Geographical Distribution of Incidence and Fatality of Coronary Heart Disease Hospital Admissions in Portugal Introdução à Medicina II Class13 Adviser: Armando Teixeira Pinto, PhD Faculdade de Medicina da Universidade do Porto Mestrado Integrado em Medicina 2009/2010

TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

Cardiovascular diseases are the most common cause of death in Europe. [1] Among them, coronary heart disease (CHD) is the most frequent. [1] Two million Europeans die from CHD each year, 21% men and 22% women. [2] Regional variations in cardiovascular mortality have been observed both between and within countries in Europe. [3] INTRODUCTION Importance [1] World Health Organization [2] The Women’s Health Resource [3] Tu J V, Nardi L, Willich S N. “An update on regional variation in cardiovascular mortality within Europe”. Heart J., May 2, 2008,

In Portugal In Portugal Stroke and ischemic heart disease are the leading causes of hospitalization and death, as well as of morbidity, disability, low quality of life and decrease in life expectancy. [4] The analysis of regional variance in CHD is important for the classification of regions in high- and low- risk regions. [3] INTRODUCTION Importance [4] Direcção geral de saúde. Actualização do Programa Nacional de Prevenção e Controlo das Doenças Cardiovasculares [3] Tu J V, Nardi L, Willich S N. “An update on regional variation in cardiovascular mortality within Europe”. Heart J., May 2, 2008,

INTRODUCTION Coronary Disease [5] NATIONAL HEART, LUNG, AND BLOOD INSTITUTE - Coronary Artery Disease.

TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

Analyze the variation in the CHD hospital admissions’ Fatality and Incidence in Portugal (continental) both on a national and on a regional level throughout the year period. AIM

TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

PARTICIPANTS AND METHODS Study design Observacional Portugal (continental) Retrospective (from 2000 to 2007)

Database Data from all Portuguese Public Hospitals, from 2000 to PARTICIPANTS AND METHODS Data collection Extract of the GDH Database variables

PARTICIPANTS AND METHODS Study variables ICD-9 codes ( ) Gender Age (“0 to 14”; “15 to 24”; “25 to 64”; “65 to 74” and more than 75”) Hospitalization Period (HP) Nuts II distribution (patient residence) Number of hospital admissions and deaths by CHD Number of habitants (external data) CHD Incidence and Fatality standardized and ajusted ratios (SIR and SFR)

PARTICIPANTS AND METHODS Study variables NUTS II distribution performed in the study

Exclusion criteria Ages above 112 Admissions from Açores and Madeira Hospitalization Period (days) <1 (Patients with HP inferior to 1 day in case of death or transference to the hospital unit or discharge on personal demand were not excluded) Admissions with undefined sex

PARTICIPANTS AND METHODS Statistical analysis What did we study? Geographical distribution of incidence and fatality of CHD (hospital admissions). Evolution of incidence and fatality of CHD (hospital admissions) along the period.

PARTICIPANTS AND METHODS Statistical analysis INCIDENCE = number of hospital admissions from CHD number of habitants FATALITY = number of hospital deaths from CHD number of hospital admissions from CHD

Maps construction of geographical distribution for incidence and fatality – R Statistical analysis tool – SPSS Statistics 17.0 PARTICIPANTS AND METHODS Statistical analysis

Incidence adjusted rate = SIR * Incidence crude rate PARTICIPANTS AND METHODS Statistical analysis SIR = Number of expected admissions by CHD Number of observed admissions by CHD

PARTICIPANTS AND METHODS Statistical analysis

Portugal Norte SIR CIR Centro SIR CIR Lisboa e Vale do Tejo SIR CIR Alentejo SIR CIR Algarve SIR CIR Table 1: Comparison on age- and gender- standardized incidence rates (SIR) and crude incidence rates (CIR). Importance of standardization

TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

2000 RESULTS Geographical distribution of SIR by NUTS II

2001 RESULTS Geographical distribution of SIR by NUTS II

2002 RESULTS Geographical distribution of SIR by NUTS II

2003 RESULTS Geographical distribution of SIR by NUTS II

2004 RESULTS Geographical distribution of SIR by NUTS II

2005 RESULTS Geographical distribution of SIR by NUTS II

2006 RESULTS Geographical distribution of SIR by NUTS II

2007 RESULTS Geographical distribution of SIR by NUTS II

RESULTS Geographical distribution of SFR by NUTS II 2000

RESULTS Geographical distribution of SFR by NUTS II 2001

RESULTS Geographical distribution of SFR by NUTS II 2002

RESULTS Geographical distribution of SFR by NUTS II 2003

RESULTS Geographical distribution of SFR by NUTS II 2004

RESULTS Geographical distribution of SFR by NUTS II 2005

RESULTS Geographical distribution of SFR by NUTS II 2006

RESULTS Geographical distribution of SFR by NUTS II 2007

RESULTS Geographical distribution of SFR by NUTS II

RESULTS Adjusted incidence rate Figure 1: Age- and gender- adjusted rates of hospital admissions because of coronary heart disease per population in Continental Portugal,

RESULTS Adjusted fatality rate Figure 2: Age- and gender- adjusted in-hospital case fatality rates among patients with coronary heart disease in Continental Portugal,

RESULTS Adjusted incidence rate VS Adjusted fatality rate Figure 3: Comparison on age- and gender- adjusted rates of hospital admissions because of coronary heart disease per population and age- and gender- standardized in-hospital case fatality rates among patients with coronary heart disease in Continental Portugal,

TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

There were regional differences on the distribution of the incidence of CHD Continental Portugal Gender and age only were not responsible for the regional variation Lisboa e Vale do Tejo Highest incidence rate of CHD, but fatality rate similar to the other regions decrease on the incidence rate of CHD in the period of the study DISCUSSION

Other regions The incidence and fatality of CHD in these regions were very similar. Centro presents the lowest incidence rate of CHD, but fatality rate similar to the other regions. DISCUSSION

RESULTS Adjusted incidence rate VS Adjusted fatality rate Figure 3: Comparison on age- and gender- adjusted rates of hospital admissions because of coronary heart disease per population and age- and gender- standardized in-hospital case fatality rates among patients with coronary heart disease in Continental Portugal,

Possible bias from errors in the database Missing values : admissions that don’t include address, gender, age or hospitalization cause Wrong data Several hospitalizations for the same person Hospital transferences Choosing the main diagnosis as the inclusion criteria may create unexpected bias Different data quality between regions Non-inclusion of private inpatients Non-inclusion of individuals with CHD who haven’t been hospitalized DISCUSSION Limitations

Better classification of regions into high- and low- risk incidence and fatality of CHD Improvement of healthcare at regional levels, decreasing incidence and fatality of CHD Better use of available resources Adoption of more preventive measures Stimulation for further analysis and studies DISCUSSION Value

Risk factors Cultural factors Lifestyles Preventive measures of CHD Evaluation of CHD treatment efficiency DISCUSSION Further Studies

TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

REFERENCES [1] WORLD HEALTH ORGANIZATION - Top 10 causes of death. [Consult. 27 Out. 2009]. WWW: [2] IMAGINUS: THE WOMEN’S HEALTH RESOURCE - Coronary Artery Disease (CAD) Overview.[Consult. 20 Out. 2009]. WWW: [3] Tu J V, Nardi L, Fang J. Muller-Nordhorn J, Binting S, Roll S, Willich S N. “An update on regional variation in cardiovascular mortality within Europe”. Heart J., May 2, 2008; 29 (10): [4] DIRECÇÃO GERAL DE SAÚDE. MINISTÉRIO DA SAÚDE. Circular Normativa. Actualização do Programa Nacional de Prevenção e Controlo das Doenças Cardiovasculares. Ministério da Saúde [5] NATIONAL HEART, LUNG, AND BLOOD INSTITUTE - Coronary Artery Disease. [Consult. 19 Out. 2009]. WWW: [6] WORLD HEALTH ORGANIZATION - International Classification of Diseases (ICD). [Consult. 20 Out. 2009]. WWW: [7] CENTERS FOR DISEASE CONTROL AND PREVENTION - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). (1 Set. 2009). [Consult. 22 Out. 2009]. WWW: [8] INSTITUTO NACIONAL DE ESTATÍSTICA. População residente (N.º) por Local de residência, Sexo e Grupo etário (Por ciclos de vida); Anual. [9] “National trends in rates of death and hospital admissions related to acute myocardial infarction, heart failure and stroke”, 1994–2004. CMAJ. 2009;180:E118–25.

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