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我国心血管病防治:挑战、成因和对策
中国医学科学院 阜外心血管病医院国家心血管病中心 医学研究统计中心
杨进刚
on behalf of China PEACE investigators
Fuwai Hospital, National Center for Cardiovascular Diseases, China
China Patient-centered Evaluative Assessment of Cardiac Events
Trends in Characteristics, Treatment andOutcomes Among Patients With AMI
in China from 2001 to 2011China PEACE-Retrospective AMI Study
China PEACE-Retrospective AMI Study
Three time points over a decade: 2001, 2006, 2011
A nationally representative sample ofhospitalizations for AMI using two-stage randomsampling.
Standardized central medical chart abstraction(accuracy >98%)
Rigorous data quality monitoring at each stage
4
Hospitalization Rate for AMI
20
15
Trends in Testing
100
Troponin Creatinine Echocardiogram
% 50
0
2001 2006 2011*
*
P<0.001
*
*
Trends in Medications
100
Aspirin* Clopidogrel* Statins BB* ACE-I/ARB
%50
0
2001 2006 2011P<0.001
P=0.24P=0.13
****
Trends in Reperfusion Therapy
Trends: In-hospital Outcomes
Marked increases in rate of AMI hospitalization
More frequent use of procedures and testing
Persistent gaps in quality of care
No significant improvement in mortality
Summary: AMI in China 2001-2011
Evidence for Future Quality Improvement Strategies
N=2432
NINGXIA
Provincial level Prefecture level County level
Hospital Distribution throughout mainland of China
105 Hospitals30 Provincial level44 Prefecture level31 County level
N=12999
22.40%
10.90%
26.20%
40.50% 1-7 day12-24 h6-12 h≤6 h
STEMI
Times from symptom onset to hospital arrival
38.90%
14.70%
16.90%
29.60%
NSTEMI
provincial perfecture county0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
no-reperfusionPrimary PCIfibronolysis
Percentage of Reperfusion in pts with STEMI
provincial perfecture county0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
2.50%
4.10%
8.30%
mortality
In-hospital mortality rate in pts with AMI
省级(n=5325)
地市级(n=8508)
县级(n=2255)
年龄 60.50 ±13.83 61.93 ±15.66 64.10 ±15.02
既往 PCI/GABG 363 (7.1%) 434 (5.2%) 59 (2.7%)
糖尿病 1107 (22.2%) 1653 (20.3%) 359 (17.5%)
吸烟史 2567 (50.1%) 3584 (42.6%) 854 (38.5%)
Killip>III 级 377 (6.7%) 827 (9.8%) 283 (12.6%)
转院 1876 (36.1%) 1870 (22.0%) 95 (4.2%)
距发病时间 <3h 877 (16.9%) 1876 (22.4%) 667 (30.4%)
D2N,min(Q1,Q3) 130(28, 1064) 65 (27,260) 75 (30,615)
D2B, min(Q1,Q3)
165 (85,885) 136 (80,750) 291 (91,760)
GP2b/3a 拮抗剂 2004 (41.3%) 2182 (28.0%) 360 (16.9%)
三个级别医院就诊患者的差别
Conclusion
• Findings from the China Acute Myocardial Infarction Registry provide an overview of the treatment that patients actually receive and the outcome, providing the opportunity to assess daily practice in a large population of patients with AMI in China.
• The variation in the management and outcome in patients with AMI by region and by type of hospitals reported in this study in China merit further investigation to reduce the observed disparities.
Cost-effectiveness of optimal use of AMItreatments and impact on CHD mortality inChina
Dong Zhao
Capital Medical University Beijing Anzhen Hospital
Beijing Institute of Heart, Lung & Blood Vessel Diseases
2
5
Strategies of reducing AMI mortality
Primary prevention
Acute treatment
Secondary prevention
Increasing survival from improving treatment
11
Key treatment strategies of AMIrecommended by the guidelines
17
Questions & Hypotheses:
1.Which of these recommended treatmentstrategies would be cost-effective in China ifthe utilities of each or combinations of themwere optimal to 100%.
2.If the opitmal use of recommened treatmenthave remarkable impact on total CHD mortalityin China?
