title: The relative impact of inadequate primary and secondary prevention on cardiovascular mortality in the United States.
abstract: OBJECTIVE
  We developed a model to estimate the costs incurred by ineffective primary and secondary prevention in terms of excess cardiovascular disease (CVD) mortality in a nationally representative sample of the US population.
  
  
  METHODS
  Cox proportional hazards analyses were used to examine the effect of inadequate risk factor control on the incidence of fatal stroke and myocardial infarction (MI) during a follow-up period of 13.4+/-3.6 years after adjusting for differences in age, gender, and ethnicity in a national cohort of 9252 adults who participated in the Second National Health and Nutrition Examination Survey (NHANES) Mortality Follow-up Study. Inadequate risk factor modification was defined by presence of either blood pressure >140/90 mm Hg, serum cholesterol >200 mg/dL, or active cigarette smoking. Using the data from 4115 adults screened in the NHANES 1999 to 2000, population attributable risk (PAR) percent and associated cost incurred (expressed as proportion of total 1-year cost incurred for CVD mortality in year 2001) was estimated.
  
  
  RESULTS
  CVD mortality risk increased in a stepwise manner for persons with no previous MI or stroke and > or =2 inadequately controlled risk factors (2x); and previous history of MI and stroke and adequately controlled risk factors (2.6x), 1 inadequately controlled risk factor (4.3x), and > or =2 inadequately controlled risk factors (5.7x). The PAR was 14% (estimated cost incurred 13.2 billion dollars) among persons with > or =2 inadequately controlled risk factors without previous MI or stroke (estimated 17% of total US population). Among persons with previous MI or stroke, the PAR was 7% (cost incurred 6.2 billion dollars) and 8% (cost incurred 7.4 billion dollars) for 1 inadequately controlled risk factor and > or =2 inadequately controlled risk factors, respectively. An excess of cost of 13.6 billion dollars was spent on 4% of the total population (persons with inadequate secondary prevention).
  
  
  CONCLUSIONS
  The model demonstrates the differential risk of mortality from inadequately controlled cardiovascular risk factors in primary and secondary prevention settings. The large financial cost incurred by inadequate primary and secondary prevention justifies intensive efforts directed toward detection and treatment of cardiovascular risk factors.
authors.affiliation: Zeenat Qureshi Stroke Research Center, Department of Neurology and Neurosciences, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103-2425, USA. aiqureshi@hotmail.com
authors.forename: Adnan I
authors.initials: AI
authors.lastname: Qureshi
authors.forename: M Fareed K
authors.initials: MF
authors.lastname: Suri
authors.forename: Jawad F
authors.initials: JF
authors.lastname: Kirmani
authors.forename: Afshin A
authors.initials: AA
authors.lastname: Divani
mesh_terms: D000206:Actuarial Analysis; D000368:Aged; D002318:Cardiovascular Diseases / Q000191:economics / Q000401:mortality / Q000517:prevention & control; D017281:Cost of Illness; D005260:Female; D005500:Follow-Up Studies; D006306:Health Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D011322:Primary Prevention / Q000191:economics; D016016:Proportional Hazards Models; D012306:Risk; D014481:United States / Q000453:epidemiology