An Analysis Of The Necessity And Feasibility To Integrate Dyslipidemia Into Basic Public Health Service Project

Objective:This study will analyze the necessity and feasibility to integrate dyslipidemia management into National Basic Public Health Service Project(NPHS).The necessity will be analyzed from three dimensions:the causation chain of cardiovascular and cerebrovascular diseases,dyslipidemia and its disease burden,as well as universal health coverage for health equity.The feasibility will be analyzed based on the theoretical dimensions of "Three Forces" theory of the Health System(Capacity,Incentive,Pressure),practical experiences from the Pilot Project of Chinese Adult Dyslipidemia Health Management Services(hereinafter referred to the pilot project)[1].and affordability evaluation.Evidence-based suggestions and practical cases will be given to carry out standardized management and intervention of dyslipidemia as well as relevant policies on the basis of standardized management and intervention of hypertension and diabetes at the primary level.Methods:1.Literature research:for the relevant background data and the relevant supporting literature and policies,computer network is used to collect and review the related literature both domestic and abroad,to collect and sort out scientific literature,treatises,guidelines and reports,as well as to review and analyze the global epidemic trend of noncommunicable diseases(NCDs),as well as cardiovascular and cerebrovascular diseases and especially dyslipidemia,the influence and disease burden of dyslipidemia on cardiovascular and cerebrovascular diseases,the prevalence and control status of dyslipidemia in China,the relevant guidelines for dyslipidemia management in China,as well as the theoretical basis,international experiences of dyslipidemia management.The database includes CNKI,PubMed,CHKD and Wanfang Data knowledge service platform;Key journals searched include Circulation,Stroke,Chinese Journal of cardiovascular disease,Chinese Journal of chronic diseases,Chinese Journal of Health Management,etc.Key words:dyslipidemia,dyslipidemia management,cardiovascular and cerebrovascular diseases,basic public health services2.Qualititive interviews:①One-on-one or group interviews with medical staff,patients and family members,as well as managers in community health service centers/township health centers,and policy makers in local health administrative institutions in pilot cities and counties had been conducted through investigating 6 pilot cities and counties of the pilot project to better understand the working condition of basic public health services and the prevention and treatment of non-communicable diseases among primary health institutions in pilot cities and counties(see the appendix for the investigation plan and interview outline).②By organizing symposiums,expert consultation and other methods,various forms of interviews and consultations with experts in the fields of non-communicable diseases,cardiovascular and cerebrovascular diseases,basic health services,policy makers and other stakeholders had been carried out,and the implementing path of dyslipidemia management and comprehensive prevention and treatment of cardiovascular and cerebrovascular diseases in primary health institutions had been discussed.Health economics evaluation:as an important evidence-based ground for the feasibility analysis of integrating dyslipidemia management into basic public health services,①through the cost calculation and effect analysis of dyslipidemia management implemented in two pilot cities and counties(Qianjiang and Shenzhen)the Pilot Project of Dyslipidemia Health Management Services in Chinese Adults,the health economics model is used to calculate the cost and effect of follow-up interventions.The cost-effectiveness analysis of the incremental cost and incremental effect ratio(△ cost/△ effect)of the two pilot cities and counties are carried out.②Budget Impact Analysis was used to estimate the input cost and output of dyslipidemia management intervention in primary health institutions in the short term.Input mainly refers to the specific costs of implementing the intervention,including the cost of equipment,drugs and staff during the intervention.The study combined the results of cost estimation and effect analysis in Qianjiang and Shenzhen,two pilot cities and counties,to estimate the cost input and output in a specific period of time(1-5 years)for a specific number of people in urgent need of 1 dyslipidemia management.③The cost of per capita investment after increasing dyslipidemia management for patients with hypertension and/or diabetes complicated with dyslipidemia who are included in the national basic public health service project is calculated.Through the above two health economics evaluation methods,this paper analyzes the feasibility of dyslipidemia management at primary level.Results:1.Necessity analysis of incorporating lipid management into basic public health service projects(1)By the cause chain of cardiovascular and cerebrovascular diseases:dyslipidemia,hypertension and diabetes are all cardiovascular and cerebrovascular risk factors[2].Improving intermediate risk factors such as hypertension,hyperglycemia,dyslipidemia,overweight and obesity can significantly reduce major non-communicable diseases such as cardiovascular and cerebrovascular diseases,diabetes[3].The "San Gao" should not be separated,but should be managed together,which not only conforms to the comprehensive risk control principle of cardiovascular and cerebrovascular diseases,but also achieves a synergistic effect of 1+1+1>3[1][4].(2)By blood lipid levels and disease burden,as well as the prevalence and control status of dyslipidemia in China are not optimistic:In 2020,the prevalence of dyslipidemia among residents aged 18 and above in China was 35.6%[5,6].(3)By health equity and universal health coverage:the original intention of basic public health services is to promote the gradual equalization of basic public health services[7].However,currently,health services in China are still imbalanced between urban and rural areas and the population.According to the prevalence rate of dyslipidemia in 2002,there are 160 million patients with dyslipidemia in China.Apart from patients with diabetes or hypertension who have been included in the National Basic Public Health Services(NBPHS),there is still a huge gap that has not been included in the management of NCDs.The utilization rate of health records can reflect the effective coverage rate of hypertension and diabetes patients in NBPHS,in which is still a gap compared with the filing rate.2.Feasibility analysis of integrating dyslipidemia management into National Basic Public Health Service ProjectsFrom the perspective of Capability:①There is sufficient evidence both domestically and internationally regarding the effective prevention and control of cardiovascular and cerebrovascular diseases through dyslipidemia management.The US,UK and Finland have respectively implemented comprehensive prevention and treatment of cardiovascular disease risk factors[8],effectively reducing the mortality rate of cardiovascular diseases in the population and achieving good experience and results.