1
|
Kerniss H, Marín LAM, Clemens K, Litfin C, Seidel-Sarpong A, Hanses U, Rühle S, Schmucker J, Osteresch R, Fach A, Eitel I, Hambrecht R, Wienbergen H. Long-term risk factor management and adverse events in patients with early-onset myocardial infarction-a "real-world" study. Clin Res Cardiol 2024:10.1007/s00392-024-02478-3. [PMID: 38896124 DOI: 10.1007/s00392-024-02478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND International guidelines emphasize the importance of preventive efforts after early-onset myocardial infarction (EOMI); however, data on "real-world" long-term risk factor management and adverse event rates in this special patient group is scarce. METHODS In this German registry study, 301 patients with MI aged ≤ 45 years were investigated. Risk factor control was assessed at the time of index MI and after 1 year. Major adverse cardiac and cerebrovascular events (MACCE) and its predictors were analyzed during long-term follow-up (median duration 49 months). RESULTS A majority of patients with EOMI presented with insufficient risk factor control, even during 1-year follow-up. After 1-year 42% of patients were persistent smokers; 74% were physically inactive. The rate of obesity increased significantly from index MI (41%) to 1-year follow-up (46%, p = 0.03) as well as the rate of dysglycemia (index MI: 40%; 1-year follow-up: 51%, p < 0.01) and diabetes mellitus (index MI: 20%; 1-year follow-up: 24%, p < 0.01). 66% of the patients with diabetes mellitus had unsatisfactory HbA1c after 1 year; 69% of the patients did not attain guideline-recommended lipid targets. The rate of MACCE during long-term follow-up was 20% (incidence rate 0.05 per person-year). In a multivariable analysis smoking (HR 2.2, HR 1.3-3.7, p < 0.01) and physical inactivity (HR 2.8, HR 1.2-6.7, p = 0.02) were significant predictors for the occurrence of MACCE. CONCLUSION Insufficient long-term risk factor control was common in patients with EOMI and was associated with an elevated rate of MACCE. The study reveals that better strategies for prevention in young patients are crucially needed.
Collapse
Affiliation(s)
- Hatim Kerniss
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Luis Alberto Mata Marín
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Kilian Clemens
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Carina Litfin
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Annemarie Seidel-Sarpong
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Ulrich Hanses
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Stephan Rühle
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Johannes Schmucker
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Rico Osteresch
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Andreas Fach
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Ingo Eitel
- Lübeck University Heart Center, Medical Clinic II, Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Rainer Hambrecht
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany
| | - Harm Wienbergen
- Bremen Institute for Heart and Circulation Research (BIHKF), Senator-Weßling-Str. 2, 28277, Bremen, Germany.
- Lübeck University Heart Center, Medical Clinic II, Lübeck, Germany.
| |
Collapse
|
2
|
Dempsey K, Ferguson C, Walczak A, Middleton S, Levi C, Morton RL, Boydell K, Campbell M, Cass A, Duff J, Elliott C, Geelhoed G, Jones A, Keech W, Leone V, Liew D, Linedale E, Mackinolty C, McFayden L, Norris S, Skouteris H, Story D, Tucker R, Wakerman J, Wallis L, Waterhouse T, Wiggers J. Which strategies support the effective use of clinical practice guidelines and clinical quality registry data to inform health service delivery? A systematic review. Syst Rev 2022; 11:237. [PMID: 36352475 PMCID: PMC9644489 DOI: 10.1186/s13643-022-02104-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Empirical evidence suggests data and insights from the clinical practice guidelines and clinical quality registries are not being fully utilised, leaving health service managers, clinicians and providers without clear guidance on how best to improve healthcare delivery. This lack of uptake of existing research knowledge represents low value to the healthcare system and needs to change. METHODS Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews) were systematically searched. Included studies were published between 2000 and 2020 reporting on the attributes, evidence usage and impact of clinical practice guidelines and clinical quality registries on health service delivery. RESULTS Twenty-six articles including one randomised controlled trial, eight before-and-after studies, eight case studies/reviews, five surveys and four interview studies, covering a wide range of medical conditions and conducted in the USA, Australia and Europe, were identified. Five complementary strategies were derived to maximise the likelihood of best practice health service delivery: (1) feedback and transparency, (2) intervention sustainability, (3) clinical practice guideline adherence, (4) productive partnerships and (5) whole-of-team approach. CONCLUSION These five strategies, used in context-relevant combinations, are most likely to support the application of existing high-quality data, adding value to health service delivery. The review highlighted the limitations of study design in opportunistic registry studies that do not produce clear, usable evidence to guide changes to health service implementation practices. Recommendations include exploration of innovative methodologies, improved coordination of national registries and the use of incentives to encourage guideline adherence and wider dissemination of strategies used by successful registries.
