overview of cvd epidemiology helen johansen (plus a cast of thousands) i. what is surveillance?...

Overview of CVD EpidemiologyHelen Johansen (plus a cast of thousands)

I. What is surveillance?

Where to get Info

Data sources

Type of information

II. What is CVD?

AMI

Heart Failure

Stroke

III.Overview of stats

Mortality

Hospitalization

A bit on CHF

A bit on AMI

IV. Risk factors

Combo

Physical activity

Body weight

Diabetes

High blood pressure

V. Costs of CVD

VI. Future directions

What is surveillance?What is surveillance?

Surveillance is the ongoing collection, analysis, and use of health data for the

planning, implementation, and assessment of disease treatment and control.

Surveillance is the foundation for planning

and supporting prevention strategies

Identify extent of the problemIdentifying differences by gender, age and regionMap emerging patterns and trendsContribute to policy makingMeasure progress in prevention and treatmentMeasuring health care utilization levels

Uses of surveillance dataUses of surveillance data

Improve the health of Canadians

Improve the health of the health care system

Mortality

Rates

PYLL

Prevalence

Incidence

Health care utilization

hospital (days, procedures)

physician claims

drugs

Risk Factors

Costs

Information by person, place and time

Information by person, place and timeMortality

Rates

PYLL

Prevalence

Incidence



physician claims

drugs

Risk Factors

Costs

Analytical: Outcome studies, Clinical trials, Micro-stimulation modelling……

Information by person, place and time

Mortality

Rates

PYLL

Prevalence

Incidence



physician claims

drugs

Risk Factors

Costs

Vital Statistics

Surveys, record linkage

Registries, record linkage

Administrative databases

hospital

physician claims

drugs

Surveys

Aggregate consumption data + Admin data

Lif

e C

ycle

Birth

Risk Factors

Disease - Onset

Disease - Progression

Disease interactions

Disability

Death

Integrated Surveillance FrameworkPerson Risk Indicators

Enviro-Determin Indicators

Prom-Prev Indicators

Management Indicators

Examples:SmokingCholesterolPhysical activityNutritionBlood pressureDiabetesLiteracy/ educationIncomeStress

Examples: air qualityWater qualitysecond hand smokeChemical exposuresingle parent familiesimmigrant CrimeEmploymentlow income

Examples: risk factor prog.public awareness of riskssmoking cessation prog.anti-smoking bylawsrisk factor screening teenage birthssocial assistance

Examples: Number & type of doctorsprimary care visitsPrescriptionsdrug adverse reactionstreatment effectivenessservice wait timesRehabilitationinfant mortalitysurvival/cure

Health Status Indicators

Examples: PrevalenceIncidenceHospitalizationReadmission Hospital daysComorbidityMortality rateHealth adjusted life expectancyFunctional status

Direct-simple measures: Prevalence, Mortality Derived Indicators/Data-Integration: Outcomes, Incidence What if tools / Projections

Data sourcesCCHSCHMSNPHS

Data sourcesCCHSCHMSNPHS

Data sourcesHPOISurvey

Data sourcesVital StatsHPOIAdministration Data

Data sourcesVital StatsHPOIAdministration Data

Information types:

What info can one get from Hospital data ?

• Prevalence estimates• Incidence estimates• In-hospital surgeries• Case fatality• Length of stay• Time to readmission• Co morbidities

• Link to mortality to get death out of hospital

• Link to surveys• Link to drug plan….

Age, sex, Health regions, Hospital, Census variables…

Hospital alone Hospital linked

Current Canadian sources of CVD dataCVD_in_Canada Series:• Joint publication of the CHSFC, PHAC, STC, CIHI, CCS and CCORT• published every two years. Last issue was “The Increasing Burden of

Heart Disease and Stroke in Canada”.

Health indicators • Series of set indicators by Health region out every two years free on the

web by STC and CIHI.-Mortality Rates for AMI, Stroke -30-day AMI In-hospital Mortality -30-day Stroke In-hospital Mortality -365-day Relative Survival Rate for AMI-180-day Relative Survival Rate for Stroke

-

-Wait Times for Cardiac Surgery-Re-admissions for AMI, Heart Failure-Smoking -Physical Activity -Obesity CCORT www.ccort.ca (Maps and Atlas can be downloaded for free)

• A group of CVD researchers, funded by grants, that uses surveys and linkable administrative data to describe the state of CVD risk factors, interventions and outcomes across health regions.

• Its output is a series of research papers in the CJC and an Atlas.

http://www.ccort.ca/

Useful sites from PHAC1. Centre for Chronic Disease Prevention and Control in the Public Health

Agency of Canada: http://www.phac-aspc.gc.ca/ccdpc-cpcmc/index_e.html

2. Here is a link to PHAC 'surveillance' web page:http://www.phac-aspc.gc.ca/ccdpc-cpcmc/surveil_e.html

3. This is a link to the CVD sub site:http://www.phac-aspc.gc.ca/ccdpc-cpcmc/cvd-mcv/index_e.html

At the above link, you can be directed to the following: - CVD Online (outdated) (see below for infobase) - Publications - Inventory of CVD databases (currently being updated)

