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11Totusi, calitatea serviciilor de asistentâ medicalâ primará monitorizatâ de diverse mecanisme, cum ar fi controalele interne, inspectiile si evaluârile, a fost consideratâ marginalâ în anul 2012 [2].
Concluzii
Política nationalâ de sânâtate pentru anii 20072021 si Strategia de dezvoltare a sistemului de sânâtate pentru anii2008-2017 au servit ca documente principale de orientare pentru initiativele de reformâ ulte-rioare în sistemul de sânâtate din Republica Moldova. Chiar dacâ au existat trei schimbâri de guvernare de atunci, sistemul de sânâtate, fiind un sistem dinamic, deschis, este în proces de autoreglare.
Domeniile principale de dezvoltare a asistentei medicale primare continuâ sâ fie axate pe asigurarea accesului universal a întregii populatii la servicii de calitate si gestionarea efectivâ a resurselor.
Bibliografie
1. Declaration of Alma Ata. international conference on primary health care, Alma-Ata, USSR, 6-12 September 1978. Geneva, WHO, 1978. http://www.un.org/ ru/documents/decl_conv/declarations/almaata78.
shtml
2. Evaluation of the structure and provision of primary care în the Republic of Moldova. A survey-based project, Republic of Moldova Health Policy Paper Series No. 5.
3. http://www.euro.who.int/en/countries/republic-of-moldova/publications
4. Evaluation of Moldova's 2004 health financing reform. Health Financing Policy Paper 2008/3.
5. Turcanu G., Domente S., Buga M., Richardson E. Republic of Moldova:health system review. in: Health Systems în Transition, 2012, nr. 14(7), p. 1-151.
6. Atun R., Richardson E., Shishkin S., Kacevicius G, Cio-canu M., Sava V. and Ancker S. Moldova:Health system review. in: Health Systems în Transition, 2008; nr. 10(5), p. 1-138.
7. Bariere §i factori ce faciliteazá accesul la serviciile de sânâtate în Republica Moldova. Copenhaga: Biroul Regional pentru Europa al OMS, 2012.
8. Ambulatory care sensitive conditions în the Republic of Moldova. January 2015, 42 p.
Natalia Zarbailov, conf. univ., Catedra Medicinâ de Familie, IP USMF Nicolae Testemitanu, tel: 069481481,
e-mail: natalia.zarbailov@usmf.md
CZU: 616.1:614.253(478)
STATUS OF CARDIOVASCULAR POPULATION HEALTH IN THE REPUBLIC OF MOLDOVA
Elena RAEVSCHI1, Ion ABABW, Laurence SPERLING2, Eleonora VATAMAN3,
'Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, 2The Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, USA, 'Institute of Cardiology of the Republic of Moldova
Summary
Reducing burden of cardiovascular diseases and other non-communicable diseases (NCD) is an overriding global priority. World Health Organization (WHO) established a set of actions in base of six objectives in order to strengthen international cooperation, national capacity to respond, multisectoral action to reduce risk factors, identified through people-centered primary care, and strengthening progress monitoring in attaining the NCD targets. The purpose of the study was to estimate the prevalence of cardiovascular health in population-centered primary health in order to highlight the need to strengthen cardiovascular diseases control and prevention in the Republic of Moldova. The assessment ofcardiovascular health was performed in base of cross-sectional study sample (n=2,612) using American Heart Association (AHA) methodology. The result of the study identified the distribution of cardiovascular health levels as follows: ideal in 0.6% (95% CI 0.3-0.9%), intermediate in 18.3% (95% CI 16.8-19.9%), and poor cardiovascular health in 81% (95% CI 79.4-82.6%) of cases. Uncommon presence of ideal cardiovascular health level (0.6%) underlines the needs to improve cardiovascular health among adults in the Republic of Moldova with emphasis on primary care, as first line population contact.
