CLINICAL
Review ARticle
A Call to Action: Responding to the Future Forecasting of Cardiovascular Disease in America Robert lee Page ii, PharmD, MSPH, FAHA, FccP, FAScP, FASHP, BcPS (AQ cards); vahram Ghushchyan, PhD; Kavita Nair, PhD
Robert Lee Page II
Stakeholder Perspective, page 287
Am Health Drug Benefits. 2011;4(5):280-288 www.AHDBonline.com Disclosures are at end of text
Background: Cardiovascular disease (CVD) continues to be a leading cost driver for payers in the United States. The American Heart Association estimates that more than 75 million individuals nationwide have some form of CVD. Individuals aged 20 to 45 years are developing CVD at higher rates than ever before. Objectives: To discuss the alarming increase in the rate of CVD in young adults (aged 18-45 years) previously only seen in older adults (aged ≥65 years) and describe the 5 primary risk factors (smoking, obesity, hypertension, diabetes, and dyslipidemia) that contribute to this new trend in the working-age population. Discussion: Using Medical Expenditure Panel Survey data, this article outlines the increased prevalence of the 3 primary components of CVD—stroke, heart failure, and myocardial infarction—in younger adults and the cost impact on payers and on US society. The examples provided in this article highlight the need for increased efforts by all healthcare stakeholders, and by payers in particular, to develop prevention strategies for CVD risk factors targeted at young adults to curb the alarming rise in CVD among this age-group. Conclusion: This article provides compelling evidence for the need to institute prevention measures to curb the growing prevalence of CVD risk factors among younger adults in the United States.
D
espite advances in life-saving medical interventions and pharmacotherapies, cardiovascular disease (CVD) continues to be a leading killer in the United States.1 The spectrum of CVD consists of hypertension, chronic heart disease (CHD; including myocardial infarction [MI] and angina), heart failure, and stroke. Based on 2009 data from the American Heart Association (AHA), 76.4 million Americans have been diagnosed with hypertension, 16.3 million have CHD, 5.7 million have heart failure, and 7 million have stroke.2 Beginning in adolescence, CVD can stay dormant for Dr Page is Associate Professor of Clinical Pharmacy and Physical Medicine, School of Pharmacy and Medicine, and Clinical Specialist, Division of Cardiology; Dr Ghushchyan is Research Assistant Professor of Clinical Pharmacy, School of Pharmacy; and Dr Nair is Associate Professor of Clinical Pharmacy, School of Pharmacy, University of Colorado University of Colorado Anschutz Medical Campus, Aurora, CO.
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many years before emerging in adulthood. Among each of the components of CVD, CHD accounts for 1 in every 6 American deaths, heart failure for 1 in every 9 deaths, and stroke for 1 in every 18 deaths.2 Despite these dramatic statistics, CVD mortality rates have begun to decline over the past decade (Figure 1).2,3 These reductions are primarily a result of advances in medical and interventional therapies, as well as to increased acceptance and application of evidence-based guidelines.2,3 In addition, over the past decade the AHA and the American College of Cardiology (ACC) have launched nationwide campaigns that incentivize health systems to improve the overall quality of hospital care through the implementation of CVD quality core measures. Recently, a large population-based study suggested that the age- and sex-adjusted incidence of acute MI exhibited a 24% relative decrease between 1999 and 2008 and that the age- and sex-adjusted 30-day mortality rate after acute MI decreased from 10.5% in 1999 to 7.8% in 2008 (P 75 million Americans have some form of cardiovascular disease (CVD), and almost half of the US population will have it by 2030. The AHA projects a 9.9% increase in the prevalence of CVD by 2030, a 16.6% increase in chronic heart disease, and a 25% increase in heart failure and stroke. Direct medical costs for CVD are expected to rise from $272.5 billion in 2010 to $818.1 billion in 2030, representing a 3-fold increase. Young adults aged 20 to 45 years are developing CVD at an alarmingly high rate that was until recently only seen in older adults. The CVD risk factors once documented in older adults have shifted to young adults aged 20 to 45 years who are developing CVD at an alarmingly high rate. Because CVD is increasing in younger adults who are in the workforce, employers and payers need to focus their attention on a younger population of adults. Risk factor modification earlier in life has a greater impact than more significant risk reductions later in life; prevention efforts at a younger age may therefore have a lasting impact later in life. Instituting preventive measures in young adults may also result in significant cost-savings to payers.
