Healthy Hearts, Healthy Aging

Healthy Hearts, Healthy Aging Thailand Report calls for better adoption of health innovation in reducing the cardiovascular disease burden in Thailand

Bayer Thai Co., Ltd. recently held a stakeholder dialogue to examine the cardiovascular (CV) health imperatives associated with population aging in Thailand, and foster multi-stakeholder collaboration in embracing innovative therapies and technologies for long-term prevention of stroke, heart attacks and other serious cardiovascular events in seniors living with cardiovascular diseases (CVD).

At the dialogue with welcome remarks from Mr. Riaz Buksh, General Manager of Pharmaceuticals Division, Bayer Thai Co., Ltd., attended by local cardiologists across Thailand, experts discussed insights and recommendations from the newly-published Thailand edition of the Heathy Hearts Healthy Aging APAC Report, developed in partnership between Bayer and NUS Enterprise, the entrepreneurial arm of the National University of Singapore (NUS). The Thai edition of the Healthy Hearts, Healthy Aging Asia Pacific Report, collates curated insights from local cardiovascular health experts; Dr. Wacin Buddhari, Director of the Cardiac Catheterization Laboratory, Cardiac Center, King Chulalongkorn Memorial Hospital and Professor Rungroj Krittayaphong, Professor of Medicine of the Division of Cardiology, Department of Medicine, Siriraj Hospital, Mahidol University of Siriraj Hospital.

The report examines the rising burden of CVD in light of the rapidly aging population in Thailand, highlights the importance of health innovations, and sets out recommendations on how Thailand can achieve better prevention, treatment and care outcomes for CVD patients.

Aging trends in Thailand

In 2001, Thailand became an aging society with over 7% of its population aged 65 and above[1]. In 2019, its senior population is estimated to be about 11% of its population, and is expected to reach more than 35% of its population in 2050, when Thailand will become a super-aged society[1,2].

An aging population implies an increased susceptibility to chronic diseases and their related disability and dependency, and a consequential increase in healthcare demand[3]. Non-communicable diseases (NCDs) such as heart disease, cancer, diabetes, high blood pressure and obesity will be major health threats for seniors and represent a significant burden on national health system.

The Burden of Cardiovascular Diseases in Thailand

Non-communicable diseases (NCDs), or chronic diseases, account for over 70% of total deaths in Thailand[4]. Over 50% of the elderly population in Thailand suffer at least one chronic disease[5].Cardiovascular disease (CVD) is a primary focus as it was the leading cause of death in 2016, accounting for 23% of the total mortality[6].

Cardiovascular diseases represent a variety of disorders of the heart and blood vessels, such as atrial fibrillation (AF), and stroke. Atrial Fibrillation (AF), a heart condition characterized by irregular heart rhythms, increases the risk of stroke caused by blood clots by five-fold. Strokes due to AF are more severe, causing disability in over 50% of patients and generally worse outcomes than strokes due to other causes.

The 20-year National Strategic Plan for Public Health highlights cerebrovascular diseases including strokes, and ischemic heart diseases, also known as coronary heart diseases (CHD), as two of the top five health threats and top five causes of deaths among chronic diseases in Thailand[7]. Death rates of CHD and stroke rose by 24% and 19.7% respectively from 2007 to 2017 in Thailand[8].

While deaths from these serious CV events are unfortunate, their related burden of disability is significant. Over the period 2007 to 2017, it was reported that both CHD and stroke are among the top ten contributors of Disability-Adjusted Life Years (DALYs)[8].

According to the National Statistical Office in Thailand, the number of inpatient visits from serious cardiac events such as heart attacks was over 84,000 in 2017, an increase of about 25% from about 67,000 in 2013. Stroke, on the other hand, accounted for over 26,000 inpatient visits in 2017, up by more than 50% from about 17,000 in 2013[9].

These statistics show that living with CVD can be challenging for seniors, their families and caregivers, and this burden increases exponentially with the occurrence of a serious CV event, which is often linked to severe disabilities, frequent hospitalizations and intensive long-term care.

“With the population aging trends in Thailand, the rates of atherosclerosis-related conditions like stroke will continue to rise. Besides rising mortality rates, one has to look at the burden relating to post-stroke care. Currently, we don’t have ample public health facilities to take care of post-stroke patients with disabilities. If a patient suffers a stroke, the burden of care will be on the family. Most of the time, a family member will need to stay at home to take care of the elderly patient,” said Dr. Wacin.

Recommendations on the Adoption of Health Innovation

The panel discussion echoed the findings of the Healthy Hearts Heathy Aging Thailand report, in that the rising rates of aging-related diseases such as CVD, giving rise to unmet medical needs, can potentially be tackled with innovative treatments and technologies, as well as with more education and awareness for both healthcare practitioners and patients.