Keywords: cardiovascular health, primary health care, Republic of Moldova
Rezumat
Starea de sanatate a populatiei din Republica Moldova: aspect cardiovascular
Reducereapoverii bolilor cardiovasculare (BCV) §i a altor boli netransmisibile (BNT) este o prioritate imperativa globala. Organizatia Mondiala a Sanatatii a stabilit o serie de actiuni in baza a §ase obiective, pentru a fortifica cooperarea internationala, capacitatea nationala de a ras-punde, actiunea multisectoriala de reducere a factorilor de risc, identificati prin intermediul populatiei orientate spre asistenta medicalaprimara (AMP), §i consolidarea monito-rizarii progreselor in atingerea tintelor privind BNT. Scopul studiului a fost de a estima prevalenta sanatatii cardiovasculare in populatia centratape AMP, in vederea evidentierii necesitatii de fortificare a controlului §i preventiei bolilor
cardiovasculare în Republica Moldova. Evaluarea sänätätii cardiovasculare a fost efectuatä în baza studiului transversal selectiv (n=2,612), aplicând metodologia Asociatiei Americane a Inimii. Rezultatele cercetärii au identificat distributia sänätätii cardiovasculare pe nivele dupä cum urmeazä: ideal în 0.6% (95% II 0.3-0.9%), intermediar în 18.3% (95% II 16.8-19.9%) §i sänätate cardiovascularä precarä în 81% (95% II 79.4-82.6%) cazuri. Prezenta rarä a sänätätii cardiovasculare ideale (0.6%) evidentiazä nece-sitatea de a mbunätäti sänätatea cardiovascularä la adultii din Republica Moldova, cu accent pe asistenta medicalä primarä, ca un contact de primä linie cu populatia.
Cuvinte-cheie: sänätate cardiovascularä, asistentä medi-calä primarä, Republica Moldova
Резюме
Состояние сердечнососудистого здоровья населения в Республике Молдова
Снижение бремени сердечнососудистых заболеваний и других неинфекционных заболеваний (НИЗ) является основным глобальным приоритетом. Всемирная Организация Здравоохранения (ВОЗ) определила ряд действий в соответствии с шестью задачами в целях укрепления международного сотрудничества, национального потенциала на реагирование, многосекторальных действий по сокращению факторов риска, выявленных посредством населения ориентированного на первичную медицинскую помощь, и усиление мониторинга прогресса в достижении целей касательно НИЗ. Цель исследования состояла в том, чтобы оценить распространённость сердечнососудистого здоровья среди населения ориентированного на первичную медицинскую помощь, с тем чтобы подчеркнуть необходи-мостьукрепления контроля и профилактики сердечнососудистых заболеваний в Республике Молдова. Оценка сердечнососудистого здоровья была проведена на базе выборочного поперечного исследования (n=2,612) с использованием методологии Американской Кардиологической Ассоциации. Результаты исследования определили распределения уровней сердечнососудистого здоровья следующим образом: идеальный уровень в 0.6% (95% ДИ 0.3-0.9%), промежуточный в 18.3% (95% ДИ 16.8-19.9%), и плохое сердечнососудистое здоровье в 81% (95% ДИ 79.4-82.6%) случаев. Редкое наличие идеального уровня сердечнососудистого здоровья (0.6%) подчеркивает необходимость улучшения сердечнососудистого здоровья среди взрослых в Республике Молдова с акцентом на первичной медицинской помощи, в качестве первой линии контакта с населением.
Ключевые слова: сердечнососудистое здоровье, первичная медицинская помощь, Республика Молдова
Background
World health Organization (WHO) defined strengthen the health system at all levels, with emphasis on primary care as one of the ten actions required
to attain the global target 1 : a 25% relative reduction in overall premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025 (referred to as "25x25") [5, 6]. Republic of Moldova set National target 2020 a relative reduction of premature mortality from cardiovascular disease by 10%, cancer by 7%, and digestive diseases, diabetes and chronic respiratory disease together by 10% [7, 9, 10, 11]. Achieving the National target to reduce premature mortality from cardiovascular diseases and other non-communicable diseases (NCD) will require reducing behavioral risk factors and health conditions which determined them [7, 9, 10, 11].
The American Heart Association (AHA) has recently defined ideal cardiovascular health as absence of disease and presence of 7 key health factors. The spectrum of each individual health or behavioral factor is classified by 3 categories: poor, intermediate and ideal [4].
