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Kjesbu I, Prescott E, Rasmusen H. K. H, Osler M, Larsen ML, Gustafsson I, Zwisler AD, Sibilitz KL. Socioeconomic and ethnical disparity in coronary heart disease outcomes in Denmark and the effect of cardiac rehabilitation—A nationwide registry study. PLoS One 2022; 17:e0276768. [PMCID: PMC9639811 DOI: 10.1371/journal.pone.0276768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022] Open
Abstract
Aims Cardiovascular patients with low socioeconomic status and non-western ethnic background have worse prognostic outcomes. The aim of this nationwide study was first to address whether short-term effects of hospital-based outpatient cardiac rehabilitation (CR) are similar across educational level and ethnic background, and secondly to study whether known disparity in long-term prognosis in patients with cardiovascular disese is diminished by CR participation. Methods All patients with myocardial infarction and/or coronary revascularization from August 2015 until March 2018 in the Danish national patient registry or the Danish cardiac rehabilitation database (DHRD) were included. We used descriptive statistics to address disparity in achievement of quality indicators in CR, and Cox proportional hazard regression to examine the association between the disparity measures and MACE (cardiovascular hospitalization and all-cause mortality) with adjustment for age, gender, index-diagnose and co-morbidity. Results We identified 34,511 patients of whom 19,383 had participated in CR and 9,882 provided information on CR outcomes from the DHRD. We demonstrated a socioeconomic gradient in improvements in VO2peak, and non-western patients were less often screened for depression or receive dietary consulting. We found a strong socioeconomic gradient in MACE irrespective of CR participation, medication, and risk factor control (adjusted HR 0.65 (95% CI 0.56–0.77) for high versus low education). Non-western origin was associated with higher risk of MACE (adjusted HR 1.2 (1.1–1.4)). Conclusion We found only minor socioeconomic and ethnic differences in achievement of CR quality indicators but strong differences in CHD prognosis indication that conventional risk factor control and medical treatment following CR do not diminish the socioeconomic and ethnical disparity in CHD prognosis.
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Affiliation(s)
- Ingunn Kjesbu
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
| | - Hanne Rasmusen H. K.
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
| | - Merete Osler
- Centre for Clinical Research and Disease Prevention, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Ida Gustafsson
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
| | - Ann Dorthe Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Kjesbu I, Prescott E, Rasmusen HK, Osler M, Larsen ML, Gustafsson I, Zwisler AD, Sibilitz KL. Cardiac rehabilitation do not diminish the socioeconomic and ethnical disparity in patients with coronary heart disease. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
Cardiac patients with low socioeconomic status and non-western ethnic background have worse outcomes. The aim of this nationwide study was to determine whether the immediate effect of CR differs between groups defined by socioeconomic status and ethnic background, and whether disparity in the prognosis of cardiac patients is diminished by CR participation.
Methods
We included all patients in Denmark with myocardial infarction and/or coronary revascularization from August 2015 until March 2018. Level of education, as a marker for socioeconomic status, was divided into four groups, and ethnicity into Danish, non-Western and Western. Participation in CR was identified through the Danish Cardiac Rehabilitation Database (DHRD) and the Danish National Patient Register. Primary outcome was achievement of CR quality indicators, including risk factor control and medication, from DHRD, and secondary outcome a composite endpoint of cardiovascular disease hospitalization and all-cause mortality (MACE).
Results
We identified 34,511 patients of whom 19,383 had participated in CR and 9,882 provided information on CR data from DHRD. Higher education was associated with greater improvement in VO2peak and non-western patients were less likely to be screened for depression or receive dietary consulting. No other significant disparity in CR quality indicators, was found across education and ethnicity. There was a strong socioeconomic gradient in MACE irrespective of CR participation, medication and risk factor control (adjusted HR 0.71 (0.58–0.86) for high versus low education). Similarly, non-western origin was associated with higher risk of MACE (adjusted HR 1.2 (1.1–1.4).