Collapse
Affiliation(s)
- Kathy Dempsey
- Faculty of Medicine and Health, NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW, 2050, Australia.
| | | | - Adam Walczak
- Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), University of NSW, Kensington, Australia
| | - Sandy Middleton
- Nursing Research Unit, Australian Catholic University, Sydney, Australia
| | - Christopher Levi
- Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), University of NSW, Kensington, Australia
| | - Rachael L Morton
- Faculty of Medicine and Health, NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW, 2050, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Maehl N, Bleckwenn M, Riedel-Heller SG, Mehlhorn S, Lippmann S, Deutsch T, Schrimpf A. The Impact of the COVID-19 Pandemic on Avoidance of Health Care, Symptom Severity, and Mental Well-Being in Patients With Coronary Artery Disease. Front Med (Lausanne) 2022; 8:760265. [PMID: 34977066 PMCID: PMC8714893 DOI: 10.3389/fmed.2021.760265] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/10/2021] [Indexed: 12/27/2022] Open
Abstract
The COVID-19 pandemic affected regular health care for patients with chronic diseases. However, the impact of the pandemic on primary care for patients with coronary artery disease (CAD) who are enrolled in a structured disease management program (DMP) in Germany is not clear. We investigated whether the pandemic affected primary care and health outcomes of DMP-CAD patients (n = 750) by using a questionnaire assessing patients' utilization of medical care, CAD symptoms, as well as health behavior and mental health since March 2020. We found that out of concern about getting infected with COVID-19, 9.1% of the patients did not consult a medical practitioner despite having CAD symptoms. Perceived own influence on infection risk was lower and anxiety was higher in these patients compared to symptomatic CAD patients who consulted a physician. Among the patients who reported chest pain lasting longer than 30 min, one third did not consult a medical practitioner subsequently. These patients were generally more worried about COVID-19. Patients with at least one worsening CAD symptom (chest pain, dyspnea, perspiration, or nausea without apparent reason) since the pandemic showed more depressive symptoms, higher anxiety scores, and were less likely to consult a doctor despite having CAD symptoms out of fear of infection. Our results provide evidence that the majority of patients received sufficient medical care during the COVID-19 pandemic in Germany. However, one in ten patients could be considered particularly at risk for medical undersupply and adverse health outcomes. The perceived infection risk with COVID-19 might have facilitated the decision not to consult a medical doctor.
Collapse
Affiliation(s)
- Nathalie Maehl
- Department of General Practice, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Markus Bleckwenn
- Department of General Practice, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Leipzig University, Leipzig, Germany
| | | | - Stefan Lippmann
- Department of General Practice, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Tobias Deutsch
- Department of General Practice, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Anne Schrimpf
- Department of General Practice, Faculty of Medicine, Leipzig University, Leipzig, Germany
| |
Collapse
|
4
|
Fischer C, Höpner J, Hartwig S, Noutsias M, Mikolajczyk R. Participation in disease management programs and major adverse cardiac events in patients after acute myocardial infarction: a longitudinal study based on registry data. BMC Cardiovasc Disord 2021; 21:18. [PMID: 33407174 PMCID: PMC7788767 DOI: 10.1186/s12872-020-01832-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022] Open
Abstract
Background Cardiovascular diseases are still the main cause of death in the western world. However, diminishing mortality rates of acute myocardial infarction (AMI) are motivating the need to investigate the process of secondary prevention after AMI. Besides cardiac rehabilitation, disease management programs (DMPs) are an important component of outpatient care after AMI in Germany. This study aims to analyze outcomes after AMI among those who participated in DMPs and cardiac rehabilitation (CR) in a region with overall increased cardiovascular morbidity and mortality. Methods Based on data from a regional myocardial infarction registry and a 2-year follow-up period, we assessed the occurrence of major adverse cardiac events (MACE) in relation to participation in CR and DMP, risk factors for complications and individual healths well as lifestyle characteristics. Multivariable Cox regression was performed to compare survival time between participants and non-participants until an adverse event occurred. Results Of 1094 observed patients post-AMI, 272 were enrolled in a DMP. An association between DMP participation and lower hazard rates for MACE compared to non-enrollees could not be proven in the crude model (hazard ratio = 0.93; 95% confidence interval = 0.65–1.33). When adjusted for possible confounding variables, these results remained virtually unchanged (1.03; 0.72–1.48). Furthermore, smokers and obese patients showed a distinctly lower chance of DMP enrollment. In contrast, those who participated in CR showed a lower risk for MACE in crude (0.52; 0.41–0.65) and adjusted analysis (0.56; 0.44–0.71). Conclusions Participation in DMP was not associated with a lower risk of MACE, but participation in CR showed beneficial effects. Adjustment only slightly changed effect estimates in both cases, but it is still important to consider potential effects of additional confounding variables.
