“Reverse Targeting”“Reverse Targeting”

Professor Shahryar A. SheikhPresident, World Heart Federation

1st Annual Dr. Abdul Haque KhanMemorial International Cardiology SymposiumKarachi14 March 2008

Effect of Socioeconomic Status

on Cardiovascular Care

80%

AdvanceCardiac

Care

AdvanceCardiac

Care

39 %

26 %16 %

19 %

Population, %Population, %

3 %

11 %

15 % 71 %

Health $, PPP, %Health $, PPP, %

Distribution of Global Population & Health Expenditure, by Income in 2000

Distribution of Global Population & Health Expenditure, by Income in 2000

■ High, >$16,000

■ Higher Middle, $ 6-16000

■ Lower Middle, $ 2 - 6000

■ Low, <2000

■ High, >$16,000

■ Higher Middle, $ 6-16000

■ Lower Middle, $ 2 - 6000

■ Low, <2000

Globalization Research Centre, 2004;1:10% GDP to Health0 2 4 6 8 10 12 14

United States

GermanyFrance

Greece

Italy

OECD avg.

Japan

Spain

Poland

Mexico

Turkey

1222

786

569

169 147

37 25 18

0

200

400

600

800

1000

1200

1400

North Australia Europe MEAN South Russia Asia Africa

Nu

mb

er o

f C

ases

The Number of cardiac surgical procedures performed on an annual basis globally (Reproduced from Unger F. Worldwide survey on cardiac intervention 1995. Cor European 1999;7:128-46: with permission of Springer-Verlag)

Unger F, Cor Europpaeum. 1999;7:128-46

Cardiac Surgical Procedures Performed on an Annual Basis

GloballyWorldwide Survey on Cardiac Interventions, 1995

Cardiac Surgical Procedures Performed on an Annual Basis

GloballyWorldwide Survey on Cardiac Interventions, 1995

Under-5 mortality rates per 1000 live births by socioeconomic quintile of household

Inequalities in health between and within countries: poverty and inequality

Inequalities in health between and within countries: poverty and inequality

0

20

40

60

80

100

120

140

160 Poorest fifth2nd poorest fifthMiddle fifth

2nd richest fitthRichest fifth

Indonesia Brazil India Kenya

Death rates from CHD by socio-economic class,Death rates from CHD by socio-economic class,age 15 or 20 to 74 years, England and Walesage 15 or 20 to 74 years, England and Wales

Death rates from CHD by socio-economic class,Death rates from CHD by socio-economic class,age 15 or 20 to 74 years, England and Walesage 15 or 20 to 74 years, England and Wales

0

50

100

150

200

250

1970/72 1990/93

Deaths per 100,000

Drever et al Pop. Trends 1996;86:15-20

Professional

Intermediate

N Skillednon-manual

M Skilled manual

Partly skilled

Unskilled

SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)

SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)

P Jha et al., Lancet 2006; 368:367

50

40

30

20

10

0

Englandand Wales

USA Canada Poland

Social class NeighborhoodIncome

EducationEducation

Ris

k o

f d

yin

g a

t a

ge

s 3

5-69

ye

ars

(%)

High (I

/II)

Med

(III/

IV)

Low (V)

Low (<12

yrs

)

Med

(12

yrs)

High (>

12 y

rs)

Low (<12

yrs

)

Med

(12

yrs)

High (>

12 y

rs)

High (2

0%)

Med

(60%

)

Low (20%

)

43%

31%

21% 20%

37%

34%36%

21%24%

26%

50%

32%

22%

10%

5%6% 8%

13%14% 15%

4%4%

10%

19%

SmokingAny Cause

Rural: Economic Status, % Rural: Economic Status, %

(SE%)(SE%)Urban: Economic Status, % Urban: Economic Status, %

(SE%)(SE%)

Age Range, yAge Range, y LowLow MiddleMiddle HighHigh LowLow MiddleMiddle HighHigh

Infectious diseaseInfectious disease

Annual episodes of diarrhea Annual episodes of diarrhea 0-50-5 11.011.0(0.8)(0.8) 11.311.3(0.8)(0.8) 12.712.7aa(1.5)(1.5) 12.412.4(1.0)(1.0) 10.510.5(1.1)(1.1) 7.97.9(0.8)(0.8)