The Healthy Hearts Healthy Aging Thailand report highlighted some key areas in address rising CVD rates, such as:

1. More Research Data Needed to Support Access to Innovative Therapies

There remain barriers in terms of patient access to the latest guideline-directed treatments for Thai CVD patients, which is a contributing factor to poor control and management of CV risk factors.

“For lipid and blood pressure reducing drugs, most doctors know that they need to use them as indicated by clinical practice guidelines. However, as some of the guideline-directed medications are not covered by certain national health insurance schemes or listed in the National Essential Drug List (NED), these treatments are not prescribed to a large proportion of patients, and such patients end up with no access to many of the latest guideline-directed treatments,” said Dr. Wacin.

Professor Rungroj said, “I run the national registry for atrial fibrillation, which includes more than 3,000 patients. It was reported that 70% of these patients use anticoagulants for stroke prevention, but only 9% of them are prescribed with the newer oral anticoagulant therapies recommended by treatment guidelines.”

“While NOACs are indeed easier to administer and more suitable for high-risk patients with other comorbidities, more local cost-effectiveness data is needed to overcome the barrier for such treatments to gain access into the national reimbursement systems like Universal Coverage Scheme, which covers the majority of the Thai population.”

Most recently, a new combined regimen of a non-vitamin K antagonist oral anticoagulant (NOAC) and an antiplatelet therapy has shown better effectiveness in the prevention of major CV events such as strokes and heart attacks in coronary artery diseases (CAD) and peripheral artery diseases (PAD)[10].

“In my own practice, I have been using more aggressive preventive therapies over the last 20 years. What I observed is that patients on these therapies have a more stable condition, and they are coming back with fewer serious cardiovascular events as compared to years ago, before these aggressive preventive treatments were available. We need more research and studies to be conducted in Thailand to support these observations about the efficacy and potential cost-benefit analysis of these therapies,” said Dr. Wacin.

2. Enabling Access to Patients with High Unmet Needs

According to Dr. Wacin, most doctors start looking for new innovations when there are unmet needs, which existing treatments are unable to address. “There are some patients whose diseases are still progressing — or who are at risk of more serious CV conditions— as well as those whose doctors cannot prevent their condition from worsening and gaps in achieving optimal management of the disease with current treatments. These are the situations in which doctors look for new innovation or treatments, or anything that can improve patient outcomes,”

A possible solution is to enable access of such therapies for specific patient populations with high unmet medical needs, instead of widespread implementation of reimbursement. This would be a good first step to overcoming this access barrier for patients, and encourage doctors to prescribe such therapies to their patients, especially when current therapies have proven to be sub-optimal.

Another way to help patients access new therapies would be to implement a patient co-pay system. With a rapidly aging population and rising CVD rates, healthcare spending and costs will inevitably rise. An alternative financing model for new innovation, such as a co-pay system, would help balance the financial burden on the UHC system while increasing patient access to these therapies. This way, people who are able and willing can share the cost of innovative treatments and get access to better health outcomes.

3. More Education and Awareness of New Preventive Health Innovation to Encourage Uptake

According to Dr. Wacin, even where physicians are aware of new treatment guidelines, they may not be convinced about the results of a trial even if it is in the guidelines. In particular, preventive treatments see even more challenges to adoption as it is hard to assess if patients are optimally protected from the risks of more serious cardiac events, as the results of such treatments do not make themselves immediately apparent.

Doctors must be educated about the cost-benefit and efficacy of new innovative therapies. Equally important is public education about the availability of new health innovations that, when used with the right patients, can reap better health outcomes, including increasing life expectancy, decreases doctor visits, less hospitalizations and less risk of a serious CVD event. Thus, heavy public and physician education are important areas to work on.

4. Patient Education on Adherence for Better Outcomes

In terms of patient education, improvement in patient adherence to treatments is one important aspect of achieving better outcomes for CVD patients. Evidence is mounting which shows that when patients discontinue taking their medication, this leads to higher costs of care and adverse health outcomes.

This is especially crucial for preventive therapies, as they lose their efficacy if medication is stopped. Non-adherence to cardiovascular medications has been associated with increased risk of morbidity and mortality.

“Currently, the government, NGOs and many medical societies such as the Cardiac Society, are working together to raise awareness and promote a healthier lifestyle to prevent people from developing CVDs or having secondary events. More can be done to increase awareness among doctors and patients on medication adherence. We hope to see the positive impact of awareness and education efforts translate into a reduction in CVD rates in future,” said Professor Rungroj.

