Ulf Maywald

Incidence and prevalence of atrial fibrillation: an analysis based on 8.3 million patients

AIMS Based on an analysis of claims-based data of 8.298 million members of two German statutory health insurance funds, the aim of this contribution is to quantify age-/gender-specific prevalence/incidence of atrial fibrillation (AF) in a German setting. METHODS AND RESULTS Patients were classified as AF prevalent, if they had received at least two outpatient diagnoses of AF (ICD10-Code I48.1-) in two different quarters of the year and/or had received at least one main AF diagnosis during inpatient treatment between 1 January 2007 and 12 December 2008. They were considered to have had new onset AF in 2008 under the following conditions; first, there was no AF diagnosis in 2007; secondly, patients had not received oral anticoagulant medication in 2007; and thirdly, patients had received either one inpatient/two outpatient diagnoses of AF in 2008. In our sample, a total of 176 891 patients had AF. AF prevalence was 2.132%. The average age of these AF patients was 73.1 years, and 55.5% (98 190 patients) were male. The incidence of AF in our sample was 4.358 cases/1000 person-years in men and 3.868 cases/1000 person-years in women. CONCLUSION A comparison of the distribution of AF prevalence/incidence in our population with that in already published studies showed that our figures were higher, especially in the age groups above 70 years. Our data show that in a large industrial nation such as Germany care provision structures are going to be challenged by a requirement to treat more AF patients in the future.

First Patient-Centered Drug Information Service in Germany—A Descriptive Study

BACKGROUND The majority of patients have unmet drug information needs, and patients’ knowledge of their own treatment is often poor. This is a major obstacle to a more patient-centered healthcare system. OBJECTIVE To explore patterns of patients’ unmet drug information needs and outcomes of counseling patients by a drug and therapy information center (DTIC). METHODS We established the first German DTIC for patients. In this descriptive study, data obtained on callers within 24 months were analyzed. Questionnaires for gathering information about callers’ characteristics and the outcome of the advice were sent to all patients using the service after consultation. Data on all inquiries and evaluation sheets were documented and analyzed by a standardized database. RESULTS During 24 months, 2049 telephone calls were recorded. Patients’ unmet information needs were mainly related to adverse drug reactions/drug interactions (31.0%) and therapy information (27.2%). In 81.0% of the cases, patients’ uncertainties regarding their prescribed medications were reduced, 37.9% discussed the advice with their physician, and 18.3% reported a reduction of physician visits as a result of our advice. The patient–physician relationship remained mainly (70.6%) unaffected after our intervention. CONCLUSIONS The DTIC is useful as a source of medical expert advice. The service can help to reduce medication problems based on inadequate information and therefore avoid unnecessary healthcare utilization. With the knowledge provided, patients can participate in decisions affecting their own health. This procedure encourages greater confidence in the merits of drug therapy.

Comparison of Inhibitory Effects of Irbesartan and Atorvastatin Treatment on the Renin Angiotensin System (RAS) in Veins: A Randomized Double‐Blind Crossover Trial in Healthy Subjects

Experimental studies point to an interplay between hypercholesterolemia and hypertension, acting through the renin angiotensin system. In a crossover study design with 8 healthy subjects, the authors tested the hypothesis that statin treatment exerts renin angiotensin system–modulating effects in veins by down‐regulation of AT1‐receptors, resulting in reduced Angiotensin II (Ang II)–induced venoconstriction and by increasing the pleiotropic Ang II–metabolite Ang‐(1–7). Irbesartan was used as positive control. Ang II–induced venoconstriction was 49% ± 9% before and 64% ± 10% after 30 days of atorvastatin treatment compared to 50% ± 8% before and 15% ± 9% after irbesartan (P = .004). Plasma angiotensin levels significantly increased only after irbesartan treatment (Ang II: 35 ± 4 vs 329 ± 101 pg/mL [P = .02]; Ang‐(1–7): 10 ± 3 vs 35 ± 6 pg/mL [P = .01]) compared to atorvastatin treatment (Ang II: 26 ± 5 vs 31 ± 4 pg/mL [P = ns]; Ang‐(1–7): 9 ± 2 vs 11 ± 3 pg/mL [P = ns]). The data indicate that atorvastatin does not inhibit Ang II–induced venoconstriction in vivo and point toward a supportive role of Ang‐(1–7) in contributing to the antihypertensive and beneficial vascular effects of irbesartan.

