Prevalence, Mortality, and Indicators of Health Care Supply-Association Analysis of Cardiovascular Diseases in Germany

Sex differences in cardiologic medication provision for adults with coronary heart disease: an analysis of health claims data from 2018 to 2020 in Saxony-Anhalt, Germany

BACKGROUND

Coronary heart diseases (CHDs) have experienced the largest increase worldwide as a cause of death, accounting for 16% of all deaths. In Saxony-Anhalt, a federal state in Germany, both CHD morbidity and acute myocardial infarction mortality rates are particularly high. Several risk factors associated with CHDs have been studied in Saxony-Anhalt, but sex differences in service use and medication have not been investigated. This study therefore aimed to investigate sex differences in the quality and quantity of cardiological care provided to adults with CHD.

METHODS

This study used health claims data from 2018 to 2020 to analyse the utilisation of healthcare services and adherence to medication-related guideline recommendations in primary and specialist care. The sample included 133,661 individuals with CHD from a major statutory health insurance company (Germany).

RESULTS

Almost all CHD patients (> 99%) received continuous primary care. Continuous cardiologist utilisation was lower for females than for males, with 15.0% and 22.2%, respectively, and sporadic utilisation showed greater differences, with 33.5% of females and 43.4% of males seeking sporadic cardiologist consultations. Additionally, 43.1% of the identified CHD patients participated in disease management programmes (DMPs). The study also examined the impact of DMP participation and cardiologist care on medication uptake and revealed that sex differences in medication uptake, except for statin use, were mitigated by these factors. Statins were prescribed to 42.9% of the CHD patients eligible for statin prescription in accordance with the QiSA indicator for statin prescription eligibility. However, there were significant sex differences in statin utilisation. Female CHD patients were less likely to use statins (35.2%) than male CHD patients were (50.1%). The difference in statin utilisation persisted after adjustment for DMP participation and cardiologist consultation.

CONCLUSIONS

This study highlights sex differences in the utilisation of cardiological healthcare services for patients with CHD in the Saxony-Anhalt cohort. These findings underscore the continuing need for interventions to reduce sex inequalities in accessing healthcare and providing health care for patients with CHD. Factors at the health care system, patient, and physician levels should be further investigated to eventually improve statin prescription in people with CHD, especially women.

[Development of an Index of Social Structures to Determine the Sociostructural Need for Physicians in Outpatient Care in Brandenburg]

INTRODUCTION

Despite the growing numbers of physicians in outpatient care, continuing discussion about the planning of physician requirements suggests remaining problems in this field, which could be due to focussing on the ratio of physician to population rather than on morbidity-based evaluations. Against this background, this paper tries to depict the latent need in outpatient care, illustrates supply and demand and further tests the hypothesis that there is a relative inequality in distribution due to physicians preferring to locate in socially privileged areas in the German state of Brandenburg.

METHODS

We aggregated all data available on a small scale with potential impact on demand and examined it via principal component analysis. The generated factor was mapped together with the locations of general practitioners and specialists in general care. Using linear regressions, the number of practitioners was compared to the local index value to determine regional inequalities.

RESULTS

The PCA suggested a one factor solution; that factor was designated Social Structure Index due to its values. The mapping showed a tendency of higher index values towards the central areas of Brandenburg surrounding Berlin. Regressions of the number of practitioners against the index values revealed no significant differences between communities with high and low index values.

CONCLUSION

The extension of factors concluding the evaluation of physician demand in outpatient care confirms the problems of physician supply in rural areas, where sparse populations meet social disadvantages and poor accessibility. An underlying inequality in distribution in terms of physicians preferring socially privileged areas could not be detected.

[Access to cardiological care infrastructure in the federal state of Brandenburg considering the local care needs]

AIM OF THE STUDY

In a nationwide comparison, the state of Brandenburg has one of the highest morbidity and mortality rates of ischemic heart disease. Access to medical care infrastructure is considered to be one possible explanation for regional health inequalities. Accordingly, the study aims to calculate the distances to different types of cardiology care at the community level and to consider these in the context of local care needs.

