copy the linklink copied!7. Conclusions and implications for policy, data improvements and monitoring

Abstract

Evidence shows that since 2010 several countries are experiencing a slowdown in the rate of decline in cardiovascular disease mortality, while a few countries are experiencing increases in mortality rates. For some countries, incidence rates of coronary events are declining less than mortality rates, suggesting that the impact of preventive measures has been more modest than improvements in acute coronary care. Socio-economic inequalities in cardiovascular disease mortality are a major contributor to overall inequalities in mortality, and illustrate the scope for tackling potentially avoidable morbidity and mortality. Improvements in national and international data and monitoring to support more timely and effective policy responses for preventing, managing and treating cardiovascular disease, and for tackling socio-economic and gender inequalities, are needed urgently.

    

copy the linklink copied!Raising international awareness about the slowdown in CVD mortality improvements

The slowdown in CVD mortality has received some prominence in the United Kingdom and the United States in the context of slowing improvements in life expectancy overall. However, it has received little or no consideration in most other countries affected. Nor has there, until now, been any international move to examine and comment on a phenomenon affecting several European and other high-income countries.

This report starts an international dialogue about the potential causes of the slowdown in CVD mortality improvements, policy interventions that could help to reverse the slowdown, and international collaboration and learning from what appears to be a growing phenomenon.

The case for action is strong

The slowdown of improvements in CVD mortality in some high-income countries in recent years is a cause for serious concern, for several reasons. As Ms Løgstrup’s presentation to the workshop showed, large historical declines notwithstanding, CVD remains among the leading causes of death in European and other high-income countries. It accounts directly for large numbers of deaths among older people and those of working ages, and also indirectly by increasing susceptibility, for example, to respiratory diseases such as influenza and pneumonia. CVD-related mortality is higher among those using illicit drugs. CVD risk factors and heart disease are also associated with the development of dementia later in life, so early prevention and treatment could potentially mitigate the onset of dementia and costs associated with it (Hakim, Ng and Turek, 2013[1]). Many countries have wide socio-economic differentials in CVD mortality, which contribute to large inequalities in overall mortality and evidence from some countries (e.g. France, United Kingdom) points to gender differences in treatment and survival.

Several speakers warned against complacency: trends in younger age groups suggest that the decline in CVD mortality may be stalling in some European countries, or even turning to an increase. Given Professor O’Flaherty’s warning that CVD mortality rates can change rapidly – for better or for worse – with changes in risk factors, these trends need to be monitored closely.

While improvements in CVD mortality continue to contribute most to improvements in life expectancy, Professor Ho’s analysis for this workshop shows clearly that in the countries that have experienced the greatest slowdown in life expectancy improvements since 2010, this slowdown has been driven by distinct condition-specific trends. CVD has been a significant contributor to the slowdown, along with mental and nervous system disorders (which largely reflects changes in coding of deaths to dementia); other, major but less significant contributors being deaths from external causes among males and from respiratory disease including influenza and pneumonia among females.

Strategies for reducing the burden of CVD need to target both primary prevention (i.e. reduced incidence of CVD through public health action to tackle the risk factors, the use of fiscal and regulatory measures etc.) and improvements in secondary prevention and case-fatality (i.e. ensuring people who develop CVD or its risk factors receive timely, equitable and evidence-based clinical care). Clearly, the optimal policy mix will be country-specific and depend on the specific context, epidemiological trends, health system, policies and priorities, etc.

The cost of inaction or inappropriate action in tackling the significant morbidity associated with CVD can be high, including the indirect costs associated with, for example, higher levels of dementia and disability. We discuss below some of the high-level policy implications of discussions at the workshop. This overview is not designed to be comprehensive or prescriptive.

Preventing CVD is key

In line with wider evidence, several speakers and workshop participants highlighted that many CVD deaths are preventable; hence, risk reduction through strengthening preventive measures should be a priority. The GBD analysis presented by Dr Johnson shows that, overall, the leading risk factors for CVD remain largely unchanged, and all are amenable to intervention. Good progress has been made in some areas, such as tobacco control, but adverse trends in obesity and diabetes are widespread, and there is scope to do more in almost all areas of primary prevention.

