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Health care utilisation and medication one year after myocardial infarction in Germany – a claims data analysis
IJCA-27864; No of Pages 7 International Journal of Cardiology xxx (xxxx) xxx
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Health care utilisation and medication one year after myocardial infarction in Germany – a claims data analysis Raven Ulrich a,1, Tobias Pischon b,1, Bernt-Peter Robra d,1, Christian Freier a,1, Christoph Heintze a,1, Wolfram J. Herrmann a,c,⁎,1 a
Charité-Universitätsmedizin Berlin, Germany Max Delbrück Center for Molecular Medicine, Germany Hochschule Furtwangen University, Furtwangen, Germany d Otto von Guericke University of Magdeburg b c
a r t i c l e
i n f o
Article history: Received 21 January 2019 Received in revised form 10 July 2019 Accepted 15 July 2019 Available online xxxx Keywords: Myocardial infarction Aftercare Long-term care Secondary prevention Pharmacotherapy General practice
a b s t r a c t Background: After myocardial infarction, guidelines recommend pharmaceutical treatment with a combination of five different types of drugs for prevention in patients. However, studies from different countries have shown that this goal is not achieved in many patients. The aim of this study was to assess both healthcare and prescribed pharmaceutical treatment in the fourth quarter after index myocardial infarction. Methods: We conducted a claims data analysis with the data of patients who had had a myocardial infarction in the years 2013 or 2014, using information from the largest German health insurance fund (‘AOK’). We analysed contact with physicians, hospital care and actual prescriptions for medication recommended in international guidelines, referring to beta-blockers, ACE inhibitors or angiotensin II receptor blockers, P2Y12-antiplatelet agents, acetylsalicylic acid and statins, one year after myocardial infarction. Analysis was stratified by age and sex, compared between patient groups and over time. Results: We identified 2352 patients who had survived myocardial infarction. Some 96.9% of these participants had at least one contact with their general practitioner (GP) one year after myocardial infarction, 22.8% contacted a cardiologist and 19.7% were hospitalised. Prescription rates range from 37.8% for acetylsalicylic acid to 70.4% for ACE inhibitors. However, only 24.1% received statins, beta-blockers, ACE inhibitors and an antiplatelet drug simultaneously. Prescription of recommended drugs after myocardial infarction decreased steadily over time. Discussion: Long-term medical prevention after myocardial infarction is improvable. GPs should take care of the pharmaceutical prevention after myocardial infarction as they are the physicians seen most intensively in this period. © 2019 Elsevier B.V. All rights reserved.
1. Introduction Myocardial infarction is a frequent event, with incidence rates ranging between 184 and 218 per 100,000 people per year in the USA [1–3]. The case fatality rate of myocardial infarction has been decreasing for many years in most European countries and the USA [4–6]. Today, the proportion of patients who die within 30 days following myocardial infarction ranges from 2.9% to 14.8% in European countries. This figure is higher in women than men [5]. In Germany, 15% of men aged between 70 and 79 have a medical history of myocardial infarction compared to 6% of women in this age group [7].
⁎ Corresponding author at: Hochschule Furtwangen University, Robert-Gerwig-Platz 1, 78120 Furtwangen, Germany. E-mail address: [email protected] (W.J. Herrmann). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Following myocardial infarction, guidelines recommend lifelong pharmaceutical prevention with beta-blockers, ACE inhibitors or angiotensin II receptor blockers, acetylsalicylic acid and statins if not contraindicated. Additionally, dependent on the individual situation, a P2Y12 platelet inhibitor is recommended for up to 12 months [8–10]. Patients who receive less pharmaceutical prevention, especially those who take fewer than four of these drugs, have a significantly higher mortality rate [11,12]. The prescription rate of these five drugs has been increasing for many years, as has been found in Germany [13] and the Netherlands [14]. However, several studies have shown that many patients may still not achieve the recommended number of drugs. For example, a Dutch study using claims data from between 2012 and 2013 found that 82% of myocardial infarction survivors collect beta-blockers from pharmacies one year after myocardial infarction, 74% ACE inhibitors or angiotensin-II-receptor-blockers, 85% statins, 76% antiplatelet drugs and 81% acetylsalicylic acid [15]. In
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Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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Germany, five years after myocardial infarction, only 17% of patients are still retrieving prescriptions for statins from pharmacies. However, the greatest decrease in medication intake takes place in the first year after myocardial infarction [16]. Differences in treatment for men and women have been found. Fewer women than men receive statins, ACE inhibitors, antiplatelet agents and acetylsalicylic acid for prevention following myocardial infarction [14,15]. However, even if female patients are taking antihypertensive drugs and statins, blood pressure and cholesterol are less controlled after myocardial infarction compared to males [13]. Women have a higher risk of certain side effects such as coughing after taking ACE inhibitors [17]. Additionally, a previous study showed that women with symptomatic heart failure were less adherent to their medication than men [18]. Another important factor for healthcare delivery is the age of patients. Elderly patients receive dual antiplatelet therapy and antihypertensive drugs less frequently [19]. Increasing age is also a predictor for worse adherence [12]. Pharmacotherapy is usually prescribed by physicians. However, there is a dearth of studies concerned with the current situation of health care utilisation one year after myocardial infarction and beyond: Ayanian et al. examined health care utilisation after myocardial infarction in 1994 and 1995 in seven states of the US [21]. The only study from this century conducted with claims data shows that nearly all patients in Germany visit the general practitioner (GP) following myocardial infarction [20], however they did not stratify their results by age group. Approximately half of these patients visit a cardiologist after myocardial infarction, mostly in the first quarter after discharge. [20,21]. Survey data from Germany has shown that patients who had a myocardial infarction in their history have on average 5.8 contacts per year with GPs, 2.4 contacts more than patients who have not had a myocardial infarction [7]. Thus, there is a lack of comprehensive data on health care utilisation after myocardial infarction including data on age and gender. Especially, there is no study integrating the analysis of both healthcare utilisation including GP and cardiologist as well as pharmaceutical treatment based on the same dataset. Given that the medication intake rate decreases most during the first year, the aim of this study is to describe both healthcare utilisation and pharmaceutical treatment of patients one year after myocardial infarction in Germany.
first myocardial infarction during the previously mentioned period. We identified 3069 patients who met this definition from the 500,002 insured people. A total of 717 patients were excluded from further analysis as they had not survived at least four complete quarters after the initial myocardial infarction. Therefore, we analysed a sample of 2352 participants who had survived myocardial infarction (Fig. 1). For all analyses beyond the fourth quarter, the population decreases quarterly.
