Patient experiences with a phone-based cardiovascular risk reduction intervention: Are there differences between women and men?

OBJECTIVES

To explore gender-based differences in experiences with a telehealth-delivered intervention for reduction of cardiovascular risk.

METHODS

We conducted 23 semi-structured qualitative interviews by telephone with 11 women and 12 men who received a 12-month, pharmacist-delivered, telephone-based medication and behavioral management intervention. We used content analysis to identify themes.

RESULTS

We identified three common themes for both men and women: ease and convenience of phone support, preference for proactive outreach, and need for trust building in the context of telehealth. While both genders appreciated the social support from the intervention pharmacist, women voiced appreciation for accountability whereas men generally spoke about encouragement.

CONCLUSIONS

Rapport building may differ between telehealth and in-person healthcare visits; our work highlights how men and women's experiences can differ with telehealth care and which can inform the development of future, purposeful rapport building activities to strengthen the clinician-patient interaction.

PRACTICE IMPLICATIONS

Clinicians should seek opportunities to provide frequent and routine support for patients with chronic disease. Telehealth interventions may benefit from gender-specific tailoring of social support.

Adherence to recommendations for secondary prevention medications after myocardial infarction in Estonia: comparison of real-world data from 2004 to 2005 and 2017 to 2018

Background

Relatively high rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported, but register-based, objective real-world data is scarce. We aimed to analyse adherence to guideline-recommended medications for secondary prevention of MI in 2017 to 2018 (period II) and compare the results with data from 2004 to 2005 (period I) in Estonia.

Methods

Study populations were formed based on data from the Estonian Health Insurance Fund’s database and on Estonian Myocardial Infarction Register. By linking to the Estonian Medical Prescription Centre database adherence to guideline-recommended medications for MI secondary prevention was assessed for 1 year follow-up period from the first hospitalization due to MI. Data was analysed using the defined daily dosages methodology.

Results

Total of 6694 and 6060 cases of MI were reported in periods I and II, respectively. At least one prescription during the follow up period was found for beta-blockers in 81.0% and 83.5% (p = 0.001), for angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) in 76.9% and 66.0% (p < 0.001), and for statins in 44.0% and 67.0% (p < 0.001) of patients in period I and II, respectively. P2Y12 inhibitors were used by 76.4% of patients in period II. The logistic regression analysis adjusted to gender and age revealed that some drugs and drug combinations were not allocated similarly in different age and gender groups.

Conclusions

In Estonia, adherence to MI secondary prevention guideline-recommended medications has improved. But as adherence is still not ideal more attention should be drawn to MI secondary prevention through systematic guideline implementation.

Health care service use and costs for a cohort of high-needs elderly diabetic patients

AIMS

To describe the impact of diabetes comorbidities on the health care services use and costs of a cohort of elderly patients with diabetes and high health care needs (HHCN), based on real-world data.

METHODS

We focused on a cohort of diabetic patients with HHCN belonging to Resource Utilization Bands 4 and 5 according to the Adjusted Clinical Group (ACG) system. Their comorbidities were assessed using the clinical diagnoses that the ACG system assigns to single patients by combining different information flows. Regression models were applied to analyze the associations between comorbidities and health care service use or costs, adjusting for age and sex.

RESULTS

Our analyses showed that all health care service usage measures (e.g. access to emergency care; number of outpatient visits) and the total annual costs and pharmacy costs are associated significantly with comorbidity class. Instead, no differences in hospitalization rates by comorbidity class were revealed.

CONCLUSION

The association between a larger number of comorbidities and higher total health care service usage and costs was seen mainly for primary care services. This underscores the need to strengthen primary care for today's aging and multimorbid population.