Objective
To evaluate the status of cardiovascular health among adults in the Republic of Moldova using AHA defined metrics, in order to justify the needs to strengthen the prevention and control of cardiovascular diseases and the underlying behavior risk factors and health conditions through people-centered primary health care in the Republic of Moldova.
Methods
A population transversal study design was performed. Multistage sampling methods were used to select 2,612 participants visiting physicians for primary care assistance. Respondents were aged 18+ years, comprising both sexes, as well as residents of all districts of the country.
There was used the formula of sample size to estimate confidence interval for one sample within dichotomous outcome in order to calculate the survey size. Cluster sampling procedure was carried out to select according to geographical criteria following by clusters previously selected convenience sampling (all physicians' visitors in the period of March - June 2015 willing to participate).
Validated questionnaire was used as tool of data collection comprising items related to demographic and social status, behaviors and health conditions.
Cardiovascular health of population was measured using cardiovascular health metrics according to methodology of American Heart Association [4]. The cardiovascular health factors of smoking, physical activity, healthy diet score, body mass index (BMI), blood pressure, total cholesterol, and blood glucose were measured.
Distribution of individual baseline cardiovascular health metrics was identified according the definition of ideal, intermediate and poor categories for each of 7 health metrics as follows [2]:
1. Smoking: ideal (never or quit >12 months), intermediate (former <12 months), and poor (current);
2. Physical activity: ideal (>150 min/week moderate), intermediate (6-149 min/week moderate), and poor (1-5 min/week moderate);
3. A healthy diet score: ideal (4-5 components), intermediate (2-3 components) and poor (0-1 components);
4. Body mass index: ideal (<25 kg/m2), intermediate (25-29.9 kg/m2), and poor (>30 kg/m2);
5. Blood pressure: ideal (<120/<80 mmHg), intermediate (SBP 120-139 or DBP 80-89 mmHg), and poor (SBP > 140 or DBP > 90 mmHg);
6. Total cholesterol: ideal (<190 mg/dl - 5.0 mmol/l), intermediate (200-239 mg/dl - 5.0-6.19 mmol/l), and poor (> 240 mg/dl - 6.2 mmol/l);
7. Fasting serum glucose: ideal (<100 mg/dl -6.1 mmol/l), intermediate (100-125 mg/dl - 6.1-6.9 mmol/l), and poor (>126 mg/dl - 7.0 mmol/l).
According to the complete definition of the cardiovascular health levels were defined on base of all 7 cardiovascular health metrics categories as follows [1, 2, 3]:
• Ideal Cardiovascular Health level: all 7 metrics at ideal categories;
• Intermediate Cardiovascular Health level: at least 1-7 health metrics at intermediate categories, but no poor categories;
• Poor Cardiovascular Health level: at least 1-7 health metrics at poor categories.
Results
Distribution of study population by age groups were identified in 11.4% (95% CI 10.2-12.6%) for ages 18 to 39 years, 60.1% (95% CI 58.2-61.9%) for ages 40 to 64 years, and 28.5% (95% CI 26.8-30.3%) for ages 65+ years old. Study participants had a mean age of 56,8±13,8 years. Distribution of respondents by gender was as follows: 34.8% (95% CI 33.0-36.7%) for male and 65.2% (95% CI 63.3-67.0%) for female. Distribution of respondents by area of residence was as follows: 44.1% (95% CI 42.2-46.0%) for urban area and 55.9% (95% CI 54.0-57.8%) for rural area.