Conclusion
We found strong socioeconomic and ethnic disparity in prognosis of CHD patients which were unaffected by CR participation. The results indicate that CR, conventional risk factor control and medical treatment have limited impact on these disparities.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Figure 1Figure 2
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Affiliation(s)
- I Kjesbu
- Bispebjerg University Hospital, Copenhagen, Denmark
| | - E Prescott
- Bispebjerg University Hospital, Copenhagen, Denmark
| | - H K Rasmusen
- Bispebjerg University Hospital, Copenhagen, Denmark
| | - M Osler
- University of Copenhagen, Section of Epidemiology, Department of Public Health, Copenhagen, Denmark
| | - M L Larsen
- Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark
| | - I Gustafsson
- Bispebjerg University Hospital, Copenhagen, Denmark
| | - A D Zwisler
- University of Southern Denmark, National Centre of Rehabilitation and Palliation, University Hospital Odense, Odense, Denmark
| | - K L Sibilitz
- Rigshospitalet - Copenhagen University Hospital, Cardiology, Copenhagen, Denmark
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Thygesen LC, Zinckernagel L, Dalal H, Egstrup K, Glumer C, Gronbaek M, Holmberg T, Kober L, La Cour K, Nakano A, Nielsen CV, Sibilitz KL, Tolstrup JS, Zwisler AD, Taylor RS. Cardiac rehabilitation for patients with heart failure: a national Danish register-based study of predictors of referral and outcomes. Eur J Cardiovasc Nurs 2021. [DOI: 10.1093/eurjcn/zvab060.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation
Background
Heart failure (HF) places a large burden on patients and society as a major cause of morbidity, mortality and healthcare costs. Participation in exercise-based cardiac rehabilitation (CR) in people with HF is a clinically and cost-effective strategy and recommended in international clinical guidelines.
Purpose
The aims of this study were to: (1) examine the temporal trends and predictors of national CR referral, and (2) compare the risk of hospital readmission and mortality in those referred for CR compared to no referral.
Methods
All patients in Denmark with incident HF were identified by the Danish Heart Failure Register in the period 2010 to 2018 (n = 33,257) and CR referral assessed within 120 days of hospital admission. Multivariable logistic regression models were used to evaluate the association between CR referral and predictors and to compare risk of hospital readmission and mortality until 1 year between referred and not referred patients.
Results
Overall, 45.0% of HF patients were referred to exercise-based CR, increasing from 31.7% in 2010 to 52.2% in 2018. Factors independently associated with higher CR referral were: NYHA functional class II, LVEF <50%, diagnosis of myocardial infarction and use of ACE inhibitor. Male gender, older age, region, unemployment, retirement, living alone, non-Danish ethnic origin, lower educational level, NYHA class IV, treatment for hypertension, existing chronic obstructive lung disease and stroke were associated with lower CR referral. CR referral was associated with lower risk of readmission (adjusted odds ratio: 0.90;95%CI: 0.85-0.95), HF-specific mortality (0.61; 0.39-0.95) and all-cause mortality (0.61; 0.55-0.69) as compared to no referral.
Conclusions
Although CR referral has increased over time, only some 1 in 2 diagnosed HF patients in Denmark are referred to exercise-based CR. CR referral is associated with lower risk in readmissions and mortality. Strategies to promote CR referral including healthcare professional education on the benefits of CR and alternative methods of CR delivery are urgently needed to improve access to CR, especially for high-risk groups.
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Affiliation(s)
- LC Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - L Zinckernagel
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - H Dalal
- University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, United Kingdom of Great Britain & Northern Ireland
| | - K Egstrup
- Department of Cardiovascular Research, Odense University Hospital, Svendborg, Denmark
| | - C Glumer
- Center for diabetes in the city of Copenhagen, Copenhagen, Denmark
| | - M Gronbaek
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - T Holmberg
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - L Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - K La Cour
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - A Nakano
- The Danish Clinical Registries (RKKP), Aarhus, Denmark
| | - CV Nielsen
- DEFACTUM, Regional Hospital West Jutland, Central Denmark Region, Institute of Public Health, Aarhus University, Aarhus, Denmark
| | - KL Sibilitz
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - JS Tolstrup
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - AD Zwisler
- REHPA The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Nyborg, Denmark
| | - RS Taylor
- Institute of Health and Well Being, University of Glasgow, Glasgow, United Kingdom of Great Britain & Northern Ireland
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Borregaard B, Weiss MG, Riber LP, Dahl JS, Ekholm O, Sibilitz KL, Kjeldsen BJ, Moeller JE. P3517Occurrence and predictors of readmission due to significant pericardial effusion after heart valve surgery. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- B Borregaard
- Odense University Hospital, Department of Cardiothoracic and Vascular Surgery, Odense, Denmark
