Prevention – turning hindsight into foresight

Prevention is often overlooked and undervalued.

Looking back, we can see the value of prevention in avoiding adverse events like strokes and heart attacks or averting major health crises like the coronavirus (COVID-19).

The New South Wales Chief Medical Officer recently remarked  “hindsight is a great thing,” referring to the Ruby Princess cruise ship and its 2,700 passengers who disembarked in Sydney, many with COVID-19 symptoms.

COVID-19 has brought prevention squarely back into the spotlight. Public education campaigns focus on the importance of hand hygiene, social distancing and staying at home to prevent the spread of infection. In addition, pro-active testing for COVID-19 promotes early detection and intervention, especially in geographical hotspots. We are seeing governments investing decisively in prevention measures to “flatten the curve,” which we know will pay dividends down the track.

Chronic disease and prevention

The COVID-19 pandemic is undoubtedly the most significant health and economic challenge this country has faced in a century. Investment in prevention, early detection and intervention is vital to our response and our ability to recover from this crisis. These steps apply equally, if not so dramatically, to non-communicable diseases like diabetes, stroke, cancer, kidney and heart disease.

Chronic disease has the potential to steadily devastate our health system and communities into the future. Today, one in two Australians have a chronic disease like stroke, heart disease, cancer, diabetes or chronic kidney disease, and many more are carers or family members of those living with chronic disease. Evidence shows these numbers are increasing.

Yet funding for prevention and early detection of chronic disease is minimal. Less than 1.5 percent of the national health budget is currently spent on prevention and Australia ranks a lowly 16th among OECD countries for expenditure per capita on prevention and other public health measures. Meanwhile, treatment and management of chronic conditions accounts for almost one-third of Australia’s national health spending.

As recognised in managing COVID-19, investment in prevention generates dividends both now and in the future. Evidence shows for every dollar invested in selected public health interventions in high income countries, there was a $14 return on that investment. Greater funding for chronic disease prevention would reap long-term benefits with a healthier population, reduced hospitalisations and lives saved.

We know that almost 40 percent of chronic disease burden could be prevented by reducing modifiable risk factors like overweight and obesity, high blood pressure, unhealthy diet, alcohol consumption, smoking and physical inactivity. However, our health system is geared towards treating chronic disease rather than preventing it. Primary care visits are largely responsive in nature and driven by the Medicare Benefits Schedule. Public hospitals are struggling under the weight of ever-increasing emergency presentations, many of which could be avoided by more proactive prevention programs in the community.

Shifting hindsight to foresight

While chronic diseases are the leading cause of premature death in Australia, many of us underestimate our own risk.

Nearly 90 percent of Australians rate their health as excellent, very good or good. But the risk factors tell a different story. Almost two in three Australian adults and around one-quarter of our children are overweight or obese. Unhealthy foods contribute more than one-third of our daily energy intake. Nine out of 10 people don’t eat enough fruit or vegetables, and around one in three adults have high blood pressure. Despite these frightening red flags, many in the community are unaware of their risk or are untreated.

There is a disconnect between our perceptions of good health and the reality seen in hospitals across Australia. Like an iceberg, our risk factors are building up under the surface and a health scare is often the first sign that something is seriously wrong.

Reducing risk factors could dramatically lower disease burden. For example, if all Australians were a healthy weight, we could reduce burden from diabetes by 53 percent, chronic kidney disease by 38 percent, stroke by 22 percent, coronary heart disease by 25 percent and up to 38 percent for certain cancers.

Support for risk assessment and early detection

A national approach to risk assessment and early detection has enormous potential to help people understand and manage their risk, and to detect existing disease.

The Government-funded national breast, bowel and cervical cancer screening programs are excellent examples. Cervical cancer is almost eradicated in Australia, and we know that early detection of breast and bowel cancers can improve treatment outcomes.

Despite the proven success of these world-class screening programs, we are lagging behind in risk assessment and early detection of vascular diseases including heart disease, stroke, chronic kidney disease and diabetes. Vascular diseases share common risk factors and interact to increase risk. Without early detection and management, these diseases often lead to severe end-stage disease, critical emergency events and significant economic and community burden.

Cardiovascular disease accounted for more than one in four deaths in 2017 and 1.1 million hospitalisations in 2016-17. Chronic kidney disease and type 2 diabetes are increasing fast, yet many people are living with undiagnosed disease. Around 1.5 million Australians may have undiagnosed kidney disease and up to 500,000 Australians could have silent undiagnosed type 2 diabetes. A late diagnosis can result in serious complications and require intense treatment.

Integrated health checks

Integrated health checks in general practice can help people understand and manage their risk through referrals to behaviour change programs and prescription of medication, if required. Early management can halt or even reverse disease progression, and limit potentially preventable hospitalisations.

An integrated health check includes absolute vascular disease risk assessment plus blood and urine tests for detection of type 2 diabetes and chronic kidney disease. The absolute cardiovascular disease risk calculator helps health professionals to consider existing disease and assess the likelihood of a vascular disease event in the next five years.

Although clinical practice guidelines recommend regular risk assessment at various ages, there is no nationally consistent approach and health checks are not routinely conducted in primary care.

The upcoming National Preventive Health Strategy and Primary Health Care 10-Year Plan provide an excellent opportunity to prioritise integrated health checks to support risk assessment, early detection and intervention.

We know that preventing and managing disease has social, financial and economic benefits, and there is good evidence that regular health checks can keep people well in the community.

The World Health Organization recommends cardiovascular disease risk assessment and management as a ‘Best Buy’, meaning it is a cost-effective and feasible approach to reduce vascular disease. In Australia, the ACE-Prevention study recommended screening and treatment for kidney disease as one of the most cost-effective, and even cost-saving, preventive measures in Australia.

In the current COVID-19 climate, chronic disease prevention and detection cannot be overlooked. Risk factors like unhealthy diet, alcohol consumption and physical inactivity may be increasing as people stay at home, and we have seen reports of a drop off in GP consultations and pathology testing that could further delay early detection of disease. There are concerns about the effects of COVID-19 on those living with chronic disease, as well as its long-term effects on survivors.

The Government’s decisive response to COVID-19 has highlighted prevention and early detection as a necessary investment in health, and we will continue to advocate for proven measures in the fight to prevent, detect and manage chronic disease in the future.

As William Blake wrote, “Hindsight is a wonderful thing but foresight is better, especially when it comes to saving life or some pain!”

The Australian Chronic Disease Prevention Alliance (ACDPA) brings together Council Australia; Diabetes Australia; National Heart Foundation of Australia; Kidney Health Australia; and Stroke Foundation to collectively advocate for prevention, early detection, integrated risk assessment and effective management of chronic disease risk.