Signs of Maturity

Lifestyle changes and improvements in healthcare mean that deaths owing to heart disease continue to fall. Yet relative inequalities have widened. Dr Madhavi Bajekal investigates what growing old means for different social group

Analysing recent socioeconomic trends in coronary heart disease mortality in England, 2000–2007: a population modelling study

Background Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups. Methods and Findings A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%–107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%–47%) to the overall decline in CHD mortality: ranging from about 44% (31%–61%) in the most deprived to 29% (16%–42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%–40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (−9%; −17% to −3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%–70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions. Conclusions The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities

Review of Disability Estimates and Definitions: A study carried out on behalf of the Department for Work and Pensions

This report presents findings of a review of survey estimates of the prevalence of disability in Britain and the definitions of disability used in government social surveys. The study examines the relative merits and methodological robustness of a variety of estimates of the prevalence of disability produced by surveys. The review involved: A technical review of the existing surveys and estimates; A consultation exercise involving key stakeholders and users of disability estimates to explore their views on measurement and definitional issues of disability; An exploration of what might be done to ensure consistency over time of estimates and definitions of disability in Great Britain

Trajectories of Disease Accumulation Using Electronic Health Records

Multimorbidity is a major problem for patients and health services. However, we still do not know much about the common trajectories of disease accumulation that patients follow. We apply a data-driven method to an electronic health record dataset (CPRD) to analyse and condense the main trajectories to multimorbidity into simple networks. This analysis has never been done specifically for multimorbidity trajectories and using primary care based electronic health records. We start the analysis by evaluating temporal correlations between diseases to determine which pairs of disease appear significantly in sequence. Then, we use patient trajectories together with the temporal correlations to build networks of disease accumulation. These networks are able to represent the main pathways that patients follow to acquire multiple chronic conditions. The first network that we find contains the common diseases that multimorbid patients suffer from and shows how diseases like diabetes, COPD, cancer and osteoporosis are crucial in the disease trajectories. The results we present can help better characterize multimorbid patients and highlight common combinations helping to focus treatment to prevent or delay multimorbidity progression

Spatial mapping of hepatitis C prevalence in recent injecting drug users in contact with services.

In developed countries the majority of hepatitis C virus (HCV) infections occur in injecting drug users (IDUs) with prevalence in IDUs often high, but with wide geographical differences within countries. Estimates of local prevalence are needed for planning services for IDUs, but it is not practical to conduct HCV seroprevalence surveys in all areas. In this study survey data from IDUs attending specialist services were collected in 52/149 sites in England between 2006 and 2008. Spatially correlated random-effects models were used to estimate HCV prevalence for all sites, using auxiliary data to aid prediction. Estimates ranged from 14% to 82%, with larger cities, London and the North West having the highest HCV prevalence. The methods used generated robust estimates for each area, with a well-identified spatial pattern that improved predictions. Such models may be of use in other areas of study where surveillance data are sparse

The slowdown in mortality improvement rates 2011–2017: a multi-country analysis

Mortality rates have been falling or ‘improving’ in many demographically developed countries since the 1950s. However, there has been a slowdown since 2010 in the speed of improvement and this phenomenon has been particularly marked at ages over 50. To understand better this mortality slowdown, we have analysed long-run mortality trends of a group of developed countries using data up to 2017 from the Human Mortality Database. Specifically, we have used statistical models to parametrise the historical mortality trends of 21 countries between 1965 and 2010 and then forecast trends beyond 2011. We find that many countries have experienced lower mortality improvement rates in 2011–2017 than in the previous decade and also experienced lower improvement rates in 2011–2017 than would have been forecast based on the models fitted to data prior to 2011. Some of the Scandinavian populations have bucked the stalling mortality improvement trend, experiencing higher mortality improvement rates than the forecasts. We conclude that part of the slowdown in mortality improvement rates of the over 1950s since 2011 would have been expected from historical trends in many countries, especially among men. However, there has been a notable slowdown since 2011, compared with the model forecasts, in many countries especially among women. A few countries had higher mortality improvement rates than forecast. A better understanding of the drivers behind these complex trends would help decision makers in insurance companies and pension funds and also inform public policy

Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data.

