In 2000, all of the provinces/territories received funding through the Primary Health Care Transition Fund (PHCTF) to support implementation of primary health care initiatives, including chronic disease management and prevention (Health Canada, 2007). However, British Columbia (BC) and Alberta had already begun to create useful programs, models and toolkits to address these issues prior to this funding (Health Canada, 2007). The Ministry of Health collaborated with the British Columbia Medical Association to develop frameworks for chronic disease management (Health Canada, 2007). BC used the money received from the PHCTF to make improvements in care for people with diabetes and congestive heart failure, specifically (Health Canada, 2007). An evaluation of the initiatives for these chronic illnesses showed that quality of care increased, mortality decreased, and hospitalizations decreased (Health Canada, 2007). One of the ways in which BC showed leadership is through the development of the “Expanded Chronic Care Model”, which is illustrated in Figure 1 (Health Canada, 2007). Other regions have adopted this model (Health Canada, 2007).
Figure 1. Expanded Chronic Care Model (Health Canada, 2007).
The other major advancement that BC was responsible for is the creation of the Chronic Disease Management Toolkit, an information technology infrastructure that has been used across Canada (Health Canada, 2007). In general, the progress of chronic disease management strategies for other provinces/territories were ameliorated if BC or Alberta were involved in the planning (Health Canada, 2007).
Healthy Families BC (HFBC) provides resources and programs that target chronic disease management (Healthy Families BC, 2012). The pillars of the province’s health promotion strategy are health eating, healthy lifestyles, resources for parents, and fostering healthy communities (Healthy Families BC, 2012). The mission of HFBC is to improve British Columbians quality of life by guiding them to make healthier choices (Healthy Families BC, 2012). The HFBC programs help parents ensure their children are raised in a healthy home (Healthy Families BC, 2012). HFBC provides information about breastfeeding, facts needed to make informed choices when dining out, strategies for coping with challenging behaviours, and tips on starting conversations about healthy decisions (Healthy Families BC, 2012). For example, the Alcohol Sense program is useful for teaching parents/adult role models how to encourage their children to make wise choices regarding alcohol (Healthy Families BC, 2012). The Sodium Sense program is a good example of educating people to make better eating choices by recognizing the amount of sodium they consume daily and identifying which foods are higher or lower in sodium (Healthy Families BC, 2012).
Areas for future improvement in BC’s chronic disease management strategies largely revolve around using technology to help organize information and remind initiation of follow-up. Some examples of information technology goals include (Health Canada, 2007):
1) Use computerized prompts to provide patients with laboratory results.
2) List patients in a physician’s practice by diagnosis or health risk.
3) Create reminders when a patient is due or overdue for a test or preventative treatment.
4) Track all medications taken by patient including prescriptions from other doctors.
The Ministry of Health’s (2013) action plan to optimize health outcomes is illustrated in Figure 2.
Figure 2. Imperative Actions (Ministry of Health, 2013)
Kothari et al. (2013) examined documents from government and non-governmental organizations that implemented policies and programs in British Columbia and Ontario. The provinces' program implementation differed based on delivery structures as well as philosophical approaches (Kothari et al., 2013). Both provinces were similar in expectations in terms of adoption of healthy behaviours, use of information, healthy environments, and increased public awareness to prevent chronic disease (Kothari et al., 2013).
The Ministry of Health stresses the importance of self-management programs in addition to primary and community-based health care and support services (Ministry of Health, 2013). The framework proposed by them is shown in Figure 3 (Ministry of Health, 2013).
Figure 3. Visionary Goals (Ministry of Health, 2013)
Chronic Disease Surveillance
In British Columbia, the BC Centre for Disease Control is responsible for programs that collect, analyze, and share data about health status and chronic diseases among BC residents (BC Centre for Disease Control, 2021b). The Population & Public Health (PPH) Program also focuses on protective and risk factors among British Columbians in relation to chronic diseases and health outcomes (BC Centre for Disease Control, 2021b). Social determinants of health are a key area of interest for the PPH surveillance team including demographic factors and socio-economic status (BC Centre for Disease Control, 2021b). This surveillance program uses health equity indicators to measure the performance of health systems (BC Centre for Disease Control, 2021b). PPH plays a leadership role alongside the Ministry of Health to support Healthy Families BC (HFBC) action plans (BC Centre for Disease Control, 2021b). HFBC views health promotion, such as food security initiatives, to be integral to chronic disease prevention (BC Centre for Disease Control, 2021b). Healthy Communities and Healthy Schools were two provincial HFBC initiatives that have been a priority for chronic disease surveillance (BC Centre for Disease Control, 2021b).
The Chronic Disease Dashboard on the BC Centre for Disease Control website is an interactive tool that provides summary statistics on various conditions in BC between 2000-2018 (BC Centre for Disease Control, 2021a). The data can be viewed in a bar chart, line graph, data table, or on a map of the province. The geographic map is especially interesting since you can choose a condition and see which areas have highest incidence or prevalence. You can zoom in to a specific region, then hover over the desired area to reveal the crude incidence or prevalence (95% confidence intervals) per 1,000 population at risk, health authority, health service delivery area, and reporting year. Selections can be made between many diseases to see the visual depiction of its distribution in the province. The age sex chart tab gives insight into how certain diseases have vulnerable groups that are more impacted. The changes over time tab shows trends, filtered by sex, age group or region. The top 10 leading conditions in all of BC in 2017/2018 based on incidence were (BC Centre for Disease Control, 2021a).
