The “Heart Disease and Stroke Statistics—2013 Update” and the Need for a National Cardiovascular Surveillance System
2012; Lippincott Williams & Wilkins; Volume: 127; Issue: 1 Linguagem: Inglês
10.1161/circulationaha.112.155911
ISSN1524-4539
AutoresStephen Sidney, Wayne D. Rosamond, Virginia J. Howard, Russell V. Luepker,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 127, No. 1The "Heart Disease and Stroke Statistics—2013 Update" and the Need for a National Cardiovascular Surveillance System Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBThe "Heart Disease and Stroke Statistics—2013 Update" and the Need for a National Cardiovascular Surveillance System Stephen Sidney, MD, MPH, Wayne D. Rosamond, PhD, MS, Virginia J. Howard, PhD, MSPH and Russell V. Luepker, MD, MSon behalf of the National Forum for Heart Disease and Stroke Prevention Stephen SidneyStephen Sidney From the Division of Research, Kaiser Permanente Northern California, Oakland, CA (S.S.); Gillings School of Global Public Health, University of North Carolina at Chapel Hill (W.D.R.); University of Alabama at Birmingham, School of Public Health (V.J.H.); and University of Minnesota, School of Public Health, Minneapolis (R.V.L.). , Wayne D. RosamondWayne D. Rosamond From the Division of Research, Kaiser Permanente Northern California, Oakland, CA (S.S.); Gillings School of Global Public Health, University of North Carolina at Chapel Hill (W.D.R.); University of Alabama at Birmingham, School of Public Health (V.J.H.); and University of Minnesota, School of Public Health, Minneapolis (R.V.L.). , Virginia J. HowardVirginia J. Howard From the Division of Research, Kaiser Permanente Northern California, Oakland, CA (S.S.); Gillings School of Global Public Health, University of North Carolina at Chapel Hill (W.D.R.); University of Alabama at Birmingham, School of Public Health (V.J.H.); and University of Minnesota, School of Public Health, Minneapolis (R.V.L.). and Russell V. LuepkerRussell V. Luepker From the Division of Research, Kaiser Permanente Northern California, Oakland, CA (S.S.); Gillings School of Global Public Health, University of North Carolina at Chapel Hill (W.D.R.); University of Alabama at Birmingham, School of Public Health (V.J.H.); and University of Minnesota, School of Public Health, Minneapolis (R.V.L.). and on behalf of the National Forum for Heart Disease and Stroke Prevention Originally published13 Dec 2012https://doi.org/10.1161/CIRCULATIONAHA.112.155911Circulation. 2013;127:21–23Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 IntroductionThe "Heart Disease and Stroke Statistics—2013 Update," published by the American Heart Association (AHA) in this issue of Circulation,1 and the Institute of Medicine (IOM) report, "A National Framework for Surveillance of Cardiovascular and Chronic Lung Diseases," published last year,2 attest to the importance and value of timely, high-quality, population-based data on the incidence of heart disease and stroke and their risk factors. The annual Heart Disease and Stroke Statistics Update is the authoritative source of annual estimates of incidence, prevalence, and risk factor distribution in the country. It is carefully crafted from a wide variety of separate federally and privately funded studies of various designs, reach, and sample size. In its breath, quality, and style it represents a national treasure of the best available information on the burden of heart disease and stroke events and risk factors that is a highly valued resource in the medical and public health communities. Indeed, the Heart Disease and Stroke Statistics Update is cited nearly 2000 times each year in the scientific literature. However, even this compilation of the best data available does not have national representative or timely data on heart disease and stroke incidence at its disposal. It is our best guess at questions for which we should not be guessing. More comprehensive monitoring of the occurrence of cardiovascular diseases (CVD), which cause more death and disability than any other medical conditions, is important to the physical and economic health of the country. The IOM report is clear in its overall message and resolute in its vision; we need to strengthen our ability to monitor the cardiovascular health of the country and create a national system to capture information on heart disease and stroke. The Heart Disease and Stroke Statistics Update appearing in this issue is our best effort toward that goal, but more can and should be done to measure the cardiovascular health of the nation.Article see p e6The Heart Disease and Stroke Statistics Update reviews a wide range of current efforts to monitor cardiovascular disease and risk factors in the United States, but the report also illustrates that these efforts, in general, represent a segmental approach at a time when a national approach is needed. Such efforts have been called for during the past decade, most recently in the 2011 IOM report. The recommendations of the IOM report include that the Secretary of Health and Human Services (HHS) establish a standing national working group to oversee and coordinate cardiovascular surveillance activity. These and other goals of the IOM report are consistent with the earlier recommendations of Goff et al.3 The report also recommended a framework for surveillance that encompassed not just disease outcomes and traditional risk factors but a broad range of variables influencing the treatment and course of cardiovascular disease.The National Vital Statistics system and its mandatory reporting of causes of death allows the use of mortality data to evaluate the burden of CVD. CVD mortality rates can be calculated by demographic factors (eg, age, race/ethnicity, sex), at regional (eg, county or state) and national levels, and allow for monitoring trends over time, though the inaccuracies and poor validity of death certificate coding are well known.4 Currently there is no similar system for the reporting of nonfatal stroke and MI events occurring in communities to allow for national statistics on these events. These data are needed for evaluating whether or not the interventions and programs in place in the community are actually working and to plan for the creation of new efforts to reduce morbidity and disability. In other words, significant data elements that are needed to practice evidence-based prevention are missing at the national level.Public Health Goals Require Supporting Surveillance DataPublic health goals targeting cardiovascular risk factors and disease outcomes include the Million