Low rate of revascularization procedures and poor prognosis particularly in male patients with peripheral artery disease - A propensity score matched analysis.

BACKGROUND: Few data discuss the impact of sex on diagnostic and therapeutic procedures and outcome of patients with peripheral artery disease (PAD). METHODS: We obtained data on 41,873 PAD patients between 2009 and 2011 (including a 4-year follow-up) from the largest German public health insurance (BARMER GEK). Propensity Score Matching (PSM) was performed to evaluate the impact of sex on treatment, complications, in-hospital and long-term outcome. RESULTS: Of 41,873 PAD patients, there were 23,282 (55.6%) male and 18,591 (44.4%) female. Male patients were younger (69±11years vs. 75±12years in females; p<0.001) but had higher obesity (8.0% vs 6.5%), dyslipidemia (33.2% vs 28.1%), smoking (12.9% vs 9.2%), coronary artery disease (29.4% vs 19.5%), or diabetes rates (35.8% vs 28.1%; each p<0.001). Almost three in five revascularizations applied to minor clinical stages, revascularization rate in critical limb ischemia (CLI) was 49% at in-hospital and 58.8% inc. follow-up in both sexes (Rutherford 6). PSM accounting for risk factors and PAD stages showed lower use of endovascular and higher use of surgical revascularization in males compared to females. Male sex was associated with higher in-hospital amputation and was an independent risk factor during follow-up for both amputation (HR 1.284; p<0.001) and death (HR 1.155; p<0.001). CONCLUSIONS: Data show low rates of revascularization procedures particularly at advanced PAD stages (CLI). Male sex is associated with higher use of surgical, but lower use of endovascular and overall procedures, and higher amputation and mortality during follow-up.

Old benefit as much as young patients with stroke from high-intensity neurorehabilitation: cohort analysis.

BACKGROUND AND OBJECTIVE: In current clinical practice, old patients with stroke are less frequently admitted to neurorehabilitation units following acute care than younger patients based on an assumption that old age negatively impacts the benefit obtained from high-intensity neurorehabilitation. Our objective was to test this assumption empirically in a large sample of patients with stroke. METHODS: Functional recovery during 4 weeks of inpatient neurorehabilitation was assessed with the Barthel Index (BI) in 422 middle-aged (<65 years), 1399 old (65-80 years) and 473 very old (>80 years) patients with stroke. Overall functional recovery, recovery patterns and the relationship between therapy intensity and recovery were statistically compared between the three age groups. RESULTS: Overall functional recovery was statistically equivalent in middle-aged, old and very old patients (average improvement in BI total score: middle-aged: 15 points; old: 15 points; very old: 14 points). A novel item-wise logistic regression analysis (see Pedersen, Severinsen & Nielsen, 2014, Neurorehabil Neural Repair) revealed that this was true for 9 of the 10 everyday functions assessed by the BI. Furthermore, functional recovery was predicted by the amount of therapy (R=0.14; p=0.0001), and age did not moderate this relationship between therapy intensity and recovery (p=0.70). CONCLUSIONS: Old and even very old patients with stroke benefit from specialised inpatient neurorehabilitation and high amounts of therapy in the same degree as younger patients. Contrary to current clinical practice, old age should not be a criterion against admission to a neurorehabilitation unit following acute stroke treatment.

Atrial fibrillation is a risk marker for worse in-hospital and long-term outcome in patients with peripheral artery disease.

OBJECTIVES: To investigate the relevance of atrial fibrillation or flutter (AF) for outcome of patients who are hospitalized for peripheral artery disease (PAD) and/or critical limb ischemia (CLI). METHODS AND RESULTS: We compared baseline data, co-morbidities, procedural data as well as in-hospital and long-term outcome of 41,882 patients who were hospitalized with PAD or CLI between 2009 and 2011 according to whether they did or did not have atrial fibrillation/flutter. Follow-up was available until December 2012. Of these, 5622 patients (13.4%) had AF. AF patients were significantly older (78±9 vs. 70±11years) and had significantly more comorbidities, such as diabetes (40.8 vs. 31.1%), chronic kidney disease (40.1 vs. 19.0%), coronary artery disease (38.0 vs. 23.0%) and chronic heart failure (26.9 vs. 7.2%, each p<0.001). They had more advanced PAD as shown by higher Rutherford classes. In-hospital complications including acute renal failure, myocardial infarction, stroke sepsis and death occurred significantly more often (each p<0.001). Duration of hospital stay was significantly longer and costs were markedly higher in patients with AF (each p<0.001). Using multivariate Cox regression analyses regarding long-term outcomes, AF was an independent predictor for death (HRR 1.46; 95% CI 1.39-1.52, p<0.001), ischemic stroke (HRR 1.63; 95% CI 1.44-1.85) and amputation (HRR 1.14; 95% CI 1.07-1.21). CONCLUSION: Presence of AF in patients admitted for PAD and CLI is associated with worse in-hospital and long-term outcome than in patients without AF. This effect was independent of numerous other comorbidities and stage of vascular disease.