| | - M G Weiss
- Odense University Hospital, Department of Cardiothoracic and Vascular Surgery, Odense, Denmark
| | - L P Riber
- Odense University Hospital, Department of Cardiothoracic and Vascular Surgery, Odense, Denmark
| | - J S Dahl
- Odense University Hospital, Cardiology, Odense, Denmark
| | - O Ekholm
- National Institute of Public Health, Copenhagen, Denmark
| | - K L Sibilitz
- Hvidovre University Hospital, Cardiology, Hvidovre, Denmark
| | - B J Kjeldsen
- Odense University Hospital, Department of Cardiothoracic and Vascular Surgery, Odense, Denmark
| | - J E Moeller
- Odense University Hospital, Cardiology, Odense, Denmark
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Lund K, Sibilitz KL, Berg SK, Thygesen LC, Taylor RS, Zwisler AD. Physical activity increases survival after heart valve surgery. Heart 2016; 102:1388-95. [DOI: 10.1136/heartjnl-2015-308827] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/16/2016] [Indexed: 11/04/2022] Open
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Hansen TB, Zwisler AD, Berg SK, Sibilitz KL, Buus N, Lee A. Cardiac rehabilitation patients' perspectives on the recovery following heart valve surgery: a narrative analysis. J Adv Nurs 2016; 72:1097-108. [PMID: 26799453 DOI: 10.1111/jan.12904] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 01/08/2023]
Abstract
AIMS To explore the structure and content of narratives about the recovery process among patients undergoing heart valve surgery participating in cardiac rehabilitation. BACKGROUND Several studies with short-term follow-up have shown that recovering from cardiac surgery can be challenging, but evidence on the long-term recovery process is very limited, especially following heart valve surgery. Furthermore, few studies have explored the recovery process among cardiac rehabilitation participants. DESIGN A qualitative study with serial interviews analysed using narrative methods. METHODS We collected data over 18 months (April 2013-October 2014). We recruited nine patients undergoing heart valve surgery from a randomized trial, CopenHeartVR and conducted 27 individual narrative interviews at 2-3 weeks, 3-4 months and 8-9 months after surgery. FINDINGS Following heart valve surgery, the participants expected to return to normality. The analysis identified four courses of recovery, with three non-linear complex pathways deviating from the classic restitution narrative: the frustrated struggle to resume normality, the challenged expectation of normality - being in a limbo and becoming a heart patient. These deviating pathways were characterized by physical, existential and mental challenges even up to 9 months after surgery. CONCLUSION The recovery processes of participants' in cardiac rehabilitation were often more complicated than anticipated. Patients undergoing heart valve surgery may benefit from more extensive medical follow-up immediately after discharge, individual psychological assessment and individualized, realistic information about the recovery trajectory.
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Affiliation(s)
| | - Ann Dorthe Zwisler
- National Centre of Rehabilitation and Palliation, University of Southern Denmark
| | | | | | - Niels Buus
- Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anne Lee
- Institute of Public Health, University of Southern Denmark, Odense, Denmark
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Hansen TB, Zwisler AD, Berg SK, Sibilitz KL, Thygesen LC, Doherty P, Søgaard R. Exercise-based cardiac rehabilitation after heart valve surgery: cost analysis of healthcare use and sick leave. Open Heart 2015; 2:e000288. [PMID: 26301099 PMCID: PMC4538388 DOI: 10.1136/openhrt-2015-000288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 01/05/2023] Open
Abstract
Background Owing to a lack of evidence, patients undergoing heart valve surgery have been offered exercise-based cardiac rehabilitation (CR) since 2009 based on recommendations for patients with ischaemic heart disease in Denmark. The aim of this study was to investigate the impact of CR on the costs of healthcare use and sick leave among heart valve surgery patients over 12 months post surgery. Methods We conducted a nationwide survey on the CR participation of all patients having undergone valve surgery between 1 January 2011 and 30 June 2011 (n=667). Among the responders (n=500, 75%), the resource use categories of primary and secondary healthcare, prescription medication and sick leave were analysed for CR participants (n=277) and non-participants (n=223) over 12 months. A difference-in-difference analysis was undertaken. All estimates were presented as the means per patient (95% CI) based on non-parametric bootstrapping of SEs. Results Total costs during the 12 months following surgery were €16 065 per patient (95% CI 13 730 to 18 399) in the CR group and €15 182 (12 695 to 17 670) in the non-CR group. CR led to 5.6 (2.9 to 8.3, p<0.01) more outpatient visits per patient. No statistically significant differences in other cost categories or total costs €1330 (−4427 to 7086, p=0.65) were found between the groups. Conclusions CR, as provided in Denmark, can be considered cost neutral. CR is associated with more outpatient visits, but CR participation potentially offsets more expensive outpatient visits. Further studies should investigate the benefits of CR to heart valve surgery patients as part of a formal cost-utility analysis.