Treatments strategies in acute period
A1 Rising the use of Aspirin, β-blockers, statins and ACEI during
The first 30 days after onset from current utility rate to 100%
A2 Rising the use of clopidogrel in patients with AMI to 100%
B Rising the use of unfractinated heparin in patients with NSTEMI to 100%
C1 Rising the use of primary PCI in tertiary hospital and thrombolysis
in secondary hospital in patients with STEMI (with considerationof the availibility of PCI technology) to 100%
C2 Rising the use of primary PCI in all patients with STEMI to 100%
C3 Rising the use of primary PCI in high risk patients with NSTEMI in tertiary
hospital to 100%
20
21
Cost-effectiveness measurements• Incremental cost-effectiveness ratios were used to evaluate
the cost-effectiveness of optimal use of the key treatments.ICERs were calculated by dividing the incremental changesin total health care costs by the incremental changes inQALYs.
• WHO- CHOICE criteria were used to assess the degree ofcost-effectiveness.
• Highly cost-effective: ICER less than the GDP per capita.
• Moderately cost-effective: ICERs were between 1 to 3 timesof GDP per capita.
• Not cost-effective: ICER more than 3 times of GDP per
capita.
(In
crea
sed
acu
te t
reat
men
t co
st in
mil
lion
s)
Comparison of options of optimal use of treatmentstrategies for effects, cost and cost-effectiveness
-9800.00-3300.00 -3200.00
-1900.00
-30000
-20000
-10000
0
pPCIin STEMI
pPCI+Thrombolysis
Fourmedications
PCI inNSTEMI
Clopidogrelin AMI
Unfractionatedheparin
(C2) in STEMI(C1) (A1) (C3) (A2) ( B)
-36300 deaths
-53600 deaths
$1099millions
$610millions
$152millions $112millons
0
200
400
-40000
-50000
-600001200
1000
800
600
pPCIin STEMI
(C2)
pPCI+Thrombolysisin STEMI(C1)
PCI inNSTEMI
(C3)
Clopidogrelin AMI(A2)
$34millionsFour
medications(A1)
$5millionsUnfractionatedheparin 23
(B)
ICERBA1C1C2A2C3
$2800$3100$9000$10700$17600$23400
Nu
mb
er o
f d
eath
pre
ven
ted
du
rin
g
acu
te p
erio
d
Nu
mb
er o
f d
eath
pre
ven
ted
du
rin
g
acu
te p
erio
d
-36300 deaths
-53600 deaths
-9800.00-3300.00 -3200.00
-1900.00
-30000
-20000
-10000
0
pPCIin STEMI
pPCI+Thrombolysis
Fourmedications
PCI inNSTEMI
Clopidogrelin AMI
Unfractionatedheparin
(C2) in STEMI(C1) (A1) (C3) (A2) ( B)
$1099millions
$152millions$112.millions $34millons
0
200
800$610millions
600
400
1000
-40000
-50000
-600001200
pPCIin STEMI
(C2)
pPCI+Thrombolysisin STEMI(C1)
PCI inNSTEMI
(C3)
Clopidogrelin AMI(A2)
Fourmedications
(A1)
$5millons
Unfractionatedheparin 24
(B)
A1+BA1+B+A2A1+B+C1
Highly cost-effectiveNot cost-effectiveModerate cost effective
A1+B+C1+C3 Not cost-effective
Cost-effectiveness of combined strategies(I
ncr
ease
d a
cute
tre
atm
ent
cost
in m
illi
ons)
Number of death prevented duringacute period
(Percentage of reduction inmortality rate
-36300 deaths
-53600 deaths
-9800.00-3300.00 -3200.00
-1900.00
-30000
-20000
-10000
0
pPCIin STEMI
pPCI+Thrombolysis
Fourmedications
PCI inNSTEMI
Clopidogrelin AMI
Unfractionatedheparin
(C2) in STEMI(C1) (A1) (C3) (A2) ( B)
-7.5%
-5%
-1.3%
-0.3%
-5
-6
-7
-8
-3
-4
-2
-40000
-50000
-600000
-1
pPCIin STEMI
(C2)
pPCI+Thrombolysisin STEMI(C1)
PCI inNSTEMI
(C3)
Clopidogrelin AMI(A2)
Fourmedications
(A1)
Unfractionatedheparin 25
(B)
A1+B+C1+C3 Maximum a 10%reduction in mortality rate of CHD.
Impact on CHD mortality by optimal use of thetreatment strategies
-0.4% -0.4%
26
Conclusions
o Most hospital-based AMI treatment strategies recommended by the guidelines would be highly or moderately cost-effective in China;
o Full and simultaneous improvements of all standard hospital based AMI treatment strategies assessed in this study would only attributed to 9.6% reduction in the CHD mortality rate;
o Given the trend toward higher absolute numbers and rates of CHD in China, prehospital emergency care, public education on symptoms of AMI and availability of treatments for AMI should be improved.
