Executive Summary
The Growing Burden of Heart Disease and Stroke in Canada 2003 is the sixth edition of our biennial publication on the status of cardiovascular diseases in Canada. It serves as a natural sequel to the previous edition, The Changing Face of Heart Disease and Stroke in Canada 2000, which focused on the unfavourable profile of determinants of cardiovascular disease with an aging population and the adoption of unhealthy lifestyles by young Canadians, immigrants and native peoples. In this edition, we highlight the ongoing high cost that these diseases impose on our society, both in financial terms and in quality of life. With a predicted increase in the number of cases of cardiovascular diseases over the next 20 years, the resulting burden is expected to continue to increase.
Canadians run a high risk of developing cardiovascular diseases: 8 out of 10 individuals have at least one of the following risk factors - smoking, physical inactivity, being overweight, high blood pressure and diabetes - and 1 in 10 have three or more. As a result, unless community interventions with a sufficient preventive dose are implemented, the cardiovascular epidemic will continue. Addressing these risk factors will prevent not only cardiovascular diseases, but also many other chronic diseases that share the same risk factors.
For some risk factors, the trends are encouraging. Both physical inactivity in the adult population and smoking in general have decreased over the past 8 years, based on self-reported data. Unfortunately, the trends among other risk factors continue to give cause for concern. The percentage of the male population who are overweight has shown little change, and in fact, obesity is increasing among men (from 13.5% in 1994 to 16.1% in 2000). In addition, the prevalence of both self-reported high blood pressure and diabetes has increased. (High blood pressure rose from 11.6% to 14.4% and diabetes from 3.7% to 4.7% between 1994 and 2000.)
Young people carry a high level of risk for cardiovascular diseases. Nearly two-fifths (38.7%) of teenaged girls are physically inactive. Over one-quarter of men and women in their twenties are overweight. Among young women in their later teens (18 and 19 years), 1 in 5 smokes cigarettes daily; among young men in the same age group, the statistic is nearly 1 in 4. Lifestyle habits that are formed in this early stage tend to be continued through life.
Risk factors differ between men and women. Women tend to be more physically inactive and to report having high blood pressure. More men than women smoke. Men are more likely to consume less than the recommended amount of fruits and vegetables and to be overweight.
The prevalence of all risk factors varies by region. In comparison to Canada as a whole, British Columbia tends to have a lower prevalence of all risk factors, while prevalence in Newfoundland tends to be higher. In spite of this, the previous east-west gradient in risk factors as seen in past reports has become muted, with some prairie provinces having higher risk factors and some eastern provinces having lower risk factors than other provinces or territories.
A major limitation of the existing data is its lack of physical and biochemical measures of cardiovascular risk. Most provinces have not repeated the Heart Health Surveys that were conducted between 1985 and 1990, leaving a critical void in information about the detection and control of high blood pressure and dyslipidemia in Canada. In addition, we must rely on self-reported weight and height to estimate the prevalence of being overweight in the population.
Heart disease and stroke are chronic lifelong diseases that can be treated to relieve symptoms, improve the quality of life and reduce early death. Cardiovascular diseases are a major cause of hospitalization among both men and women, as either the primary or an associated health problem. Although national data are unavailable, it is reasonable to assume that cardiovascular diseases are also a major factor in emergency department and outpatient visits. Although hospitalization rates for cardiovascular diseases (except for congestive heart failure) are decreasing, the actual numbers of hospitalizations will increase in the future because of the aging of the population.
While hospitalization rates have been decreasing, the number of prescriptions for cardiovascular diseases has increased during the 1990s. Improved treatment, including the introduction of new drugs may have decreased the need for hospitalization. Unfortunately, national data do not exist on the health effect of this increased prescription use, the appropriateness of prescriptions, or patient compliance.
The number of several interventional procedures, including coronary artery bypass grafting, angioplasties, valve surgery, pacemaker implantation and heart transplantation, has been increasing. This may reflect the increase in the aging population in Canada. And the actual number of procedures is actually much higher, since many procedures are being performed on an outpatient basis and are, therefore, not included in hospitalization data. In fact, this increased use of outpatient facilities for procedures that were previously performed in hospital may, in part, account for the decrease in hospitalization rates for cardiovascular diseases. The increase in procedures has a major impact on health care costs. It also puts a strain on the limited availability of both human resources and equipment.
Sex differences exist in cardiovascular disease hospitalization rates and procedures. Men have higher hospitalization rates than women for all cardiovascular diseases. The difference is smallest for cerebrovascular disease and congestive heart failure. All procedures are performed more often on men than women. Whether these differences reflect gender attitudes of health professionals or biology, or both, requires further study.