2.3. Health care utilisation and pharmaceutical treatment We analysed on the one hand the utilisation of GPs, cardiologists, general internists, laboratory investigations, inpatient and outpatient hospital treatments, and on the other hand, pharmaceutical treatment as recommended by guidelines in the fourth complete quarter after the initial myocardial infarction. Additionally, we analysed the time trend of healthcare utilisation and prescription of medication quarterly until the eighth quarter after myocardial infarction. For utilisation of GPs, cardiologists and general internists, we evaluated all claims from ambulatory health care according to the speciality of physician available for the provider site and the individual physician. In Germany, many people have a GP, but it is not obligatory to obtain a referral in order to contact a specialist [22]. Both GPs and internists in Germany can work in primary care; these were both counted as GPs according to statutory requirements. General internists working in specialist care were counted separately. For a boarder picture of the utilisation of healthcare facilities, we widened the time frame to a three-quarter interval including one further quarter before and one after the fourth quarter following myocardial infarction. For receiving laboratory investigations, we evaluated every treatment of a laboratory physician with the above-mentioned method. Simple laboratory tests conducted in the doctor's office such as urine test strips were not included. In- and outpatient hospital treatments were counted without restrictions to a certain diagnosis. Additionally, we analysed prescriptions which had been filled at pharmacies. The following recommended drug groups were analysed using their ATC-Code: ACE inhibitors or angiotensin II receptor blockers (C09A, C09B, C09C, C09D, C10BX04), beta-blockers (C07), acetylsalicylic acid (B01AC06, B01AC56, C10BX01, C10BX02, C10BX04), P2Y12-antiplatelet agents, including Prasugrel, Ticagrelor and Clopidogrel (B01AC22, B01AC24, B01AC04, B01AC34), and statins (C10AA, C10BA, C10BX). In order to enhance sensitivity for patients who were provided with drugs, we included in the analysis of medication in the fourth quarter all those who collected a pharmaceutical with a defined daily dose (DDD) of N360 in the first quarter, N270 in the second quarter or N180 in the third quarter. For the analysis of the time trend of filled prescriptions, we only counted filled prescriptions for the respective quarter.
2.4. Statistical analysis We performed all analyses with the statistical programme R, version 3.3.2 (2016-1031) [23]. We analysed the relative proportion of patients who used different health care facilities and the relative proportion of patients who filled prescriptions at pharmacies. In order to analyse health care utilisation and pharmaceutical treatment in the fourth quarter after myocardial infarction, stratified by age and sex, we split the population into four age groups using quartiles of age (65.8, 77.9 and 86.1 years) as cut-off values. We used a t-test to calculate p-values for the mean age difference between male and female patients. All other p-values were calculated using the chi-square test. We
2. Methods We analysed administrative data from insured persons in Germany one year after myocardial infarction, with a focus on utilisation of outpatient and inpatient care as well as pharmaceutical prevention. 2.1. Data source In Germany, health insurance is compulsory, but people can choose between many health insurance funds. The biggest group is the local health insurance funds Allgemeine Ortskrankenkasse (AOK), which insures 24 million people. We used the claims of 500,002 randomly sampled persons insured by AOK as data for this article. Sampling was stratified by age and sex with strata proportional to the source population. Participants were insured by AOK between January 1st, 2011 and December 31st, 2015 or until their death in 2013, 2014 or 2015. The data contained all claims from inpatient and outpatient care, including medication. These data were obtained for remuneration purposes. They included diagnosis, drug prescriptions, procedures, dates of treatment and prescription, as well as information about the billing physician, doctor's office or hospital. Guided by remuneration intervals, the time intervals of the data are quarters of a year. Data was provided by the Scientific Research Institute of the regional health insurance funds (Wissenschaftliches Institut der AOK). 2.2. Study population Our analyses included all persons who were admitted to hospital in 2013 and 2014 and who left hospital with a discharge diagnosis of myocardial infarction. A myocardial infarction was defined as hospital discharge diagnosis I21 (acute myocardial infarction) or I22 (subsequent myocardial infarction) according to ICD-10. The index event was the
Fig. 1. Flow chart for the sampling of analysed participants following myocardial infarction.
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
R. Ulrich et al. / International Journal of Cardiology xxx (xxxx) xxx calculated confidence intervals (CI) for a confidence level of 95%. P-values of b0.05 were considered significant.
3. Results 3.1. Sample We identified 3069 patients who had had a myocardial infarction in the years 2013 and 2014. The greatest risk of death was during the first month after myocardial infarction. Some 717 patients died between the index and the fourth quarter following myocardial infarction and were thus excluded. Therefore, 2352 patients were included in the analysis (Fig. 1), of whom another 39 died during the fifth quarter. A total of 36.8% were female, and mean age at myocardial infarction was 75.8 (SD = 13.5) years. Half a per cent of participants were younger than 40. Women were on average older (80.1 vs. 73.2 years, p b 0.001) than men.
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the proportion of hospitalisations, from 16.2% (CI: 13.4–19.3) in the youngest age group to 23.4% (CI: 20.1–28.0) in the oldest age group. The utilisation of GP increased from 94.4% (CI: 92.2–96.0) in the youngest age group to 98.1% in the 77.9- to 86.1-year-old age group (CI: 96.7–99). Only the utilisation of cardiologists decreased from the second age group on, particularly between the 65.8- to 77.9-year-old age group (29.5%, CI: 26.0–33.3) and the 77.9- to 86.1-year-old age group (19.1%, CI: 16.1–22.4). 3.5. Healthcare utilisation in quarters three to five In the nine-month period from the third to fifth quarter following myocardial infarction, nearly every patient visited a GP (98.8%, CI: 98.2% - 99.1%), 40.3% (CI: 38.4% - 42.3%) contacted a cardiologist and 53.8% (CI: 51.8% - 55.8%) had a laboratory investigation. Thirteen patients (0.6%) did not visit any physician as an outpatient at all, while 40.1% (CI: 38.1%–42.0%) of all patients were admitted to hospital at least once.
