32
THE MARYLAND BURDEN OF Heart DISEASE AND STROKE Maryland Department of Health & Mental Hygiene Family Health Administration Office of Chronic Disease Prevention 2009 Data Review
THE MARYLAND BURDEN OF
Heart DISEASE AND STROKE
Maryland Department of Health & Mental Hygiene
Family Health Administration
Office of Chronic Disease Prevention
2009 Data Review
Martin O’Malley
Governor
Anthony G. Brown Lt. Governor
John M. Colmers Secretary
Department of Health and Mental Hygiene
Russell Moy, M.D., M.P.H. Director
Family Health Administration
Joan H. Salim Deputy Director
Family Health Administration
Audrey S. Regan, Ph.D. Director
Office of Chronic Disease Prevention
Maria Prince, M.D., M.P.H.
Medical Director Office of Chronic Disease Prevention
Discrimination Policy: The services and facilities of the Maryland Department of Health and Mental Hygiene (DHMH) are operated on a non-discriminatory basis. This policy prohibits discrimination on the basis of race, color, sex or national origin and applies to the provisions of employment and granting of advantages, privileges, and accommodations. The Department, in compliance with the Americans with Disabilities Act, ensures that qualified individuals with disabilities are given an opportunity to participate in and benefit from DHMH services, programs, benefits, and employment opportunities. Acknowledgements: This report was prepared by the Office of Chronic Disease Prevention at the Maryland Department of Health and Mental Hygiene with funding provided through a Cooperative Agreement with the Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention (UDP000749-02).
TABLE OF CONTENTS Executive Summary …………………………………………………………………. 5
Burden of Heart Disease in Maryland …………………………………..................... 6
Heart Disease Prevalence ……………………………………………………. 6
Heart Disease Mortality ………………...…………….…………………….. 10
Heart Disease Hospitalization Data …………………………………………. 13
Burden of Stroke in Maryland ………………………………………………………. 17 Stroke Prevalence …………………………………………………………… 17
Stroke Mortality ……………………………………………………………... 19
Stroke Hospitalization Data …………………………………………………. 21
Heart Disease, Stroke and Related Risk Factors …………………………………..... 24
Maryland Heart Disease and Stroke Prevention Program …………………………... 27
Appendix A: Data Sources ………………………………………………………….. 28
Appendix B: Definitions ……………………………………………………………. 30
Appendix C: Disease Diagnosis ……………………………………………….……. 32
5
EXECUTIVE SUMMARY
Heart disease and stroke are the numbers one and three causes of death for Maryland residents. The public health impact of heart disease and stroke is substantial, both in terms of disease burden and cost. In 2008, an estimated $1.2 billion of adult medical expenditures in Maryland were attributable to heart disease and stroke (Maryland Health Services Cost Review Commission). Coronary heart disease (angina or/and heart attack) and stroke are linked to higher prevalence rates, high hospitalization rates, and high mortality. Controlling risk factors such as high blood pressure, high blood cholesterol and diabetes play an important role in heart disease and stroke prevention. In 2008, over half (63.4%) of Maryland residents were overweight and obese and high blood pressure was a common co-occurring condition among residents who have experienced heart attack or stroke (Maryland BRFSS). SPECIAL POPULATIONS It was estimated from 2005 to 2008 that heart disease and stroke affected certain segments of the population disproportionately based on race and ethnicity, gender, age, and education and income levels. Angina and heart attack were most prevalent among white males. The prevalence of coronary heart disease has increased the most among white males and
black females. Coronary heart disease and stroke were most prevalent among Maryland adults aged 55
and over, with a lower household income ($15k-25k), and with less education. Black Marylanders had almost twice the age-adjusted hospital discharge rate for heart
failure, non-specific chest pain, and stroke than white Marylanders. Black Marylanders had nearly 5-6 times the hypertension rate of white Marylanders. Black males experienced the highest levels of age-adjusted death associated with
coronary heart disease, hypertensive heart disease and stroke. Data sources, disease definitions and disease diagnosis can be found in Appendix A-C (pp29-32).
RECOMMENDATIONS This Burden Report is released in conjunction with the Maryland Heart Disease and Stroke Prevention and Control Plan (The 5 Year Plan), a joint publication of the Maryland Department of Health and Mental Hygiene and the Governor’s Heart Disease and Stroke Prevention Council. The five year Plan identifies specific recommendations, activities and partners to improve the morbidity and mortality associated with cardiovascular disease and stroke in Maryland. Sources utilized in this report include data from the Behavioral Risk Factor Surveillance System (BRFSS), the Maryland Health Services Cost Review Commission and the Maryland Vital Statistics Administration.
6
BURDEN OF Heart DISEASE IN MARYLAND Coronary Heart Disease Prevalence This report discusses prevalence as it refers to coronary heart disease (angina or/and heart attack) as defined by the Maryland Behavior Risk Factor Surveillance System (Maryland BRFSS, 2005-2008, since 2009 is not available). This section highlights differences in coronary heart disease prevalence based on race and ethnicity, gender, age, education and income levels from 2005 to 2008. The overall prevalence of angina in Maryland has increased from 3.7 percent in 2005 to 4.4 percent in 2008 (Figure 1). Prevalence remains highest in white males (6.5 percent) and lowest in black females (3.3 percent, Figure 1). Figure 1. Prevalence of Angina in Maryland, Overall and by Gender/Race, 2005-2008
Source: Maryland BRFSS Prevalence of heart attack in Maryland has increased overall and across all races/genders from 2005 to 2008 (Figure 2) with the exception of white females and black males. The prevalence of heart attack for white males increased from 4.7 percent in 2005 to 6.7 percent in 2008 (Figure 2).