341,745
1980
-30000
-50000
-10000
10000
fewer deathsin 2000
Risk Factors worse +17%Obesity (increase)Diabetes (increase)
+7%+10%
Risk Factors better -65%Population BP fall -20%Smoking -12%Cholesterol (diet) -24%Physical activity -5%
Treatments -47%AMI treatments -10%Secondary prevention -11%Heart failure -9%Angina:CABG & PTCA -5%Hypertension therapies -7%Statins (primary prevention) -5%
Unexplained -9%
2000
Explaining the fall in CHD deaths in USA1980-2000 : RESULTS
NEJM 2007; 356: 2388.
1981
Explaining the fall in coronary heart diseasedeaths in England & Wales 1981-2000
-60000
-80000
0
-20000
-40000
Risk Factors worse +13%Obesity (increase) +3.5%Diabetes (increase) +4.8%Physical activity (less) +4.4%
Risk Factors better -71%Smoking -41%Cholesterol -9%Population BP fall -9%Deprivation -3%Other factors -8%
Treatments -42%AMI treatments -8%Secondary prevention -11%Heart failure -12%Angina:CABG & PTCA -4%Angina: Aspirin etc -5%Hypertension therapies -3%
Unal, Critchley & CapewellCirculation 2004 109(9) 1101
68,230fewer deathsin 2000
2000
2007 年 2008 年 2009 年0.0
20.0
40.0
60.0
80.0
100.0
71.7 71.8 73.2 69.1 69.4 70.2
院前
死亡
构成
比(
%)
女性男性
2007-2009 年北京市男女两性急性冠心病事件院前死亡构成比( % )
39孙佳艺,等 . 《中华心血管病杂志》, 2012
0 20 40 60 80 100
91.4
88.6
84.2
80.0
70.7
67.6
70.4
0 20 40 60 80 100
93.8
83.6
84.6
73.3
67.8
70.1
78.3
85+
75-84
65-74
55-64
45-54
35-44
25-34
2007-2009 年合计北京市男女两性各年龄组急性冠心病事件院前死亡构成比( % )
40
男性 女性
孙佳艺,等 . 《中华心血管病杂志》, 2012
Clinical Pathways for Acute Coronary Syndromes in China
Dr. Du Xin
The George Institute for Global HealthBeijing Anzhen Hospital, Capital Medical University
• A long-term collaboration between The George Institute,Chinese Society of Cardiology and Ministry of Health
• The study was sponsored by Sanofi
• CPACS Phase 1(2004-2006): Prospective register study– 51 hospitals across the country– 3000 patients
• CPACS Phase 2(2007-2011): cluster randomised trial ofclinical pathway for evidence-based management of ACS– 75 hospitals across the country– >16,000 patients
CPACS: A quality of care improvementinitiative in China
Implement and evaluate a quality improvementinitiative for the care of hospitalised ACSpatients in China
CPACS 2: cluster randomised trial
Participating centres
75 participating centers
50 level 3 hospitals
25 level 2 hospitals
Intervention: performance measurement andfeedback
Clinical pathway implementation with cyclicalaudit feedback and pathway modification
• % of reperfusion therapy for STEMI• Door-to-needle time• Door-to-balloon time
• % diagnoses consistent with ECG and biomarker findings• % of high-risk patients undergoing invasive therapy• % of low-risk patients undergoing functional testing• % on optimum medical therapy on discharge• Length of hospital stay
key performance indicators used inCPACS-2
• Major bleeding episodes
Primary and secondary outcomes
