JUSTUS WARREN TASK FORCE MEETING DECEMBER 05, 2012

Transcription

1 SAMUEL TCHWENKO, MD, MPH Epidemiologist, Heart Disease & Stroke Prevention Branch Chronic Disease & Injury Section; Division of Public Health NC Department of Health & Human Services JUSTUS WARREN TASK FORCE MEETING DECEMBER 05,

2 INTRODUCTION MORTALITY MORBIDITY ECONOMIC IMPACT RISK FACTORS DISPARITIES CONCLUSION 2

3 I00-I78 I00-I09, I11, I13, I20-I51 Hypertensive Essential Renal (primary) Disease Hypertension (I12) (I10) Other peripheral vascular diseases (I73) Rheumatic fever with heart involvement (I01) Secondary Rheumatic chorea (I02) Acute pericarditis (I30) Rheumatic mitral valve diseases (I05) Hypertension Pulmonary embolism (I26) Rheumatic aortic valve diseases (I06) Pulmonary valve disorders (I37) (I15) Rheumatic tricuspid valve diseases (I07) Endocarditis, valve unspecified (I38) I60-I69 Multiple valve diseases (I08) Acute myocarditis (I40) Other rheumatic heart diseases (I09) Cardiomyopathy (I42) Subarachnoid haemorrhage (I60) Hypertensive heart disease (I11) Atrio-ventricular and left Intra-cerebral haemorrhage (I61) Hypertensive heart and renal disease (I13) bundle-branch block (I44) Other non-traumatic intracranial haemorrhage (I62) Other pulmonary heart diseases (I27) Other conduction disorders (I45) Cerebral infarction (I63) Other diseases of pulmonary vessels (I28) Cardiac arrest (I46) Stroke, not specified as haemorrage of infarction (I64) Other diseases of pericardium (I31) Paroxysmal tachycardia (I47) Other cerebrovascular diseases (I67) Acute and sub-acute endocarditis (I33) Atrial fibrillation and flutter (I48) Non-rheumatic mitral valve disorders (I34) Other cardiac arrhythmias (I49) Non-rheumatic aortic valve disorders (I35) Complications and ill-defined descriptions Non-rheumatic tricuspid valve disorders (I36) of heart disease (I51) I20-I25 Angina pectoris (I20) Acute myocardial infarction (I21) Subsequent myocardial infarction (I22) Other acute ischaemic heart diseases (I24) Chronic ischaemic heart disease (I25) Q20-Q28 Cardiac chambers and connections (Q20) Cardiac septa (Q21) Pulmonary and tricuspid valves (Q22) Aortic and mitral valves (Q23) Other congenital malformations of heart (Q24) I50 Heart failure(i50) Atherosclerosis (I70) Diseases of the capillaries (I78) Other aneurysm (I72) Other disorders of arteries Arterial and arterioles embolism (I77) and thrombosis (I74) 3

4 CVD and Leading Causes of Death, N.C., 2010 Cancer 18,013 23% Heart Disease 17,090 22% Stroke 4,281 5% Other CVD 1,861 2% All other causes 30,107 38% Other Unintentional Injuries* 2,762 4% Chronic Lower Respiratory Disease 4,490 6% *Unintentional injuries other than motor-vehicles injuries. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Leading Causes of Death in North Carolina, SCHS Online Database,

5 Percent Percentage of Deaths Caused by CVD, N.C., (n=23,150) 36.3 (n=17,579) (n=4,760) (n =23,294) (n=18,520) (n=4,446) (n=25,552) (n=19,838) (n=5,329) (n=25,726) (n=19,649) (n=5,692) * 1990** 1996** 2000** 2010*** Total CVD Stroke Heart Disease (n=23,232) 21.7 (n=17,090) 5.4 (n=4,281) 1996=Establishment of Justus-Warren Task Force *Total CVD estimate is the sum of deaths from diseases of the heart, hypertension, cerebrovascular diseases, and atherosclerosis. **Total CVD estimate is the sum of deaths from diseases of the heart, cerebrovascular diseases, and atherosclerosis. ***Total CVD Deaths includes deaths from ICD-10 codes I00-I99 Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Leading Causes of Death in North Carolina. SCHS Online Database,

6 Age-Adjusted Death Rate Major Cardiovascular Disease Death Rates, NC vs. US North Carolina United States 0 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Major Cardiovascular Disease: : ICD-10 codes I00-I78; : ICD-9 codes , multiplied by comparability ratio of Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

7 Age-Adjusted Death Rate Heart Disease Death Rates, NC vs. US, North Carolina 0 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year United States Heart Disease: : ICD-10 codes I00-I09, I11, I13, I20-I51; : ICD-9 codes , 402, 404, multiplied by comparability ratio of Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

8 Age-Adjusted Death Rate Stroke Death Rates, NC vs. US, North Carolina United States 0 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Stroke: : ICD-10 codes I60-I69; : ICD-9 codes , multiplied by comparability ratio of Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

