The European Journal of Public Health Advance Access originally published online on June 23, 2006
The European Journal of Public Health 2007 17(2):193-198; doi:10.1093/eurpub/ckl090
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Health services research |
Life-years-gained from population risk factor changes and modern cardiology treatments in Ireland
Zubair Kabir1, Kathleen Bennett1, Emer Shelley2, Belgin Unal3, Julia Critchley4, John Feely1 and Simon Capewell5
1 Department of Pharmacology & Therapeutics, Trinity College & St. James's Hospital Dublin, Ireland
2 Department of Health and Children, Dublin Ireland
3 Department of Public Health, Dokuz Eylul University School of Medicine 
zmir, Turkey
4 School of Population and Health Sciences, University of Newcastle upon Tyne UK
5 Department of Public Health, University of Liverpool UK
Correspondence: Dr Zubair Kabir, Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland, tel: +353 1 6083404; fax: +353 1 4539033; email: kabirzin{at}yahoo.com
Received January 23, 2006, accepted May 19, 2006
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Abstract |
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Background: Coronary heart disease (CHD) mortality rates in Ireland have halved since the mid-1980s, and adult life expectancy has also steadily improved. This study estimated the life-years-gained by CHD treatments and by changes in cardiovascular risk factor levels. Methods: A previously validated Irish IMPACT CHD mortality model was used to integrate large amounts of data on (i) patient numbers, (ii) treatment uptake, (iii) risk factor trends, (iv) effectiveness of cardiology treatments and risk factor reductions, and (v) median survival in patients with and without CHD, all stratified by age and sex. Results were tested in rigorous sensitivity analyses. Results: There were 3763 fewer CHD deaths than expected in 2000 compared with the base year, 1985. This resulted in
44 060 life-years-gained among people aged 25–84. Specific medical and surgical treatments given in 2000 for CHD patients together gained 14 505 life-years. Population changes in cholesterol and smoking levels accounted for some 32 705 life-years-gained, 66% from reductions in cholesterol alone. Adverse changes in obesity and diabetes resulted in a loss of 3670 life-years. Conclusions: Use of modern cardiology treatments in Ireland from 1985 to 2000 gained many thousands of life-years. However, twice as many life-years were generated by relatively modest reductions in major risk factors. Effective policies, such as the promotion of healthy diets, and weight reduction, together with the recent nationwide workplace smoking ban, will be essential to maintain and further enhance health gain.
Keywords: coronary heart disease, Ireland, life-years-gained, risk factors, treatments
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Introduction |
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Coronary heart disease (CHD) death rates in Ireland are amongst the highest in Europe.1 However, CHD death rates have almost halved over the past 15 years.1 The majority of international studies consistently suggest that improvements in treatment explain up to half of the CHD mortality decline.2,3 Examples include 43% of the decrease in the US between 1980 and 1990,4 48% in New Zealand between 1982 and 1993,3 24% in Finland between 1982 and 1997,5 40% in Scotland between 1975 and 1994,6 42% in England and Wales between 1981 and 2000,7 and 44% in Ireland between 1985 and 2000.8 All these studies also show that about half of the actual fall in recent CHD death rates are due to improvements in population risk factors, mainly cholesterol, smoking, and blood pressure reductions.4–8 Such observations reinforce the importance of both primary and secondary preventative strategies in CHD from a public-health policy perspective.
