline in CHD mortality in men aged 35-64

NCD monitoring in THLMorbidity:

• Utilization of administrative registers

– Hospital discharge data

– Cancer register

– Infectious disease register

• Special registers to monitor disease incidence– FINAMI register

• FINMONICA 1983-1992, FINAMI 1993-2002

• Population health examination surveys (prevalence data)– Mini-Finland (1978-80) and Health 2000 Survey

– The National FINRISK Study• every fifth year since 1972

Use of administrative registers in monitoring NCD morbidity

• Routine administrative registers

– Causes-of-Death register (Statistics Finland)

– Hospital Discharge Register (Stakes)

– Drug reimbursement register (KELA)

• Computerized registers, cover the whole country and all age-groups, not standardized

• Can be linked together using the personal ID code: www.ktl.fi/cvdr

Age-adjusted CHD incidence in Finland between 1991-2006

www.ktl.fi/cvdr

FINAMI

FINAMI registerMethods

• Population-based MI register aiming to record each coronary event in the populations of monitored areas

• Specific MI and Stroke registers

– FINMONICA MI and stroke registers 1983-92

– FINAMI register 1993-

– FINSTROKE register 1993-1997

• Planned for research: standardized data, established QC procedures, accurate and reliable results

• Expensive and laborious to maintain, cannot cover the whole country and all age groups

FINAMI

Age-standardized incidence of first CHD events

Men 35-74

0

100

200

300

400

500

600

700

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Ra

te/1

00 0

00

Joensuu area

Kuopio

Oulu

Turku

Trend (%/year): Joensuu area -4.3 (-6.5,-2.1), Kuopio -1.8 (-4.1, 0.6),

Turku -1.9 (-3.7,-0.2), Oulu 1.5 (-1.2, 4.1), FINAMI areas -1.9 (-3.0, -0.8; p=0.006)

Health2000 SurveyAim and target population

• Assess health and functional capacity of Finnish adult population

• Target population: population aged more than 18 years

• 160 municipalities included in the sample

• HES survey for population 30 years or more

• HIS survey for young adults (18-29 years)

Survey contents

• At home

– Health interview

– Health questionnaire

• At health center

– Anthropometric measurements

– Spirometry, bioimpedance, bone density

– Blood sampling

– Oral examination

– Functional capacity tests

– Clinical examination

– Mental Health Interview

0

5

10

15

20

25

30

35

40

Hip Knee Back Hip Knee Back

%

Mini-Finland Health 2000

Age-adjusted prevalence of hip osteoarthritis,

knee osteoarthritis and low back syndrome (definite or probable) in women, diagnosed by the examining doctor, in Health

2000 and the Mini-Finland survey

30-64 65+

NCD monitoring in THL

Risk factors:

• Population health examination and health interview surveys

– The National FINRISK Study (HES)• every fifth year since 1972

– Health Behavior among the Finnish Adult Population Survey (HIS)• every year since 1978

– Health Behavior among the Finnish Elderly Population (HIS)• every second year since 1993

National FINRISK Study

every five years since 1972

risk factors of cardiovascular

diseases, diabetes, cancer and

astma and allergy

stratified random samples from

population register

population aged 25-64 years

stratified by age and sex

sample size 8000 – 12 000 /

survey

participation rate 67 – 88 %

questionnaire, anthropometrics

and laboratory analyses

Measurements, laboratory analyses

height and weight

waist and hip circumference

blood pressure

(2-3 measurements)

pulse

serum cholesterol

HDL, triglyserides, GGT

Methodology

WHO MONICA Project protocol

http://www.ktl.fi/monica

European Health Risk Monitoring (EHRM) recommendations

http://www.ktl.fi/ehrm

115

120

125

130

135

140

145

150

155

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province

mmHg

North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007

Systolic blood pressure in men (30–59 y)

Systolic blood pressure in women (30–59 y)

115

120

125

130

135

140

145

150

155

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province

mmHg

North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007

Body mass index in men aged 30-59

25

26

27

28

29

30

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province

Kg/m2

BMI by education, women 25-64 years

25

26

27

28

1997 2002 2007

Highest

Medium

Lowest

kg/m2

Health Behaviour among the Finnish Adult Population, 1978-2007

• Since 1978, National Public Health Institute (KTL) has monitored health behaviour annually among the adult population by postal survey

• Each year a random sample of Finnish citizens aged 15-64 years has been drawn from the Population Register

• The sample size has been 5000

• The questionnaire, consistently mailed between April and June, has remained essentially the same over the years

• The average response rate has been 70% among men and 80% among women. In the entire data the number of participants is over 100 000.