9 Age-adjusted Death Rate Coronary Heart Disease Death Rates, North Carolina United States '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 Year Coronary Heart Disease: : ICD-10 codes I20-I25; : ICD-9 codes , multiplied by comparability ratio of Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

10 Contribution of prevention to decline in CVD mortality About 44% of the reduction in national coronary heart disease mortality that occurred between 1980 and 2000, is attributed to changes in risk factors (Ford et al. 2007). Positive contributions: reduction in total cholesterol, systolic blood pressure, smoking and physical inactivity Negative contributions: Increase in diabetes and obesity 47% attributed to treatment 10

11 Percent Premature Major Cardiovascular Disease Deaths, NC vs. US North Carolina United States 10 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05 '07 '09 Year Premature= Less than 65 years of age. Major Cardiovascular Disease: : ICD-10 codes I00-I78; : ICD-9 codes , Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, and CDC WONDER Online Database,

12 MORBIDITY Over 650,000 adult North Carolinians (about 9.2% of the adult population) have a history of either heart attack, angina or stroke Cardiovascular disease is the leading cause of hospitalization in North Carolina 162,329 CVD hospital discharges (about 16.7% of all discharges) in ,000 stroke 108,000 heart disease 39,000 heart attacks Heart disease and Stroke are among the top ten leading causes of disability in noninstitutionalized US adults. 12

13 Age-Adjusted Discharge Rate CVD Hospital Discharge Rates, N.C., ,000 2,500 2,000 1,500 1, Total Males Females 0 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM Codes ; Principal diagnosis only. Discharge rates per 100,000 population, age-adjusted to the U.S standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012.

14 Total Hospital Charges in 2011 Dollars Cardiovascular Disease Hospital Charges, N.C., $6,000,000,000 $5,000,000,000 $4,000,000,000 Total Males Females $3,000,000,000 $2,000,000,000 $1,000,000,000 $0 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM codes ; Principal diagnosis only. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012. Charges adjusted to 2011 dollars using the Bureau of Labor Statistics Consumer Price Index tables for Medical Care for years , U.S. city average, not seasonally adjusted. Year

15 Charges per Stay in 2011 Dollars Cardiovascular Disease: Average Hospital Charges per Stay, N.C., $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Total Males Females '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM codes ; Principal diagnosis only. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012. Charges adjusted to 2011 dollars using the Bureau of Labor Statistics Consumer Price Index tables for Medical Care for years , U.S. city average, not seasonally adjusted.

16 Medicaid Cost in U.S. Dollars Annual Medicaid Costs for Selected CVD Sub-Categories, N.C., 2011 $700,000,000 $648,317,030 $600,000,000 $500,000,000 $400,000,000 $300,000,000 $200,000,000 $100,000,000 $231,402,818 $177,403,772 $189,045,580 $75,022,000 $70,995,836 $0 Total CVD Heart Disease Stroke Hypertension CHF CHD ICD-10: I00- I99, Q20-Q28 ICD-10: I00-I09, I11, I13, I20-I51 ICD-10: I60-I69 ICD-10: I10-I15 ICD-10: I50 ICD-10: I20-I25 CHD: Coronary Heart Disease. CHF: Congestive Heart Failure. Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Annual Medicaid Cost due to CVD, Produced by: State Center for Health Statistics, 09/19/2012.

17 257, ,700 36, ,566 27,771 38,808 Annual Cost per Beneficiary Number of Beneficiaries Annual Medicaid Costs per Beneficiary for Selected CVD Sub-Categories, N.C., 2011 $5, Annual Cost per Beneficiary Number of Beneficiaries $4, ,000 $4, , ,000 $3, $2, $2, $2, $1, $2, ,000 $1, ,000 $1, ,000 $0.00 Total CVD Hypertension CHD Heart Disease CHF Stroke ICD-10: I00-I99, Q20-Q28 ICD-10: I10-I15 ICD-10: I20-I25 ICD-10: I00-I09, I11, I13, I20-I51 CHD: Coronary Heart Disease. CHF: Congestive Heart Failure. Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Annual Medicaid Cost due to CVD, Produced by: State Center for Health Statistics, 09/19/2012. ICD-10: I50 ICD-10: I60-I69 0

18 RISK FACTORS Nine risk factors account for more than 90% of the risk of initial heart attacks and strokes (INTERHEART & INTERSTROKE studies): 1. Hypertension 2. Current smoking 3. Obesity (abdominal) 4. Unhealthy diet 5. Physical inactivity 6. Diabetes 7. Alcohol intake 8. Psychosocial factors (psychological stress, financial stress, major adverse life events, locus of control, depression) 9. Abnormal lipids (e.g. cholesterol) 18

19 RISK FACTORS High blood pressure Primary or contributing cause for 45% of all CVD deaths If completely eliminated from the population, there will be 34.6% fewer cases of stroke and 17.9% fewer cases of myocardial infarction Responsible for about 45% of all strokes occurring in hypertensive individuals High cholesterol and other lipid abnormalities Stronger risk factor for heart attacks compared to strokes 19

20 Percent Prevalence of Modifiable Risk Factors: Overweight & Obesity, N.C Total Overweight Obese '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Total Obese Overweight Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, Extracted by: Heart Disease and Stroke Branch: 10/11/2012.