The prevalence of smoking by categories was 21.5% (95% CI 19.9-23.0%) for poor, 4.9% (95% CI 4.1-5.8%) intermediate and 73.6% (95% CI 71.9-75.3%) ideal cardiovascular health. For physical activity an ideal level was found in 80.6% (95% CI 79.1-82.2%), intermediate 14% (95% CI 12.6-15.3%),
and poor 5.4% (95% CI 4.5-6.3%). A healthy diet score was poor for 20.5% (95% CI 19.0-22.1%), intermediate 35.5% (95% CI 33.7-37.4%), and ideal 43.9% (95% CI 42.0-45.8%). The prevalence of poor BMI was 33.5% (95% CI 31.7-35.3%), intermediate 37.6% (95% CI 35.7-39.5%) and ideal 28.8% (95% CI 27.1 -30.6%). Only 7.5% (95% CI 6.5-8.5%) achieved an ideal level of blood pressure, 40.1% (95% CI 38.2-42.0%) intermediate and 52.4% (95% CI 50.5-54.4%) poor. The prevalence for blood cholesterol and glucose of poor, intermediate and ideal level respectively was as follows: 18.9% (95% CI 17.3-20.4%), 42.7%, (95% CI 40.7-44.7%) 38.4 (95% CI 36.5-40.3%)% and 8.0% (95% CI 6.9-9.1%), 4.7% (95% CI 3.8-5.5%), 87.3% (95% CI 86.0-88.6%).
When assessing the complete definition of cardiovascular health (all 7 metrics), ideal was only present in 0.6% (95% CI 0.3-0.9%), intermediate 18.3% (95% CI 16.8-19.9%), and 81% (95% CI 79.482.6%) had poor cardiovascular health.
Discussions
World Health Organization determined to strengthen and orient health systems to address the prevention and control of non-communicable diseases (NCD) and underlying risk factors through people-centered primary health care and universal health coverage as one of the six objectives of Global NCD Action Plan [5]. Setting national targets on control and prevention of cardiovascular diseases and other NCD [7, 9, 10, 11], Republic of Moldova need to track progress in attaining them by establish a monitoring of risk factors focused on population-centered primary care and universal health coverage.
Conclusions
Ideal cardiovascular health in the Republic of Moldova is uncommon (0.6%). To improve cardiovascular health among adults in the Republic of Moldova population-based as well as individual approaches with emphasis on primary care, as first line population contact, are needed.
References
1. Benjamin E., et al. Heart Disease and Stoke Statistics - 2017 Update. A Report From the American Heart Association. In: Circulation, 2017 , nr. 135, p. 37.
2. Folsom A., et al. Community Prevalence of Ideal Cardiovascular Health, by the American Heart Association Definition, and Relationship With Cardiovascular Disease Incidence. In: Journal of the American College of Cardiology, 2011, nr. 57(16), p. 160-166.
3. Ford E., et al. Ideal Cardiovascular Health and Mortality from All Causes and Diseases of the Circulatory System Among Adults in the United States. In: Circulation, 2012, p. 987-995. DOI: 10.1161/ CIRCULATIQNAHA.111.049122
4. Lloyd-Jones D., et al. Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction. The American Heart Association's Strategic Impact Goal Through 2020 and Beyond. in: Circulation, 2010, p. 586-613. DOi: 10.1161/ CiRCULATiONAHA.109.192703
5. World Health Organization. Global action plan for the prevention and control of non-communicable diseases 2013-2020. Geneva, 2013. http://apps.who.int/iris/b itstream/10665/94384/1/9789241506236_eng.pdf (retrieved at 27.10.2016).
6. World Health Organization. Global status report on non-communicable diseases 2014. Geneva, 2014. http://www.who.int/nmh/publications/ncd-status-report-2014/en/ (retrieved at 20.10.2017).
7. Hotararea Parlamentului RM nr. 82 din 12 aprilie 2012. Strategia nationala de prevenire §i control al bolilor netransmisibilepeanii2012-2020. in: Monitorul Oficial al Republicii Moldova, nr. 126-129 din 22.06.2012, art. 412. http://lex.justice.md/index.php?action= view&view=doc&lang=1&id=343682 (retrieved at 27.10.2017).
8. Hotararea Guvernului RM nr. 1032 din 20 decembrie 2013. Startegia nationala de sanatate publica pentru anii 2014-2020. in: Monitorul Oficial al Republicii Moldova, nr. 304-310 din 27.12.2013, art. 1139. http:// lex.justice.md/index.php?action=view&view=doc&la ng=1&id=350833 (retrieved at 4.03.2018).
9. Hotararea Guvernului RM nr. 300 din 24 aprilie 2014. Programul national de prevenire §i con trol al bolilor car-diovascularepentru anii2014-2020. in: Monitorul Oficial al Republicii Moldova, nr. 104-109 din 6.05.2014, art. 327. http://lex.justice.md/index.php?action= view&view=doc&lang=1&id=352739 (retrieved at 27.10.2016).