Figure 1 US Deaths from Diseases of the Heart, 1900-2007 1000
Deaths, in thousands
800
600
400
200
0 1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
2007
Year
NOTE: The vertical line marks the beginning in the decline of deaths from heart disease. Adapted with permission from Roger VL, et al. Circulation. 2011;123:e18-e209.
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Subsequently, as seen in Table 1, total direct medical costs for CVD are expected to rise from $272.5 billion in 2010 to $818.1 billion in 2030, representing a 3-fold increase.5 Because heart failure, CHD, and stroke are debilitating diseases, it is not surprising that indirect costs are also expected to increase from 53% to 80%. Indirect costs associated with CHD are estimated to account for about 40% of all CVD costs.5 To provide logic behind these drastic projections, the AHA suggests that rapid growth in the aging US population, combined with the growth in per-capita medical expenditures, may be the primary drivers of increased CVD-related costs. The population with the highest costs for CVD will be those aged ≥65 years, with the greatest increase in those aged ≥85 years. Heart failure remains the leading discharge diagnosis for patients aged ≥65 years and has been estimated to account for more than 37% of Medicare spending.6 Unlike heart failure, acute coronary syndrome (ACS), an umbrella term encompassing MI and unstable angina, is common among the working-age population: about 47% of all patients with ACS are younger than age 65 years.7 Results from the Worcester Heart Attack Study show that between 1975 and 2005, the overall incidence of MI was 66 per 100,000 among adults aged 25 to 54 years.8 For employers and payers, patients with ACS impose a substantial direct cost burden, as well as a dramatic indirect cost burden on employers.9,10 In a retrospective analysis of 30,200 patients with ACS, Johnston and colleagues estimated that compared with patients
Figure 2 Projections of Crude CVD Prevalence in the United States, 2010-2030 All CVDa HTN CHD
HF Stroke
45 40
Prevalence, %
35 30 25 20 15 10 5 0 2010
2015
2020
2025
2030
Year a
Includes HTN, CHD, HF, and stroke. CHD indicates coronary heart disease; CVD, cardiovascular disease; HF, heart failure; HTN, hypertension. Source: Reference 5.
Table 1 Projected Direct Medical Costs of CVD in the United States, in Billions (2008 dollars) Year
All CVDa
HTN
CHD
HF
Stroke
HTN as risk factorb
2010
$272.5
$69.9
$35.7
$24.7
$28.3
$130.7
2015
$358.0
$91.4
$46.8
$32.4
$38.0
$170.4
2020
$470.3
$119.1
$61.4
$42.9
$51.3
$222.5
2025
$621.6
$155.0
$81.1
$57.5
$70.0
$293.6
2030
$818.1
$200.3
$106.4
$77.7
$95.6
$389.0
200
186
198
215
238
198
Change, %
a Includes HTN, CHD, HF, stroke, as well as cardiac dysrhythmias, rheumatic heart disease, cardiomyopathy, pulmonary heart disease, and other or ill-defined “heart” diseases; does not include HTN as a risk factor. b Includes a portion of the costs of complications associated with HTN, including CHF, CHD, stroke, and other CVDs. The cost of HTN as a risk factor should not be included to calculate the costs of all CVD. CHD indicates coronary heart disease; CVD, cardiovascular disease; HF, heart failure; HTN, hypertension. Adapted with permission from Heidenreich PA, et al. Circulation. 2011;123:933-944.
