1. 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

2. TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

3. TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

4. 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 http://www.who.int/mediacentre/factsheets/fs310/en/index.html [2] The Women’s Health Resource http://www.imaginis.com/heart-disease/cad_ov.asp [3] Tu J V, Nardi L, Willich S N. “An update on regional variation in cardiovascular mortality within Europe”. Heart J., May 2, 2008,

5. 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. 2006. [3] Tu J V, Nardi L, Willich S N. “An update on regional variation in cardiovascular mortality within Europe”. Heart J., May 2, 2008,

6. INTRODUCTION Coronary Disease [5] NATIONAL HEART, LUNG, AND BLOOD INSTITUTE - Coronary Artery Disease. http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html

7. TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

8. 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 2000-2007 year period. AIM

9. TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

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

11. Database Data from all Portuguese Public Hospitals, from 2000 to 2007. PARTICIPANTS AND METHODS Data collection Extract of the GDH Database variables

12. PARTICIPANTS AND METHODS Study variables ICD-9 codes (410-414) 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)

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

14. 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

15. 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 2000-2007 period.

16. 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

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

18. 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

19. PARTICIPANTS AND METHODS Statistical analysis

20. 20002001200220032004200520062007 Portugal 281286284287291289277281 Norte SIR 224233 232230235223256 CIR 203211212210209214207235 Centro SIR 162175174185192199197192 CIR 177191 203210217207209 Lisboa e Vale do Tejo SIR 503506493496498476437408 CIR 491493480483485464432398 Alentejo SIR 204194197198207213228253 CIR 244234237238249255275300 Algarve SIR 241217254242259238241261 CIR 264236264262279255261278 Table 1: Comparison on age- and gender- standardized incidence rates (SIR) and crude incidence rates (CIR). Importance of standardization

21. TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

22. 2000 RESULTS Geographical distribution of SIR by NUTS II

23. 2001 RESULTS Geographical distribution of SIR by NUTS II

24. 2002 RESULTS Geographical distribution of SIR by NUTS II

25. 2003 RESULTS Geographical distribution of SIR by NUTS II

26. 2004 RESULTS Geographical distribution of SIR by NUTS II

27. 2005 RESULTS Geographical distribution of SIR by NUTS II

28. 2006 RESULTS Geographical distribution of SIR by NUTS II

29. 2007 RESULTS Geographical distribution of SIR by NUTS II

30. 20002007

31. RESULTS Geographical distribution of SFR by NUTS II 2000

32. RESULTS Geographical distribution of SFR by NUTS II 2001

33. RESULTS Geographical distribution of SFR by NUTS II 2002

34. RESULTS Geographical distribution of SFR by NUTS II 2003

35. RESULTS Geographical distribution of SFR by NUTS II 2004

36. RESULTS Geographical distribution of SFR by NUTS II 2005

37. RESULTS Geographical distribution of SFR by NUTS II 2006

38. RESULTS Geographical distribution of SFR by NUTS II 2007

39. RESULTS Geographical distribution of SFR by NUTS II 20002007

40. RESULTS Adjusted incidence rate Figure 1: Age- and gender- adjusted rates of hospital admissions because of coronary heart disease per 100 000 population in Continental Portugal, 2000-2007.

41. RESULTS Adjusted fatality rate Figure 2: Age- and gender- adjusted in-hospital case fatality rates among patients with coronary heart disease in Continental Portugal, 2000-2007.

42. 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 100 000 population and age- and gender- standardized in-hospital case fatality rates among patients with coronary heart disease in Continental Portugal, 2000- 2007.

43. TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

44. 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 2004-2007 period of the study DISCUSSION

45. 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

46. 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 100 000 population and age- and gender- standardized in-hospital case fatality rates among patients with coronary heart disease in Continental Portugal, 2000- 2007.

47. 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

48. 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

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

50. TABLE OF CONTENTS INTRODUCTION AIM PARTICIPANTS AND METHODS RESULTS DISCUSSION REFERENCES

51. REFERENCES [1] WORLD HEALTH ORGANIZATION - Top 10 causes of death. [Consult. 27 Out. 2009]. WWW: http://www.who.int/mediacentre/factsheets/fs310/en/index.html [2] IMAGINUS: THE WOMEN’S HEALTH RESOURCE - Coronary Artery Disease (CAD) Overview.[Consult. 20 Out. 2009]. WWW: http://www.imaginis.com/heart-disease/cad_ov.asp [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): 1316 - 1326. [4] DIRECÇÃO GERAL DE SAÚDE. MINISTÉRIO DA SAÚDE. Circular Normativa. Actualização do Programa Nacional de Prevenção e Controlo das Doenças Cardiovasculares. Ministério da Saúde 2006. [5] NATIONAL HEART, LUNG, AND BLOOD INSTITUTE - Coronary Artery Disease. [Consult. 19 Out. 2009]. WWW: http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html#cat596 [6] WORLD HEALTH ORGANIZATION - International Classification of Diseases (ICD). [Consult. 20 Out. 2009]. WWW: http://www.who.int/classifications/icd/en/http://www.who.int/classifications/icd/en/ [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: http://www.cdc.gov/nchs/icd/icd9cm.htm [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.

52. REFERENCES [10] Johansen H, Bernier J, Finès P, Brien S, Ghali W, Wolfson M. “Variations by health region in treatment and survival after heart attack”. Health Rep. 2009 Jun;20(2):29-34. [11] Tsiskaridze A, Djibuti M, van Melle G, Lomidze G, Apridonidze S, Gaurashvili I, Piechowski-Jozwiak B, Shakarishvili R, Bogousslavsky J. “Stroke Incidence and 30-Day Case-Fatality in a Suburb of Tbilisi” Stroke, 2004, 35:2523-2528. [11] Wolfe C D A, Taub N A, Woodrow J, Richardson E, Warburton F G, Burney P G J. “Does the incidence, severity, or case fatality of stroke vary in southern England?”, Journal of Epidemiology and Community Health 1993; 47: 139-143 [12] Périssé G, Medronho R A, Escosteguy C C. “Urban space and mortality from ischemic heart disease in the elderly in Rio de Janeiro.” Arq. Bras. Cardiol. Mar 05, 2010. [13] Lang T, Ducimetiere P, Arveiler D, et al. “Incidence, case fatality, risk factors of acute coronary heart disease and occupational categories in men aged 30-59 in France”. International Journal of Epidemiology 1997; 26: 47-57 [14] Bertoni A G, Kirk J K, Case L D, Kay C, Goff D C Jr, Narayan K M, Bell R A. “The effects of race and region on cardiovascular morbidity among elderly Americans with diabetes”. Diabetes Care. 2005 Nov;28(11):2620-5. [15] Chaves A P, André C. “A percepção da qualidade de vida da pessoa com doença coronária referenciada à consulta de cardiologia do hospital distrital de Santarém”, EP. Out, 2008