Successfully reported this slideshow.

Cardiovascular disease inequalities: causes and consequences

4,558 views

Published on

Cardiovascular disease inequalities: causes and consequences. Capewell S. Conference on Cardiovascular Diseases (Madrid: Ministry of Health and Social Policy; 2010).

Published in: Health & Medicine
  • Be the first to comment

Cardiovascular disease inequalities: causes and consequences

  1. 1. Cardiovascular disease risk factors factors CVD Inequalities Causes, Consequences & Challenges Challenges Simon Capewell Professor of Clinical Epidemiology LIVERPOOL UNIVERSITY UK Madrid, 18th February 2010 Thanks: Susanne Logstrup, Sophie O’Kelly,Muri el Muri Mioulet, Lars Ryden, Ilaria Leggeri, Robin Ireland, Philip James,M artinO ’Flaherty, Julia Critchley, M O RosalindRai ne, Hilary Graham, Maddy Bajekal, Rai MargaretWh itehead, PeterWh incup, EarlFFord, Pedro Wh Wh Marques-Vidal, Sarah Wild, Ann Capewell European Society European Society of Cardiology of Cardiology & & European Heart Network European Heart Network 2009
  2. 2. Cardiovascular disease risk factors factors CVD Inequalities Causes, consequences & challenges challenges THIS TALK Big inequalities CVD burden of disease disease Big inequalities in CVD risk factors Choices for CVD prevention: ⇑⇓ Inequalities Inequalities
  3. 3. WHO Commission on Social Determinants of Health Health 2008 2008
  4. 4. Life expectancy at birth (men) Glasgow, Scotland (deprived suburb) 54 54 India 61 61 Philippines 65 65 Lithuania 66 66 Poland 71 71 Mexico 72 72 Cuba 75 75 US 75 75 UK 76 76 WHO Commission on Social Determinants of Health 2008
  5. 5. Life expectancy at birth (men) Glasgow, Scotland (deprived suburb) 54 54 India 61 61 Philippines 65 65 Lithuania 66 66 Poland 71 71 Mexico 72 72 Cuba 75 75 US 75 75 UK 76 76 Glasgow, Scotland (affluent suburb) 82 82 WHO Commission on Social Determinants of Health 2008
  6. 6. WHO Commission on Social Determinants of Health Health Three overarching recommendations recommendations • Improve conditions of daily life • Tackle the inequitable distribution of power, money & resources • Measure & understand the problem and assess the impact of action http://www.euro.who.int/socialdeterminants/publications/publications
  7. 7. WHO Commission on Social Determinants of Health Health Three overarching recommendations recommendations • Improve conditions of daily life • Tackle the inequitable distribution of power, money & resources • Measure & understand the problem and assess the impact of action http://www.euro.who.int/socialdeterminants/publications/publications
  8. 8. Poverty rates before & after income transfers (direct tax & welfare benefits) EU & USA 2000 Smeeding 2005 H Graham 2009
  9. 9. Poverty rates before & after income transfers (direct tax & welfare benefits) EU & USA 2000 40 30 20 10 0 US UK Sweden Smeeding 2005 before after H Graham 2009
  10. 10. WHO Commission on Social Determinants of Health Health Three overarching recommendations recommendations • Improve conditions of daily life • Tackle the inequitable distribution of power, money & resources • Measure & understand the problem & assess the impact of action http://www.euro.who.int/socialdeterminants/publications/publications
  11. 11. Cardiovascular disease (CVD) risk factors CVD Inequalities Causes, consequences & choices Big inequalities in CVD burden of disease disease
  12. 12. Inequalities in CVD disease burden burden Poverty (Deprivation) (Deprivation)
