Preventing cardiovascular disease in primary care: role of a national risk factor management program

Cost-effectiveness of natriuretic peptide-based screening and collaborative care: a report from the STOP-HF (St Vincent's Screening TO Prevent Heart Failure) study

AIMS

Prevention of cardiovascular disease and heart failure (HF) in a cost-effective manner is a public health goal. This work aims to assess the cost-effectiveness of the St Vincent's Screening TO Prevent Heart Failure (STOP-HF) intervention.

METHODS AND RESULTS

This is a substudy of 1054 participants with cardiovascular risk factors [median age 65.8 years, interquartile range (IQR) 57.8:72.4, with 4.3 years, IQR 3.4:5.2, follow-up]. Annual natriuretic peptide-based screening was performed, with collaborative cardiovascular care between specialist physicians and general practitioners provided to patients with BNP levels >50 pg/mL. Analysis of cost per case prevented and cost-effectiveness per quality-adjusted life year (QALY) gained was performed. The primary clinical endpoint of LV dysfunction (LVD) with or without HF was reduced in intervention patients [odds ratio (OR) 0.60; 95% confidence interval (CI) 0.38-0.94; P = 0.026]. There were 157 deaths and/or emergency hospitalizations for major adverse cardiac events (MACE) in the control group vs. 102 in the intervention group (OR 0.68; 95% CI 0.49-0.93; P = 0.01). The cost per case of LVD/HF prevented was €9683 (sensitivity range -€843 to €20 210), whereas the cost per MACE prevented was €3471 (sensitivity range -€302 to €7245). Cardiovascular hospitalization savings offset increased outpatient and primary care costs. The cost per QALY gain was €1104 and the intervention has an 88% probability of being cost-effective at a willingness to pay threshold of €30 000.

CONCLUSION

Among patients with cardiovascular risk factors, natriuretic peptide-based screening and collaborative care reduced LVD, HF, and MACE, and has a high probability of being cost-effective.

TRIAL REGISTRATION

NCT00921960.

Attitudes towards acceptance of an innovative home-based and remote sensing rehabilitation protocol among cardiovascular patients in Shantou, China

BACKGROUND

Cardiac rehabilitation (CR) protocols have diversified to include home-based cardiac tele-rehabilitation (HBCTR) as an alternative to hospital-based or center-based CR. To adopt the use of home-based cardiac tele-rehabilitation, it is necessary to assess cardiac patients' attitudes towards acceptance of such e-health technology, especially in China where knowledge of such technology is deficient.

METHODS

Interviews were conducted in the First Affiliated Hospital of Shantou University Medical College, Shantou, China. After percutaneous coronary interventional (PCI) surgery, patients completed the survey.

RESULTS

Among the 150 patients, only 13% had ever heard of HBCTR. After an introduction of our HBCTR program, 60% of patients were willing to participate in the program. From our multivariate analysis of questionnaire data, age (OR: 0.92, 95% CI: 0.86-0.98; P = 0.007), average family monthly income (OR: 0.13, 95% CI: 0.05-0.34; P < 0.001), education level (OR: 0.24, 95% CI: 0.10-0.59; P = 0.002) and physical exercise time (OR: 0.19, 95% CI: 0.06-0.56; P = 0.003) were independent predictors for acceptance of HBCTR. From the reasons for participation, patients selected: enhanced safety and independence (28.3%), ability to self-monitor physical conditions daily (25.4%), and having automatic and emergency alert (23.1%). Reasons for refusal were: too cumbersome operation (34.3%) and unnecessary protocol (19.4%).

CONCLUSIONS

Most patients lacked knowledge about HBCTR but volunteered to participate after they have learned about the program. Several personal and life-style factors influenced their acceptance of the program. These indicate that both improvement of technology and better understanding of the program will enhance active participation.

Health Care Access, Utilization, and Management in Adult Chinese, Koreans, and Vietnamese with Cardiovascular Disease and Hypertension

BACKGROUND

Asians are often pooled together when evaluating disparities in health care indicators (access, utilization, and management), though substantial variation may exist across different Asian ethnicities.

OBJECTIVE

The aim of this study was to compare health care indicators among Chinese, Korean, Vietnamese, and non-Hispanic white (NHW) adults with cardiovascular disease and hypertension (CVD/HTN).

METHODS

We analyzed health care indicators using multivariable logistic regression in a sample of Asians and NHWs with CVD/HTN from the 2011-2012 California Health Interview Survey (CHIS).

