1. Studying mortality trends: The IMPACT CHD Policy Model
Charity No:
Studying mortality trends: The IMPACT CHD Policy Model
Prof Simon Capewell
Chair of Clinical Epidemiology
DIVISION OF PUBLIC HEALTH
LIVERPOOL UNIVERSITY UK
14th January 2008
Particular thanks to: Julia Critchley, Kath Bennett
Martin O’Flaherty, Robin Ireland, Ann Capewell
Greeting:
Good afternoon and thank you for coming to this presentation!
Today I would like to talk about our research project titled … Before starting my presentation I would like to thank Simon and Julia for their valuable scientific and social support.
Guven araliklarini koyarsan iyi olur results tablosuna
CHD icin akis semasini koy
Degiskenlerin tanimlarini koy 1

2. International mortality trends 1968-2003 men, coronary heart disease [CHD]
Source:BHF Heartstats (WHO statistics Men aged , Standardised)

3. Why have CHD mortality rates halved?
International mortality trends men, coronary heart disease [CHD]
Why have CHD mortality rates halved?
Source:BHF Heartstats (WHO statistics Men aged , Standardised)

4. Why did CHD mortality halve in spite of population ageing??
Explaining the fall in coronary heart disease deaths in England & Wales ?
Why did CHD mortality halve in spite of population ageing??
68,230
fewer deaths
in 2000 
1981
2000
  Unal, Critchley & Capewell Circulation (9) 1101

5. Explaining the fall in coronary heart disease deaths in England & Wales 1981-2000
Risk Factors worse +13%
Risk Factors better -71%   
Treatments %
68,230
fewer deaths
in 2000 
1981
2000
  Unal, Critchley & Capewell Circulation (9) 1101

6. Explaining the fall in coronary heart disease deaths in England & Wales 1981-2000
Risk Factors worse +13%
Obesity (increase) %
Diabetes (increase) %
Physical activity (less) +4.4%
Risk Factors better -71%
Smoking %
Cholesterol %
Population BP fall -9%
Deprivation %
Other factors -8%
  Treatments %
AMI treatments %
Secondary prevention -11%
Heart failure %
Angina:CABG & PTCA -4%
Angina: Aspirin etc %
Hypertension therapies -3%
68,230
fewer deaths
in 2000 
1981
2000
  Unal, Critchley & Capewell Circulation (9) 1101

7. Risk Factors obviously powerful but was it tablets or lifestyles??

8. Population secular trends
CHD prevention in England & Wales : Population v. High Risk Strategies Deaths prevented or postponed (Sensitivity analysis )
Population secular trends
C h o l e s t e r o l
Population diet
Blood Pressure
Diet in
CHD
patients
Statins
CHD
patients
Treating
High
Risk
Secular trends
CHD
patients
High
Risk
Statins
Unal et al BMJ 8

9. Population secular trends
CHD prevention in England & Wales : Population v. High Risk Strategies Deaths prevented or postponed (Sensitivity analysis )
Population secular trends
C h o l e s t e r o l
Population diet
Blood Pressure
Diet in
CHD
patients
Statins
CHD
patients
Treating
High
Risk
Secular trends
CHD
patients
High
Risk
Statins
Unal et al BMJ 9

10. Explaining the fall in CHD deaths in USA 1980-2000 : RESULTS
NEJM 2007; 356: 2388.
Risk Factors worse +17%
Obesity (increase) %
Diabetes (increase) %
Risk Factors better -65%
Population BP fall -20%
Smoking %
Cholesterol (diet) -24%
Physical activity -5%
 Treatments %
AMI treatments %
Secondary prevention -11%
Heart failure %
Angina:CABG & PTCA -5%
Hypertension therapies -7%
Statins (primary prevention) -5%
  Unexplained %
341,745
fewer deaths
in 
1980
2000

11. Comparisons with other studies: % CHD mortality falls attributed to
NEJM 2007; 356: 2388.

12. EXPLOITING THE IMPACT MODEL
Replication in other populations
Populations with RISING CHD
Calculating life-years gained
Cost effectiveness
WHAT IF treatment uptakes increased?
WHAT IF risk factors reduced further?

13. [ Capewell, Pell et al et al Eur Heart J 1999 20 1836 ]
WHAT IF Treatment Uptakes in England & Wales Increased? Actual Uptakes  50% 25,805 Deaths prevented or postponed (DPPs) IF Uptakes at least 80% 20,910 additional DPPs
Capewell et al Heart
[ Capewell, Pell et al et al Eur Heart J ]

14. IF Treatment Uptakes Increased in England & Wales Actual Uptakes  50%
IF Treatment Uptakes Increased in England & Wales Actual Uptakes  50% 25,805 Deaths prevented/ postponed (DPPs) IF Uptakes at least 80% 20,910 additional DPPs
Capewell et al Heart

15. EXPLOITING THE IMPACT MODEL
Replication in other populations
Populations with RISING CHD
Calculating life-years gained
Cost effectiveness
WHAT IF treatment uptakes increased?
WHAT IF risk factors reduced further?