The case for prevention is strong, especially given the evidence from some countries that incidence rates of coronary events are declining less than mortality rates, suggesting that the impact of preventive measures has been more modest than improvements in acute coronary care. The rising prevalence of obesity and diabetes could be a contributory factor, including in stagnating mortality declines at young age groups in some countries.

Public health policies and prevention strategies have long targeted some of these CVD risk factors with, in past decades, great success in achieving their aim of reducing CVD mortality. However, CVD remains a major killer and these risk factors continue to cause many preventable deaths, added to which is the risk that the rising prevalence of obesity and diabetes globally could erode or even reverse the mortality gains made to date.

Professor O’Flaherty argues that CVD mortality trends can change rapidly in both directions, and their key drivers are largely concentrated in lifestyle risks. Reducing the burden of CVD must be a priority, to be delivered not just by health care systems acting in isolation, but also via appropriately designed, population-level government policies, such as fiscal and regulatory measures designed to promote lifestyle changes such as reductions in sugar, salt, fat and tobacco consumption. Evidence shows that such policies can deliver large and rapid health and economic gains in terms of reducing CVD, are cost-effective, and reduce cost and demand pressures on the health care system.

Likewise, Professor Kunst argued for population-level strategies aimed at changing lifestyle risk factors and addressing the wider determinants of health beyond the health sector, as the approaches most likely to be effective in reducing inequalities in CVD mortality.

The OECD has also shown that policies aimed at tobacco and obesity control can have a widespread impact on promoting healthy lifestyles, and more can be done to integrate regulations and public health programmes (OECD, 2015[2]). The OECD report on the obesity epidemic (OECD, 2019[3]) discusses several policy options for addressing this growing public health problem, including food and menu labelling, regulation of advertising of unhealthy foods to children and the promotion of exercise, including by doctors and schools. The report discusses the opportunities, and the challenges in implementation, of policies that are innovative, or have been demonstrated to be effective, including policies that aim to: influence lifestyle choices through information and education, expand healthy choice options, modify the costs of health-related choices, and regulate or restrict unhealthy options.

The GBD and other evidence also points to the considerable scope for improvements in secondary prevention. Recognising the role of late diagnosis and under-treatment in preventing CVD, for example, the recently published NHS Long Term Plan for England (NHS, 2019[4]) lays down specific ambitions to reduce the number of strokes, heart attacks and dementia cases over the next ten years through the detection and management of atrial fibrillation, high blood pressure and high cholesterol.

Finally, an emerging and potentially preventable contributory factor to CVD deaths noted by Professor Ho is the rising trend in use of opioids (prescribed and illicit) in some countries e.g. the United States, the United Kingdom, Canada, Norway and Sweden. Targeted policies are needed to tackle this growing public health problem which is causing mortality among young adults to stall, and even rise, in some high-income countries.

Improvements in the management and treatment of CVD are also called for

The workshop did not focus on the clinical management of CVD, except to note that improvements may be called for in some countries depending on the specific circumstances, and unequal access to good quality of care means there is still considerable scope to reduce the burden of CVD and deaths from it. Advances in the prevention and treatment of CVD in high-income countries over recent decades have been dramatic and have outpaced those for many other diseases, contributing to longer, healthier lives and reduced inequalities. Medical and technological innovations have enabled the control of risk factors such as high cholesterol and blood pressure, improved management of diabetes, and effective clinical care in the event of an acute episode such as a heart attack or stroke, have transformed outcomes for people with CVD. Timely access to high quality, evidence-based health services and technologies has facilitated this transformation in CVD care.

Despite these gains, the OECD’s report on CVD and diabetes (OECD, 2015[2]) noted several challenges in reducing the heavy, residual burden of CVD and mortality from it, such as delays in diagnosis of CVD risk factors and diabetes, lack of adherence to clinical guidelines, ageing populations with increasingly complex care needs, and gaps in timely access to specialist care. The report called for improvements in access to high quality primary and secondary care services, compliance with clinical guidelines, standards of emergency care, integration and coordination with other parts of the health care system, and continuity of care. It also noted the need to address variations in access to and the quality of care.