Health Behaviour among the Finnish Adult Population, 1978-2007

• The primary purpose of the monitoring is to obtain information on health behaviours such as smoking and food habits and changes in them

• The questionnaire also contains questions on the following topics: dental health, self-perceived health, the use of health services, the consumption of alcohol and physical exercise

• In addition, there are questions related to change process and health campaigns

• This monitoring system provide information for health policy decision-making, and can be used for evaluating specific health promotion campaigns and programmes

Proportion of daily smokers in the population aged 15-64 years in Finland, 1978-2006

Health Behaviour among the Finnish Adult Population 1978–2006

0

10

20

30

40

50

78-7

9

80-8

1

82-8

3

84-8

5

86-8

7

88-8

9

90-9

1

92-9

3

94-9

5

96-9

7

98-9

9

2000

-01

2002

-03

2004

2005

2006

year

%

Men

Women

Fat used for cooking at home in Finland in 1978-2006

Health Behaviour among the Finnish Adult Population 1978–2006

0

10

20

30

40

50

60

70

80

90

100

78 79 80 81 82 83 84 85 86 87 90 91 92 93 94 95 96 97 98 9920

00

2001

2002

2003

2004

2005

2006

year

%

no fat at all

Vegetable oil

Liquid vegetable oil preparation

Low fat spread

Soft margarine

Hard margarine

Mixture of butter and oil

Butter

//

NCD monitoring in THL

Nutrition:

• Dietary surveys

– The FINDIET Study

Oulu 1997 -

Kuopio 1982 -

Pohjois-Karjala 1982 -

Turku and Loimaa 1982 -

Helsinki and Vantaa 1992 -

FINNISH DIETARY SURVEYS

1982, 1992, 1997, 2002, 2007

FINMONICA/FINRISK surveys

Diet subsample 3000-4000

Response rates, 60-70%

3-day food record, 1982, -92

24 h recall, 1997

48 h recall, 2002 and 2007

www.thl.fi/nutrition, Pirjo Pietinen

Food composition database FINELI

www.fineli.fi

0

10

20

30

40

1982 1987 1992 1997 2002 2007

Total fat (~ 30 EN%)

SAFA (~10 EN%)

MUFA (10-15 EN%)

PUFA (5-10 EN%)

EN%

Year

Recommendations

Fat intake

The FINDIET Study

Fiber intake (g/MJ)(recommendation 3 g/MJ)

Men

Women

g/MJ3,02,01,00,0

Area

OuluNorth-KareliaKuopioTurku-LoimaaHelsinki-Vantaa

FINDIET 1997

Salt intake in Finland 1977-2007

0

2

4

6

8

10

12

14

16

18

1977

1979

1981

1982

1987

1991

1992

1994

1997

1998

2002

2007

Calculated, men

Calculated, women

24 hour urine, men

24 hour urine, women

Linear (24 hour urine, men)

Linear (24 hour urine,women)

Linear (Calculated, men)

Linear (Calculated, women)

g/day

The FINDIET Study

Recent development

• Child health monitoring system

– aim to collect relevant health data directly from child health care and school health care for national monitoring purposes

– LATE –project

– www.thl.fi/lastenterveysseuranta

– www.terveytemme.fi/lastenterveys

• Immigrant health survey (MAAMU)

http://www.thl.fi/lastenterveysseurantahttp://www.terveytemme.fi/lastenterveys

National Health Monitoring in Finland

• Covers different aspects of health and welfare from mortality to health behavior and quality of life

• Relatively good geographical coverage

• Covers several population groups: youth, adults, elderly. Also child health monitoring under development.

• Possibility to monitor health also in different sosioeconomic groups

• Data collected by different means – however possibility to build up national and local health profiles

Dissemination and utilization of data

• Legislation in Finland mandates municipalities to monitor the health of population

• Reliable, comparable and up-to date health information needed on local level

• Development of key health indicators

• Dissemination of information and data interpretation through visual tools: www.terveytemme.fi

Health indicators by sosioeconomic status

Source: The National FINRISK Study (2002 and 2007)

Increased serum cholesterol (> 5 mmol/l)

South Finland

Increased serum cholesterol (> 5 mmol/l)

all FINRISK areas

Low

Hig

h

Mediu

m

Low

Mediu

m

Hig

h

Thank you!