0.0
2.0
4.0
6.0
8.0
10.0
Year
Perc
enta
ge
Overall 3.7 4.5 3.9 4.4
White Males 5.4 6.8 6.5 6.5
White Females 3.6 3.9 2.5 3.7
Black Males 3.4 4.8 2.4 4.1
Black Females 2.1 3.7 3.5 3.3
2005 2006 2007 2008
7
Figure 2. Prevalence of Heart Attack in Maryland, Overall and by Gender/Race, 2005-2008 Source: Maryland BRFSS
Coronary heart disease prevalence in Maryland was the highest among white males, and increased from 7.4 percent in 2005 to 9.4 percent in 2008(Figure 3). Prevalence of coronary heart disease has also increased among black females, moving from 3.8 percent in 2005 to 5 percent in 2008 (Figure 3). Figure 3. Prevalence of Coronary Heart disease in Maryland, Overall and by Gender/Race, 2005-2008
Source: Maryland BRFSS
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Year
Perc
enta
ge
Overall 5.6 6.7 5.7 6.3
White Males 7.4 9.8 8.3 9.4
White Females 5.2 5.4 4.1 5.1
Black Males 5.6 7.8 5.0 5.9
Black Females 3.8 5.8 5.1 5.0
2005 2006 2007 2008
0.0
2.0
4.0
6.0
8.0
10.0
Year
Per
cent
age
Overall 3.6 4.3 3.4 3.9
White Males 4.7 6.2 4.8 6.7
White Females 3.2 3.3 2.5 2.7
Black Males 4.1 6.2 4.2 3.4
Black Females 2.6 3.6 3.1 3.2
2005 2006 2007 2008
8
Maryland residents ages 55 and over compromised the highest prevalence of coronary heart disease from 2005 to 2008 (Figure 4). Residents with less than a high school education experiences more than three times the prevalence of heart disease (14.7 percent) compared to those that attainted a college level education (4.1 percent). The prevalence of coronary heart disease decrease as income level increases. Maryland residents earning less than $25,000 per year experience almost four times the prevalence of coronary heart disease than those making more than $75,000 per year (Figure 5). In 2005-2008, the Somerset county had the highest prevalence of heart attack, three times the state average prevalence at 3.8% (Map 1) and Allegany county had the highest prevalence of angina (9%) and twice the state average prevalence at 4.1% (Map 2). Figure 4. Prevalence of Coronary Heart Disease in Maryland by Age, 2005-2008 (4 Year Average)
Source: Maryland BRFSS Figure 5. Prevalence of Coronary Heart Disease in Maryland, by Education and Income, 2005-2008 (4
Year Average) Source: Maryland BRFSS
0.92.0
6.4
9.1
15.3
22.8
0.0
5.0
10.0
15.0
20.0
25.0
25-34 35-44 45-54 55-64 65-74 75+
Age
Perce
ntage
14.7
7.3
4.1
15.0
12.6
7.9
4.73.3
0.0
5.0
10.0
15.0
20.0
< HighSchool
HighSchool
College <$15K $15K-24.9K
$25K-$49.9K
$50k-$74.9K
$75k
Education Income
Perc
enta
ge
9
Map 1. Percent of Residents Ever Told by a Doctor They Had a Heart Attack (Myocardial
Infarction), 2005-2008 (4 Year Average) Source: Maryland BRFSS
Map 2. Percent of Residents Ever Told by a Doctor They Had Angina, 2005-2008 (4 Year Average)
Source: Maryland BRFSS
10
Heart Disease Mortality Of all types of heart disease, coronary heart disease had the highest mortality in Maryland (Figure 6a). The overall age-adjusted death rate attributable to coronary heart disease has declined between 2005 and 2008 from 166.5 to 147.1 deaths per 100,000 population. The largest reduction took place among white females and black females (Figure 6b). The age-adjusted death from coronary heart disease is disproportionately highest among black males at 239.3 (Figure 6b). In 2008, Seven of Maryland’s twenty-four jurisdictions had mortality of coronary heart disease that were above the Healthy People 2010 goal of reducing age-adjusted death rate associated with coronary heart disease to 166 per 100,000 populations (Table 1). Black males had the highest mortality of hypertensive heart disease (Figure 6c). Age-adjusted death rate of heart failure in both white and black have declined between 2005 and 2008 (Figure 6d) Figure 6a. Age-adjusted Death Rates for Heart Disease in Maryland, 2005 – 2008 Source: Maryland Vital Statistics Administration/MATCH Figure 6b. Age-adjusted Death Rates for Coronary Heart Disease in Maryland, Overall and by Race
and Gender, 2005 – 2008; Source: Maryland Vital Statistics Administration
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Year
Age-a
djuste
d deat
h rate
s per
100,0
00
Acute myocardial infarction 49.2 44.7 42.8 39.5
Other ischemic heart disease 98.3 96.0 96.5 93.1
Hypertensive heart disease 15.1 15.6 15.4 15.6
Heart Failure 13.5 12.7 11.0 11.0
All other heart disease 33.7 35.4 37.3 37.4
2005 2006 2007 2008
11
Table 1. Crude and Age-adjusted Death Rates for Coronary Heart Disease in Maryland by County, 2008, Source: Maryland Vital Statistics Administration/MATCH Region Crude rate per 100, 000 population