3.2. Pharmaceutical treatment in the fourth quarter 3.6. Time trend of healthcare utilisation One year after myocardial infarction, 70.4% of patients (CI: 68.5% 72.2%) received ACE inhibitors or angiotensin II receptor blockers in a pharmacy, 64.5% (CI: 62.6% - 66.4%) beta-blockers, 38.7% (CI: 36.8%– 40.7%) P2Y12-antiplatelets, 37.8% (CI: 35.9% - 39.8%) acetylsalicylic acid and 61.0% (CI: 59.0%–63.0%) statins. Fig. 2 shows the ratio of received drugs by sex and age. Men received significantly more P2Y12antiplatelet agents (41.1% vs. 34.6%, p = 0.002) and more statins (65.2% vs. 53.7%, p b 0.001) than women. Age differences are especially seen in the use of statins. The highest proportion of patients receiving statins was the 65.8- to 77.9-year-old group (70.5%, CI: 66.7–74.0). This proportion dropped down to 56.3% (CI: 52.2–60.2) in the 77.9- to 86.1-year-old patients. 3.3. Time trend of pharmaceutical treatment Fig. 3 shows the time trend for pharmacy-filled prescriptions of the recommended drug groups. Acetylsalicylic acid and P2Y12antiplatelets are represented in one drug group. Some 44.1% (CI: 42.146.1) of all surviving participants received all four drug groups in the index quarter, although this rapidly dropped down to 24.1% (CI: 22.4–25.8) in the fourth quarter and 19.6% (CI: 17.4–22.00) in the eighth quarter. 68.9% (CI: 67.0–70.7) of patients received at least three recommended drug groups in the index quarter, which dropped to 49.1% (CI: 46.2–52.0) in the eighth quarter. Antiplatelet agents ascended the most, from 14.5% (CI: 13.1–15.9) in the quarter before the myocardial infarction to 73.3% (CI: 71.5–75.1) in the quarter of myocardial infarction before descending to 46.6% (CI: 43.7–49.5) in the eighth quarter. 3.4. Healthcare utilisation in the fourth quarter One year after myocardial infarction, 96.9% (CI: 96.1% - 97.5%) of patients visited a GP at least once in a three-month period. In addition, 22.8% (CI: 21.1% - 24.5%) visited a cardiologist and 34.1% (CI: 32.3%– 36.1%) received a laboratory investigation. Only 34 patients (1.4%) did not visit any physician as an outpatient at all. Some 19.7% (CI: 18.2% 21.4%) were hospitalised for any condition. Patients visited a mean of four different physicians during the fourth quarter following myocardial infarction. Fig. 2 shows health care utilisation by sex and age. More women had at least one contact with a GP than men (98.4% vs. 96.0%, p b 0.01) as well as at least one inpatient hospital stay (23.4% vs. 17.6%, p b 0.001). However, men visited a cardiologist significantly more often than women (25.2% vs. 18.7%, p b 0.001). From the youngest age group to the 77.9- to 86.1-year-old group, the proportion of laboratory investigations increased from 29.3% (CI: 25.7–33.1) to 37.8 (34.0–41.8), as did
As shown in Fig. 4, a significantly higher percentage of patients visited a GP after the myocardial infarction than before (p b 0.001). The ratio of patients visiting a cardiologist increases over the event of the myocardial infarction as well. 4. Discussion This study is the first claims data analysis to describe both pharmaceutical treatment and healthcare utilisation one year after myocardial infarction. Our results show that nearly every patient visited a GP in the fourth quarter after myocardial infarction, whereas a fifth of the patients visited a cardiologist and another fifth of the patients had to be admitted to hospital in the fourth quarter following myocardial infarction. Hence, among the different medical disciplines, the GP is by far the most frequently used health care provider during this time period. As the time after myocardial infarction increases, the number of patients who were filling prescriptions for the recommended medical treatment decreased. Elderly and female patients were less well supplied with drugs for prevention. Elderly women, in particular, have a high probability of under-provision with statins. 4.1. Pharmaceutical treatment Compared to other studies, the proportion of patients in our study who receive medication was lower for nearly all drug groups [15,16,24]. In a similar piece of research using claims data from Germany, Mangiapane et al. (2011) found higher rates of patients for nearly all recommended drug groups. The largest difference was found in patients who received acetylsalicylic acid, an additional 28 percentage points found in Mangiapane's study compared to ours. The number of patients who received ACE inhibitors was the only factor which stayed the same across the two studies: 69% in Mangiapane's study compared to 70% in ours. However, these are the values 90 days after myocardial infarction; Mangiapane et al. found decreasing treatment persistence [16]. Eindhoven et al. (2018) conducted a claims data analysis 1 year after myocardial infarction in the Netherlands using data from 2012 and 2013. They found similar proportions for ACE inhibitors; 74% in their study compared to 70% in ours. The largest difference was again seen in the prescription of acetylsalicylic acid, which was 43 percentage points higher in the Dutch study than in ours. However, acetylsalicylic acid is available without prescription in Germany and was therefore underestimated in our study [15]. Kotseva et al. (2016) conducted a European wide interview-based study six months after myocardial infarction and found higher rates of
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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Fig. 2. Utilisation of inpatient and outpatient care (upper bar chart) and pharmaceutical treatment (lower bar chart) in the fourth quarter following myocardial infarction, stratified by age (quartiles) and sex.
