Caitlin Donato and Christine Patton-Mitchell
July 19, 2010
PHC 6000 – Epidemiology Epidemiology of Coronary Heart Disease
We pledge that we have not plagiarized on any aspect of this assignment.
Executive Summary
Coronary heart disease (CHD) is a significant worldwide health issue. Its prevalence and impact both from the emotional toll of loss of life and from the financial toll on patients, providers, and insurers, make its continued study vital to achieve reduction and prevention goals.
This paper will examine the patterns and trends of CHD, working from a broad global perspective, then on to a discussion of specific US patterns, narrowing to look at Florida, and finally drilling down to look at CHD reporting for Orange County, Florida. Playing such a big role in the healthcare landscape, there are a large number of CHD studies and reports to draw data from global to local. We will draw extensively from the data pools from two of the recognized authorities in CHD, The American Heart Association (AHA) and the Center for Disease Control (CDC).
After exploring patterns and trends of CHD, we will next look at the risk factors associated with this disease. Risk factors for CHD fall into three main categories: major factors, contributing factors, and modifiable factors. We will discuss all of these categories, with a focus on the modifiable factors as a key element to reduction and prevention. We will conclude this section with a look at some of the emerging risk factors being studied stemming from the healthcare industry’s continued study of this disease.
In the last sections of the paper, we will evaluate CHD prevention efforts and implications for public health intervention. Several of the main programs will be discussed such as the Department of Health and Human Services’ Healthy People 2010, The CDC’s WISEWOMAN initiative, and AHA programs. We will look at state and local programs in Florida such as the Florida Heart Disease and Stroke Prevention Program. In looking at results from both national and local programs, we will conclude with proposed strategies for improving programs to increase program effectiveness in reducing CHD.
1. Patterns and Trends:
Coronary Heart Disease continues to be a significant issue both in the United States and abroad. According to the World Health Organization, worldwide deaths from CHD in 2005 numbered 7.6 million (AHA, 2010a, p2). Although since the 1970s CHD mortality rates, when adjusted for age, were reduced by half in most industrialized countries, this decline in incidence rates diminished beginning in the 1990s and is now on the rise (Capewell et al., 2010, p.120). Current projections for CHD show a 120% increase for women and a 137% increase for men. By 2020, the WHO predicts that there will be 11.1 million deaths annually across the globe from CHD (AHA, 2010a, p.2).
Posing such a large issue in global healthcare, several worldwide initiatives were developed to help study, monitor, and provide information and possible solutions to improve CHD. The Seven Countries Study was developed to help explain the variation in CHD death rates across seven different countries ranging from Finland, with the highest rate, to Japan, with the lowest rate. Following this, the WHO initiated the MONICA Project (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease). The MONICA Project is the largest study of CHD ever undertaken and collects answers beyond any single country and measures incidence rates, case fatality, risk-factor levels, and medical care (WHO, 2010, p.1).
When viewing CHD globally, the MONICA Project reports that 21% of incidences are attributable to those having a body mass index (BMI) above 21kg. 22% of CHD is caused by physical inactivity. 53% of CHD deaths are in men and 47% of CHD deaths are in women. Similar to the Seven Countries Study, MONICA results show that for men, Finland continues to have the highest coronary event rate and it is the lowest in China. For women, CHD is highest in the United Kingdom and tied for the lowest in Spain and China (AHA, 2010a, p.1).
In the United States, heart disease continues to be the leading cause of death for both men and women. The American Heart Association reports that every 34 seconds someone has a heart attack, and each minute someone in the United States dies from a heart disease related event. In 2006, CHD was responsible for 1 out of every 6 deaths in the United States. In 2010, it is estimated that 785,000 Americans will suffer from a new coronary attack while approximately 470,000 will have a recurrent attack (Lloyd et al., 2010, p. 47).
CHD is also a very large financial burden on our healthcare system with costs rising year after year. In 2004, direct costs were reported in excess of $150 billion (Capewell et al., 2010, p. 120). In 2010, CHD costs will have risen to $316.4 billion (CDC, 2010a, para.1). In addition to national statistics, CHD can be further examined at the state level. The CDC provides a visual representation of heart disease death rates by state and by county for the period of 2000-2006 (See Appendix B).
At the state level in Florida, coronary heart disease statistics are tracked by Florida’s Department of Health and trend information can be found in its 2007 Cardiovascular Surveillance Summary. CHD is the leading cause of death in Florida with 34,310 deaths reported in 2005. CHD comprises 58% of all of Florida’s cardiovascular disease deaths and over 20% of all causes of death (FDOH, 2007, p.7).
In Florida, both Whites and Blacks have shown large declines in age-adjusted death rates over the past 21 years. Death rates for Hispanics, in comparison, have only declined in recent years. Age adjusted death rates were 152 per 100,000 for Blacks and 144 per 100,000 for Hispanics, and 137 per 100,000 for Whites. Similar to national statistics, males in Florida have a higher rate of CHD deaths, with 2003 data showing a 64% higher rate for males over females (FDOH, 2007, p.9). Florida’s Department of Health also tracks data against CHD risk factors in order to view trends (See Appendix C & D).
At the county level, the Orange County Health Department exists as part of the Florida Department of Health and also tracks CHD statistics. In the period from 2003 to 2007, deaths from CHD have declined from 210.9 per 100,000 to 170.9 per 100,000. However, the CHD death rate in Orange County is slightly higher than the overall death rate for the state of Florida (OCHD, 2010, para. 1). Full 2006-2008 CHD data for Orange County is now available as part of Florida’s Community Health Assessment Resource Tool Set (CHARTS) program. During this 2-year period, CHD deaths were reported at 995 events with an age-adjusted rate of 116.4. This exceeds the US Healthy People 2010 benchmark goal of 162 per 100,000. Orange County experienced 4,988 hospitalizations for CHD during this same time period, which equates to an age-adjusted rate of 534 per 100,000 (Florida CHARTS, 2010, p. 1).
