Full document - International Hospital Federation

More documents

Recommendations

Info

Innovation in clinical specialities: cardiovascular disease number of deaths postponed or prevented but did not alter the relative contribution of each risk factor (Table 5, columns 5 and 6). Thus, regardless of whether best, minimum or maximum estimates were considered, the most substantial contributions came from the changes in cholesterol, blood pressure and smoking (Table 5). Discussion Success in achieving the HP2010 targets could almost halve predicted CHD deaths in 2010, or indeed in 2015. Our findings are reassuringly consistent with earlier studies in the England, 23 Scotland 22 and the USA 12 . In the United Kingdom, a modest reduction in mean population cholesterol level from 225 mg/dl to 200 mg/dl could reduce CHD deaths by approximately half. 14,15,24 In contrast, a rather optimistic 25% reduction in the prevalence of obesity would probably prevent just 2% of CHD deaths. 15,24 A corresponding 25% reduction in the prevalence of inactivity might prevent 1% of CHD deaths. 15,29 Although CHD death rates have been falling in the USA for four decades, they are now plateauing in young men and women. 2 Recent declines in total cholesterol have been modest, blood pressure is now rising among women and obesity and diabetes are 20 000 0 -20 000 -40 000 -60 000 -80 000 -100 000 -120 000 -140 000 -160 000 -180 000 -5000 -45 000 -85 000 -125 000 -28 300 -33 540 C holes terol -103 080 25-34 355-300 1525 2235 -1525 2190 -48 635 Systo lic B P -82 520 35-44 -4190 -12 175 Smoking -10 020 -6810 -12 010 -26 270 -33 670 -60 135 IF Current trends continue to 2010 IF Healthy People 2010 targets IF USA Low Risk stratum -20815 45-54 -45 770 -1450 IF Current trends continue to 2010 IF Healthy People 2010 targets IF USA Low Risk stratum -43 615 55-64 -88 500 8105 BMI P hysical A ctivity -17 430 -20 535 -8775 -52 300 65-74 -106 295 15885 rising steeply. Furthermore, population aging will increase the numbers of CHD deaths in that country and elsewhere. 30 There is no room for complacency. Continuation of recent risk factor trends should result in approximately 20 000 fewer coronary deaths in 2010 than in 2000. This reflects some 50 000 fewer deaths expected from improvements in total cholesterol, smoking, physical activity and male blood pressure, but more than half of the gain is negated by approximately 30 000 additional deaths attributable to increases in rates of obesity and diabetes, plus systolic blood pressure increases among women. Increasing treatments could not compensate for these worsening risk factors. In 2000, barely 40% of eligible patients received appropriate therapies. 10 Even raising this proportion to an optimistic 50% would only postpone approximately 60 000 additional deaths in 2010. 31 Successfully achieving the specific risk factor reductions proposed in the HP2010 targets could prevent or postpone approximately 190 000 CHD deaths. This would potentially halve the mortality burden seen in 2000. The HP2010 objectives for cholesterol and physical activity remain potentially attainable. However, attaining the targets for obesity, diabetes and female blood pressure appear more challenging because of the need to actually reverse recent adverse trends. 3 Successfully reducing population risk factor levels to those already seen in the healthiest (lowrisk) stratum could result in approximately 370 000 fewer CHD deaths among people aged 25–84 years. This figure would represent a 96% decrease compared to the 2000 baseline of 388 000 1,3 and is somewhat larger than the 85% reduction predicted by other studies. 24,25 Although probably an overestimate, the results for this third scenario show an aspirational ideal to highlight potential future gains. However, the “low-risk stratum” in the population of the USA remains frustratingly small, even when defined only by smoking, blood -71 860 pressure and cholesterol: 6% in the 1970s 32 and, even now, only 7.5% among whites and 4% among African Americans. 33 -43 900 -11 840 -61 790 Diabetes Figure 1: Estimated reductions in coronary heart disease mortality in the United . States 2. Estimated of America reductions in 2010 under in coronary three different heart disease scenarios mortality in the United State 75-84 -119 705 Figure 2: Estimated reductions in coronary heart disease mortality in the United States of America in 2010 by age group under three different scenarios Achieving risk factor reductions Although fashionable, screening and treating high-risk individuals would necessitate medicating 15% to 25% of all adults. 34,35 Furthermore, the key goal is not intervention but sustained risk factor reductions. 35 The whole population approach described by Rose 13 appears both more effective and cost-effective. 13–15 Similar conclusions have been reported previously in Dutch, Finnish and American cohorts. 12,35 Lowering cholesterol should therefore remain a priority in the USA, as it offers a potentially powerful 1% mortality reduction for every 1 mg/dl decrease in total cholesterol. 6 Large cholesterol declines have already been achieved by comprehensive national policies elsewhere (-20% in Finland 18 and -15% in Mauritius 36 ). In contrast, in the USA between 1988 and 2004 total cholesterol fell barely 3% in adults (from 206 to 201 mg/dl). 37 Furthermore, these levels remain well above the optimal, prompting recent national dietary policies to further reduce total cholesterol levels. 2,3,38 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010 73