patients who received medication compared to our estimates for one year after MI. The difference ranges from five percentage points for ACE inhibitors to 19 percentage points for beta-blockers and 25 or 23 percentage points for statins (61% versus 86% for men or 84% for women). Thus, the larger intervals following myocardial infarction used in our study might explain our lower values, particularly regarding the steady decrease in filled prescriptions over time [24]. The gender differences we found for P2Y12-antiplatelets and statins are in line with many other studies. For example, Heer et al. (2006) found that women receive less clopidogrel [25], while Elst et al. (2005) found that women receive less statins [14]. Findings from Eindhoven et al. (2018) support the lower utilisation of statins and P2Y12antiplatelets but also stated that women receive significantly less acetylsalicylic acid, ACE inhibitors and beta-blockers [15]. Reasons for the under-provision of medication are complex. They can be patient-related, such as contraindications for certain drug groups. Patients may experience or fear side-effects [26,27], meaning they may not fill their prescription at a pharmacy. However, Rana et al. (2018) found that only a small number of patients with a medical history of myocardial infarction do not fill in their prescriptions [28]. Reasons can also be physician-related, such as uncertainty of the individual risk-benefit-ratio or lack of knowledge about a patient's diagnosis [29]. There are many potential explanations for the sex and age differences in pharmacotherapy. It is possible that the type of infarction influenced our findings since patients with non-ST elevation myocardial infarction (NSTEMI) are more often older and female, consider their diagnosis less severe and receive on average less medication than set out
by the guidelines [11,30,31]. In our study, it was unfortunately not possible to distinguish patients with NSTEMI from patients with STEMI. Previous studies emphasise further possible explanations for differences in filling prescriptions between men and women. Women receive fewer percutaneous coronary interventions compared to men [15,25,32,33] and suffer more comorbidities such as diabetes mellitus, hypertension, heart failure and obesity [25,34]. Additionally, physicians and women themselves underestimate women's cardiovascular risk [35]. However, our study shows that most underprescribing for women is mainly due to their higher age. A possible explanation for the lower drug utilisation of elderly patients is the increasing number of comorbidities and polypharmacy in this group. Since mobility is an issue for some older patients, getting drugs from a pharmacy may be a barrier [36]. Decreasing cognition with increasing age must also be considered a barrier for older patients. Furthermore, this group may face additional financial issues which could prevent them from obtaining medication [37,38]. 4.2. Healthcare utilisation As in previous German studies, the GP is the physician visited by most patients [7,20]. However, the percentage of patients seeing the GP is higher in this study compared to the survey results of Pohl et al. (97% vs. 86%), possibly due to recall bias with underestimation in the survey data. Nonetheless, both sets of results demonstrate that the GP is the most constantly visited physician. We found a slightly lower rate of patients who visited the cardiologist in a nine-month period
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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Fig. 3. Number of medications (bar chart) and each individual drug group (line chart) recommended by the guidelines and received by patients who survived a myocardial infarction, indicated in each quarter of a year separately. Acetylsalicylic acid and P2Y12-antiplatelets are represented in one drug group. Quarter 0 is the quarter in which the myocardial infarction occurred; quarters with negative numbers represent the quarters before myocardial infarction.
than Radzimanowski et al. (2018) found for the first year (40% vs. 51%) [20]. One reason for the decreasing utilisation of the cardiologist after the fourth quarter may be the ending of P2Y12-antiplatelet therapy
after 12 months [9,10]. Restricted mobility is an issue for older people and may explain why elderly women visit a cardiologist less often [36]. A Percutaneous coronary intervention (PCI) as therapy of acute
Fig. 4. Proportion of patients who used the health facilities of GP, cardiologist, general internist and hospital and who received laboratory testing at least once in a quarter of a year. Quarter 0 is the quarter in which the myocardial infarction occurred (red line), while quarters with negative numbers represent the quarters before myocardial infarction. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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myocardial infarction may also be a driver to visit the cardiologist since mainly male patients and young patients receive an acute PCI [15,25,39,40]. It is striking that 40% of all patients had a rehospitalisation due to any condition from the third to the fifth quarter after myocardial infarction. One reason for this may be the suboptimal pharmaceutical prevention, as a previous study has shown that patients who take statins have fewer hospitalisations [41]. 4.3. Strength and limitations There are differences in the treatment of myocardial infarction between countries, possibly due to differences in the financing of health care services [24,42]. Furthermore, there are differences in patients insured in different health insurances. Patients insured by the AOK health care fund are more likely to have a BMI of N30. More people who did not graduate from high school and/or who are chronically sick are insured at AOK, which may cause a higher incidence of myocardial infarction in our study population [43,44]. Thus, our population is only partly representative of the German population. An advantage of the study is the large sample. However, some subpopulations are small, such as women in the youngest age group. Diagnoses from remuneration data can be of limited validity. However, the positive predictive value for myocardial infarction as first or second discharge diagnosis is considered to be 94% [45]. Pharmaceutical data are usually valid if they are retrieved in a pharmacy. However, a part of our analysis is based on DDD, which gives only an estimate of the rate of use. People treated with unusual doses may be misclassified by this approach. The use of Acetylsalicylic acid is underestimated, as it is available without prescription. 4.4. Conclusions There are still many patients in Germany who receive insufficient preventive pharmacotherapy after their myocardial infarction. Importantly, with increasing time after myocardial infarction, the number of drugs taken decreases. Nearly all patients visit a GP while there is a longitudinal continuity of GP care, demonstrated by frequent consultations, suggesting that the GP surgery might be the right place to focus on improving long-term medical prevention after myocardial infarction as well as patients' adherence to this medication. Every visit to the GP can be used to improve medical therapy, but one year after a myocardial infarction seems to be an especially good point in time for an intervention to reassess and improve medical prevention. GPs should especially focus on elderly women, as they are most prone to under-provision. Declaration of Competing Interest BPR is member of the advisory board on quality assurance with claims data at the Scientific Research Institute of the regional health insurance funds (Wissenschaftliches Institut der AOK) The other authors declare to have no potential conflict of interest. Acknowledgements We thank the Scientific Research Institute of the regional health insurance funds (Wissenschaftliches Institut der AOK) for providing the data. References [1] R.J. Goldberg, J. Yarzebski, D. Lessard, J.M. Gore, A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective, J. Am. Coll. Cardiol. 33 (1999) 1533–1539, https://doi.org/10.1016/S0735-1097(99)00040-6. [2] V.L. Roger, S.J. Jacobsen, S.A. Weston, T.Y. Goraya, J. Killian, G.S. Reeder, T.E. Kottke, B.P. Yawn, R.L. Frye, Trends in the incidence and survival of patients with hospitalized myocardial infarction, Olmsted County, Minnesota, 1979 to 1994, Ann. Intern. Med. 136 (2002) 341–348, https://doi.org/10.7326/0003-4819-136-5-20020305000005.
