Over the past half-century, the U.S. has seen sizable improvements in both mortality and disease burden due to cardiovascular disease, along with recent signs of improvement in the quality of care provided to heart disease patients. Cardiovascular disease — which includes heart attack, arrhythmia, heart valve problems, and stroke – has long been a leading cause of death in the U.S. for both men and women and across most racial and ethnic groups. However, 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. Although the decline in mortality rates for all cardiovascular disease has slowed since 2011, the recent approval of new cholesterol drugs and less invasive surgeries may encourage further declines.
As a leading cause of death and disease burden, it understandably follows that circulatory system diseases are a major driver of health care spending. Nonetheless, spending on circulatory diseases has actually slowed in recent years, driven by both a markedly slow growth in the cost of treating these conditions and by a simultaneous drop in the number of people being treated. Our latest chart collection explores some of the deeper trends in cardiovascular disease prevalence, spending, and health outcomes.
Improvements in Cardiovascular Disease Outcomes and Quality of Care
Experts believe that progress in cardiovascular disease prevention, diagnosis, and treatment have all contributed to improved health outcomes, in addition to significant reductions in major risk factors. Both the U.S. and comparably wealthy OECD countries have made dramatic progress in lowering mortality from cardiovascular diseases. The U.S. mortality rate has fallen 57% from 1983 to 2013 (from 590 deaths per 100,000 people to 253). On average, comparably large and wealthy countries (those with above median GDP and above median GDP per capita) have seen an average improvement of 61% over the same time period (from 567 deaths per 100,000 people to 223).The cost of treating heart disease has dropped, even as outcomes improve Click To Tweet
Disease burden has also decreased for cardiovascular diseases. Disease burden, which includes both premature death and the years lived with disabling health conditions, is measured as “disability-adjusted life years” or DALYs. For cardiovascular diseases, disease burden in the U.S. has fallen 36% from 1990 to 2013 (from 5,134 to 3,261 disease adjusted life years per 100,000 people). In similarly large and wealthy countries, disease burden for cardiovascular diseases has improved an average of 48% over the same time period (from 4,394 in 1990 to 2,288 in 2013).
In addition to improvement in overall disease burden caused by cardiovascular disease, there has also been improvement in the U.S. and abroad in disease burden for cardiovascular diseases associated with many of the leading risk factors, such as smoking, hypertension, high blood cholesterol, physical inactivity, high body-mass index, and high blood sugar levels. According to data from the Institute of Health Metrics and Evaluation (IHME), disease burden for cardiovascular diseases attributable to high systolic blood pressure dropped from 2,560 DALYs in 1990 to 1,455 in 2013; for those attributable to low physical activity, disease burden dropped from 734 DALYs to 441; for those attributable to smoking, disease burden dropped from 1,197 DALYs to 532; for those attributable to high body-mass index, disease burden decreased from 1,714 DALYs to 1,304; and for those cardiovascular diseases attributable to high total cholesterol, disease burden dropped from 1,703 DALYs to 806.
Several recent advancements in both care delivery and medical technologies are in the spotlight now, as mortality rates for cardiovascular disease continue to decline. Improvements in the quality of emergency response to heart attack nationwide, including shorter response times and improved care coordination, have been identified as a major driver of improved heart attack survival rates. The National Healthcare Quality and Disparities Reports suggest that since data became available in 2005, more people nationwide are receiving evidence-based care for a heart attack when they arrive at a hospital, and more patients who are hospitalized for heart failure are given evidence-based prescriptions upon discharge. Between 2005 and 2012, the percent of hospital patients with a heart attack who received percutaneous coronary intervention (angioplasty) within 90 minutes of arrival rose 53%, and the percent who received fibrinolytic medication (drugs that dissolve blood clots) within 30 minutes increased 24%. There was also a 14% increase in the percent of heart failure patients discharged with a prescription for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker. Mortality within 30 days of hospital admittance for heart attacks (acute myocardial infarction) and ischemic strokes (caused by blood clots) are lower in the United States than in comparable countries, and both improved slightly from 2010 to 2013.