Collapse
Affiliation(s)
- Christian Fischer
- Institute of Medical Epidemiology, Biometrics and Informatics, Medical Faculty of Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Jens Höpner
- Institute of Medical Epidemiology, Biometrics and Informatics, Medical Faculty of Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Saskia Hartwig
- Institute of Medical Epidemiology, Biometrics and Informatics, Medical Faculty of Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III (KIM III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Germany
| | - Rafael Mikolajczyk
- Institute of Medical Epidemiology, Biometrics and Informatics, Medical Faculty of Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Germany.
| |
Collapse
|
5
|
Kirsch F, Becker C, Kurz C, Schwettmann L, Schramm A. Effects of adherence to pharmacological secondary prevention after acute myocardial infarction on health care costs - an analysis of real-world data. BMC Health Serv Res 2020; 20:1145. [PMID: 33342431 PMCID: PMC7751107 DOI: 10.1186/s12913-020-05946-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022] Open
Abstract
Background Acute myocardial infarction (AMI), a major source of morbidity and mortality, is also associated with excess costs. Findings from previous studies were divergent regarding the effect on health care expenditure of adherence to guideline-recommended medication. However, gender-specific medication effectiveness, correlating the effectiveness of concomitant medication and variation in adherence over time, has not yet been considered. Methods We aim to measure the effect of adherence on health care expenditures stratified by gender from a third-party payer’s perspective in a sample of statutory insured Disease Management Program participants over a follow-up period of 3-years. In 3627 AMI patients, the proportion of days covered (PDC) for four guideline-recommended medications was calculated. A generalized additive mixed model was used, taking into account inter-individual effects (mean PDC rate) and intra-individual effects (deviation from the mean PDC rate). Results Regarding inter-individual effects, for both sexes only anti-platelet agents had a significant negative influence indicating that higher mean PDC rates lead to higher costs. With respect to intra-individual effects, for females higher deviations from the mean PDC rate for angiotensin-converting enzyme (ACE) inhibitors, anti-platelet agents, and statins were associated with higher costs. Furthermore, for males, an increasing positive deviation from the PDC mean increases costs for β-blockers and a negative deviation decreases costs. For anti-platelet agents, an increasing deviation from the PDC-mean slightly increases costs. Conclusion Positive and negative deviation from the mean PDC rate, independent of how high the mean was, usually negatively affect health care expenditures. Therefore, continuity in intake of guideline-recommended medication is important to save costs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05946-4.
Collapse
Affiliation(s)
- Florian Kirsch
- Munich School of Management, Institute of Health Economics and Health Care Management, Ludwigstraße 28 1, 80539, Munich, Germany. .,Institute of Health Economics and Health Care Management, HelmholtzZentrum München, Neuherberg, Germany.