Nutritional statusNutritional status

AnemiaAnemia 0-50-5 68.168.1(3.0)(3.0) 66.266.2(3.5)(3.5) 65.065.0(6.6)(6.6) 65.665.6(6.0)(6.0) 64.264.2(3.9)(3.9) 52.852.8(8.6)(8.6)

WastingWasting 0-50-5 18.318.3(2.0)(2.0) 14.114.1(2.5)(2.5) 10.010.0(2.2)(2.2) 14.514.5(2.4)(2.4) 12.812.8(2.4)(2.4) 12.512.5(2.3)(2.3)

Anemia, males,Anemia, males, 15-4415-44 28.028.0aa(3.2)(3.2) 20.520.5(2.6)(2.6) 17.817.8(4.5)(4.5) 16.816.8(3.9)(3.9) 13.613.6(2.6)(2.6) 11.511.5(3.5)(3.5)

Anemia, femalesAnemia, females 15-4415-44 51.551.5(3.8)(3.8) 38.738.7(3.3)(3.3) 32.832.8(4.1)(4.1) 47.547.5(6.7)(6.7) 40.740.7(3.6)(3.6) 38.038.0(4.6)(4.6)

UnderweightUnderweight 25-6425-64 32.932.9aa(1.5)(1.5) 25.625.6aa(2.1)(2.1) 15.115.1(2.8)(2.8) 24.124.1(3.6)(3.6) 17.717.7(1.4)(1.4) 10.310.3(1.5)(1.5)

OverweightOverweight 25-6425-64 9.19.1aa(0.8)(0.8) 14.614.6aa(1.4)(1.4) 27.027.0aa(4.8)(4.8) 21.221.2(2.5)(2.5) 27.127.1(1.8)(1.8) 41.941.9(2.7)(2.7)

Chronic disease risk factorsChronic disease risk factors

HypertensionHypertension 45-6445-64 22.022.0(1.8)(1.8) 32.232.2(3.5)(3.5) 52.152.1(4.7)(4.7) 29.729.7(4.2)(4.2) 40.740.7(3.3)(3.3) 46.046.0(3.8)(3.8)

High CholesterolHigh Cholesterol 45-6445-64 13.713.7aa(1.8)(1.8) 16.916.9(2.5)(2.5) 26.726.7(5.7)(5.7) 22.122.1(3.7)(3.7) 22.622.6(2.9)(2.9) 27.827.8(4.0)(4.0)

Male smoking Male smoking 25-6425-64 35.535.5aa(2.3)(2.3) 33.633.6aa(2.4)(2.4) 33.733.7(5.0)(5.0) 57.057.0(5.0)(5.0) 45.545.5(2.8)(2.8) 33.033.0(3.3)(3.3)

Female SmokingFemale Smoking 25-6425-64 4.04.0aa(0.7)(0.7) 4.84.8(1.1)(1.1) 2.32.3(1.2)(1.2) 9.19.1(2.1)(2.1) 5.05.0(1.6)(1.6) 2.42.4(1.0)(1.0)

Selected Health Status Indicators:Selected Health Status Indicators: National Health Survey of Pakistan, 1990–1994National Health Survey of Pakistan, 1990–1994Selected Health Status Indicators:Selected Health Status Indicators: National Health Survey of Pakistan, 1990–1994National Health Survey of Pakistan, 1990–1994

G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98

Male, % (SE%)Male, % (SE%) Female, % (SE%)Female, % (SE%)

Age Range, yAge Range, y

United United StatesStates PakistanPakistan

United United StatesStates PakistanPakistan

Nutritional StatusNutritional Status

AnemiaAnemia 15-4415-44 1.51.5aa(0.3)(0.3) 20.620.6bb(1.8)(1.8) 10.410.4bb(0.7)(0.7) 44.444.4aa(2.4)(2.4)

UnderweightUnderweight 25-6425-64 0.80.8aa(0.2)(0.2) 25.025.0bb(1.3)(1.3) 3.23.2bb(0.4)(0.4) 25.325.3(1.4)(1.4)