Explaining the Decrease of In-Hospital Mortality from Ischemic Stroke.

BACKGROUND: Mortality from ischemic stroke has declined over time. However, little is known about the reasons for the decreased mortality. We therefore aimed to evaluate trends in in-hospital mortality and to identify factors associated with these trends. METHODS: This study was based on a prospective database of 26 hospitals of the Stroke Register of Northwestern Germany, which included 73,614 patients admitted between 2000 and 2011. Time trends in observed (crude) and risk-adjusted in-hospital mortality were assessed. Independent factors associated with death after stroke were evaluated using multivariable logistic regression analysis. RESULTS: The observed in-hospital mortality decreased from 6.6% in 2000 to 4.6% in 2008 (P < 0.001 for trend) and then remained fairly stable. The risk-adjusted mortality decreased from 2.85% in 2000 to 1.86% in 2008 (P < 0.01 for trend) and then increased to 2.32% in 2011. Use of in-hospital treatments including antiplatelets within 48 hours, antihypertensive therapy, statins, antidiabetics, physiotherapy and anticoagulants increased over time and was significantly associated with a decrease in mortality. The association of the year of admission with mortality became insignificant after adjustment for antiplatelet therapy within 48 hours (from OR 0.96; 95% CI, 0.94-0.98, to OR 0.99; 95% CI, 0.97-1.01) and physiotherapy (from OR 0.96; 95% CI, 0.94-0.97, to OR 0.99; 95% CI, 0.97-1.00). CONCLUSIONS: In-hospital mortality decreased by approximately one third between 2000 and 2008. This decline was paralleled by improvements in different in-hospital managements, and we demonstrated that it was partly mediated by early antiplatelet therapy and physiotherapy use.

Associations between depression subtypes, depression severity and diet quality: cross-sectional findings from the BiDirect Study.

BACKGROUND: Depression is supposed to be associated with an unhealthy lifestyle including poor diet. The objective of this study was to investigate differences in diet quality between patients with a clinical diagnosis of depression and population-based controls. Additionally, we aimed to examine effects of specific depression characteristics on diet by analyzing if diet quality varies between patients with distinct depression subtypes, and if depression severity is associated with diet quality. METHODS: The study included 1660 participants from the BiDirect Study (n = 840 patients with depression, n = 820 population-based controls). The psychiatric assessment was based on clinical interviews and a combination of depression scales in order to provide the classification of depression subtypes and severity. Diet quality scores, reflecting the adherence to a healthy dietary pattern, were calculated on the basis of an 18-item food frequency questionnaire. Using analysis of covariance, we calculated adjusted means of diet quality scores and tested differences between groups (adjusted for socio-demographic, lifestyle-, and health-related factors). RESULTS: We found no differences in diet quality between controls and patients with depression if depression was considered as one entity. However, we did find differences between patients with distinct subtypes of depression. Patients with melancholic depression reported the highest diet quality scores, whereas patients with atypical depression reported the lowest scores. Depression severity was not associated with diet quality. CONCLUSIONS: Previous literature has commonly treated depression as a homogeneous entity. However, subtypes of depression may be associated with diet quality in different ways. Further studies are needed to enlighten the diet-depression relationship and the role of distinct depression subtypes.

Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence.

AIMS: Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed. METHODS AND RESULTS: From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €). CONCLUSION: Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.

The influence of neighborhood unemployment on mortality after stroke.

BACKGROUND: Few studies have investigated the impact of neighborhood characteristics on mortality after stroke. Aim of our study was to analyze the influence of district unemployment as indicator of neighborhood socioeconomic status (SES-NH) on poststroke mortality, and to compare these results with the mortality in the underlying general population. METHODS: Our analyses involve 2 prospective cohort studies from the city of Dortmund, Germany. In the Dortmund Stroke Register (DOST), consecutive stroke patients (N=1883) were recruited from acute care hospitals. In the Dortmund Health Study (DHS), a random general population sample was drawn (n=2291; response rate 66.9%). Vital status was ascertained in the city's registration office and information on district unemployment was obtained from the city's statistical office. We performed multilevel survival analyses to examine the association between district unemployment and mortality. RESULTS: The association between neighborhood unemployment and mortality was weak and not statistically significant in the stroke cohort. Only stroke patients exposed to the highest district unemployment (fourth quartile) had slightly higher mortality risks. In the general population sample, higher district unemployment was significantly associated with higher mortality following a social gradient. After adjustment for education, health-related behavior and morbidity was made the strength of this association decreased. CONCLUSIONS: The impact of SES-NH on mortality was different for stroke patients and the general population. Differences in the association between SES-NH and mortality may be partly explained by disease-related characteristics of the stroke cohort such as homogeneous lifestyles, similar morbidity profiles, medical factors, and old age.