  13. 13. Deprivation & Heart Attack Incidence (patients aged <65 Scotland 1990-2000) 25 20 20 event rate per 1000 15 15 Hospital 10 10 admissions Deaths by 30 days 5 Pre-hospital 0 deaths deaths (Affluent) 1 2 3 4 5 (Deprived) deprivation quintile MacIntyre et al BMJ 2000
  14. 14. Inequalities in CVD disease burden burden Age Men & Women Women
  15. 15. CVD Patients: AGE UK 2006 10000 1000 Mor tality rate/100,000 (log scale) 100 MEN 10 1 <34 35-44 45-54 55 -64 65-74 75-84 85+ AGE (years)
  16. 16. CVD Patients: SEX & AGE UK 2006 10000 1000 Mor tality rate/100,000 (log scale) 100 MEN 10 WOMEN 1 <34 35-44 45-54 55 -64 65-74 75-84 85+ AGE (years)
  17. 17. Inequalities in CVD disease burden burden Geography Geography
  18. 18. North/South Inequalities in CVD www.heartstats.org
  19. 19. Big CVD inequalitiesyears) in the WHO European Region Cardiovascular mortality (up to 65 across Europe < 300 < 240 < 180 < 120 Most recent data 0 - 60 No data SDR per 100000 ….the main contributor to a 20 year difference in life expectancy across EU
  20. 20. Inequalities in CVD disease burden burden Trends Trends
  21. 21. Most Deprived Inequality ratio = 1.9 Most Affluent Inequality ratio = 1.7
  22. 22. EUROPE Total mortality INEQUALITIES (inequality ratios) INEQUALITIES increased between 1980s and 1990s in many EU countries Mackenbach et al. IJE 2003 32:830
  23. 23. Cardiovascular disease (CVD) risk factors factors CVD Inequalities Causes, consequences & choices THIS TALK Big inequalities in CVD disease burden Big inequalities in CVD risk factors factors Choices for CVD prevention
  24. 24. CVD risk factors factors
  25. 25. MODIFIABLE MODIFIABLE CVD risk factors factors
  26. 26. Five year CHD death rates in in British men aged 35-64 64 (British Regional Heart Study) 20 17 15 Smokers NON-Smokers 12 10 1117.5 10 10.8 6 5 6 High Cholesterol 4 2 Low Cholesterol High Low High Low BP BP BP Blood Pressure
  27. 27. CVD causation pathways Upstream risk factors Downstream Risk factors
  28. 28. CVD causation pathways Upstream risk factors Blood Smoking Lipids Diabetes Pressure Downstream CVD events Risk factors
  29. 29. CVD causation pathways Upstream risk factors Diet BMI Obesity Activity Blood Smoking Lipids Diabetes Pressure Downstream CVD events Risk factors
  30. 30. CVD causation pathways Deprivation Upstream risk factors Diet Obesity Activity Blood Smoking Lipids Diabetes Pressure Downstream CVD events risk factors
  31. 31. GRADIENTS IN CVD risk factors factors
  32. 32. GRADIENTS IN CVD risk factors factors SMOKING SMOKING
  33. 33. Smoking Place & Social Class
  34. 34. Trends in Cigarette smoking among women 60 Affluent & Deprived groups Britain, 1958-2000 50 40 Deprived 30 20 Affluent 10 0 1958 1978 1998 Goddard 2008 w omen-professional w omen-unsk manual Graham 2009
  35. 35. Socio-economic inequalities • Five fold social gradients in premature CVD mortality rates • Mostly explained by gradients in smoking & diet & other pathways [stress, adrenaline etc]
  36. 36. Nigel Unwin
  37. 37. Deprived Affluent
  38. 38. CVD causation pathways Deprivation Upstream risk factors Diet Obesity Activity Blood Smoking Lipids Diabetes Pressure Downstream CVD RISK risk factors
  39. 39. Higher CVD risk in deprived groups Proportion of men exceeding 10% risk of CVD death within one decade (Qrisk database) Affluent Quintiles of the Townsend score Deprived Hippisley-Cox Heart 2007
  40. 40. Cardiovascular disease (CVD) risk factors factors CVD Inequalities Causes, consequences & choices THIS TALK Big inequalities in CVD Big inequalities in CVD risk factors Choices for CVD prevention