| | - Christian Becker
- Institute of Health Economics and Health Care Management, HelmholtzZentrum München, Neuherberg, Germany
| | - Christoph Kurz
- Institute of Health Economics and Health Care Management, HelmholtzZentrum München, Neuherberg, Germany
| | - Lars Schwettmann
- Institute of Health Economics and Health Care Management, HelmholtzZentrum München, Neuherberg, Germany
| | - Anja Schramm
- AOK Bayern, Service Center of Health Care Management, Regensburg, Germany
| |
Collapse
|
6
|
Kirsch F, Becker C, Schramm A, Maier W, Leidl R. Patients with coronary artery disease after acute myocardial infarction: effects of continuous enrollment in a structured Disease Management Program on adherence to guideline-recommended medication, health care expenditures, and survival. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:607-619. [PMID: 32006188 PMCID: PMC7214389 DOI: 10.1007/s10198-020-01158-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 01/06/2020] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Acute myocardial infarction (AMI) carries increased risk of mortality and excess costs. Disease Management Programs (DMPs) providing guideline-recommended care for chronic diseases seem an intuitively appealing way to enhance health outcomes for patients with chronic conditions such as AMI. The aim of the study is to compare adherence to guideline-recommended medication, health care expenditures and survival of patients enrolled and not enrolled in the German DMP for coronary artery disease (CAD) after an AMI from the perspective of a third-party payer over a follow-up period of 3 years. METHODS The study is based on routinely collected data from a regional statutory health insurance fund (n = 15,360). A propensity score matching with caliper method was conducted. Afterwards guideline-recommended medication, health care expenditures, and survival between patients enrolled and not enrolled in the DMP were compared with generalized linear and Cox proportional hazard models. RESULTS The propensity score matching resulted in 3870 pairs of AMI patients previously and continuously enrolled and not enrolled in the DMP. In the 3-year follow-up period the proportion of days covered rates for ACE-inhibitors (60.95% vs. 58.92%), anti-platelet agents (74.20% vs. 70.66%), statins (54.18% vs. 52.13%), and β-blockers (61.95% vs. 52.64%) were higher in the DMP group. Besides that, DMP participants induced lower health care expenditures per day (€58.24 vs. €72.72) and had a significantly lower risk of death (HR: 0.757). CONCLUSION Previous and continuous enrollment in the DMP CAD for patients after AMI is a promising strategy as it enhances guideline-recommended medication, reduces health care expenditures and the risk of death.
Collapse
Affiliation(s)
- Florian Kirsch
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany.
- Munich School of Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Christian Becker
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Anja Schramm
- AOK Bayern, Service Center of Health Care Management, Regensburg, Germany
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Reiner Leidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
- Munich School of Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
7
|
Seidl H, Hunger M, Meisinger C, Kirchberger I, Kuch B, Leidl R, Holle R. The 3-Year Cost-Effectiveness of a Nurse-Based Case Management versus Usual Care for Elderly Patients with Myocardial Infarction: Results from the KORINNA Follow-Up Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:441-450. [PMID: 28292489 DOI: 10.1016/j.jval.2016.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 09/23/2016] [Accepted: 10/02/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To assess the 3-year cost-effectiveness of a nurse-based case management intervention in elderly patients with myocardial infarction from a societal perspective. METHODS The intervention consisted of one home visit and quarterly telephone calls in the first year, and semi-annual calls in the following 2 years. The primary effect measures were quality-adjusted life-years (QALYs), on the basis of the EuroQol five-dimensional questionnaire (EQ-5D-3L) and adjusted life-years from patients' self-rated health states according to the visual analogue scale (VAS-ALs). A linear regression model was used for adjusted life-years and a gamma model for costs. Estimation uncertainty was addressed by cost-effectiveness acceptability curves, which indicate the likelihood of cost-effectiveness for a given value of willingness to pay. The secondary objective was to examine EQ-5D-3L utility scores and VAS scores among survivors using linear mixed models. RESULTS Primary outcomes regarding QALY gains (+0.0295; P = 0.76) and VAS-AL gains (+0.1332; P = 0.09) in the intervention group were not significant. The overall cost difference was -€2575 (P = 0.30). The probability of cost-effectiveness of the case management at a willingness-to-pay value of €0 per QALY was 84% in the case of QALYs and 81% in the case of VAS-ALs. Secondary outcomes concerning survivors' quality of life were significantly better in the intervention group (EQ-5D-3L utilities: +0.104, P = 0.005; VAS: +8.15, P = 0.001) after 3 years. CONCLUSIONS The case management was cost-neutral and led to an important and significant improvement in health status among survivors. It was associated with higher QALYs and lower costs but the differences in costs and QALYs were not statistically significant.
