2025 Volume 89 Issue 5 Pages 543-549
In Japan, cerebrovascular diseases and cardiovascular diseases (CVDs) are major causes of death and long-term care. Against this, the Cerebrovascular and Cardiovascular Disease Control Act was passed by a legislative body and promulgated in December 2018, and enacted on December 1, 2019. Based on the Japanese National Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular Disease (Japanese National Plan), prefectural plans have been formulated and published from March 2021 to January 2023. Although the majority of individual measures were comprehensively articulated in accordance with the Japanese National Plan, some prefectures did not describe individual measures such as research, collection of medical information, consultation support for patients with CVD, palliative care, assistance for patients with sequelae, support for maintaining a balance between treatment and work, and measures from childhood and adolescence. Furthermore, a few specific indicators were set for these measures and those related to chronic care. This review identifies the current status of prefectural plans and discusses future challenges and directions.
In Japan, cerebrovascular diseases and cardiovascular diseases (CVDs) are the leading causes of death and the need for long-term care. The Cerebrovascular and Cardiovascular Disease Control Act was passed by a legislative body in December 2018 and enacted on December 1, 2019.1 As a strategic response to this Act, the Japanese National Plan for the Promotion of Measures Against Cerebrovascular and Cardiovascular Disease (Japanese National Plan) was formulated and approved by the Cabinet on October 27, 2020.2 The Japanese National Plan sets forth 2 primary objectives: to extend healthy life expectancy by 3 years by 2040 compared with 2016; and to decrease the age-adjusted mortality of CVD. Therefore, understanding the first phase of each prefectural plan against CVD and its specific characteristics, and using this information in future CVD countermeasures, is essential.
In alignment with the Japanese National Plan, prefectural plans have been formulated and published (Supplementary Table 1), with ongoing efforts being dedicated to their implementation. However, a notable gap exists in the available information concerning the specific goals established and the execution strategies employed in each prefecture. Therefore, this study aimed to examine the initial phase of each prefectural plan by ascertaining the timing of formulation, elucidating the description of individual measure elements, evaluating the utilization of logic models, and assessing the status of indicator establishment.
The status of the formulation of prefectural plans was assessed by examining publicly available information from prefectural websites. The prefectural websites were examined in October 2021, February, July and October 2022, and March 2023.
Table 1 provides an overview of the timeline of the development of prefectural plans. The earliest prefectural plans were crafted by Akita and Tochigi prefectures and were formulated in March 2021. One year after the development of the Japanese National Plan, 4 prefectures had developed their plans. By October 2021, 8 prefectures had developed prefectural plans. Subsequently, in March and April 2022, prefectural plans were formulated in 32 prefectures, indicating a substantial effort to align with the prefectural plan’s implementation scheduled for fiscal year (FY) 2022. For the remaining 3 prefectures, 2 prefectural plans were released in December 2022 and 1 was released in January 2023.
Timing of Prefectural Plan Formulation
| Date | Prefectures |
|---|---|
| March 2021 | Akita, Tochigi |
| April 2021 | Tottori |
| July 2021 | Tokyo |
| October 2021 | Fukushima, Gifu, Shimane, Tokushima |
| December 2021 | Hokkaido |
| January 2022 | Yamagata, Yamanashi, Aichi |
| March 2022 | Aomori, Iwate, Miyagi, Ibaragi, Kanagawa, Niigata, Toyama, Ishikawa, Fukui, Nagano, Shizuoka, Mie, Shiga, Osaka, Wakayama, Okayama, Hiroshima, Yamaguchi, Kagawa, Ehime, Kochi, Fukuoka, Saga, Nagasaki, Kumamoto, Oita, Miyazaki, Kagoshima, Okinawa |
| April 2022 | Gunma, Saitama, Hyogo |
| December 2022 | Nara, Chiba |
| January 2023 | Kyoto |
The Japanese National Plan consists of 1 foundational measure, namely establishing a system for collecting and disseminating medical information on CVD, and 3 major measures:
1. Spreading awareness of preventive measures and accurate information on CVD
2. Enhancing service provision systems related to health, medical care, and welfare services
3. Promoting research on CVD.3
Furthermore, the Japanese National Plan describes 10 specific measures based on the Enhancement of service provision systems related to health, medical care, and welfare services domain: (1) promoting health checkups to prevent CVD; (2) improving emergency transportation systems; (3) securing emergency medical care and establishing medical care provision systems for CVD; (4) providing measures against CVD based on social cooperation and patient support; (5) developing a system to provide medical care and rehabilitation for CVD; (6) providing appropriate information and consultation support for CVD; (7) providing palliative care for CVD; (8) supporting patients with the aftereffects of CVD; (9) providing support for balancing treatment and work; and (10) implementing measures for CVD that need consideration from childhood and young adulthood onward.3 Our investigation focused on ascertaining whether specific initiatives were described for each of these elements in the prefectures. Initiatives that solely monitored the national trends or considered measures were excluded. With regard to Element 6, the provision of appropriate information and consultation support for CVD, descriptions limited to employment support for patients were excluded. Hence, judgments were made based on whether there was a description of efforts related to the provision of comprehensive information and consultation support.