Age-adjusted death rate per 100,000 population
Maryland 151.8 147.1 Allegany 307.6 206.3 Anne Arundel 131.4 145.5 Baltimore County 186.4 146.3 Calvert 143.8 174.3 Caroline 196.9 177.6 Carroll 141.5 136.7 Cecil 167.7 173.1 Charles 96.6 136.0 Dorchester 249.7 153.0 Frederick 129.3 143.8 Garrett 191.9 138.0 Harford 144.2 155.1 Howard 99.3 130.7 Kent 249.1 142.8 Montgomery 105.8 93.7 Prince George’s 134.1 174.7 Queen Anne’s 139.5 138.0 St. Mary’s 115.3 142.6 Somerset 248.3 224.0 Talbot 252.8 129.1 Washington 188.1 155.5 Wicomico 235.5 200.9 Worcester 293.8 164.9 Baltimore City 213.5 200.2 Figure 6c. Age-adjusted death rates for Hypertensive Heart Disease in Maryland by Race and Gender,2005-2008 Source: Maryland Vital Statistics Administration/MATCH
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Year
Age-a
djus
ted de
ath r
ates
per 1
00,00
0
White Males 13.1 15.6 15.0 16.2
White Females 9.9 9.2 9.4 9.7
Black Males 32.2 35.0 35.0 32.7
Black Females 22.8 21.1 20.2 19.9
2005 2006 2007 2008
12
Figure 6d. Age-adjusted Death Rates for Heart Failure in Maryland by Race and Gender, 2005-2008 Source: Maryland Vital Statistics Administration/MATCH
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Year
Age
-adj
uste
d de
ath
rate
s per
100
,000
White Males 14.6 13.5 12.2 12.7
White Females 13.2 12.7 10.2 10.0
Black Males 15.1 12.1 12.8 12.4
Black Females 12.6 9.8 10.4 10.0
2005 2006 2007 2008
13
Heart Disease Hospital Data In 2008, coronary atherosclerosis and other heart disease contributed to 19.6 percent of hospital discharges for heart disease while acute myocardial infarctions accounted for 10.7 percent (Figure 7). Non-specific chest pain constituted 24 percent and non-hypertensive congestive heart failure did 22.7 percent of hospital discharges for heart disease (Figure 7). Figure 7. Percentage of Hospital Discharges for Heart Disease 2008
Source: Maryland Health Services Cost Review Commission/MATCH Age-adjusted hospital discharge rate from total coronary heart disease (including heart attack) and heart failure have declined 30-60 per 100,000 population except nonspecific chest pain (Figure 8). Nonspecific chest pain made up a largest proportion of heart disease related hospital discharges at 354 per 100,000 population in 2008, and have increased from 314 (2005) to 354 (2008) per 100,000 population (Figure 8). White adults with coronary heart disease had the highest age-adjusted hospital discharge rate from 2005 to 2008 (Figure 9a). Black adults had almost twice the age-adjusted hospitalization rate for heart failure (Figure 9band nonspecific chest pain (Figure 9d), and nearly 5-6 times the rate of hypertension than white adults (Figure 9c). In 2005-2008, the lower Eastern Shore area exhibited the highest hospital discharge rates from coronary heart disease. Figure 8. Age-adjusted Hospital Discharge Rate from Heart Disease, Overall, 2005-2008
Source: Maryland Health Services Cost Review Commission/MATCH
1.5%
0.3%
22.7%
1.7%
10.7%
19.6%
24.0%
3.7%
0.2%
1.2%14.5%
Heart valve disorders
Cardiac arrest and ventricularfibrillation
Congestive heart failure;nonhypertensive
Peri-; endo-; and myocarditis;cardiomyopathy (except that causedby TB or STD)
Acute myocardial infarction
Coronary atherosclerosis and otherheart disease
Nonspecific chest pain
Pulmonary heart disease
Other and ill-defined heart disease
Conduction disorders
Cardiac dysrhythmias
0
100
200
300
400
Year
Age-a
djuste
d disch
arge ra
te per
100,0
00
Congestive heart failure;nonhypertensive
374 368 349 348
Acute myocardialinfarction
193 176 164 161
Coronaryatherosclerosis andother heart disease
354 347 303 290
Nonspecific chest pain 314 355 362 354
2005 2006 2007 2008
14
Figure 9a. Age-adjusted Hospital Discharge Rate from Angina (Coronary Heart Disease) in Maryland by Race and Gender, 2005-2008
Source: Maryland Health Services Cost Review Commission/MATCH Figure 9b. Age-adjusted Hospital Discharge Rate from Heart Failure in Maryland by Race and Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH Figure 9c. Age-adjusted Hospital Discharge Rate from hypertension in Maryland by Race and Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH
0
100
200
300
400
500
600
Year
Age-a
djuste
d disc
harge
rate
per 10
0,000
White Males 490.3 476.9 414.5 395.6
White Females 245.7 245.0 205.0 205.0
Black Males 363.9 327.0 309.6 292.8
Black Females 293.3 286.7 252.0 239.4
2005 2006 2007 2008
0
200
400
600
800
Year
Age-a
djuste
d disch
arge ra
te per
100,0
00
White Males 342.0 329.8 315.1 315.0
White Females 263.1 249.5 230.4 224.9
