Percentage low-density lipoprotein-cholesterol response to a given statin dose is not fixed across the pre-treatment range: Real world evidence from clinical practice: Data from the ESC-EORP EUROASPIRE V Study.

AIMS: Recent European guidelines recommend in patients with atherosclerotic cardiovascular disease to achieve a reduction of low-density lipoprotein-cholesterol of at least 50% if the baseline low-density lipoprotein-cholesterol level is between 1.8 and 3.5 mmol/L. Systematic reviews have associated a given statin/dose combination with a fixed percentage low-density lipoprotein-cholesterol response. Algorithms for detecting cases and estimating the prevalence of familial hypercholesterolaemia often rely on such fixed percentage reductions. METHODS AND RESULTS: We used data from 915 coronary patients participating in the EUROASPIRE V study in whom atorvastatin or rosuvastatin therapy was initiated at hospital discharge and who were still using these drugs at the same dose at a follow-up visit 6 or more months later. Pre and on-treatment low-density lipoprotein-cholesterol levels were compared across the full low-density lipoprotein-cholesterol range. The prevalence of FH was estimated using the Dutch Lipid Clinic Network criteria, once using observed pre-treatment low-density lipoprotein-cholesterol and once using imputed pre-treatment low-density lipoprotein-cholesterol by following the common strategy of applying fixed correction factors to on-treatment low-density lipoprotein-cholesterol. Inter-individual variation in the low-density lipoprotein-cholesterol response to a fixed statin and dose was considerable, with a strong inverse relation of percentage reductions to pre-treatment low-density lipoprotein-cholesterol. The percentage low-density lipoprotein-cholesterol response was markedly lower at the left end of the pre-treatment low-density lipoprotein-cholesterol range especially for levels less than 3 mmol/L. The estimated prevalence of familial hypercholesterolaemia was 2% if using observed pre-treatment low-density lipoprotein-cholesterol and 10% when using imputed low-density lipoprotein-cholesterol. CONCLUSION: The inter-individual variation in the percentage low-density lipoprotein-cholesterol response to a given dose of a statin is largely dependent on the pre-treatment level: the lower the pre-treatment low-density lipoprotein-cholesterol level the smaller the percentage low-density lipoprotein-cholesterol reduction. The use of uniform correction factors to estimate pre-treatment low-density lipoprotein-cholesterol is not justified.

Return to work and associations with psychosocial well-being and health-related quality of life in coronary heart disease patients: Results from EUROASPIRE IV.

BACKGROUND: Coronary heart disease (CHD) can lead to loss of workability and early retirement. We aimed to investigate return to work (RTW) and its relationship towards psychosocial well-being and health-related quality of life (HRQoL). DESIGN: Secondary analyses were applied to cross-sectional data from the EUROASPIRE IV survey (European Action on Secondary and Primary prevention through Intervention to Reduce Events). METHODS: Participants were examined and interviewed at 6-36 months following the recruiting event. Psychosocial well-being and HRQoL were evaluated by completing the 'Hospital Anxiety and Depression Scale' and 'HeartQoL' questionnaire. Using generalised mixed models, we calculated the odds ratios for RTW. Depression, anxiety and adjusted means of HeartQoL were estimated accounting for RTW. RESULTS: Out of 3291 employed patients, the majority (76.0%) returned to work, of which 85.6% were men, but there was a general underrepresentation of women. Young (p < 0.001), high-educated (p < 0.001) patients without prior cardiovascular events (p < 0.05) were better off regarding RTW. No significant associations with CHD risk factors and cardiac rehabilitation were established. Those that rejoined the workforce were less susceptible to psychosocial distress (anxiety/depression, p < 0.001) and experienced a better quality of life (p < 0.001). CONCLUSION: These findings provide evidence that non-modifiable factors (sociodemographic factors, cardiovascular history), more than classical risk factors, are associated with RTW, and that patients who resume work display better psychosocial well-being and HRQoL. Our results illustrate a need for tailored cardiac rehabilitation with a focus on work-related aspects, mental health and HRQoL indicators to reach sustainable RTW, especially in vulnerable groups like less educated and elderly patients.

The equity dimension in evaluations of the quality and outcomes framework: a systematic review.

BACKGROUND: Pay-for-performance systems raise concerns regarding inequity in health care because providers might select patients for whom targets can easily be reached. This paper aims to describe the evolution of pre-existing (in)equity in health care in the period after the introduction of the Quality and Outcomes Framework (QOF) in the UK and to describe (in)equities in exception reporting. In this evaluation, a theory-based framework conceptualising equity in terms of equal access, equal treatment and equal treatment outcomes for people in equal need is used to guide the work. METHODS: A systematic MEDLINE and Econlit search identified 317 studies. Of these, 290 were excluded because they were not related to the evaluation of QOF, they lacked an equity dimension in the evaluation, their qualitative research focused on experiences or on the nature of the consultation, or unsuitable methodology was used to pronounce upon equity after the introduction of QOF. RESULTS: None of the publications (n = 27) assessed equity in access to health care. Concerning equity in treatment and (intermediate) treatment outcomes, overall quality scores generally improved. For the majority of the observed indicators, all citizens benefit from this improvement, yet the extent to which different patient groups benefit tends to vary and to be highly dependent on the type and complexity of the indicator(s) under study, the observed patient group(s) and the characteristics of the study. In general, the introduction of QOF was favourable for the aged and for males. Total QOF scores did not seem to vary according to ethnicity. For deprivation, small but significant residual differences were observed after the introduction of QOF favouring less deprived groups. These differences are mainly due to differences at the practice level. The variance in exception reporting according to gender and socio-economic position is low. CONCLUSIONS: Although QOF seems not to be socially selective at first glance, this does not mean QOF does not contribute to the inverse care law. Introducing different targets for specific patient groups and including appropriate, non-disease specific and patient-centred indicators that grasp the complexity of primary care might refine the equity dimension of the evaluation of QOF. Also, information on the actual uptake of care, information at the patient level and monitoring of individuals' health care utilisation tracks could make large contributions to an in-depth evaluation. Finally, evaluating pay-for-quality initiatives in a broader health systems impact assessment strategy with equity as a full assessment criterion is of utmost importance.