4. Here is the link to the latest publication (Growing Burden):http://www.cvdinfobase.ca/cvdbook /

5. Finally, here is a link to INFObase: http://www.cvdinfobase.ca/

http://www.phac-aspc.gc.ca/ccdpc-cpcmc/index_e.html

http://www.phac-aspc.gc.ca/ccdpc-cpcmc/surveil_e.html

http://www.phac-aspc.gc.ca/ccdpc-cpcmc/cvd-mcv/index_e.html

http://www.cvdinfobase.ca/cvdbook/



http://www.cvdinfobase.ca/



Useful sites from Stat Can• Health Portal• http://cansim2.statcan.ca/cgi-win/cnsmcgi.pgm?Lang=E&SP_Action=Theme&SP_ID=2966

• Health Indicator publication:• http://dissemination.statcan.ca/bsolc/english/bsolc?catno=82-221-XWE

• Community Profiles• http://www12.statcan.ca/english/census06/data/profiles/community/Index.cfm?Lang=E

• Health Reports• http://www.statcan.ca/bsolc/english/bsolc?catno=82-003-X

• Health Webpage• http://cansim2.statcan.ca/cgi-win/cnsmcgi.pgm?Lang=E&ResultTemplate=Srch2&CORCmd=GetTList&CORId=2966

• Health Profiles• http://www.statcan.ca/bsolc/english/bsolc?catno=82-576-X&CHROPG=1

• Health by Subject• http://www.statcan.ca/cgi-bin/downpub/freepub.cgi?subject=2966#2966

• CANSIM Tables Vital Stats• http://cansim2.statcan.ca/cgi-win/cnsmcgi.exe?&Lang=E&RootDir=CII/&ResultTemplate=CII/

CII_FLst&Array_Pick=1&ArrayId=102*

• CANSIM Tables CCHS• http://cansim2.statcan.ca/cgi-win/cnsmcgi.exe?&Lang=E&RootDir=CII/&ResultTemplate=CII/


• CANSIM Tables Census• http://cansim2.statcan.ca/cgi-win/cnsmcgi.exe?&Lang=E&RootDir=CII/&ResultTemplate=CII/


CHF 428

CARDIOVASCULAR DISEASE 430-438

CEREBROVASCULAR 430-438 IHD 410-414

Heart attack

AMI 410

Intracerebral Hemorhage 431

Subarachnoid Hemorhage 430

Acute but Ill Defined 436

Ischemic Stroke 434

Acute stroke 430, 431, 434, 436

Common Cardiovascular diseases

A myocardial infarction occurs when an atherosclerotic plaque slowly builds up in the inner lining of a coronary artery and then suddenly ruptures, totally occluding the artery and preventing blood flow downstream.

Acute myocardial infarction (AMI or MI), more commonly known as a heart attack, is a disease state that occurs when the blood supply to a part of the heart is interrupted. The resulting ischemia or oxygen shortage causes damage and potential death of heart tissue.

http://en.wikipedia.org/wiki/Image:Heart_attack_diagram.png

http://en.wikipedia.org/wiki/Atherosclerosis

http://en.wikipedia.org/wiki/Atheroma

http://en.wikipedia.org/wiki/Coronary_artery

http://en.wikipedia.org/wiki/Blood_flow

Stroke (or cerebrovascular accident or CVA) is the clinical designation for a rapidly developing loss of brain function due to an interruption in the blood supply to all or part of the brain. This phenomenon can be caused by thrombosis, embolism, or hemorrhage (= haemorrhage)

Strokes can be classified into two major categories: ischemic and hemorrhagic.

In an ischemic stroke, which is the cause of approximately 80% of strokes, a blood vessel becomes occluded and the blood supply to part of the brain is totally or partially blocked.

A hemorrhagic stroke, or cerebral hemorrhage, is a form of stroke that occurs when a blood vessel in the brain ruptures or bleeds. There are two types of hemorrhagic stroke: intracerebral hemorrhage (bleeding into the brain) , and subarachnoid hemorrhage (bleeding around the brain). Hemorrhagic strokes are more dangerous than their more common counterpart, ischemic strokes.

Congestive heart failure (CHF), also called congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood through the body.

Heart failure is a progressive disorder in which damage to the heart causes weakening of the cardiovascular system. It manifests by fluid congestion or inadequate blood flow to tissues.

The term "heart failure" simply means that your heart isn't pumping blood as well as it should. Heart failure doesn't mean your heart has stopped working or that you are having a heart attack (but, people with heart failure often have had a heart attack in the past). Heart failure is also called congestive heart failure, or CHF. "Congestive" means fluid is building up in the body because the heart isn't pumping properly.

The Epidemic of CVD MortalityNorth America, 20th c.

1950 1970

Ischemicheart disease

Cerebrovasculardisease

1900

mor

talit

y

0

5

10

15

20

25

30

FemalesMales

Females 0.5 0.5 0.6 1.2 1.9 6 11.7 21.8 4.1

Males 0.5 0.5 0.7 1.4 3.9 10.4 19.3 27 5.5

15-19 20-24 25-34 35-44 45-54 55-64 65-74 75+ 12+

Percentage of individuals aged 12+ who report having heart disease by age group and gender, Canada, 2005

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Canadian Community Health Survey Data.

