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Innovation in clinical specialities: cardiovascular disease (1988–2002), 3,4 linear projections were made from 1988–1994 through 1999–2002 to the country’s population in 2010 of recent trends in total cholesterol (mg/dl), smoking (%), systolic blood pressure (mmHg), body mass index (BMI) (kg/m 2 ), all diabetes (%) and any leisure-time physical activity (%), all stratified by age and sex 10,22,23 (Table 3). The second scenario assumed risk factor levels equal to the substantial but feasible reductions defined in the HP2010 objectives. 3 In the absence of specific HP2010 targets for BMI, total diabetes and systolic blood pressure, we assumed that: (i) the 15% obesity target would equate to a population mean BMI of 25 kg/m 2 for men and 26 kg/m 2 for women; (ii) the 25 per 1000 population clinically diagnosed diabetes prevalence target would equate to a total (diagnosed and undiagnosed) type 1 and type 2 diabetes prevalence of 6%; and (iii) the 16% hypertension prevalence target would equate to a population mean systolic blood pressure of 119 mmHg, representing a 5 mmHg reduction from 2000 levels (Table 3). In the third scenario, mean population risk factors were assumed to reach levels already observed in the “healthiest” stratum of cohorts in the USA, as defined by Stamler et al. 24 and Daviglus et al. 25 Levels for specific risk factors were as follows: (i) no smoking among men or women; (ii) 175.6 mg/dl (4.54 mmol/l) total cholesterol for men and 179.6 mg/dl (4.64 mmol/l) for women; (iii) a mean systolic blood pressure of 115.7 mmHg for men and 114.7 mmHg for women, representing a 10mmHg reduction from 2000 levels; (iv) a BMI of 25.5 kg/m 2 for men and 23.6 kg/m 2 for women; (v) zero prevalence of diabetes among both men and women. 24,25 Physical activity was not specifically considered by in these studies, 24,25 so we defined the level in the lowest risk stratum as 100%, with everyone undertaking some leisure-time physical activity. (Table 3). To preserve the focus on risk factor changes, we assumed that the proportion of the population receiving medical and surgical treatments for CHD would remain constant. Sensitivity analysis Because of the uncertainties surrounding some of the estimates, a multi-way sensitivity analysis was performed using the analysis of extremes method. 28 Minimum and maximum estimates of deaths prevented or postponed were generated using minimum and maximum plausible values for the main parameters: 95% confidence intervals when available; otherwise, the best value ±20%. 10,22,23,28 The Supplementary Appendix (available at: http://content.nejm.org/cgi/data/356/23/2388/DC1/1) provides worked examples of the calculations used in the model plus further details on the methods and data sources used. 10 Results Trends and estimates Approximately 388 000 CHD deaths among people aged 25–84 years would be expected in 2010 if the same age-specific death rates recorded in 2000 (the base year) were also observed in 2010. This number would represent 15% more than the 338 000 deaths observed in 2000, reflecting population aging compounded by an increase in population size (Table 4). Between 1997 and 2002, the overall annual declines observed in CHD mortality rates were 2% for men and 1% for women. Table base-year 5: Estimated following reduction changes in coronary in specific heart risk factors disease mortality in the United States of America in 2010 compared with the 2000 base-year following changes in specific risk factors Risk factor changes Absolute values Fewer (additional) CHD deaths in 2010 with risk factor changes a MenBest estimate WomenBest estimate Men Women Best estimate Minimum Maximum Smoking prevalence in 2000 27.3% 21.9% If recent trends continue to 2010 22.6% 18.7% -10 000 -8 000 -12 000 - 7 000 -3 000 If HP2010 targets are achieved 12.0% 12.0% -26 000 -21 000 -32 000 - 18 000 -8 000 If all in low-risk stratum 0% 0% -60 000 -48 000 -72 000 - 42 000 -18000 Total cholesterol in 2000 205.0 206.9 If recent trends continue to 2010 204.2 204.3 -28 000 -17 000 -41 000 - 15 000 -14 000 If HP 2010 targets are achieved 199.0 199.0 -40 000 -24 000 -59 000 - 17 000 -24 000 If all in low-risk stratum 175.6 179.6 -103 000 -70 000 -160 000 - 68 000 -35 000 Population systolic blood pressure in 2000 124.4 123.9 I f recent trends continue to 2010 125.3 128.5 (+2 000) (+1 000) (+4 000) - 6 000 (+8 000) If HP2010 targets are achieved 119.4 118.9 -48 000 -39 000 -58 000 - 28 000 -20 000 If all in low-risk