Qureshi Adnan I, Suri M Fareed K, Kirmani Jawad F, Divani Afshin A
Zeenat Qureshi Stroke Research Center, Department of Neurology and Neurosciences, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103-2425, USA.
Stroke. 2004 Oct;35(10):2346-50. doi: 10.1161/01.STR.0000141417.66620.09. Epub 2004 Sep 2.
We developed a model to estimate the costs incurred by ineffective primary and secondary prevention in terms of excess cardiovascular disease (CVD) mortality in a nationally representative sample of the US population.
Cox proportional hazards analyses were used to examine the effect of inadequate risk factor control on the incidence of fatal stroke and myocardial infarction (MI) during a follow-up period of 13.4+/-3.6 years after adjusting for differences in age, gender, and ethnicity in a national cohort of 9252 adults who participated in the Second National Health and Nutrition Examination Survey (NHANES) Mortality Follow-up Study. Inadequate risk factor modification was defined by presence of either blood pressure >140/90 mm Hg, serum cholesterol >200 mg/dL, or active cigarette smoking. Using the data from 4115 adults screened in the NHANES 1999 to 2000, population attributable risk (PAR) percent and associated cost incurred (expressed as proportion of total 1-year cost incurred for CVD mortality in year 2001) was estimated.
CVD mortality risk increased in a stepwise manner for persons with no previous MI or stroke and > or =2 inadequately controlled risk factors (2x); and previous history of MI and stroke and adequately controlled risk factors (2.6x), 1 inadequately controlled risk factor (4.3x), and > or =2 inadequately controlled risk factors (5.7x). The PAR was 14% (estimated cost incurred 13.2 billion dollars) among persons with > or =2 inadequately controlled risk factors without previous MI or stroke (estimated 17% of total US population). Among persons with previous MI or stroke, the PAR was 7% (cost incurred 6.2 billion dollars) and 8% (cost incurred 7.4 billion dollars) for 1 inadequately controlled risk factor and > or =2 inadequately controlled risk factors, respectively. An excess of cost of 13.6 billion dollars was spent on 4% of the total population (persons with inadequate secondary prevention).
The model demonstrates the differential risk of mortality from inadequately controlled cardiovascular risk factors in primary and secondary prevention settings. The large financial cost incurred by inadequate primary and secondary prevention justifies intensive efforts directed toward detection and treatment of cardiovascular risk factors.
我们开发了一个模型，用以估算在美国具有全国代表性的人群样本中，因一级和二级预防无效导致心血管疾病（CVD）超额死亡所产生的成本。
在一项针对9252名参与第二次全国健康与营养检查调查（NHANES）死亡率随访研究的成年人全国队列中，在调整年龄、性别和种族差异后，采用Cox比例风险分析来检验危险因素控制不充分对13.4±3.6年随访期内致命性卒中和心肌梗死（MI）发生率的影响。危险因素改善不充分的定义为收缩压>140/90 mmHg、血清胆固醇>200 mg/dL或当前吸烟。利用1999年至2000年NHANES中4115名成年人的筛查数据，估算人群归因风险（PAR）百分比及相关成本（以2001年CVD死亡的1年总成本的比例表示）。
对于既往无MI或卒中且有≥2个危险因素控制不充分的人群（2倍）；以及既往有MI和卒中病史且危险因素控制充分的人群（2.6倍）、1个危险因素控制不充分的人群（4.3倍）和≥2个危险因素控制不充分的人群（5.7倍），CVD死亡风险呈逐步上升趋势。在既往无MI或卒中且有≥2个危险因素控制不充分的人群中（估计占美国总人口的17%），PAR为14%（估计成本为132亿美元）。在既往有MI或卒中的人群中，对于1个危险因素控制不充分和≥2个危险因素控制不充分的人群，PAR分别为7%（成本为62亿美元）和8%（成本为74亿美元）。在占总人口4%的人群（二级预防不充分的人群）上额外花费了136亿美元。
该模型表明了在一级和二级预防环境中，心血管危险因素控制不充分导致的不同死亡风险。一级和二级预防不充分所产生的巨大经济成本证明了针对心血管危险因素的检测和治疗进行强化努力的合理性。