0102030405060708090

100

Need help Have activityrestrictions

>1 disabilityday in the past

14 days

Depressed

heart disease stroke without HD or stroke

Percentage of individuals aged 12+ years with heart disease or stroke who report limitations in their lives compared to those without heart

disease or stroke, Canada, 2005


0

5

10

15

20

25

30

35

Male Female Male Female Male Female Male Female Male Female

Age 20-49 Age 50-64 Age 65-79 Age 80+

Proportion of adults in the general population aged 20+ years, who reported heart conditions by age and sex, Canada, 2003(CCHS)

Heart disease Stroke Heart Attack Angina CHF

Top 10 diagnoses for seniors (65+) by office-based physicians (thousands of visits) 1999

15,000

10,000

5,000

0

Diseases of circulatory systemEndocrine/nutrition/metabolic/immunityMusculoskeletal diseaseDisease of respiratory systemCentral nervous systemSymptomatic and ill-defined conditionsMental disordersDiseases of digestive systemNeoplasmsDiseases of genitourinary system

Source: IMS Health Canada

Figure 2-34 Number of prescriptions for treatment of cardiovascular diseases, Canada, 1996-2001 (millions)

30.032.5

43.5

0

10

20

30

40

50

1996 1998 2001

Num

ber

(mill

ions

)

Source: Health Canada, using data from IMS Health, Canada

Other (94.1)29%

CVD (43.5)14%

Analgesic (19.7)6%

Anti-arthritic

(15.0)5%

Bronchial Therapy

(14.3)5%

Anti-spasmodic/

Anti-secretory

(14.9)5%

Cholesterol Agents (12.4)4%

Diruetic (11.7)4%

Anti-infective

(24.6)8%

Psychotherapeutic (35.3)11%Hormone

(27.1)9%

Source: Health Canada, using data from IMS Health, Canada

Figure 2-35 Estimated number and percent of prescriptions dispensed, top 10 therapeutic classes, Canada, 2001 (millions)

Mortality

Leading Causes of Death, Number and Percentage of Deaths,Canada, 2003

Other IHD (22,129) AMI (18,662)

Cerebrovascular (15,283) Other CVD (18,181)

Accid./Poison/Viol. (14,099) Cancer (67,423)

Infectious Diseases (3,607) Diabetes (7,970)

Other (40,339) Respiratory (18,472)

All CardiovascularDisease (74,255) 33%

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Vital Statistics data.

0

100

200

300

400

500

600

IHD CEREBROVASCULAR AMI Heart Failure

Mortality Rates for Males and Females by CVD types, Canada, 1950-2004

MALE FEMALE

Cerebrovascular disease excludes transient ischemic attacks. Age-standardized to 1991 Canadian Population. Note that the coding schemes for this condition changed in 1968, 1978 and 2000 and this may influence trends.Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Vital Statistics data.

0

50

100

150

200

250

300

350

400females males

Countries with Reported Age-Standardized Mortality Rates Rate of IHD per 100.000

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Organisation for Economic Co-operation and Development (OECD) data.

0

25

50

75

100

125

150

175

200

females males

Countries with Reported Age-Standardized Mortality Rates Rate of Cerebrovascular disease per 100.000

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Organisation for Economic Co-operation and Development (OECD) data.

0

10

20

30

40

50

< 25 25-34 35-44 45-54 55-64 65-74 75+ AllAges

Men Women

Percentage of Total Deaths Due to Cardiovascular Diseases by Age Group and Gender, Canada, 2003


05

101520253035404550

Men Women

Percent of Total Deaths Due to CVD by Gender and year, Canada, 1990-2003

ICD10 codes: I00-I78. Age-standardized to 1991 Canadian population..Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Vital Statistics data.

0

100

200

300

400

500

600Males Females

Chart 7. Age standardized mortality rates per 100,000 for all CVD by province, Aged 20+,

2001

Data Source: Canadian Mortality Data BaseAge/sex standardized by 5 year age groups against 2001 population* Significantly difference from all Canada rate

All Canada mortality rate

Men 409

* *

* *

All Canada mortality rate Women 258

* * **

0 50000 100000 150000 200000 250000

Injuries

Cancer

CVD

Respiratory

Digestive

Congenital Females Males

Number of Potential Years of Life Lost (PYLL) Prior to Age 75, by Disease Category, Canada, 2003


Hospitalization

Hospitalization for Men and Women by Diagnosis (Using most responsible diagnosis only), Canada, 2004 (excluding

pregnancy and childbirth, including newborns)

Mental Cardiovascular

Respiratory Digestive

Genitourinary Musculoskeletal

Injuries & Poisonings Other

All CardiovascularDisease (229,814) 17%

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Canadian Institute for Health Information data.

Percentage of patients aged 20 or older hospitalized for diseases of the circulatory system, Canada, 2001/02

Other CVD5.8%

CHF3.1%

Stroke3.7%

Other IHD5.1%

Heart Attack3.8%

All other causes of

hospitalization78.5%

Total diseases of the circulatory system (21.5%)

0

200

400

600

800

1000

1200

IHD CEREBROVASCULAR AMI Heart Failure

Hospitalization Rates for Males and Females by CVD types, Canada, 1979-2004

MALE FEMALE

Standardized rate uses 1991 Canadian Population. Cerebrovascular disease excludes transient ischemic attacks. Using most responsible diagnosis only. Note that the coding schemes for this condition changed in 1968, 1978 and 2000 and this may influence trends.Source: Public Health Agency of Canada, 2007 using data from Hospital Morbidity Database, Statistics Canada and CIHI.

