Selv-vurderet helbred ved udskrivelsen blandt patienter med IHD

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1 Herlev og Gentofte Hospital Selv-vurderet helbred ved udskrivelsen blandt patienter med IHD Resultater fra det nationale DenHeart studie Medforfattere: Margrethe Herning, Pernille Palm Johansen, Jan Skov Jensen, Anne Vinggaard Christensen, Britt Borregaard, Kathrine Sjøstedt Gandrup Nielsen, Lars Thrysoee, Charlotte Brun Thorup, Marianne Vamosi, Knud Juel, Ola Ekholm, Selina Kikkenborg Berg Trine Bernholdt Rasmussen Sygeplejerske, cand. cur., ph.d. postdoc Hjertemedicinsk afdeling, Herlev og Gentofte Hospital 1

2 PATIENT-VURDERET HELBRED Kliniske parametre & sundhedsadfærd har været i fokus som behandlingsmål Brug for viden fra patientens perspektiv om det at være syg => PROs Væsentlige prognostiske markører. Brug for store studier

3 DENHEART Design: Landsdækkende spørgeskemaundersøgelse med kobling til danske registre Formål: Undersøge PROs Deltagere: Alle patienter udskrevet fra et af de fem nationale hjertecentre i perioden 15. april april sygeplejersker var involveret i dataindsamlingen

4 FORMÅL 1) Beskrive patient-rapporterede outcomes (PROs) på tværs af tre sub-grupper; kronisk iskæmisk hjertesygdom/stabil angina (IHD/AP), non-stelevation myocardie infarkt/unstabil angina (NSTEMI/UAP) og ST-elevation myocardie infarkt (STEMI), og 2) Undersøge prædiktive betydning af sociodemografiske- og kliniske karakteristika samt selv-rapporteret sundhedsadfærd for PROs. 3) Undersøge sammenhængen mellem PROs og 1- årsmortalitet.

5 DATA Spørgeskemaer: SF-12 (Short-Form 12) Selv-vurderet helbred PCS/MCS HADS (Hospital Anxiety and depression Scale) Angst og depression (score 8 mulig A/D, score 11sandsynlig A/D) EuroQol (EQ-5D) Helbredsstatus/funktionel status HeartQol Sygdomsspecifik QoL ESAS (Edmonton Symptom Assessment Scale) - Symptombyrde tillægsspørgsmål sundhedsadfærd Registre: LPR (Landspatientregisteret) CPR (Det centrale personregister) Uddannelsesregisteret Register vedr. indkomst

6 Figure 1. Patient flow-chart Patients with ischemic heart disease discharged/transferred from a Heart Centre April 15 th 2013 to April 15 th 2014 (n=13,825) Excluded (n=598): - Not able to participate due to illness (n=290) - Not able to participate due to language barrier (n=308) Eligible patients (n=13,517) Non-responders (n=6,338): No returned questionnaire (n=4,422) Returned non-completed questionnaire: - Did not want to participate (n=789) - Questionnaire not handed out (n=757) - Questionnaire returned blank (n=157) - Other reason, not specified (n=213) Patients with completed questionnaire (n=7,179) IHD/AP (n=4,686) NSTEMI/UAP (n=1,626) STEMI (n=855) Other (n=12)