• Primary outcome: 8 key performance indicators• Secondary outcome : in hospital events
• Death• Cardiac death• Major Adverse Cardiovascular Events (MACE) comprising all-
cause mortality, MI and stroke
Group A(early intervention):32 hospitals
Lost to follow-up: 0 hospital
Analysis: 32 hospitals50 (range 50-50) patients per hospital
Group B (late intervention): 38 hospitals
Lost to follow-up: 0 hospital
Analysis: 38 hospitals50 (range 50-50) patients per hospital
CPACS-2 resultsAssessed for eligibility: 82 hospitals
Excluded: 7 hospitalsRefused to participate (4)Other reason (3)
Eligible: 75 hospitals
Pilot hospitals: 5 hospitals
Randomised: 70 hospitals
Length of stay in days (ICC=0.107)
11.31 (7.43) 12.05 (9.03)Un-adjusted
Adjusted
-0.74 (-2.11, 0.63)
-0.77 (-2.15, 0.62)
0.290
0.278
(n=1900) (n=1600)Control Intervention Mean difference
(95% CI) p-valueFavoursControl
FavoursIntervention
-3 0 3Mean difference (day)
-25 0 25Mean difference (min)
DTN time for STEMI patientsundergoing thrombolysisin min (ICC=0.191)
99.00 (81.41) 79.06 (66.15)Un-adjusted
Adjusted
11.89 (-21.3,45.06)
18.06 (-13.4,49.54)
0.483
0.261
DTB timefor STEMI patientsundergoing primary PCI in min (ICC=0.114)
130.09 (90.98) 141.09 (103.69)Un-adjusted
Adjusted
-10.6 (-44.4,23.21)
-11.0 (-45.2,23.22)
0.539
0.528
(n=1900) (n=1600)Control Intervention Mean difference
(95% CI) p-valueFavoursControl
FavoursIntervention
Primary outcome: Continuous KPIs
Patientswith final diagnosis(UAP or MI) consistentwith biomarkerfinding (ICC=0.08)
1720/1855 (92.7%) 1398/1568 (89.2%)Un-adjusted
Adjusted
0.96 (0.91, 1.01)
0.95 (0.89, 1.02)
0.118
0.163
Low-riskpatientsundergoing functionaltesting(ICC=0.058)
Un-adjusted 9/141 (6.4%) 1/90 (1.1%) 0.25 (0.03, 2.07) 0.197
Adjusted
High-risk patientsundergoing coronaryangiography(ICC=0.462)
689/1504 (45.8%) 690/1350 (51.1%)Un-adjusted
Adjusted
1.14 (0.82, 1.58)
1.02 (0.81, 1.29)
0.444
0.849
Patientsdischarged on appropriate medicaltherapy (ICC=0.112)
932/1822 (51.2%) 976/1555 (62.8%)Un-adjusted
Adjusted
1.23 (1.06, 1.42)
1.21 (1.06, 1.37)
0.007
0.004
STEMI patientsreceiving appropriate reperfusion therapy (ICC=0.096)
229/720 (31.8%) 290/679 (42.7%)Un-adjusted
Adjusted
0.069
0.070
Control(n=1900)
Intervention(n=1600)
Risk ratio(95% CI) p-value
Favours FavoursControl Intervention
0.1 1Risk ratio
1.24 (0.98, 1.55)
1.25 (0.98, 1.59)
10
Primary outcome: Binary KPIs
Death (ICC=0.018)
78/1900 4.11% 41/1596 2.57%Un-adjusted
Adjusted
1.60 (0.97, 2.64)
1.78 (0.85, 3.72)
0.066
0.128
Cardiac death (ICC=0.013)
60/1900 3.16% 35/1596 2.19%Un-adjusted
Adjusted
1.44 (0.85, 2.45)
1.37 (0.67, 2.80)
0.178
0.390
Major adverse cardiovascular events(ICC=0.087)
122/1900 6.42% 92/1596 5.76%Un-adjusted
Adjusted
1.12 (0.58, 2.14)
1.59 (0.86, 2.96)
0.741
0.142
Major bleeding episodes(ICC=0.131)