Risk factors are also tracked at the county level for adults with CHD. Of those affected, 27% have diabetes, 33% are obese, 61% have high blood pressure, 62% have high cholesterol, 59% are inactive, and 20% smoke (OCHD, 2010, para. 1).
2. Identify the Risk Factors:
The American Heart Association groups risk factors for coronary heart disease into: major risk factors, contributing risk factors, and modifiable risk factors. Major risk factors are those factors that can dramatically increase the risk of CHD. These risk factors cannot be changed, and having multiple risk factors in this category will increase the likelihood of developing CHD. The first major risk factor is increasing age. Instances of CHD increase, as people get older. The AHA reports that 82% of CHD fatalities occur in people who are 65 years or older (AHA, 2010b, para. 1).
The second major risk factor is male gender. Men have a greater likelihood of suffering heart attacks. They are also more prone to attacks earlier in life than women. The third major factor consists of heredity and race. Families with a history of CHD will find a more frequent incidence rate of CHD than those without. CHD also presents a higher risk among Mexican Americans, American Indians, native Hawaiians, and some Asian Americans. African Americans have a greater risk of CHD than Caucasian Americans due to having a greater likelihood of severe high blood pressure (AHA, 2010b, para. 2).
The second category is classified as contributing risk factors. These factors have shown an association with increased instances of CHD, but the exact significance has yet to have been precisely determined. These risk factors include stress, alcohol, and diet (AHA, 2010b, para. 2).
The last category includes risk factors that can be reduced, treated, or controlled. This can be done either through medicine or by changing lifestyle habits. These factors include smoking, high blood cholesterol, high blood pressure, physical inactivity, obesity, and diabetes.
Smoking tobacco increases the likelihood of developing CHD between 2-4 times above people who do not smoke. Additionally, secondhand smoke can unfortunately also increase the likelihood of CHD. In 2008, a study reported that despite all of the information regarding the ill effects of smoking, 23% of men and 18% of women responded that they were still cigarette smokers. The study showed that in high school students, 23% of male students and 18% of female students smoked (Lloyd et al., 2010, p. 47).
Cholesterol is affected by age, sex, hereditary, and diet. The risk of CHD increases as a person’s blood cholesterol increases. With too much cholesterol, it builds up on artery walls. This contributes to plaque build up which makes arteries narrow and less flexible. High blood pressure is also a modifiable risk factor. It is known as a silent killer except in its most extreme form which is also know as a hypertensive crisis, because there are no symptoms and people with high blood pressure may actually be unaware that damage is occurring to their heart and arteries. High blood pressure causes the heart to thicken and stiffen. This increases the risk of stroke, heart attack, and congestive heart failure. 77% of Americans treated for a first stroke also have high blood pressure. 69% who have a heart attack and 74% of Americans with congestive heart failure also have high blood pressure (AHA, 2010b, para. 4).
Physical inactivity and obesity are also risk factors. A sedentary lifestyle can often lead to people becoming overweight or obese. Excess weight makes the heart have to work harder and also raises blood pressure and blood cholesterol levels. These factors continue to be an issue in the United States. It is estimated that 144,100,000 or 66.3% of Americans over the age of 20 are overweight or obese. This estimate is made more staggering when you add in the fact that 31.9%, or 23,500,000 children aged 2 to 19 years are also overweight or obese. This in many ways is due to the increasing estimates of inactivity in children. A 2007 study of high school aged boys and girls reported that when surveyed about their activity during the previous week, 31.8% of females and 18% of males reported that they had not participated in at least one hour of physical activity in the last 7 days. A 2008 National Health Survey reported 58% of adults responded that they did not engage in any vigorous physical activity (Lloyd et al., 2010, p.48).
Additionally, excess body fat can also cause the onset of the last modifiable risk factor, diabetes. 65% of people with diabetes die from some type of heart or blood vessel disease. In 2006, it was estimated that 17,200,000 Americans had diagnosed diabetes. This equates to 7.7% of our adult population. It was further estimated in 2006 that 6,100,000 Americans had undiagnosed diabetes. Diabetes has shown to be more prevalent in African Americans, Mexican Americans, and Hispanic and Latino Americans (Lloyd et al., 2010, p. 48).
Beyond the traditional risk factors associated with CHD, scientific research is helping to identify new and emerging risk factors. More than 100 new risk factors have been proposed due to their potential to help identify and improve risk of CHD. Some of these new risk factors are independent predictors of CHD, while others are linked to the existing, more traditional risk factors. Examples of new factors include leukocyte count, fasting blood glucose level, and instances of periodontal disease (Helfand, 2009, p. 502). Continued study of both current and emerging risk factors can assist in identifying ways to predict, treat, and prevent coronary heart disease.
3. Preventative Strategies or Efforts:
Since the introduction of prevention programs over the past fifty years, there has been a decrease in heart disease morbidity. If the rate of coronary heart disease deaths from 1960 continued today, more then 1.6 million deaths would occur each year. We can attribute the fact that we only have 500,000 deaths yearly, at least partially, to the success of prevention programs. In 1960, there was no knowledge of the effect that smoking, cholesterol, high blood pressure, and obesity had on the development of CHD. It was not uncommon for someone in there 50’s or 60’s to die of a heart attack. There have been improvements in trends over the past 50 years; however, it is still a largely preventable disease that remains the leading cause of death in the US (CDC, 2010a, p.1). Before we can discuss suggestions for public health intervention, we should first examine what the state of Florida is currently doing that is yielding these numbers.
The Department of Health and Human Services developed Healthy People 2010 initiatives, which have recognized the need for continued preventive strategies in the US. One goal of Healthy People 2010 is to, “reduce cardiovascular disease and improve quality of life by promoting recommended levels of physical activity; promoting weight management; improving diet and nutrition; eliminating tobacco use; preventing and controlling high blood pressure; preventing and reducing elevated cholesterol; and preventing and controlling diabetes” (U.S. department, 2009, p. 3). The Healthy People 2010 nationwide target for death rate per 100,000 (age-adjusted) is 146.93 for both men and women. The Center for Disease Control has tracked progress on heart disease mortality rate, from 2000-2006, of each Florida County. Orange County reported between 412-428 per 100,000 persons annual deaths which bring the death rate higher than desirable in our county (CDC, 2006c, p. 1).