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A Call to Action: Cardiovascular Disease in America
without CHD, the incremental annual direct cost of ACS to employers was $40,671 between 2002 and 2007 (P 75,000) of MassHealth members were smokers enrolled in the program.24,25 At 2.5 years after implementation of the program, 26% of MassHealth smokers quit smoking, which resulted in a 38% decrease in hospitalizations for MI, a 17% drop in emergency department and clinic visits for asthma, and a 17% drop in claims for adverse
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Table 3 Summary of Preventive Health Interventions Feasible performance, % achieveda
Intervention Aspirin therapy if 10-year risk of MI ≥10%
50
Lower LDL-C to
Review ARticle
A Call to Action: Responding to the Future Forecasting of Cardiovascular Disease in America Robert lee Page ii, PharmD, MSPH, FAHA, FccP, FAScP, FASHP, BcPS (AQ cards); vahram Ghushchyan, PhD; Kavita Nair, PhD
Robert Lee Page II
Stakeholder Perspective, page 287
Am Health Drug Benefits. 2011;4(5):280-288 www.AHDBonline.com Disclosures are at end of text
Background: Cardiovascular disease (CVD) continues to be a leading cost driver for payers in the United States. The American Heart Association estimates that more than 75 million individuals nationwide have some form of CVD. Individuals aged 20 to 45 years are developing CVD at higher rates than ever before. Objectives: To discuss the alarming increase in the rate of CVD in young adults (aged 18-45 years) previously only seen in older adults (aged ≥65 years) and describe the 5 primary risk factors (smoking, obesity, hypertension, diabetes, and dyslipidemia) that contribute to this new trend in the working-age population. Discussion: Using Medical Expenditure Panel Survey data, this article outlines the increased prevalence of the 3 primary components of CVD—stroke, heart failure, and myocardial infarction—in younger adults and the cost impact on payers and on US society. The examples provided in this article highlight the need for increased efforts by all healthcare stakeholders, and by payers in particular, to develop prevention strategies for CVD risk factors targeted at young adults to curb the alarming rise in CVD among this age-group. Conclusion: This article provides compelling evidence for the need to institute prevention measures to curb the growing prevalence of CVD risk factors among younger adults in the United States.
D
espite advances in life-saving medical interventions and pharmacotherapies, cardiovascular disease (CVD) continues to be a leading killer in the United States.1 The spectrum of CVD consists of hypertension, chronic heart disease (CHD; including myocardial infarction [MI] and angina), heart failure, and stroke. Based on 2009 data from the American Heart Association (AHA), 76.4 million Americans have been diagnosed with hypertension, 16.3 million have CHD, 5.7 million have heart failure, and 7 million have stroke.2 Beginning in adolescence, CVD can stay dormant for Dr Page is Associate Professor of Clinical Pharmacy and Physical Medicine, School of Pharmacy and Medicine, and Clinical Specialist, Division of Cardiology; Dr Ghushchyan is Research Assistant Professor of Clinical Pharmacy, School of Pharmacy; and Dr Nair is Associate Professor of Clinical Pharmacy, School of Pharmacy, University of Colorado University of Colorado Anschutz Medical Campus, Aurora, CO.
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many years before emerging in adulthood. Among each of the components of CVD, CHD accounts for 1 in every 6 American deaths, heart failure for 1 in every 9 deaths, and stroke for 1 in every 18 deaths.2 Despite these dramatic statistics, CVD mortality rates have begun to decline over the past decade (Figure 1).2,3 These reductions are primarily a result of advances in medical and interventional therapies, as well as to increased acceptance and application of evidence-based guidelines.2,3 In addition, over the past decade the AHA and the American College of Cardiology (ACC) have launched nationwide campaigns that incentivize health systems to improve the overall quality of hospital care through the implementation of CVD quality core measures. Recently, a large population-based study suggested that the age- and sex-adjusted incidence of acute MI exhibited a 24% relative decrease between 1999 and 2008 and that the age- and sex-adjusted 30-day mortality rate after acute MI decreased from 10.5% in 1999 to 7.8% in 2008 (P 75 million Americans have some form of cardiovascular disease (CVD), and almost half of the US population will have it by 2030. The AHA projects a 9.9% increase in the prevalence of CVD by 2030, a 16.6% increase in chronic heart disease, and a 25% increase in heart failure and stroke. Direct medical costs for CVD are expected to rise from $272.5 billion in 2010 to $818.1 billion in 2030, representing a 3-fold increase. Young adults aged 20 to 45 years are developing CVD at an alarmingly high rate that was until recently only seen in older adults. The CVD risk factors once documented in older adults have shifted to young adults aged 20 to 45 years who are developing CVD at an alarmingly high rate. Because CVD is increasing in younger adults who are in the workforce, employers and payers need to focus their attention on a younger population of adults. Risk factor modification earlier in life has a greater impact than more significant risk reductions later in life; prevention efforts at a younger age may therefore have a lasting impact later in life. Instituting preventive measures in young adults may also result in significant cost-savings to payers.
