Coronary heart disease trends in England and Wales from 1984 to 2004: concealed levelling of mortality rates among young adults

M O’Flaherty; E Ford; S Allender; P Scarborough; S Capewell

doi:10.1136/hrt.2007.118323

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Epidemiology

Coronary heart disease trends in England and Wales from 1984 to 2004: concealed levelling of mortality rates among young adults

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2002 mortality rate for coronary heart disease in Italy: a statistical outlier or a sentinel event?
Giampiero Favato
Published on: 27 February 2008
Saving lives means spending NHS resources effectively
Michael R Chester
Published on: 30 August 2007

Published on: 27 February 2008
2002 mortality rate for coronary heart disease in Italy: a statistical outlier or a sentinel event?
- Giampiero Favato, Academic Fellow
- Other Contributors:
  Carole Print
Dear Editor,
The latest available, age-adjusted overall mortality rate for CHD in Italy refers to the year 2002 [1]. For the first time in the last twenty years, the 2002 rate (42.05 deaths per 100,000 inhabitants) showed a significant increase (+1.1%) over the previous year. The mortality rate for CHD grew by 0.8% in men and by 1.4% in women.
Since 1980, the age-adjusted mortality rate for CHD decline...
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Dear Editor,
The latest available, age-adjusted overall mortality rate for CHD in Italy refers to the year 2002 [1]. For the first time in the last twenty years, the 2002 rate (42.05 deaths per 100,000 inhabitants) showed a significant increase (+1.1%) over the previous year. The mortality rate for CHD grew by 0.8% in men and by 1.4% in women.
Since 1980, the age-adjusted mortality rate for CHD declined by 47.8% in men and 49.1% in women, showing a progressive decline in the average annual reduction of mortality rate. The average annual mortality rate declined by 3.27% in men and 3.81% in women in the 1980s, decreasing to 2.84% and 2.61% in the 1990s.
To better understand the complex dynamics of overall mortality rates, we examined the age-specific mortality data from CHD in 2002. Compared to the previous year, all age groups showed a significant decline in annual mortality rate, with the exception of the elderly population (over 75 years of age) showing a concerning 2.71% increase (1.91% in men and 3.16% in women). The increase in mortality rate seemed to be associated to ageing, growing by 0.16% in the 75-79 age group, by 1.92% in the 80-84 age group and by 6.42% in the population over 85 years. For this group, the 2002 mortality rate (2,316 per 100,000) was higher than the one registered in 1985 (2,199 deaths per 100,000).
The 2002 dramatic change in CHD mortality rate affected the weakest cohort of the Italian society, raising concerns about the equality of the welfare system. Although it is too early to draw any sustainable conclusion, previous research demonstrated that the elderly represent the population subgroup most vulnerable to unequal income distribution [2]. In the past few years, the elderly living on inadequate social pensions found their disposable income progressively sliding well below the threshold of poverty [3]. 7.2% of them admitted they could not afford one complete meal every other day, while 9.6% did not have enough money to pay for heating, clothes or medicines [4].
The 2002 “odd” mortality rate increase for CHD should provide the opportunity to better understand the difficult life conditions of the elderly and, hopefully, to take immediate social actions in favour of the most vulnerable cohort of citizens.
References
1. The cause of death was determined using the ICD-9 codes 410-414.
Mortality data available at: http://www.iss.it/site/mortalita/Scripts/SelCause.asp
2. Materia E, Cacciani L, Bugarini C et al (2005).
Income inequality and mortality in Italy.
European Journal of Public Health. Vol.15, No4:411 -417
3. Istituto Nazionale di Statistica – ISTAT (2004).
La povertá relativa in Italia. Anno 2003.
Available at: http://www.istat.it/salastampa/comunicati/non_calendario/20041013_00/
4. Istituto Nazionale di Statistica – ISTAT (2004).
I consumi delle famiglie. Anno 2002.
Available at: http://www.istat.it/dati/catalogo/20040330_00/
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Conflict of Interest:
None declared.
- Back to top
Published on: 30 August 2007
Saving lives means spending NHS resources effectively
- Michael R Chester, Consultant Cardiologist & Director NRAC
Dear Editor,
O'Flaherty and colleagues (1) have identified a worrying change in the hitherto improving CHD mortality data in England and Wales that has occurred despite record spending on coronary revascularisation. They correctly propose that the health intervention measures, as recommended by Wanless (2) and supported by the National Heart Forum (3) and NICE (4), should be urgently implemented in an attempt to p...
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Dear Editor,
O'Flaherty and colleagues (1) have identified a worrying change in the hitherto improving CHD mortality data in England and Wales that has occurred despite record spending on coronary revascularisation. They correctly propose that the health intervention measures, as recommended by Wanless (2) and supported by the National Heart Forum (3) and NICE (4), should be urgently implemented in an attempt to prevent premature death especially in young socially disadvantaged adults.
What 0'Flaherty and colleagues fail to address is the funding issue. As Wanless hints in his report, the most logical and theoretically least challenging way to fund the expansion of effective preventative interventions is to redeploy resources from wasteful and expensive practices that are unproven or whose cost/benefit balance cannot be justified.
PCT commissioners have a duty to optimise the effectiveness of NHS resources and should urgently review their blank cheque approach to palliative percutaneous coronary intervention (PCI). The Courage trial (5) confirmed that PCI does not improve prognosis and is only marginally superior to optimal drug treatment in ameliorating symptoms in low-risk stable angina patients. Griffin et al., (6) confirmed the suspicions first raised following the RITA-2 study (7), that the high cost of PCI cannot be justified. These data, coupled with concerns over late drug eluting stent (DES) thrombosis and the controversy around the inappropriate implantation of DES in unlicensed situations have combined to change practice in the US where manufacturers have recently reported a more than 40% slump in DES sales.
When the QALY cost of preventative measures (£20-£400) (4) are compared to PCI (£47,000) (6) the case for redeploying resources becomes overwhelming, especially when the effectiveness of preventative measures take account of their ability to reduce the need for expensive revascularisation procedures.
References
1. O'Flaherty M E, Ford E S, Allender S, Scarborough P, Capewell S.
Coronary heart disease trends in England and Wales from 1984 to 2004: concealed leveling of mortality rates among young adults
Heart published online 19 Jul 2007; doi:10.1136/hrt.2007.118323
2. Wanless report.
http://www.hm- treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless_final.cfm
3. The National Heart Forum And The UKPHA Submission To: HM Treasury
Review: Securing Good Health for the Whole Population by Derek Wanless.
December 2003. LS\WANLESS\7791
4. NICE Public Health Intervention Guidance no.2
http://www.nice.org.uk/page.aspx?o=PhysicalActivityandEnv
5. Boden et al.
Optimal Medical Therapy with or without PCI for Stable Coronary Disease.
N Engl J Med 2007; 356:1503-1516
6. Griffin et al.
Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study.
BMJ 2007;334:624(24 March)
7. Sculpher MJ, Smith DH, Clayton T, Henderson R, Buxton MJ, Pocock SJ, et al.
Coronary angioplasty versus medical therapy for angina.
Eur Heart J 2002;23:1291-300
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Conflict of Interest:
None declared.
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