Descriptions of the individual measures are presented in Table 2. In general, descriptions were extensive, drawing from each prefecture’s past efforts and regional characteristics. Almost all individual measures were comprehensively described, except for the promotion of research on CVD and the establishment of a system for collecting and providing medical information on CVD, which were only mentioned in 13 and 12 prefectural plans, respectively. Although some plans described research tailored to the characteristics of each prefecture, the content of the research and the development of a system for collecting and providing medical information were relatively more focused on the national direction. The elements not mentioned in more than 2 prefectures were Elements 6 (providing appropriate information and consultation support for CVD), 7 (providing palliative care for CVD), 8 (supporting patients with the aftereffects of CVD), 9 (providing support for balancing treatment and work), and 10 (implementing measures for CVD that need consideration from childhood and young adulthood onward), which were not found in 6, 7, 2, 4, and 7 prefectural plans, respectively. These elements are less emphasized in health promotion and medical plans. However, the Ministry of Health, Labour and Welfare is anticipated to reinforce efforts, particularly with the implementation of a model project supporting patients with CVD to balance treatment and work from FY2019 to FY2021, along with the launch of a model project for a comprehensive support center for CVD from FY2022. In addition, recent initiatives by the Japanese Society for Adult Congenital Heart Disease, such as the certification of adult congenital heart disease specialists, which started in 2022, indicate a growing focus on addressing these aspects.
Description of Individual Measures in the National Plan and Prefectural Plans
| Measures in the National Plan | No. (%) prefectures describing the measure |
|---|---|
| 1. Spreading awareness of preventive measures and accurate information on CVD | 47 (100) |
| 2. Enhancing service provision systems related to health, medical care, and welfare services | |
| 1. Promoting health checkups to prevent CVD | 47 (100) |
| 2. Improving emergency transportation systems | 46 (98) |
| 3. Securing emergency medical care and establishing medical care provision systems for CVD | 46 (98) |
| 4. Providing measures against CVD based on social cooperation and patient support | 47 (100) |
| 5. Developing a system to provide medical care and rehabilitation for CVD | 46 (98) |
| 6. Providing appropriate information and consultation support for CVD | 41 (87) |
| 7. Providing palliative care for CVD | 40 (85) |
| 8. Supporting patients with the aftereffects of CVD | 45 (96) |
| 9. Providing support for balancing treatment and work | 43 (91) |
| 10. Implementing measures for CVD that need consideration from childhood and young adulthood onward | 40 (85) |
| 3. Promoting research on CVD | 13 (28) |
| Base: Establishing a system for collecting and providing medical information on CVD | 12 (26) |
CVD, cerebrovascular and cardiovascular disease.