Cardiovascular diseases have a significant economic impact in Canada. In its report, Economic Burden of Illness in Canada, 1998, Health Canada estimated the total cost of cardiovascular diseases on the health sector of the Canadian economy to be $18,472.9 million (11.6% of the total cost of all illnesses), which includes a direct cost of $6,818.1 million (8.1% of the total direct cost of all illnesses) and an indirect cost of $11,654.8 million (15.4% of the total indirect cost of all illnesses).
“Direct costs are defined as the value of goods and services for which payment was made and resources used in treatment, care and rehabilitation related to illness or injury. The five direct cost components in this report are organized and measured in terms of hospital care expenditures; drug expenditures; physician care expenditures; expenditures for care in other institutions; and additional direct health expenditures (including other professionals, capital, public health, prepayment administration, health research, etc). Other direct costs borne by patients or other payers (such as costs for transportation to health providers, special diets and clothing) are not included.
Indirect costs are defined as the value of economic output lost because of illness, injury-related work disability, or premature death. The three indirect cost components in this report are measured in terms of the value of years of life lost due to premature death (mortality costs), and the value of activity days lost due to short-term and long-term disability (morbidity costs due to long- and short-term disability). Other indirect costs, including the value of time lost from work and leisure activities by family members or friends who care for the patient, are not included in this report.” (EBIC)
In 1998, the total economic burden of illness was $159,434.5 million dollars - $83,954.9 million in direct costs and $75,479.6 million in indirect costs. $38,266.0 million of total costs could not be assigned to any particular disease category. These “unattributable” costs constituted a significant proportion (24.0%) of the total costs. Thus, the total costs related to cardiovascular diseases could be much higher.
The direct, indirect and total costs for 1998 were less than those incurred in 1993, when calculated using 1998 dollars. There is no clear explanation for this. Unattributable costs were much higher in 1998 compared to 1993, however, (38, 266.0 million compared to 29, 443.6 million, respectively) representing an increase from 17.6% to 24.0% of total costs. Their impact on cardiovascular disease costs is uncertain. Nonetheless, understanding how to control costs and maximize efficiency is an imperative.
In terms of the direct costs of cardiovascular diseases in Canada in 1998, the major cost components were: hospital care ($4,161.8 million; 61.0% of CVD direct costs), drugs ($1,772.8 million; 26.0%), physician care ($822.3 million; 12.1%), and additional direct health expenditures including research ($61.2 million; 0.9%).
The major components of the indirect cost of cardiovascular diseases in 1998 were: costs due to mortality (as cost of premature death) ($8,250.0 million; 70.8% of CVD indirect costs), morbidity due to long-term disability ($3,151.5 million; 27.0%), and morbidity due to short-term disability ($253.3 million; 2.2%).
Cardiovascular diseases are the most costly contributors to both direct and indirect health costs in Canada - they are also largely preventable. Approximately 80% of the population has at least one modifiable risk factor for cardiovascular diseases. Therefore, decreasing these risk factors in the population can have a great impact on reducing the costs of cardiovascular disease.
The commonly held perception is that cardiovascular diseases affect primarily older people. While many of the health care costs are associated with individuals 65 years of age and over, cardiovascular diseases among younger adults also have a major economic impact. Preventing cardiovascular diseases in this age group, then, has long-term economic implications.
Hospitalization for cardiovascular diseases costs over $4 billion annually. Since hospitalization rates increase with age (see Chapter 2) and the number of individuals over the age of 65 years in Canada is growing, hospital costs are likely to increase in the future.
The number of prescription drugs for cardiovascular diseases has been increasing. Thus, the cost of prescription drugs is also likely to increase in the future.
The Economic Burden of Illness in Canada, 1998 faced significant challenges in the use of existing data to describe the economic burden of illness in Canada from a health perspective. One major obstacle that EBIC faced is that health care costs associated with other aspects of health problem management, such as home care, residential care and therapy are difficult to capture and difficult to assign to particular disease categories and are, therefore, assigned as “unattributable” costs. The high proportion of “unattributable” costs makes analysis and interpretation of the data difficult, and calls for a refinement and improvement in data collection. In addition, greater detail in the data analysis would permit tracking of changes in one cost component in relation to others for specific diseases.
The most recent report on the economic burden of illness uses data from 1998. While this is useful from a research perspective, the time lag limits its application for surveillance. Policy-makers who are making decisions for the year 2003 need more current information.
When considering health outcomes from cardiovascular disease (heart disease and stroke), mortality tends to receive the greatest attention due to the availability of the data. But since many live with cardiovascular disease, it is important to consider who develops it (incidence), who is currently living with it (prevalence), and the nature of their disabilities and the quality of their lives.
Cardiovascular diseases are the underlying cause of death for 1 in 3 Canadians. The number of deaths and, by proxy, the number of Canadians with cardiovascular disease, will likely increase as the population ages. Thus, the burden of cardiovascular diseases will continue for many more years.