5. Public-Private Collaboration Can Improve Access to Innovation

Public-private collaboration has been shown to improve access to healthcare[11]. On one hand, public-private partnerships among academia, start-ups, entrepreneurs and industry are the drivers of both traditional research and open innovation, and they are also key players in the development of novel medications and ground-breaking technologies. On the other hand, the region’s governments and healthcare systems also play a crucial role in pushing CVD prevention higher up on their agendas, and in developing policies that can keep pace with innovation, enabling speedier approvals of new therapies and technologies and ensuring timely access and adoption of these innovations by patients.

The new Public Private Partnership (PPP) Strategic Plan presents new opportunities for such collaboration. Published by the Thai government in December 2017, the plan sets out sectors in which infrastructure projects can be developed as PPPs, and also delineates projects in the PPP pipeline.

Under the 2nd PPP Strategic Plan & Project Pipeline (2017-2021), the development of public health infrastructure, and pharmaceutical and medical equipment facilities are subsectors in which the government encourages participation and investments from the private sector[12].

“With multisectoral collaboration between stakeholders and a shared focus on access to healthcare outcomes, we can foster an ideal ecosystem for health innovations to thrive and evolve to serve a rapidly aging patient population in Thailand,” said Dr. Paneeya Sutabutra, Country Medical Director of Bayer Thai Co., Ltd. “We hope this report will serve as a call to action, and will stimulate nation-wide dialogues and collaborations that will support health systems in preventive long-term care of CVDs. Bayer is fully committed to developing innovative solutions for CVD patients and their caregivers to improve their quality of life, but we can only support health system sustainability and patient access to therapies by collaborating with various stakeholders across different disciplines and communities.”

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1. HelpAge International, “Ageing Population in Thailand”, 2019. Accessible at: http://ageingasia.org/ageing-population-thailand/#keyfacts

2. Department of Health, Ministry of Public Health Thailand. “Policies on Health of Older Adults in Thailand Presentation”, 2019. Accessible at: https://www.duke-nus.edu.sg/docs/librariesprovider3/education-docs/1)-policies-on-the-health-of-older-adults-(thailand)-by-dr-kitti-larpsombatsiri.pdf?sfvrsn=e28d57e9_4

3. ISEAS Yusof Ishak Institute, “Managing Thailand’s Ageing Population”. Accessible at: https://think-asia.org/bitstream/handle/11540/9989/ISEAS_Perspective_2019_32.pdf?sequence=1http://hdl.handle.net/11540/9989

4. World Health Organisation, Accessible at: https://www.who.int/ncds/un-task-force/press-release-30-august-2018/en/

5. P. Ethisan, R. Somrongthong, J. Ahmed, et al., “Factors Related to Physical Activity Among the Elderly Population in Rural Thailand,” Journal of Primary Care & Community Health, 31 October 2016. Accessible at: https://journals.sagepub.com/doi/full/10.1177/2150131916675899 (Last accessed: 27 October 2019).

6. World Health Organisation “Noncommunicable Diseases (NCD) Country Profiles: Thailand”, 2018.

7. Ministry of Public Health, “Twenty-Year National Strategic Plan for Public Health: 2017-2036", 2018. Accessible at: http://164.115.27.97/digital/files/original/2ddc0ac1ececa4c666af70165c23e011.pdf

8. The Institute for Health Metrics and Evaluation (IHME), “Thailand”, 2017. Accessible at: http://www.healthdata.org/thailand

9. National Statistical Office, “Health Statistics - Number of In-patients (UC and CSMBS) According to 298 Causes of Diseases, All Diagnosis Per 100,000 Population by Sex: 2013 - 2017”, 2017. Accessible at: http://statbbi.nso.go.th/staticreport/page/sector/en/05.aspxhttp://statbbi.nso.go.th/staticreport/page/sector/en/01.aspx

10. Eikelboom, J.W., Connolly S.J., Bosch J., et al., N Engl J Med 2017; 377:1319-1330. Accessible at: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.119.039609 (Last accessed: 27 October 2019).

11. Brink News, “Public + Private = Better Health Care in Southeast Asia”, 13 October 2017. Accessible at: https://www.brinknews.com/public-private-better-health-care-in-southeast-asia/?utm_source=BRINK+Asia (Last accessed: 27 October 2019)

12. PriceWaterhouseCoopers, “Infrastructure Developments and Public Private Partnerships in Thailand: A 2018 Update”, 2018. Accessible at: https://www.pwc.com/th/en/deals/assets/public-private-partnerships-in-thailand-2018.pdf (Last accessed: 27 October 2019).