METHODOLOGY

Preventive sports facilities, general practitioners, outpatient specialist care, hospitals with cardiac catheterization laboratory and outpatient rehabilitation were chosen and mapped as essential facilities for cardiological care. Thereafter, the distances across the road network from the center of each Brandenburg community to the nearest location of each care facility was calculated and divided into quintiles. Medians and interquartile ranges of the German Index of Socioeconomic Deprivation and the proportion of the population over 65 were used as measures of the need for care. They were then related to the distance quintiles per type of care facility.

RESULTS

For 60% of Brandenburg's municipalities, general practitioners were found to be within 2.5 km, preventive sports facilities within 19.6 km, cardiology practices within 18.3 km, hospitals with cardiac catheterization laboratories within 22.7 km, and outpatient rehabilitation facilities within 14.7 km. The median of the German Index of Socioeconomic Deprivation rose with increasing distance for all types of care facilities. The median of the proportion of over 65-year-olds showed no significant variation between distance quintiles.

CONCLUSIONS

The results show that a high proportion of the population lives far away from cardiology care services, while a high proportion seems to be able to reach a general practitioner. In Brandenburg, a regional and locally oriented cross-sectoral care seems to be necessary.

The In-Hospital Care of Patients With Peripheral Arterial Occlusive Disease

BACKGROUND

Studies from Denmark and the USA have shown differences in treatment outcomes for patients with peripheral arterial occlusive disease (PAOD) between hospitals of different size and certification status. For Germany, it is not known whether certification as a specialist center for vascular diseases or hospital size is associated with differences in the primary treatment outcome.

METHODS

Using data from the German Federal Statistical Office, all hospitalizations due to PAOD of Fontaine stage IIb or higher were included in our study and the hospitals were classified according to their size and certification status. PAOD stage, age, sex, and comorbidities were documented for each hospitalization. Univariate and multivariate logistic regressions were performed to identify independent variables that predict various treatment endpoints.

RESULTS

A total of 558 785 hospitalizations were included for analysis, of which 29% were in hospitals with certified vascular centers. In multivariate analysis, admissions to certified hospitals were associated with lower rates of major amputation (odds ratio [OR] 0.95, 95% confidence interval [0.92; 0.98], p = 0.003) and higher rates of minor amputation (OR 1.04 [1.01; 1.06], p = 0.004) with no difference observed in mortality (OR 0.99 [0.96; 1.03], p = 0.791). Admissions to larger hospitals were associated with more comorbidities, longer hospital stays, and higher rates of mortality and amputations.

CONCLUSION

Treatments in certified hospitals are associated with fewer major and more minor amputations. This may reflect intensification of therapy targeting preservation of functional limbs.

Understanding the importance of social determinants and rurality for the long-term outcome after acute myocardial infarction: study protocol for a single-centre cohort study

INTRODUCTION

Acute myocardial infarction (AMI) is a major public health issue in Germany with considerable regional differences in morbidity and mortality. Possible reasons for regional differences include a higher prevalence of cardiovascular risk factors, infrastructural deficits, different levels of healthcare quality or social determinants. We aim to study associations of social determinants and of rural infrastructure with the quality of medical care (eg, time to reperfusion or medication adherence) and on the long-term outcome after myocardial infarction.

METHODS AND ANALYSIS

We will employ a prospective cohort study design. Patients who are admitted with AMI will be invited to participate. We aim to recruit a total of 1000 participants over the course of 5 years. Information on outpatient care prior to AMI, acute healthcare of AMI, healthcare-related environmental factors and social determinants will be collected. Baseline data will be assessed in interviews and from the electronic data system of the hospital. Follow-up will be conducted after an observation period of 1 year via patient interviews. The outcomes of interest are cardiac and all-cause mortality, changes in quality of life, changes in health status of heart failure, major adverse cardiovascular events and participation in rehabilitation programmes.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee of Brandenburg Medical School (reference: E-01-20200923). Research findings will be disseminated and shared in different ways and include presenting at international and national conferences, publishing in peer-reviewed journals and facilitating dissemination workshops within local communities with patients and healthcare professionals.

TRIALS REGISTRATION NUMBER

DRKS00024463.