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Affiliation(s)
- T B Hansen
- Department of Cardiology , Roskilde Hospital , Roskilde , Denmark ; Centre for Applied Health Services Research, University of Southern Denmark , Odense , Denmark ; Department of Cardiology , The Heart Centre, Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - A D Zwisler
- Department of Cardiology , The Heart Centre, Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark . ; National Institute of Public Health, University of Southern Denmark , Copenhagen , Denmark ; National Centre of Rehabilitation and Palliation, University of Southern Denmark and University Hospital of Odense , Odense , Denmark
| | - S K Berg
- Department of Cardiology , The Heart Centre, Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - K L Sibilitz
- Department of Cardiology , The Heart Centre, Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - L C Thygesen
- National Institute of Public Health, University of Southern Denmark , Copenhagen , Denmark
| | - P Doherty
- Department of Health Sciences , University of York , York , UK
| | - R Søgaard
- Department of Public Health , Aarhus University , Aarhus , Denmark ; Department of Clinical Medicine , Aarhus University , Aarhus , Denmark
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Sibilitz KL, Berg SK, Hansen TB, Risom SS, Rasmussen TB, Hassager C, Køber L, Gluud C, Thygesen LC, Lindschou J, Schmid JP, Taylor RS, Zwisler AD. Update to the study protocol, including statistical analysis plan for a randomized clinical trial comparing comprehensive cardiac rehabilitation after heart valve surgery with control: the CopenHeartVR trial. Trials 2015; 16:38. [PMID: 25887433 PMCID: PMC4326522 DOI: 10.1186/s13063-015-0562-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heart valve diseases are common with an estimated prevalence of 2.5% in the Western world. The number is rising because of an ageing population. Once symptomatic, heart valve diseases are potentially lethal, and heavily influence daily living and quality of life. Surgical treatment, either valve replacement or repair, remains the treatment of choice. However, post-surgery, the transition to daily living may become a physical, mental and social challenge. We hypothesize that a comprehensive cardiac rehabilitation program can improve physical capacity and self-assessed mental health and reduce hospitalization and healthcare costs after heart valve surgery. METHODS This randomized clinical trial, CopenHeartVR, aims to investigate whether cardiac rehabilitation in addition to usual care is superior to treatment as usual after heart valve surgery. The trial will randomly allocate 210 patients 1:1 to an intervention or a control group, using central randomization, and blinded outcome assessment and statistical analyses. The intervention consists of 12 weeks of physical exercise and a psycho-educational intervention comprising five consultations. The primary outcome is peak oxygen uptake (VO2 peak) measured by cardiopulmonary exercise testing with ventilatory gas analysis. The secondary outcome is self-assessed mental health measured by the standardized questionnaire Short Form-36. Long-term healthcare utilization and mortality as well as biochemistry, echocardiography and cost-benefit will be assessed. A mixed-method design will be used to evaluate qualitative and quantitative findings, encompassing a survey-based study before the trial and a qualitative pre- and post-intervention study. CONCLUSION This randomized clinical trial will contribute with evidence of whether cardiac rehabilitation should be provided after heart valve surgery. The study is approved by the local regional Research Ethics Committee (H-1-2011-157), and the Danish Data Protection Agency (j.nr. 2007-58-0015). TRIAL REGISTRATION Trial registered 16 March 2012; ClinicalTrials.gov ( NCT01558765 ).
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Affiliation(s)
- Kirstine Laerum Sibilitz
- The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Selina Kikkenborg Berg
- The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Department of Cardiology, Gentofte Hospital, Gentofte, Denmark. .,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | | | - Signe Stelling Risom
- The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Trine Bernholdt Rasmussen
- The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Department of Cardiology, Gentofte Hospital, Gentofte, Denmark.
| | - Christian Hassager
- The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Lars Køber
- The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Jean Paul Schmid
- Cardiology Clinic, Tiefenau Hospital and University of Bern, Bern, Switzerland.
| | - Rod S Taylor
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark. .,University of Exeter Medical School, Health Services Research, University of Exeter, Exeter, Devon, UK.
| | - Ann-Dorthe Zwisler
- The Heart Centre, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark. .,Department of Cardiology, Holbæk Sygehus, Holbæk, Denmark.
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