Black Males 681.1 698.2 681.1 690.8
Black Females 555.7 567.1 526.7 523.5
2005 2006 2007 2008
0
50
100
150
200
250
300
350
Year
Age-a
djuste
d disc
harge
rate
per10
0,000
White Males 58.0 54.9 53.4 56.2
White Females 60.6 59.9 61.1 61.6
Black Males 317.0 321.6 297.6 309.7
Black Females 290.7 313.1 304.3 297.7
2005 2006 2007 2008
15
Figure 9d. Age-adjusted Hospital Discharge Rate from Non-Specific Chest Pain in Maryland by Race and Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH Heart disease accounted for $1 billion of hospital expenses in 2008, almost half of which ($428 million) were due to coronary heart disease. The leading heart disease related hospital discharge costs from 2005 through 2008 were coronary atherosclerosis, non-hypertensive congestive heart failure and acute myocardial infarction (Figure 10a). Heart valve disorders remain the highest average hospital discharge cost of heart diseases (Figure 10b). Figure 10a. Annual Total Cost of Hospital Charges for Heart Disease in Maryland, 2005 - 2008 Source: Maryland Health Services Cost Review Commission/MATCH
0
100
200
300
400
500
600
700
Year
Age-a
djuste
d Disch
arge r
ate
per 10
0,000
White Males 256.4 275.1 283.8 265.2
White Females 245.1 273.5 289.2 286.4
Black Males 429.4 497.0 490.4 491.5
Black Females 530.5 622.3 623.3 616.8
2005 2006 2007 2008
0 5,000 10,000 15,000 20,000 25,000 30,000
2005
2006
2007
2008
Year
Annual Total Cost ($10,000)
Cardiac dysrhythmias
Conduction disorders
Other and ill-defined heart disease
Pulmonary heart disease
Nonspecific chest pain
Coronary atherosclerosis andother heart disease
Acute myocardial infarction
Peri-; endo-; and myocarditis;cardiomyopathy (except thatcaused by TB or STD)Congestive heart failure;nonhypertensive
Cardiac arrest and ventricularfibrillation
Heart valve disorders
16
Figure 10b. Annual Average Cost of Hospital Charges for Coronary Heart Disease in Maryland, 2005 -
2008 Source: Maryland Health Services Cost Review Commission/MATCH
0 10 20 30 40 50
2005
2006
2007
2008
Year
Annual Average Cost ($X1,000)
Cardiac dysrhythmias
Conduction disorders
Other and ill-defined heart disease
Pulmonary heart disease
Nonspecific chest pain
Coronary atherosclerosis and otherheart disease
Acute myocardial infarction
Peri-; endo-; and myocarditis;cardiomyopathy (except that caused byTB or STD)Congestive heart failure;nonhypertensive
Cardiac arrest and ventricular fibrillation
Heart valve disorders
17
BURDEN OF STROKE IN MARYLAND Stroke Prevalence This section highlights differences in stroke (cerebrovascular disease) prevalence based on race and ethnicity, gender, age, education and income levels. The prevalence of stroke in Maryland has varied slightly from 2005 to 2008 with the overall prevalence moving from 2.1 percent in 2005 to 2.6 percent in 2008 (Figure 11). 2008 prevalence indicates that women have a slightly higher prevalence of stroke than men at 2.9 percent (Figure 11). Figure 11. Prevalence of Stroke in Maryland, Overall and by Race and Gender 2005-2008 Source: Maryland BRFSS Maryland residents ages 65 and over have the highest prevalence of stroke at 6.2 percent, almost two times higher than residents ages 55 to 64 (Figure 12). Stroke prevalence increases among Maryland residents as the level of education decreases. Maryland residents with less than a high school education have twice the prevalence of stroke than residents with a high school education, and more than four times the prevalence of those with a college education (Figure 13). The same is true for income. Stroke prevalence is the highest among those residents earning the least. Maryland residents earning between $15,000 and $24,900 per year experience prevalence of stroke three times higher than residents earning $50,000 or more per year (Figure 13). Figure 12. Prevalence of Stroke in Maryland, by Age 2005-2008 Source: Maryland BRFSS
0.0
1.0
2.0
3.0
4.0
Year
Perc
enta
ge
Overall 2.1 2.6 2.3 2.6
White Males 2.1 2.7 2.7 2.5
White Females 2.2 2.8 1.9 2.9
Black Males 2.0 3.5 2.2 2.5
Black Females 2.5 2.3 2.9 2.9
2005 2006 2007 2008
0.3 0.71.7
3.3
6.2
11.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
25-34 35-44 45-54 55-64 65-74 75+
Age
Percen
tage
18
Figure 13. Prevalence of Stroke in Maryland, by Education and Income 2005-2008 Source: Maryland BRFSS
The following map graphically represents, by county, the distribution of Maryland residents who have been told by a doctor they have had a stroke. Cecil had the highest prevalence of stroke (3.9%) in Maryland jurisdiction (Map 3). Map 3. Maryland Residents Ever Told by a Doctor They Had a Stroke 2005-2008 (4 Year Average) Source: Maryland BRFSS