The state of Florida has attempted to develop strategies to prevent coronary heart disease within the state. The Florida Heart Disease and Stroke Prevention Program (HDSPP) has teamed up with other local health agencies in an attempt to increase awareness and reduce prevalence (CDC, 2010d, p. 3).
Their first prevention strategy includes funding employee wellness programs in four school districts. The Polk County School District have already found a reduction in healthcare costs due to this employee wellness program (CDC, 2010d, p. 3).
The HDSPP have also partnered with Florida’s Primary Care Association to increase the number of community health centers that are using the Health Resources and Services Administration’s Health Disparity Collaborative (HDC) for cardiovascular disease. The HDC is a proactive approach to health designed to identify high-risk patients and promote lifestyle changes (CDC, 2010d, p. 3).
The HDSPP is also providing assistance to the Florida Medical Quality Assurance, Inc. to train pharmacy students and Nova Southeast University to expand pharmacy interventions to include medication evaluation and patient education. The goal behind this objective is to promote positive health outcomes through medication adherence to those who have suffered coronary heart disease (CDC, 2010d, p. 3).
Another Florida prevention strategy for CHD from the HDSPP was establishing the State Employee Wellness Interagency Council to critique and modify current worksite policies related to employee wellness (CDC, 2010d, p. 3).
The next partnership of the HDSPP is with the State Department of Health’s Diabetes Prevention and Control Program. Their main aim with this prevention program is to focus on online healthcare professional continuing education programs. These programs address pre-hypertension, hypertension, and cholesterol control (CDC, 2010d, p. 3).
The final critical partnership is with the Emergency Medical Services Tracking and Reporting System. The HDSPP provides assistance in the training of first responders in an attempt to improve emergency response and upload heart disease data to the National EMS Information System (CDC, 2010d, p. 3).
At the national level, there are also several prevention programs including the CDC’s WISEWOMAN Program to educate low-income, under or uninsured women on screening, and the effects of dietary, physical activity, and smoking on coronary heart disease (CDC, 2010e, p. 2). Another prevention campaign is the American Heart Association’s nationwide Go Red For Women. This is a campaign geared towards empowering and educating women. The Heart Truth Campaign introduced the Red Dress as a national symbol for women and heart disease awareness. And finally, National Wear Red Day is a day nationwide when Americans wear red to show their support for heart disease awareness (CDC, 2010b, p. 1).
4. Implications for Public Health Interventions:
As previously stated, heart disease mortality is exceeding the Healthy People 2010 target of 146.93 per 100,000 persons. There are plenty of heart disease prevention programs in place at the national, state, and county level; however, proper assessment needs to be taken to ensure these programs are going to yield the highest results.
The first step a public health intervention must take is to properly define the risk of heart disease within a specific population to ensure that their programs are addressing the issues of that area. The Florida Bureau of Chronic Disease Prevention and Health Promotion releases an annual report on the rate of coronary heart disease risk factors within the state population (CDC, 2010d, p.
2).
According to the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey results:
- 28.2% had high blood pressure
- 19.3% were smokers
- 62.1% were overweight
- 52.7% reported no exercise in the prior 30 days
- 73.8% ate fruits and vegetables less than 5 times a day
For a coronary heart disease prevention program to be effective in the state of Florida, it should be centered around these areas of high concern. As stated previously, the State of Florida has several programs in place, but, as apparent in these numbers, they are doing little to reduce the risk factors that lead to CHD.
As indicated by the rates above, Florida health interventions need to be more effective. Awareness has been a driving factor in many interventions, while exercise and nutrition education have seemed to take a back seat in many programs. Incorporating an exercise adherence program into already established prevention programs may be able to address three of these five risk factors: high blood pressure, overweight, and physical activity. Healthy People 2020 have acknowledged this need by adopting a new objective of “increasing overall cardiovascular health in the U.S. population” (Healthy people, 2009). Physical activity and nutrition could be used to measure the progress of this objective.
One focus of improving intervention programs is a more cohesive collaboration. Increasing exercise was an objective for Healthy People 2010, but there was a lack of local collaboration to implement. This would entail a more direct alignment with county, state, and federal programs (CDC, 2010d, p. 2). For example, Healthy People 2020 objectives are broad and unobtainable without narrowing the scope down to the county level. Examining the objective previously stated of increasing cardiovascular health, there are several implementations that could be made at the county level to achieve this. Holding nutrition and exercise education courses at establishments frequented by the county’s population promotes attendance. Creating adult sport leagues within the area can promote physical activity. Promoting changes to vending machines within city buildings can create a culture of health around healthy eating.
Another key aspect to effective health intervention programs is constant evaluation. Program evaluation is a systematic method to determine the success of a program (Smith, 2006, p. 4). One method that should be used to evaluate prevention programs is a quality-adjusted life years (QALY). At the state level, the Florida HDSPP can conduct these ratios for each of their programs in order to find which are effective, which should be modified, and which should be eliminated. QALY adds the number of additional years of life a program is expected to generate, and incorporates the quality of life associated with those years. QALY enable a fair evaluation to be made between two prevention programs that otherwise would not be directly comparable (Fleming, 2008, p. 210).
Evaluation goes beyond the scope of QALY however. Programs must be monitored more closely throughout the intervention as well. Monitoring a program is essential to observe and measure the progress of a prevention program. If any current prevention program is not already monitoring their program, this could be a huge reason for the lack of success in reducing heart disease to targeted levels. Proper monitoring should include data on program implementation, resources allocation, client characteristics, and access to services (Smith, 2006, p. 2).
There are several programs in place at the national, state, and county level that attempt to raise awareness, and promote health. These programs have not, however, resulted in reducing the incidence rate of coronary heart disease to targeted levels. Effectiveness of these programs can be increased through a more thorough collaboration, and stronger evaluation and monitoring systems.
