Burgess, A., Maslin-Prothero, S., Lathlean, J., Smith, H., Turnbull, J., George, S., Gerard, K. and Lattimer, V.
Integrated out-of-hours care: The challenges of partnership working and the potential solutions
Journal of Epidemiology and Community Health, 59, (Supplement), supplement The Society for Social Medicine 49th Annual Scientific Meeting: 14-16 September 2005, The University of Glasgow, .
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Background: Between 1980 and 2000, age adjusted coronary heart disease (CHD) mortality rates in the US fell by over 40%. Our study aimed to examine how much of this fall could be attributed to medical and surgical treatments, and how much to changes in cardiovascular risk factors.
Methods: We applied the previously validated, cell based IMPACT CHD mortality model to the USA population of 281 million. This model synthesises data on:
* numbers of patients with various forms of CHD
* the proportion receiving specific treatments
* the effectiveness of these treatments (survival benefit over a minimum of one year)
* population trends in major risk factors
* the corresponding changes in mortality.
The main data sources were published trials and meta-analyses, official statistics, clinical audits, and NHANES surveys.
Results: Between 1980 and 2000, CHD mortality rates in the US fell by 45% in men and by 41% in women aged 25–84 years. This resulted in 274 275 fewer deaths in 2000. Approximately 48% of this fall was attributed to treatments in individuals (including 13% heart failure treatments, 11% secondary prevention therapies, 7% initial treatments of acute myocardial infarction, and 7% from revascularisation procedures). Approximately 50% of the mortality fall was attributable to changes in population risk factors: reductions in cholesterol (20%), smoking (22%), and blood pressure (30%), substantially offset by increases in diabetes (–9%) and obesity (–4%). Improvements in physical activity were modest and poorly quantified. The mortality fall attributable to other, unmeasured factors appeared minimal (<2%), representing a model fit of 97.5% The proportional contributions of specific treatments and risk factor changes to the overall mortality decrease remained relatively consistent in sensitivity analyses.
Conclusions: Approximately half the substantial fall in CHD mortality rates in the US population between 1980 and 2000 was attributable to reductions in major risk factors, mainly smoking, cholesterol, and blood pressure. Worrying adverse trends were seen in obesity and diabetes. Almost half the mortality fall was attributable to therapies in the community and in hospital. This emphasises the importance of a comprehensive CHD strategy which promotes primary prevention, particularly a healthier diet and tobacco control, and which maximises the population coverage of effective treatments, especially medications for secondary prevention and heart failure.
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