OverweightOverweight 25-6425-64 61.861.8aa(1.0)(1.0) 13.213.2bb(1.0)(1.0) 51.951.9bb(1.3)(1.3) 22.622.6aa(1.3)(1.3)

Chronic disease risk factorsChronic disease risk factors

High cholesterolHigh cholesterol 45-6445-64 66.666.6aa(1.7)(1.7) 15.315.3bb(1.6)(1.6) 71.071.0bb(1.6)(1.6) 20.2920.29aa(1.9)(1.9)

HypertensionHypertension 45-6445-64 36.236.2(1.9)(1.9) 28.828.8bb(1.8)(1.8) 32.832.8(1.6)(1.6) 32.732.7(2.1)(2.1)

Smoking Smoking 25-4425-44 36.736.7aa(1.3)(1.3) 40.640.6(1.7)(1.7) 30.030.0bb(1.3)(1.3) 3.93.9aa(0.5)(0.5)

SmokingSmoking 45-6445-64 31.331.3aa(1.7)(1.7) 35.135.1(2.2)(2.2) 25.125.1bb(1.2)(1.2) 5.45.4aa(0.8)(0.8)Note. NHANES III= Third National Health and Nutrition Examination Survey.aProbability less than .05 that men and women within country are at equal levels.bProbability less than .05 that US men and women are at equal levels with Pakistani men and women, respectively.

National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994

G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98

Selected Health Status Indicators Comparing Selected Health Status Indicators Comparing the United States and Pakistan:the United States and Pakistan:

Selected Health Status Indicators Comparing Selected Health Status Indicators Comparing the United States and Pakistan:the United States and Pakistan:

Male, %Male, % Female, %Female, % Male, SE %Male, SE % Female, SE %Female, SE %

United United StatesStates PakistanPakistan

United United StatesStates PakistanPakistan

United United StatesStates PakistanPakistan

United United StatesStates PakistanPakistan

HypertensionHypertension

Not awareNot aware 31.931.9aa 86.786.7bb 21.521.5bb 70.570.5aa 2.52.5 2.22.2 1.81.8 3.03.0

Aware, not treatedAware, not treated 19.619.6 6.26.2bb 14.614.6bb 13.513.5bb 2.02.0 1.41.4 1.71.7 1.91.9

Treated, not controlledTreated, not controlled 25.425.4 4.74.7bb 28.828.8bb 11.311.3aa 1.81.8 1.31.3 2.12.1 1.91.9

Controlled Controlled 23.023.0aa 2.42.4bb 35.135.1bb 4.84.8 1.71.7 0.90.9 2.52.5 1.41.4

Dental healthDental health

Decayed and missing teethDecayed and missing teeth 9.99.9 10.410.4 10.110.1bb 15.215.2aa 0.40.4 0.50.5 0.40.4 0.70.7

Any filled teethAny filled teeth 78.078.0 2.32.3bb 77.477.4bb 2.02.0 1.41.4 0.60.6 1.41.4 0.60.6

Note. NHANES III= Third National Health and Nutrition Examination Survey.Note. NHANES III= Third National Health and Nutrition Examination Survey.aaProbability less than .05 that men and women within country are at equal levels.Probability less than .05 that men and women within country are at equal levels.bbProbability less than .05 that US men and women are at equal levels with Pakistani men and women, respectivelyProbability less than .05 that US men and women are at equal levels with Pakistani men and women, respectively..

Indicators of Access to and Appropriateness Indicators of Access to and Appropriateness of Health Care for Adultsof Health Care for Adults

Indicators of Access to and Appropriateness Indicators of Access to and Appropriateness of Health Care for Adultsof Health Care for Adults

National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994

G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98

0

10

20

30

40

Q1 Q2 Q3 Q4

CABGPCI

Income Quartile

Per

cen

t

Overall Rates

0

10

20

30

40

Q1 Q2 Q3 Q4

CABGPCI

Men

Income Quartile

Per

cen

t

Effects of Socioeconomic Status on PCI & CABGAlberta, Canada

Effects of Socioeconomic Status on PCI & CABGAlberta, Canada

0

10

20

30

40

Q1 Q2 Q3 Q4

CABGPCI

Income

Per

cen

t

Women

Am. J M, 2007, 120, 33-39

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1 2 3 4 5

Angiography within 6 mo

Waiting time for angiography

Mortality at 1 yr

Income Quintile

Ra

tio

Adjusted Relative Rates of Angiography within Six Months after Acute Myocardial Infarction, Waiting Times for Angiography, and One-Year Mortality According to Income Quintile.