Capewell, S., Ford, E., Croft, J., Critchley, J., Greenlund, K., & Labarthe, D. (2010). Cardiovascular risk factor trends and potential for reducing coronary heart disease mortality in the United States of America. Bulletin of the World Health Organization, 88(2), 120-130. Retrieved from Academic Search Premier database.
Center for Disease Control and Prevention. (2010b, January 26). February is American Heart Month. Retrieved June 30, 2010, from http://www.cdc.gov/Features/HeartMonth/
Lloyd, J., Adams, R., Brown, T., Carnethon, M., Dai, S., De Simone, G., et al. (2010). Heart Disease and Stroke Statistics 2010 Update: Journal of the American Heart Association, 121 (7), e46-e216. Retrieved July 6, 2010, from AHA Journals Web site: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192667
Thomas, C., Smith, B., & Wright-DeAgüero, L. (2006). The Program Evaluation and Monitoring System: a key source of data for monitoring evidence-based HIV prevention program processes and outcomes. AIDS Education & Prevention, 18(4), 74-80. Retrieved from CINAHL Plus with Full Text database.
Appendix A: Collaborating with a partner for this paper was extremely beneficial. Through our weekly postings we were both able to find interesting information regarding coronary heart disease. The information we found independently was unique and added to a more broad scope of information. As a partnership we were able to research different areas, and then come together and choose which areas would be most relevant to include in our paper. This helped out our research efforts greatly. If we had been working independently on this paper our scope of information would have been much narrower. Therefore, in the research and brainstorming session having a partner was extremely helpful.
We were able to combine our strengths to create a well thought out and executed paper. Caitlin has a great sense of organization and planning. She divided the paper up into portions and assigned deadlines to follow. The deadlines ensured that we were able to stay on track and address any issues we may come across early. Caitlin broke the paper into four stages. Our first stage was research. We worked independently to gather data and research on coronary heart disease and current prevention programs. Our first deadline to combine and discuss our findings was June 3rd. After the first deadline, we had a much clearer grasp on our topic.
For the second stage, Caitlin broke the paper into defining which partner would be responsible for which section. We both reviewed the assignment and based on our research we were able to divide the paper accordingly. Christine had found more research on risk factors and trends for the disease, so we thought it would be best for her to do section one and two. Caitlin had stronger information about preventative strategies, so she was assigned section three and four. We worked independently to create a rough outline for our individual sections, and then came together for our second deadline on June 17th to discuss. The third stage was defined as a finished rough draft, which was due July 7th. On that day we came together to discuss our final sections.
The fourth and final stage was proofreading, and editing. We edited both our own and our partner’s portions. This final due date for making any changes was July 15th. These breakdowns of the paper and deadlines contributed greatly to the collaborative efforts of this project. It allowed us adequate time to consider all portions of the assignment.
Christine is strong in written communication and execution. She was able to coordinate the Wiki so that we could share our work and submit any edits to one location. The execution of creating our Wiki was extremely helpful. Christine was in charge of uploading and changes and we were able to utilize the Wiki to share information on days that we were not able to meet. She was also able to provide help to her partner whenever there were technical questions regarding the Wiki. Christine also made sure to send reminders of what was due and deadlines that were approaching. Christine also sent out reminders to continue posting our updates weekly in the class discussion folder. This made the execution even smoother for our group. When we got down to stage four of our paper, Christine did an exceptional job editing all portions. She was able to ensure that the sum of our work was greater then our individual contribution.
Christine and Caitlin were not only able to identify our individual strengths and weaknesses, but also determine ways in which we could maximize our strengths that would eliminate our weaknesses. One example of this was apparent in the proofing portion. Caitlin has a stronger ability to proof for grammatical errors. Christine has a stronger ability to proof the paper for content inconsistencies. For that reason, we decided to both proof the entire paper rather than just proofing our personal sections. Caitlin proofed with more of a focus on grammar, while Christine checked for more content issues. This is one example of how we were able to accentuate our strengths for this paper in a way that overshadowed our weaknesses.
Not only did we learn more from working together in terms of research, but also on how to work together. Working in teams is a realistic aspect of the work force. While studying for our master’s degree, we should be pushed to work with fellow classmates. It teaches a skill that cannot be taught in a textbook. Yet working together for a project ensures that we can learn both team building skills as well as epidemiology principles. In the workforce, we will have to rely on others and be able to work in teams to get our jobs done. Everyone has strengths and weaknesses that are unique to him or her.
As a partnership, we were able to gather more knowledge on our topic of coronary heart disease. From that we were able to develop a greater scope of knowledge regarding the topic. Once we collaborated on the research, we could ensure that we were using the most relevant information. Lastly, we learned valuable team building skills that will transfer as useful experience in the workforce. This project was an interesting assignment that taught both of us a great deal about the topic of coronary heart disease, as well as working in a partnership.
July 19, 2010
PHC 6000 – Epidemiology
Epidemiology of Coronary Heart Disease
We pledge that we have not plagiarized on any aspect of this assignment.
Executive Summary
Coronary heart disease (CHD) is a significant worldwide health issue. Its prevalence and impact both from the emotional toll of loss of life and from the financial toll on patients, providers, and insurers, make its continued study vital to achieve reduction and prevention goals.
This paper will examine the patterns and trends of CHD, working from a broad global perspective, then on to a discussion of specific US patterns, narrowing to look at Florida, and finally drilling down to look at CHD reporting for Orange County, Florida. Playing such a big role in the healthcare landscape, there are a large number of CHD studies and reports to draw data from global to local. We will draw extensively from the data pools from two of the recognized authorities in CHD, The American Heart Association (AHA) and the Center for Disease Control (CDC).
After exploring patterns and trends of CHD, we will next look at the risk factors associated with this disease. Risk factors for CHD fall into three main categories: major factors, contributing factors, and modifiable factors. We will discuss all of these categories, with a focus on the modifiable factors as a key element to reduction and prevention. We will conclude this section with a look at some of the emerging risk factors being studied stemming from the healthcare industry’s continued study of this disease.