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Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Health care utilisation and medication one year after myocardial infarction in Germany – a claims data analysis Raven Ulrich a,1, Tobias Pischon b,1, Bernt-Peter Robra d,1, Christian Freier a,1, Christoph Heintze a,1, Wolfram J. Herrmann a,c,⁎,1 a
Charité-Universitätsmedizin Berlin, Germany Max Delbrück Center for Molecular Medicine, Germany Hochschule Furtwangen University, Furtwangen, Germany d Otto von Guericke University of Magdeburg b c
a r t i c l e
i n f o
Article history: Received 21 January 2019 Received in revised form 10 July 2019 Accepted 15 July 2019 Available online xxxx Keywords: Myocardial infarction Aftercare Long-term care Secondary prevention Pharmacotherapy General practice
a b s t r a c t Background: After myocardial infarction, guidelines recommend pharmaceutical treatment with a combination of five different types of drugs for prevention in patients. However, studies from different countries have shown that this goal is not achieved in many patients. The aim of this study was to assess both healthcare and prescribed pharmaceutical treatment in the fourth quarter after index myocardial infarction. Methods: We conducted a claims data analysis with the data of patients who had had a myocardial infarction in the years 2013 or 2014, using information from the largest German health insurance fund (‘AOK’). We analysed contact with physicians, hospital care and actual prescriptions for medication recommended in international guidelines, referring to beta-blockers, ACE inhibitors or angiotensin II receptor blockers, P2Y12-antiplatelet agents, acetylsalicylic acid and statins, one year after myocardial infarction. Analysis was stratified by age and sex, compared between patient groups and over time. Results: We identified 2352 patients who had survived myocardial infarction. Some 96.9% of these participants had at least one contact with their general practitioner (GP) one year after myocardial infarction, 22.8% contacted a cardiologist and 19.7% were hospitalised. Prescription rates range from 37.8% for acetylsalicylic acid to 70.4% for ACE inhibitors. However, only 24.1% received statins, beta-blockers, ACE inhibitors and an antiplatelet drug simultaneously. Prescription of recommended drugs after myocardial infarction decreased steadily over time. Discussion: Long-term medical prevention after myocardial infarction is improvable. GPs should take care of the pharmaceutical prevention after myocardial infarction as they are the physicians seen most intensively in this period. © 2019 Elsevier B.V. All rights reserved.
1. Introduction Myocardial infarction is a frequent event, with incidence rates ranging between 184 and 218 per 100,000 people per year in the USA [1–3]. The case fatality rate of myocardial infarction has been decreasing for many years in most European countries and the USA [4–6]. Today, the proportion of patients who die within 30 days following myocardial infarction ranges from 2.9% to 14.8% in European countries. This figure is higher in women than men [5]. In Germany, 15% of men aged between 70 and 79 have a medical history of myocardial infarction compared to 6% of women in this age group [7].
⁎ Corresponding author at: Hochschule Furtwangen University, Robert-Gerwig-Platz 1, 78120 Furtwangen, Germany. E-mail address: [email protected] (W.J. Herrmann). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Following myocardial infarction, guidelines recommend lifelong pharmaceutical prevention with beta-blockers, ACE inhibitors or angiotensin II receptor blockers, acetylsalicylic acid and statins if not contraindicated. Additionally, dependent on the individual situation, a P2Y12 platelet inhibitor is recommended for up to 12 months [8–10]. Patients who receive less pharmaceutical prevention, especially those who take fewer than four of these drugs, have a significantly higher mortality rate [11,12]. The prescription rate of these five drugs has been increasing for many years, as has been found in Germany [13] and the Netherlands [14]. However, several studies have shown that many patients may still not achieve the recommended number of drugs. For example, a Dutch study using claims data from between 2012 and 2013 found that 82% of myocardial infarction survivors collect beta-blockers from pharmacies one year after myocardial infarction, 74% ACE inhibitors or angiotensin-II-receptor-blockers, 85% statins, 76% antiplatelet drugs and 81% acetylsalicylic acid [15]. In
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Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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R. Ulrich et al. / International Journal of Cardiology xxx (xxxx) xxx
Germany, five years after myocardial infarction, only 17% of patients are still retrieving prescriptions for statins from pharmacies. However, the greatest decrease in medication intake takes place in the first year after myocardial infarction [16]. Differences in treatment for men and women have been found. Fewer women than men receive statins, ACE inhibitors, antiplatelet agents and acetylsalicylic acid for prevention following myocardial infarction [14,15]. However, even if female patients are taking antihypertensive drugs and statins, blood pressure and cholesterol are less controlled after myocardial infarction compared to males [13]. Women have a higher risk of certain side effects such as coughing after taking ACE inhibitors [17]. Additionally, a previous study showed that women with symptomatic heart failure were less adherent to their medication than men [18]. Another important factor for healthcare delivery is the age of patients. Elderly patients receive dual antiplatelet therapy and antihypertensive drugs less frequently [19]. Increasing age is also a predictor for worse adherence [12]. Pharmacotherapy is usually prescribed by physicians. However, there is a dearth of studies concerned with the current situation of health care utilisation one year after myocardial infarction and beyond: Ayanian et al. examined health care utilisation after myocardial infarction in 1994 and 1995 in seven states of the US [21]. The only study from this century conducted with claims data shows that nearly all patients in Germany visit the general practitioner (GP) following myocardial infarction [20], however they did not stratify their results by age group. Approximately half of these patients visit a cardiologist after myocardial infarction, mostly in the first quarter after discharge. [20,21]. Survey data from Germany has shown that patients who had a myocardial infarction in their history have on average 5.8 contacts per year with GPs, 2.4 contacts more than patients who have not had a myocardial infarction [7]. Thus, there is a lack of comprehensive data on health care utilisation after myocardial infarction including data on age and gender. Especially, there is no study integrating the analysis of both healthcare utilisation including GP and cardiologist as well as pharmaceutical treatment based on the same dataset. Given that the medication intake rate decreases most during the first year, the aim of this study is to describe both healthcare utilisation and pharmaceutical treatment of patients one year after myocardial infarction in Germany.
first myocardial infarction during the previously mentioned period. We identified 3069 patients who met this definition from the 500,002 insured people. A total of 717 patients were excluded from further analysis as they had not survived at least four complete quarters after the initial myocardial infarction. Therefore, we analysed a sample of 2352 participants who had survived myocardial infarction (Fig. 1). For all analyses beyond the fourth quarter, the population decreases quarterly.