In 2015, the FDA approved a new class of cholesterol-reducing drugs, which may work for patients who have not responded to statins (currently the standard drug therapy). Minimally invasive surgeries have also been approved, which may benefit high-risk heart disease patients. Additionally, there are also a broad range of promising advancements in cardiovascular disease research that may result in new drug therapies and treatments in the future, including research into new methods and classes of drugs for reducing cholesterol; new surgical procedures and devices; lifestyle changes for reducing the risk of heart disease and stroke; and genetic links to risk factors.
Heart disease and stroke are the only chronic diseases among the leading causes of death with greatly improved death rates – on the whole, death rates for cancers have improved relatively slowly, have increased for chronic lower respiratory disease, and have seen little to no improvement for diabetes, chronic lung disease, and chronic kidney disease. Despite these notable gains, cardiovascular disease remains one of the top two contributors to disease burden, topped only by mental health and substance use disorders. Similarly, heart disease in particular remains the overall leading cause of death in the United States, accounting for 23.4% of deaths in 2014 – slightly more than cancer, which resulted in 22.5% of deaths. Meanwhile, stroke is the fifth leading cause of death, accounting for 5.1% of deaths in 2014. A recent study of CDC mortality data found that since 2011, the declining mortality rates for heart disease and stroke have slowed significantly since 2011.
Disparities exist as well. People with less education tend to have higher rates of cardiovascular conditions and the associated risk factors. Similarly, individuals with lower incomes also tend to have higher rates. These groups experience higher rates of hypertension, a major risk factor for heart disease and stroke affecting 1 in 4 adults in the U.S. Although all racial/ethnic groups are experiencing a decline in mortality from cardiovascular disease, compared to other groups, blacks continue to see the highest mortality rate due to cardiovascular diseases (283 deaths per 100,000 in 2014, compared to 221 on average for all races).
Slow Growth in the Cost of Treating Heart Disease in the U.S.
Remarkably, much of the progress in cardiovascular disease outcomes and quality of care has come at a time when the cost of treating these conditions has grown at very low rates. While health care spending has grown slowly in recent years across the board (due at least in part to the sluggish economy), circulatory diseases in particular have seen persistently slow growth, even after the Great Recession. Spending on the treatment of all diseases broadly rebounded slightly post-recession (growing 3.9% on average from 2010-2012, 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 0.3% annual growth from 2010 – 2012, down from 1.5% annually in the previous three year period.
Much of the most recent slowdown is due to very slow growth in the cost of treating each case of circulatory illness, as well as a continued decline in treated prevalence (the number of people being treated). One factor in the cost of treating each case of an illness is the price of pharmaceutical drugs. For circulatory diseases, Cozaar and Hyzaar (drugs used to treat high blood pressure) lost patent protection in April 2010.
Despite this slow growth in spending, circulatory conditions still represent a substantial portion of national health spending. In 2012, the U.S. spent $241 billion on the treatment of circulatory diseases, according to estimates by the Bureau of Economic Analysis (BEA), constituting about 13% of total medical services spending on disease treatment. Per capita spending on circulatory diseases was about $770 in 2012. Our analysis of BEA data also finds that circulatory system diseases accounted for 8.6% of the growth in medical services spending from 2000 to 2012.
Cardiovascular disease and its risk factors are costly to insurers and patients alike. Our analysis of data from the Medical Expenditure Panel Survey finds that people with a current or prior diagnosis of heart disease, stroke, high blood pressure, or high cholesterol have higher health spending on average than those without a diagnosis. People with these diagnoses also face higher average out of pocket costs.
The U.S. has seen substantial improvements in health outcomes for cardiovascular diseases, while also keeping spending growth low. Spending on circulatory diseases is high, largely because there are so many people with these conditions, but treated prevalence is actually dropping and the cost of treatment has grown very slowly relative to other conditions. While this degree of improvement — and at such a low cost — may not be achievable for all disease areas, the recent trends in cardiovascular disease treatment demonstrate that better care and better outcomes do not necessarily need to come with a higher price tag.