Gender differences and health inequality: Evolution of cardiovascular risk in workers

The aim was to find out if there are any such differences due to gender in a cohort of workers followed for ten years, comparing their lifestyles and following the evolution of the main cardiovascular risk factors (CVRF) and their impact on cardiovascular risk. An observational longitudinal study of 698 civil servants workers (186 women and 512 men) of a local government office from Córdoba (Spain), was conducted over the period 2003-2014. We compared the initial and final prevalence of physical activity, smoking, obesity, hypertension, metabolic syndrome and diabetes. Cardiovascular risk was also assessed using the REGICOR (Registre Gironí del Cor) and SCORE (Systematic Coronary Risk Evaluation) equations. There was a greater rise in the prevalence of hypertension and hypercholesterolemia in the cohort in women than in men (94.2% vs. 38% and 92% vs 21.1%), while the reduction in smoking also differed by gender (26.4% vs. 36.5%). It could be that since women present a lower cardiovascular risk profile, they are treated less or less effort is made to keep the risk factors low, resulting in a worse evolution of smoking, hypercholesterolemia and hypertension in women.

Prescribing and medical non-adherence after myocardial infarction: qualitative interviews with general practitioners in Germany

BACKGROUND

An increasing prevalence of having survived a myocardial infarction increases the importance of medical secondary prevention. Although preventive medication reduces mortality, prescribing and adherence are known to be frequently insufficient. General practitioners are the most important prescriber. However, their perspective on prescribing and medical non-adherence following myocardial infarction has not yet been explored. Thus, the aim of this study was to explore the general practitioners' perspective on long-term care after myocardial infarction focussing on medical prevention.

METHODS

In this qualitative interview study we conducted episodic interviews with sixteen general practitioners from rural and urban surgeries in Germany. Framework analysis with focus on general practitioners' prescribing and patients' non-adherence was performed.

RESULTS

Almost all general practitioners reported following guidelines for myocardial infarction aftercare and prescribing the medication that was initiated in the hospital; however, they described deviating from guidelines because of drugs' side effects or patients' intolerances. Some questioned the benefits of medical secondary prevention for the oldest of patients. General practitioners perceived good adherence among their patients who had had an MI while they regarded their methods for assessing medical non-adherence as limited. They perceived diverse reasons for non-adherence, particularly side effects, patients' freedom from symptoms and patients' indifference to health. They attributed mainly negative characteristics, like lack of knowledge and understanding, to non-adherent patients. These characteristics contribute to the difficulty of convincing these patients to take medications as prescribed. General practitioners improved adherence by preventing side effects, explaining the medication's necessity, facilitating intake and involving patients in decision-making. However, about half of the general practitioners reported threatening their patients with negative consequences of non-adherence.

CONCLUSIONS

General practitioners should be aware that discharge medication can be insufficient and thus, should always check hospital recommendations for accordance with guideline recommendations. Improving physicians' communication skills and informing and motivating patients in an adequate manner, for example in simple language, should be an important goal in the hospital and the general practitioner setting. General practitioners should assess patients' motivations through motivational interviewing, which no general practitioner mentioned during the interviews, and talk with them about adherence and long-term treatment goals regularly.

[Secondary prevention of coronary heart disease in women and men in Germany from 1997-1999 and from 2008-2011-Trend analysis with two national health population surveys]

BACKGROUND

The benefit of medicines in the secondary prevention of coronary heart disease (CHD) has been demonstrated in women and men. However, gender-specific differences have been observed in the prescription of these medicines. Information on trends in prevalence use in women and men from population-based studies are still lacking.

METHODS

Data of people aged 40-79 years with CHD from the national health interview and examination surveys for adults in Germany from 1997-1999 (GNHIES98, n = 411) and from 2008-2011 (DEGS1, n = 440) were analyzed. Trend analyses via multivariable regression models, taking into account relevant covariables, were used to calculate the prevalence of medicine use in secondary prevention of CHD between GNHIES98 and DEGS1. The following groups were considered: antiplatelet, statins, beta-receptor blockers, agents acting on the renin-angiotensin system (RAS blocker), calcium-channel blockers, and nitrate.