The quality of oral anticoagulation in general practice in patients with atrial fibrillation

BACKGROUND The aims of this study were to evaluate the quality of oral anticoagulation (OAC) in AF patients in the practices of general practitioners (GPs) in Germany and to investigate possible causal factors which influence OAC quality. METHODS We conducted a multi-center, non-interventional, prospective observational cohort study among general practitioners (GPs) in Germany. To assess the quality of OAC on the basis of the prospectively documented international normalized ratio (INR) values, the time in therapeutic range (TTR) was calculated using the Rosendaal linear trend method. The causes of poor OAC quality were identified by a multivariate analysis model (logistical regression; poor OAC quality: TTR <60%). RESULTS AND CONCLUSIONS For 525 OAC patients (66.8%; patients with at least 2 prospectively documented INR values) the average TTR (target range of 2.0-3.0) was 67.6%. About 34.7% of the patients had a TTR <60%. None of the variables representing characteristics of the medical practices were capable of explaining the occurrence of poor OAC quality. However, with regard to care provision-based variables, the existence of a brief discontinuation of medication was important. As the existence of adherence barriers increased, the probability of poor anticoagulation quality increased. In conclusion, the provision of OAC in the German health care system is to be regarded as good, but far from ideal. Our causal analysis shows that patient-based factors should be addressed through the provision of improved training and that the rationale behind the interruption of OAC treatment should be critically examined.

Epidemiology of urinary tract infections in type 2 diabetes mellitus patients: An analysis based on a large sample of 456,586 German T2DM patients

INTRODUCTION This analysis was conducted to investigate urinary tract infection (UTI) incidence among Type 2 Diabetes mellitus (T2DM) patients in Germany in a real-world setting and to identify risk factors associated with UTI incidence/recurrence. METHODS Our cohort study was conducted based on an anonymized dataset from a regional German sickness fund (2010-2012). A UTI event was mainly identified through observed outpatient/inpatient UTI diagnoses. We reported the number of UTI events per 1000 patient-years. Furthermore, the proportion of patients affected by ≥1 and ≥2 UTI events in the observational period was separately reported. Finally, three multivariate Cox regression analyses were conducted to identify factors that may be associated with UTI event risk or recurrent UTI event risk. RESULTS A total of 456,586 T2DM-prevalent patients were identified (mean age 72.8years, 56.1% female, mean Charlson Comorbidity Index (CCI) of 7.3). Overall, the UTI event rate was 87.3 events per 1000 patient-years (111.8/55.8 per 1000 patient-years for women/men (p<0.001)). The highest UTI event rates were observed for those aged >89years. After 730days after first observed T2DM diagnosis, the proportion of women/men still UTI-event-free was 80.9%/90.2% (p<0.001). Most important factors associated with UTI risk in our three models were older age (Hazard Ratio (HR)=1.56-1.70 for >79years), female gender (HR=1.38-1.57), UTIs in the previous two years (HR=2.77-5.94), number of comorbidities as measured by the CCI (HR=1.32-1.52 for CCI>6) and at least one cystoscopy in the previous year (HR=2.06-5.48). Furthermore, high HbA1c values in the previous year (HR=1.29-1.4 referring to HbA1c>9.5%) and a poor kidney function (HR=1.11-1.211 referring to glomerular filtration rate (GFR)<60ml/min) increased the UTI event risk. DISCUSSION Our study confirms that UTI event risk is high in T2DM patients. Older female patients having experienced previous UTIs face an above-average UTI risk, especially if these risk factors are associated with poor glycemic control and poor kidney function.