Objective To quantify the contributions of prevention and treatment to the trends in mortality due to coronary heart disease in Scotland. Design Retrospective analysis using IMPACTSEC, a previously validated policy model, to apportion the recent decline in coronary heart disease mortality to changes in major cardiovascular risk factors and to increases in more than 40 treatments in nine non-overlapping groups of patients. Setting Scotland. Participants All adults aged 25 years or over, stratified by sex, age group, and fifths of Scottish Index of Multiple Deprivation. Main outcome measure Deaths prevented or postponed. Results 5770 fewer deaths from coronary heart disease occurred in 2010 than would be expected if the 2000 mortality rates had persisted (8042 rather than 13813). This reflected a 43% fall in coronary heart disease mortality rates (from 262 to 148 deaths per 100000). Improved treatments accounted for approximately 43% (95% confidence interval 33% to 61%) of the fall in mortality, and this benefit was evenly distributed across deprivation fifths. Notable treatment contributions came from primary prevention for hypercholesterolaemia (13%), secondary prevention drugs (11%), and chronic angina treatments (7%). Risk factor improvements accounted for approximately 39% (28% to 49%) of the fall in mortality (44% in the most deprived fifth compared with only 36% in the most affluent fifth). Reductions in systolic blood pressure contributed more than one third (37%) of the decline in mortality, with no socioeconomic patterning. Smaller contributions came from falls in total cholesterol (9%), smoking (4%), and inactivity (2%). However, increases in obesity and diabetes offset some of these benefits, potentially increasing mortality by 4% and 8% respectively. Diabetes showed strong socioeconomic patterning (12% increase in the most deprived fifth compared with 5% for the most affluent fifth). Conclusions Increases in medical treatments accounted for almost half of the large recent decline in mortality due to coronary heart disease in Scotland. Furthermore, the Scottish National Health Service seems to have delivered these benefits equitably. However, the substantial contributions from population falls in blood pressure and other risk factors were diminished by adverse trends in obesity and diabetes. Additional population-wide interventions are urgently needed to reduce coronary heart disease mortality and inequalities in future decades

Mind the Gap: A Study of Cause-Specific Mortality by Socioeconomic Circumstances

Socioeconomic groups may be exposed to varying levels of mortality; this is certainly the case in the United Kingdom, where the gaps in life expectancy, differentiated by socioeconomic circumstances, are widening. The reasons for such diverging trends are yet unclear, but a study of cause-specific mortality may provide rich insight into this phenomenon. Therefore, we investigate the relationship between socioeconomic circumstances and cause-specific mortality using a unique dataset obtained from the U.K. Office for National Statistics. We apply a multinomial logistic framework; the reason is twofold. First, covariates such as socioeconomic circumstances are readily incorporated, and, second, the framework is able to handle the intrinsic dependence amongst the competing causes. As a consequence of the dataset and modeling framework, we are able to investigate the impact of improvements in cause-specific mortality by socioeconomic circumstances. We assess the impact using (residual) life expectancy, a measure of aggregate mortality. Of main interest are the gaps in life expectancy among socioeconomic groups, the trends in these gaps over time, and the ability to identify the causes most influential in reducing these gaps. This analysis is performed through the investigation of different scenarios: first, by eliminating one cause of death at a time; second, by meeting a target set by the World Health Organization (WHO), called WHO 25 × 25; and third, by developing an optimal strategy to increase life expectancy and reduce inequalities

Modelling Future Coronary Heart Disease Mortality to 2030 in the British Isles.

OBJECTIVE: Despite rapid declines over the last two decades, coronary heart disease (CHD) mortality rates in the British Isles are still amongst the highest in Europe. This study uses a modelling approach to compare the potential impact of future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland. METHODS: CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. Risk factor trends data from recent surveys at baseline were used to model alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; relative decreases in (iii) dietary salt intake of up to 30% by 2030 and (iv) dietary saturated fat of up to 6% by 2030. Probabilistic sensitivity analyses were then conducted. RESULTS: Projected populations in 2030 were 1.3, 3.4 and 3.9 million in NI, RoI and Scotland respectively (adults aged 25-84). In 2030: assuming recent declining mortality trends continue: 15% absolute reductions in smoking could decrease CHD deaths by 5.8-7.2%. 15% absolute reductions in physical inactivity levels could decrease CHD deaths by 3.1-3.6%. Relative reductions in salt intake of 30% could decrease CHD deaths by 5.2-5.6% and a 6% reduction in saturated fat intake might decrease CHD deaths by some 7.8-9.0%. These projections remained stable under a wide range of sensitivity analyses. CONCLUSIONS: Feasible reductions in four cardiovascular risk factors (already achieved elsewhere) could substantially reduce future coronary deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity