THE MARYLAND BURDEN OF Heart DISEASE AND STROKE
Maryland Department of Health & Mental Hygiene
Family Health Administration
Office of Chronic Disease Prevention
2009 Data Review
Martin O’Malley Governor
Anthony G. Brown Lt. Governor
John M. Colmers Secretary Department of Health and Mental Hygiene
Russell Moy, M.D., M.P.H. Director Family Health Administration
Joan H. Salim Deputy Director Family Health Administration
Audrey S. Regan, Ph.D. Director Office of Chronic Disease Prevention
Maria Prince, M.D., M.P.H. Medical Director Office of Chronic Disease Prevention
Discrimination Policy:
The services and facilities of the Maryland Department of Health and Mental Hygiene (DHMH) are operated on a non-discriminatory basis. This policy prohibits discrimination on the basis of race, color, sex or national origin and applies to the provisions of employment and granting of advantages, privileges, and accommodations. The Department, in compliance with the Americans with Disabilities Act, ensures that qualified individuals with disabilities are given an opportunity to participate in and benefit from DHMH services, programs, benefits, and employment opportunities.
Acknowledgements: This report was prepared by the Office of Chronic Disease Prevention at the Maryland Department of Health and Mental Hygiene with funding provided through a Cooperative Agreement with the Centers for Disease Control and Prevention, Division of Heart Disease and Stroke Prevention (UDP000749-02).
TABLE OF CONTENTS
Executive Summary …………………………………………………………………. 5 Burden of Heart Disease in Maryland …………………………………...... 6 Heart Disease Prevalence ……………………………………………………. 6 Heart Disease Mortality ………………...…………….…………………….. 10 Heart Disease Hospitalization Data …………………………………………. 13 Burden of Stroke in Maryland ………………………………………………………. 17 Stroke Prevalence …………………………………………………………… 17 Stroke Mortality ……………………………………………………………... 19 Stroke Hospitalization Data …………………………………………………. 21 Heart Disease, Stroke and Related Risk Factors …………………………………..... 24 Maryland Heart Disease and Stroke Prevention Program …………………………... 27 Appendix A: Data Sources ………………………………………………………….. 28 Appendix B: Definitions ……………………………………………………………. 30 Appendix C: Disease Diagnosis ……………………………………………….……. 32
EXECUTIVE SUMMARY
Heart disease and stroke are the numbers one and three causes of death for Maryland residents. The public health impact of heart disease and stroke is substantial, both in terms of disease burden and cost. In 2008, an estimated $1.2 billion of adult medical expenditures in Maryland were attributable to heart disease and stroke (Maryland Health Services Cost Review Commission). Coronary heart disease (angina or/and heart attack) and stroke are linked to higher prevalence rates, high hospitalization rates, and high mortality. Controlling risk factors such as high blood pressure, high blood cholesterol and diabetes play an important role in heart disease and stroke prevention. In 2008, over half (63.4%) of Maryland residents were overweight and obese and high blood pressure was a common co-occurring condition among residents who have experienced heart attack or stroke (Maryland BRFSS).
SPECIAL POPULATIONS
It was estimated from 2005 to 2008 that heart disease and stroke affected certain segments of the population disproportionately based on race and ethnicity, gender, age, and education and income levels.
. Angina and heart attack were most prevalent among white males. . The prevalence of coronary heart disease has increased the most among white males and black females. . Coronary heart disease and stroke were most prevalent among Maryland adults aged 55 and over, with a lower household income ($15k-25k), and with less education. . Black Marylanders had almost twice the age-adjusted hospital discharge rate for heart failure, non-specific chest pain, and stroke than white Marylanders. . Black Marylanders had nearly 5-6 times the hypertension rate of white Marylanders. . Black males experienced the highest levels of age-adjusted death associated with coronary heart disease, hypertensive heart disease and stroke.
Data sources, disease definitions and disease diagnosis can be found in Appendix A-C (pp29- 32).
RECOMMENDATIONS
This Burden Report is released in conjunction with the Maryland Heart Disease and Stroke Prevention and Control Plan (The 5 Year Plan), a joint publication of the Maryland Department of Health and Mental Hygiene and the Governor’s Heart Disease and Stroke Prevention Council. The five year Plan identifies specific recommendations, activities and partners to improve the morbidity and mortality associated with cardiovascular disease and stroke in Maryland.
Sources utilized in this report include data from the Behavioral Risk Factor Surveillance System (BRFSS), the Maryland Health Services Cost Review Commission and the Maryland Vital Statistics Administration.
5
BURDEN OF Heart DISEASE IN MARYLAND
Coronary Heart Disease Prevalence
This report discusses prevalence as it refers to coronary heart disease (angina or/and heart attack) as defined by the Maryland Behavior Risk Factor Surveillance System (Maryland BRFSS, 2005- 2008, since 2009 is not available). This section highlights differences in coronary heart disease prevalence based on race and ethnicity, gender, age, education and income levels from 2005 to 2008.
The overall prevalence of angina in Maryland has increased from 3.7 percent in 2005 to 4.4 percent in 2008 (Figure 1). Prevalence remains highest in white males (6.5 percent) and lowest in black females (3.3 percent, Figure 1).