2.3. Health care utilisation and pharmaceutical treatment We analysed on the one hand the utilisation of GPs, cardiologists, general internists, laboratory investigations, inpatient and outpatient hospital treatments, and on the other hand, pharmaceutical treatment as recommended by guidelines in the fourth complete quarter after the initial myocardial infarction. Additionally, we analysed the time trend of healthcare utilisation and prescription of medication quarterly until the eighth quarter after myocardial infarction. For utilisation of GPs, cardiologists and general internists, we evaluated all claims from ambulatory health care according to the speciality of physician available for the provider site and the individual physician. In Germany, many people have a GP, but it is not obligatory to obtain a referral in order to contact a specialist [22]. Both GPs and internists in Germany can work in primary care; these were both counted as GPs according to statutory requirements. General internists working in specialist care were counted separately. For a boarder picture of the utilisation of healthcare facilities, we widened the time frame to a three-quarter interval including one further quarter before and one after the fourth quarter following myocardial infarction. For receiving laboratory investigations, we evaluated every treatment of a laboratory physician with the above-mentioned method. Simple laboratory tests conducted in the doctor's office such as urine test strips were not included. In- and outpatient hospital treatments were counted without restrictions to a certain diagnosis. Additionally, we analysed prescriptions which had been filled at pharmacies. The following recommended drug groups were analysed using their ATC-Code: ACE inhibitors or angiotensin II receptor blockers (C09A, C09B, C09C, C09D, C10BX04), beta-blockers (C07), acetylsalicylic acid (B01AC06, B01AC56, C10BX01, C10BX02, C10BX04), P2Y12-antiplatelet agents, including Prasugrel, Ticagrelor and Clopidogrel (B01AC22, B01AC24, B01AC04, B01AC34), and statins (C10AA, C10BA, C10BX). In order to enhance sensitivity for patients who were provided with drugs, we included in the analysis of medication in the fourth quarter all those who collected a pharmaceutical with a defined daily dose (DDD) of N360 in the first quarter, N270 in the second quarter or N180 in the third quarter. For the analysis of the time trend of filled prescriptions, we only counted filled prescriptions for the respective quarter.
2.4. Statistical analysis We performed all analyses with the statistical programme R, version 3.3.2 (2016-1031) [23]. We analysed the relative proportion of patients who used different health care facilities and the relative proportion of patients who filled prescriptions at pharmacies. In order to analyse health care utilisation and pharmaceutical treatment in the fourth quarter after myocardial infarction, stratified by age and sex, we split the population into four age groups using quartiles of age (65.8, 77.9 and 86.1 years) as cut-off values. We used a t-test to calculate p-values for the mean age difference between male and female patients. All other p-values were calculated using the chi-square test. We
2. Methods We analysed administrative data from insured persons in Germany one year after myocardial infarction, with a focus on utilisation of outpatient and inpatient care as well as pharmaceutical prevention. 2.1. Data source In Germany, health insurance is compulsory, but people can choose between many health insurance funds. The biggest group is the local health insurance funds Allgemeine Ortskrankenkasse (AOK), which insures 24 million people. We used the claims of 500,002 randomly sampled persons insured by AOK as data for this article. Sampling was stratified by age and sex with strata proportional to the source population. Participants were insured by AOK between January 1st, 2011 and December 31st, 2015 or until their death in 2013, 2014 or 2015. The data contained all claims from inpatient and outpatient care, including medication. These data were obtained for remuneration purposes. They included diagnosis, drug prescriptions, procedures, dates of treatment and prescription, as well as information about the billing physician, doctor's office or hospital. Guided by remuneration intervals, the time intervals of the data are quarters of a year. Data was provided by the Scientific Research Institute of the regional health insurance funds (Wissenschaftliches Institut der AOK). 2.2. Study population Our analyses included all persons who were admitted to hospital in 2013 and 2014 and who left hospital with a discharge diagnosis of myocardial infarction. A myocardial infarction was defined as hospital discharge diagnosis I21 (acute myocardial infarction) or I22 (subsequent myocardial infarction) according to ICD-10. The index event was the
Fig. 1. Flow chart for the sampling of analysed participants following myocardial infarction.
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
R. Ulrich et al. / International Journal of Cardiology xxx (xxxx) xxx calculated confidence intervals (CI) for a confidence level of 95%. P-values of b0.05 were considered significant.
3. Results 3.1. Sample We identified 3069 patients who had had a myocardial infarction in the years 2013 and 2014. The greatest risk of death was during the first month after myocardial infarction. Some 717 patients died between the index and the fourth quarter following myocardial infarction and were thus excluded. Therefore, 2352 patients were included in the analysis (Fig. 1), of whom another 39 died during the fifth quarter. A total of 36.8% were female, and mean age at myocardial infarction was 75.8 (SD = 13.5) years. Half a per cent of participants were younger than 40. Women were on average older (80.1 vs. 73.2 years, p b 0.001) than men.
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the proportion of hospitalisations, from 16.2% (CI: 13.4–19.3) in the youngest age group to 23.4% (CI: 20.1–28.0) in the oldest age group. The utilisation of GP increased from 94.4% (CI: 92.2–96.0) in the youngest age group to 98.1% in the 77.9- to 86.1-year-old age group (CI: 96.7–99). Only the utilisation of cardiologists decreased from the second age group on, particularly between the 65.8- to 77.9-year-old age group (29.5%, CI: 26.0–33.3) and the 77.9- to 86.1-year-old age group (19.1%, CI: 16.1–22.4). 3.5. Healthcare utilisation in quarters three to five In the nine-month period from the third to fifth quarter following myocardial infarction, nearly every patient visited a GP (98.8%, CI: 98.2% - 99.1%), 40.3% (CI: 38.4% - 42.3%) contacted a cardiologist and 53.8% (CI: 51.8% - 55.8%) had a laboratory investigation. Thirteen patients (0.6%) did not visit any physician as an outpatient at all, while 40.1% (CI: 38.1%–42.0%) of all patients were admitted to hospital at least once.