  41. 41. CVD process: in an individual 100% Survival 0% Birth Youth Middle Age Age (years) ⇒ Artery Atheroma Thrombosis Capewell et al 2009
  42. 42. CVD process: in an individual 100% Natural Cou rse of CVD Survival 0% Birth Youth Middle Age Age (years) ⇒ Artery Atheroma Thrombosis Capewell et al 2009
  43. 43. CVD process: in an individual 100% Natural Cou rse of CVD Survival First Stroke or Heart Attack 0% Birth Youth Middle Age Age (years) ⇒ Artery Atheroma Thrombosis Capewell et al 2009
  44. 44. CVD process: in an individual 100% Natural Cou rse of CVD Survival First Stroke or or NO Symptoms Heart Attack Attack Symptoms Sudden Death Typical Lucky (common) decline 0% Birth Youth Middle Age Age (years) ⇒ Capewell et al 2009
  45. 45. CVD process: in an individual 100% Natural Cou rse of CVD Survival First Stroke or or NO Symptoms Heart Attack Attack Symptoms Secondary prevention Health services Sudden Death Typical Lucky (common) decline 0% Birth Youth Middle Age Age (years) ⇒ Capewell et al 2009
  46. 46. CVD process: in an individual 100% Natural Cou rse of CVD Disease Promotion Survival Primary Prevention First Stroke or NO Symptoms Heart Attack Symptoms Secondary prevention Health services Sudden Death Typical Lucky (common) decline 0% Birth Youth Middle Age Age (years) ⇒ Capewell et al 2009
  47. 47. CVD Prevention in a POPULATION 100% Natural Cou rse of CVD Advertising Survival Primary Prevention First Stroke or Heart Attack 0% 0% 60 70 Age (years) 80 80 Capewell et al 2009
  48. 48. CVD Prevention in a POPULATION 100% Natural Cou rse of CVD More advertising Survival Primary Prevention First Stroke or Heart Attack 0% 0% 60 70 Age (years) 80 80 Capewell et al 2009
  49. 49. CVD Prevention in a POPULATION 100% Natural Cou rse of CVD Advertising Eg ⇑ tobacco control Survival EFFECTIVE Primary DELAYED First Stroke Prevention or Heart Attack 0% 0% 60 70 Age (years) 80 80 Capewell et al 2009
  50. 50. CVD Prevention in a POPULATION 100% HEALTH PROTECTION Natural Cou Eg by tobacco or salt rse of CVD legislation Survival EFFECTIVE Primary First Stroke or Heart Prevention Attack PREVENTED 0% 60 70 Age (years) 80 Capewell et al 2009
  51. 51. CVD prevention strategies strategies • High Risk Individual Approach • Population-based Approach
  52. 52. CVD prevention approaches approaches Prevalence % Blood Pressure distribution in the 30 population 20 10 0 110 120 130 Systolic BP 160 160
  53. 53. CVD prevention: High risk individual approach Prevalence % Blood Pressure distribution in the 30 population 20 SBP >140 mmHg 10 0 110 120 130 Systolic BP 160 160
  54. 54. CVD prevention: High risk individual approach Prevalence % Blood Pressure distribution in the 30 population 20 BP >140 mmHg Medications 10 0 110 120 130 Systolic BP 160 160
  55. 55. Population-based CVD prevention strategy strategy Prevalence % Shifting Blood Pressure distribution 30 20 10 0 110 120 130 Systolic BP 160 160
  56. 56. Population-based CVD prevention strategy strategy Prevalence % Shifting Blood Pressure distribution 30 20 10 0 110 120 130 Systolic BP 160 160
  57. 57. Population-based CVD prevention strategy strategy Prevalence % Shifting Blood Pressure distribution 30 20 Fewer BP >140 mmHg Less treatments 10 0 110 120 130 Systolic BP 160 160
  58. 58. Whole-population approach for preventing CVD: successful policies – Farmers subsidies to stop dairy & beef , start fruit & berry production (Finland) – Support food reformulation (All)
  59. 59. Whole-population approach for preventing CVD: successful policies – Farmers subsidies to stop dairy & beef , start fruit & berry production (Finland) – Support food reformulation (All) – Banning transfats (Denmark) – Halving dietary salt (Finland) – Promoting smoke-free public spaces (Ireland, UK ,Italy etc)