The mortality figures provide only part of the picture, however. Overall, 5.7% of Canadian adults, and nearly 1 in 4 aged 70+ years, report having heart problems, and they, with their families, know personally the challenges of living with cardiovascular disease. They feel less healthy than the rest of the Canadian population, many must restrict their activities, and many need help with the normal activities of daily living. While the 70+ age group have the highest rates of cardiovascular disease, many Canadians develop the condition in their forties and fifties.
In comparison to other countries, Canada has one of the lowest mortality rates due to stroke. In contrast, Canada does not appear to fare as well when comparing its ischemic heart disease mortality rate to other countries. Canada may be able to learn successful approaches to reducing both the incidence and premature death rate due to ischemic heart disease from other countries.
Within Canada, variations in cardiovascular disease rates vary between the provinces/territories. Newfoundland has consistently higher mortality rates than the other provinces/territories for cardiovascular diseases overall, and for ischemic heart disease, acute myocardial infarction and cerebrovascular disease. Newfoundlanders also reported a higher prevalence of all modifiable risk factors than the Canadian population overall. Mortality rates from cardiovascular diseases were lower in the north than Canada as a whole, except for congestive heart failure.
Mortality rates for both men and women for ischemic heart disease, acute myocardial infarction and cerebrovascular disease continue to decrease. The rate for congestive heart failure is decreasing as well, but at a slower pace. This may be a result of both the rising incidence of the disease and a possible shift in diagnostic labelling from ischemic heart disease. Even though cardiovascular disease mortality rates have decreased, in the future the number of women who will die from cardiovascular diseases is expected to increase, due to the aging population. As a result, the burden of cardiovascular diseases in the population will increase.
Cardiovascular diseases affect men and women differently. More men than women die from ischemic heart disease and acute myocardial infarction, but more women than men die from congestive heart failure and cerebrovascular disease.
A wide variety of factors interact to influence health: income and social status, social support networks, education, employment and working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender, and culture. Some of these, such as personal health practices, relate to the individual alone. Others, such as social environments, relate to the environment in which the individual lives.
Income and education can influence the adoption of healthy behaviours. Increased income permits a wider array of lifestyle choices that can influence health. Higher levels of education not only increase knowledge and skills specific to healthy behaviours, but also provide access to more lucrative employment.
Individuals who live in poverty must cope with the daily stress of meeting basic needs. Lifestyle choices, such as smoking, may be adopted to help cope with this stress. Lack of income may limit an individual’s ability to purchase healthy food, which in turn may lead to health problems. Likewise, the individual may lack the income to purchase medication that would improve a health problem such as high blood pressure.
Ischemic heart disease mortality including premature death correlates with neighbourhood income, with the wealthiest quintile having the lowest rates and the poorest quintile the highest. Differentials in health care after acute myocardial infarction are not responsible for most of the differences in survival across socio-economic categories. Thus socio-economic differences in mortality rates for ischemic heart disease appear to be due primarily to differences in incidence rather than in treatment and survival.
The analysis of the Canadian Community Health Survey (CCHS) data provides one possible reason for the income disparity in mortality rates. Individuals in the lowest income quintile had a higher proportion of risk factors than those in the highest quintile. To be effective, then, preventive policies must address socio-economic disparities.
The increasingly higher mortality rates due to diabetes in the lowest income group may indicate higher rates of diabetes among low income groups. Since diabetes is a risk factor for ischemic heart disease, low income individuals with diabetes are also at increased risk for ischemic heart disease.
Public policies can mediate the effect of inequities in risk for cardiovascular disease by decreasing exposure to risk factors or facilitating the adoption of healthy behaviours. For example, regulating exposure to environmental tobacco smoke in the service industry, where wages tend to be lower compared to other occupations, would reduce the risk of cardiovascular disease by decreasing exposure to a risk factor and encouraging smoking cessation.
As a prerequisite to developing effective interventions, research is also required to provide a better understanding of the way in which socio-economic differences mediate their effects on outcomes.
Given the importance of the social determinants of health, the ability to report mortality and morbidity data linked to individual and family level socio-economic characteristics, such as education, occupation, race, ethnicity and period of immigration, is a desirable, essential component of a cardiovascular disease surveillance system.
· Develop policies and implement community level and national programs with a sufficient preventive dose to decrease the high prevalence of cardiovascular disease risk factors.
· Implement policies and programs to encourage the adoption of healthy behaviours among children and youth.
· Conduct periodic surveys of nationally representative samples that include physical and biochemical measures to assess the prevalence of hypercholesterolemia, high blood pressure, diabetes and being overweight.
· Invest in the prevention and reduction of risk factors for cardiovascular diseases to decrease the economic burden of cardiovascular diseases in Canada.
· Develop effective and less expensive alternatives to hospital care for cardiovascular disease problems to mitigate against the anticipated increase in hospital costs associated with acute care.
· Improve the timeliness and quality of existing administrative data and develop additional data sources to enhance the use of economic data for surveillance purposes.