stratum 115.7 114.7 -83 000 -75 000 -108 000 - 54 000 -29 000 Body mass index (BMI) in 2000 27.86 28.51 If recent upward trends continue to 2010 29.18 30.16 (+8 000) (+5 000) (+11 000) (+5 000) (+3 000) If HP2010 targets are achieved 25.00 26.00 -17 000 -10 000 -24 000 - 12 000 -5 000 If all in low-risk stratum 25.50 23.60 -21 000 -12 000 -27 000 - 10 000 -10 000 Diabetes in 2000 11.7% 9.5% If recent upward trends continue to 2010 15.2% 10.1% (+16 000) (+5 000) (+22 000) (+11 000) (+5 000) If HP2010 targets are achieved 6.0% 6.0% -44 000 -26 000 -66 000 - 24 000 -20 000 If all in low-risk stratum 0% 0% -72 000 -49 000 -100 000 - 38 000 -34 000 Physical activity in 2000 75.1% 70.5% If recent trends continue to 2010 80.8% 74.1% -7 000 -6 000 -9 000 - 4 000 -2 000 If HP2010 targets are achieved 80% 80% -12 000 -10 000 -14 000 - 6 000 -6 000 If all in low-risk stratum 100% 100% -34 000 -27 000 -40 000 - 18 000 -16 000 If recent downward trends continue (smoking, n/a n/a -51 000 -29 000 -57 000 - 32 000 19 000 cholesterol, physical inactivity male BP) If recent upward trends continue (female BP, obesity, n/a n/a (+32 000) (+10 000) (+32 000) (+16 000) (+16 000) diabetes) Net effect if recent trends continue n/a n/a -19 000 -10 000 -25 000 - 16 000 -3 000 If HP2010 targets are achieved n/a n/a -188 000 -129 000 -252 000 -105 000 -83 000 If all in low-risk stratum n/a n/a -372 000 -281 000 -507 000 - 230 000 -142 000 If only smoking, cholesterol and BP match low-risk n/a n/a -246 000 -194 000 -339 000 - 164 000 -82 000 stratum If only BMI, diabetes and physical activity match low-risk n/a n/a -126 000 -87 000 -167 000 - 66 000 -60 000 stratum HP2010, Health People 2010; BP, systolic blood pressure <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010 71
Innovation in clinical specialities: cardiovascular disease Table Table 6: 6. Reductions Reductions in coronary in coronary heart heart disease disease mortality mortality achievable achievable in in the the United United States States of of America America in 2010 in 2010 compared compared with with 2000 2000 Age groups(years) Scenario Total Men Women If recent trends continue (+355 ) (+55) (+305) If HP2010 targets are achieved 300 225 75 25–34 If all achieved low-risk stratum values 2 000 b 1 000 1 000 I f recent trends continue (+2 000) (+380) (+1 000) If HP2010 targets are achieved 4 000 3 000 2 000 35–44 If all achieved low-risk stratum values 12 000 8 000 4 000 I f recent trends continue (+2 000) (+2 000) (+115) If HP2010 targets are achieved 20 000 16 000 5 000 45–54 If all achieved low-risk stratum values 46 000 35 000 11 005 If recent trends continue 1 000 2 000 -1 000 If HP2010 targets are achieved 44 000 27 000 16 000 55–64 If all achieved low-risk stratum values 89 000 57 000 31 000 If recent trends continue 9 000 10 000 (+1 000) If HP2010 targets are achieved 52 000 28 000 25 000 65–74 If all achieved low-risk stratum values 106 000 62 000 44 000 If recent trends continue 12 000 7 000 5 000 If HP2010 targets are achieved 62 000 25 000 37 000 75–84 If all achieved low-risk stratum values 120 000 67 000 53 000 If recent trends continue 19 000 16 000 3 000 If HP2010 targets are achieved 188 000 105 000 83 000 Totals If all achieved low-risk stratum values 372 000 230 000 142 000 HP2010, Healthy People 2010 a Additional deaths shown as a positive value: e.g. (+355) b Number of deaths from coronary heart disease rounded to nearest 1000 on this and subsequent rows However, declines were minimal among men younger than 45 years of age, and increases were seen among women in that age group. Three of the six major risk factors declined between 1988 and 2002, while obesity and diabetes increased. Systolic blood pressure rates rose among women and fluctuated among men. Assuming continuation of the same trends, the overall result would be approximately 19 000 fewer deaths in 2010 than in 2000 (minimum estimate 10 000 and maximum estimate 25 000). This represents some 51 000 fewer deaths because of improvements in total cholesterol and men’s blood pressure, less smoking and increased physical activity, minus approximately 32 000 additional deaths attributable to adverse trends in obesity, diabetes and women’s blood pressure (Table 5). Approximately 188 000 fewer CHD deaths than in 2000 (minimum 129 000, maximum 252 000) could be achieved by reaching the specific reductions in cardiovascular risk factors called for in HP2010: (i) approximately 40 000 fewer deaths if population mean cholesterol levels declined to 199 mg/dl (5.15 mmol/l) among both men and women; (ii) approximately 26 000 fewer deaths if the smoking prevalence fell to 12% among both men and women; (iii) approximately 48 000 fewer deaths, assuming a decrease in mean systolic blood pressure to 119.4 mmHg among men and 118.9 mmHg among women (representing a 5 mmHg reduction in all age groups); (iv) approximately 12 000 fewer deaths, assuming an increase in physical activity rates (to 80% among both men and women); (v) approximately 17 000 fewer deaths, assuming a substantial decrease in BMI to 25.0 kg/m 2 for men and 26.0 kg/m 2 for women; (vi) approximately 44 000 fewer deaths, assuming a substantial decrease in total diabetes prevalence to 6% among both men and women. If the ideal scenario were achieved, with mean population cardiovascular risk factors reduced substantially to levels already observed in the healthiest stratum of cohorts, 24,25 approximately 372 000 CHD deaths (minimum 281 000, maximum 507 000) could be prevented or postponed (Figure 1). The 372 000 fewer deaths would be distributed as follows: (i) approximately 103 000 fewer deaths if population mean cholesterol levels declined to 175.6 mg/dl (4.54 mmol/l) among men and 179.6 mg/dl (4.64 mmol/l) among women; (ii) approximately 60 000 fewer deaths if smoking prevalence fell to zero; (iii) approximately 83 000 fewer deaths, assuming a 10 mmHg decrease in mean systolic blood pressure to 115.7 mmHg for men and114.7 mmHg for women; (iv) approximately 34 000 fewer deaths if all men and women were physically active; (v) approximately 21 000 fewer deaths, assuming a decrease in BMI to 25.5 in men and 23.6 in women; (vi) approximately 72 000 fewer deaths, assuming a zero prevalence of diabetes (Table 5). Estimated mortality benefits Under the scenario in which current trends continued, approximately 16 000 fewer deaths would occur among men and 3000 among women. In the two more optimistic scenarios, men would consistently benefit more than women, gaining 54% of the 182 000 fewer deaths under the HP2010 reductions scenario and 62% of the 372 000 fewer deaths if low-risk stratum levels are assumed (Table 5). Gains would predominantly occur among men aged 45–84 years and among women aged 65–84 years (Figure 2). Of the 372 000 fewer deaths in the most optimistic scenario, 252 000 (68%) would represent premature deaths avoided, that is, deaths among those under 75 years of age (Table 6). Extensive sensitivity analyses examined the impact of higher and lower values for model parameters. 28 Changing the values influenced the 72 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010
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International Hospital Federation I
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Introduction Sterile Barrier System
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Contents Healthcare transformation
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International Hospital Federation H
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Introduction Introduction ERIC DE R
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Innovation and strategy 14 Creativi
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Innovation and strategy: creativity
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Innovation and strategy: risk manag
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Innovation and strategy: risk manag
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Page 119 and 120: Company Profile: Wipak Medical Wipa
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Innovations in patient care: infect
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Innovation in patient care: patient
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Innovation in patient care: patient
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IHF reference The International Hos
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C M Y CM MY CY CMY K with support f
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IHF reference IHF Governing Council
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IHF reference IHF Consultants Audit
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IHF reference JAPAN JAPAN HOSPITAL
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IHF reference KENYA THE NAIROBI HOS
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IHF Corporate Member Profiles GE He
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How Can Health Organizations Get th
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