Between 1985 and 2000, Irish life expectancy at birth increased by 4 years for both men and women.9 However, it remains unclear which CHD interventions have made the biggest contribution to increasing life expectancy. Furthermore, few studies have used life-years-gained as an outcome measure when examining CHD disease burden and the impact of interventions. A recent UK study suggested that modest reductions in major cardiovascular risk factors, such as smoking, cholesterol, and blood pressure levels, might have gained four times as many life-years as did cardiology treatments.10,11 The primary aim of this study was therefore to estimate the life-years-gained due to cardiology treatments and changes in population risk factor levels that occurred from 1985 to 2000 in Ireland, using a previously validated IMPACT CHD mortality model.8,11
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Methods |
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Estimating the number of deaths prevented or postponed in Ireland in 2000
The number of CHD deaths prevented or postponed in 2000 that could be attributed to improved cardiac treatment uptake and risk factor changes since 1985 was estimated using the IMPACT CHD mortality model. The IMPACT CHD mortality model has been described in detail elsewhere.7,8,11 In brief, the model was first developed in 1996 for Scotland and has since been validated in several different countries, including Finland,5 New Zealand,3 and Ireland.8 The Irish IMPACT CHD mortality model has been refined further, and now includes the most recent relative risk estimates from the INTERHEART study12 and recent data on log-linear beta coefficients for absolute differences.5 The numbers in this paper, therefore, do not correspond exactly with our earlier publication.8 In brief, the model synthesizes large amounts of data stratified by age and gender describing (i) numbers of patients in different CHD categories, (ii) uptake of specific medical and surgical treatments, (iii) population trends in major cardiovascular risk factors (smoking, cholesterol, hypertension, obesity, diabetes, and physical activity), and (iv) effectiveness of specific cardiology treatments and risk factor reductions.8
The number of CHD deaths prevented or postponed by each treatment group was based on the relative mortality reduction reported in published trials and meta-analyses applied to the case fatality observed in unselected patient cohorts. To avoid double counting, adjustments were first made for overlaps between different treatment groups, by subtracting the overlapping subgroup from the main group. For instance, the post-myocardial infarct (MI) survivors total was reduced by 25%, to allow for those post-MI patients who subsequently developed heart failure.13
Risk factor changes 1985–2000
The IMPACT CHD mortality model used population subgroups as the unit of analysis for risk factor distribution.
For cholesterol, blood pressure, and smoking changes, the IMPACT CHD mortality model employs beta regression (ß) coefficients obtained from recent studies.5,14 Each ß coefficient quantifies the relationship between absolute population change in a specific risk factor and the consequent change in population mortality rates from CHD mortality.
For the fall in each major risk factor, the subsequent reduction in deaths was then estimated as the product of three variables: the number of CHD deaths observed in 1985 (the base year), absolute difference in risk factor prevalence rates, and the regression coefficient. However, for the remaining risk factors (diabetes, obesity, and physical activity) where absolute ß coefficients are not available to date, relative risk estimates from the recent INTERHEART study12 were used in the population attributable fraction method. For example the number of deaths prevented or postponed due to changing diabetes prevalence rates is the product of the number of CHD deaths in 1985, and the difference in attributable deaths due to the absolute increase in diabetes prevalence between 1985 and 2000 using the conventional population attributable risk formula.13
Sources of the Irish data and detailed technical appendices can be found on the IMPACT website.13 The website also provides details on operational definitions of the six cardiovascular risk factors studied, on the polypharmacy issues, how double counting of patients are adjusted for, as well as an in-depth calculation of the number of deaths prevented or postponed, with examples.
Median survival data
Deaths prevented or postponed by medical and surgical treatments
For each treatment category, median survival was obtained from the best available population-based data. Estimates of survival after coronary surgery were obtained from the Irish Cardiac Surgery Register15 plus a recent cohort study in Scotland.16 Angioplasty for angina was assumed to have a similar survival benefit.17
Because other survival data in Ireland are limited,18 most age-specific median survival data were obtained from large cohort studies of unselected patients with acute myocardial infarction or heart failure in the UK.19,20 The data for Ireland are likely to be very similar to the UK pattern, as Ireland has followed similar CHD mortality and treatment trends since the mid-1980s. Median survival estimates for patients treated for hypertension were based on the Glasgow Blood Pressure Clinic cohort.21
Deaths prevented or postponed by reductions in CHD risk factors
Age-specific median survival was derived for three separate groups of individuals using an established methodology:8 (i) in patients with recognized CHD, median survival was assumed to be very similar to that in age-matched myocardial infarction survivors; (ii) in asymptomatic individuals, median survival was based on age-specific life expectancy for the general population (calculated from Irish life-tables);9 and (iii) in subjects with symptomatic but unrecognized CHD, median survival was assumed to lie midway between the values for the myocardial infarction survivors and the general population. These assumptions were all tested in subsequent robust sensitivity analyses.