Arzneimittelberatungsdienste als Instrumente der Versorgungsforschung

ZusammenfassungHintergrund:Beratungsdienste für Ärzte und Patienten tragen zur Verbesserung der Arzt-Patient-Kommunikation bei und können die aktuelle Versorgungslage beschreiben.Methodik:Die Daten des seit 1995 etablierten Arzneimittelberatungsdienstes für Ärzte (ABDÄ) und des seit 2001 bestehenden Patienteninformationsdienstes (ABDP) am Institut für Klinische Pharmakologie der TU Dresden wurden deskriptiv ausgewertet.Ergebnisse:Beide Beratungsdienste wurden häufig in Anspruch genommen (2004: 129 ärztliche Anfragen vs. 1 358 Patientenanfragen). Die Anfragen in beiden Beratungsdiensten bezogen sich in der Hauptsache auf hochprävalente Arzneimittelgruppen, am häufigsten wurde zu kardiovaskulären Therapeutika (ABDÄ: 20%; ABDP: 30%) und Psychopharmaka (ABDÄ: 22%; ABDP: 17%) Auskunft gegeben.Schlussfolgerung:Die Ergebnisse legen nahe, dass aus Patientensicht von den Angehörigen der Heilberufe nicht ausreichend über die verordnete Medikation aufgeklärt wird. Auch wenn in beiden Beratungsdiensten inhaltlich ähnliche Arzneimittelgruppen Gegenstand der Anfrage waren, dürfte ein Zeitproblem eher für mangelnde Aufklärung verantwortlich zu machen sein als ärztliche Wissensdefizite.AbstractBackground:Patient- and physician-centered drug information services (DICs) can contribute to a better communication between doctors and patients and health care research. Furthermore, gaps within health care can be identified.Methods:Data of two DICs (the physician-centered service is in operation for almost 10 years, the patient-centered service since 2001), both established in the Institute of Clinical Pharmacology of the TU Dresden, Germany, were analyzed using descriptive statistics.Results:The consultation frequency in both DICs was high (2004: 129 enquiries by physicians; 1,358 by patients). Questions concerning highly prevalent drug groups, i. e., cardiovascular drugs (physicians: 20%; patients: 30%) and drugs targeting the central nervous system (physicians: 22%; patients: 17%) were asked most frequently.Conclusion:The results indicate that patient’s drug information in primary care needs improvement. Although in both DICs similar drug groups were asked, the authors suggest that the time factor is the core obstacle to sufficient information rather than knowledge deficits of physicians.

Evaluation of a program of integrated care to reduce recurrent osteoporotic fractures

To evaluate the outcomes of patients participating in a program of integrated care for osteoporosis in terms of medication supply, fracture incidence and expenses.

Characterization of vascular reactivity in dorsal hand veins after oral rosiglitazone treatment in healthy subjects

OBJECTIVE In clinical studies with diabetic patients thiazolidinediones have been shown to restore abnormal vascular function which might be attributed to improved blood sugar control or to restoration of vascular endothelium and smooth muscle responsiveness. The present study was undertaken to investigate whether rosiglitazone modulates vascular responsiveness to different vasoactive agents and exerts renin-angiotensin-system (RAS)-inhibiting properties in healthy subjects in vivo. METHODS 24 healthy male subjects were randomized to receive either rosiglitazone or placebo. Venoconstrictor responses to angiotensin II (Ang II) and phenylephrine, and endothelium-dependent response to histamine and insulin, and endothelium-independent response to glyceroltrinitrate were compared using the dorsal hand vein compliance method. Effects on the RAS were investigated by plasma level determinations of Ang II and angiotensin-(1-7). Treatment effects on the systemic arterial system were investigated by standardized pulse-wave-analysis. RESULTS Rosiglitazone significantly inhibited venoconstrictor responses to Ang II by 19% (-70% vs. -51% constriction, p = 0.034) and in the presence of rosiglitazone the ED80 for phenylephrine was increased (ED80: 317 A+/- 86 ng vs. 531 A+/- 102 ng; p = 0.010). Rosiglitazone treatment was without effect on endothelium-dependent dilation, blood pressure, pulse-wave-velocity and plasma angiotensin peptide levels. CONCLUSIONS The data of the present study in veins of healthy subjects are consistent with data from in vitro and animal studies supporting a direct effect of rosiglitazone on venous tone by modulation of the vascular smooth muscle response via AT1-receptor-downregulation.