42/1893 2.22% 19/1596 1.19%Un-adjusted
Adjusted
1.87 (0.84, 4.19)
1.91 (0.59, 6.15)
0.125
0.277
Control(n=1900)
Intervention(n=1600)
Risk ratio(95% CI) p-value
FavoursControl
FavoursIntervention
0.20 1 5Risk ratio
Abbreviations:DNT, door-to-needle; DTB, door-to-balloon;PCI, Percutaneouscoronaryinterventions;STEMI, ST segementelevationmyocardialinfarction;ICC, inter-clustercoordination
Secondary outcomes: in hospital events
Time trend analysis
Time trend analysis
System barriers to the evidence-basedcare of ACS patients
• Lack of leadership and support for implementing qualityimprovement
••
Variation in the capacity of clinical services and QI resources
Healthcare funding constraints and high out-of-pocketexpenses
••
Fears of patient disputes and litigation
Patient-related factors
城市男性 城市女性 农村男性 农村女性0
50
100
150
200
250
300
350
244.1
213.6234
206.6231.1
198.0
255.1
217.2
2004 2008
5.33% 9.02%7.30% 5.13%
粗死
亡率
(1/
100
000)
张啸飞,等 . 《中华心血管病杂志》, 2012
2004 年和 2008 年城乡男女两性心血管病死亡率
55
张啸飞,等 . 《中华心血管病杂志》, 2012
2004 年和 2008 年我国人群缺血性心脏病死亡率
全国 城市男性 城市女性 农村男性 农村女性0
20
40
60
80
100
66.1
78.672.1
63.858.7
70.0
80.2 72.5 72.5
63.4
2004 2008
7.46%2.03% 0.55% 13.64% 8.00%
粗死
亡率
(1/
100
000)
标化率: 2004 : 57.9/10 万 2008 : 56.2/10 万
56
城市 农村 城市 农村男 女
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
3.3 2.9
1.4 1.3
5.9
3.7
6.6
4.1 3.7
2.5
9.0
5.8
18-44 45-59 ≥60
高胆固醇血症患病率(%)
年龄
中国城市农村人群高总胆固醇血症( TC ≥6.22mmol/L) 的患病率 ( 97 409 名 18 岁以上人群, 2010 年)
李剑虹等 中华预防医学杂志 2012 46:414-418
总患病率 3.3%
东部 中部 西部 东部 中部 西部男 女
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
2.2
1.4 1.5
1.2 0.9
0.5
3.6
1.8
3.2
4.2
1.9
2.9
3.4
1.6 1.8
6.2
3.1
4.3
18-44 45-59 ≥60
高低密度脂蛋白血症患病率(%)
中国各地区人群高 LDL-C ( LDL-C≥4.14 mmol/L) 的患病率 ( 97 409 名 18 岁以上人群, 2010 年)
李剑虹等 中华预防医学杂志 2012 46:414-418
2.1%
城市 农村 城市 农村男 女
30.0
35.0
40.0
45.0
50.0
55.0
60.0
56.2
52.6
38.7 40.2
49.8
46.3
35.1
38.8
48.0
42.6
39.1 37.8
18-44 45-59 ≥60低高密度脂蛋白血症患病率(%)
中国城市农村人群低 HDL-C ( HDL-C < 1.04 mmol/L) 的患病率 ( 97 409 名 18 岁以上人群, 2010 年)
李剑虹等 中华预防医学杂志 2012 46:414-418
总患病率 44.3%
东部 中部 西部 东部 中部 西部男 女
30.0
35.0
40.0
45.0
50.0
55.0
60.0
52.9 51.7
56.8
38.4 37.1
44.7 46.3
47.9 49.1
34.6
39.6 40.3
44.7
39.9
48.8
39.1
34.5
41.1
18-44 45-59 ≥60低高密度脂蛋白血症患病率(%)
中国各地区人群低 HDL-C ( HDL-C < 1.04 mmol/L) 的患病率( 97 409 名 18 岁以上人群, 2010 年)
李剑虹等 中华预防医学杂志 2012 46:414-418
年龄组( 岁 )
男性 女性
2007 2008 2009增加率( % ) 2007 2008 2009
增加率( %
)
25-34 11.2 8.9 10.5 -6.3 1.6 0.4 0.5 -68.8
35-44 61.1 70.0 79.6 30.3 7.9 6.5 7.3 -7.6
45-54 170.2 193.4 205.9 21.0 26.2 29.6 29.0 10.7
55-64 335.8 376.4 393.6 17.2 110.3 123.3 124.5 12.9
65-74 689.9 745.9 744.5 7.9 491.6 500.5 499.2 1.5
75-84 1330.9 1378.9 1343.6 1.0 1208.0 1274.4 1243.2 2.9
≥85 2353.4 2319.6 2093.5 -11.0 2495.9 2577.2 2379.7 -4.7
2007-2009 年北京市男女两性不同年龄组急性冠心病事件发病率( 1/10 万)
61孙佳艺,等 . 《中华心血管病杂志》, 2012
A: 西城区B: 东城区C: 宣武区D: 崇文区
51 ~ 100
101 ~ 150
151 ~ 200
