Telephone Health Coaching and Remote Exercise Monitoring (TeGeCoach) in Peripheral Arterial Occlusive Disease—a Randomized Controlled Trial

BACKGROUND

Supervised exercise programs are commonly used to treat intermittent claudication (IC). Home-based exercise programs have been developed to lower barriers to participation. We studied the effects of one such program (TeGeCoach) on self-reported walking ability in patients with IC.

METHODS

In a pragmatic, multicenter, randomized and controlled trial (registration number NCT03496948), 1982 patients with symptomatic IC, insured by one of three German statutory health-insurance carriers, received either telephone health coaching with remote exercise monitoring (TeGeCoach; n = 994) or routine care (n = 988). The primary outcome was the change in Walking Impairment Questionnaire (WIQ) scores 12 and 24 months after the start of the intervention (intention-to-treat analysis). The secondary outcomes were health-related quality of life, symptoms of depression or anxiety, health competence, patient activation, alcohol use, and nicotine dependence.

RESULTS

There was a significant difference between arms in favor of TeGeCoach in the WIQ (p<0.0001). Patients in the TeGeCoach arm had WIQ scores that were 6.30 points higher at 12 months (Bonferroni-corrected 95% CI [4.02; 8.59], Cohen's d = 0.26) and 4.55 points higher at 24 months ([2.20; 6.91], d = 0.19). They also fared better in some of the secondary outcomes at 12 months, including physical health-related quality of life and patient activation, with at least small effect sizes (d > 0.20). The average daily step count was no higher in the TeGeCoach group.

CONCLUSION

The observed reductions of symptom burden indicate the benefit of home-based exercise programs in the treatment of intermittent claudication. Such programs expand the opportunities for the guideline-oriented treatment of IC. Future studies should address the effect of home-based exercise programs on clinical variables, e.g., the 6-minute walk test.

The effect of telephone health coaching and remote exercise monitoring for peripheral artery disease (TeGeCoach) on health care cost and utilization: results of a randomized controlled trial

BACKGROUND

Peripheral artery disease (PAD) is the third most prevalent atherosclerotic cardiovascular disease. In 2016, costs per patient associated with PAD exceeded even the health-economic burden of coronary heart disease. Although affecting over 200 million people worldwide, a clear consensus on the most beneficial components to be included in home-based exercise programs for patients with peripheral artery disease is lacking. The aim of the study was to examine the health care use and costs caused by the 12-month patient-centered 'Telephone Health Coaching and Remote Exercise Monitoring for Peripheral Artery Disease' (TeGeCoach) program in a randomized controlled trial.

METHODS

This is a two-arm, parallel-group, open-label, pragmatic, randomized, controlled clinical trial (TeGeCoach) at three German statutory health insurance funds with follow-up assessments after 12 and 24-months. Study outcomes were medication use (daily defined doses), days in hospital, sick pay days and health care costs, from the health insurers' perspective. Claims data from the participating health insurers were used for analyses. The main analytic approach was an intention-to-treat (ITT) analysis. Other approaches (modified ITT, per protocol, and as treated) were executed additionally as sensitivity analysis. Random-effects regression models were calculated to determine difference-in-difference (DD) estimators for the first- and the second year of follow-up. Additionally, existing differences at baseline between both groups were treated with entropy balancing to check for the stability of the calculated estimators.

RESULTS

One thousand six hundred eighty-five patients (Intervention group (IG) = 806; Control group (CG) = 879) were finally included in ITT analyses. The analyses showed non-significant effects of the intervention on savings (first year: - 352€; second year: - 215€). Sensitivity analyses confirmed primary results and showed even larger savings.

CONCLUSION

Based on health insurance claims data, a significant reduction due to the home-based TeGeCoach program could not be found for health care use and costs in patients with PAD. Nevertheless, in all sensitivity analysis a tendency became apparent for a non-significant cost reducing effect.

TRIAL REGISTRATION

NCT03496948 (www.

CLINICALTRIALS

gov), initial release on 23 March 2018.

How to make value-based health insurance designs more effective? A systematic review and meta-analysis

Value-based health insurance designs (VBIDs) are one approach to increase adherence to highly effective medications and simultaneously contain rising health care costs. The objective of this systematic review was to identify VBID effects on adherence and incentive designs within these programs that were associated with higher effects. Eight economic and medical databases were searched for literature. Random effects meta-analyses and mixed effects meta-regressions were used to synthesize VBID effects on adherence. Thirteen references with evaluation studies, including 12 patient populations with 79 outcomes, were used for primary meta-analyses. For qualitative review and sensitivity analyses, up to 19 references including 20 populations with 119 outcomes were used. Evidence of synthesized effects was good, because references with high risk of bias were excluded. VBIDs significantly increased adherence in all indication areas. Highest effects were found in medications indicated in heart diseases (4.05%-points, p < 0.0001). Each additional year increased effects by 0.15%-points (p < 0.01). VBIDs with education were more effective than without education, but the difference was not significant. Effects of VBIDs with full coverage were more than twice as high as effects of VBID without that option (4.52 vs 1.81%-points, p < 0.05). These findings were robust in most sensitivity analyses. It is concluded that VBID implementation should be encouraged, especially for patients with heart diseases, and that full coverage was associated with higher effects. This review may provide insight for policy-makers into how to make VBIDs more effective.