Innovation in clinical specialities: cardiovascular disease Smoking prevalence remains above 20% overall in the USA and is even higher in certain groups. This represents substantial room for improvement. Success in reducing tobacco use requires two comprehensive strategies: preventing young people from starting to smoke, and promoting cessation among smokers. 39 Examples of successful efforts include intensive antismoking programmes in California (USA); 40 advertising bans in Finland, Iceland and Norway; and smoke-free environments legislation in Ireland, Italy, Scotland and New York City in the USA. 41 It is encouraging that many more states in the USA are now passing laws requiring smoke-free environments. 41 The recent blood pressure trends in women are alarming. This is a powerful risk factor; every 1 mmHg reduction in systolic blood pressure could prevent approximately 10 000 CHD deaths each year in the population of the USA. 7 Furthermore, population blood pressure has been decreasing in most industrialized countries in recent decades, reflecting dietary trends rather than use of medications. 42–44 The American Public Health Association has called on industry to reduce the salt content of processed food over the next decade, which could contribute to meeting the dietary guidelines for daily sodium intake of less than 2300 mg. 44,45 Our analysis suggested that the current adverse trends in the USA – increases in obesity and diabetes rates and blood pressure in women – will probably cause approximately 30 000 additional CHD deaths in 2010. Obese individuals with pre-diabetes can benefit from a combination of diet, exercise advice and behavioural therapy, 46 but prevention is preferable. Yet today’s obesogenic environment is reinforced by powerful commercial, political, economic and social factors, 47 and thus reversing these trends will require substantial efforts and appears daunting. 2,3,32 Recent increases in physical activity in the USA are encouraging, echoing trends in Canada, Finland and elsewhere. 5,18,48 Although engaging in adequate physical activity confers many health benefits, our analyses found that the potential reductions in CHD mortality appeared modest in the USA, as elsewhere. 15,23 Interventions promoting activity among individuals seldom show long-term sustainability. 48 However, physical activity in populations may be increased by 4% to 9% through multiple interventions. 23,49 The IMPACT model Our current analyses used the validated IMPACT model for the USA. 10 Recent high-quality data from NHANES and other large national studies reflected many events in a very large population. The model is comprehensive and transparent; it uses recent, reliable and reasonably precise age-specific regression coefficients from substantial meta-analyses 6,7 and relative risk values obtained from the large INTERHEART study. 27 Every key assumption is addressed and justified in the Supplementary Appendix (available at: http://content.nejm.org/cgi/data/356/23/2388/DC1/1). All models are simplifications of reality, with clear limitations. First, this model considered only mortality, not morbidity. However, our estimates of fewer deaths can easily be translated into a 12-fold increase in life-years gained. 50 Second, the model only explained 91% of the mortality decrease, leaving 9% unexplained. Third, several assumptions were necessary, for instance, that any delay in mortality reduction (lag time) would be relatively unimportant over a 10-year scenario. 10,17,23 However, extending the projections from 2000–2010 to 2000–2015 would generate very similar results. Although all coefficients were independent, coming from multivariate logistic regression analyses, 6,7,27 some may not have been fully adjusted and thus “residual confounding” may remain, along with some imprecision. 10 Furthermore, the population-attributable risk approach may have slightly overestimated the contributions of diabetes, smoking and physical activity. Some net overestimation of benefits is thus possible, particularly for the ideal scenario. Conversely, underestimation was also possible because the model assumed similar change across the population. Larger reductions among older, more motivated individuals with higher mortality rates might generate greater benefits. Model development and comparisons with other models may be useful, along with consideration of “novel” risk factors, such as high levels of C-reactive protein. 