201 ~ 250
A: 西城区B: 东城区C: 宣武区D: 崇文区
51 ~ 100
101 ~ 150
151 ~ 200
201 ~ 250
A: 西城区B: 东城区C: 宣武区D: 崇文区
51 ~ 100
101 ~ 150
151 ~ 200
201 ~ 250
2007-2009 年北京市各区县 25 岁以上居民急性冠心病事件年龄标化发病率
62
2007 2008 2009
孙佳艺,等 . 《中华心血管病杂志》, 2012
标化
发病
率(
1/10
万)
2008年
2007 年 2009年
2007-2009 年北京市不同地区急性冠心病事件年龄标化发病率
63
城四区 近郊 远郊0
50
100
150
200
250
孙佳艺,等 . 《中华心血管病杂志》, 2012
北京急性冠心病院前死亡占 95.0%
• 2007-2009 年北京地区 25 - 45 岁急性冠心病事件共3489 例(男 3183 例,女 306 例),年龄( 40.5±4.3 )岁
• 总病死率 3 年合计为 26.0% ,女性明显高于男性( 51.0% 比 23.6% , P<0.05 )
• 郊区和农村地区的总病死率高于城区( 28.9% 比22.9% , P<0.05 )。
• 25~45 岁急性冠心病事件院前死亡在总死亡中的比例 3年合计为 95.0% (男 95.2% ,女 94.2% )
• 64.8% 的院前死亡发生地点在家中。
北京青年急性冠心病事件院前死亡流行病学研究 . 中华内科杂志 2012
在最近的 3 年里,深圳一共发生了 4619 例心源性猝死,平均每天 4 例;在这 4619 例病例中,只有 143 例( 3.1% )被“活着”送往医院,最后只有 3 例( 0.06% )出院。
冠心病患者的初次临床表现
女性
0患者比例 (%)
男性
20 40 60
Murabito et al Circ 1993 88: 2548
Framingham Heart Study (n=5144) 首次事件为心梗或猝死的患者比例
约 60%约 60%
约 45%约 45%
首次冠心病的表现 : Framingham 研究
表现( % )心肌梗死 心绞痛 猝死
年龄 男 女 男 女 男 女 35-64 43% 28% 41% 59% 9% 4%65-84 55% 44% 28% 41% 11% 7.4%
跟踪了 44 年
____________________________________________________________
________________________________________________________
____________________________________________________________
70Libby P. Lancet. 1996;348:S4-S7.
中膜
–T lymphocyte
– Macrophagefoam cell (tissue factor+)– “Activated” intimal SMC (HLA-DR+)–Normal medial SMC
纤维帽内膜 脂核
管腔
斑块的解剖
引起心肌梗死的斑块所致的狭窄
68%
18% 14%
0
20
40
60
<50% 50%–70% >70%
狭窄程度
心梗 (%)
Falk et al:Circulation 1995;92:657–671
www.drsarma.in 74
火山爆发
血栓
纤维帽
脂肪核
小结 1 :中国心肌梗死诊疗面临的几个问题
• 医院内心肌梗死患者在增加• 院前死亡率高• 患者从发病到达医院较晚, 1/4 在发病 24 小
时后到达• 心血管病年轻化趋势明显• 再灌注治疗仍然不足,县医院有待提高• 提高医疗质量需要强有力的有效的干预措施• 我国血脂异常有新动向,农村心血管病发病率
增加迅猛
中国居民 DALY 中所占比例最高的 10 种危险因素
Rapid health transition in China, 1990–2010. Lancet 2013; 381: 1987
肿瘤心血管病循环系统疾病糖尿病和内分泌系统疾
病慢性呼吸道疾病
The Prospective Urban Rural Epidemiologic (PURE) study of
154,000 people from 628 communities in 17 countries
Prospective Urban Rural Epidemiologic (PURE) Study
155,000 adults(400,000 people) from 17 countries (LIC, MIC, HIC)
Urban and Rural 600 communities
Societal level influences (Socioeconomic, tobacco & other health policies, relative food prices and availability, built environment,
indoor/outdoor pollution)
Lifestyle behaviours X genes
Individual risk factors
CVD, DM, Obesity, Cancers,Obstructive Airways Disease,Renal dis,Injuries,Depression.
Canada - 82
Brazil - 14
Argentina - 20
Chile - 5
Colombia - 58
South Africa - 8
Zimbabwe - 3
India - 90
Pakistan - 4
B’desh - 56
Sweden - 31
Poland - 4
Turkey - 44
UAE-3
Iran - 20China - 115
Malaysia - 71
Classification of Countries
Based on World Bank classifications at the beginning of the study (2003 – 2007):
HIC: Canada, Sweden & UAE.• UMIC: Argentina,Brasil,Chile,Poland,Turkey, S
Africa,Malaysia.• LMIC: Colombia,Iran,China .• LIC: India,Bangladesh,Pakistan,Zimbabwe.