RESULTS

In one decade, the prevalence had increased for antiplatelet (24.0% vs. 59.6%), statins (18.5% vs. 56.2%), beta-receptor blockers (24.7% vs. 65.5%), and RAS blockers (31.6% vs. 69.0%). The prevalence of calcium-channel blockers (33.3% vs. 20.5%) and nitrate (40.6% vs. 10.1%) had decreased. In GNHIES98, men were more likely to use RAS blockers. Significant gender differences were found in DEGS1 only for angiotensin-converting-enzyme (ACE) inhibitors.

CONCLUSION

This study showed an improvement in the use of drugs for the secondary prevention of CHD in both sexes.

Trends and variations in the prescribing of secondary preventative cardiovascular therapies for non-ST elevation myocardial infarction (NSTEMI) in Malaysia

PURPOSE

Information is lacking on prescribing of preventative cardiovascular pharmacotherapies for patients with non-ST elevation myocardial infarction (NSTEMI) in the Asian region. This study examined the prescribing rate of these pharmacotherapies, comparing NSTEMI to STEMI, and variations across demographics and clinical factors within the NSTEMI group in the multi-ethnic Malaysian population.

METHODS

This is a retrospective analysis of the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry from year 2006 to 2013 (n = 30,873). On-discharge pharmacotherapies examined were aspirin, ADP-antagonists, statins, ACE-inhibitors, angiotensin-II-receptor blockers, and beta-blockers. Multivariate logistic regression was used to calculate adjusted odds ratio of receiving individual pharmacotherapies according to patients' characteristics in NSTEMI patients (n = 11,390).

RESULTS

Prescribing rates for cardiovascular pharmacotherapies had significantly increased especially for ADP-antagonists (76%) in NSTEMI patients. More than 85% were prescribed statins and antiplatelets but rates remained significantly lower compared to STEMI. Women and those over 65 years old were less likely to be prescribed these pharmacotherapies compared to men and younger NSTEMI patients. Chinese and Indians were more likely to receive selected pharmacotherapies compared to Malays (main ethnicity). Geographical variations were observed; East Malaysian (Malaysian Borneo) patients were less likely to receive these compared to Western region of Malaysian Peninsular. Underprescribing in patients with risk factors such as diabetes were observed with other co-morbidities influencing prescribing selectively.

CONCLUSION

This study uncovers demographic and clinical variations in cardiovascular pharmacotherapies prescribing for NSTEMI. Concerted efforts by policy makers, specialty societies, and physicians are required focusing on elderly, women, Malays, East Malaysians, and high-risk patients.

Characterization and cholesterol management in patients with cardiovascular events and/or type 2 diabetes in the Netherlands

OBJECTIVE

To describe clinical characteristics and cholesterol management of patients with cardiovascular events (CVEs) and/or type 2 diabetes mellitus (T2DM) with high low-density lipoprotein cholesterol (LDL-C) > 1.8 mmol/L in the Netherlands.

RESEARCH DESIGN AND METHODS

From the PHARMO Database Network a cross-sectional cohort was constructed. The descriptive study included patients on lipid modifying therapy (LMT) in 2009, classified as high cardiovascular risk based on a history of T2DM or CVE, with 2010 LDL-C levels above 1.8 mmol/L (2011 European Society of Cardiology [ESC] target). Sub-cohorts were created: T2DM + CVE from the T2DM cohort and multiple CVE from the CVE only cohort.

MAIN OUTCOME MEASURES

Clinical characteristics and drug treatment were determined at the time of the last LDL-C measurement in 2010.