Estimation of life-years-gained
This study did not calculate the increased Irish life expectancy in men and women between 1985 and 2000 following modern cardiology treatments and improvements in population risk factors. Instead, the number of life-years-gained (LYG) in 2000 for each treatment category and for each risk factor change was estimated across gender and age groups. Each LYG estimate was calculated as the number of deaths prevented or postponed in 2000 from the IMPACT CHD mortality model, multiplied by the age-specific median survival for the age-gender group.8,11 The LYG total was then obtained by summing individual LYG values across every age and gender category for each specific treatment group and for every risk factor studied. Our LYG estimates were not explicitly adjusted for the influence of other competing causes of mortality such as cancer. However, these are generally modest, amounting to less than one extra year of life.22,23 Interaction was not tested in this model.
Sensitivity analyses
A robust sensitivity analysis was performed using the analysis of extremes method.24 This addressed the uncertainties surrounding the key variables, such as patient numbers, treatment uptake, treatment efficacy, and median survival, as well as potential overlaps between different treatment and risk factor categories. ‘Best’ estimates are the point estimates, while ‘minimum’ and ‘maximum’ estimates of life-years-gained were generated using 95% confidence interval values where available, and clinically plausible minimum and maximum values for all other variables.24 Illustrative examples of specific analyses and calculations are shown in the appendices of the recent England and Wales model publication,7 and on the IMPACT website.13 This method does not involve any probabilistic interpretation as in confidence interval estimation.
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Results |
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Between 1985 and 2000, CHD mortality rates in Ireland fell by 47% in men and in women aged 25–84. This resulted in 3763 fewer ‘observed’ deaths in 2000 compared with the expected number given the CHD mortality rates in 1985 (8681 expected minus 4918 observed). These 3763 fewer deaths in 2000 were associated with an estimated gain of 44 060 life-years among those aged 25–84 (minimum estimate 19 555, maximum estimate 63 460) (tables 1 and 2). Overall, the IMPACT CHD model predicted 3679 fewer deaths,
98% of the observed CHD mortality fall. The remaining 2% of the mortality fall was attributed to other unmeasured factors.
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Life-years-gained by specific medical and surgical treatments (table 1)
Specific medical and surgical treatments for patients with CHD prevented or postponed
1885 deaths in Ireland in year 2000. They therefore gained 14 505 life-years (minimum 7270, maximum 22 470) in total, which represented almost 33% (14 505/44 060) of the total LYGs. Almost 25% of the total LYGs were generated through secondary prevention and angina treatments alone.
Life-years-gained by risk factor changes in the population (table 2)
Approximately 1795 deaths were prevented or postponed in 2000 by risk factor changes in the population between 1985 and 2000. This accounted for some 29 555 life-years-gained (minimum estimate 12 285, maximum estimate 40 990) and represented almost 67% (29 555/44 060) of the total LYGs. Almost two-thirds of the extra life-years came from reductions in population cholesterol levels alone. However, these gains were offset by worsening trends in obesity and diabetes prevalence between 1985 and 2000. The changes in all the population risk factors are detailed in table 2.
Sensitivity analyses (tables 1 and 2)
Following a robust ‘analysis of extremes’ method sensitivity analyses, the relative contributions from risk factor reductions remained consistently 2-fold greater than the contribution from treatments, irrespective of whether best, maximum, or minimum estimates were considered (tables 1 and 2).
Age and sex distribution of life-years-gained (figure 1)
The majority of life-years were gained by individuals aged 55–74 years. More life-years were gained by men than women in all age groups: 71% (10 260/14 505) of the life-years-gained by medical and surgical treatments, and 73% (21 460/29 555) of the life-years-gained by risk factor reductions were in men.
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Discussion |
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Some 3765 fewer CHD deaths were observed in Ireland in 2000 compared with 1985.8 This represents
44 060 additional years of life gained. Each death avoided by treating a recognized CHD patient yielded an additional 8 years of life, on average (total LYG for treatments divided by total deaths prevented/postponed due to treatments). However, each death prevented/postponed by risk factor reductions gained an additional 16 years of life, on average. These gains were reassuringly close to previous studies.10,11,25 There were interesting sex differences in the life-years generated in both risk factor and treatment groups. Previous studies suggest a sex-difference in life expectancy following cardiovascular interventions, with men consistently gaining more life-years.22,25,26 Furthermore, in Ireland, risk factors are more aggressively managed in men27 while female cardiac patients are less likely to receive secondary preventative therapies.28,29
Medical and surgical treatments in 2000 together gained 14 505 life-years, with over 40% coming from secondary prevention alone. This emphasizes that simple inexpensive treatments applied to all eligible patients can potentially produce large gains, at low cost. However, the greatest gains came from the reduction in population cholesterol (65.6%), followed by the decrease in smoking prevalence (8.6%). Such substantial gains through the reductions in major risk factors emphasize the huge importance of population strategies for primary prevention of chronic diseases.
