What do we know about cardiovascular disease spending and outcomes in the United States?

This collection of charts and a related brief explore trends in health outcomes, quality of care, and treatment costs for heart disease and related conditions. Mortality rates have improved dramatically ever since mortality due to coronary heart disease reached its peak in the 1960s. In recent years, the continuing decline in mortality has largely been due to improved treatment protocols

Mortality rates for cardiovascular diseases have fallen dramatically over the last 30 years

The U.S. and other countries have made dramatic progress in lowering mortality from cardiovascular diseases, which include heart disease and stroke. In the U.S., the mortality rate has fallen from 590 deaths per 100,000 people in 1983 to 253 in 2013. Recently, this has been due in large part to improvements in emergency response for heart attack patients, in addition to medical advances, reduced smoking rates, and improvements in controlling cholesterol and blood pressure. This chart collection explores prevalence, spending, and health outcomes for cardiovascular disease and related conditions.

Heart disease is the leading cause of death in the United States

Heart disease refers to heart ailments such as heart attack, arrhythmia, and heart valve problems, and is included in a more broad set of cardiovascular diseases, such as stroke and acute rheumatic fever. The U.S. has seen significant improvements in both mortality and disease burden due to heart disease over the past few decades, as well as more recent improvement in some indicators of quality of care for heart disease. Heart disease has long been the leading cause of death in the U.S. and currently remains so, accounting for 23.4% of all deaths in 2015 – slightly more than malignant neoplasms (cancer), which accounted for 22% of all deaths. Stroke is the fifth leading cause of death, accounting for 5.2% of all deaths in 2015.

Mortality due to cardiovascular disease has declined for all races in the U.S., but remains highest for blacks

All racial/ethnic groups in the U.S. have had a similar decline in mortality due to cardiovascular disease. However, mortality for blacks has remained high, dropping from 443 deaths per 100,000 people in 2000 to 284 in 2015, compared to the the total population’s mortality decline from 343 deaths per 100,000 people to 224. Cardiovascular disease mortality is lowest among Asians and Pacific Islanders. From 2014 to 2015, there was an increase in the age-adjusted death rate for cardiovascular disease among all races except American Indians and Alaskan Natives.

U.S. disease burden for cardiovascular diseases has decreased 40% in the past 25 years

Aside from mortality and prevalence, another way to measure the effect cardiovascular disease has on health is to look at the burden of disease, which takes into account both years of life lost due to premature death as well as years of productive life lost to poor health or disability. According to data from the Institute for Health Metrics and Evaluation, cardiovascular diseases are the third leading cause of disease burden in the U.S, resulting in 3,065 DALYs per 100,000 population in 2015, a 40% improvement from 1990.

For a given population, DALYs are calculated by summing the Years of Life Lost (YLL) prematurely and the Years Lived with Disability (YLD, which are weighted). For each of the disease categories with improvements in age-standardized DALYs, the improvement has come primarily from a reduction in the years of life lost (as opposed to a reduction in the year lived with disability).

Disease burden has decreased for cardiovascular diseases attributable to many leading risk factors

The U.S. has also seen improvement in the contribution of leading risk factors to disease burden for cardiovascular diseases. Smoking, hypertension, high blood cholesterol, physical inactivity, high body-mass index, and high blood sugar levels are all leading risk factors for heart disease and stroke, and instances of cardiovascular disease are often attributable to more than one of these factors. When we look at cardiovascular diseases by known linked risk factors, we find that high systolic blood pressure is the primary contributor to disability adjusted life years (DALYs) for cardiovascular disease, followed by high body-mass index, high total cholesterol, and high fasting plasma glucose. From 1990 to 2015, disease burden decreased significantly for cardiovascular diseases attributable to the risk factors shown above.

The prevalence of both heart disease and stroke has been stable over the past 11 years

The prevalence of heart disease and stroke among adults in the U.S. remained about the same from 2004 to 2015. The prevalence of hypertension (high blood pressure, a major risk factor for heart disease and stroke) has risen slightly from 22% in 2004 to 25% in 2015.

People with lower incomes are more likely to suffer from heart disease, stroke, and hypertension

The prevalences of heart disease, stroke, and hypertension among adults in the U.S. drop slightly as family income increases. Fourteen percent of adults in families with a yearly income below $35,000 experience heart disease, compared to 10% of adults in families with an income of $100,000 or more. Four percent of adults in families with an income below $35,000 experience stroke, while just over 1% of those in families with an income of $100,000 or more do so. This disparity is more marked for the prevalence of hypertension among adults: hypertension affects 29% of adults in families with an annual income below $35,000, compared to 22% of adults in families with an income of $100,000 or more per year.