6.7
3.0
1.5
7.6
5.3
2.7
1.60.9
0.0
2.0
4.0
6.0
8.0
10.0
< HighSchool
HighSchool
College <$15K $15K-24.9K
$25K-$49.9K
$50k-$74.9K
$75k
Education Income
Perc
enta
ge
19
Stroke Mortality Stroke is the third leading cause of death in Maryland. The overall death rate attributable to stroke has declined from 2005 to 2008 from 45 to 40 deaths per 100,000 residents. Black males experienced the largest decline in stroke mortality across the four years from 58.4 to 49.7 deaths (Figure 14). Black females also experienced a higher decline in stroke deaths than white males and females moving from 49.2 in 2005 to 41.8 in 2008. In 2008, four of twenty-four Maryland’s jirisdictions had death rates from stoke that were higher than Healthy people 2010 goal of resucing death rate associated with stroke to 48 per 100,000 populations (Table 2). Figure 14. Maryland Age Adjusted Death Rates for Cerebrovascular Disease 2005-2008 Source: Maryland Vital Statistics Administration/MATCH
Map 4. Comparison of County Age Adjusted Death Rates for Stroke to the Maryland Average, 2006-2008 Source: Maryland Vital Statistics Administration
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Year
Age-a
djus
ted d
eath
rates
pe
r 100
,000
Overall 45.0 43.5 40.5 40.0
White males 41.6 40.5 39.0 37.3
White females 41.9 41.1 36.9 38.0
Black Males 58.4 57.6 54.5 49.7
Black Females 49.2 44.9 45.4 41.8
2005 2006 2007 2008
20
Table 2. Crude and Age Adjusted Death Rate for Stroke by County, 2008 Source: Maryland Vital Statistics Administration/MATCH
Region Crude rate per 100,000 population
Age-adjusted death rate per 100,000 population
Maryland 39.9 40 Allegany 65.1 41.8 Anne Arundel 35.9 41.4 Baltimore County 57.5 44.6 Calvert 23.7 29.8 Caroline 33.2 * Carroll 54.9 56.7 Cecil 26.0 28.7 Charles 30.5 49.7 Dorchester 78.1 50.3 Frederick 37.7 44.6 Garrett 70.7 50.2 Harford 33.3 38.7 Howard 30.2 43.1 Kent 49.6 * Montgomery 33.8 31.4 Prince George’s 25.7 33.8 Queen Anne’s 53.1 51.8 St. Mary’s 34.5 44.3 Somerset 19.1 * Talbot 96.6 47.6 Washington 42.0 34.2 Wicomico 37.2 32.7 Worcester 54.8 31.4 Baltimore City 49.3 48 * Rates based on fewer than 20 deaths are not included.
21
Stroke Hospital Data Acute stroke disease is the most common cerebrovascular disease related to Maryland hospital discharges in 2008 (55%), followed by transient cerebral ischemia (28%, Figure 15). The percent of hospital discharges of cerebral vascular disease for transient cerebral ischemia has increased 15% (Figure 16); acute stroke has decreased over the past three years; and occlusion or stenosis of the precerebral arteries has remained steady (Figure 16). Figure 15. Maryland Percentage Hospital Discharges for Various Types of Cerebrovascular Disease,
2008 Source: Maryland Health Services Cost Review Commission/MATCH Figure 16. Maryland Percentage of Total Cerebrovascular Disease Hospital Discharges, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH
55%
13%
2%
28%
2%Acute cerebrovasculardisease
Occlusion or stenosisof precerebral arteries
Other and ill-definedcerebrovascular disease
Transient cerebralischemia
Late effects ofcerebrovascular disease
0
20
40
60
Year
Perce
ntage
of tot
al cer
ebrov
ascula
r dise
ase
Acute cerebrovasculardisease
57.1 56.3 55 54.5
Occlusion or Stenosis ofpercerebral arteries
13.6 13.2 12.9 13.2
Transient cerebralischemia
23.9 25.9 27.2 27.5
2005 2006 2007 2008
22
Although both genders experienced an increase of stroke hospitalization from 2005 to 2008, males have consistently higher rates than women (Figure 17). The age adjusted hospital discharge rate for strokes among black Marylanders is nearly twice as high as that of their white counterparts (Figure 17). In 2005-2008, the Lower Eastern Shore area exhibited the highest hospital discharge rates from strokes when compared to other areas in Maryland Figure 17. Maryland Age Adjusted Hospital Discharge Rates for Cerebrovascular Disease Overall and
by Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission Cerebrovascular disease accounted for $230 million of Maryland hospital expenses in 2008. $162 million were due to acute stroke and $32 million to transient cerebral ischemia (Figure 18). Figure 18. Annual Total Cost of Hospital Charges for Cerebrovascular Disease in Maryland, 2005 – 2008 Source: Maryland Health Services Cost Review Commission/MATCH
From 2005 - 2008 average hospital charges associated with cerebrovascular disease have increased except for the late effects of cerebrovascular disease, which have decreased (Figure 19).