Figure 1. Prevalence of Angina in Maryland, Overall and by Gender/Race, 2005-2008 Source: Maryland BRFSS
10.0 8.0
6.0
4.0 Percentage 2.0
0.0 2005 2006 2007 2008 Overall 3.7 4.5 3.9 4.4 White Males 5.4 6.8 6.5 6.5 White Females 3.6 3.9 2.5 3.7 Black Males 3.4 4.8 2.4 4.1 Black Females 2.1 3.7 3.5 3.3 Year
Prevalence of heart attack in Maryland has increased overall and across all races/genders from 2005 to 2008 (Figure 2) with the exception of white females and black males. The prevalence of heart attack for white males increased from 4.7 percent in 2005 to 6.7 percent in 2008 (Figure 2).
6
Figure 2. Prevalence of Heart Attack in Maryland, Overall and by Gender/Race, 2005-2008 Source: Maryland BRFSS
10.0
8.0
6.0
4.0 Percentage 2.0
0.0 2005 2006 2007 2008 Overall 3.6 4.3 3.4 3.9 White Males 4.7 6.2 4.8 6.7 White Females 3.2 3.3 2.5 2.7 Black Males 4.1 6.2 4.2 3.4 Black Females 2.6 3.6 3.1 3.2
Year Coronary heart disease prevalence in Maryland was the highest among white males, and increased from 7.4 percent in 2005 to 9.4 percent in 2008(Figure 3). Prevalence of coronary heart disease has also increased among black females, moving from 3.8 percent in 2005 to 5 percent in 2008 (Figure 3).
Figure 3. Prevalence of Coronary Heart disease in Maryland, Overall and by Gender/Race, 2005-2008 Source: Maryland BRFSS
12.0
10.0
8.0
6.0
4.0
Percentage 2.0
0.0 2005 2006 2007 2008
Overall 5.6 6.7 5.7 6.3 White Males 7.4 9.8 8.3 9.4 White Females 5.2 5.4 4.1 5.1
Black Males 5.6 7.8 5.0 5.9
Black Females 3.8 5.8 5.1 5.0
Ye ar
7
Maryland residents ages 55 and over compromised the highest prevalence of coronary heart disease from 2005 to 2008 (Figure 4). Residents with less than a high school education experiences more than three times the prevalence of heart disease (14.7 percent) compared to those that attainted a college level education (4.1 percent). The prevalence of coronary heart disease decrease as income level increases. Maryland residents earning less than $25,000 per year experience almost four times the prevalence of coronary heart disease than those making more than $75,000 per year (Figure 5). In 2005-2008, the Somerset county had the highest prevalence of heart attack, three times the state average prevalence at 3.8% (Map 1) and Allegany county had the highest prevalence of angina (9%) and twice the state average prevalence at 4.1% (Map 2).
Figure 4. Prevalence of Coronary Heart Disease in Maryland by Age, 2005-2008 (4 Year Average) Source: Maryland BRFSS
25.0 22.8
20.0 15.3 15.0
9.1 10.0 Percentage 6.4 5.0 2.0 0.9 0.0 25-34 35-44 45-54 55-64 65-74 75+ Age
Figure 5. Prevalence of Coronary Heart Disease in Maryland, by Education and Income, 2005-2008 (4 Year Average) Source: Maryland BRFSS
20.0
14.7 15.0 15.0 12.6
10.0
7.3 7.9 Percentage
4.1 4.7 5.0 3.3
0.0 < High High College <$15K $15K- $25K- $50k- $75k School School 24.9K $49.9K $74.9K
Education Income
8
Map 1. Percent of Residents Ever Told by a Doctor They Had a Heart Attack (Myocardial Infarction), 2005-2008 (4 Year Average) Source: Maryland BRFSS
Map 2. Percent of Residents Ever Told by a Doctor They Had Angina, 2005-2008 (4 Year Average) Source: Maryland BRFSS
9
Heart Disease Mortality
Of all types of heart disease, coronary heart disease had the highest mortality in Maryland (Figure 6a). The overall age-adjusted death rate attributable to coronary heart disease has declined between 2005 and 2008 from 166.5 to 147.1 deaths per 100,000 population. The largest reduction took place among white females and black females (Figure 6b). The age-adjusted death from coronary heart disease is disproportionately highest among black males at 239.3 (Figure 6b). In 2008, Seven of Maryland’s twenty-four jurisdictions had mortality of coronary heart disease that were above the Healthy People 2010 goal of reducing age-adjusted death rate associated with coronary heart disease to 166 per 100,000 populations (Table 1).