②Technical guidelines such as the "Guidelines for the Prevention and Treatment of Adult Dyslipidemia in China"[6],"Comprehensive Prevention and Treatment Guidelines for Cardiovascular Diseases in Community Population(Trial)",and "Comprehensive Management Practice Guidelines for Cardiovascular Diseases at Primary Level " provide technical support for basic public health service standards.③The expert consensus on comprehensive prevention and control of cardiovascular diseases has gradually been reached.④ There is a relatively mature primary human resource team for hypertension and diabetes management services,and the service capacity has been improved[9,10].From the perspective of incentive:①The NBPHS is gradually improving[11].The construction of primary institutions has steadily increased,the human resource has continued to grow,and remarkable achievements have been made in disease control.The construction of monitoring systems and information technology has yielded fruitful results,and the equalization of basic public health services has been continuously promoted[12-14].②The "China NCDs Prevention and Control Work Plan(2017-2025)," "Healthy China"2030 Plan Outline,"and" Healthy China Action(2019-2030)"have laid a solid policy foundation with national plans and policies for NCDs prevention and control.③The implimentation of National Demonstrating Districts for comprehensive prevention and control of NCDs,and the national specific prevention and control project of "Early Screening of High-risk Cardiovascular Population" provide focus points for the implementation of comprehensive management of cardiovascular and cerebrovascular diseases at the primary level.From the perspective of pressure,①Relevant documents such as the "National Basic Public Health Service Project Performance Assessment Guidance Plan" and others have been successively introduced,and through the establishment of an assessment mechanism,equal emphasis on rewards and punishments,continuously improves NBPHS[15].②NBPHS is the largest population intervention practice for patients with diabetes and hypertension in China so far[16,17].The health management effect and overall service satisfaction of patients with hypertension and diabetes are closely related to standardized management.Residents’ sense of acquisition and satisfaction with BPHS are important indicators for evaluation[16,17].③The workload and repetitive labor pressure faced by primay medical staff,especially in the standardized management process of NCDs,can be avoided or reduced.From the perspective of practical case—the pilot project,through the implementation of two phases of the pilot project,comprehensive management and capacity building of risk factors for dyslipidemia and cardiovascular/cerebrovascular diseases have been carried out in 6 pilot cities and counties in the eastern,central,and western regions of China.This proves that implementing dyslipidemia management and "San Gao Gong Guan" measures at the primary level is feasible and effective.①Through education for the general population and follow-up management for key populations,the awareness rate of knowledge on the prevention and treatment of dyslipidemia has significantly improved.②After follow-up and management,healthy behaviors such as dietary control,active exercises,and medication adherence have gradually been developed among patients.③The management effect of blood lipid levels is gradually showing.④The comprehensive management capability of primary staff for cardiovascular and cerebrovascular diseases has significantly improved,and the quality of medical treatment has also been improved.From the perspective of affordability,①Through the cost-effectiveness analysis of dyslipidemia management in Qianjiang and Shenzhen,two pilot cities and counties of the pilot project,the results show that the added cost of combining the management of dyslipidemia patients and hypertension or/and diabetes patients is greatly reduced to 2030 yuan.②The Budget Impact Analysis estimates a target of 5 years,covering 2.5 million people in 5 years.The results show that a total of 60000 cardiovascular events caused by dyslipidemia can be prevented within 5 years,and 7500 deaths caused by cardiovascular diseases can be prevented.It costs 159 million yuan to manage 2.5 million dyslipidemia patients in Qianjiang in five years,and 500 million yuan or 89 million yuan to manage 250 patients with dyslipidemia alone or with hypertension and diabetes in Shenzhen in five years.At the same time,it can save up to 1.276 billion yuan in medical and work-related expenses for cardiovascular events caused by dyslipidemia.The results showed that the input-output ratio of diabetes/hypertension patients with combined management of dyslipidemia could reach 1.16.③The cost of dyslipidemia management increased among patients with hypertension and diabetes combined with dyslipidemia who have been included in BPHS was calculated.The results showed that after dyslipidemia management in patients with three types of comorbidities,the per capita investment cost of the entire population increased by RMB1.56 Yuan,0.58 Yuan,and 0.50 Yuan,respectively,which is cost-effective.Conclusion and suggestions:1.Multi-party collaboration.Based on the coordination mechanism formed under the guidance of national policies such as the Basic Public Health Services,General Practitioner Contract Service System,Graded Diagnosis and Treatment System,the National Demonstrating Districts for Comprehensive Prevention and Control of NCDs,and so on.Government-led,multi sectoral coordination,up and down linkage,social participation,and comprehensive prevention and control of Cardio/cerebral Vascular disease are the key points to explore a multi-coordinated management model.2.Multi measures implimentation.Multiple intervention strategies such as health education for the general population,training for medical personnel,and management of key populations will be implemented together.3."San Gao Gong Guan".Comprehensive management of Cardio/cerebral Vascular disease risk factors shall be carried out for key populations.4.Develop primary management standards.Formulate management specifications for Dyslipidemia(Hypercholesterolemia)at the primary level,as well as comprehensive management specifications for Hypertension,Diabetes and Dyslipidemia.