0
100
200
300
400
500
Year
Age-a
djuste
d disc
harge
rate
per 10
0,000
Overall 316.6 316.3 321.5 330.1
White Males 306.5 299.2 303.8 310.7
White Females 261.2 264.3 270.8 275.3
Black Males 426.8 419.2 409.2 439.1
Black Females 403.7 420.4 423.7 429.4
2005 2006 2007 2008
0
50,000,000
100,000,000
150,000,000
200,000,000
Type of Cerebrovascular disease
Annu
al to
tal c
ost (
$)
2005 127,537,984 20,038,152 6,480,175 22,575,677 6,780,582
2006 143,794,811 21,166,182 7,263,568 27,078,696 3,839,948
2007 151,326,762 21,611,318 8,395,077 30,344,860 3,942,107
2008 162,328,962 24,577,292 8,860,746 32,892,910 4,061,745
Acute cerebrovascular
disease
Occlusion or stenosis of precerebral
Other and ill-defined
cerebrovascular
Transient cerebral ischemia
Late effects of cerebrovascular
disease
23
Figure 19. Annual Average Cost of Hospital Charges for Cerebrovascular Disease in Maryland, 2005 -
2008 Source: Maryland Health Services Cost Review Commission
0
5,000
10,000
15,000
20,000
25,000
Type of Cerebrovascular disease
Ann
ual a
vera
ge co
st ($
)
2005 12,800 8,412 16,701 5,400 12,487
2006 14,526 9,096 18,250 5,946 9,253
2007 15,131 9,228 18,491 6,146 9,083
2008 15,666 9,780 20,002 6,301 8,849
Acute cerebrovascular
disease
Occlusion or stenosis of
precerebral arteries
Other and ill-defined
cerebrovascular
Transient cerebral ischemia
Late effects of cerebrovascular
disease
24
BURDEN OF HEART DISEASE
AND STROKE IN MARYLAND Heart Disease, Stroke and Related Risk Factors Common risk factors for both heart disease and stroke include high blood cholesterol, high blood pressure, overweight/obesity, inadequate physical activity (no leisure time physical activity), smoking status (current and former smokers) and poor nutrition (less than one serving of fruits and vegetables per day). This section examines these risk factors, and others, in the Maryland population and their co-occurrence with residents reporting heart disease and stroke. The most prevalent risk factor for heart disease and stroke among Maryland residents is high cholesterol (36.9%), followed by overweight at 36.7% and high blood pressure at 29.8%. Viewed together, overweight and obesity are prevalent among 63.4% of the population (Figure 20). Inadequate physical activity, smoking (current smoker only, Figure 20), and diabetes follow. Figure 20. Prevalence of Chronic Disease Risk Factors in Maryland, 2007/2008 Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
Although the prevalence of diabetes among Maryland residents is not as common as other risk factors, it is estimated that Maryland adults who have been diagnosed with diabetes (compared to those who have not diagnosed with diabetes) are about 4.8 times more likely also to have suffered from heart attack and angina (Figures 21 and 22). The same is true for stroke and diabetes (Figure 23). High blood pressure is the most common co-occurrence for heart attack, angina and stroke.
4.2
8.7
14.9
2426.7
29.8
36.7 36.9
0
10
20
30
40
PoorNutrition
(<1time/day)
Diabetes Smoking Physicalinactivity
Obesity High bloodpressure(2007)
Overweight Highcholesterol
(2007)
Risk Factors
Per
cent
age
25
Figure 21. Prevalence of Heart Attack with Risk Factors, 2007/2008
Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
Figure 22. Prevalence of Angina with Risk Factors, 2007/ 2008 Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
5.2
4.8
4.4
2.5
2.2
1.9
1.4
1.2
0 1 2 3 4 5 6
High Blood Pressure (2007)
Diabetes
High Cholesterol (2007)
Smoking
Physical Inactivity
Obesity
Overweight
Nutrition (1 or <1 serving fruitsand vegetables/day)
Risk
Facto
rs
Prevalence Ratios (Heart Attack with Risk Factors/Heart Attack without Risk
Factors)
5.6
5.1
4.9
2
1.7
1.4
1.2
2.1
0 1 2 3 4 5 6
High Blood Pressure (2007)
High Cholesterol (2007)
Diabetes
Smoking
Obesity
Physical Inactivity
Overweight
Nutrition (1 or <1 serving fruitsand vegetables/day)
Ris
k F
acto
rs
Prevalence Ratios (Angina with Risk Factors/Angina without Risk Factors)
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Figure 23. Prevalence of Stroke with Risk Factors, 2007/ 2008 Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
6.4
4.8
2.4
2.3
2.0
1.5
1.4
1.0
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0
High Blood Pressure (2007)
Diabetes
High Cholesterol (2007)
Physical Inactivity
Smoking
Nutrition (1 or <1 serving fruits andvegetables/day)
Obesity
Overweight
Risk
Fac
tors
Prevalence Ratios (Stroke with Risk Factors/Stroke without Risk factors)
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MARYLAND HEART DISEASE AND STROKE
PREVENTION PROGRAM The Maryland Heart Disease and Stroke Prevention Program, along with other state and local partners, will use the report findings to guide the implementation of statewide strategies found in the Maryland Heart Disease and Stroke Prevention and Control Plan. This Report, in conjunction with the Plan, are requirements of the cooperative CDC funding agreement of the Maryland Heart Disease and Stroke Prevention Program. Based on the Social-ecological Model, the essential strategies of the program are to use education, policy and systems changes to increase heart disease and stroke prevention with emphasis on six program priority areas:
1. Addressing control of high blood pressure and high blood cholesterol in adults and older adults
2. Increasing knowledge of signs and symptoms for heart disease and stroke and the
importance of calling 9-1-1
3. Improving emergency response
4. Improving quality of heart disease and stroke care
5. Eliminating health disparities
6. Focusing on the health care and worksite settings Additional required activities of the cooperative agreement are to develop the foundation for a comprehensive cardiovascular disease prevention program through:
1. Partnership development 2. Definition of the burden of heart disease and stroke
3. Development of a State Plan
4. Pilot testing interventions
The Governor’s Council on Heart Disease and Stroke serves as the advisory group for the grant providing strategic planning leadership and partnering in the production and evaluation of the Plan. Additional information is available through the Office of Chronic Disease Prevention web site: http://fha.maryland.gov/cdp/ .
