Evidence that cardiovascular disease is contributing to the slowdown in improvements in life expectancy in some OECD countries prompted OECD and The King’s Fund to convene an international workshop to examine this issue. Invitees included members of OECD’s Health Care Quality and Outcomes Working Party and five international experts. This publication describes the workshop proceedings and conclusions about the evidence on trends in cardiovascular disease mortality, their drivers and the policy implications. The report includes contributions by the plenary speakers, Susanne Løgstrup (European Heart Network), Jessica Ho (University of Southern California), Catherine Johnson (Institute of Health Metrics and Evaluation), Anton Kunst (Amsterdam AMC) and Martin O’Flaherty (University of Liverpool). It shows cardiovascular disease is an important contributor to slowing life expectancy improvements in some countries, and flags some measurement problems such as international differences and changes in diagnostic practices and cause of death coding, and the complex linkages between cardiovascular disease and other causes of death. The report calls for improvements in national and international data and monitoring to support more timely and effective policy responses for preventing, managing and treating cardiovascular disease, and for tackling socio-economic and gender inequalities.
Is Cardiovascular Disease Slowing Improvements in Life Expectancy?
Abstract
Executive summary
Recently published data in Health at a Glance 2019 show that gains in life expectancy at birth across OECD countries have slowed considerably in recent years. Evidence of this slowdown and its drivers have been highlighted in an OECD Working Paper on trends in life expectancy in the European Union (EU) and some other high-income countries.
Other than in the United Kingdom and the United States, in many countries the underlying drivers of these trends have not been fully examined. While the underlying causes will doubtless vary between countries, the available evidence to date suggests there are also some common drivers. Collaborative international investigations can facilitate improved understanding of common drivers and inform appropriate policy action.
Decelerating rates of improvement in cardiovascular disease (CVD) mortality are a major contributor to the recent slowdown in improvements in life expectancy at birth observed in the United Kingdom and the United States. Although less is known about how much CVD contributes to the slowdown in overall mortality improvements in other countries, the pace of CVD mortality improvement is slowing also in many European countries. A joint OECD and King’s Fund international workshop held in Paris on 6th November 2019 called for greater international awareness of this issue and further international collaboration to better inform policies. The workshop raised domestic and international awareness of the slowdown in CVD mortality improvements, against the background of slowing improvements in overall mortality, and initiated international dialogue about the potential causes. It drew attention to the need for effective monitoring and policies to reverse the slowdown. Key findings as reflected in these proceedings are as follows.
CVD remains a leading cause of death in many OECD countries, despite the dramatic improvement in CVD mortality globally since the 1970s that delivered significant increases in life expectancy. In the European Union (EU), CVD is the leading cause of death accounting for 37% of all deaths and 22% of premature deaths, with a greater than six‑fold variation in mortality between member states. The economic burden of CVD is estimated to cost the economies of the EU around EUR 210 billion per year (2015 figures), half of which is health care spending and 26% is lost productivity.
Today, CVD mortality is about half of the levels in 1995, mostly because of reductions that occurred before 2010. Lower CVD mortality made the largest contribution to gains in life expectancy both before and after 2010. However, after 2010 CVD mortality has been plateauing or even increasing in several OECD countries.
The magnitude of the slowdown of CVD mortality improvement is considerable in some countries. For example, in the United States the average annualised rate of reduction in CVD mortality among men fell from 13.63 deaths per 100 000 greater between 2000 and 2010 to 3.19 deaths since 2010 – a reduction of more than 70%. Also, Italy recorded significantly lower rates of reduction in CVD mortality in both sexes of 66% since 2010, compared to the period between 2000 and 2010. Rates of reduction in CVD mortality greater than 50% since 2010 (when compared with the prior decade) were also recorded in some other OECD countries like the Netherlands, Austria, Ireland and Canada among men and women, Portugal among men, and Israel and Iceland among women.
The main risk factors driving CVD mortality are potentially avoidable. Rising prevalence of several common risk factors for CVD, including elevated low-density lipoprotein cholesterol, systolic blood pressure, fasting plasma glucose and BMI, are contributing to decelerating improvements in CVD mortality.