16. Kelly & Capewell HDA 2004 www
Estimating the potential changes in CHD mortality in England & Wales between 2000 and 2010
WHAT IF risk factors
a) continue recent trends ?
b) undergo additional reductions ?
(as already achieved in
Australia, USA, Sweden, Finland etc)
  Unal et al J Clin Epid
Kelly & Capewell HDA 2004 www

17. Potential changes in CHD mortality in England &
Wales between 2000 and IF risk factors
a) continue recent trends
b) additional reductions already achieved elsewhere
  Unal et al J Clin Epid

18. Thus, to reduce CHD mortality in UK
The IMPACT Model
Thus, to reduce CHD mortality in UK
Modest additional risk factor reductions already achieved in USA & Scandinavia
could prevent or postpone over 50,000 deaths by 2010
halving current CHD deaths (100,000) in UK
  Unal et al J Clin Epid

19. CHD primary prevention programme
hence:
Heart of Mersey
CHD primary prevention programme
Key Targets:
Healthier food
Smoking reduction

20. Is the party over? 20

21. US Trends in age-adjusted CHD mortality rates: men & women aged ≥35 years
Ford & Capewell JACC

22. US Trends in AGE-SPECIFIC CHD mortality rates: men & women aged ≥35 years
Ford & Capewell JACC

23. Trends in age-specific CHD mortality rates England & Wales [lines indicate 5 year moving averages]
Heart~ July 2007 doi: /hrt

24. Using IMPACT to explain CHD trends and examine future policy options Conclusions
CHD mortality: big falls in UK & elsewhere
25%-50% due to “evidence-based” therapies
50% -75% due to risk factor reductions
(especially smoking & cholesterol)

25. Using IMPACT to explain CHD trends and examine future policy options Conclusions
CHD mortality: big falls in UK & elsewhere
25%-50% due to “evidence-based” therapies
50% -75% due to risk factor reductions
(especially smoking & cholesterol)
small reductions in UK risk factors
could Halve CHD deaths
Healthy diet & Tobacco control
remain top policy priorities

26. Reserve slides 26

27. IMPACT Model: Main Components
RISK F FACTORS
Patient
Groups
TREATMENTS
OUTCOMES
Blood Pressure
AMI
Angina
Heart Failure
2' Prevention
Medical Therapy
Cholesterol
BMI & Diabetes
Smoking
Physical Activity
Blood Pressure
Age & Sex
CABG/PTCA
surgery
Medical
Death
Survival
Ford et al NEJM 27

28. Modelling UK trends to 2010 2010 predicted
  Unal, Critchley & Capewell Circulation (9) 1101; J Clin Epid ; Heart

29. If more treatments for more patients
Modelling UK trends to predicted IF additional treatments per 100,000
If more treatments for more patients
 21,000 fewer deaths
  Unal, Critchley & Capewell Circulation (9) 1101; Heart ; J Clin Epid

30. Additional risk factor reductions If more treatments for more patients
Modelling UK trends to predicted IF additional treatments per 100,000 IF modest risk factor reductions
Additional risk factor reductions
 50,000 fewer deaths
If more treatments for more patients
 21,000 fewer deaths
  Unal, Critchley & Capewell Circulation (9) 1101; Heart ; J Clin Epid

31. The Natural History of CHD
Natural Course of CHD
 Atheroma
Atheroma & Thrombosis
Hanlon, Capewell et al 1997

32. CHD Prevention options
Natural Course of CHD
Hanlon, Capewell et al 1997

33. US Trends in AGE-SPECIFIC CHD mortality rates: men & women aged ≥35 years
Ford & Capewell JACC

34. IMPACT2 CVD Policy Model
Population
Policies &
Behaviours
Biological
Risk Factors
Combined
CVD Risk
CVD
Patient
Groups
OUTPUTS 34

35. Populations: UK>E&W>Regions>PCTs
Policies &
Behaviours
Biological
Risk Factors
Combined
CVD Risk
CVD
Patient
Groups
OUTPUTS
SUDS
NON-SUDS
Chronic
Angina
Unstable
Angina
CHD Death
Combined
CVD Risk
First MI
Early
Heart
Failure
From
any
State
Recurrent MI
Severe
Heart Failure
Non-CHD Death MI
survivors
Stroke
Other CVD
Populations: UK>E&W>Regions>PCTs
Outputs: Population-based incidence, prevalence; Deaths prevented; Life-Years; Life expectancy; Costs; Cost-effectiveness ratios

36. Populations: UK>E&W>Regions>PCTs
Policies &
Behaviours
Biological
Risk Factors
Combined
CVD Risk
CVD
Patient
Groups
OUTPUTS
Diabetes or
IGT
SUDS
NON-SUDS
Physical
Activity
Unstable
Angina
Chronic
Angina
CHD Death
Combined
CVD Risk
Obesity
(BMI)
Diet
Cholesterol
LDL
(& HDL)
Early
Heart
Failure
Acute MI
From
any
State
Smoking
Blood
Pressure
Recurrent MI
Severe
Heart Failure
Non-CHD Death MI
survivors
Deprivation
Additional
CVD
Risk Factors
Stroke
Other CVD
Populations: UK>E&W>Regions>PCTs
Outputs: Population-based incidence, prevalence; Deaths prevented; Life-Years; Life expectancy; Costs; Cost-effectiveness ratios 36

37. IMPACT2 structure 37

38. Additional risk factor reductions achieved elsewhere
UK level TARGET in 2010
SMOKING % % (USA 2002)
CHOLESTEROL
(mmol/l) Gothenberg (Sweden),
Stanford (USA) & Perth (Australia)
BLOOD PRESSURE
(Diastolic BP mmHg) (4 mmHg fall)
New Zealand (4.4 )
Finland (5.2 ) & France (6.0 )
OBESITY USA: 15% prevalence reduction by 2010 (??)
PHYSICAL ACTIVITY increase prevalence by 5% (?) [best]
DIABETES No successful community reductions
Assume 5% decrease in prevalence (??)
  Unal et al J Clin Epid