3.2. Pharmaceutical treatment in the fourth quarter 3.6. Time trend of healthcare utilisation One year after myocardial infarction, 70.4% of patients (CI: 68.5% 72.2%) received ACE inhibitors or angiotensin II receptor blockers in a pharmacy, 64.5% (CI: 62.6% - 66.4%) beta-blockers, 38.7% (CI: 36.8%– 40.7%) P2Y12-antiplatelets, 37.8% (CI: 35.9% - 39.8%) acetylsalicylic acid and 61.0% (CI: 59.0%–63.0%) statins. Fig. 2 shows the ratio of received drugs by sex and age. Men received significantly more P2Y12antiplatelet agents (41.1% vs. 34.6%, p = 0.002) and more statins (65.2% vs. 53.7%, p b 0.001) than women. Age differences are especially seen in the use of statins. The highest proportion of patients receiving statins was the 65.8- to 77.9-year-old group (70.5%, CI: 66.7–74.0). This proportion dropped down to 56.3% (CI: 52.2–60.2) in the 77.9- to 86.1-year-old patients. 3.3. Time trend of pharmaceutical treatment Fig. 3 shows the time trend for pharmacy-filled prescriptions of the recommended drug groups. Acetylsalicylic acid and P2Y12antiplatelets are represented in one drug group. Some 44.1% (CI: 42.146.1) of all surviving participants received all four drug groups in the index quarter, although this rapidly dropped down to 24.1% (CI: 22.4–25.8) in the fourth quarter and 19.6% (CI: 17.4–22.00) in the eighth quarter. 68.9% (CI: 67.0–70.7) of patients received at least three recommended drug groups in the index quarter, which dropped to 49.1% (CI: 46.2–52.0) in the eighth quarter. Antiplatelet agents ascended the most, from 14.5% (CI: 13.1–15.9) in the quarter before the myocardial infarction to 73.3% (CI: 71.5–75.1) in the quarter of myocardial infarction before descending to 46.6% (CI: 43.7–49.5) in the eighth quarter. 3.4. Healthcare utilisation in the fourth quarter One year after myocardial infarction, 96.9% (CI: 96.1% - 97.5%) of patients visited a GP at least once in a three-month period. In addition, 22.8% (CI: 21.1% - 24.5%) visited a cardiologist and 34.1% (CI: 32.3%– 36.1%) received a laboratory investigation. Only 34 patients (1.4%) did not visit any physician as an outpatient at all. Some 19.7% (CI: 18.2% 21.4%) were hospitalised for any condition. Patients visited a mean of four different physicians during the fourth quarter following myocardial infarction. Fig. 2 shows health care utilisation by sex and age. More women had at least one contact with a GP than men (98.4% vs. 96.0%, p b 0.01) as well as at least one inpatient hospital stay (23.4% vs. 17.6%, p b 0.001). However, men visited a cardiologist significantly more often than women (25.2% vs. 18.7%, p b 0.001). From the youngest age group to the 77.9- to 86.1-year-old group, the proportion of laboratory investigations increased from 29.3% (CI: 25.7–33.1) to 37.8 (34.0–41.8), as did
As shown in Fig. 4, a significantly higher percentage of patients visited a GP after the myocardial infarction than before (p b 0.001). The ratio of patients visiting a cardiologist increases over the event of the myocardial infarction as well. 4. Discussion This study is the first claims data analysis to describe both pharmaceutical treatment and healthcare utilisation one year after myocardial infarction. Our results show that nearly every patient visited a GP in the fourth quarter after myocardial infarction, whereas a fifth of the patients visited a cardiologist and another fifth of the patients had to be admitted to hospital in the fourth quarter following myocardial infarction. Hence, among the different medical disciplines, the GP is by far the most frequently used health care provider during this time period. As the time after myocardial infarction increases, the number of patients who were filling prescriptions for the recommended medical treatment decreased. Elderly and female patients were less well supplied with drugs for prevention. Elderly women, in particular, have a high probability of under-provision with statins. 4.1. Pharmaceutical treatment Compared to other studies, the proportion of patients in our study who receive medication was lower for nearly all drug groups [15,16,24]. In a similar piece of research using claims data from Germany, Mangiapane et al. (2011) found higher rates of patients for nearly all recommended drug groups. The largest difference was found in patients who received acetylsalicylic acid, an additional 28 percentage points found in Mangiapane's study compared to ours. The number of patients who received ACE inhibitors was the only factor which stayed the same across the two studies: 69% in Mangiapane's study compared to 70% in ours. However, these are the values 90 days after myocardial infarction; Mangiapane et al. found decreasing treatment persistence [16]. Eindhoven et al. (2018) conducted a claims data analysis 1 year after myocardial infarction in the Netherlands using data from 2012 and 2013. They found similar proportions for ACE inhibitors; 74% in their study compared to 70% in ours. The largest difference was again seen in the prescription of acetylsalicylic acid, which was 43 percentage points higher in the Dutch study than in ours. However, acetylsalicylic acid is available without prescription in Germany and was therefore underestimated in our study [15]. Kotseva et al. (2016) conducted a European wide interview-based study six months after myocardial infarction and found higher rates of
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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Fig. 2. Utilisation of inpatient and outpatient care (upper bar chart) and pharmaceutical treatment (lower bar chart) in the fourth quarter following myocardial infarction, stratified by age (quartiles) and sex.