Age and gender standardized rates per 1000 pers-years by Economic Levels
Death MI † Stroke †Heart
Failure † CVD ‡
N Rate N Rate N Rate N Rate N RateHIC 138 1.7 139 1.8 106 1.5 36 0.5 564 7.8
MIC 1131 3.8 452 1.5 509 1.7 152 0.5 1370 4.6
LIC 1031 7.4 419 2.9 152 1.1 45 0.3 730 5.1
Total 2300 4.4 1010 2.0 767 1.5 233 0.4 2664 5.2
†MI = MI/Sudden Unexpected Death/Non-sudden Unexpected Death/Other Heart Disease‡CVD = MI/Stroke/heart failure
Age and gender standardized rates per 1000 pers-years by Economic Levels
CVD Fatal CVD Severe CVDOther Hosp
CVD
N Rate N Rate N Rate N RateHIC 564 7.8 39 0.5 273 3.7 291 4.0
MIC 1370 4.6 387 1.3 1079 3.6 291 1.0
LIC 730 5.1 383 2.7 603 4.2 127 0.9
Total 2664 5.2 809 1.6 1955 3.8 709 1.4
Note: CVD = MI + Stroke + Heart Failure + other hospitalized CVD Fatal CVD = Fatal MI + Fatal Stroke + Fatal Heart Failure + other fatal CVD Severe CVD = Fatal CVD + MI + Stroke + Heart Failure
Case fatality rates by Economic Levels
MI Stroke Heart Failure
Overall FatalFatality Rate Overall Fatal
Fatality Rate
Overall Fatal
Fatality Rate
N N % N N % N N %HIC 139 23 16.5 106 5 4.7 36 5 13.9
MIC 452 225 49.8 509 126 24.8 152 46 30.3
LIC 419 294 70.2 152 73 48.0 45 23 51.1
Total 1010 542 53.7 767 204 26.6 233 74 31.8
Fatality rate = (N Fatal/N overall)*100.
Age and gender standardized event rates/1000 person-years – by Country economy
Case fatality rate (%) – by Country economy
Proportion of Causes of Death by Economic Status of the Country
Overall CVD Cancer Injury
Respiratory
Other NCD Other
N % % % % % %HIC 126 23.8 53.2 5.6 4.0 5.6 7.9MIC 871 36.9 30.3 6.3 5.2 4.9 16.4LIC 745 45.5 11.8 9.4 9.0 8.2 16.1Total Number 1742 39.6 24.1 7.6 6.7 6.4 15.7
Number of hospitalizationsby Economic Level
Economic
Level ParticipantOnce or
MoreTwice or
MoreThree or
MoreHIC 15904 2769(17.4) 714(4.5) 212(1.3)
MIC 98487 4986(5.1) 866(0.9) 232(0.2)
LIC 30514 2498(8.2) 252(0.8) 40(0.1)
Total 144905 10253(7.1) 1832(1.3) 484(0.3)
Number of hospitalizationsby Country
Country ParticipantOnce or
MoreTwice or
MoreThree or
MoreBrazil 6081 746(12.3) 163(2.7) 33(0.5)
South Africa 3120 148(4.7) 3(0.1)
Colombia 6656 100(1.5) 7(0.1) 1(0.0)
China 46347 586(1.3) 67(0.1) 21(0.0)
India 27719 2269(8.2) 228(0.8) 36(0.1)
Pakistan 1699 104(6.1) 4(0.2)
Zimbabwe 1096 125(11.4) 20(1.8) 4(0.4)
Total 144905 10253(7.1) 1832(1.3) 484(0.3)
PURE: Contrasting associations between risk factor burden, CVD incidence and mortality in high, middle and low income countries
中美最新心血管病报告对比
中美最新心血管病报告对比
中美最新心血管病报告对比
1984到 1999年北京冠心病死亡率变化1984到 1999年北京冠心病死亡率变化
增加了 1608 例死亡
胆固醇 77%
糖尿病 19% BMI 4% 吸烟 1%
治疗改善减少的死亡AMI 治疗 41%二级预防 20%心衰 10%心绞痛 :CABG & PTCA 2%降压治疗 24%
20001984
治疗改善减少了 642 例死亡
Circulation J Critchley, J Liu D Zhao 2004 110:1236-1244
危险因素恶化
小结 2
• 疾病谱的转变– 从传染性疾病转向慢性非传染性疾病– 从严重致命性心血管病转向非致命性心血管病– 从心血管病转向肿瘤
• 从社会角度看,单纯从生物医学技术角度看(危险因素的多少)并不能说明一个人的心血管危险情况。
• 心血管病的干预有充分的循证医学证据• 两国心血管病流行面临双重压力:危险因素的流行和疾
病治疗的薄弱• 全社会动员,而非仅依靠医生,才能做好心血管病的防
治。
Good Outcome
Intermediate Outcome
Bad Outcome
Outcomes from an RCT
Traditional EBM Approach
Mean Treatment Effect
• Clinical trials and EBM provide answers for “average” patients
• In real life, however, there are no average patients
• Clinical trials and EBM provide answers for “average” patients
• In real life, however, there are no average patients
“Well designed clinical trials are good experiments but poor surveys”——N. Longford
The health professions - and health care delivery –are changing ...