0

200

400

600

800

1000

1200

1400

1600

1800

2000

25-34 35-44 45-54

55-64 65-74 75-85+

AMI Hospitalization Rates per 100,000 for Males and Females by Age Group, Canada, 1971-2004

MALE FEMALE

Source: Public Health Agency of Canada, 2007 using data from Hospital Morbidity Database, Statistics Canada and CIHI.

Number of Hospitalizations for Cardiovascular Disease by Age Group and Gender, Canada, 2003/04

0

20000

40000

60000

80000

100000

120000

140000

Responsible condition Associated Condition

F/M F/M F/M F/M F/M F/M F/M 25-34 35-44 45-54 55-64 65-74 75-84 85+


Age standardized rate per 100,000 for Selected CVD hospital visits and patients by sex, Aged 20+,

Canada, 1994/95 to 2000/01

AMI0

50

100

150

200

250

300

350

400

450

94/95 95/96 96/97 97/98 98/99 99/00 00/01 01/02

age

stan

dard

ized

rat

e/10

0,00

0

IHD0

200

400

600

800

1000

1200

1400

94/95 95/96 96/97 97/98 98/99 99/00 00/01 01/02

age

stan

dar

diz

ed r

ate/

100,

000

0

50

100

150

200

250

300

350

400

450

94/95 95/96 96/97 97/98 98/99 99/00 00/01 01/02

age

stan

dard

ized

rat

e/10

0,00

0

Stroke CHF0

50

100

150

200

250

300

350

400

450

94/95 95/96 96/97 97/98 98/99 99/00 00/01 01/02

age

stan

dard

ized

rat

e/10

0,00

0

Patients per 100,000 femalesVisits per 100,000 femalesVisits per 100,000 males

Patients per 100,000 males

Data Source: Health Person Oriented Information Database, HPOIAge-standardized to 2001, 5 year age groups

Age adjusted Rate for male and female hospitalized AMI visits and patients by fiscal year, Canada, 1994/95 to 2004/05.

0

50

100

150

200

250

300

350

400

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Fiscal year

Ag

e ad

just

ed r

ate/

100,

000

Male visitsFemale visitsMale patientsFemale patients

Data source: HPOI Statistics Canada.Condition was defined as the most responsible diagnosis ICD 9 codes 410; ICD10 CA codes I21,I22. Standardized to 1991 by 5 year age groups from age 20; Population data from Statistics Canada 2001 census.

Is AMI decreasing?

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

55000

60000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

year

Nu

mb

er

0

25

50

75

100

125

150

175

200

225

250

275

300

325

350

Ag

e st

d r

ate

per

100

,000

Number Crude rate Standardized rate

AMI Hospitalized Patients (Most Responsible Diagnosis), Canada, 1994-2004

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

55000

60000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

year

Nu

mb

er

chf ami stroke

Number of Hospitalized Patients by disease type (Most Responsible Diagnosis), Canada, 1994-2004

The “Greying of Canada”

Between 1991 and 2001, the population aged 80 years and over rose 41% to 932,000.

It is expected to increase an additional 43% between 2001 and 2011. By then, it will have surpassed an estimated 1.3 million.

The population from 45 to 64 years of age increased 36% between 1991 and 2001, witnessing the entry of the baby boomers into this group.

Total Number of Hospital Days

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

CVD AMI IHD Stroke CHF

Nu

mb

er o

f D

ays

Age/sex standardized† average number of days in hospital/patient by

year

0

2

4

6

8

10

12

14

16

18


Av

era

ge

nu

mb

er

of

da

ys

94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02

Age/sex standardized† percentage of hospital patients who die in hospital by

year

0

2

4

6

8

10

12

14

16

18


pe

rce

nta

ge

of

pa

tie

nts

Cardiovascular Disease Trends from all Hospital Records in Canada, aged 20+, 1994/95 to 2001/02

Data Source: Health Person Oriented Information Database, HPOI†Age-sex standardized to all CVD Patients in 1994/95 using 5 year age groups from age 20+.

4%

10%19%

11%

6%

9% 9%

16%

16%

3%

4%

9%

9%10%

11%18%

20%

16%

Neoplasms Mental CVD RespiratoryDigestive Genitourinary Musculoskeletal Injuries & PoisoningsOther

Number of days stayed by disease chapter and sex, 2004

MALE FEMALE

Some quick examples of CHF research:

Readmissions

Time trends

Projections

0

10

20

30

40

50

60

0 4 8 12 16 20 24 28 32 36 40 44 48 52

Weeks

Cum

ulat

ive

Perc

enta

ge

20-4445-6465-7980+

Denominator is Index CHF patients = 83,213

Cumulative rate of first re-hospitalization in Index CHF patients by age, Canada, 1996/97.

Time from discharge of index series of visits.