Socioeconomic Status Access to Cardiac Procedures and Mortality

Rates of Use of Procedures and Waiting Times

Socioeconomic Status Access to Cardiac Procedures and Mortality

Rates of Use of Procedures and Waiting Times

Socioeconomic Status Access to Cardiac Procedures and Mortality

Socioeconomic Status Access to Cardiac Procedures and Mortality

Days after Acute Myocardial InfarctionKaplan-Meier Survival Curves According to Quintile of Neighborhood Median IncomeKaplan-Meier Survival Curves According to Quintile of Neighborhood Median Income

David A. alter.,NEJM 1999;341:1359-67

Cardiovascular Care in PakistanCardiovascular Care in PakistanIn Patients

(2006)In Patients

(2006)

60 %

21 %

10 %

9 %

Out Patients (2006)

Out Patients (2006)

8 %8 %

7 %

77 %

Total PCI 1886

Total PCI 1886

64 %

7 %

13 %

16 %

■ Paying ■ Poor

■ G. User ■ Entitled

S. Sheikh, ESC, 2007

■ Paying ■ Poor

■ G. User ■ Entitled

In PatientsIn Patients

60 %

21 %

10 %

9 %

PTMCPTMC

6% 3 %6 %

85 %PCIPCI

64 %

7 %

13 %

16 %

Socioeconomic Status and Cardiovascular DiseaseSocioeconomic Status and Cardiovascular Disease

S. Sheikh, ESC, 2007

3047

1172 1145

3238

1200

136252 298

0

500

1000

1500

2000

2500

3000

3500

Paying G. User Entitled PoorCor. Angio PCI

3047

1172 1145

3238

1200

136252 298

0

500

1000

1500

2000

2500

3000

3500

Paying G. User Entitled PoorCor. Angio PCI

Socioeconomic Gradient and Cardiovascular CareSocioeconomic Gradient and Cardiovascular Care

39%39%

11%11%22%22% 9%9%

S. Sheikh, ESC, 2007

The World’s Priorities? Annual ExpenditureThe World’s Priorities? Annual ExpenditureBasic education for all $ 6 billion*

Cosmetics in the United States $ 8 billion*

Safe water and sanitation for all $ 9 billion*

Ice Cream in Europe $ 11 billion*

Reproductive health for all women $ 12 billion*

Perfumes in Europe and the United States $ 12 billion*

Basic health and nutrition $ 13 billion*

Pet food in Europe and The Unites States $ 17 billion

Business entertainment in Japan $ 35 billion

Cigarettes in Europe $ 50 billion

Alcoholic drinks in Europe $ 105 billion

Narcotic drugs in the world $ 400 billion

Military spending in the world $ 780 billion

*Estimated additional annual cost to achieve universal access to basic social services in all developing countries Human development Report 1998

Expanding gap between the wealthy and

the poor in our society represents the

single greatest threat to our free standing

democracy.

Expanding gap between the wealthy and

the poor in our society represents the

single greatest threat to our free standing

democracy. SENATOR BOB KERY

(Nebraska)

No other group of people in world can claim such a wonderful position in life or more rewarding job. Because of our unique talent and position in world’s social spectrum. We have social obligations that only we are capable of addressing.

Let us light a candle instead of deploring the darkness.

Socioeconomic gradient remains the most

important barrier amongst the countries, or

within a developing country, for appropriate

application of cardiovascular care.

Sharing Science/Building Capacity

2008 World Congress of Cardiology, Buenos Aires,

Argentina - http://www.worldcardiocongress.org

Next World Congresses:

2010 World Congress of Cardiology, Beijing, China