In the JournalsPerspective

Disparities in CVD burden persist among US states

Despite marked improvements in CVD burden between 1990 and 2016, large disparities remain in total CVD burden among U.S. states, according to a study published in JAMA Cardiology.

Global Burden of Disease Study

Gregory A. Roth, MD, MPH, assistant professor of cardiology at the University of Washington in Seattle, and colleagues analyzed data the Global Burden of Disease Study 2016, which included information on prevalence, incidence, risk exposure and mortality. CVD was estimated in the 10 most common global causes of CVD-related death with the addition of another category to combine other CVD and circulatory conditions.

Each state’s population counts were retrieved from the U.S. Census Bureau. Inpatient and outpatient claims data on state levels were retrieved from a database of public and private insurance schemes.

The Cause of Death Ensemble Model was used to estimate all-CV, all-cause and cause-specific mortality. Researchers also calculated disability-adjusted life-year for each age-sex-year-state-cause strata.

US Map Google Image
Large disparities remain in total CVD burden among U.S. states
Photo credit: Adobe Stock.

Age-standardized CVD DALYs decreased in all states between 1990 and 2016.

Large rises in relative rank ordering for total CVD DALYs were seen in several states, including Alabama, Alaska, Arkansas, Kentucky, Kansas, Indiana, Iowa, Missouri and Oklahoma. The rate of decline for DALYs was significant in all states, although it varied across states. Between 2010 and 2016, total CVD burden increased for men and women in the following states: Indiana, Kentucky, Michigan, Mississippi, Missouri, New Mexico and South Dakota.

The burden of CVD was twice as great in men vs. women in all states for cardiomyopathy, ischemic heart disease and aortic aneurysm. The leading cause of CVD DALYs in all states was ischemic heart disease, and it was the second most common when varied by state.

Causes of DALYs

The greatest number of DALYs was caused by dietary risk factors in almost all states, which was followed by high BMI, high systolic BP, high fasting plasma glucose level, high total cholesterol level, low levels of physical activity and tobacco smoking. There may be more unmeasured risks beyond the traditional factors, which was shown by increases in risk-deleted CVD DALY rates in 16 states between 2006 and 2016.

“These findings support the idea that tremendous gains in cardiovascular health are possible even in states with lower socioeconomic levels but that relative disparities between states have changed very little,” Roth and colleagues wrote. “These relative disparities may be of particular concern for Alabama, Mississippi, Oklahoma and Tennessee, given their recent decision to not expand their respective Medicaid systems.”

Mark D. Huffman

In a related editorial, Wayne D. Rosamond, PhD, MS, professor in the department of epidemiology at the University of North Carolina Gillings School of Global Public Health, wrote, “The article by the Global Burden of Cardiovascular Diseases Collaboration is a major step forward in this study and measurement of the burden and trends of CVD and may indeed provide benchmarks for regions committed to creating positive change and preventing a reversal of decades of favorable trends in CVD burden across the United States.”

Analyzing future data will become important in preventing and controlling CVD, Mark D. Huffman, MD, MPH, associate professor of preventive medicine (epidemiology) and medicine (cardiology) at Northwestern University Feinberg School of Medicine, wrote in a related editor’s note.

“How close to truth will these estimates be in 5, 10 or 15 years,” he wrote. “If not these investigators, then who will take up this complex yet crucial work of surveillance using all available data with consistent methods? Whose duty is this? These important questions will likely remain and be debated while decisions will need to be made on how best to prevent and control CVD, the leading causes of death in the United States and globally. Estimates such as these, imperfect though they are, will be important for informing such decisions now and in the future.” – by Darlene Dobkowski

Disclosures: Roth and Rosamond report no relevant financial disclosures. Huffman reports he received funding from the World Heart Federation for serving as its senior program adviser for the Emerging Leaders program, which is sponsored by Boehringer Ingelheim and Novartis, and support from AstraZeneca and Verily. Please see the study for all other authors’ relevant financial disclosures.

Despite marked improvements in CVD burden between 1990 and 2016, large disparities remain in total CVD burden among U.S. states, according to a study published in JAMA Cardiology.

Global Burden of Disease Study

Gregory A. Roth, MD, MPH, assistant professor of cardiology at the University of Washington in Seattle, and colleagues analyzed data the Global Burden of Disease Study 2016, which included information on prevalence, incidence, risk exposure and mortality. CVD was estimated in the 10 most common global causes of CVD-related death with the addition of another category to combine other CVD and circulatory conditions.

Each state’s population counts were retrieved from the U.S. Census Bureau. Inpatient and outpatient claims data on state levels were retrieved from a database of public and private insurance schemes.

The Cause of Death Ensemble Model was used to estimate all-CV, all-cause and cause-specific mortality. Researchers also calculated disability-adjusted life-year for each age-sex-year-state-cause strata.