Collapse
Affiliation(s)
- Hildegard Seidl
- Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany.
| | - Matthias Hunger
- Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany
| | - Christa Meisinger
- KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Augsburg, Germany; Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany
| | - Inge Kirchberger
- KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Augsburg, Germany; Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany
| | - Bernhard Kuch
- Department for Internal Medicine/Cardiology, Donau-Ries-Kliniken, Nördlingen, Germany
| | - Reiner Leidl
- Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany
| | - Rolf Holle
- Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany
| |
Collapse
|
8
|
Hirsch K, Bohley S, Mau W, Schmidt-Pokrzywniak A. The RHESA-CARE study: an extended baseline survey of the regional myocardial infarction registry of Saxony-Anhalt (RHESA) design and objectives. BMC Cardiovasc Disord 2016; 16:159. [PMID: 27534534 PMCID: PMC4989530 DOI: 10.1186/s12872-016-0336-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 07/27/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is a leading cause of death in Europe. In Germany, a declining mortality rate from acute myocardial infarction (AMI) has been observed in the last decades. Nevertheless, there are large differences between the federal states when looking at the mortality and morbidity of AMI. Saxony-Anhalt is one of the federal states with the highest mortality rates for AMI in Germany. In 2012, the regional myocardial infarction registry of Saxony-Anhalt (RHESA) was established to investigate the individual, infrastructural, and health care factors with respect to an urban (city of Halle) and rural (region of Altmark) population. For detailed observation the RHESA-CARE study was conducted in 2014. RHESA-CARE focuses on the symptoms during infarction, the behaviour of patients while alerting for infarction, the use of rehabilitation possibilities, and long-term care. METHODS/DESIGN RHESA-CARE is an extended baseline survey of AMI patients registered in RHESA who are aged 25 or more, and inhabitants of the city of Halle (Saale) or the district of Altmark in the federal state of Saxony-Anhalt, Germany. Detailed information was collected on classical and psychosocial cardiovascular risk factors as well as factors of alerting behaviour, first aid, and utilization of medical and rehabilitation services. High data quality is ensured by a detailed system of quality control. DISCUSSION RHESA-CARE has the main objective to investigate factors that influence morbidity and mortality rates due to AMI. Another purpose is the comparison of a rural and urban patient population. It provides an opportunity to serve as a base for improvement of patients' behaviour and health care as well as further research.
Collapse
Affiliation(s)
- Katharina Hirsch
- Martin Luther University Halle-Wittenberg, Institute of Medical Epidemiology, Biostatistics, and Informatics, Magdeburger Str. 8, Halle (Saale), D-06097 Germany
| | - Stefanie Bohley
- Martin Luther University Halle-Wittenberg, Institute of Medical Epidemiology, Biostatistics, and Informatics, Magdeburger Str. 8, Halle (Saale), D-06097 Germany
| | - Wilfried Mau
- Martin Luther University Halle-Wittenberg, Institute of Rehabilitation Medicine, Magdeburger Str. 8, Halle (Saale), D-06097 Germany
| | - Andrea Schmidt-Pokrzywniak
- Martin Luther University Halle-Wittenberg, Institute of Medical Epidemiology, Biostatistics, and Informatics, Magdeburger Str. 8, Halle (Saale), D-06097 Germany
| |
Collapse
|
9
|
Temporal deformation pattern in acute and late phases of ST-elevation myocardial infarction: incremental value of longitudinal post-systolic strain to assess myocardial viability. Clin Res Cardiol 2016; 105:815-26. [DOI: 10.1007/s00392-016-0989-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
|
10
|
Morphine interaction with prasugrel: a double-blind, cross-over trial in healthy volunteers. Clin Res Cardiol 2015; 105:349-55. [PMID: 26493304 PMCID: PMC4805697 DOI: 10.1007/s00392-015-0927-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/15/2015] [Indexed: 01/01/2023]
Abstract
Background Morphine decreases the concentrations and effects of clopidogrel, which could lead to treatment failure in myocardial infarction. Objectives To clarify whether more potent P2Y12-inhibitors may provide an effective alternative, we examined drug–drug interactions between morphine and prasugrel. Methods Twelve healthy volunteers received 60 mg prasugrel with placebo or 5 mg morphine intravenously in a randomized, double-blind, placebo-controlled, cross-over trial. Pharmacokinetics were determined by liquid chromatography tandem mass spectrometry, and prasugrel effects were measured by platelet function tests. Results Morphine neither diminished total drug exposure (AUC), which was the primary endpoint, nor significantly delayed drug absorption of prasugrel. However, morphine reduced maximal plasma concentrations (Cmax) of prasugrel active metabolite by 31 % (p = 0.019). Morphine slightly, but not significantly, delayed the onset of maximal inhibition of platelet plug formation under high shear rates (30 vs. 20 min). Whole blood aggregation was not influenced. Conclusions Although morphine significantly decreases the maximal plasma concentrations of prasugrel active metabolite, it does not diminish its effects on platelets to a clinically relevant degree in healthy volunteers. However, it should be considered that the observed decrease in Cmax of prasugrel active metabolite caused by morphine co-administration may gain relevance in STEMI patients. Clinical Trial Registration: NCT01369186, EUDRA-CT#: 2010-023761-22.