Black males had the highest mortality of hypertensive heart disease (Figure 6c). Age-adjusted death rate of heart failure in both white and black have declined between 2005 and 2008 (Figure 6d)
Figure 6a. Age-adjusted Death Rates for Heart Disease in Maryland, 2005 – 2008 Source: Maryland Vital Statistics Administration/MATCH
120.0
100.0
80.0
60.0
40.0
20.0 Age-adjusted 100,000 death per rates 0.0 2005 2006 2007 2008 Acute myocardial infarction 49.2 44.7 42.8 39.5 Other ischemic heart disease 98.3 96.0 96.5 93.1 Hypertensive heart disease 15.1 15.6 15.4 15.6 Heart Failure 13.5 12.7 11.0 11.0 All other heart disease 33.7 35.4 37.3 37.4
Year Figure 6b. Age-adjusted Death Rates for Coronary Heart Disease in Maryland, Overall and by Race and Gender, 2005 – 2008; Source: Maryland Vital Statistics Administration
10
Table 1. Crude and Age-adjusted Death Rates for Coronary Heart Disease in Maryland by County, 2008, Source: Maryland Vital Statistics Administration/MATCH Age-adjusted death rate per 100,000 Region Crude rate per 100, 000 population population Maryland 151.8 147.1 Allegany 307.6 206.3 Anne Arundel 131.4 145.5 Baltimore County 186.4 146.3 Calvert 143.8 174.3 Caroline 196.9 177.6 Carroll 141.5 136.7 Cecil 167.7 173.1 Charles 96.6 136.0 Dorchester 249.7 153.0 Frederick 129.3 143.8 Garrett 191.9 138.0 Harford 144.2 155.1 Howard 99.3 130.7 Kent 249.1 142.8 Montgomery 105.8 93.7 Prince George’s 134.1 174.7 Queen Anne’s 139.5 138.0 St. Mary’s 115.3 142.6 Somerset 248.3 224.0 Talbot 252.8 129.1 Washington 188.1 155.5 Wicomico 235.5 200.9 Worcester 293.8 164.9 Baltimore City 213.5 200.2
Figure 6c. Age-adjusted death rates for Hypertensive Heart Disease in Maryland by Race and Gender,2005-2008 Source: Maryland Vital Statistics Administration/MATCH
40.0
35.0
30.0
25.0
20.0 15.0 10.0 5.0 Age-adjusted death 100,000 rates per 0.0 2005 2006 2007 2008
White Males 13.1 15.6 15.0 16.2 White Females 9.9 9.2 9.4 9.7 Black Males 32.2 35.0 35.0 32.7 Black Females 22.8 21.1 20.2 19.9
Year
11
Figure 6d. Age-adjusted Death Rates for Heart Failure in Maryland by Race and Gender, 2005-2008 Source: Maryland Vital Statistics Administration/MATCH
16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0
Age-adjusted death 100,000 rates per 0.0 2005 2006 2007 2008 White Males 14.6 13.5 12.2 12.7 White Females 13.2 12.7 10.2 10.0 Black Males 15.1 12.1 12.8 12.4 Black Females 12.6 9.8 10.4 10.0
Year
12
Heart Disease Hospital Data
In 2008, coronary atherosclerosis and other heart disease contributed to 19.6 percent of hospital discharges for heart disease while acute myocardial infarctions accounted for 10.7 percent (Figure 7). Non-specific chest pain constituted 24 percent and non-hypertensive congestive heart failure did 22.7 percent of hospital discharges for heart disease (Figure 7).
Figure 7. Percentage of Hospital Discharges for Heart Disease 2008 Source: Maryland Health Services Cost Review Commission/MATCH
Heart valve disorders
Cardiac arrest and ventricular 1.5% fibrillation 0.3% Congestive heart failure; 14.5% nonhypertensive 1.2% 22.7% Peri-; endo-; and myocarditis; 0.2% cardiomyopathy (except that caused by TB or STD) 3.7% Acute myocardial infarction
Coronary atherosclerosis and other heart disease 1.7% Nonspecific chest pain
24.0% 10.7% Pulmonary heart disease
Other and ill-defined heart disease
19.6% Conduction disorders Cardiac dysrhythmias
Age-adjusted hospital discharge rate from total coronary heart disease (including heart attack) and heart failure have declined 30-60 per 100,000 population except nonspecific chest pain (Figure 8). Nonspecific chest pain made up a largest proportion of heart disease related hospital discharges at 354 per 100,000 population in 2008, and have increased from 314 (2005) to 354 (2008) per 100,000 population (Figure 8). White adults with coronary heart disease had the highest age-adjusted hospital discharge rate from 2005 to 2008 (Figure 9a). Black adults had almost twice the age-adjusted hospitalization rate for heart failure (Figure 9band nonspecific chest pain (Figure 9d), and nearly 5-6 times the rate of hypertension than white adults (Figure 9c). In 2005-2008, the lower Eastern Shore area exhibited the highest hospital discharge rates from coronary heart disease. Figure 8. Age-adjusted Hospital Discharge Rate from Heart Disease, Overall, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH
400
300
200
100,000 per 100 Age-adjusted rate discharge
0 2005 2006 2007 2008 Congestive heart failure; 374 368 349 348 nonhypertensive Acute myocardial 193 176 164 161 infarction Coronary 354 347 303 290 atherosclerosis and other heart disease Nonspecific chest pain 314 355 362 354 Year 13
Figure 9a. Age-adjusted Hospital Discharge Rate from Angina (Coronary Heart Disease) in Maryland by Race and Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH
600
500 400 300 100,000 per 200 100 Age-adjusted rate discharge 0 2005 2006 2007 2008 White Males 490.3 476.9 414.5 395.6 White Females 245.7 245.0 205.0 205.0 Black Males 363.9 327.0 309.6 292.8 Black Females 293.3 286.7 252.0 239.4 Year
Figure 9b. Age-adjusted Hospital Discharge Rate from Heart Failure in Maryland by Race and Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH
800
600
400
per 100,000 per 200
Age-adjusted rate discharge 0 2005 2006 2007 2008
White Males 342.0 329.8 315.1 315.0 White Females 263.1 249.5 230.4 224.9 Black Males 681.1 698.2 681.1 690.8 Black Females 555.7 567.1 526.7 523.5 Year
Figure 9c. Age-adjusted Hospital Discharge Rate from hypertension in Maryland by Race and Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH 350
300
250
200 150 per100,000 100 50 Age-adjusted discharge rate rate discharge Age-adjusted 0 2005 2006 2007 2008 White M ales 58.0 54.9 53.4 56.2 White Females 60.6 59.9 61.1 61.6 Black M ales 317.0 321.6 297.6 309.7 Black Females 290.7 313.1 304.3 297.7
Year
14
Figure 9d. Age-adjusted Hospital Discharge Rate from Non-Specific Chest Pain in Maryland by Race and Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH
700 600 500 400
300
100,000 per 200 100
Age-adjusted rate Discharge 0 2005 2006 2007 2008 White Males 256.4 275.1 283.8 265.2 White Females 245.1 273.5 289.2 286.4 Black Males 429.4 497.0 490.4 491.5 Black Females 530.5 622.3 623.3 616.8
Year
Heart disease accounted for $1 billion of hospital expenses in 2008, almost half of which ($428 million) were due to coronary heart disease. The leading heart disease related hospital discharge costs from 2005 through 2008 were coronary atherosclerosis, non-hypertensive congestive heart failure and acute myocardial infarction (Figure 10a). Heart valve disorders remain the highest average hospital discharge cost of heart diseases (Figure 10b).