7 * Life style factors #, n (%) Male, n (%) 4252 (67) 5194 (72) 3347 (71) 1173 (72) 674 (79) Age, mean (range) 66 (18-102) 65 (18-97) 66 (18-95) 66 (29-96) 62 (25-97) Table Married, 1. n Sociodemographic, % clinical- and 3583 self-reported (57) 4665 health (65) behaviour 3069 (65) characteristics 1061 (65) 535 (63) Events/procedures during Responders DenHeart index admission, n (%) Nonresponders responders Total * Percutaneous coronary intervention (PCI) 2820 (45) 3246 (45) 1557 IHD/AP (33) NSTEMI/UAP 922 (57) 767 STEMI (90) Coronary Artery Bypass graft (CABG) 256 (4) 309 (4) 264 (6) 42 (3) 3 (0) n Tu co-morbidity score, n (%) Male, n (%) 4252 (67) 5194 (72) 3347 (71) 1173 (72) 674 (79) Age, 0 mean (range) (18-102) (54) (18-97) (58) (18-95) (53) (29-96) (60) (25-97) (78) Married, 1 n % (57) (27) (65) (27) (65) (29) (65) (26) (63) (17) Events/procedures 2 during 757 (12) 719 (10) 542 (12) 144 (9) 33 (4) DenHeart 3+ index admission, n (%) 466 (7) 391 (5) 305 (7) 78 (5) 8 (1) Percutaneous Life style factors coronary, n (%) intervention (PCI) 2820 (45) 3246 (45) 1557 (33) 922 (57) 767 (90) Coronary Body Mass Artery Index Bypass (BMI) graft 25 (CABG) 256 N/A (4) (70) (4) (72) (6) (68) (3) 5663 (69) (0) Tu Body co-morbidity Mass Index score (BMI), n 30 (%) 0 Current smoker N/A 3413 (54) N/A 1729 (26) (58) (18) 1138 (26) (53) (16) 398 (26) (60) (18) 193 (24) (78) (27) 1 Non-smoker 1673 (27) N/A (27) (82) (29) (84) (26) (82) (17) (73) 2 Ever smoked 757 (12) N/A (10) (73) (12) (73) (72) (9) (76) (4) 3+ Alcohol intake above high risk limit $ 466 N/A (7) (5) (8) (7) (10) (5) 798 (10) (1) Nonresponders Total responders IHD/AP NSTEMI/UAP STEMI n IHD = Ischemic Heart Disease; AP = Angina Pectoris; NSTEMI = Non-ST-segment Elevation Myocardial Infarction; UAP = Unstable Angina Pectoris; STEMI = ST-segment Elevation Myocardial Infarction; SD = standard deviation, Continuous variables are presented as mean (range for age, SD for income) and categorical variables as number (percentages); Income is Body Mass Index (BMI) 25 N/A 4712 (70) 3121 (72) 1025 (68) 566 (69) gross income before taxes and interests; Tu co-morbidity score is an index score calculating the rate of co-morbidity based on predefined diagnoses; # Information about BMI, smoking and Body alcohol consumption Mass Index is based (BMI) on self-report 30 data and therefore only presented for responders; N/A The Danish 1729 National (26) Board of Health 1138 defines (26) the high risk 398 limit for (26) alcohol consumption 193 as (24) a weekly intake exceeding 21 units for men and 14 units for women. Current smoker N/A 1236 (18) 731 (16) 282 (18) 223 (27) Non-smoker N/A 5733 (82) 3838 (84) 1287 (82) 608 (73) Ever smoked N/A 5110 (73) 3344 (73) 1135 (72) 631 (76) Alcohol intake above high risk limit $ N/A 543 (8) 313 (7) 151 (10) 79 (10) IHD = Ischemic Heart Disease; AP = Angina Pectoris; NSTEMI = Non-ST-segment Elevation Myocardial Infarction; UAP = Unstable Angina Pectoris; STEMI = ST-segment Elevation Myocardial Infarction; SD = standard deviation, Continuous variables are presented as mean (range for age, SD for income) and categorical variables as number (percentages); Income is gross income before taxes and interests; Tu co-morbidity score is an index score calculating the rate of co-morbidity based on predefined diagnoses; # Information about BMI, smoking and alcohol consumption is based on self-report data and therefore only presented for responders; $ The Danish National Board of Health defines the high risk limit for alcohol consumption as a