The large gains due to cholesterol reduction are consistent with dietary improvements in the population over the 15-year-period study, and also the improved detection and management of raised cholesterol levels in individuals at increased risk. The relatively small gains from smoking reduction partly reflects the lower prevalence of smoking at the study outset, compounded by a relatively slow annual decline in the smoking between 1985 and 2000 in Ireland.30 This should improve following the national workplace smoking ban.31
Adverse trends between 1985 and 2000 were seen for obesity and diabetes. They together caused 385 additional CHD deaths and a loss of 3670 life-years. This merits further attention from a public-health policy perspective, particularly given the recent trends in adult obesity.32
All modelling studies have limitations. They are dependent on the variable quality and extent of data available on CHD patients, treatment uptakes, and risk factor trends.33 Assumptions therefore have to be made, and a robust sensitivity analysis becomes essential.24 The minimum and maximum values around the model estimates were relatively wide, suggesting some uncertainties at the margins. Furthermore, the IMPACT CHD mortality model assumes that estimates of efficacy from randomized controlled trials can be generalized to effectiveness in clinical practice, irrespective of the baseline level of risk. This appears reasonable.34 It also assumes that the mortality reductions from concomitant risk factor reductions and treatments within the same patient are independent and additive. In addition, the INTERHEART study risk estimates used in the present study are independent effects arising from a multivariate analysis.15 Risk factor lag times were also not explicitly considered in the present study. However, they may be relatively unimportant over a 15 year analysis, because mortality reduction occurs relatively quickly, within 2–4 years of reducing cholesterol levels or quitting smoking.14,35,36 Using LYG did not take account of improvements in Quality of Life due to treatments, resulting in Quality-adjusted life-years (QALYs). Despite such inherent methodological limitations, extensive validation and rigorous sensitivity analyses demonstrated the basic robustness of the Irish IMPACT CHD mortality model.
Future policy implications
The implementation of the National Cardiovascular Health Strategy will continue to improve life expectancy, and address health inequalities.37,38 Further gains in life-years may be expected from the recent nationwide workplace smoking ban31 and the implementation of the National Task Force on Obesity report.39 The worsening trends in diabetes and obesity should now be addressed aggressively. In conclusion, modern cardiology treatments in Ireland in 2000 gained many thousands of life-years. However, twice as many life-years were generated by relatively modest reductions mainly in dietary cholesterol and smoking prevalence.
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Acknowledgments |
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We thank Professor Ivan Perry of the University of Cork (Department of Public Health and Epidemiology) for providing some valuable data for our initial model. Dr Zubair Kabir was funded by a Research Grant from the Irish Heart Foundation.
Contributors
KB and ES conceived the original idea, SC originally developed the IMPACT CHD model, with inputs from JC and BU. ZK, KB, and SC developed and analysed the Irish IMPACT model. All contributed to the interpretation of the data, as well as the drafting of this manuscript, KB is the guarantor of this paper. The funding organization has no role in the design, analysis, and interpretation of this study.
What is already known on this topic
• The three classical cardiovascular risk factors (cholesterol, smoking, and hypertension) explain almost two-thirds of the decline in CHD mortality.
• Limited evidence exists on the potential life-gains following improvements in major population risk factors, as compared to gains from modern cardiology treatments.
What this study adds
• Twice as many potential life-years can be gained through improvements in the major cardiovascular risk factors compared to gains from modern cardiology treatments.
• Cholesterol level reductions in the Irish population achieved almost two-thirds of the overall life-years gained in 2000.
• Adverse trends in obesity and diabetes will offset future gains from improvements in the major cardiovascular risk factors.
Policy implications
• Greater health gains can be achieved through modest improvements in three main cardiovascular risk factors.
• National Cardiovascular Health Strategy should prioritize primary preventative approach in addition to secondary prevention.
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