In the last sections of the paper, we will evaluate CHD prevention efforts and implications for public health intervention. Several of the main programs will be discussed such as the Department of Health and Human Services’ Healthy People 2010, The CDC’s WISEWOMAN initiative, and AHA programs. We will look at state and local programs in Florida such as the Florida Heart Disease and Stroke Prevention Program. In looking at results from both national and local programs, we will conclude with proposed strategies for improving programs to increase program effectiveness in reducing CHD.
1. Patterns and Trends:
Coronary Heart Disease continues to be a significant issue both in the United States and abroad. According to the World Health Organization, worldwide deaths from CHD in 2005 numbered 7.6 million (AHA, 2010a, p2). Although since the 1970s CHD mortality rates, when adjusted for age, were reduced by half in most industrialized countries, this decline in incidence rates diminished beginning in the 1990s and is now on the rise (Capewell et al., 2010, p.120). Current projections for CHD show a 120% increase for women and a 137% increase for men. By 2020, the WHO predicts that there will be 11.1 million deaths annually across the globe from CHD (AHA, 2010a, p.2).
Posing such a large issue in global healthcare, several worldwide initiatives were developed to help study, monitor, and provide information and possible solutions to improve CHD. The Seven Countries Study was developed to help explain the variation in CHD death rates across seven different countries ranging from Finland, with the highest rate, to Japan, with the lowest rate. Following this, the WHO initiated the MONICA Project (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease). The MONICA Project is the largest study of CHD ever undertaken and collects answers beyond any single country and measures incidence rates, case fatality, risk-factor levels, and medical care (WHO, 2010, p.1).
When viewing CHD globally, the MONICA Project reports that 21% of incidences are attributable to those having a body mass index (BMI) above 21kg. 22% of CHD is caused by physical inactivity. 53% of CHD deaths are in men and 47% of CHD deaths are in women. Similar to the Seven Countries Study, MONICA results show that for men, Finland continues to have the highest coronary event rate and it is the lowest in China. For women, CHD is highest in the United Kingdom and tied for the lowest in Spain and China (AHA, 2010a, p.1).
In the United States, heart disease continues to be the leading cause of death for both men and women. The American Heart Association reports that every 34 seconds someone has a heart attack, and each minute someone in the United States dies from a heart disease related event. In 2006, CHD was responsible for 1 out of every 6 deaths in the United States. In 2010, it is estimated that 785,000 Americans will suffer from a new coronary attack while approximately 470,000 will have a recurrent attack (Lloyd et al., 2010, p. 47).
CHD is also a very large financial burden on our healthcare system with costs rising year after year. In 2004, direct costs were reported in excess of $150 billion (Capewell et al., 2010, p. 120). In 2010, CHD costs will have risen to $316.4 billion (CDC, 2010a, para.1). In addition to national statistics, CHD can be further examined at the state level. The CDC provides a visual representation of heart disease death rates by state and by county for the period of 2000-2006 (See Appendix B).
At the state level in Florida, coronary heart disease statistics are tracked by Florida’s Department of Health and trend information can be found in its 2007 Cardiovascular Surveillance Summary. CHD is the leading cause of death in Florida with 34,310 deaths reported in 2005. CHD comprises 58% of all of Florida’s cardiovascular disease deaths and over 20% of all causes of death (FDOH, 2007, p.7).
In Florida, both Whites and Blacks have shown large declines in age-adjusted death rates over the past 21 years. Death rates for Hispanics, in comparison, have only declined in recent years. Age adjusted death rates were 152 per 100,000 for Blacks and 144 per 100,000 for Hispanics, and 137 per 100,000 for Whites. Similar to national statistics, males in Florida have a higher rate of CHD deaths, with 2003 data showing a 64% higher rate for males over females (FDOH, 2007, p.9). Florida’s Department of Health also tracks data against CHD risk factors in order to view trends (See Appendix C & D).
At the county level, the Orange County Health Department exists as part of the Florida Department of Health and also tracks CHD statistics. In the period from 2003 to 2007, deaths from CHD have declined from 210.9 per 100,000 to 170.9 per 100,000. However, the CHD death rate in Orange County is slightly higher than the overall death rate for the state of Florida (OCHD, 2010, para. 1). Full 2006-2008 CHD data for Orange County is now available as part of Florida’s Community Health Assessment Resource Tool Set (CHARTS) program. During this 2-year period, CHD deaths were reported at 995 events with an age-adjusted rate of 116.4. This exceeds the US Healthy People 2010 benchmark goal of 162 per 100,000. Orange County experienced 4,988 hospitalizations for CHD during this same time period, which equates to an age-adjusted rate of 534 per 100,000 (Florida CHARTS, 2010, p. 1).
Risk factors are also tracked at the county level for adults with CHD. Of those affected, 27% have diabetes, 33% are obese, 61% have high blood pressure, 62% have high cholesterol, 59% are inactive, and 20% smoke (OCHD, 2010, para. 1).
2. Identify the Risk Factors:
The American Heart Association groups risk factors for coronary heart disease into: major risk factors, contributing risk factors, and modifiable risk factors. Major risk factors are those factors that can dramatically increase the risk of CHD. These risk factors cannot be changed, and having multiple risk factors in this category will increase the likelihood of developing CHD. The first major risk factor is increasing age. Instances of CHD increase, as people get older. The AHA reports that 82% of CHD fatalities occur in people who are 65 years or older (AHA, 2010b, para. 1).
The second major risk factor is male gender. Men have a greater likelihood of suffering heart attacks. They are also more prone to attacks earlier in life than women. The third major factor consists of heredity and race. Families with a history of CHD will find a more frequent incidence rate of CHD than those without. CHD also presents a higher risk among Mexican Americans, American Indians, native Hawaiians, and some Asian Americans. African Americans have a greater risk of CHD than Caucasian Americans due to having a greater likelihood of severe high blood pressure (AHA, 2010b, para. 2).
The second category is classified as contributing risk factors. These factors have shown an association with increased instances of CHD, but the exact significance has yet to have been precisely determined. These risk factors include stress, alcohol, and diet (AHA, 2010b, para. 2).