Dietary patterns and the risk of depression in adults: a systematic review of observational studies.

PURPOSE: Diet, a modifiable lifestyle factor, may influence the development of depression. We performed a systematic review of observational studies examining the relationship between dietary patterns and depression in healthy adults. METHODS: A literature research was conducted searching various electronic databases up to May 2013. Study selection was based on predefined inclusion and exclusion criteria. Included studies were reviewed, and relevant data were extracted by two independent researchers. Due to a high level of heterogeneity, no meta-analysis was conducted. Therefore, main results are presented in a descriptive way. RESULTS: In total, 16 studies met the inclusion criteria and are part of this review. Dietary patterns most commonly found were traditional/healthy patterns, Western/unhealthy patterns and Mediterranean patterns. The available literature suggests a protective effect of healthy and Mediterranean patterns, as well as a potential positive association of Western patterns and depression. However, comparison of the included studies was difficult, due to differences in relevant study characteristics and methodological limitations. CONCLUSIONS: There are indications that dietary patterns may have influence on the onset of depression, but no firm conclusion can be drawn at this point. Further research is needed to clarify the diet-depression relationship, preferably in the form of methodological strong prospective studies using more homogeneous methods.

Who receives rehabilitation after stroke?: Data from the quality assurance project "Stroke Register Northwest Germany".

BACKGROUND: Neurological rehabilitation after stroke lowers rates of death, dependency, and institutionalization. Little research has yet addressed the factors affecting the selection of ischemic stroke patients for rehabilitative treatment. METHOD: The database for this study consisted of all cases of ischemic stroke (ICD-10 code I63) that occurred in 2010 and 2011 in the neurological inpatient care facilities participating in the "Stroke Register Northwest Germany" quality assurance project. A primary target group for rehabilitation was defined a priori (Barthel Index at discharge ≤ 65, no premorbid nursing dependency, no transfer to another acute-care hospital after initial treatment of stroke). Among these patients, factors potentially affecting the provision of rehabilitative treatment were studied with binary logistic regression and multilevel logistic regression. RESULTS: There were 96 955 cases of ischemic stroke in the 127 participating hospitals. 40.8% and 11.4% of these patients underwent neurological and geriatric rehabilitation, respectively. The primary target group for rehabilitation contained 14 486 patients, 14.9% of whom underwent no rehabilitation after their acute treatment. The chances of undergoing subsequent rehabilitation were higher for patients with paresis and dysarthria on admission. Female sex, older age, impaired consciousness at admission, prior history of stroke, and lack of counseling by the hospital social services were all associated with a lower probability of undergoing rehabilitation. CONCLUSION: In this study, 54.4% of all ischemic stroke patients and 85.1% of all patients in a primary target group for rehabilitation that was defined a priori underwent rehabilitation after acute care for stroke. Older patients and those who had had a previous stroke were less likely to undergo rehabilitation. Counseling by hospital social services increased the probability of rehabilitation. The potential exclusion of stroke patients from rehabilitation because of old age should be critically examined in every relevant case.

Identification of possible risk factors for alcohol use disorders among general practitioners in Rhineland-Palatinate, Germany.

QUESTIONS UNDER STUDY: Research on alcohol use disorders among physicians has been scarce in Germany. The aim of our study was to identify possible risk factors for alcohol use disorders among general practitioners (GPs) working in the outpatient sector in the federal German state of Rhineland-Palatinate (RP). METHODS: An anonymous survey was carried out between June and July 2009. 2,092 practice-based GPs in the federal German state of RP were asked to take part in the cross-sectional study via postal mail. The CAGE screening tool was used in its German version (CAGE-G) to screen for alcohol use disorders (AUD). Moreover, possible risk factors such as work stress (effort-reward imbalance), stress experienced in the leisure time and personality characteristics (Type D personality, resilience) were included in the questionnaire. RESULTS: 808 GPs participated (response rate 38.6%), n = 790 were eligible for the analysis. The frequency of AUD according to the CAGE-G was 18.9% (n = 149). Moreover, nearly one in four general practitioners reported consuming alcohol on a daily basis (23.0%, n = 182). In the logistic regression analyses, stress experienced in the leisure time was positively related to the occurrence of AUD, whereas resilience was negatively associated. CONCLUSIONS: AUD as screened for by the CAGE-G was frequent in our sample of German GPs. Approaches to reduce their occurrence could comprise actions helping physicians to relieve stress in their leisure time. Furthermore, measures to increase physicians' resilience by improving coping strategies might prove useful.