The Guidelines for Prefectural Cerebrovascular and Cardiovascular Disease Control Promotion Plans,4 issued by the Director of the Cancer and Disease Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, emphasize the significance of identifying CVD control issues in each prefecture, logically examining specific solutions, and incorporating effective measures. The guidelines stress the importance of demonstrating the connection between each measure and the issues at hand, suggesting the use of tools such as logic models.4 In addition, in the US, the Centers for Disease Control and Prevention (CDC) Division for Heart Disease and Stroke Prevention has issued an evaluation guide, advocating for the development and use of logic models as assessment tools to support the evaluation of heart disease, stroke, and prevention activities within US states.5 Therefore, we investigated the use of logic models as tools in prefectural planning. The Japanese Circulation Society (JCS) provided a draft logic model at the end of August 2021 to each recommended member of the prefectural countermeasure promotion committee, aiming to promote the development of prefectural plans (Supplementary Figure). The proposed logic model of the JCS outlines the final outcomes as a reduction in the incidence of death from CVD and improvement in the quality of life of patients with CVD. Indicators for intermediate and initial outcomes were categorized into prevention, rescue, acute care, recovery, and chronic care and relapse prevention (Figure). We also examined the use of the logic model proposed by the JCS.
Framework of the proposed logic model of the Japanese Circulation Society. *Initial outcomes vary by prefecture.
Thirty-one prefectures included the logic model as a tool, with 10 of them believed to have, at least partially, referenced the proposal from the JCS. Among the logic models potentially derived from this proposal, some indicators were outlined with numerical values left unspecified, raising concerns about the feasibility of obtaining these numerical values even though the indicators set were deemed desirable.
Indicators were selected from each prefectural plan by comparing them with the indicators proposed in the logic model presented by the JCS. Initially, we considered using the following medical plan-based classifications: prevention; rescue; acute care; recovery; and chronic care and relapse prevention. However, upon preliminary examination of the prefectural plans, additional categories emerged, such as: community cooperation; information and consultation support, support for residual symptoms, and support for balancing treatment and work; measures from childhood and young adulthood; and research and infrastructure development. These categories extend beyond medical care and are not confined to a disease stage. Consequently, we decided to incorporate these into the classification and extract relevant indicators. Broad indicators that cannot be classified separately were listed as “final outcomes”. Indicators lacking current numerical values and those serving as monitoring indicators were also included in the analysis. In addition, indicators with similar purposes were counted together. The screening of prefectural plans was independently conducted by 2 experienced researchers (H.Y. and Y.S.).
Table 3 presents the indicators set for more than two thirds of prefectures. Notably, no indicators were set in more than two thirds of prefectures for categories such as: chronic care and relapse prevention; community cooperation; information and consultation support, support for residual symptoms, and support for balancing treatment and work; measures from childhood and young adulthood; and research and infrastructure development. All extracted indicators are listed in Supplementary Tables 2–11.
Indicators Set by More Than Two Thirds of Prefectures
| Indicator | No. prefectures |
|---|---|
| Prevention | |
| Percentage receiving specified health checkups | 44 |
| Percentage receiving specified health guidance | 44 |
| Smoking rate | 42 |
| Rescue | |
| Average time taken from the time of emergency call (awareness) to the time of admission to a medical institution | 33 |
| Acute care | |
| Number of percutaneous coronary interventions (for acute myocardial infarction) | 35 |
| Number of cardiovascular rehabilitation services provided to inpatients | 33 |
| Recovery | |
| Number of cardiovascular rehabilitation services provided to inpatients (reprinted) | 33 |
| Chronic care and relapse prevention | |
| None | |
| Community cooperation | |
| None | |
| Information and consultation support, support for residual symptoms, and support for balancing treatment and work | |
| None | |
| Measures from childhood and young adulthood | |
| None | |
| Research and infrastructure development | |
| None | |
| Final outcome | |
| Healthy life expectancy | 36 |
| Patients returning to home or other living arrangements (percentage) | 32 |
Prevention
Eighty-nine different indicators were established, of which 3 were set by more than two thirds of prefectures. Notably, many prefectures have provided detailed descriptions of the strategies used for prevention and the promotion of public awareness. Rates of smoking, uptake of specified health checkups, and implementation of specified health guidance were set as indicators by more than 40 prefectures.
RescueThirty-seven different indicators were set, with the average time from emergency calls to hospital admission being used by more than two thirds of prefectures. In addition, certain prefectures have established indicators for 12-lead electrocardiogram transmission systems and doctor’s helicopters.