8 Table 2. Patient-reported outcomes on self-rated health, symptoms of anxiety and depression, quality of life, symptom distress and social network Total responders IHD/AP NSTEMI/UAP STEMI p* n SF-12, mean (SD) PCS 41.6 (10.9) 40.3 (10.7) 42.7 (10.8) 46.5 (10.1) <0.001 MCS 48.5 (10.8) 48.0 (10.8) 48.7 (10.6) 50.7 (10.6) <0.001 HADS HADS-A, mean (SD) 5.9 (4.2) 6.0 (4.2) 6.0 (4.3) 5.2 (4.2) <0.001 HADS-A 8, n % 2259 (32.8) 1499 (33.3) 527 (33.8) 233 (28.1) <0.05 HADS-A 11, n % 1069 (15.5) 714 (15.9) 251 (16.1) 104 (12.6) <0.05 HADS-D, mean (SD) 4.3 (3.7) 4.5 (3.7) 4.3 (3.8) 3.5 (3.5) <0.001 HADS-D 8, n % 1365 (19.7) 942 (20.8) 308 (19.6) 115 (13.8) <0.001 HADS-D 11, n % 513 (7.4) 354 (7.8) 114 (7.3) 45 (5.4) <0.05 EQ-5D, mean (SD) EQ-5D 3L crosswalk 0.8 (0.2) 0.7 (0.1) 0.8 (0.2) 0.8 (0.2) <0.001 EQ-5D VAS 68.6 (19.7) 67.9 (19.6) 68.8 (20.2) 72.3 (19.3) <0.001 HeartQoL, mean (SD) HeartQoL global 1.7 (0.8) 1.6 (0.7) 1.8 (0.8) 2.1 (0.8) <0.001 HeartQoL physical 1.6 (0.9) 1.5 (0.8) 1.7 (0.9) 2.1 (0.8) <0.001 HeartQoL emotional 2.1 (0.8) 2.1 (0.8) 2.1 (0.9) 2.3 (0.8) <0.001 ESAS, mean (SD) Symptom Distress Score 20.6 (16.8) 21.6 (17.0) 19.8 (16.9) 16.4 (15.0) <0.001 Fatigue 4.0 (2.9) 4.2 (2.9) 3.8 (2.9) 3.5 (2.8) <0.001 Shortness of breath 3.2 (3.1) 3.5 (3.2) 2.8 (3.0) 2.0 (2.6) <0.001 Chest pains 2.5 (2.8) 2.8 (2.8) 2.2 (2.8) 1.2 (2.2) <0.001 Heart palpitations 1.8 (2.5) 2.1 (2.6) 1.7 (2.4) 0.9 (1.7) <0.001 Dizziness or near-fainting 1.7 (2.5) 1.8 (2.5) 1.6 (2.5) 1.1 (1.9) <0.001 Physical level of fitness Less good or poor, n % 2382 (34.0) 1639 (35.7) 514 (32.5) 229 (27.4) <0.001

9 Table 2. Patient-reported outcomes on self-rated health, symptoms of anxiety and depression, quality of life, symptom distress and social network Total responders IHD/AP NSTEMI/UAP STEMI p* n Feeling safe about returning home from hospital Feeling unsafe or very unsafe, n (%) 336 (4.8) 179 (3.9) 102 (6.5) 55 (6.7) <0.001 Knowing what symptoms should elicit contact to GP or hospital No, n % 493 (7.1) 227 (5.0) 160 (10.2) 106 (12.8) <0.001 Knowing who to contact with questions on disease/treatment No, n % 395 (5.7) 185 (4.1) 129 (8.2) 81 (9.8) <0.001 IHD = Ischemic Heart Disease; AP = Angina Pectoris; NSTEMI = Non-ST-segment Elevation Myocardial Infarction; UAP = Unstable Angina Pectoris; STEMI = ST-segment Elevation Myocardial Infarction; SD = standard deviation; PCS = physical component score; MCS = mental component score; HADS-A = Hospital Anxiety and Depression Scale - Anxiety; HADS-D = Hospital Anxiety and Depression Scale - Depression; GP = General Practitioner. * Differences in means between groups were tested using the F-test adjusted for sex, age, marital status and co-morbidity. Differences in proportions between all diagnostic groups were tested by the Pearson χ2-test.

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14 KONKLUSION Der er en signifikant og klinisk betydende forskel i PROs på tværs af sub-grupper af patienter med IHD Kvindeligt køn, symptom byrde og lavere uddannelsesniveau, bl.a., prædikterer ringe PROs. Patienter I live efter et år rapporterer signifikant bedre PROs sammenlignet med patienter døde indenfor et år. Ringe PROs prædikterer 1-års mortalitet

15 HVAD KAN VI BRUGE RESULTATERNE TIL? Identificere problemstillinger og indsatsområder Standard værdier til realistisk målsætning Screenings værktøjer => Særlige risikogrupper og udvikle særlige pleje- og behandlingstilbud Hensigtsmæssig allokering af ressourcer

16 Tak! Spørgsmål? : trine.bernholdt.rasmussen@regionh.dk : :