Progress in reducing inequalities in cardiovascular disease mortality in Europe

Abstract

Objective: To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

Methods: In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

Results: Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

Conclusions: Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

Keywords: cardiovascular diseases; europe; inequalities; mortality; socioeconomic position.

Figure 1

Trends in total cardiovascular disease mortality (ASMR, age-standardised mortality rate) and inequalities (Relative and Slope Index of Inequality) by educational level, population and gender, 35–79 years.

Figure 2

Changes in absolute and relative educational inequalities in total cardiovascular disease mortality between 2000-2004 (period in which data became available for all populations) and 2010–2014, by population and gender, 35–79 years. Note: changes in relative inequalities (ratio measures) were calculated using the following formula where RII stands for Relative Index of Inequality: 100*(RII_2010-14-RII_{2000- 04})/(RII_2000-04 – 1). Changes in absolute inequalities (difference measures) were calculated using the following formula where SII stands for Slope Index of Inequality: 100* SII_2010-14-SII_2000-04)/(SII_2000-04).

Figure 3

Total cardiovascular disease age-standardised mortality rates (ASMR) and 95% CI among low and high educated, by population and gender, 35-79 years, 2010–2014.