1) Mood and anxiety disorders 2) Hypertension 3) Diabetes 4) Osteoarthirits 5) Ischemic heart disease 6) Chronic obstructive pulmonary disease 7) Osteoporosis 8) Asthma 9) Alzheimer’s Disease and other dementia 10) Chronic kidney disease
Tracking for some of these chronic diseases are shown in Figure 4.
Figure 4. Chronic disease incidence rates for Vancouver Coastal Health Authority (Provincial Health Services Authority, 2021)
Funding
The development of initiatives and allocation of funding support for chronic disease prevention by primary health care practitioners are the responsibility of the Ministry of Health Services and the General Practice Services Committee (BC Ministry of Healthy Living and Sport, 2010). This committee involves the collaboration of the Ministry of Health Services, the BC Medical Association and the Society of General Practitioners of BC (BC Ministry of Healthy Living and Sport, 2010). The Ministry of Health ensures that regional health authorities receive adequate funding (BC Ministry of Healthy Living and Sport, 2010). The BC Government/BC Medical Association (BCMA) Agreement addresses funding for information technology investments, Practice Support Program Teams, and “physician champions” to work with local family physicians and health authorities (BC Ministry of Healthy Living and Sport, 2010). The General Practice Service Committee includes BCMA, Ministry of Health Services and Society of General Practitioners of BC (BC Ministry of Healthy Living and Sport, 2010). This committee has allocated additional funding for prevention of cardiovascular disease and improvements in complex care for patients with two or more chronic illnesses (BC Ministry of Healthy Living and Sport, 2010). Also, General Practice Service Committee created financial incentives for the management of patients with congestive heart failure, diabetes and hypertension (BC Ministry of Healthy Living and Sport, 2010). The large amount of federal funding came from the Primary Health Care Transition Fund (Health Canada, 2007). This allowed for improvements in chronic disease surveillance, management, and prevention (Health Canada, 2007). Physicians in BC have received financial incentive to target people aged 50-70 to help with chronic disease prevention, with the funds aiming to support change management (Health Canada, 2007).
Primary Determinants of Chronic Disease
The top two preventable contributing causes of death in BC are first smoking and then obesity (Ministry of Health, 2013). Tobacco use kills more than 6000 British Columbians yearly and costs the BC economy ~ $2.3 billion (Ministry of Health, 2013). Obesity costs the BC economy ~ $730-830 million (Ministry of Health, 2013). Illnesses related to obesity have been found to result in the premature death of ~2000 British Columbians each year (Ministry of Health, 2013). Smoking tobacco and overeating or eating unhealthy foods are linked to many health determinants such as coping skills, social supports, healthy behaviours. People from lower income neighbourhoods are more likely to develop chronic disease (Ministry of Health, 2013). Race, ethnicity and aboriginal self-determination play a role as well. First Nations populations in BC are disproportionately impacted by diabetes, with diabetes rates 40% higher than that of the general population (Ministry of Health, 2013). Improving social determinants of chronic disease is a key component of BC's prevention strategy.
BC Centre for Disease Control (2021a). Chronic disease dashboard. Retrie ved from http://www.bccdc.ca/health-professionals/data-reports/chronic-disease-dashboard BC Centre for Disease Control (2021b) Population & public health surveillance. Retrieved from http://www.bccdc.ca/our-services/programs/population-public-health-surveillance BC Ministry of Health Living and Sport (2010). Model core program paper: Chronic disease. CORE public health functions of BC. Retrieved from https://www2.gov.bc.ca/assets/gov/ health/about-bc-s-health-care-system/public-health/healthy-living-and-healthy- communities/chronic_disease-model_core_program_paper.pdf Health Canada (2007, March). Primary health care transition fund.: Chronic disease prevention and management. Synthesis series on sharing insights. Retrieved from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/hcs-sss/alt_formats/hpb- dgps/pdf/prim/2006-chronic-chroniques-eng.pdf Healthy Families BC (2012). Welcome to Healthy Families BC! Retrieved from https://www.healthyfamiliesbc.ca/home/about-us Kothari, A., Gore, D., MacDonald, M., Bursey, G., Allan, D., Scarr, J. (2013). Chronic disease prevention policy in British Columbia and Ontario in light of public health renewal: A comparative policy analysis. BMC Public Health, 13, 934-948. Retrieved from http://www.biomedcentral.com/1471-2458/13/934 Ministry of Health (2013, March). Promote, protect, prevent: Our health begins here. BC’s guiding framework for public health. Retrieved from https://www.health.gov.bc.ca/library/publications/year/2013/BC-guiding-framework-for- public-health.pdf Provincial Health Services Authority (2021). Health status and chronic disease. BC community health data. Retrieved from http://communityhealth.phsa.ca/HealthProfiles/
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