  60. 60. Ireland: modelling reductions in in cardiovascular risk factors factors Primary Prevention Population Approach ⇓ Risk Factors in everyone Versus High Risk strategy using statin & blood pressure medications BMC Public Health 2007 7 117
  61. 61. CHD prevention in Ireland 1985-2000: Population v. High Risk Strategies Deaths prevented or postponed (Sensitivity analysis ) BMC Public Health. High 2007; 7:117. Risk Population Treating Statins secular BP High Population trends Risk Diet diet change change in Blood CHD patients Pressure Cholesterol BMC Public Health 2007 7 117
  62. 62. CHD prevention in Ireland 1985-2000: Population v. High Risk Strategies Deaths prevented or postponed (Sensitivity analysis ) High Risk Population Treating Statins secular BP High Population trends Risk Diet diet change change in Blood CHD patients Pressure Cholesterol BMC Public Health 2007 7 117
  63. 63. NICE Programme Development Group: CVD prevention in populations Will CVD prevention widen health inequalities? Simon Capewell 25th June 2009
  64. 64. The UK high risk approach for preventing CVD UK Department of Health programme: programme: NHS Health Checks
  65. 65. The UK high risk approach for preventing CVD UK Department of Health programme: NHS Health Checks – All adults aged 40+ screened for CVD risk – If 20%+ risk CVD event in the next ten years, treat with: with: • lifestyle advice plus • tablets to reduce cholesterol & blood pressure
  66. 66. Evidence that high risk approach may increase social inequalities Tudor Hart’s “Inverse Care Law” Tugwell’s “staircase effect” J Tudor Hart . The inverse care law. Lancet 1971;1; 405. P Tugwell; BMJ 2006;33 2; 358 inverse 1; Tugw BMJ 2006; 33 35
  67. 67. Evidence that high risk approach may increase social inequalities Tudor Hart’s “Inverse Care Law” • The availability of good medical care tends to vary inversely with actual need Tugwell’s “staircase effect” Disadvantage can occur at every stage: – Health beliefs, health behaviour, presentation participation, persistence or adherence J Tudor Hart . The inverse care law. Lancet 1971;1; 405. P Tugwell; BMJ 2006;33 2; 358 inverse 1; Tugw BMJ 2006; 33 35
  68. 68. Evidence that high risk approach may increase social inequalities Prescribing gradients Long term adherence Smoking cessation Nutrition interventions in individuals individuals Oldroyd J. JECH 2008; 62:573. Thomsen R W, Br J Clin Pharm. 2005; 60;534; 62:573. 2005; Ashworth, M, QJof Amb Care Management: 2008; 31; 220; 220; Vrijens B, BMJ 2008;336:1114; Morisky D. Clin Hypertension 2008; 10; 348 Vrijens 2008;336:11 348 Johnell K BMC PublicHealt h2005, 5: 17 BMC Healt 2005, 5: Chaudhry HJ. Current Ather. Ather. Rep 2008; 10; 19; Bouchard MH, Br J Clin Pharmacol. 2007 63(6): 698 Bouchard 63(6): 698
  69. 69. Evidence that whole POPULATION CVD prevention reduces social inequalities Kivimaki, Marmot et al Lancet 2008 15 year risk of CHD death • calculated in British men aged 55 • quantified the benefits of decreasing risk factors uniformly across population [systolic blood pressure ⇓10mmHg total cholesterol⇓ 2mmol/l & glucose ⇓ 1 mmol/l ]
  70. 70. Evidence that whole POPULATION CVD prevention reduces social inequalities Kivimaki, Marmot et al Lancet 2008 15 year risk of CHD death • calculated in British men aged 55 • quantified the benefits of decreasing risk factors uniformly across population [systolic blood pressure ⇓10mmHg total cholesterol⇓ 2mmol/l & glucose ⇓ 1 mmol/l ] • Would reduce the absolute mortality gap between affluent & deprived by ≈70%