10. Hotararea Guvernului RM nr. 300 din 24 aprilie 2014. Planul de actiuni pe anii 2014 -2020 privind imple-mentarea Programului national de prevenire §i control al bolilor cardiovasculare pentru anii 2014-2020. in: Monitorul Oficial al Republicii Moldova, nr. 104-109 din 6.05.2014, art. 327. http://lex.justice.md/index. php?action=view&view=doc&lang=1&id=352739 (retrieved at 27.10.2016).
11. Hotararea Guvernului RM nr. 403 din 6 aprilie 2016. Planul national de actiuni pentru anii 2016-2020 privind implementarea Strategiei nationale de prevenire §i control al bolilor netransmisibile pe anii 2012-2020. in: Monitorul Oficial al Republicii Moldova, nr. 100-105 din 15.04.2016, art. 464. http://lex.justice.md/index. php?action=view&view=doc&lang=1&id=364230 (retrieved at 27.10.2017).
Elena Raevschi, conf. univ., Catedra Medicinó Socialâ Management Sanitar„Nicolae Testemitanu", IP USMF Nicolae Testemitanu, tel. 069233157
e-mail: elena.raevschi@usmf.md
CZU: 616.1/.9-036.12:614.253.1
MULTIMORBIDITATEA: UN CONCEPT SPECIFIC MEDICINEI DE FAMILIE
Virginia ÇALARU1, Diana CHIOSA Maria MUNTEANU1, Angela ANISEP, Zinaida ALEXA4, Angela CIOBANU5, Tatiana ZATÎC6, Ghenadie CUROCICHIN12,
'Catedra Medicinä de Familie, IP USMF Nicolae Testemitanu, 2Laboratorul de Geneticä, IP USMF Nicolae Testemitanu, 3Agentia Nationala pentru Sänätate Publica, 4Catedra Endocrinologie, IP USMF Nicolae Testemitanu, 5Biroul OMS din República Moldova, 6Ministerul Sänätätii, Muncii §i Protectiei Sociale
Rezumat
Patologiile cronice netransmisibile sunt principala cauzä de morbiditate §i mortalitate la nivel global. Astfel, odatä cu îmbâtrânireapopulatiei §i creçterea expunerii la factorii de risc pentru bolile cronice, prevalenta fenomenului de multimorbiditate create, acesta fiind definit ca asocierea concomitentä a douä §i mai multe patologii cronice la acela§i individ. Datele de literaturä consemneazä cä pacientii cu multimorbiditate utilizeazä mai frecvent ser-viciile medicale, cauzeazä costuri de sänätate mai mari, dar rezultatele interventiilor terapeutice sunt mai joase. Astfel, multimorbiditatea ar putea fi consideratä o cauzä de ineficientä a asistentei medicale, de conduitä suboptimä a pacientilor cu boli cronice §i de bariere în comunicare. In ciuda prevalentei tot mai mari a multimorbiditätii, existä putine date cu privire la dimensiunile fenomenului, factorii determinanti ai acestuia §i impactul lor asupra practicii medicilor de familie din Republica Moldova. Astfel, scopul studiului afost de a determinafrecventapacientilor cu multimorbiditate în practica cotidianä a medicului de familie §i identificarea particularitätilor acestor pacienti.
Cuvinte-cheie: pacient, multimorbiditate, medicinä de familie
Summary
The multimorbidity: a concept specific to family medicine
Chronic non-transmissible pathologies are the main cause of morbidity and mortality globally. The ageing ofpopula-tions and increasing exposure to risk factors for chronic diseases, the prevalence of chronic disease multimorbidity is rising. The definition of multimorbidity is the concomitant association of two and more chronic pathologies in the same individual. The available data suggests that patients with multimorbidity are more likely to use medical services, cause higher health costs, but the results of therapeutic interventions are lower. The multimorbidity could be considered a cause of ineffectiveness of health care, suboptimal behavior of patients with chronic diseases and communication barriers. Despite the increasing prevalence of multimorbidity,