Acute CareForty-eight different indicators were set, of which 2 were set by more than two thirds of prefectures. In addition to acute myocardial infarction and ischemic heart disease, some prefectures have established indicators for aortic emergencies and arrhythmias.
RecoveryThirty-eight different indicators were set. Of these, more than two thirds of prefectures had set indicators for cardiovascular rehabilitation overlapping with acute phase. In comparison, fewer prefectures have established indicators related to palliative care.
Chronic Care and Relapse PreventionThirty-three different indicators were set, but none was set by more than two thirds of prefectures. Many indicators related to the chronic phase and prevention of recurrence were not limited to CVD.
Community CooperationTwenty-four different indicators were set, but none of these indicators was by more than two thirds of prefectures. The indicators predominantly align with those indicated in medical plans, proposed by academic societies, and related to tools such as handbooks on heart failure.
Information and Consultation Support, Support for Residual Symptoms, and Support for Balancing Treatment and WorkTen different indicators were set, but none of these indicators was set by more than two thirds of prefectures. No indicators were proposed by medical plans or academic societies in this field; the number of prefectures that had set indicators and the number of indicators set were relatively small. However, indicators related to support for balancing treatment and work were set.
Measures From Childhood and Young AdulthoodFifteen different indicators were set, but none of these indicators was set by more than two thirds of prefectures. Similar to the field of information and consultation support, support for residual symptoms, and support for balancing treatment and work, no indicators were proposed by medical plans or academic societies. The number of prefectures that set indicators and the number of indicators set were relatively small. However, the established indicators primarily focused on the early detection of pediatric CVD patients, the development of transitional care systems, and consultation support on living with treatment.
Research and Infrastructure DevelopmentTwo indicators were mentioned: the status of CVD data collection and the status of data utilization. However, no numerical values or targets were set.
Final OutcomeTwenty-six indicators were set, of which 2 (healthy life expectancy and patients returning to home and other life [percentage]) were set by more than two thirds of prefectures. In addition to age-adjusted mortality rates for CVD, some prefectures have used age-adjusted mortality rates for ischemic heart disease, aortic diseases such as aortic dissection, and heart failure, as indicators. Ten prefectures used heart failure rehospitalization as an indicator; however, the definitions for rehospitalization for heart failure varied.
Some prefectures conducted their own surveys and established their own indicators. Although the increased burden on prefectural officials and lack of national comparisons are considered challenges for independent surveys, one notable advantage of such surveys is the ability to obtain interesting indicators tailored to regional characteristics. After selecting the indicators, the potential for horizontal development in prefectures with similar regional characteristics or nationwide development was also considered.
Although some reviews have been conducted regarding the Cerebrovascular and Cardiovascular Disease Control Act, related countermeasures, the Japanese National Plan, and each prefectural plan,3,6–9 only a few studies have comprehensively reviewed and discussed multiple prefectural plans. In the US, the CDC has been actively engaged in heart disease and stroke prevention since the late 1980s. In 1998, the US Congress funded the CDC to launch a national, state-based, heart disease and stroke prevention program.10 In addition, initiatives such as the development of an evaluation guide for the prevention of heart disease and stroke have been undertaken.5 Notably, there is a national initiative called Million Hearts (https://millionhearts.hhs.gov/ (accessed April 3, 2024)), led by the US Department of Health and Human Services and the CDC, with the active participation of numerous companies. In contrast, national CVD plans are not widespread in Europe. However, the European Heart Network, in collaboration with the European Society of Cardiology, has published Fighting Cardiovascular Disease: A Blueprint for EU Action,11 advocating for the European Union (EU) to develop a comprehensive CVD plan.12 In the UK, CVD is a top priority in the National Health Service’s Long Term Plan.13 In Spain, the Cardiovascular Health Strategy was developed by the National Health System.14 However, data on CVD measures in different regions are limited.