  71. 71. Evidence that whole POPULATION CVD prevention reduces social inequalities Diet interventions • Folic acid fortification of cereals (USA population1996) Dowd IJE 2008; 37(5):1059 Dowd IJE 2008; 37(5):1059
  72. 72. Evidence that whole POPULATION CVD prevention reduces social inequalities Diet interventions Folic acid fortification of cereals (USA population1996) Blood folate levels: Social gradients ⇓⇓ ≈ 70% Dowd IJE 2008; 37(5):1059 Dowd IJE 2008; 37(5):1059
  73. 73. Evidence that whole POPULATION CVD prevention reduces social inequalities Smoking • cigarette price increases more effective in deprived groups TownsendBMJ 1994; 309; 923 Town send BMJ 1994; 309; 923 “increase in tobacco price may have the potential potential to reduce smoking related health inequalities” Main Meta-analysis. BMC Public Health 2008; 8; 178 Meta- BM
  74. 74. CVD prevention & health inequalities VERDICT ♥ High Risk Strategies toscreen & treat individuals typically widen social inequalities
  75. 75. CVD prevention & health inequalities VERDICT ♥ High Risk Strategies toscreen & treat individuals typically widen social inequalities ♥ Population wide policy interventions usually narrow the inequalities gap
  76. 76. CVD population prevention prevention ⇒ € COST SAVINGS
  77. 77. CVD population-wide prevention prevention ⇒ € COST SAVINGS SAVINGS • USA Trust for America’s Health • Australia Abelson • UK Wanless Report 2004 (save € 40 billion) NICE Guidance 2010 [Draft] (save € 5 billion – €10 billion)
  78. 78. Cardiovascular disease (CVD) risk factors factors CVD Inequalities Causes, consequences & choices Social Inequalities in CVD treatments?
  79. 79. Deprived patients get less treatment Those who need most care get least care
  80. 80. Deprived patients get less treatment Those who need most care get least care – Management & drugs (Roland 2009) – Referral from primary care (Dixon; McBride & Raine) – Under-use of diagnostics (Hippisley Cox) – Less Revascularization BJGP 2000; 50: 449; BMJ 1997; 314: 257 – Less rehabilitation
  81. 81. Deprived patients get less treatment OLD patients get less treatment WOMEN get less treatment
  82. 82. Cardiovascular disease (CVD) risk factors factors CVD Inequalities Causes, consequences & choices CVD Inequalities in UK UK How big are the inequalities in YOUR country??
  83. 83. CVD prevention in EU WHAT WE HAVE ACHIEVED • European Heart Health Charter (EHHC) EHHC) • Spanish Presidency Declaration 2002 2002 • Council Conclusions 2004
  84. 84. CVD prevention in EU EU WHAT WE HAVE ACHIEVED • European Heart Health Charter (EHHC) • Spanish Presidency Declaration 2002 • Council Conclusions 2004 WHAT WE CAN DO NOW • ⇑ Tobacco Control [& price] • ⇑ fruit & vegetable consumption • ⇓ meat & dairy [& HELP climate change] • Ban junk food advertising • Ban trans fats
  85. 85. Cardiovascular disease risk factors CVD Inequalities Causes, consequences & challenges CONCLUSIONS Big CVD inequalities burden of disease - Social, Age, Sex, Place, Ethnicity Ethnicity Big inequalities in CVD risk factors - Smoking & Diet (Blood Pressure & Cholesterol)
  86. 86. Cardiovascular disease risk factors CVD Inequalities Causes, consequences & choices CONCLUSIONS Big CVD inequalities burden of disease - Social, Age, Sex, Place, Ethnicity Big inequalities in CVD risk factors - Smoking & Diet (BP & Cholesterol) Choices for CVD prevention: -Individual approach ⇑CVD Inequalities⇑ -Population approach ⇓CVD Inequalities⇓

×