Arzneimittelberatungsdienste für Ärzte und Patienten

ZusammenfassungDie wachsende Anzahl von Arzneimitteln und Innovationen führt zu einer Unübersichtlichkeit des Arzneimittelmarktes, bei der die Vielfalt möglicher Neben- und Wechselwirkungen ad hoc kaum beachtet werden kann. Aus diesen Gründen ist es notwendig, dem behandelnden Arzt mit effizienten und interessenunabhängigen Arzneimittelinfodiensten sichere und kritisch evaluierte Unterstützung in der Pharmakotherapie zu geben. Daher hat sich in den letzten Jahren eine Reihe von Angeboten zur individualisierten Arzneimittelinformation für Ärzte etabliert, deren Qualität und Nützlichkeit für die Pharmakotherapie aus Sicht dieser Nutzergruppe positiv eingeschätzt wurden.Auch auf Seiten der Patienten sind Informationsdefizite zur Arzneimitteltherapie zu verzeichnen, die auf generelle Mängel in der Arzt-Patienten-Kommunikation zurückzuführen sind. An diesem Punkt knüpfen patientenorientierte Arzneimittelberatungsdienste an, die dem Patienten ein verbessertes Selbstbewusstsein hinsichtlich seiner Erkrankung, dem Vertrauen in seine Arzneitherapie und dem Selbstmanagement von Symptomen geben. In der Evaluation dieser Angebote wurde der Service von den Patienten als sinnvoller Service bewertet.AbstractThe growing number of medicinal products and innovations has led to great complexity in the pharmaceutical market. The variety of possible drug interactions and side effects can only be overviewed with difficulty. Therefore, it is necessary that services for physicians be offered in order to provide critically evaluated and independent drug information for pharmacotherapy. In recent decades, a series of hospital based drug information centres have been established. Their quality and usefulness for patients have been positively evaluated by the users. Many patients are also insufficiently informed on their own drug therapy. This deficit is based on a general lack in communication between the patient and physician. Patient-orientated drug information services can help strengthen patients in their drug therapy and self management of symptoms, and to improve compliance. Such services have also been positively evaluated by patients.

Cardiovascular comorbidity and cardiovascular risk factors in patients with chronic inflammatory skin diseases: A case-control study utilising a population-based administrative database

Background : : Psoriasis (PSO) and atopic eczema (AE) are chronic inflammatory disorders that primarily affect the skin. Data on cardiovascular comorbidity in PSO is scarce, and studies on the association of cardiovascular disease/cardiovascular risk factors and AE are missing. Methods : We performed two separate case-control studies for PSO and AE utilising an administrative health care database including approximately 250,000 individuals from Germany. Cases with AE (n=6,296) and cases with PSO (n=3,156) were individually-matched (1:1) to controls with the same age and sex. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated based on the observed prevalences of cardiovascular morbidity among cases and controls. Results : Patients with AE had a higher risk of obesity (OR,95%CI 1.24, 1.07-1.44). None of the other cardiovascular risk factors or diseases studied was associated with AE. PSO was significantly associated with hypertension (OR,95%CI 1.45, 1.27-1.66), diabetes mellitus type-2 (OR,95%CI 1.35, 1.13-1.61), obesity (OR,95%CI 1.58, 1.34-1.85), dyslipidemia (OR,95%CI 1.42, 1.14-1.77), and atherosclerosis (OR,95%CI 1.81, 1.37-2.41). Despite their unfavorable cardiovascular risk factor profile, patients with PSO were not at increased risk of adverse cardiovascular events (myocardial infarction OR,95%CI 1.14, 0.74-1.77; cerebral apoplexy OR,95%CI 0.94, 0.57-1.55). Conclusions : Chronic inflammation due to AE does not appear to cause adverse cardiovascular comorbidities. In contrast, PSO is associated with an adverse cardiovascular risk factor profile, but this does not necessarily appear to translate into a higher risk for cardiovascular events. This study does not rule out that specific treatments for AE or PSO modify the risk of cardiovascular disease.