21 Percent Prevalence of Modifiable Risk Factors: Smoking and Physical Inactivity, N.C Smoking Physical Inactivity 10 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Smoking Physical Inactivity Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, Extracted by: Heart Disease and Stroke Branch: 10/11/2012.

22 Percent Prevalence of Modifiable Risk Factors: High Cholesterol, Hypertension, Diabetes, and Recommended Fruits and Vegetables Consumption, N.C High Cholesterol Diabetes Hypertension Recommended Fruits and Vegetables Consumption* 5 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year High Cholesterol Hypertension Diabetes Fruits & Vegetables *Consumed five or more servings of fruits or vegetables per day Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, Extracted by: Heart Disease and Stroke Branch: 10/11/2012.

23 DISPARITIES/NON-MODIFIABLE RISK FACTORS Race/Ethnicity: African Americans bear a greater burden of CVD Gender: Men are more like to get a heart attack at an earlier age (<55 years) than women Age: Risk of CVD increases with age irrespective of the presence of potentially modifiable risk factors Socio-Economic Status (Education, income): The poor and less educated bear a greater burden of CVD Geographical location: The eastern part of the state has a greater burden of CVD (especially stroke) 23

24 Age-Adjusted Death Rate 500 Major Cardiovascular Disease Death Rates by Race/Ethnicity, N.C., '99 '01 '03 '05 '07 '09 Year Non Hispanic African American Non Hispanic Whites Hispanics American Indian or Alaska Native Asian or Pacific Islander Overall Major Cardiovascular Disease: : ICD-10 codes I00-I78. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database,

25 Percent CVD Modifiable Risk Factors by Race and Ethnicity, N.C., 2011 White Black American Indian Hispanic Overweight & High Cholesterol Hypertension Physical Inactivity* Current Smoker Diabetes Obese Adults=18+ *Physical Inactivity=Respondent answered No to During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Behavioral Risk Factor Surveillance System, Extracted by: Heart Disease and Stroke Branch: 10/16/2012.

26 Cardiovascular Disease Death Rates by County of Residence, N.C., Death Rate N.C. overall: U.S.: Total Cardiovascular Disease, including congenital malformations: ICD-10 codes I00-I99; Q20-Q28. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database,

27 Heart Disease Death Rates by County of Residence, N.C., Death Rate N.C. overall: Heart Disease: ICD-10 codes I00-I09, I11, I13, I20-I51. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. N.C. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Volume 2: Leading Causes of Death in North Carolina 2010, U.S. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database,

28 Stroke Death Rates by County of Residence, N.C., Death Rate N.C. overall: 47.8 Stroke: ICD-10 codes I60-I69. Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. N.C. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. Volume 2: Leading Causes of Death in North Carolina 2010, U.S. Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database,

29 Cardiovascular Disease Hospital Discharge Rates by County of Residence, N.C., Hospital Discharge Rate N.C. overall: Total Cardiovascular Disease, excluding congenital malformations: ICD-9-CM codes: ; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012.

30 Heart Disease Hospital Discharge Rates by County of Residence, N.C., Hospital Discharge Rate N.C. overall: Heart Disease: ICD-9-CM codes: , , 402, 404, , ; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012.

31 Stroke Hospital Discharge Rates by County of Residence, N.C., Hospital Discharge Rate N.C. overall: Stroke: ICD-9-CM codes ; Principal diagnosis only; N.C. residents only. Discharge rates per 100,000 population age-adjusted to the U.S standard population. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012.

32 CONCLUSION Major progress in curbing CVD mortality over the past 3 decades CVD still among the top killers of North Carolinians Premature deaths as a proportion of all CVD deaths on the rise Steady rise in the prevalence of several key modifiable risk factors Disparities by race/ethnicity, social class and geographic location persist Projected exponential rise in the already hefty economic burden of CVD Need for continued and renewed focus on control of risk factors 32

33 References Centers for Disease Control and Prevention (CDC). CDC WONDER; compressed mortality file; underlying cause-of-death. Updated Accessed 05/17, North Carolina State Center for Health Statistics (NC-SCHS). North carolina vital statistics, volume 2: Leading causes of death North Carolina State Center for Health Statistics (NC-SCHS). Behavioral risk factor surveillance system. Updated Accessed 07/17, North Carolina State Center for Health Statistics (NC-SCHS). North carolina provisional inpatient hospital discharges, Centers for Disease Control and Prevention (CDC). Prevalence and most common causes of disability among adults--united states, MMWR Morb Mortal Wkly Rep. 2009;58(16): Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, et al. (2007) Explaining the decrease in US deaths from coronary disease, N Engl J Med 356: Detailed technical appendix of model available. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet. 2004;364(9438): doi: /S (04) O'Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study. Lancet. 2010;376(9735): doi: /S (10) IOM (Institute of Medicine) A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. 33