Inequalities in CVD mortality are wide even in European countries with generous welfare schemes. Such inequalities are associated with a socio-economic gradient in the major CVD risk factors. Biological and lifestyle factors are influenced by wider determinants such as social status and societal, economic, cultural and environmental conditions. For example, in England avoidable CVD mortality at ages under 75 years varies approximately four‑fold between the most and least deprived groups.
Recent trends in some European countries show that absolute inequalities in CVD mortality between socio-economic groups have narrowed since the 1990s, with improvements in equitable access and the quality of medical care. However, relative inequalities in CVD mortality have widened and reducing them further remains an important challenge for European health systems.
CVD remains a major killer and the economic costs of inaction are high. For example, the cumulative health, social care and informal care cost of the slowdown in CVD mortality improvements in England and Wales over 2020‑29 is estimated to total GBP 47.6 billion.
There is a need to avoid complacency about CVD mortality and the assumption that falling trends would continue into the future. Lifestyle risk factors remain a major preventable contributor to deaths, including premature mortality. Evidence consistently shows that increases in obesity and diabetes offset a significant proportion (10‑14%) of the mortality reductions attributed to favourable changes in other risk factors, including smoking. The OECD estimates that overweight will claim as many as 92 million lives and obesity and overweight‑related diseases will reduce life expectancy by nearly 3 years by 2050.
Stronger prevention measures and continued investment in earlier diagnosis and treatment of CVD are needed. Population-level policies, including fiscal and regulatory measures to stimulate lifestyle changes, and policy actions related to food policy, alcohol intake, physical activity and smoking can deliver large and rapid health and economic gains in terms of reducing CVD mortality. Evidence across OECD shows about 40 to 72% of falls in deaths can be attributed to risk factors declines in smoking, blood pressure and cholesterol levels, and 23 to 55% to access to acute care and secondary prevention.
Such policies can be cost-effective, have a rapid impact and reduce pressures on the health care system, not requiring health care resources while reducing social inequalities in CVD. Reducing the unequal burden of CVD is also likely to require a combination of targeted policies beyond the health sector, in deprived communities, alongside structural policies to improve diets, increase physical activity and reduce smoking and alcohol intake. These policies need to address social constructs and the wider, “upstream” determinants of ill health beyond individual lifestyle and health-related behaviours, such as housing, employment, urban renewal and the environment. Evidence offers insights of health gains achieved by combining approaches to identify and manage high-risk individuals alongside population-level strategies on smoking and food.
Several constraints in currently available data on CVD are obstacles to the timely and informative monitoring of levels and trends in CVD and its determinants. A number of improvements to data systems would make data flows more comprehensive, timely, efficient and relevant in the context of changing epidemiological patterns, and fit-for-purpose for monitoring and supporting appropriate service responses. This will facilitate more effective monitoring of mortality trends at national and sub-national levels, and internationally, and facilitate the early identification of slowing improvements and adverse trends.
Improvements are also needed to harmonise coding practices over time and across countries. Current differences in coding practices for diagnostics, comorbidities and causes of death across countries and over time hamper trend analyses.
More can be done to improve monitoring though linkage of different datasets (e.g. primary and hospital care records, clinical data and death records), which can greatly enhance monitoring capabilities for assessment of risk factors, health care needs and use of services across different population groups, and inform policy action.
Better monitoring is also needed on the newly emerging risk factors for CVD such as air pollution and drug abuse. Rising mortality associated with drug use (prescribed and illicit) in the United States and several European countries, along with some severe influenza and pneumonia seasons in recent years, have contributed to CVD deaths and slowing improvements in life expectancy.
This publication presents the proceedings from a workshop on CVD mortality convened jointly by The King’s Fund and OECD. It raises awareness about the decelerating improvements in CVD mortality rates in several OECD countries, and its implications for policy and monitoring. CVD remains a major killer and its risk factors continue to cause many preventable deaths and large socio-economic inequalities in mortality rates. In addition, there is a risk that the rising prevalence of obesity and diabetes globally could erode or even reverse the mortality gains made to date.
Such warning signs call for urgent action from policy makers and researchers. More is needed to better understand and implement a mix of appropriate policies targeting effective early detection, primary prevention, secondary prevention and treatment. Additional improvements in data and monitoring processes will be key to making data systems and data flows more comprehensive, timely, efficient, and relevant in the context of changing epidemiological patterns, and fit-for-purpose for policy responses. This publication discusses the evidence and priorities for taking further action.