In Japan, the Cancer Control Act was approved in 2006, requiring each prefecture to formulate a Prefectural Plan to Promote Cancer Control. Some studies comparing these prefectural plans are available.15 In the US, the National Cancer Act was passed in 1971, leading to the ongoing implementation of measures.16,17 In 1998, the CDC established the National Comprehensive Cancer Control Program, which supports the development and implementation of state-specific cancer control promotion plans.18 Several studies have been published reviewing planning and implementation at the state level.19–21
Based on our findings, we have identified 4 major challenges for future consideration:
1. Specific indicators are required: many indicators set for the recovery phase and beyond are not specific to CVD
2. Clear definitions are needed: some indicators, such as “palliative care”, are considered important but lack clear and uniform definitions
3. Measures should be coupled with evaluations: certain aspects necessitate careful consideration of how to assess changes on the recipient side
4. Consistency between measures and indicators should be ensured: some measures are listed as individual measures, but without corresponding indicators.
For Points 1 and 2 above, patients with CVD are frequently complicated by other diseases, necessitating a comprehensive approach. To prevent recurrence, exploration of indicators closely related to CVD, particularly those specifically tailored for the recovery phase and beyond, is essential. In a field of high interest to many prefectures, where indexing is desirable, it is also necessary to examine definitions and indicators that can be evaluated and compared among prefectures in accordance with the clinical guidelines and actual conditions of medical care. For Point 3 above, careful consideration is required on how to survey the perspectives of individuals receiving medical care and evaluate the survey results. Studies focusing on specific regions and target diseases will also be considered. Based on survey results, intervention methods, including the promotion of public awareness, may also be considered. For Point 4 above, in addition to the challenges of setting indicators, there may be a lack of data to understand the actual situation. Similar to Points 1–3, it is necessary to consider the indicators and definitions specifically tailored for CVD and devise strategies to obtain data, including the viewpoints of recipients. Collaboration with the Japanese Government’s ongoing project to build a CVD database is anticipated to yield valuable indicators for CVD. At this time, it cannot be asserted that sufficient data or evidence exist for the aforementioned aspects. Scientific verification and the accumulation of evidence from research must be integrated into the indicators and individual measures.
Although the duration since the formulation and implementation of prefectural plans remains short in many prefectures, the second phase of the Japanese National Plan has already been formulated. During the formulation process, updating the evaluation indicators was also discussed. In the second phase of the Japanese National Plan, new indicators (which were set as indicators in some prefectures in the first phase of the prefectural plan) have been proposed, such as: the percutaneous coronary intervention (PCI) implementation rate for patients with acute myocardial infarction; the number of participants in basic training for work/treatment balance support coordinators; and the number of participants in heart failure palliative care training courses.
Our survey demonstrated the status of prefectural plan formulation and content. Most prefectural plans were formulated in March or April 2022 and implemented in FY2022. In many prefectural plans, individual policy elements of the Japanese National Plan were comprehensively described, but some prefectures did not describe measures for the: promotion of research on CVD; establishment of a system for collecting and providing medical information on CVD; provision of appropriate information and consultation support for CVD; provision of palliative care for CVD; support for patients with aftereffects of CVD; provision of support for balancing treatment and work; and provision of measures for CVD that need consideration from childhood and young adulthood onward. Thirty-one prefectures intended to use the logic model as a tool. No indicators were set in more than two thirds of prefectures for: chronic care and relapse prevention; community cooperation; information and consultation support, support for residual symptoms, and support for balancing treatment and work; measures from childhood and young adulthood; and research and infrastructure development. During the survey, we also identified future challenges, including the establishment of indicators for the recovery period and beyond and the development of survey methods for individuals receiving medical care.
We hope that the contents of the first phase of the prefectural plans, which were discussed and formulated based on the situation in each region, and the process of discussion will be used in future prefectural plans and lead to better CVD control measures.
The authors thank Editage (www.editage.jp) for English language editing a draft of this paper.
This work was supported by the Ministry of Health, Labour and Welfare (Grant no. 21FA1101).
Y.S. and K.H. are members of Circulation Journal’s Editorial Team.
Because this study does not fall within the Ethical Guidelines for Medical and Health Research Involving Human Subjects, we determined that approval from the Ethical Review Board Osaka University Hospital was not required.
Please find supplementary file(s);
https://doi.org/10.1253/circj.CJ-24-0211