Figure 10a. Annual Total Cost of Hospital Charges for Heart Disease in Maryland, 2005 - 2008 Source: Maryland Health Services Cost Review Commission/MATCH
Cardiac dysrhythmias
Conduction disorders 2008 Other and ill-defined heart disease
Pulmonary heart disease 2007 Nonspecific chest pain
Coronary atherosclerosis and Year other heart disease
2006 Acute myocardial infarction
Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by TB or STD) Congestive heart failure; 2005 nonhypertensive Cardiac arrest and ventricular fibrillation
0 5,000 10,000 15,000 20,000 25,000 30,000 Heart valve disorders
Annual Total Cost ($10,000)
15
Figure 10b. Annual Average Cost of Hospital Charges for Coronary Heart Disease in Maryland, 2005 - 2008 Source: Maryland Health Services Cost Review Commission/MATCH
Cardiac dysrhythmias
2008 Conduction disorders
Other and ill-defined heart disease
Pulmonary heart disease 2007
Nonspecific chest pain
Year Coronary atherosclerosis and other 2006 heart disease Acute myocardial infarction
Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by 2005 TB or STD) Congestive heart failure; nonhypertensive Cardiac arrest and ventricular fibrillation 0 10 20 30 40 50 Heart valve disorders Annual Average Cost ($X1,000)
16
BURDEN OF STROKE IN MARYLAND Stroke Prevalence
This section highlights differences in stroke (cerebrovascular disease) prevalence based on race and ethnicity, gender, age, education and income levels. The prevalence of stroke in Maryland has varied slightly from 2005 to 2008 with the overall prevalence moving from 2.1 percent in 2005 to 2.6 percent in 2008 (Figure 11). 2008 prevalence indicates that women have a slightly higher prevalence of stroke than men at 2.9 percent (Figure 11).
Figure 11. Prevalence of Stroke in Maryland, Overall and by Race and Gender 2005-2008 Source: Maryland BRFSS
4.0
3.0
2.0
Percentage 1.0
0.0 2005 2006 2007 2008
Overall 2.1 2.6 2.3 2.6 White Males 2.1 2.7 2.7 2.5 White Females 2.2 2.8 1.9 2.9 Black Males 2.0 3.5 2.2 2.5 Black Females 2.5 2.3 2.9 2.9
Year Maryland residents ages 65 and over have the highest prevalence of stroke at 6.2 percent, almost two times higher than residents ages 55 to 64 (Figure 12). Stroke prevalence increases among Maryland residents as the level of education decreases. Maryland residents with less than a high school education have twice the prevalence of stroke than residents with a high school education, and more than four times the prevalence of those with a college education (Figure 13). The same is true for income. Stroke prevalence is the highest among those residents earning the least. Maryland residents earning between $15,000 and $24,900 per year experience prevalence of stroke three times higher than residents earning $50,000 or more per year (Figure 13).
Figure 12. Prevalence of Stroke in Maryland, by Age 2005-2008 Source: Maryland BRFSS
12.0 11.0 10.0
8.0 6.2 6.0 Percentage 4.0 3.3
1.7 2.0 0.7 0.3 0.0 25-34 35-44 45-54 55-64 65-74 75+
Age 17
Figure 13. Prevalence of Stroke in Maryland, by Education and Income 2005-2008 Source: Maryland BRFSS
10.0
8.0 7.6 6.7
6.0 5.3
4.0 Percentage 3.0 2.7
2.0 1.5 1.6 0.9
0.0 < High High College <$15K $15K- $25K- $50k- $75k School School 24.9K $49.9K $74.9K Education Income
The following map graphically represents, by county, the distribution of Maryland residents who have been told by a doctor they have had a stroke. Cecil had the highest prevalence of stroke (3.9%) in Maryland jurisdiction (Map 3).