US Map Google Image
Large disparities remain in total CVD burden among U.S. states
Photo credit: Adobe Stock.

Age-standardized CVD DALYs decreased in all states between 1990 and 2016.

Large rises in relative rank ordering for total CVD DALYs were seen in several states, including Alabama, Alaska, Arkansas, Kentucky, Kansas, Indiana, Iowa, Missouri and Oklahoma. The rate of decline for DALYs was significant in all states, although it varied across states. Between 2010 and 2016, total CVD burden increased for men and women in the following states: Indiana, Kentucky, Michigan, Mississippi, Missouri, New Mexico and South Dakota.

The burden of CVD was twice as great in men vs. women in all states for cardiomyopathy, ischemic heart disease and aortic aneurysm. The leading cause of CVD DALYs in all states was ischemic heart disease, and it was the second most common when varied by state.

Causes of DALYs

The greatest number of DALYs was caused by dietary risk factors in almost all states, which was followed by high BMI, high systolic BP, high fasting plasma glucose level, high total cholesterol level, low levels of physical activity and tobacco smoking. There may be more unmeasured risks beyond the traditional factors, which was shown by increases in risk-deleted CVD DALY rates in 16 states between 2006 and 2016.

“These findings support the idea that tremendous gains in cardiovascular health are possible even in states with lower socioeconomic levels but that relative disparities between states have changed very little,” Roth and colleagues wrote. “These relative disparities may be of particular concern for Alabama, Mississippi, Oklahoma and Tennessee, given their recent decision to not expand their respective Medicaid systems.”

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Mark D. Huffman

In a related editorial, Wayne D. Rosamond, PhD, MS, professor in the department of epidemiology at the University of North Carolina Gillings School of Global Public Health, wrote, “The article by the Global Burden of Cardiovascular Diseases Collaboration is a major step forward in this study and measurement of the burden and trends of CVD and may indeed provide benchmarks for regions committed to creating positive change and preventing a reversal of decades of favorable trends in CVD burden across the United States.”

Analyzing future data will become important in preventing and controlling CVD, Mark D. Huffman, MD, MPH, associate professor of preventive medicine (epidemiology) and medicine (cardiology) at Northwestern University Feinberg School of Medicine, wrote in a related editor’s note.

“How close to truth will these estimates be in 5, 10 or 15 years,” he wrote. “If not these investigators, then who will take up this complex yet crucial work of surveillance using all available data with consistent methods? Whose duty is this? These important questions will likely remain and be debated while decisions will need to be made on how best to prevent and control CVD, the leading causes of death in the United States and globally. Estimates such as these, imperfect though they are, will be important for informing such decisions now and in the future.” – by Darlene Dobkowski

Disclosures: Roth and Rosamond report no relevant financial disclosures. Huffman reports he received funding from the World Heart Federation for serving as its senior program adviser for the Emerging Leaders program, which is sponsored by Boehringer Ingelheim and Novartis, and support from AstraZeneca and Verily. Please see the study for all other authors’ relevant financial disclosures.

    Perspective

    Alanna Morris

    From a public health perspective, this a very important study and the findings are fascinating. The good news is that the burden of CVD is going down for the most part across the U.S. The bad news, however, is that the burden is not going down uniformly across the country, with certain states, particularly those in the Southeast and parts of the Midwest, experiencing much slower declines than in other parts of the U.S. Accordingly, the overall burden of CVD remains highest in those parts of the country.
    Also important is the finding that the rate of decline was slower for women than for men in all states during the study period.

    Another very important finding from this research is that, “For almost all states, the greatest proportion of age-standardized CVD DALYs was attributable to dietary risk factors, followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity.” As a cardiologist, this gives me hope that we can continue to improve the burden of CVD in this country and globally by continuing to encourage patients to focus on improving their modifiable risk factors including diet, body weight, smoking and physical activity.

    The authors point out a number of limitations of the current study that I would like to see explored in future analyses. The authors note that variation in health care quality between states may have contributed to some of the observed disparities. Although expansion of Medicaid under the Affordable Care Act is a relatively recent phenomenon, it would be very interesting to see how this legislation may have contributed to some of the disparities in rates of CVD decline in the more recent era.

    Also, the authors did not incorporate race or ethnicity as a contributor to disparities across the states, even though they point out that, “The concentration of CVD burden in states with higher proportions of individuals that identify their race as black/African American or American Indian/Alaska Native.” I would like to see this explored in a future analysis.

    • Alanna Morris, MD, MSc, FHFSA
    • Cardiology Today Next Gen Innovator
      Assistant Professor of Medicine, Division of Cardiology
      Emory University Clinical Cardiovascular Research Institute

    Disclosures: Morris reports no relevant financial disclosures.