2,3,51 It may also be useful for future studies to address economic and ethnic analyses and seek to validate the model using 2010 data when it becomes available. However, our rigorous sensitivity analyses were reassuring and suggested that the key findings are unlikely to change substantially. 10,17,23 Moreover, even crude estimates are potentially valuable for planners and policy-makers. In conclusion, implementing evidence-based policies to better control tobacco use and achieve healthier diets could potentially halve future CHD deaths in the United States of America. ❏ Acknowledgements We thank Wayne H Giles, Umed A Ajani and Thomas E Kottke for helpful comments on the original model. Funding: This study was supported by investigator salaries only – Higher Education Funding Council for England (SC, JAC) and United States Centers for Disease Control and Prevention (ESF, JBC, KJG, DRL). Competing interests: None declared. Originally published in Bulletin of the World Health Organization; Article DOI: 10.2471/BLT.08.057885 References 1. Heart disease and stroke statistics: 2008 Update. Dallas, TX: American Heart Association; 2008. Publication: Bulletin of the World Health Organization; Type: Policy and Practice Article DOI: 10.2471/BLT.08.057885 2. Ford ES, Capewell S. Coronary heart disease mortality among young adults in the US from 1980 through 2002: concealed levelling of mortality rates. J Am Coll Cardiol 2007;50:2128- 32. PMID:18036449 doi:10.1016/j.jacc.2007.05.056 3. Department of Health and Human Services. Healthy people 2010: understanding and improving health and objectives for improving health. Washington, DC: Government Printing Office; 2000. Available from: http://www.cdc.gov/nchs/hphome.htm [accessed on 5 October 2009]. 4. Public health action plan to prevent heart disease and stroke. Atlanta, GA: Centers for Disease Control and Prevention; 2008. Available from: http://www.cdc.gov/dhdsp/ library/action_plan/index.htm [accessed on 5 October 2009]. 5. Centers for Disease Control and Prevention. Prevalence of no leisure-time physical activity – 35 states and the District of Columbia, 1988–2002. MMWR Morb Mortal Wkly Rep. 2004;53:82-6. PMID:14762333 6. Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994;308:367- 72. PMID:8043072 7. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903-13. PMID:12493255 doi:10.1016/S0140- 6736(02)11911-8 8. Bogers RP, Bemelmans WJ, Hoogenveen RT, Boshuizen HC, Woodward M, Knekt P, et al. Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons. Arch Intern Med 2007;167:1720-8. PMID:17846390 doi:10.1001/archinte.167.16.1720 9. Hunink MG, Goldman L, Tosteson AN, Mittleman MA, Goldman PA, Williams LW, et al. The 74 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010
Page 1:
International Hospital Federation I
Page 4 and 5:
Introduction Sterile Barrier System
Page 6 and 7:
Contents Healthcare transformation
Page 8 and 9:
International Hospital Federation H
Page 11 and 12:
Introduction Introduction ERIC DE R
Page 13:
Innovation and strategy 14 Creativi
Page 16 and 17:
Innovation and strategy: creativity
Page 18 and 19:
Innovation and strategy: risk manag
Page 20 and 21:
Page 22 and 23:
Page 24 and 25: Innovation and strategy: risk manag
Page 26 and 27: Innovation and stategy: Acceleratin
Page 28 and 29: Innovation and stategy: Acceleratin
Page 30 and 31: Innovation and policy: disease surv
Page 36 and 37: Innovation and clinical specialitie
Page 42 and 43: Innovation and strategy: infectious
Page 48 and 49: Innovation and policy: infectious d
Page 54 and 55: Innovation in clinical specialities
Page 82 and 83: Innovations and clinical specialiti
Page 90 and 91: Company Profile: Shimadzu Europa Gm
Page 116: Innovation and clinical specialitie
Page 119 and 120: Company Profile: Wipak Medical Wipa
Page 121 and 122: Innovations in patient care: infect
Page 123 and 124: Innovations in patient care: infect
Page 125 and 126:
Innovations in patient care: infect
Page 127 and 128:
Innovations in patient care: infect
Page 129 and 130:
Innovation in patient care: patient
Page 131 and 132:
Innovation in patient care: patient
Page 133 and 134:
IHF reference The International Hos
Page 135 and 136:
C M Y CM MY CY CMY K with support f
Page 137 and 138:
IHF reference IHF Governing Council
Page 139 and 140:
IHF reference IHF Consultants Audit
Page 141 and 142:
IHF reference JAPAN JAPAN HOSPITAL
Page 143 and 144:
IHF reference KENYA THE NAIROBI HOS
Page 145 and 146:
IHF Corporate Member Profiles GE He
Page 147:
How Can Health Organizations Get th
show all

Full document - International Hospital Federation

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?