The last category includes risk factors that can be reduced, treated, or controlled. This can be done either through medicine or by changing lifestyle habits. These factors include smoking, high blood cholesterol, high blood pressure, physical inactivity, obesity, and diabetes.
Smoking tobacco increases the likelihood of developing CHD between 2-4 times above people who do not smoke. Additionally, secondhand smoke can unfortunately also increase the likelihood of CHD. In 2008, a study reported that despite all of the information regarding the ill effects of smoking, 23% of men and 18% of women responded that they were still cigarette smokers. The study showed that in high school students, 23% of male students and 18% of female students smoked (Lloyd et al., 2010, p. 47).
Cholesterol is affected by age, sex, hereditary, and diet. The risk of CHD increases as a person’s blood cholesterol increases. With too much cholesterol, it builds up on artery walls. This contributes to plaque build up which makes arteries narrow and less flexible. High blood pressure is also a modifiable risk factor. It is known as a silent killer except in its most extreme form which is also know as a hypertensive crisis, because there are no symptoms and people with high blood pressure may actually be unaware that damage is occurring to their heart and arteries. High blood pressure causes the heart to thicken and stiffen. This increases the risk of stroke, heart attack, and congestive heart failure. 77% of Americans treated for a first stroke also have high blood pressure. 69% who have a heart attack and 74% of Americans with congestive heart failure also have high blood pressure (AHA, 2010b, para. 4).
Physical inactivity and obesity are also risk factors. A sedentary lifestyle can often lead to people becoming overweight or obese. Excess weight makes the heart have to work harder and also raises blood pressure and blood cholesterol levels. These factors continue to be an issue in the United States. It is estimated that 144,100,000 or 66.3% of Americans over the age of 20 are overweight or obese. This estimate is made more staggering when you add in the fact that 31.9%, or 23,500,000 children aged 2 to 19 years are also overweight or obese. This in many ways is due to the increasing estimates of inactivity in children. A 2007 study of high school aged boys and girls reported that when surveyed about their activity during the previous week, 31.8% of females and 18% of males reported that they had not participated in at least one hour of physical activity in the last 7 days. A 2008 National Health Survey reported 58% of adults responded that they did not engage in any vigorous physical activity (Lloyd et al., 2010, p.48).
Additionally, excess body fat can also cause the onset of the last modifiable risk factor, diabetes. 65% of people with diabetes die from some type of heart or blood vessel disease. In 2006, it was estimated that 17,200,000 Americans had diagnosed diabetes. This equates to 7.7% of our adult population. It was further estimated in 2006 that 6,100,000 Americans had undiagnosed diabetes. Diabetes has shown to be more prevalent in African Americans, Mexican Americans, and Hispanic and Latino Americans (Lloyd et al., 2010, p. 48).
Beyond the traditional risk factors associated with CHD, scientific research is helping to identify new and emerging risk factors. More than 100 new risk factors have been proposed due to their potential to help identify and improve risk of CHD. Some of these new risk factors are independent predictors of CHD, while others are linked to the existing, more traditional risk factors. Examples of new factors include leukocyte count, fasting blood glucose level, and instances of periodontal disease (Helfand, 2009, p. 502). Continued study of both current and emerging risk factors can assist in identifying ways to predict, treat, and prevent coronary heart disease.
3. Preventative Strategies or Efforts:
Since the introduction of prevention programs over the past fifty years, there has been a decrease in heart disease morbidity. If the rate of coronary heart disease deaths from 1960 continued today, more then 1.6 million deaths would occur each year. We can attribute the fact that we only have 500,000 deaths yearly, at least partially, to the success of prevention programs. In 1960, there was no knowledge of the effect that smoking, cholesterol, high blood pressure, and obesity had on the development of CHD. It was not uncommon for someone in there 50’s or 60’s to die of a heart attack. There have been improvements in trends over the past 50 years; however, it is still a largely preventable disease that remains the leading cause of death in the US (CDC, 2010a, p.1). Before we can discuss suggestions for public health intervention, we should first examine what the state of Florida is currently doing that is yielding these numbers.
The Department of Health and Human Services developed Healthy People 2010 initiatives, which have recognized the need for continued preventive strategies in the US. One goal of Healthy People 2010 is to, “reduce cardiovascular disease and improve quality of life by promoting recommended levels of physical activity; promoting weight management; improving diet and nutrition; eliminating tobacco use; preventing and controlling high blood pressure; preventing and reducing elevated cholesterol; and preventing and controlling diabetes” (U.S. department, 2009, p. 3). The Healthy People 2010 nationwide target for death rate per 100,000 (age-adjusted) is 146.93 for both men and women. The Center for Disease Control has tracked progress on heart disease mortality rate, from 2000-2006, of each Florida County. Orange County reported between 412-428 per 100,000 persons annual deaths which bring the death rate higher than desirable in our county (CDC, 2006c, p. 1).
The state of Florida has attempted to develop strategies to prevent coronary heart disease within the state. The Florida Heart Disease and Stroke Prevention Program (HDSPP) has teamed up with other local health agencies in an attempt to increase awareness and reduce prevalence (CDC, 2010d, p. 3).
Their first prevention strategy includes funding employee wellness programs in four school districts. The Polk County School District have already found a reduction in healthcare costs due to this employee wellness program (CDC, 2010d, p. 3).
The HDSPP have also partnered with Florida’s Primary Care Association to increase the number of community health centers that are using the Health Resources and Services Administration’s Health Disparity Collaborative (HDC) for cardiovascular disease. The HDC is a proactive approach to health designed to identify high-risk patients and promote lifestyle changes (CDC, 2010d, p. 3).
The HDSPP is also providing assistance to the Florida Medical Quality Assurance, Inc. to train pharmacy students and Nova Southeast University to expand pharmacy interventions to include medication evaluation and patient education. The goal behind this objective is to promote positive health outcomes through medication adherence to those who have suffered coronary heart disease (CDC, 2010d, p. 3).
Another Florida prevention strategy for CHD from the HDSPP was establishing the State Employee Wellness Interagency Council to critique and modify current worksite policies related to employee wellness (CDC, 2010d, p. 3).