RESULTS

Koreans had the lowest utilization of emergency room (ER) or inpatient hospital services; Vietnamese had the lowest access to a personal doctor; Chinese had the lowest adjusted odds of having seen a doctor in the prior 12 months; and all Asians received fewer written heart disease care plans compared to NHWs. Even when utilization of ER for heart disease appeared to be similar, lack of access to a doctor was a more common reason noted by Asians versus NHWs. However, a lower proportion of Asians reported delays in receiving prescription or care. Accounting for differences across groups did not diminish these disparities.

CONCLUSION

Health care indicators varied by race and across Asian ethnicities even after controlling for sociodemographic factors, insurance coverage, and health status. Future studies should consider oversampling other Asian ethnicities and assessing more in depth the potential impact of ethnicity-related factors on disparities in health care indicators.

The effectiveness of the cardiovascular disease prevention programme 'KardioPro' initiated by a German sickness fund: a time-to-event analysis of routine data

Background

Cardiovascular disease is the leading cause of morbidity and mortality in the developed world. To reduce this burden of disease, a German sickness fund (‘Siemens-Betriebskrankenkasse’, SBK) initiated the prevention programme ‘KardioPro’ including primary (risk factor reduction) and secondary (screening) prevention and guideline-based treatment. The aim of this study was to assess the effectiveness of ‘KardioPro’ as it is implemented in the real world.

Methods

The study is based on sickness fund routine data. The control group was selected from non-participants via propensity score matching. Study analysis was based on time-to-event analysis via Cox proportional hazards regression with the endpoint ‘all-cause mortality, acute myocardial infarction (MI) and ischemic stroke (1)’, ‘all-cause mortality (2)’ and ‘non-fatal acute MI and ischemic stroke (3)’.

Results

A total of 26,202 insurants were included, 13,101 participants and 13,101 control subjects. ‘KardioPro’ enrolment was associated with risk reductions of 23.5% (95% confidence interval (CI) 13.0–32.7%) (1), 41.7% (95% CI 30.2–51.2%) (2) and 3.5% (hazard ratio 0.965, 95% CI 0.811–1.148) (3). This corresponds to an absolute risk reduction of 0.29% (1), 0.31% (2) and 0.03% (3) per year.

Conclusion

The prevention programme initiated by a German statutory sickness fund appears to be effective with regard to all-cause mortality. The non-significant reduction in non-fatal events might result from a shift from fatal to non-fatal events.

Sleep to lower elevated blood pressure: study protocol for a randomized controlled trial

Background

Sleep is an essential component of good physical and mental health. Previous studies have reported that poor quality sleep is associated with an increased risk of hypertension and cardiovascular disease. Hypertension is the most common and important risk factor for cardiovascular disease, and even modest reductions in blood pressure can result in significant reductions in the risk of stroke and myocardial infarction. In this trial, we will determine the efficacy of an online sleep intervention in improving blood pressure, in participants with hypertension and poor sleep quality.

Methods

Trial design: Randomized-controlled, two-group, parallel, blinded, single-center, Phase II trial of 134 participants. Population and recruitment: Primary prevention population of participants with hypertension (systolic blood pressure, 130 to 160 mm Hg; diastolic blood pressure, <110 mm Hg) and poor sleep quality in a community setting. Intervention: Multicomponent online sleep intervention consisting of sleep information, sleep hygiene education, and cognitive behavioral therapy. Comparator: Standardized cardiovascular risk factor and lifestyle-education session (usual care). Primary outcome: Change in mean 24-hour ambulatory systolic blood pressure between baseline and 8-week follow-up. Hypertension has been selected as the primary outcome measure because of its robust association with both poor sleep quality and cardiovascular disease. Statistical analyses: Intention-to-treat analysis by using a linear mixed model.

Trial registration

ClinicalTrials.gov: NCT01809821, registered March 8, 2013.

Stroke prevention: managing modifiable risk factors

Prevention plays a crucial role in counteracting morbidity and mortality related to ischemic stroke. It has been estimated that 50% of stroke are preventable through control of modifiable risk factors and lifestyle changes. Antihypertensive treatment is recommended for both prevention of recurrent stroke and other vascular events. The use of antiplatelets and statins has been shown to reduce the risk of recurrent stroke and other vascular events. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are indicated in stroke prevention because they also promote vascular health. Effective secondary-prevention strategies for selected patients include carotid revascularization for high-grade carotid stenosis and vitamin K antagonist treatment for atrial fibrillation. The results of recent clinical trials investigating new anticoagulants (factor Xa inhibitors and direct thrombin inhibitors) clearly indicate alternative strategies in stroke prevention for patients with atrial fibrillation. This paper describes the current landscape and developments in stroke prevention with special reference to medical treatment in secondary prevention of ischemic stroke.