Number of CHF deaths and hospital episodes of those ages 20+ by month, April, 1994 to December 2004, Canada

0

1000

2000

3000

4000

5000

6000

7000

Apr-94 Apr-95 Apr-96 Apr-97 Apr-98 Apr-99 Apr-00 Apr-01 Apr-02 Apr-03 Apr-04

0

200

400

600

Hospital Episodes

Deaths

0

500

1000

1500

2000

2500

3000

3500

Apr-94 Apr-95 Apr-96 Apr-97 Apr-98 Apr-99 Apr-00 Apr-01 Apr-02 Apr-03 Apr-04

0

100

200

300

400

Number of CHF deaths and hospital episodes of those ages 20+ by month and sex, April, 1994 to December 2004, Canada

Hospital Episodes

Deaths

MenWomen

MenWomen

Number of CHF deaths of those ages 20+ by month and sex, Canada, 2004

0

500

1000

1500

2000

2500

20-49 50-59 60-69 70-79 80+

male female

Ten year average number of CHF deaths per month by age and sex Canada,1995-2004

0

50

100

150

200

250

Jun

Jul

Aug

Sep O

ct N

ov D

ec J

an F

eb M

ar A

pr M

ay

Male 20-59

Male 60-69

Male 70-79

Male 80+

Female 20-59

Female60-69

Female70-79

Female80+

010,00020,00030,00040,00050,00060,00070,00080,00090,000

100,000

1996 2000 2005 2010 2015 2020 2025Year

Num

ber

Projected number of “incident hospitalizations” for CHF patients, first diagnose, using high, medium and low population growth projections Canada, 1996 to 2050.

Given the aging population and average annual changein hospital rates over the previous 10 years, the number of CHF incident hospital cases per year is projected to more than double by the year 2025.

0

500

1000

1500

2000

2500

3000

3500

25-34 35-44 45-54

55-64 65-74 75-85+

HEART FAILURE Hospitalization Rates per 100,000 for Males and Females by Age Group, Canada, 1979-2004

MALE FEMALE


010,00020,00030,00040,00050,00060,00070,00080,00090,000

100,000

1996 2000 2005 2010 2015 2020 2025Year

Num

ber

Projected number of “incident hospitalizations” for CHF patients, first diagnose, using high, medium and low population growth projections Canada, 1996 to 2050.

Given the aging population and average annual changein hospital rates over the previous 10 years, the number of CHF incident hospital cases per year is projected to more than double by the year 2025. To keep the current number of incident cases the same as in 1996/97, the incidence of would have to decrease by 2.6% per year.

Revascularization and survival trends of Canadian acute myocardial infarction (AMI)

patients, 1995/96 to 2003/04• METHODS – DEFINITIONS - LIMITATIONS

• REVASCULARIZATION• How did revascularization rates within thirty days of a

heart attack change between 1995/96 and 2003/04?

• 30 DAY SURVIVAL

• How did death rates in hospital within thirty-days of a heart attack change between 1995/96 and 2003/04?

• RELATION OF REVASCULARIZATION TO SURVIVAL?• Are the heart attack patients revascularized within thirty

days between 1995/96 and 2003/04 more likely to survive 30 days?

# Age adjusted percentage of AMI patients who were revascularized within thirty days by year and sex, Nine

provinces, Canada

0

10

20

30

40

50

1995 1996 1997 1998 1999 2000 2001 2002 2003

male female

Revascularization rates within thirty-days of their attack increased in all provinces between 1995/96 and 2003/04. Male rates increased from 14% to 44%; female ones from 12% to 36%.

* Average Time to revascularization for AMI patients by age and sex, Canada, 1995/96 and 2003/04

0

10

20

30

40

50

60

70

80

1995

2003

On average, time-to-revascularization within one year of an heart attack decreased for all age and sex groups.

Male 20-44

Male 45-64

Male 65-79

Male 80+

Female 20-44

Female 45-64

Female 65-79

Female 80+

#Age adjusted percentage of AMI patients who died within thirty days by year and sex, Nine provinces, Canada

0

2

4

6

8

10

12

14

1995 1996 1997 1998 1999 2000 2001 2002 2003

Male Female

The percentage who died thirty-days after their attack decreased over time. Females have decreased more than males. In the most recent years, rates have levelled out.

5

7

9

11

13

15

0 10 20 30 40 50 60 70

% revascularized within 30 days

% d

yin

g w

ith

in 3

0 d

ays

NF NS NB QBON MA SA ALBC Linear (NF) Linear (AL) Linear (QB)Linear (MA) Linear (SA) Linear (BC) Linear (ON)Linear (NS) Linear (NB)

Provinces

Charts show the % of heart attack patients (AMI) dying within 30 days (in hospital) by % revascularized within 30 days. Rates are adjusted by age, sex and Charlson co-morbidities, 1995/96 to 2003/04 Almost all provinces showed a decreasing death rate with an increasing rate of revascularization.

Risk Factors

“How you live is how you die”

Core Data

BMI as a measure of obesity;

Physical inactivity;

Blood pressure;

Diabetes;

Smoking;

Cholesterol; and

Nutrition (consumption of fruits & vegetables)

“The risk factors of today are the

diseases of tomorrow …”

The focus is on Non CommunicableThe focus is on Non CommunicableDisease Risk Factor SurveillanceDisease Risk Factor Surveillance

Proportion of deaths attributable to leading risk factors

Proportion of deaths attributable to leading risk factors

World Health Organization Global Burden of Disease StudyWorld Health Organization Global Burden of Disease Study

Murray et al, 1996.