Determinants of adherence and effects on health-related quality of life after myocardial infarction: a prospective cohort study

BACKGROUND

Adherence to recommendations and medication is deemed to be important for effectiveness of case management interventions. Thus, reasons for non-adherence and effects on health-related quality of life (HRQoL) should be fully understood. The objective of this research was to identify determinants of non-adherence to medication and recommendations, and to test whether increased adherence improved HRQoL in patients after myocardial infarction (MI) in a case management intervention.

METHODS

Data were obtained from the intervention group of the KORINNA study, a randomized controlled trail of a nurse-led case management intervention with targeted recommendations in the elderly after MI in Germany. Reasons for non-adherence were described. Logistic mixed effects models and OLS (ordinary least squares) were used to analyze the effect of recommendations on the probability of adherence and the association between adherence and HRQoL.

RESULTS

One hundred and twenty-seven patients with 965 contacts were included. Frequent reasons for non-adherence to medication and recommendations were "forgotten" (22%; 11%), "reluctant" (18%; 18%), "side effects" (38%; 7%), "the problem disappeared" (6%; 13%), and "barriers" (0%; 13%). The probability of adherence was lowest for disease and self-management (38%) and highest for visits to the doctor (61%). Only if patients diverging from prescribed medication because of side effects were also considered as adherent, 3-year medication adherence was associated with a significant gain of 0.34 quality-adjusted life years (QALYs).

CONCLUSIONS

Most important determinants of non-adherence to medication were side effects, and to recommendations reluctance. Recommended improvements in disease and self-management were least likely adhered. Medication adherence was associated with HRQoL.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02893746 , retrospectively registered, date assigned 27/03/2009.

Claims Data Analysis of Tumor Necrosis Factor Inhibitor Treatment Dosing Among Patients with Rheumatoid Arthritis: A Systematic Review of Methods

Background

With tumor necrosis factor inhibitors, changes of dosing, switching between drugs, insufficient adherence, and persistence are frequent in rheumatoid arthritis. Because this is often associated with decreased efficiency and increased costs, dosage analyses based on claims data are of increasing interest for healthcare providers and payers. Nevertheless, no standardized methods exist to ensure high-quality research.

Objective

In this review, we compare and discuss applied methods in claims data-based dosage analyses of tumor necrosis factor inhibitor prescriptions in patients with rheumatoid arthritis.

Methods

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The dosage analysis methods performed within the selected studies were classified into switching, persistence, adherence, and dosage-change analyses, and were then compared and finally discussed.

Results

A total of 45 studies were found to be relevant. In most studies, a change in dose or persistence was evaluated, followed by switching and adherence analyses. Analyses of changed dose exhibit the most extensive variation of methods. We divided them into three principal methods, where a specified reference dose is compared with (1) the last dose, (2) any dose, or (3) all doses.

Conclusion

The systematic review identified a high variation of methods. Our results may be helpful for choosing appropriate methods in future studies. The results also demonstrate the need for evidence-based recommendations of methods used in claims data research.

Investigation into the mechanism of tetracycline-induced steatosis: study in isolated hepatocytes

Tetracycline is known to cause hepatic dysfunction in humans by inducing steatosis. Accumulation of fat in the liver could result from biochemical effects at various levels in the sequence from protein and triglyceride synthesis to lipoprotein secretion. The effects of tetracycline on the synthesis and secretion of triglycerides and proteins were studied in isolated rat hepatocytes surviving in suspension for up to 2.5 hr. Interpretation of the results obtained for tetracycline was made by comparison with results obtained, under the same experimental conditions, for the well-known steatogenic compounds, cycloheximide and colchicine. The data indicate that tetracycline produces a concentration-dependent inhibition of 14C-triglyceride secretion without affecting triglyceride synthesis. This inhibition explains the intracellular triglyceride accumulation. However, tetracycline does not affect protein secretion. Furthermore, it was demonstrated that the effect of tetracycline on protein synthesis was not related to inhibition of triglyceride release. In conclusion, it is proposed that the effect of tetracycline could be at the level of the association between triglycerides and apoproteins to form lipoproteins.

