Scotland has produced many excellent people and ideas. Few, if asked, would number
among them the Scottish Morbidity Record Scheme. In this scheme, each person admitted
to a Scottish hospital since 1981 has been assigned a unique identifying number, used
for all subsequent hospital admissions. These are also linked to diagnostic codes,
and to the General Register office relating to all deaths in the UK, and the Scottish
Cancer Registry. This results in a fantastic tool for examining disease and outcomes.
It has been used to examine the five-year survival after initial hospital admission
for common cardiac conditions and cancers [1].
Methods
Information for all of Scotland (population about 5 million) for first hospital
admissions for 1991 were used. Excluded were patients who had an admission for their
index condition in the preceding 10 years, and, for cancer patients, any with an
admission for any malignant neoplasm.
All deaths occurring in individuals before their expected age of death, taken from
life-expectance tables for age-matched populations in 1991, were defined as
premature. The number of expected life-years lost was calculated by subtracting the
actual age at death from the expected age of death. Loss of expected life was then
calculated as a median for each diagnosis and for a 1000 population.
Results
There were 14,842 initial diagnoses for women of heart failure, myocardial
infarction, and breast, lung, bowel and ovarian cancer. There were 16,224 initial
diagnoses for men for heart failure, myocardial infarction, and lung, bowel, prostate
and bladder cancer. The numbers, mean age and annual incidence are shown in Table 1.
Table 1: After first hospital admission with heart condition or common cancer in
Scotland, 1991. Incidence, five year survival, and expected life years lost per
person and per 1000 population
|
Sex/condition
|
Number |
Mean age |
Annual incidence per 1000 |
Five year survival (%) |
Median expected life-years lost per person |
Expected life years lost per 1000 |
|
Women
|
| Heart failure |
3606 |
76 |
1.4 |
25 |
6.8 |
5.1 |
| Myocardial infarction |
4916 |
72 |
1.9 |
48 |
7.9 |
6.7 |
| Lung cancer |
2902 |
62 |
0.4 |
5 |
13.1 |
6.7 |
| Breast cancer |
1490 |
70 |
0.8 |
65 |
16.5 |
7.0 |
| Large bowel cancer |
1402 |
72 |
0.4 |
35 |
10.2 |
3.0 |
| Ovarian cancer |
526 |
64 |
0.2 |
30 |
14.6 |
2.3 |
|
Men
|
| Heart failure |
3241 |
71 |
1.3 |
25 |
8.7 |
6.8 |
| Myocardial infarction |
6932 |
64 |
2.8 |
60 |
9.7 |
9.4 |
| Lung cancer |
2695 |
69 |
0.8 |
5 |
14.4 |
12.3 |
| Large bowel cancer |
1385 |
69 |
0.6 |
35 |
10.3 |
3.6 |
| Prostate cancer |
1211 |
74 |
0.5 |
38 |
5.6 |
1.2 |
| Bladder cancer |
760 |
69 |
0.3 |
52 |
6.7 |
0.9 |
Also shown are the five-year survivals (read from graphs, so limited accuracy
here), and the median expected life years lost to individual patients with a
diagnosis and for a population of 1000 (adjusted for the proportion of deaths
that were premature).
Common cardiac conditions in men and women were more common than cancers, but
were associated with similar five-year survival rates and life years lost.
Five-year survival for heart failure in men and women was associated with a low
survival rate (25%), even when adjusted for age. The age-specific probability of
surviving five years for the population was about 80% for women and 75% for men.
Comment
The fact that common cardiac conditions and cancers are associated with poor
outcomes is hardly a matter of surprise. What is interesting here is that we have
reasonable numbers in a whole population and with information collected
systematically. We can compare societal impacts of the various diseases on
mortality directly.
The heart failure angle
There is more than just interesting comparative figures in this paper, though.
It also contains an argument why we should probably be doing more about heart
failure, and doing more more effectively. In doing so it reviews, for instance,
other studies in other developed countries, and demonstrates that survival rates
in Scotland were broadly similar to those in the USA, Australia and other
European countries. This is not just a Scottish problem.
It goes on to review briefly the burden of the disease, and the benefits of
screening and palliative care programs, making comparisons with cancer screening
and screening for malignant hypertension. It finally reviews specific initiatives
that could be used in heart failure programs.
There is much food for thought here. The authors' interest is in heart failure,
and their discussion is worth reading because it is wide ranging and intelligent.
They make a point that better results can be achieved with heart failure, and
subsequent hospital admissions avoided, by the use of nurse-led, comprehensive
management programmes. But those, in PCOs or elsewhere, who have to plan and
organise services will find this rewarding and useful background reading. More
than anything else, this is one of those papers that makes you sit back and have
a quiet think about what you are doing and why.
References:
- S Stewart et al. More 'malignant' than cancer? Five-year survival following
a first admission for heart failure. European Journal of Heart Failure 2001 2:
315-322.
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