Poor water

supply

Physical inactivity

Malnutrition

12%

10%

8%

6%

4%

2%

0%

11.7%

Tobacco use

Hypertension

% o

f gl

obal

dis

abili

ty

6.0% 5.8%5.3%

3.9%

Modifiable Risk Factors (self-reported) among Adults Aged 20-59, Canada, 2005 Risk Factor Proportion of

the Population

Aged 20-59 Years (%)

Tobacco Smoking (Daily) 20.18

Physical Inactivity 49.14

Overweight (BMI ≥ 25.0) 49.36

> 5 servings per day of fruits & vegetables

59.55

High Blood Pressure* 10.25

Diabetes** 3.11

*High blood pressure was calculated using the two-question method. "Respondent has high blood pressure" and "Respondent taking meds. for high blood pressure".

**For the purposes of this report diabetes is listed as a major risk factor.



**For the purposes of this report diabetes is listed as a major risk factor.


Combined Risk Factors for Cardiovascular Disease (self-reported) among Adults Aged 20-59, Canada, 2005

Number of Risk Factors Risk Factors

(% of population)

No Risk Factors 21.92

At least 1 Risk Factor: 78.08

1 Risk Factor 39.08

2 Risk Factors 28.18

3 or More Risk Factors 10.82


Risk Factors for Heart Disease and Stroke among Adults Aged 18+ Years of Various Ethnic Backgrounds, Canada, 2005

Risk Factor Percent of Population with Risk Factor

White ChineseSouth Asian Black

Southeast Asian

Aboriginal

Tobacco Smoking (Daily) 19.0 5.8 6.7 10.0 20.57** 37.4

Physical Inactivity 55.2 66.3 59.4 61.9 61.3 54.0

Overweight (BMI ≥ 25.0) 52.5 19.5 38.2 53.3 34.5 60.0

≥ 5 servings per day of Fruits & Vegs 58.2 68.4 61.9 59.4 69.1 64.3

High Blood Pressure* 22.3 13.2 16.8 24.5 17.6 18.7

Diabetes 5.3 6.1 4.56** 6.4

**Sample size ≤ 30


The Canadian Way of Life

heavy into sports… eh!

Physical inactivity, 12+, by age group and gender, Canada, 2005

0

20

40

60

80

Age Group

Per

cen

t (%

)

Females Males

Females 30 38 43 49 51 53 51 55 72 50

Males 20 25 35 46 51 52 51 46 57 45

12-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75+ 12+

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Canadian Community Health Survey Data, excludes not stated.

0

10

20

30

40

50

60

70

Male 58 51.6 53.2 46.9 48.4

Female 61.8 58.6 59.3 50.5 52.3

1996 1998 2000 2002 2005

Percentage of individuals aged 20+ years who were physically inactive1, Canada, 1996 - 2005

1Energy level at or below the leisure time activity (1.5 kilcalories/kilogram/day)Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Canadian Community Health Survey Data.

Judith Mackay

RF: OBESITY (BMJ cover)Obesity: mulitple risks

Trends in Obesity Rates, Self-reported, 18+, Canada excluding territories, 1985-2005

0

5

10

15

20

Year

Per

cen

t (%

)

Obese 6.2 9.7 13.1 12.5 14.5 14.8 15.2 15.5 15.9

1985 1989 1990 1994 1996 1998 2000 2003 2004 2005

Obese: Self-reported BMI ≥ 30.0 Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Canadian Community Health Survey Data.

14.8

23.1

X Obese: Measured BMI ≥ 30.0

Trends in Obesity Rates, 18+, Canada excluding territories, 1978-2005

0

5

10

15

20

25

Year

Per

cen

t (%

)

Measured Self-reported


Overweight, 18+ Self-Reported Adult Body Mass Index 25.0 or Higher by Province/Territory, Canada,

2005

0

10

20

30

40

50

60

70

Province/Territory

Per

cen

t (%

)


Canada

HIGH BLOOD PRESSURE

High Blood Pressure*, 20+, by Age Group and Gender, Canada, 2005

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Age Group

Perc

en

tag

e (

%) Females Males

Females 3.2 6.6 11 21 36 53 62

Males 2.6 5.8 11 21 37 47 50

20-24 25-34 35-44 45-54 55-64 65-74 75+

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Canadian Community Health Survey Data.*Two part question used: Ever diagnosed with HBP / Respondent has HBP

0

5

10

15

20

1994 1996 1998 2000 2002 2004 2005

Female Male

Percentage of the general population aged 20+ years who reported having high blood pressure, Canada, 1994-2005


High Blood Pressure*, 20+, by Province/Territory, Canada, 2005

0

5

10

15

20

25

30

35

Perc

en

t (%

)

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, Canadian Community Health Survey Data.*Two part question used: Ever diagnosed with HBP / Respondent has HBP

Awareness, treatment, and control

of hypertension in Canada

Awareness, treatment, and control

of hypertension in Canada

Unaware of their hypertension

Not treated and not controlled

Treated and not controlled

Treated and controlled

16%

23%19%

42%

Of those 22% of Canadians with hypertension

The Canadian Heart Health Surveys, Joffres et al, 1997.