The next partnership of the HDSPP is with the State Department of Health’s Diabetes Prevention and Control Program. Their main aim with this prevention program is to focus on online healthcare professional continuing education programs. These programs address pre-hypertension, hypertension, and cholesterol control (CDC, 2010d, p. 3).
The final critical partnership is with the Emergency Medical Services Tracking and Reporting System. The HDSPP provides assistance in the training of first responders in an attempt to improve emergency response and upload heart disease data to the National EMS Information System (CDC, 2010d, p. 3).
At the national level, there are also several prevention programs including the CDC’s WISEWOMAN Program to educate low-income, under or uninsured women on screening, and the effects of dietary, physical activity, and smoking on coronary heart disease (CDC, 2010e, p. 2). Another prevention campaign is the American Heart Association’s nationwide Go Red For Women. This is a campaign geared towards empowering and educating women. The Heart Truth Campaign introduced the Red Dress as a national symbol for women and heart disease awareness. And finally, National Wear Red Day is a day nationwide when Americans wear red to show their support for heart disease awareness (CDC, 2010b, p. 1).
4. Implications for Public Health Interventions:
As previously stated, heart disease mortality is exceeding the Healthy People 2010 target of 146.93 per 100,000 persons. There are plenty of heart disease prevention programs in place at the national, state, and county level; however, proper assessment needs to be taken to ensure these programs are going to yield the highest results.
The first step a public health intervention must take is to properly define the risk of heart disease within a specific population to ensure that their programs are addressing the issues of that area. The Florida Bureau of Chronic Disease Prevention and Health Promotion releases an annual report on the rate of coronary heart disease risk factors within the state population (CDC, 2010d, p.
2).
According to the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey results:
- 28.2% had high blood pressure
- 19.3% were smokers
- 62.1% were overweight
- 52.7% reported no exercise in the prior 30 days
- 73.8% ate fruits and vegetables less than 5 times a day
For a coronary heart disease prevention program to be effective in the state of Florida, it should be centered around these areas of high concern. As stated previously, the State of Florida has several programs in place, but, as apparent in these numbers, they are doing little to reduce the risk factors that lead to CHD.
As indicated by the rates above, Florida health interventions need to be more effective. Awareness has been a driving factor in many interventions, while exercise and nutrition education have seemed to take a back seat in many programs. Incorporating an exercise adherence program into already established prevention programs may be able to address three of these five risk factors: high blood pressure, overweight, and physical activity. Healthy People 2020 have acknowledged this need by adopting a new objective of “increasing overall cardiovascular health in the U.S. population” (Healthy people, 2009). Physical activity and nutrition could be used to measure the progress of this objective.
One focus of improving intervention programs is a more cohesive collaboration. Increasing exercise was an objective for Healthy People 2010, but there was a lack of local collaboration to implement. This would entail a more direct alignment with county, state, and federal programs (CDC, 2010d, p. 2). For example, Healthy People 2020 objectives are broad and unobtainable without narrowing the scope down to the county level. Examining the objective previously stated of increasing cardiovascular health, there are several implementations that could be made at the county level to achieve this. Holding nutrition and exercise education courses at establishments frequented by the county’s population promotes attendance. Creating adult sport leagues within the area can promote physical activity. Promoting changes to vending machines within city buildings can create a culture of health around healthy eating.
Another key aspect to effective health intervention programs is constant evaluation. Program evaluation is a systematic method to determine the success of a program (Smith, 2006, p. 4). One method that should be used to evaluate prevention programs is a quality-adjusted life years (QALY). At the state level, the Florida HDSPP can conduct these ratios for each of their programs in order to find which are effective, which should be modified, and which should be eliminated. QALY adds the number of additional years of life a program is expected to generate, and incorporates the quality of life associated with those years. QALY enable a fair evaluation to be made between two prevention programs that otherwise would not be directly comparable (Fleming, 2008, p. 210).
Evaluation goes beyond the scope of QALY however. Programs must be monitored more closely throughout the intervention as well. Monitoring a program is essential to observe and measure the progress of a prevention program. If any current prevention program is not already monitoring their program, this could be a huge reason for the lack of success in reducing heart disease to targeted levels. Proper monitoring should include data on program implementation, resources allocation, client characteristics, and access to services (Smith, 2006, p. 2).
There are several programs in place at the national, state, and county level that attempt to raise awareness, and promote health. These programs have not, however, resulted in reducing the incidence rate of coronary heart disease to targeted levels. Effectiveness of these programs can be increased through a more thorough collaboration, and stronger evaluation and monitoring systems.
References:
American Heart Association. (2010a). International Cardiovascular Disease Statistics. Retrieved June 07, 2010, from
http://www.americanheart.org/downloadable/heart/ 1140811583642InternationalCVD.pdf
American Heart Association. (2010b, June 22). Lifestyle Changes.
Retrieved June 09, 2010, from http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/Understand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp
Capewell, S., Ford, E., Croft, J., Critchley, J., Greenlund, K., & Labarthe, D. (2010). Cardiovascular risk factor trends and potential for reducing coronary heart disease mortality in the United States of America. Bulletin of the World Health Organization, 88(2), 120-130. Retrieved from Academic Search Premier database.
Center for Disease Control and Prevention. (2010a, May 12). Fact Sheets and At-a-Glance Reports. Retrieved July 8, 2010, from
http://www.cdc.gov//dhdsp/library/fs_heart_disease.htm
Center for Disease Control and Prevention. (2010b, January 26). February is American Heart Month. Retrieved June 30, 2010, from
http://www.cdc.gov/Features/HeartMonth/
Center for Disease Control and Prevention. (2006c). Florida- Heart Disease.
Retrieved June 29, 2010, from
http://apps.nccd.cdc.gov/giscvh2/Results.aspx
Center for Disease Control and Prevention. (2010d, February 2). State Program: Florida Basic Implementation. Retrieved June 30, 2010, from http://www.cdc.gov/print.do?url=http://www.cdc.gov/dhdsp/state_program/fl.htm
Center for Disease Control and Prevention. (2010e, March 25). WISEWOMEN.