Hearts Initiative,5–7 the AHA 2020 Goals,8 and the Healthy People 2020 goals.9The Million Hearts Initiative was announced by the US Secretary of HHS in September 2011, with a goal to prevent 1 million heart attacks (aka acute myocardial infarction [AMI]) and strokes over the next 5 years by implementing clinical and community-based measures supported, in part, by provisions of the Affordable Care Act. Million Hearts is an ambitious and laudable goal. Unfortunately, there are no adequate data available to provide valid estimates of the current incidence of AMIs and strokes or to monitor the reduction in the number of events that might occur over the next 5 years in the United States.The AHA 2020 goals are to improve the cardiovascular health of all Americans by 20%, while reducing deaths from cardiovascular diseases and stroke by 20%. Cardiovascular health is assessed by improvement in the composite of Life's Simple 7 behaviors (blood pressure, physical activity, blood cholesterol, healthy diet, healthy weight, smoking status, and blood glucose) assessed by periodic National Health and Nutrition Examination Survey (NHANES) assessment, whereas deaths from cardiovascular diseases and stroke are assessed through national vital statistics. Strikingly missing from the assessment measures of the cardiovascular health of the nation are incident nonfatal cardiovascular diseases including AMI, heart failure, and stroke because, as noted above, there are no available nationally representative data.Healthy People 2020 established 24 objectives for heart disease and stroke, of which 12 are developmental (ie, metrics have not been developed for their assessment). Examples of developmental objectives include increasing the proportion of adults with hypertension who meet the recommended guidelines, and increasing the proportion of adults with elevated low-density lipoprotein cholesterol who adhere to the prescribed low-density lipoprotein cholesterol–lowering management lifestyle changes and, if indicated, medication.Timeliness of DataMuch of the available surveillance data are provided with considerable lag time between when they are collected and when they become available. For example, mortality data are usually not available until 1 to 2 years after death. NHANES data may not become publicly available for several years. Earlier availability of surveillance data would enable more timely assessment of prevention programs and new treatments.Moving ForwardBesides having the capability to measure cardiovascular disease incidence, it is also important to have high-quality data on the outcomes (eg, readmissions to hospitals or outpatient care facilities, quality of life, functional status, and medication adherence) after AMI, heart failure, and stroke because CVD has a major public health impact and drives medical use and costs. We need a data system that is strong enough to support and evaluate our public health goals, to provide usage data for health care planning, and monitor changes in the CVD epidemic. It is also important to have data to monitor potentially countervailing trends as well. For example, the epidemics of obesity and diabetes mellitus continue and could threaten the downward trends in CVD at some point. We offer the following suggestions.First, recommendations from the 2011 IOM report should be implemented. Funding mandated by the Affordable Care Act (ACA), which provides >$80 million for health care surveillance and planning specifically for the purpose of funding data collection and analysis to monitor the impact of the ACA on the health of Americans, could potentially be used for this purpose.10Second, the Community Transformation Grants (CTG) program, funded by the Affordable Care Act and administered by the Centers for Disease Control and Prevention (CDC), provides funding to support community-level efforts to reduce chronic disease to 61 communities serving ≈120 million people.11 CTG awardees have been strongly encouraged to participate in the Million Hearts Initiative. Evaluation activities are mandated for this program. If properly designed and standardized across communities, data obtained from the CTG communities would go a long way toward providing the basis for the development of a nationally representative surveillance system. Given the infrastructure that CTG funding has created, it should be possible to test systems to collect surveillance data in a cost-effective manner in a near-term time frame that would enable monitoring the Million Hearts goal for heart disease and stroke prevention, as well as assess the effectiveness of the CTGs.Third, the use of electronic medical records is proliferating. The potential of the electronic medical record as a tool of CVD surveillance is great, but significant practical challenges and barriers exist. For example, hospital claims data often do not include biomarker and imaging data that would enhance the specificity of a hospital discharge code. This is the right time to gather together stakeholders to make real progress in realizing the potential and utility of electronic medical records in CVD surveillance.The Affordable Care Act will provide access for millions of Americans to a level of health care that they have never experienced and will further strengthen the need for data systems that support cardiovascular health surveillance of risk factors, disease occurrence, and follow up. Now, more than ever, we should respond to the longstanding calls to strengthen cardiovascular health surveillance in the United States.DisclosuresAll coauthors are members of the Surveillance Work Group of the National Forum for Heart Disease and Stroke Prevention. The National Forum for Heart Disease and Stroke Prevention (http://www.hearthealthystrokefree.org) is a nonprofit organization with a mission to provide leadership and encourage collaborative action between organizations committed to heart disease and stroke prevention. Dr Howard is a current member of the American Heart Association/American Stroke Association Stroke Statistics Committee of the Cardiovascular Epidemiology and Prevention Council and a coauthor of the "Heart Disease and Stroke Statistics—2013 Update." Dr Sidney was the principal investigator of National Heart, Lung, and Blood Institute grant 1RC2HL101666, "Development of a Cardiovascular Surveillance System in the CVRN."FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Stephen Sidney, MD, MPH, Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA 94612. E-mail [email protected]References1. 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