Workshop participants noted that the balance of priorities between prevention and treatment would vary between countries, depending on the context, the country-specific drivers and the characteristics of their health care systems. While prevention clearly needs to be a priority universally, improvements in early detection, diagnosis and timely, evidence-based care will also be important for some countries.

The OECD’s 2012 review of the quality of health care in Korea (OECD, 2012[5]) was cited as the trigger for the significant improvements in CVD mortality outcomes that followed. The IHD mortality rate had been rising from its previous low levels, case-fatality was high, and stroke mortality was among the highest among OECD countries. The review identified the improvements needed across the CVD pathway, from prevention through to emergency care and post-hospital rehabilitation, in order to improve outcomes.

Reducing inequalities must be a priority

All the speakers at the workshop noted the imperative to reduce inequalities in the burden of and mortality from CVD. In many countries, socio-economic inequalities in CVD mortality are a major contributor to overall inequalities in mortality. While it is encouraging that absolute inequalities in CVD mortality are falling in several European countries, the widening of relative inequalities is less welcome and illustrates the scope for tackling potentially avoidable morbidity and mortality. Policies to address stalling in life expectancy improvements and a slowdown in CVD mortality improvements would have more traction and impact if they included strategies for narrowing differentials between different population groups.

Professor Kunst noted that, given that much of the population burden of CVD is concentrated in lower socio-economic groups, policies to accelerate declines in CVD mortality and reduce inequalities should be tailored to these groups. Interventions also need to look beyond individual-level factors and preventive actions focussed on “life styles”, to the role of policy areas beyond health, such as urban renewal, employment and social welfare, and policies should be evaluated for their impact on equity.

The experience of England from 1997 to 2010 shows that ambitious, cross-governmental strategies can be effective in reducing health inequalities (Barr, Higgerson and Whitehead, 2017[6]). Since 2010 when this approach was dropped, health inequalities have widened, as detailed in the recently published Marmot Review (The Marmot Review, 2020[7]), ten years on from the original review in 2010 (The Marmot Review, 2010[8]). Differentials in life expectancy between local areas now stand at about 9 years for males and 7 years for females. Marmot et al. (2020[7]),) call urgently for a cross-government “ambitious and world-leading health inequalities strategy” aimed at reducing inequalities in the wider socio-economic determinants of health, and supported by targets and strengthened accountability mechanisms. The King’s Fund’s Vision for Population Health (Buck et al., 2018[9]) outlines a framework for population health in England centred on four pillars: the wider determinants of health; our health behaviours and lifestyles; the places and communities we live in; an integrated health and care system. It calls for ambitious and binding national goals to drive progress, and a cross-government strategy for reducing health inequalities. Like speakers at the workshop, it recommends that the government builds on the lessons from the Soft Drinks Industry Levy by using taxation and regulation to support health improvement.

Improvements in data and monitoring processes are needed to support more timely and effective policy responses

Our invited speakers pointed to a variety of constraints applying to currently available data on CVD, which are obstacles to the timely and informative monitoring of levels and trends in CVD and its determinants:

  • Data on risk factors and incidence is scarce and patchy; workshop participants from several countries noted that survey data on lifestyle risk factors is often only available at intervals of several years, and there can be restrictions on linking the data;

  • There is a significant time lag in the availability of vital statistics data;

  • The interactions between deaths from CVD and other causes, for example, influenza and pneumonia, and illicit drug use, add to the challenges of interpreting trends in CVD mortality and identifying the underlying drivers;

  • Interpreting trends is also made more challenging with changes in coding conventions and practices, such as the increased recording in many countries of deaths to dementia, Alzheimer’s disease and other mental and nervous system disorders, deaths which previously would have had CVD or another condition coded as the underlying cause of death.