9%9%

20%20%

17.5%17.5%

20.5%20.5%

22.5%22.5%

>65 yr only>65 yr only

16%16%27%27%

6%6%

19%19%

2.5%2.5%

Control of hypertension worldwidepercent of patients with BP controlled

3. Joffres et al, Am J Hypertens 1997;10:1097

4. Marques-Vidal et al, J Hum Hypertens1997;11:213

1. JNC VI, Arch Intern Med 1997;157:2413

2. Colhoun et al, J Hypertens1998;16:747

Adapted from Mancia 1999

England2 India4

Spain4

Scotland4

Finland4

Germany4

Canada3USA1 Australia4

Zaire4

DIABETES

Percentage of the general population aged 12+ years. who reported having diabetes,Canada, 1994-

2005

0.0

1.0

2.0

3.0

4.0

5.0

6.0

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005Year

Per

cen

t (%

)

Females Males Both

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Statistics Canada, National Population Health Survey and Canadian Community Health Survey Data.

Diabetes, 12+, by Age Group and Gender, Canada, 2005

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Age Group

Per

cen

t (%

)

Females Males

Females 0.7 1.2 1.9 4.0 8.5 12 13

Males 0.9 0.9 2.1 5.0 12 17 17

20-24 25-34 35-44 45-54 55-64 65-74 75+


Diabetes, 12+, by Province/Territory, Canada, 2005

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Province/Territory

Per

cen

t (%

)


at high risk of cardiovascular disease due to diabetes, obesity and high

blood pressure

Native Peoples

Do provinces with higher rates of overweight have higher rates of

HBP or diabetes?

0

5

10

15

20

25

30

35

40 50 60 70

Percent hbp

% diabetes

Linear (Percent hbp )

Linear (% diabetes)

SMOKING

Percentage of the General Population Aged 15+ Years Who Were Daily Smokers, Canada, 1999-2005

0

5

10

15

20

25

Year

Per

cen

t (%

)

Females Males Both

Females 19 18 16 16 14 13 12

Males 23 21 20 19 19 17 18

Both 21 20 18 18 17 15 15

1999 2000 2001 2002 2003 2004 2005

Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2006 using Health Canada, Canadian Tobacco Use Monitoring Survey Data.

Tobacco: deaths by World Bank regionsestimates for 1990 and 2020

Source: Murray CJL, Lopez AD 1996

Established Market Economies

Middle Eastern Crescent

Latin America & CaribbeanSub-Saharan AfricaOther Asia and Islands

Former Socialist Countries

China

India

1990 2020

8.4 million

3 million

4.5 million

2003

On average, smoking kills 6 people a minute around the world.

Up to 72% of available landis taken up by tobaccocultivation in some developing countries

Zimbabwe derives most of itsforeign exchange fromtobacco

Smoking prevalence amongmen in Jakarta is 60%

On average, smoking kills 6 people a minute

- 1 in the European Union

- 1 in the United States

- 1 in the former USSR

- 1 in the other developed populations

- 1 in China

- 1 in other developing populations

Current Daily Smoker, 15+, by Age Group and Gender, Canada, 2005

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Age Group

Perc

en

t (%

)

Females Males

Females 8.4 15 15 17 14 12 6.6

Males 7.4 18 21 21 24 17 4.3

15-17 18-19 20-22 23-24 25-44 45-64 65+


?

Current Daily Smoker, 15+, by Province/Territory, Canada, 2005

0

2

4

6

8

10

12

14

16

18

20

BC AB SA MA ON QU NB NS PEI NFLProvince/Territory

Per

cen

t (%

)


Canada

Current Daily Smoker, 15+, by Education and Gender, Canada, 2005

0

5

10

15

20

25

30

Education

Per

cen

t (%

)

Females Males Both

Females 14 16 10 10

Males 20 27 15 12

Both 17 21 13 11

Less than secondary Secondary Some Post-secondary Post-secondary Deg.


Health Care Costs

HEALTH CARE EXPENDITURE IN CANADA

(in current dollars)

1975 1980 1985 1990 1995 2000 2005

130120110100 90 80 70 60 50 40 30 20 10 0

Bil l

ion

s of

dolla

rs

Source: Canadian Institute for Health Information

5.9% increase in 200410% of GDP in 2004

billions of $ 130.3 in 2004123.0 in 2003114.0 in 2002106.3 in 2001 97.9 in 2000 89.9 in 1999 83.7 in 1998 78.4 in 1997

Costs of disease by diagnostic category, Canada, 2000

$0.0 $2.5 $5.0 $7.5 $10.0 $12.5 $15.0 $17.5 $20.0 $22.5

Oral conditionsNutritional deficiencies

Other neoplasmsCongenital anomalies

Skin diseasesMaternal conditions

Perinatal conditions*Endocrine disorders

Diabetes mellitusRespiratory infections

Infectious and parasitic diseasesGenitourinary diseases

Sense organ diseasesRespiratory diseases

Digestive diseasesNeuropsychiatric conditions

Malignant neoplasmsInjuries

Musculoskeletal diseasesCardiovascular diseases

Costs ($ billion)

Direct Costs

Indirect Costs

Indirect Costs include Mortality and LTD onlySource: Economic Burden of Ilness in Canada, 2000