Collapse
|
11
|
Laxy M, Stark R, Meisinger C, Kirchberger I, Heier M, von Scheidt W, Holle R. The effectiveness of German disease management programs (DMPs) in patients with type 2 diabetes mellitus and coronary heart disease: results from an observational longitudinal study. Diabetol Metab Syndr 2015; 7:77. [PMID: 26388948 PMCID: PMC4574141 DOI: 10.1186/s13098-015-0065-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the population-based German disease management programs (DMPs) for diabetes mellitus (DM) and coronary heart disease (CHD) are among the biggest worldwide, evidence on the effectiveness of these programs is still inconclusive or missing, particularly for high risk patients with comorbidities. The objective of this study was therefore to analyze the impact of DMPs on process and outcome parameters in patients with both, type 2 DM and CHD. METHODS Analyses are based on two postal surveys of patients from the KORA myocardial infarction registry (southern Germany) with type 2 DM and on two postal validation studies with patients' general physicians (2006, n = 312 and 2011, n = 212). The association between DMP enrollment (being enrolled in either DMP-DM or DMP-CHD) and guideline care (defined by several process indicators) at baseline (2006) and its development until follow-up (2011) was analyzed using logistic regression models accounting for the repeated measurements structure. The impact of DMP enrollment/guideline care on cumulated (quality-adjusted) life years ((QA)LYs) over a 4-year time horizon (2006-2010) was assessed using multiple linear regression methods. Logistic regression models were applied to analyze the association between DMP status and patient self-management at follow-up. RESULTS Being enrolled in a DMP was associated with better guideline care at baseline [OR = 2.3 (95 % CI 1.27-4.03)], but not at follow-up [OR = 0.80 (95 % CI 0.40-1.58); p value for time-interaction <0.01]. DMP enrollment was not significantly [+0.15 LYs (95 % CI -0.07, 0.37); +0.06 QALYs (95 % CI -0.15, 0.26)], but treatment according to guideline care significantly [+0.40 LYs (95 % CI 0.21-0.60); +0.28 QALYs (95 % CI 0.10-0.45)] associated with higher (quality-adjusted) survival over the 4-year follow-up period. DMP enrollees further reported a somewhat better self-management than patients not being enrolled into a DMP. CONCLUSIONS The results of this study concerning the effectiveness of DMPs in patients with DM and CHD are mixed, but are weakly in favor of DMPs. However, we found a clear positive impact of guideline care on quality adjusted survival in this patient group. The development of the association between DMP enrollment and guideline care over the follow-up time indicates some external effects, which should be the subject of further investigations.
Collapse
Affiliation(s)
- Michael Laxy
- />Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />German Center for Diabetes Research, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Renée Stark
- />Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Christa Meisinger
- />Helmholtz Zentrum München, Institute of Epidemiology II, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Inge Kirchberger
- />Helmholtz Zentrum München, Institute of Epidemiology II, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Margit Heier
- />Helmholtz Zentrum München, Institute of Epidemiology II, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Wolfgang von Scheidt
- />Department of Internal Medicine I-Cardiology, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Rolf Holle
- />Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />German Center for Diabetes Research, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| |
Collapse
|
12
|
Seidl H, Hunger M, Leidl R, Meisinger C, Wende R, Kuch B, Holle R. Cost-effectiveness of nurse-based case management versus usual care for elderly patients with myocardial infarction: results from the KORINNA study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2015; 16:671-681. [PMID: 25108626 DOI: 10.1007/s10198-014-0623-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 07/11/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES We assessed the cost-effectiveness of a case management intervention by trained nurses in elderly (≥65 years) patients with myocardial infarction from a societal perspective. METHODS The intervention and observation period spanned 1 year and 329 participants were enrolled. The intervention consisted of at least one home visit and quarterly telephone calls. Data on resource use and quality of life were collected quarterly. The primary measurements of effect were quality-adjusted life years (QALYs), based on the EuroQol five-dimensional questionnaire (EQ-5D-3L) health utilities from the German time trade-off. The secondary measurements were EQ-5D-3L utility values and patients' self-rated health states according to the visual analogue scale (VAS) among survivors. To estimate mean differences, a linear regression model was used for QALYs and a gamma model for costs. Health states among the survivors were analysed using linear mixed models. To assess the impact of different health state valuation methods, VAS-adjusted life years were constructed. RESULTS The mean difference in QALYs was small and not significant (-0.0163; CI -0.0681-0.0354, p value: 0.536, n = 297). Among survivors, EQ-5D-3L utilities showed significant improvements within 6 months in the intervention group (0.051; CI 0.0028-0.0989; p value: 0.0379, n = 280) but returned towards baseline levels by month 12. The mean improvement in self-rated health (VAS) within 1 year was significantly larger in the intervention group (+9.2, CI 4.665-13.766, p value: <0.0001, n = 266). The overall cost difference was -<euro>17.61 (CI - <euro>2,601-<euro>2,615; p value: 0.9856, n = 297). The difference in VAS-adjusted life years was 0.0378 (CI -0.0040-0.0796, p value: 0.0759, n = 297). CONCLUSIONS This study could not provide evidence to conclude that the case management intervention was an effective and cost-effective alternative to usual care within a time horizon of 1 year.
