Department of Applied Health Research, University College London, London, United Kingdom.
PLoS Med. 2012;9(6):e1001237. doi: 10.1371/journal.pmed.1001237. Epub 2012 Jun 12.
Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups.
A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%-107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%-47%) to the overall decline in CHD mortality: ranging from about 44% (31%-61%) in the most deprived to 29% (16%-42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%-40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (-9%; -17% to -3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%-70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions.
The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities.
2000 年至 2007 年间，英格兰的冠心病（CHD）死亡率每年下降约 6%。然而，社会群体之间的死亡率差异在扩大，不平等现象实际上在加剧。我们试图描述这种 CHD 死亡率的降低在多大程度上归因于危险因素水平或治疗利用率的变化，包括社会经济群体之间和内部的变化。
我们使用一种广泛使用且经过复制的流行病学模型，对 2000 年至 2007 年间年龄在 25 岁及以上的英国人口按年龄、性别和地区贫困五分位数进行分层综合估计。死亡率下降，2007 年 CHD 死亡人数减少约 3.8 万。该模型解释了约 86%（95%置信区间：65%-107%）的死亡率下降。主要心血管危险因素的减少约占 CHD 死亡率总体下降的 34%（21%-47%）：从最贫困的 44%（31%-61%）到最富裕的 29%（16%-42%）不等。最大的贡献来自于未经高血压药物治疗的人群中收缩压的大幅下降（29%；18%-40%）；在贫困地区（37%）比富裕地区（25%）更为显著。在所有社会群体中，其他危险因素的贡献相对较小：总胆固醇（6%）、吸烟（3%）和体力活动（2%）。此外，由于肥胖指数和糖尿病导致的死亡率上升（-9%；-17%至-3%），这些益处在一定程度上被抵消，特别是在较贫困的五分位数中。治疗约占死亡率下降的 52%（40%-70%），在所有社会群体中公平分配。血脂降低（14%）、慢性心绞痛治疗（13%）和二级预防（11%）是最大的医疗贡献。
该模型表明，英格兰最近 CHD 死亡率的下降约有一半归因于治疗方法的改善。这种益处均匀分布在所有社会群体中。然而，主要危险因素的趋势相反，意味着它们对避免的 CHD 死亡人数的净贡献仅略高于三分之一；这些也因社会经济群体而异。存在强有力和公平的基于证据的全人群政策干预措施；现在应紧急实施这些措施，以有效解决持续存在的不平等问题。