Selected Costs for Cardiovascular Diseases Diagnostic Subcategory, Canada, 2000

($000,000s) (% of CVD Costs in Category)

Ischaemic heart disease

Cerebrovascular disease

Hospital Care $1028.20 (31.24%) $821.20 ( 24.96%)

Drugs $465.70 (21.59%) $40.90 ( 1.9%)

Mortality (as cost of premature

death)

$5554.10 (59.93%) $1498.30 (16.17%)

Long-term Disability

$480.6 (11.53%) $966.10 ( 23.18%)

HEALTH CARE COSTS

Table 3-2 Selected Costs, Cardiovascular Diseases by Sex, Canada, 2000 (in $000,000s)

Component Males Females Total

Hospital Care $1,745.9 $1,544.7 $3,290.6

Drugs $1,093.2 $1,064.0 $2,157.3

Physician Care $827.0 $804.0 $1,631.0

Mortality (as cost of premature death) $6,250.0 $3,017.9 $9,268.0

Long-Term Disability $2,444.9 $1,723.3 $4,168.2

$12,361.0 $8,154.0 $20,515.0

Future directions

Canadian Heart Health Strategy and Action Plan (CHHS-AP)Headed by Eldon R. Smith

Contact613. 569.4361 ext [email protected]

• Purpose– To reduce the growing burden and loss due to CV

disease in Canada • Description

– Independent, stakeholder driven– Comprehensive, integrated strategy– Continuum of the health system: health

policy/prevention to end-of-life care– Continuum of life: preconception to death– Address disparities– Evidence-based/best practices

mailto:[email protected]

CHHS-AP Leadership

• Leadership partners: – Heart and Stroke Foundation of Canada– Canadian Cardiovascular Society– Canadian Institutes of Health Research

(Institute for Circulatory and Respiratory Health)

• Funder:– Public Health Agency of Canada

Context for a Canadian Strategy

• CVD is Canada’s number one public health problem.• Risk factors, particularly obesity, diabetes and

hypertension are increasing.• Gaps between what we know and what we do exist in

primary and secondary prevention as well as in treatment.

• The health care system lacks integration – access is limited with significant disparities.

• Health human resources are deficient.• Care delivery models have been relatively stagnant.• Canada lacks a surveillance system for CVD.

CHHS-AP Theme Working Groups

1. Strengthening information systems for monitoring, management, evaluation and policy development

2. Creating environments conducive to cardiovascular health

3. Preventing, detecting and controlling major risk factors

4. Addressing and enhancing Aboriginal / indigenous cardiovascular health

5. Timely access to quality (acute) care and diagnostics

6. Timely access to quality chronic disease management, rehabilitation services and end-of-life care

Framework for a Comprehensive Canadian Heart Health Strategy and Action Plan

OUTCOMES

The Vision

Interventions Required

Favourable environments

Healthybehaviours

Lower population risk

Fewer acute events

Less chronic disease

Additional quality life years

Policy and environmental change

Behaviour change strategies

Prevention, detection & management of risk factors

Timely access to quality (acute) care

Timely access to quality chronic disease manage-ment/rehab

Timely access to end oflife care

1. Healthier population

3. Added quality life years

4. Decreased burden of cardiovascular disease

5. Sustainable health system

HEALTH PROMOTION PRIMARY SECONDARY

PREVENTION

TREATMENT

Improved Information and Monitoring

ACCESS to Services

Health Human Resources

2. Reducedinequities

prevalence, incidence, risk factors, mortality, etc yearly

by health region, plus Dissemination

specific research questions

Monitor treatment outcomes

Improving health care

Evaluate health promotion programs

Waiting list evaluation

Are consensus conference guidelines followed

Cost, economics

Projections, predictions models

core questions

After-discharge care

Train future staff and researchers

micro level information to aid & evaluate local efforts in improving health care

Outreach

provide follow-up

information on patients to clinics

& clinical trials.

Data validation

Knowledge Dissemination

Advisory meetings, conferences

What is wanted from a CVD surveillance system?

Appendix

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

55000

60000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

year

Nu

mb

er

0

25

50

75

100

125

150

175

200

225

250

275

300

325

350

Ag

e st

d r

ate

per

100

,000


CHF Hospitalized Patients (Most Responsible Diagnosis), Canada, 1994-2004

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

55,000

60,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

year

Nu

mb

er

0

25

50

75

100

125

150

175

200

225

250

275

300

325

350

Ag

e st

d r

ate

per

100

,000


Acute stroke Hospitalized Patients (Most Responsible Diagnosis), Canada, 1994-2004

0

2000

4000

6000

8000

10000

12000

14000

16000

25-34 35-44 45-54

55-64 65-74 75-85+

CVD Hospitalization Rates per 100,000 for Males and Females by Age Group, Canada, 1971-2004

MALE FEMALE


0

500

1000

1500

2000

2500

3000

3500

25-34 35-44 45-54

55-64 65-74 75-85+

Cerebrovascular Hospitalization Rates per 100,000 for Males and Females by Age Group, Canada, 1971-2004

MALE FEMALE


overview of cvd epidemiology helen johansen (plus a cast of thousands) i. what is surveillance?...

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