The mental health of primary care physicians in Rhineland-Palatinate, Germany: the prevalence of problems and identification of possible risk factors.

BACKGROUND: The generally high job-related stress level among physicians may lead to various health impairments in the long run. Apart from job-related stress, stress during leisure time and certain personality traits might be risk factors for health impairments. However, very little research on the health situation of primary care physicians (PCPs) in Germany is available. Therefore, the objective of the present study was to systematically assess the stress experience and the health situation of German PCPs. One main focus was on mental health. METHODS: In 2009, a state-wide survey among practice-based PCPs in the federal German state of Rhineland-Palatinate (cross-sectional study, n = 2092) was carried out in order to assess stress and strain as well as the health situation. RESULTS: 790 participants (37.7%) were eligible for the analyses. One in four PCPs exceeded the cut-off value ≥ 3 for depression in the PHQ-2 (PHQ, Patient Health Questionaire). Moreover, approximately one in six PCPs stated that he or she had used psychotropic drugs or other psychoactive substances at least once in the preceding year. Stress during leisure time, type D personality and low job satisfaction were associated with the presence of mental health impairments in the binary logistic regression analyses. CONCLUSION: All in all, it appears that mental health impairments are a common health problem among the PCPs. Target-group-specific measures should be taken in order to reduce the subjective stress level, and to foster mental hygiene. Furthermore, the development of favorable personality profiles and the corresponding behavioral patterns should be supported.

Factors influencing place of death in Germany.

CONTEXT: Knowledge about factors influencing the place of death may be very useful for the planning of public health strategies to improve the situation of terminally ill patients. OBJECTIVES: The aim of our study was to determine where people died in the German federal state of Rhineland-Palatinate in 2008. We further wanted to detect which factors had an influence on the place of death. METHODS: Our cross-sectional survey was based on a random sample of 5000 inhabitants of Rhineland-Palatinate who had died between May 25, 2008 and August 24, 2008. Relatives of these randomly drawn deceased persons were interviewed by means of a written survey. RESULTS: After removing duplicates, 4967 questionnaires were sent out. In total, 3832 questionnaires were delivered and 1378 completed, leading to a response rate of 36.0%. Of this group, 38.2% of the deceased died at home, 39.3% in a hospital, 13.4% in a nursing home, 7.5% in a palliative care facility, and 1.6% elsewhere. Suffering from cancer (adjusted odds ratio [AOR]: 1.30; 95% confidence interval [CI]: 1.01-1.68), social support (AOR being married: 1.33; 95% CI: 1.04-1.70; AOR having a nonworking relative: 1.71; 95% CI: 1.28-2.29), a high care level (AOR Care Level II: 2.79; 95% CI: 2.06-3.79, AOR Care Level III: 4.96; 95% CI: 3.40-7.24), and living in a rural municipality (AOR: 1.36; 95% CI: 1.01-1.84) were major factors favoring home death compared with institutional death. CONCLUSION: Compared with other European countries, home death is still a frequent event in the federal state of Rhineland-Palatinate. Regional health policy should consider the actual distribution of place of death and corresponding predicting factors when establishing specialized palliative care home services as designed by recent German health legislation.

End-of-life care in Germany: Study design, methods and first results of the EPACS study (Establishment of Hospice and Palliative Care Services in Germany).

BACKGROUND: In order to tackle the deficits in the provision of palliative home care, profound structural changes in the outpatient sector were introduced by law in Germany in 2007. The EPACS study was carried out (Research Accompanying the Establishment of Hospice and Palliative Care Services in Rhineland-Palatinate, Germany) to document the quality of inpatient and outpatient end-of-life care in Rhineland-Palatinate, Germany, before the implementation of these changes. With this article we focus on the study design and methods of the EPACS-Study. We further report first results regarding several aspects of outpatient end-of-life care. METHODS: The cross-sectional survey was based on a random sample of 5000 inhabitants of Rhineland-Palatinate that had died from May 25 until August 24 of the year 2008. Relatives of these randomly drawn deceased persons were interviewed by means of a written survey. RESULTS: The overall response proportion considering only those questionnaires that actually were delivered (n = 3833) was 36.0%. Factors influencing participation were age, sex, and marital status. 355 (25.8%) deceased persons had used professional home care in the four weeks prior to their death, but only very few persons had used a specialised palliative home care service (n = 30; 8.5%). There was a clear gap between the need for specialised outpatient care and the actual utilisation of these services. CONCLUSIONS: Satisfaction with professional home care was relatively high, but physicians were rated less favourable than nurses. There were deficits especially with respect to physicians' communicative and supportive skills. Further analyses are necessary to provide more detailed information about quality of care in different care settings and for distinct groups. Predictors of good care, as well as obstacles to it, must be further investigated. In the long run, a follow-up survey must be conducted to compare quality of home care before and after the structural changes in Germany.