Map 3. Maryland Residents Ever Told by a Doctor They Had a Stroke 2005-2008 (4 Year Average) Source: Maryland BRFSS
18
Stroke Mortality
Stroke is the third leading cause of death in Maryland. The overall death rate attributable to stroke has declined from 2005 to 2008 from 45 to 40 deaths per 100,000 residents. Black males experienced the largest decline in stroke mortality across the four years from 58.4 to 49.7 deaths (Figure 14). Black females also experienced a higher decline in stroke deaths than white males and females moving from 49.2 in 2005 to 41.8 in 2008. In 2008, four of twenty-four Maryland’s jirisdictions had death rates from stoke that were higher than Healthy people 2010 goal of resucing death rate associated with stroke to 48 per 100,000 populations (Table 2).
Figure 14. Maryland Age Adjusted Death Rates for Cerebrovascular Disease 2005-2008 Source: Maryland Vital Statistics Administration/MATCH
60.0
50.0 40.0
30.0
20.0 100,000 per 10.0 Age-adjusted death rates 0.0 2005 2006 2007 2008
Overall 45.0 43.5 40.5 40.0 White males 41.6 40.5 39.0 37.3 White females 41.9 41.1 36.9 38.0 Black Males 58.4 57.6 54.5 49.7 Black Females 49.2 44.9 45.4 41.8 Year Map 4. Comparison of County Age Adjusted Death Rates for Stroke to the Maryland Average, 2006-2008 Source: Maryland Vital Statistics Administration
19
Table 2. Crude and Age Adjusted Death Rate for Stroke by County, 2008 Source: Maryland Vital Statistics Administration/MATCH
Crude rate per 100,000 Age-adjusted death rate per Region population 100,000 population Maryland 39.9 40 Allegany 65.1 41.8 Anne Arundel 35.9 41.4 Baltimore County 57.5 44.6 Calvert 23.7 29.8 Caroline 33.2 * Carroll 54.9 56.7 Cecil 26.0 28.7 Charles 30.5 49.7 Dorchester 78.1 50.3 Frederick 37.7 44.6 Garrett 70.7 50.2 Harford 33.3 38.7 Howard 30.2 43.1 Kent 49.6 * Montgomery 33.8 31.4 Prince George’s 25.7 33.8 Queen Anne’s 53.1 51.8 St. Mary’s 34.5 44.3 Somerset 19.1 * Talbot 96.6 47.6 Washington 42.0 34.2 Wicomico 37.2 32.7 Worcester 54.8 31.4 Baltimore City 49.3 48 * Rates based on fewer than 20 deaths are not included.
20
Stroke Hospital Data
Acute stroke disease is the most common cerebrovascular disease related to Maryland hospital discharges in 2008 (55%), followed by transient cerebral ischemia (28%, Figure 15). The percent of hospital discharges of cerebral vascular disease for transient cerebral ischemia has increased 15% (Figure 16); acute stroke has decreased over the past three years; and occlusion or stenosis of the precerebral arteries has remained steady (Figure 16).
Figure 15. Maryland Percentage Hospital Discharges for Various Types of Cerebrovascular Disease, 2008 Source: Maryland Health Services Cost Review Commission/MATCH
Acute cerebrovascular 2% disease
Occlusion or stenosis 28% of precerebral arteries
Other and ill-defined cerebrovascular disease 55% Transient cerebral 2% ischemia
13% Late effects of cerebrovascular disease
Figure 16. Maryland Percentage of Total Cerebrovascular Disease Hospital Discharges, 2005-2008 Source: Maryland Health Services Cost Review Commission/MATCH
60
40
20 of total Percentage cerebrovascular disease 0 2005 2006 2007 2008 Acute cerebrovascular 57.1 56.3 55 54.5 disease Occlusion or Stenosis of 13.6 13.2 12.9 13.2 percerebral arteries Transient cerebral 23.9 25.9 27.2 27.5 ischemia
Ye ar
21
Although both genders experienced an increase of stroke hospitalization from 2005 to 2008, males have consistently higher rates than women (Figure 17). The age adjusted hospital discharge rate for strokes among black Marylanders is nearly twice as high as that of their white counterparts (Figure 17). In 2005-2008, the Lower Eastern Shore area exhibited the highest hospital discharge rates from strokes when compared to other areas in Maryland
Figure 17. Maryland Age Adjusted Hospital Discharge Rates for Cerebrovascular Disease Overall and by Gender, 2005-2008 Source: Maryland Health Services Cost Review Commission
500
400 300
200
100,000 per 100 Age-adjusted rate discharge 0 2005 2006 2007 2008
Overall 316.6 316.3 321.5 330.1 White M ales 306.5 299.2 303.8 310.7 White Females 261.2 264.3 270.8 275.3 Black M ales 426.8 419.2 409.2 439.1 Black Females 403.7 420.4 423.7 429.4
Year
Cerebrovascular disease accounted for $230 million of Maryland hospital expenses in 2008. $162 million were due to acute stroke and $32 million to transient cerebral ischemia (Figure 18).