Figure 1 US Deaths from Diseases of the Heart, 1900-2007 1000
Deaths, in thousands
800
600
400
200
0 1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
2007
Year
NOTE: The vertical line marks the beginning in the decline of deaths from heart disease. Adapted with permission from Roger VL, et al. Circulation. 2011;123:e18-e209.
Vol 4, No 5
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September 2011
www.AHDBonline.com
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Subsequently, as seen in Table 1, total direct medical costs for CVD are expected to rise from $272.5 billion in 2010 to $818.1 billion in 2030, representing a 3-fold increase.5 Because heart failure, CHD, and stroke are debilitating diseases, it is not surprising that indirect costs are also expected to increase from 53% to 80%. Indirect costs associated with CHD are estimated to account for about 40% of all CVD costs.5 To provide logic behind these drastic projections, the AHA suggests that rapid growth in the aging US population, combined with the growth in per-capita medical expenditures, may be the primary drivers of increased CVD-related costs. The population with the highest costs for CVD will be those aged ≥65 years, with the greatest increase in those aged ≥85 years. Heart failure remains the leading discharge diagnosis for patients aged ≥65 years and has been estimated to account for more than 37% of Medicare spending.6 Unlike heart failure, acute coronary syndrome (ACS), an umbrella term encompassing MI and unstable angina, is common among the working-age population: about 47% of all patients with ACS are younger than age 65 years.7 Results from the Worcester Heart Attack Study show that between 1975 and 2005, the overall incidence of MI was 66 per 100,000 among adults aged 25 to 54 years.8 For employers and payers, patients with ACS impose a substantial direct cost burden, as well as a dramatic indirect cost burden on employers.9,10 In a retrospective analysis of 30,200 patients with ACS, Johnston and colleagues estimated that compared with patients
Figure 2 Projections of Crude CVD Prevalence in the United States, 2010-2030 All CVDa HTN CHD
HF Stroke
45 40
Prevalence, %
35 30 25 20 15 10 5 0 2010
2015
2020
2025
2030
Year a
Includes HTN, CHD, HF, and stroke. CHD indicates coronary heart disease; CVD, cardiovascular disease; HF, heart failure; HTN, hypertension. Source: Reference 5.
Table 1 Projected Direct Medical Costs of CVD in the United States, in Billions (2008 dollars) Year
All CVDa
HTN
CHD
HF
Stroke
HTN as risk factorb
2010
$272.5
$69.9
$35.7
$24.7
$28.3
$130.7
2015
$358.0
$91.4
$46.8
$32.4
$38.0
$170.4
2020
$470.3
$119.1
$61.4
$42.9
$51.3
$222.5
2025
$621.6
$155.0
$81.1
$57.5
$70.0
$293.6
2030
$818.1
$200.3
$106.4
$77.7
$95.6
$389.0
200
186
198
215
238
198
Change, %
a Includes HTN, CHD, HF, stroke, as well as cardiac dysrhythmias, rheumatic heart disease, cardiomyopathy, pulmonary heart disease, and other or ill-defined “heart” diseases; does not include HTN as a risk factor. b Includes a portion of the costs of complications associated with HTN, including CHF, CHD, stroke, and other CVDs. The cost of HTN as a risk factor should not be included to calculate the costs of all CVD. CHD indicates coronary heart disease; CVD, cardiovascular disease; HF, heart failure; HTN, hypertension. Adapted with permission from Heidenreich PA, et al. Circulation. 2011;123:933-944.
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Vol 4, No 5
A Call to Action: Cardiovascular Disease in America
without CHD, the incremental annual direct cost of ACS to employers was $40,671 between 2002 and 2007 (P 75,000) of MassHealth members were smokers enrolled in the program.24,25 At 2.5 years after implementation of the program, 26% of MassHealth smokers quit smoking, which resulted in a 38% decrease in hospitalizations for MI, a 17% drop in emergency department and clinic visits for asthma, and a 17% drop in claims for adverse
www.AHDBonline.com
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285
CLINICAL
Table 3 Summary of Preventive Health Interventions Feasible performance, % achieveda
Intervention Aspirin therapy if 10-year risk of MI ≥10%
50
Lower LDL-C to