Retrieved June 30, 2010, from http://www.cdc.gov/print.do?url=http://www.cdc.gov/wisewomen/
Fleming, S. (2008). Managerial Epidemiology: Concepts and Cases. (2nd ed.). Chicago: Health Administration Press.
Florida CHARTS Community Health Assessment Resource Tool Set. (2008). Orange County Chronic Disease Profile. Retrieved July 05, 2010, from http://www.floridacharts.com/charts/DisplayHTML.aspx?ReportType=7244 &County=48&year=2008
Florida Department of Health. (2007). Cardiovascular Surveillance Summary, 2007.
Retrieved July 09, 2010, from http://www.doh.state.fl.us/Family/heart/PDF/cvd_surv_summ_2007.pdf
Lloyd, J., Adams, R., Brown, T., Carnethon, M., Dai, S., De Simone, G., et al. (2010). Heart Disease and Stroke Statistics 2010 Update: Journal of the American Heart Association, 121 (7), e46-e216. Retrieved July 6, 2010, from AHA Journals Web site:
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192667
National Institutes of Health. Fact Sheet: Heart Disease. Retrieved June 30, 2010, from
http://www.nih.gov/about/researchresultsforthepublic/heartdisease.pdf
Orange County Health Department. (2010). Heart Disease Statistics.
Retrieved July 3, 2010, from http://www.orchd.com/generalHealth/communityHealth/chronicDisease/heartDisease/statistics/index.asp
Thomas, C., Smith, B., & Wright-DeAgüero, L. (2006). The Program Evaluation and Monitoring System: a key source of data for monitoring evidence-based HIV prevention program processes and outcomes. AIDS Education & Prevention, 18(4), 74-80. Retrieved from CINAHL Plus with Full Text database.
U.S. Department of Health and Human Services. (2009, October 30). Heart Disease and Stroke. Retrieved June 30, 2010, from
http://www.hhs.gov/news/press/2009pres/2009.html
U.S. Department of Health and Human Services. (2009, October 30). Healthy People 2020- View Objectives. Retrieved June 30, 2010, from http://www.healthypeople.gov/hp2020/Objectives/
World Health Organization. (2010). Background, development and organization of MONICA. Retrieved June 09, 2010, from http://whqlibdoc.who.int/publications/2003/9241562234_p1-40.pdf
Appendixes:
Appendix A:
Collaborating with a partner for this paper was extremely beneficial. Through our weekly postings we were both able to find interesting information regarding coronary heart disease. The information we found independently was unique and added to a more broad scope of information. As a partnership we were able to research different areas, and then come together and choose which areas would be most relevant to include in our paper. This helped out our research efforts greatly. If we had been working independently on this paper our scope of information would have been much narrower. Therefore, in the research and brainstorming session having a partner was extremely helpful.
We were able to combine our strengths to create a well thought out and executed paper. Caitlin has a great sense of organization and planning. She divided the paper up into portions and assigned deadlines to follow. The deadlines ensured that we were able to stay on track and address any issues we may come across early. Caitlin broke the paper into four stages. Our first stage was research. We worked independently to gather data and research on coronary heart disease and current prevention programs. Our first deadline to combine and discuss our findings was June 3rd. After the first deadline, we had a much clearer grasp on our topic.
For the second stage, Caitlin broke the paper into defining which partner would be responsible for which section. We both reviewed the assignment and based on our research we were able to divide the paper accordingly. Christine had found more research on risk factors and trends for the disease, so we thought it would be best for her to do section one and two. Caitlin had stronger information about preventative strategies, so she was assigned section three and four. We worked independently to create a rough outline for our individual sections, and then came together for our second deadline on June 17th to discuss. The third stage was defined as a finished rough draft, which was due July 7th. On that day we came together to discuss our final sections.
The fourth and final stage was proofreading, and editing. We edited both our own and our partner’s portions. This final due date for making any changes was July 15th. These breakdowns of the paper and deadlines contributed greatly to the collaborative efforts of this project. It allowed us adequate time to consider all portions of the assignment.
Christine is strong in written communication and execution. She was able to coordinate the Wiki so that we could share our work and submit any edits to one location. The execution of creating our Wiki was extremely helpful. Christine was in charge of uploading and changes and we were able to utilize the Wiki to share information on days that we were not able to meet. She was also able to provide help to her partner whenever there were technical questions regarding the Wiki. Christine also made sure to send reminders of what was due and deadlines that were approaching. Christine also sent out reminders to continue posting our updates weekly in the class discussion folder. This made the execution even smoother for our group. When we got down to stage four of our paper, Christine did an exceptional job editing all portions. She was able to ensure that the sum of our work was greater then our individual contribution.
Christine and Caitlin were not only able to identify our individual strengths and weaknesses, but also determine ways in which we could maximize our strengths that would eliminate our weaknesses. One example of this was apparent in the proofing portion. Caitlin has a stronger ability to proof for grammatical errors. Christine has a stronger ability to proof the paper for content inconsistencies. For that reason, we decided to both proof the entire paper rather than just proofing our personal sections. Caitlin proofed with more of a focus on grammar, while Christine checked for more content issues. This is one example of how we were able to accentuate our strengths for this paper in a way that overshadowed our weaknesses.
Not only did we learn more from working together in terms of research, but also on how to work together. Working in teams is a realistic aspect of the work force. While studying for our master’s degree, we should be pushed to work with fellow classmates. It teaches a skill that cannot be taught in a textbook. Yet working together for a project ensures that we can learn both team building skills as well as epidemiology principles. In the workforce, we will have to rely on others and be able to work in teams to get our jobs done. Everyone has strengths and weaknesses that are unique to him or her.
As a partnership, we were able to gather more knowledge on our topic of coronary heart disease. From that we were able to develop a greater scope of knowledge regarding the topic. Once we collaborated on the research, we could ensure that we were using the most relevant information. Lastly, we learned valuable team building skills that will transfer as useful experience in the workforce. This project was an interesting assignment that taught both of us a great deal about the topic of coronary heart disease, as well as working in a partnership.