People with less education are slightly more likely to have heart disease

National Health Interview Survey data indicate a slight drop in the prevalence of heart disease among adults as their education level increases. People with less than a high school diploma are slightly more likely to have heart disease or stroke than the average U.S. adult. There is a more marked difference in the prevalence of hypertension based on education level: only those with at least a bachelor’s degree experience a below average prevalence of hypertension (23% compared to the average of 25%) and stroke (2% compared to the average of 3%).

Hospital admissions for congestive heart failure are more frequent in the U.S. than in most comparable countries

Hospital admissions for certain chronic conditions like hypertension (high blood pressure) can arise when prevention services are either not being delivered or not adhered to by patients. Hospital admission rates in the U.S. are higher than in comparable countries for congestive heart failure (which is often caused by unmanaged hypertension). However, the U.S. has lower rates of hospitalization for hypertension than comparably wealthy countries do on average, due to much higher rates of hospital admission for hypertension in Germany and Austria.

In general, more people are receiving evidence-based care for heart attack when they arrive at a hospital

Receiving evidence-based treatment upon presentation of a heart attack can minimize mortality. Between 2005 and 2012, hospital patients with a heart attack increasingly received fibrinolytic medication (drugs that dissolve blood clots) within 30 minutes of arrival. In 2013, the percentage receiving these drugs dropped from 62% to 54%.

More patients hospitalized for heart failure are given evidence-based prescriptions at discharge

Since 2005, an increasing percentage of patients who experienced heart failure and left ventricular systolic dysfunction have been discharged with a prescription for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker

Mortality rates within 30 days after hospital admission for heart attack and stroke have decreased

Mortality within 30 days of being admitted to a hospital is not entirely preventable, but can be reduced for certain diagnoses and services. Improvement in this area is often linked to improved quality of care. From 2010 to 2015, among admitted Medicare fee-for-service patients age 65 and older, 30-day mortality rates improved slightly for heart attacks (acute myocardial infarction) and ischemic strokes (caused by blood clots), but did not improve for heart failure.

30-day mortality for heart attacks and ischemic stroke are lower in the U.S. than in comparable countries

The 30-day mortality rates for heart attacks (acute myocardial infarction) and ischemic strokes (caused by blood clots) are lower in the United States than in comparable countries. The 30-day mortality rate for hemorrhagic stroke (caused by bleeding) is similar in the U.S. and comparable countries.

Spending on circulatory system diseases accounts for about 12% of disease based health expenditures

In 2013, spending on circulatory system diseases accounted for 12% of medical services spending on disease treatment ($236 billion of the $1.9 trillion total). The top five disease-based spending categories (ill-defined conditions, circulatory, musculoskeletal, respiratory, and endocrine conditions) account for roughly half (51%) of all medical services spending by disease category.

Circulatory system diseases were a leading driver of medical services spending growth from 2000-2013

Circulatory system diseases accounted for 8% of medical services spending growth from 2000 – 2013. This is down from 8.5% of medical services spending growth from 2000 – 2012. Treatments for ill-defined conditions, musculoskeletal disorders (which include back problems and arthritis), and endocrine disorders were the three largest contributors to overall health services spending growth over the 2000 – 2013 period, followed circulatory diseases.

Cost growth varied by disease both during and after the initial health spending slowdown years

Health care spending has grown slowly in recent years across the board (due at least in part to the sluggish economy), and circulatory system diseases in particular have seen persistently slow growth, even after the Great Recession. Spending on the treatment of all diseases rebounded slightly post-recession (growing 4.0% on average from 2010-2013, up from 3.7% during the 2008-2010 recessionary period). By contrast, spending growth for circulatory conditions continued to fall post-recession, to an average of 0.2% annual growth from 2010 – 2013, down from 2.6% annually in the previous five year period.

On a per capita basis, spending has increased to $747 per year to treat circulatory system diseases

In 2013, per capita spending on circulatory system diseases in the U.S. was $747, up from $544 per capita in 2000.

Diagnosis with a serious or chronic health condition is associated with higher spending

People with a current or prior diagnosis of heart disease, stroke, high blood pressure, or high cholesterol have higher spending on average than people without a diagnosis.