Figure 18. Annual Total Cost of Hospital Charges for Cerebrovascular Disease in Maryland, 2005 – 2008 Source: Maryland Health Services Cost Review Commission/MATCH
200,000,000
150,000,000
100,000,000
50,000,000
0 Annual total cost ($) cost total Annual Acute Occlusion or Other and ill- Late effects of Transient cerebrovascular stenosis of defined cerebrovascular cerebral ischemia disease precerebral cerebrovascular disease
2005 127,537,984 20,038,152 6,480,175 22,575,677 6,780,582 2006 143,794,811 21,166,182 7,263,568 27,078,696 3,839,948 2007 151,326,762 21,611,318 8,395,077 30,344,860 3,942,107 2008 162,328,962 24,577,292 8,860,746 32,892,910 4,061,745
Type of Cerebrovascular disease
From 2005 - 2008 average hospital charges associated with cerebrovascular disease have increased except for the late effects of cerebrovascular disease, which have decreased (Figure 19). 22
Figure 19. Annual Average Cost of Hospital Charges for Cerebrovascular Disease in Maryland, 2005 - 2008 Source: Maryland Health Services Cost Review Commission
25,000
20,000 15,000 10,000 5,000 Annual cost ($) average 0 Acute Occlusion or Other and ill- Late effects of Transient cerebral cerebrovascular stenosis of defined cerebrovascular ischemia disease precerebral arteries cerebrovascular disease
2005 12,800 8,412 16,701 5,400 12,487 2006 14,526 9,096 18,250 5,946 9,253 2007 15,131 9,228 18,491 6,146 9,083 2008 15,666 9,780 20,002 6,301 8,849 Type of Cerebrovascular disease
23
BURDEN OF HEART DISEASE AND STROKE IN MARYLAND
Heart Disease, Stroke and Related Risk Factors
Common risk factors for both heart disease and stroke include high blood cholesterol, high blood pressure, overweight/obesity, inadequate physical activity (no leisure time physical activity), smoking status (current and former smokers) and poor nutrition (less than one serving of fruits and vegetables per day). This section examines these risk factors, and others, in the Maryland population and their co-occurrence with residents reporting heart disease and stroke.
The most prevalent risk factor for heart disease and stroke among Maryland residents is high cholesterol (36.9%), followed by overweight at 36.7% and high blood pressure at 29.8%. Viewed together, overweight and obesity are prevalent among 63.4% of the population (Figure 20). Inadequate physical activity, smoking (current smoker only, Figure 20), and diabetes follow.
Figure 20. Prevalence of Chronic Disease Risk Factors in Maryland, 2007/2008 Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
40 36.9 36.7
29.8 30 26.7 24
20 14.9
Percentage
10 8.7 4.2
0 Poor Diabetes Smoking Physical Obesit y High blood Overweight High Nutrition inactivity pressure cholesterol (<1 (2007) (2007) time/day)
Risk Factors
Although the prevalence of diabetes among Maryland residents is not as common as other risk factors, it is estimated that Maryland adults who have been diagnosed with diabetes (compared to those who have not diagnosed with diabetes) are about 4.8 times more likely also to have suffered from heart attack and angina (Figures 21 and 22). The same is true for stroke and diabetes (Figure 23). High blood pressure is the most common co-occurrence for heart attack, angina and stroke.
24
Figure 21. Prevalence of Heart Attack with Risk Factors, 2007/2008 Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
Nutrition (1 or <1 serving fruits and vegetables/day) 1.2
Overweight 1.4
Obesity 1.9
Physical Inactivity 2.2
Smoking 2.5 FactorsRisk
High Cholesterol (2007) 4.4
Diabetes 4.8
High Blood Pressure (2007) 5.2
0 1 2 3 4 5 6 Prevalence Ratios
(Heart Attack with Risk Factors/Heart Attack without Risk
Factors)
Figure 22. Prevalence of Angina with Risk Factors, 2007/ 2008 Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
Nutrition (1 or <1 serving fruits 1.2 and vegetables/day) Overweight 1.4
Physical Inactivity 1.7
Obesity 2
Smoking 2.1
Risk FactorsRisk Diabetes 4.9
High Cholesterol (2007) 5.1
High Blood Pressure (2007) 5.6
0 1 2 3 4 5 6 Prevalence Ratios (Angina with Risk Factors/Angina without Risk Factors)
25
Figure 23. Prevalence of Stroke with Risk Factors, 2007/ 2008 Source: Maryland BRFSS 2008 and MATCH-BRFSS 2007* *High blood pressure and high blood cholesterol data from MATCH-BRFSS 2007
Overweight 1.0
Obesity 1.4
Nutrition (1 or <1 serving fruits and 1.5 vegetables/day)
Smoking 2.0
Physical Inactivity 2.3 Risk Factors High Cholesterol (2007) 2.4
Diabetes 4.8
High Blood Pressure (2007) 6.4
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0
Prevalence Ratios (Stroke with Risk Factors/Stroke without Risk factors)
26
MARYLAND HEART DISEASE AND STROKE PREVENTION PROGRAM
The Maryland Heart Disease and Stroke Prevention Program, along with other state and local partners, will use the report findings to guide the implementation of statewide strategies found in the Maryland Heart Disease and Stroke Prevention and Control Plan. This Report, in conjunction with the Plan, are requirements of the cooperative CDC funding agreement of the Maryland Heart Disease and Stroke Prevention Program. Based on the Social-ecological Model, the essential strategies of the program are to use education, policy and systems changes to increase heart disease and stroke prevention with emphasis on six program priority areas:
1. Addressing control of high blood pressure and high blood cholesterol in adults and older adults
2. Increasing knowledge of signs and symptoms for heart disease and stroke and the importance of calling 9-1-1
3. Improving emergency response
4. Improving quality of heart disease and stroke care
5. Eliminating health disparities
6. Focusing on the health care and worksite settings
Additional required activities of the cooperative agreement are to develop the foundation for a comprehensive cardiovascular disease prevention program through:
1. Partnership development
2. Definition of the burden of heart disease and stroke
3. Development of a State Plan
4. Pilot testing interventions
The Governor’s Council on Heart Disease and Stroke serves as the advisory group for the grant providing strategic planning leadership and partnering in the production and evaluation of the Plan. Additional information is available through the Office of Chronic Disease Prevention web site: http://fha.maryland.gov/cdp/ .