Maintenance of adult rat liver slices in dynamic organ culture

Adult rat liver slices were maintained for 20 h in a novel organ culture system with minimal loss of viability and function. Potassium and adenosine triphosphate levels were maintained at in vivo levels, following an initial recovery period (2 to 4 h), for up to 20 h. Protein synthesis and secretion were linear for 20 and 16 h, respectively. In addition, the liver slices synthesized glycogen between 4 and 12 h in culture. Finally, the liver slices were hormonally responsive during the 20 h culture period as exemplified by glucagon-stimulated glucose production. This system provides a simple and effective method for the culture and biochemical maintenance of adult rat liver for 20 h with minimal loss of biochemical function.

Effect of volatile anesthetics on protein synthesis and secretion by rat hepatocyte suspensions

The effect of volatile anesthetics on protein synthesis and secretion by isolated rat hepatocytes in suspension was investigated. Halothane and enflurane inhibited protein synthesis in a dose-dependent manner. Diethyl ether had little effect on protein synthesis while isoflurane caused a mild inhibition. This effect was more pronounced in hepatocytes from phenobarbital treated male rats when compared to hepatocytes from control rats. Protein synthesis in hepatocytes from phenobarbital treated female rats was inhibited similar to that seen with control male rat hepatocytes. Isoflurane, enflurane, and halothane also caused a dose-dependent inhibition of protein secretion, while diethyl ether was only mildly inhibitory. From these studies it appears that inhibition of protein synthesis and secretion might be an early and sensitive indicator of cellular injury by volatile anesthetics.

Critical biochemical functions of isolated hepatocytes as sensitive indicators of chemical toxicity

Isolated hepatocytes from adult male Wistar rats are a suitable experimental model to study the cytotoxicity of chemicals. Indeed, the isolated cells incubated in suspension in a Waymouth medium supplemented with 10% newborn calf serum maintain critical biochemical functions such as cytochrome P-450-dependent monooxygenase activity, glycogen, and protein synthesis capacities. This cellular model is used to detect the early biochemical effects of various xenobiotics, i.e., chlorpromazine, promethazine, bromobenzene, paracetamol, and isoniazid. Both cellular lysis (measured by the LDH leakage) and metabolic competence of the hepatocytes (glycogen deposits and protein synthesis) are modified as a function of both the duration of exposure to, and the concentration of, the chemicals. These results point out that the evaluation of metabolic functions of isolated cells surviving in suspension might be a sensitive test to predict early cell injury. Indeed, changes in the cellular behavior may occur before or without cell death. Furthermore, since both the cytochrome P-450 content and its dependent monooxygenase activity together with critical biochemical functions of the isolated cells remain stable, this model is of significant interest in ascertaining the mechanisms of toxicity.

Effects of diethyl maleate on protein synthesis in isolated hepatocytes

Diethyl maleate is commonly used in toxicological and drug metabolism research using isolated adult rat hepatocytes. At the highest concentrations used the effect of diethyl maleate is, however, not limited to glutathione depletion. In these conditions it inhibits protein synthesis and it impairs the "L" system for amino acid transport. It has, however, no effect on the cytochrome P-450 content or its dependent aldrin monooxygenase. The present report shows that a concentration of diethyl maleate as low as 0.2 mM is sufficient to deplete glutathione without affecting glycogen and protein synthesis, transport of amino acid or monooxygenase activity in isolated adult rat hepatocytes.

Subcellular fractionation of isolated rat hepatocytes. A comparison with liver homogenate

An improved method for the homogenization and the subsequent subcellular fractionation of hepatocytes isolated from adult rat liver is described. The homogenization procedure developed in the present study allows the preservation of the integrity of subcellular structures, as demonstrated by measurement of the activities of representative enzymes as well as by determination of their latency. The activities of representative marker enzymes, as calculated on subcellular fractions obtained by differential centrifugation of the homogenate, are identical whether the homogenate arises from isolated hepatocytes or from the whole liver. Moreover, there is a close similitude between the kinetic parameters (Km and V) of two microsomal cytochrome P450-dependent mixed-function oxidases, namely aniline hydroxylase and aminopyrine demethylase determined on microsomal preparations obtained either from isolated cells or from the whole liver.

Interference of chemicals with glycogen metabolism in isolated hepatocytes

Freshly isolated hepatocytes in suspension were used to evaluate the possible effects of certain chemicals. Conditions including the choice of the incubation medium have been defined for maintaining the cells competent for a sufficient length of time. Using paracetamol alone or in combination with diethylmaleate, we have been able to show that these chemicals markedly alter the metabolic state of the cells, as indicated by an inhibition of glycogen synthesis and even by an enhancement of glycogen degradation, without modifying membrane integrity. These effects are dose-dependent and probably mediated through modification of glycogen phosphorylase activity.