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APPENDIX A: DATA SOURCES
DATA SOURCE DESCRIPTION
MD Behavioral Risk Factor Surveillance System (BRFSS)
The Maryland BRFSS is an ongoing telephone surveillance program designed to collect data on the behaviors and conditions that place Marylanders at risk for chronic diseases, injuries, and preventable infectious diseases. The typical sample size each year is 8,900 households with an adult respondent 18 years of age or older. The data in this report are based on the weighted data. The weighting method involved adjustments of the sample proportions of selected demographic characteristics so that they equal the sample proportions in the population and also adjustments of the sample surveyed so that it represents the State population. Refer to www.marylandbrfss.org for more information on Maryland BRFSS. National BRFSS data can be downloaded from www.cdc.gov/brfss
Maryland Assessment Tool for Community health (MATCH)
Maryland Assessment Tool for Community Health (MATCH) features statistics for Maryland resident health events. Health officials, health practitioners, public health researchers and others can find Maryland population estimates along with statistics on births to Maryland resident mothers, resident deaths and hospitalizations. The information is aggregated by year of event, by county of residence and by other population characteristics. MATCH is sponsored by the Family Health Administration and is developed in partnership with the Maryland Vital Statistics Administration and the Maryland Health Care Commission.
Refer to www.matchstats.org for more information on Maryland Assessment Tool for Community Health.
MD Health Services Cost Review Commission
The Maryland Health Services Cost Review Commission created a significant data infrastructure that includes a uniform accounting and reporting system and extensive data collection on, and analysis of, every aspect of hospital operations. To fulfill its broad disclosure responsibilities, it distributes annual reports on hospital operations and makes all such Commission files accessible to the public. Refer to http://www.hscrc.state.md.us/index.cfm for more information on Maryland Health Services Cost Review Commission
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DATA SOURCE DESCRIPTION
MD Vital Statistics Administration
The Maryland Vital Statistics Administration is charged with registering all births, deaths, and fetal deaths occurring in the State of Maryland; issuing certified copies of birth, death, and marriage certificates and providing divorce verifications; compiling and analyzing vital statistics data; preparing annual estimates of the population of Maryland by political subdivision, age, race, and sex; preparing mandated vital statistics and population reports; and supplying vital statistics and population data to users in the public and private sectors. Refer to http://www.vsa.state.md.us/ for more information on Maryland Vital Statistics Administration.
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APPENDIX B: DEFINITIONS Heart disease and stroke encompass multiple health conditions and risk factors. The following terms are commonly referred to in this Burden Report. Definitions are from the American Heart Association and the American Stroke Association and can be found at www.americanheart.org and www.strokeassociation.org . For a complete list of ICD codes used to define specific data sets see Appendix C. Angina (Angina Pectoris): Medical term for chest pain or discomfort due to coronary heart disease. Angina is a symptom of a condition called myocardial ischemia. It occurs when the heart muscle (mycocardium) doesn’t get as much blood (hence as much oxygen) as it needs for a given level of work. Insufficient blood supply is called ischemia. Stable angina (or chronic stable angina) refers to “predictable” chest discomfort such as that associated with physical exertion or mental or emotional stress. Rest and/or nitroglycerin usually relieve stable angina. Unstable angina refers to unexpected chest pain and usually occurs at rest. It is typically mores ever and prolonged and is due to a reduced blood flow to the heart caused by the narrowing of the coronary arteries in atherosclerosis. Unstable angina is an acute coronary syndrome and should be treated as an emergency. Blood Pressure: The force or pressure exerted by the heart against the walls of the arteries. When the arterioles (smaller arteries) constrict (narrow), the blood must flow through a smaller “pipe” and the pressure rises. High blood pressure can result, adding to the workload of the heart and arteries. Optimal blood pressure is less than 120/80 mm Hg. High blood pressure, or hypertension, is a condition in which blood pressure levels are above the normal range. Blood pressures of 120-139 / 80-89 mm Hg are considered prehypertension. Blood pressure is considered high if it is 140/90 mm Hg or higher. Long-standing, uncontrolled high blood pressure increases the risk for heart attack, angina, stroke, chronic kidney failure and peripheral artery disease (PAD). High blood pressure may also increase the risk of developing fatty deposit in arteries (atherosclerosis). The risk of heart failure also increases due to the increased workload that high blood pressure places on the heart. Cerebrovascular Disease (Stroke): Stroke is a disease that affects the arteries leading to and within the brain. A stroke occurs when a blood vessel that carriers oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens, part of the brain cannot get the blood (oxygen) it needs, so brain cells starts to die. Stroke can be caused by either a clot obstructing the flow of blood to the brain (called an ischemic stroke) or by a blood vessel rupturing and preventing blood flow to the brain (called a hemorrhagic stroke). Cholesterol: A soft, waxy substance found among the lipids (fats) in the bloodstream and in all the body’s cells. It’s an important part of a healthy body because it’s used to form cell membranes, some hormones and is needed for other functions. Cholesterol and other fats can’t dissolve in the blood. They have to be transported to and from the cells by special carriers called lipoproteins. There are several kinds but the most important are low-density lipoprotein (LDL or “bad”) and high-density lipoprotein (HDL or “good”). Cholesterol Classifications: Total blood cholesterol is the most common measurement of blood cholesterol. Cholesterol is measured in milligrams per deciliter (mg/dL) of blood. Total