27
APPENDIX A: DATA SOURCES
DATA SOURCE DESCRIPTION
The Maryland BRFSS is an ongoing telephone surveillance program MD Behavioral Risk Factor designed to collect data on the behaviors and conditions that place Surveillance System (BRFSS) Marylanders at risk for chronic diseases, injuries, and preventable infectious diseases.
The typical sample size each year is 8,900 households with an adult respondent 18 years of age or older. The data in this report are based on the weighted data. The weighting method involved adjustments of the sample proportions of selected demographic characteristics so that they equal the sample proportions in the population and also adjustments of the sample surveyed so that it represents the State population.
Refer to www.marylandbrfss.org for more information on Maryland BRFSS. National BRFSS data can be downloaded from www.cdc.gov/brfss
Maryland Assessment Tool for Maryland Assessment Tool for Community Health (MATCH) Community health (MATCH) features statistics for Maryland resident health events. Health officials, health practitioners, public health researchers and others can find Maryland population estimates along with statistics on births to Maryland resident mothers, resident deaths and hospitalizations. The information is aggregated by year of event, by county of residence and by other population characteristics. MATCH is sponsored by the Family Health Administration and is developed in partnership with the Maryland Vital Statistics Administration and the Maryland Health Care Commission.
Refer to www.matchstats.org for more information on Maryland Assessment Tool for Community Health.
MD Health Services Cost Review The Maryland Health Services Cost Review Commission created a Commission significant data infrastructure that includes a uniform accounting and reporting system and extensive data collection on, and analysis of, every aspect of hospital operations. To fulfill its broad disclosure responsibilities, it distributes annual reports on hospital operations and makes all such Commission files accessible to the public.
Refer to http://www.hscrc.state.md.us/index.cfm for more information on Maryland Health Services Cost Review Commission
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DATA SOURCE DESCRIPTION
MD Vital Statistics Administration The Maryland Vital Statistics Administration is charged with registering all births, deaths, and fetal deaths occurring in the State of Maryland; issuing certified copies of birth, death, and marriage certificates and providing divorce verifications; compiling and analyzing vital statistics data; preparing annual estimates of the population of Maryland by political subdivision, age, race, and sex; preparing mandated vital statistics and population reports; and supplying vital statistics and population data to users in the public and private sectors.
Refer to http://www.vsa.state.md.us/ for more information on Maryland Vital Statistics Administration.
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APPENDIX B: DEFINITIONS
Heart disease and stroke encompass multiple health conditions and risk factors. The following terms are commonly referred to in this Burden Report. Definitions are from the American Heart Association and the American Stroke Association and can be found at www.americanheart.org and www.strokeassociation.org . For a complete list of ICD codes used to define specific data sets see Appendix C.
Angina (Angina Pectoris): Medical term for chest pain or discomfort due to coronary heart disease. Angina is a symptom of a condition called myocardial ischemia. It occurs when the heart muscle (mycocardium) doesn’t get as much blood (hence as much oxygen) as it needs for a given level of work. Insufficient blood supply is called ischemia. Stable angina (or chronic stable angina) refers to “predictable” chest discomfort such as that associated with physical exertion or mental or emotional stress. Rest and/or nitroglycerin usually relieve stable angina. Unstable angina refers to unexpected chest pain and usually occurs at rest. It is typically mores ever and prolonged and is due to a reduced blood flow to the heart caused by the narrowing of the coronary arteries in atherosclerosis. Unstable angina is an acute coronary syndrome and should be treated as an emergency.
Blood Pressure: The force or pressure exerted by the heart against the walls of the arteries. When the arterioles (smaller arteries) constrict (narrow), the blood must flow through a smaller “pipe” and the pressure rises. High blood pressure can result, adding to the workload of the heart and arteries. Optimal blood pressure is less than 120/80 mm Hg. High blood pressure, or hypertension, is a condition in which blood pressure levels are above the normal range. Blood pressures of 120-139 / 80-89 mm Hg are considered prehypertension. Blood pressure is considered high if it is 140/90 mm Hg or higher. Long-standing, uncontrolled high blood pressure increases the risk for heart attack, angina, stroke, chronic kidney failure and peripheral artery disease (PAD). High blood pressure may also increase the risk of developing fatty deposit in arteries (atherosclerosis). The risk of heart failure also increases due to the increased workload that high blood pressure places on the heart.
Cerebrovascular Disease (Stroke): Stroke is a disease that affects the arteries leading to and within the brain. A stroke occurs when a blood vessel that carriers oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens, part of the brain cannot get the blood (oxygen) it needs, so brain cells starts to die. Stroke can be caused by either a clot obstructing the flow of blood to the brain (called an ischemic stroke) or by a blood vessel rupturing and preventing blood flow to the brain (called a hemorrhagic stroke).