Collapse
Affiliation(s)
- Hildegard Seidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Ingolstädter Landstraße 1, 85764, Neuherberg, Germany,
| | | | | | | | | | | | | |
Collapse
|
13
|
Bozorgmehr K, Maier W, Brenner H, Saum KU, Stock C, Miksch A, Holleczek B, Szecsenyi J, Razum O. Social disparities in Disease Management Programmes for coronary heart disease in Germany: a cross-classified multilevel analysis. J Epidemiol Community Health 2015; 69:1091-101. [PMID: 26082518 PMCID: PMC4680139 DOI: 10.1136/jech-2014-204506] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 05/19/2015] [Indexed: 11/16/2022]
Abstract
Background Disease Management Programmes (DMPs) aim to improve effectiveness and equity of care but may suffer from selective enrolment. We analysed social disparities in DMP enrolment among elderly patients with coronary heart disease (CHD) in Germany, taking into account contextual effects at municipality and primary care practice levels. Methods Cross-sectional analysis of effects of educational attainment and regional deprivation on physician-reported DMP enrolment in a subsample of a large population-based cohort study in Germany, adjusting for individual-level, practice-level and area-level variables. We calculated OR and their 95% CIs (95% CI) in cross-classified, multilevel logistic regression models. Results Among N=1280 individuals with CHD (37.3% women), DMP enrolment rates were 22.2% (women) and 35% (men). The odds of DMP enrolment were significantly higher for male patients (OR=1.98 (1.50 to 2.62)), even after adjustment for potential confounding by individual-level, practice-level and area-level variables (range: OR=1.60 (1.08 to 2.36) to 2.16 (1.57 to 2.98)). Educational attainment was not significantly associated with DMP enrolment. Compared to patients living in least-deprived municipalities, the adjusted propensity of DMP enrolment was statistically significantly lower for patients living in medium-deprived municipalities (OR=0.41 (0.24 to 0.71)), and it also tended to be lower for patients living in the most-deprived municipalities (OR=0.70 (0.40 to 1.21)). Models controlling for the social situation (instead of health-related behaviour) yielded comparable effect estimates (medium-deprived/most-deprived vs least-deprived areas: OR=0.45 (0.26 to 0.78)/OR=0.68 (0.33 to 1.19)). Controlling for differences in comorbidity attenuated the deprivation effect estimates. Conclusions We found evidence for marked gender, but not educational disparities in DMP enrolment among patients with CHD. Small-area deprivation was associated with DMP enrolment, but the effects were partly explained by differences in comorbidity. Future studies on DMPs should consider contextual effects when analysing programme effectiveness or impacts on equity and efficiency.