Risk factors of deaths related to cardiovascular diseases in World Health Organization (WHO) member countries

This study aims to identify the risk factors affecting deaths related to cardiovascular diseases. The research population comprised of 194 World Health Organization (WHO) member countries, but the data analysis was conducted with the data from 152 countries as 42 of them do not have any data on study variables. Multivariable regression analysis was utilised for this study to analyse the effect of factors regarding metabolism, lifestyle, economic, socio-demographic and health system on the cardiovascular diseases related to deaths. As a result of regression analysis, the number of deaths related to cardiovascular diseases increases with the increase in blood pressure (p < .001), blood glucose (p = .032), obesity rate (p < .001), salt consumption (p < .001), GINI index (p = .002) and dependent age ratio (p < .001); the frequency of cardiovascular disease-related deaths is higher in the countries within low (p < .001) and high (p < .001) middle-income levels; yet, the number of deaths based on cardiovascular diseases diminishes with the increase in the number of doctors (p = .005) and health expenditures per capita (p = .044). The research findings are considered to guide the countries in the determination of their steps towards the prevention of deaths related to cardiovascular diseases.

Risk Factor Management in Non-Metropolitan Patients with Coronary and Peripheral Artery Disease - A Protocol of a Prospective, Multi-Center, Quality Improvement Strategy

INTRODUCTION

Coronary artery disease (CAD) and peripheral arterial disease (PAD) account for significant morbidity and mortality in Germany and are more prevalent in rural, non-metropolitan areas. The goal of this study is to screen patients for their current atherosclerotic status, initiate treatment according to the latest scientific findings using a standardised multimodal approach and track their atherosclerotic status over one year.

METHODS AND ANALYSIS

This manuscript describes the study protocol of a prospective, multicentre registry of 500 sequential patients with CAD and/or PAD in rural, non-metropolitan regions of Germany. Patients, who visit the "WalkByLab" at the Brandenburg Medical School, Brandenburg, Germany, will be assessed by using our structured, multimodal risk factor management (SMART) tool to evaluate cardiovascular morbidity data, collect information on care and deliver multimodal therapy. The study's primary objective is a cross-sectional examination of the risk profile, diagnostic and therapeutic status in this patient group. Secondary objectives include the assessment of risk factor correlations as well as changes in risk-factor profile and therapy adherence. Patients will be examined at baseline and followed up at three-monthly intervals for one year. Over this time, atherosclerotic risk factors and patient adherence to defined therapeutic strategies will be evaluated. Study completion is estimated to be December 2021. An expansion of this concept into other rural, non-metropolitan neighbouring regions is planned.

ETHICS AND DISSEMINATION

This registry was assessed and approved by the ethics committee of the Brandenburg State Medical Association, Brandenburg, Germany, and conducted in accordance with the Declaration of Helsinki. The study findings will be disseminated through usual academic channels including meeting presentations and peer-reviewed publications.

PROTOCOL VERSION

1.0.

Hospitalizations for heart failure: still major differences between East and West Germany 30 years after reunification

Aims

Heart failure (HF) is the most common primary inpatient diagnosis in Germany. We examined temporal trends of HF hospitalization within Germany focusing on regional differences.

Methods and results

We analysed aggregated data of more than 320 million hospitalizations in Germany from 2000 to 2017. Temporal trends of HF‐related parameters were analysed, focusing on regional differences between the federal states. The absolute number of HF‐related hospitalizations throughout Germany increased continuously and almost doubled (from 239 694 to 464 724 cases, +94%) with the relative increase being higher in East Germany compared with West Germany (119% vs. 88%). These regional differences persisted after age standardization with 609 and 490 cases per 100 000 population, respectively. The length of stay decreased continuously across Germany (from 14.3 to 10.2 days; −29%), while the total number of HF‐related hospital days increased by 51% in East Germany and 35% in West Germany. In 2017, HF remained the leading cause of in‐hospital death (8.9% of all cases), with a markedly higher rate in East vs. West Germany (65 vs. 43 deaths per 100 000 population).

Conclusions

Heart failure remains the most common cause of hospitalization and in‐hospital death throughout Germany. The increase in HF‐related morbidity and mortality was much higher in East Germany compared with West Germany during the observation period. A more detailed understanding of these striking disparities 30 years after the German reunification requires further investigations. There is an urgent need for action with regard to stronger control of risk factors and improvement of both chronic HF management and healthcare structures.