Participants also highlighted the importance of:

  • Linkage between different data sets e.g. primary and hospital care records, or clinical audit data and death records, which can greatly enhance monitoring capabilities for assessment of risk factors, health care needs and use of services across different population groups, and inform policy development; some participants noted that their countries already routinely link hospital administrative data and data from disease registers to mortality;

  • Monitoring not just CVD but also the other conditions associated with it, for example, influenza and pneumonia, illicit drug use, dementia, and consideration of the consequent implications for policy action – for example, the impact of changing CVD trends on the prevalence of other conditions such as dementia;

  • Monitoring the impact of policies on health equity;

  • Monitoring mortality patterns and trends at national and international level for disaggregated population groups (e.g. by age, gender, region, socio-economic groups) in order to better understand how the burden of CVD is distributed and interactions between the factors associated with CVD mortality;

  • Some workshop participants raised the possibility of OECD doing modelling work to identify optimal prevention policies, and undertaking country-specific policy analyses.

The data issues highlighted call for changes to make data systems and data flows more comprehensive, timely, efficient, relevant in the context of changing epidemiological patterns, and fit-for-purpose for monitoring and supporting appropriate service responses. The OECD report on trends in life expectancy in EU countries made recommendations relating to data for national and international agencies that are relevant here (Raleigh, 2019[10]).

Recent trends suggest that we should be cautious about assuming that historical declines in CVD mortality rates will continue. Timely monitoring of risk factor levels, disease incidence and mortality rates is essential for detecting rising public health threats at an early stage and for informing an efficient, appropriate response.

Looking forward

The workshop on CVD mortality convened jointly by The King’s Fund and OECD was a unique collaborative venture designed to highlight one of the contributors – CVD – to the slowing improvements in life expectancy seen in many European and other high-income countries.

Francesca Colombo, Head of OECD Health Division, provided closing remarks for the workshop and called attention to deliberations at the workshop, the contributions of the invited speakers, and the insights provided by the country representatives attending. This report should help to raise awareness of the slowdown in CVD mortality improvements seen in many countries, and its implications for policy and monitoring.

References

Barr, B., J. Higgerson and M. Whitehead (2017), “Investigating the impact of the English health inequalities strategy: Time trend analysis”, BMJ (Online), Vol. 358, http://dx.doi.org/10.1136/bmj.j3310. [6]

Buck, D. et al. (2018), Vision for Population Health: Towards a Healthier Future., The King’s Fund, https://www.kingsfund.org.uk/publications/vision-population-health. [9]

Hakim, A., Ng and Turek (2013), “Heart disease as a risk factor for dementia”, Clinical Epidemiology, p. 135, http://dx.doi.org/10.2147/clep.s30621. [1]

NHS (2019), The NHS Long Term Plan, NHS, http://www.longtermplan.nhs.uk. [4]

OECD (2019), The Heavy Burden of Obesity: The Economics of Prevention, OECD Health Policy Studies, OECD Publishing, Paris, https://dx.doi.org/10.1787/67450d67-en. [3]

OECD (2015), Cardiovascular Disease and Diabetes: Policies for Better Health and Quality of Care, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264233010-en. [2]

OECD (2012), OECD Reviews of Health Care Quality: Korea 2012: Raising Standards, OECD Reviews of Health Care Quality, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264173446-en. [5]

Raleigh, V. (2019), “Trends in life expectancy in EU and other OECD countries : Why are improvements slowing?”, OECD Health Working Papers, No. 108, OECD Publishing, Paris, https://dx.doi.org/10.1787/223159ab-en. [10]

The Marmot Review (2020), Health Equity in England: The Marmot Review 10 Years On, https://www.health.org.uk/funding-and-partnerships/our-partnerships/health-equity-in-england-the-marmot-review-10-years-on?gclid=EAIaIQobChMIt6Sx2PPx5wIVTbTtCh23nQh6EAAYASAAEgIaevD_BwE. [7]

The Marmot Review (2010), Fair Society, Healthy Lives The Marmot Review, https://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf. [8]

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