RESULTS

Of 10,864 very high risk patients, 66% had T2DM, 37% of whom also had CVE. In the CVE only cohort (34%), 18% had multiple events. More regular check-ups skewed inclusion towards diabetes patients. T2DM vs. CVE cohort characteristics were: 53% vs. 63% male, 42% vs. 27% obese, 19% vs. 24% current smoker, 54% vs. 51% systolic blood pressure <140 mmHg, with similar proportions in the sub-cohorts. Proportions reaching the Dutch guideline LDL-C target of <2.5 mmol/L were 56% (T2DM), 57% (T2DM + CVE), 48% (CVE only) and 53% (multiple CVE only). Frequencies of high intensity dose statin (simvastatin ≥80 mg, atorvastatin ≥40 mg or rosuvastatin ≥20 mg) were 6% (T2DM), 9% (T2DM + CVE, CVE only) and 14% (multiple CVE only); 1-2% received additional ezetimibe and 3-5% received non-statin LMT only, including ezetimibe.

CONCLUSION

Despite LMT, >40% of the patients above ESC target also failed to reach the less stringent Dutch target, even in the higher risk groups. Therefore, management of hypercholesterolemia after CVE or T2DM should be optimized to improve cardiovascular outcomes. There is substantial room for improving other cardiovascular risk factors.

Evaluating quality and its determinants in lipid control for secondary prevention of heart disease and stroke in primary care: a study in an inner London Borough

OBJECTIVES

To assess quality of management and determinants in lipid control for secondary prevention of cardiovascular disease (CVD) using multilevel regression models.

DESIGN

Cross-sectional study.

SETTING

Inner London borough, with a primary care registered population of 378,000 (2013).

PARTICIPANTS

48/49 participating general practices with 7869 patients on heart disease/stroke registers were included.

OUTCOME MEASURES

(1) Recording of current total cholesterol levels and lipid control according to national evidence-based standards. (2) Assessment of quality by age, sex, ethnicity, deprivation, presence of other risks or comorbidity in meeting both lipid measurement and control standards.

RESULTS

Some process standards were not met. Patients with a current cholesterol measurement >5 mmol/L were less likely to have a current statin prescription (adjusted OR=3.10; 95% CI 2.70 to 3.56). They were more likely to have clustering of other CVD risk factors. Women were significantly more likely to have raised cholesterol after adjustment for other factors (adjusted OR=1.74; 95% CI 1.53 to 1.98).

CONCLUSIONS

In this study, the key factor that explained poor lipid control in people with CVD was having no current prescription record of a statin. Women were more likely to have poorly controlled cholesterol (independent of comorbid risk factors and after adjusting for age, ethnicity, deprivation index and practice-level variation). Women with CVD should be offered statin prescription and may require higher statin dosage for improved control.

Systematic age-related differences in chronic disease management in a population-based cohort study: a new paradigm of primary care is required

Background

Our interest in chronic conditions is due to the fact that, worldwide, chronic diseases have overtaken infectious diseases as the leading cause of death and disability, so their management represents an important challenge for health systems. The aim of this study was to compare the performance of primary health care services in managing diabetes, congestive heart failure (CHF) and coronary heart disease (CHD), by age group.

Methods

This population-based retrospective cohort study was conducted in Italy, enrolling 1,948,622 residents ≥16 years old. A multilevel regression model was applied to analyze compliance to care processes with explanatory variables at both patient and district level, using age group as an independent variable, and adjusting for sex, citizenship, disease duration, and Charlson index on the first level, and for District Health Unit on the second level.

Results

The quality of chronic disease management showed an inverted U-shaped relationship with age. In particular, our findings indicate lower levels for young adults (16–44 year-olds), adults (45–64), and oldest old (+85) than for patients aged 65–74 in almost all quality indicators of CHD, CHF and diabetes management. Young adults (16–44 y), adults (45–64 y), the very old (75–84 y) and the oldest old (+85 y) patients with CHD, CHF and diabetes are less likely than 65–74 year-old patients to be monitored and treated using evidence-based therapies, with the exceptions of echocardiographic monitoring for CHF in young adult patients, and renal monitoring for CHF and diabetes in the very old.

Conclusion

Our study shows that more effort is needed to ensure that primary health care systems are sensitive to chronic conditions in the young and in the very elderly.