Collapse
Affiliation(s)
- Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München-German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Kai-Uwe Saum
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Stock
- Institute of Medical Biometry and Informatics, University Heidelberg, Heidelberg, Germany
| | - Antje Miksch
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Oliver Razum
- Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany
| |
Collapse
|
14
|
Bozorgmehr K, San Sebastian M, Brenner H, Razum O, Maier W, Saum KU, Holleczek B, Miksch A, Szecsenyi J. Analysing horizontal equity in enrolment in Disease Management Programmes for coronary heart disease in Germany 2008-2010. Int J Equity Health 2015; 14:28. [PMID: 25879523 PMCID: PMC4357160 DOI: 10.1186/s12939-015-0155-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 02/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Disease Management Programmes (DMPs) have been introduced in Germany ten years ago with the aim to improve effectiveness and equity of care, but little is known about the degree to which enrolment in the programme meets the principles of equity in health care. We aimed to analyse horizontal equity in DMP enrolment among patients with coronary heart disease (CHD). METHODS Cross-sectional analysis of horizontal inequities in physician-reported enrolment in the DMP for CHD in a large population-based cohort-study in Germany (2008-2010). We calculated horizontal inequity indices (HII) and their 95% confidence intervals [95%CI] for predicted need-standardised DMP enrolment across two measures of socio-economic status (SES) (educational attainment, regional deprivation) stratified by sex. Need-standardised DMP enrolment was predicted in multi-level logistic regression models. RESULTS Among N = 1,280 individuals aged 55-84 years and diagnosed with CHD, DMP enrolment rates were 22.2% (women) and 35.0% (men). Education-related inequities in need-standardised DMP enrolment favoured groups with lower education, but HII estimates were not significant. Deprivation-related inequities among women significantly favoured groups with higher SES (HII = 0.086 [0.007 ; 0.165]. No such deprivation-related inequities were seen among men (HII = 0.014 [-0.048 ; 0.077]). Deprivation-related inequities across the whole population favoured groups with higher SES (HII estimates not significant). CONCLUSION Need-standardised DMP enrolment was fairly equitable across educational levels. Deprivation-related inequities in DMP enrolment favoured women living in less deprived areas relative to those living in areas with higher deprivation. Further research is needed to gain a better understanding of the mechanisms that contribute to deprivation-related horizontal inequities in DMP enrolment among women.
Collapse
Affiliation(s)
- Kayvan Bozorgmehr
- Department of General Practice & Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
| | - Miguel San Sebastian
- Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Oliver Razum
- Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany.
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
| | - Kai-Uwe Saum
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | | | - Antje Miksch
- Department of General Practice & Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
| | - Joachim Szecsenyi
- Department of General Practice & Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
| |
Collapse
|
15
|
A high ratio of ADP-TRAP induced platelet aggregation is associated more strongly with increased mortality after coronary stent implantation than high conventional ADP induced aggregation alone. Clin Res Cardiol 2014; 103:968-75. [PMID: 25027180 DOI: 10.1007/s00392-014-0737-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 06/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to evaluate whether a high relative ADP induced aggregation (r-ADP-agg) is associated with an increased mortality in patients after coronary stent implantation. BACKGROUND Several trials were not able to improve clinical outcome by adapting platelet inhibition in patients after coronary stent implantation and high platelet reactivity (HPR). Platelet monitoring is complex and conventional definition of adenosindiphosphate (ADP) induced aggregation alone might not transfer the whole picture of adequate platelet inhibition in vivo. METHODS In a prospective single-centre observational trial multiple electrode aggregometry was performed in whole blood of patients after stent implantation. r-ADP-agg was defined as the ADP-thrombin receptor activating peptide ratio to reflect an individual degree of P2Y12 dependent platelet inhibition with a cut-off value for HPR of ≥ 50%. The primary end point was mortality. RESULTS Follow-up was completed in 176 of 184 patients (96%) with a mean follow-up time of 3.7 years. 35 (20 %) patients revealed an r-ADP-agg ≥ 50%. An r-ADP-agg ≥ 50% was associated with an increased mortality [unadjusted hazard ratio (HR) 7.006 (2.561-19.17); p = 0.0001]. In a multivariable Cox regression analysis mortality was independently associated with an r-ADP-agg ≥ 50% [HR 3.324 (1.542-7.165); p = 0.0022], ACS-setting [HR 3.249 (1.322-7.989); p = 0.0102] and severely reduced LV function [HR 5.463 (2.098-14.26); p = 0.0005]. CONCLUSION An r-ADP-agg ≥ 50% is associated with an increased mortality in patients after coronary stent implantation. Furthermore, r-ADP-agg might represent a better tool to predict clinical outcome than the conventional ADP induced platelet aggregation alone.
Collapse
|
16
|
Amann U, Kirchberger I, Heier M, Golüke H, von Scheidt W, Kuch B, Peters A, Meisinger C. Long-term survival in patients with different combinations of evidence-based medications after incident acute myocardial infarction: results from the MONICA/KORA Myocardial Infarction Registry. Clin Res Cardiol 2014; 103:655-64. [DOI: 10.1007/s00392-014-0688-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/12/2014] [Indexed: 11/29/2022]
|