From craft-based practice individual physicians, working alone (house/staff = apprentices) handcraft a customized solution for each patient based on a core ethical commitment to the patient and vast personal knowledge gained from training and experience
To profession-based practice groups of peers, treating similar patients in a shared setting plan coordinated care delivery processes (e.g., standing order sets) which individual clinicians adapt to specific patient needs early experience shows
► less expensive (facility can staff, train, supply an organize to a single core process)► less complex (which means fewer mistakes and dropped handoffs, less conflict) ► better patient outcomes
Challenges and opportunities in applying new research methodologies.
美国心血管疾病临床注册• 美国胸科医师学会 : 1000+ 医院
– Coronary artery bypass surgery– Valve surgery– Congenital heart surgery– Thoracic surgery
• 国家心血管疾病注册 : 1600+ 医院– Cath/Percutaneous coronary intervention– Implantable cardiac defibrillators (ICD)– Acute coronary syndromes (ACS)– Carotid stenting– IC3: Ambulatory CV disease (launching)
• AHA-依从指南项目 : 1500+ 医院– Coronary artery disease (CAD)– Heart failure – Stroke – Outpatient: Ambulatory module (launching)
这些临床注册…• 大规模并具有代表性
– 患者,医生,病情• 包含详细的临床资料
– 就诊资料,治疗,短期预后• 采用相似的标准化的数据定义• 高质量的
– 准确、完整、接受质控• 正在演变为纵向研究 !
– 与其它数据来源衔接
贯穿治疗过程的心血管病注册
一级预防 导致入院 的事件
事件后 :心脏康复二级预防出院
住院治疗住院
HF/Stroke AMI/Care
ACTION GWTG HF, CVAACC-PCI, ICD PVD, CongenitalSTS-CABG, Valve
ACC IC3 GWTG OutpatientTRANSLATE ACSORBIT-AF
AHA H360
临床注册 : 促进实践的改变 !
• 发现进步的“机会”– 追踪有效治疗的应用– 发现治疗的差异 (e.g., disparities)– 追踪不恰当的治疗
• 医生行为的评价 – 标准治疗及预后– 支持质量控制 ( 与 P4P 或公开信息链接)
• 易化医生主导的质量改进– 应用反馈工具来促进治疗时间的变化
住院死亡率与总的指南依从性的联系住院死亡率与总的指南依从性的联系
Peterson et al, JAMA 2006;295:1863-1912
5.95
5.16 4.97
4.16
5.064.63
4.15
6.31
0
1
2
3
4
5
6
7
<=25% 25 - 50% 50 - 75% >=75%
Hospital Composite Quality Quartiles
% I
n-H
osp
Mo
rtal
ity
Adjusted Unadjusted
Every 10% in guidelines adherence 10% in mortality (OR=0.90, 95% CI: 0.84-0.97)
At the End of the Day…
注册研究能够• 有效地收集高质量的临床数据• 追踪患者的长期治疗 • 作为科学发现的源泉• 促进新的证据转化为治疗常规
“Humanity’s greatest advances are not in its discoveries – but in how those discoveries are applied ...”
Bill Gates, June 7, 2007Harvard Commencement Address
New Paradigm of Research
• Learn from real-world results• Focus on system and teams• Involve patients and clinicians• Integrate learning and doing
• 中国临床研究面临的问题是,医生普遍不善于提出临床研究问题,也没有掌握临床研究的科学设计方法。
• 临床研究是诊疗工作密切结合、不可或缺,是改变临床实践的最根本的手段。
• 中国的医学研究人员还是“兼职、作坊和游击队式的工作方式”。
中国的临床资源丰富,潜力巨大。中国能够出最好的研究主要在临床研究方面。
Coronary Mortality in China: Fence, Ambulance, or Hospital Treatments
Thank you!