patients who received medication compared to our estimates for one year after MI. The difference ranges from five percentage points for ACE inhibitors to 19 percentage points for beta-blockers and 25 or 23 percentage points for statins (61% versus 86% for men or 84% for women). Thus, the larger intervals following myocardial infarction used in our study might explain our lower values, particularly regarding the steady decrease in filled prescriptions over time [24]. The gender differences we found for P2Y12-antiplatelets and statins are in line with many other studies. For example, Heer et al. (2006) found that women receive less clopidogrel [25], while Elst et al. (2005) found that women receive less statins [14]. Findings from Eindhoven et al. (2018) support the lower utilisation of statins and P2Y12antiplatelets but also stated that women receive significantly less acetylsalicylic acid, ACE inhibitors and beta-blockers [15]. Reasons for the under-provision of medication are complex. They can be patient-related, such as contraindications for certain drug groups. Patients may experience or fear side-effects [26,27], meaning they may not fill their prescription at a pharmacy. However, Rana et al. (2018) found that only a small number of patients with a medical history of myocardial infarction do not fill in their prescriptions [28]. Reasons can also be physician-related, such as uncertainty of the individual risk-benefit-ratio or lack of knowledge about a patient's diagnosis [29]. There are many potential explanations for the sex and age differences in pharmacotherapy. It is possible that the type of infarction influenced our findings since patients with non-ST elevation myocardial infarction (NSTEMI) are more often older and female, consider their diagnosis less severe and receive on average less medication than set out
by the guidelines [11,30,31]. In our study, it was unfortunately not possible to distinguish patients with NSTEMI from patients with STEMI. Previous studies emphasise further possible explanations for differences in filling prescriptions between men and women. Women receive fewer percutaneous coronary interventions compared to men [15,25,32,33] and suffer more comorbidities such as diabetes mellitus, hypertension, heart failure and obesity [25,34]. Additionally, physicians and women themselves underestimate women's cardiovascular risk [35]. However, our study shows that most underprescribing for women is mainly due to their higher age. A possible explanation for the lower drug utilisation of elderly patients is the increasing number of comorbidities and polypharmacy in this group. Since mobility is an issue for some older patients, getting drugs from a pharmacy may be a barrier [36]. Decreasing cognition with increasing age must also be considered a barrier for older patients. Furthermore, this group may face additional financial issues which could prevent them from obtaining medication [37,38]. 4.2. Healthcare utilisation As in previous German studies, the GP is the physician visited by most patients [7,20]. However, the percentage of patients seeing the GP is higher in this study compared to the survey results of Pohl et al. (97% vs. 86%), possibly due to recall bias with underestimation in the survey data. Nonetheless, both sets of results demonstrate that the GP is the most constantly visited physician. We found a slightly lower rate of patients who visited the cardiologist in a nine-month period
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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Fig. 3. Number of medications (bar chart) and each individual drug group (line chart) recommended by the guidelines and received by patients who survived a myocardial infarction, indicated in each quarter of a year separately. Acetylsalicylic acid and P2Y12-antiplatelets are represented in one drug group. Quarter 0 is the quarter in which the myocardial infarction occurred; quarters with negative numbers represent the quarters before myocardial infarction.
than Radzimanowski et al. (2018) found for the first year (40% vs. 51%) [20]. One reason for the decreasing utilisation of the cardiologist after the fourth quarter may be the ending of P2Y12-antiplatelet therapy
after 12 months [9,10]. Restricted mobility is an issue for older people and may explain why elderly women visit a cardiologist less often [36]. A Percutaneous coronary intervention (PCI) as therapy of acute
Fig. 4. Proportion of patients who used the health facilities of GP, cardiologist, general internist and hospital and who received laboratory testing at least once in a quarter of a year. Quarter 0 is the quarter in which the myocardial infarction occurred (red line), while quarters with negative numbers represent the quarters before myocardial infarction. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050
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myocardial infarction may also be a driver to visit the cardiologist since mainly male patients and young patients receive an acute PCI [15,25,39,40]. It is striking that 40% of all patients had a rehospitalisation due to any condition from the third to the fifth quarter after myocardial infarction. One reason for this may be the suboptimal pharmaceutical prevention, as a previous study has shown that patients who take statins have fewer hospitalisations [41]. 4.3. Strength and limitations There are differences in the treatment of myocardial infarction between countries, possibly due to differences in the financing of health care services [24,42]. Furthermore, there are differences in patients insured in different health insurances. Patients insured by the AOK health care fund are more likely to have a BMI of N30. More people who did not graduate from high school and/or who are chronically sick are insured at AOK, which may cause a higher incidence of myocardial infarction in our study population [43,44]. Thus, our population is only partly representative of the German population. An advantage of the study is the large sample. However, some subpopulations are small, such as women in the youngest age group. Diagnoses from remuneration data can be of limited validity. However, the positive predictive value for myocardial infarction as first or second discharge diagnosis is considered to be 94% [45]. Pharmaceutical data are usually valid if they are retrieved in a pharmacy. However, a part of our analysis is based on DDD, which gives only an estimate of the rate of use. People treated with unusual doses may be misclassified by this approach. The use of Acetylsalicylic acid is underestimated, as it is available without prescription. 4.4. Conclusions There are still many patients in Germany who receive insufficient preventive pharmacotherapy after their myocardial infarction. Importantly, with increasing time after myocardial infarction, the number of drugs taken decreases. Nearly all patients visit a GP while there is a longitudinal continuity of GP care, demonstrated by frequent consultations, suggesting that the GP surgery might be the right place to focus on improving long-term medical prevention after myocardial infarction as well as patients' adherence to this medication. Every visit to the GP can be used to improve medical therapy, but one year after a myocardial infarction seems to be an especially good point in time for an intervention to reassess and improve medical prevention. GPs should especially focus on elderly women, as they are most prone to under-provision. Declaration of Competing Interest BPR is member of the advisory board on quality assurance with claims data at the Scientific Research Institute of the regional health insurance funds (Wissenschaftliches Institut der AOK) The other authors declare to have no potential conflict of interest. Acknowledgements We thank the Scientific Research Institute of the regional health insurance funds (Wissenschaftliches Institut der AOK) for providing the data. References [1] R.J. Goldberg, J. Yarzebski, D. Lessard, J.M. Gore, A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective, J. Am. Coll. Cardiol. 33 (1999) 1533–1539, https://doi.org/10.1016/S0735-1097(99)00040-6. [2] V.L. Roger, S.J. Jacobsen, S.A. Weston, T.Y. Goraya, J. Killian, G.S. Reeder, T.E. Kottke, B.P. Yawn, R.L. Frye, Trends in the incidence and survival of patients with hospitalized myocardial infarction, Olmsted County, Minnesota, 1979 to 1994, Ann. Intern. Med. 136 (2002) 341–348, https://doi.org/10.7326/0003-4819-136-5-20020305000005.
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Please cite this article as: R. Ulrich, T. Pischon, B.-P. Robra, et al., Health care utilisation and medication one year after myocardial infarction in Germany – a claims da..., International Journal of Cardiology, https://doi.org/10.1016/j.ijcard.2019.07.050