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cholesterol is composed of high-density lipoprotein (HDL or “good”) cholesterol, low-density lipoprotein (LDL or “bad”) cholesterol and very-low density lipoprotein (VLDL), which carries triglycerides. Triglycerides, a common type of blood fat, can also affect cardiac arrest. Blood cholesterol and triglycerides are classified by levels that relate to the risk of heart disease. The numbers are interpreted based on all risk factors including age, family history, smoking status, blood pressure, physical activity level, weight and diabetes status. Congestive Heart Failure (Heart Failure): Because not all patients with heart failure have problems with excess fluids, such as in the lungs or extremities, the term “heart failure” is preferred over “congestive heart failure.” Heart failure is the inability of the heart to pump out all the blood that returns to it. This results in blood backing up in the veins that lead to the heart and sometimes in fluid accumulating in various parts of the body. Coronary Heart Disease (CHD): Disease of the heart caused by atherosclerotic narrowing of the coronary arteries likely to produce chest pain (angina pectoris) or heart attack. Heart Attack (Myocardial Infarction): Death of our damage to part of the heart muscle due to an insufficient blood supply. Heart attacks occur when one of the coronary arteries that supply blood to the heart muscle is blocked. Blockage is usually caused from a buildup of plaque (deposit of fat-like substances) due to atherosclerosis. If a plaque deposit tears or ruptures, a blood clot may form and block the artery, causing a heart attack. Heart attack is also called a coronary thrombosis or coronary occlusion.
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APPENDIX C: DISEASE DIAGNOSIS The following International Statistical Classification of Diseases and Related Health Problems (ICD) Codes were used to define the data sets analyzed within the report.
Cardiovascular Disease Age Data source Definition Mortality from coronary heart disease All Vital statistics Underlying cause ICD-10-CM codes I11,
I20-I25 Mortality from congestive heart failure All Vital statistics Underlying cause ICD-10-CM code I50.0 Mortality from hypertensive heart disease All Vital statistics Underlying cause ICD-10-CM codse I11.0-
I11.9, I50, I51.4-I51.9 Mortality from cerebrovascular disease (stroke)
All Vital statistics Underlying cause ICD-10-CM codes I60-I69
Hospitalization for acute myocardial infarction All MATCH Primary diagnosis ICD-9-CM code 410 Hospitalization for angina pectoris and other forms of chronic ischemic heart disease
All MATCH Primary diagnosis ICD-9-CM code 413-414
Hospitalization for congestive heart failure All MATCH Primary diagnosis ICD-9-CM code 428.0 Hospitalization for hypertension All MATCH Primary diagnosis ICD-9-CM code 401 Hospitalization for Non-specifi.c chest pain All MATCH Primary diagnosis ICD-9-CM code 786.5 Hospitalization for cerebrovascular disease (stroke)
All MATCH Primary diagnosis ICD-9-CM codes 430-438, (include transient cerebral ischemia because it accounts for 28% of total hospital discharges of cerebrovascular disease in 2008)
Prevalence of high blood cholesterol awareness among adults aged ≥18 years
≥18 years
BRFSS Respondents who report having been told by a doctor of having high blood cholesterol within the previous 5 years
Prevalence of high blood pressure awareness among adults aged ≥18 years
≥18 years
BRFSS Respondents who report having been told by a doctor, nurse or other health professional of having high blood pressure
Prevalence of heart attack, angina or stroke among adults aged ≥18 years
≥18 years
BRFSS Respondents who report having been told by a doctor of having heart attack, angina or stroke
Chronic disease linked to heart disease and stroke, Physical Activity, Nutrition and Tobacco Use
Prevalence of diabetes among adults aged ≥ 18 years
≥18 years
BRFSS Respondents who report having been told by a doctor of having diabetes
Prevalence of overweight or Obesity among adults aged ≥ 18 years
≥18 years
BRFSS Respondents who have a body mass index (BMI) ≥ 25.0 -29.99kg/m2 (overweight) and ≥ 30.0 kg/m2 (obesity) calculated from self-reported weight and height
Recommended physical activity among adults aged ≥ 18 years
≥18 years
BRFSS Respondents who report not having any leisure time physical activity for ≥ 30 minutes or running or walking for exercise during the last 30 days.
Fruit and vegetable consumption among adults aged ≥ 18 years
≥18 years
BRFSS Respondents who report eating fruits and vegetables ≥ 5 times/day or ≥ 1 and 0 time/day
Cigarette smoking among adults aged ≥ 18 years
≥18 years
BRFSS Respondents who report having smoked 100 cigarettes in their lifetime and are current smokers on every day or some days or former smoker (stopped smoking now)