Cholesterol: A soft, waxy substance found among the lipids (fats) in the bloodstream and in all the body’s cells. It’s an important part of a healthy body because it’s used to form cell membranes, some hormones and is needed for other functions. Cholesterol and other fats can’t dissolve in the blood. They have to be transported to and from the cells by special carriers called lipoproteins. There are several kinds but the most important are low-density lipoprotein (LDL or “bad”) and high-density lipoprotein (HDL or “good”).
Cholesterol Classifications: Total blood cholesterol is the most common measurement of blood cholesterol. Cholesterol is measured in milligrams per deciliter (mg/dL) of blood. Total 30
cholesterol is composed of high-density lipoprotein (HDL or “good”) cholesterol, low-density lipoprotein (LDL or “bad”) cholesterol and very-low density lipoprotein (VLDL), which carries triglycerides. Triglycerides, a common type of blood fat, can also affect cardiac arrest. Blood cholesterol and triglycerides are classified by levels that relate to the risk of heart disease. The numbers are interpreted based on all risk factors including age, family history, smoking status, blood pressure, physical activity level, weight and diabetes status.
Congestive Heart Failure (Heart Failure): Because not all patients with heart failure have problems with excess fluids, such as in the lungs or extremities, the term “heart failure” is preferred over “congestive heart failure.” Heart failure is the inability of the heart to pump out all the blood that returns to it. This results in blood backing up in the veins that lead to the heart and sometimes in fluid accumulating in various parts of the body.
Coronary Heart Disease (CHD): Disease of the heart caused by atherosclerotic narrowing of the coronary arteries likely to produce chest pain (angina pectoris) or heart attack.
Heart Attack (Myocardial Infarction): Death of our damage to part of the heart muscle due to an insufficient blood supply. Heart attacks occur when one of the coronary arteries that supply blood to the heart muscle is blocked. Blockage is usually caused from a buildup of plaque (deposit of fat-like substances) due to atherosclerosis. If a plaque deposit tears or ruptures, a blood clot may form and block the artery, causing a heart attack. Heart attack is also called a coronary thrombosis or coronary occlusion.
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APPENDIX C: DISEASE DIAGNOSIS
The following International Statistical Classification of Diseases and Related Health Problems (ICD) Codes were used to define the data sets analyzed within the report.
Cardiovascular Disease Age Data source Definition Mortality from coronary heart disease All Vital statistics Underlying cause ICD-10-CM codes I11, I20-I25 Mortality from congestive heart failure All Vital statistics Underlying cause ICD-10-CM code I50.0 Mortality from hypertensive heart disease All Vital statistics Underlying cause ICD-10-CM codse I11.0- I11.9, I50, I51.4-I51.9 Mortality from cerebrovascular disease All Vital statistics Underlying cause ICD-10-CM codes I60-I69 (stroke) Hospitalization for acute myocardial infarction All MATCH Primary diagnosis ICD-9-CM code 410 Hospitalization for angina pectoris and other All MATCH Primary diagnosis ICD-9-CM code 413-414 forms of chronic ischemic heart disease Hospitalization for congestive heart failure All MATCH Primary diagnosis ICD-9-CM code 428.0 Hospitalization for hypertension All MATCH Primary diagnosis ICD-9-CM code 401 Hospitalization for Non-specifi.c chest pain All MATCH Primary diagnosis ICD-9-CM code 786.5 Hospitalization for cerebrovascular disease All MATCH Primary diagnosis ICD-9-CM codes 430- (stroke) 438, (include transient cerebral ischemia because it accounts for 28% of total hospital discharges of cerebrovascular disease in 2008) Prevalence of high blood cholesterol ≥18 BRFSS Respondents who report having been told by awareness among adults aged ≥18 years years a doctor of having high blood cholesterol within the previous 5 years Prevalence of high blood pressure awareness ≥18 BRFSS Respondents who report having been told by among adults aged ≥18 years years a doctor, nurse or other health professional of having high blood pressure Prevalence of heart attack, angina or stroke ≥18 BRFSS Respondents who report having been told by among adults aged ≥18 years years a doctor of having heart attack, angina or stroke Chronic disease linked to heart disease and stroke, Physical Activity, Nutrition and Tobacco Use Prevalence of diabetes among adults aged ≥ 18 ≥18 BRFSS Respondents who report having been told by years years a doctor of having diabetes Prevalence of overweight or Obesity among ≥18 BRFSS Respondents who have a body mass index adults aged ≥ 18 years years (BMI) ≥ 25.0 -29.99kg/m2 (overweight) and ≥ 30.0 kg/m2 (obesity) calculated from self- reported weight and height Recommended physical activity among adults ≥18 BRFSS Respondents who report not having any aged ≥ 18 years years leisure time physical activity for ≥ 30 minutes or running or walking for exercise during the last 30 days. Fruit and vegetable consumption among adults ≥18 BRFSS Respondents who report eating fruits and aged ≥ 18 years years vegetables ≥ 5 times/day or ≥ 1 and 0 time/day Cigarette smoking among adults aged ≥ 18 ≥18 BRFSS Respondents who report having smoked 100 years years cigarettes in their lifetime and are current smokers on every day or some days or former smoker (stopped smoking now)
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