gms | German Medical Science

Background: Coronary heart disease (CHD) is the leading cause of morbidity. Mental disorders (MD) have been found to be very prevalent among patients with CHD. Especially depression, anxiety disorders, cognitive impairments and other MD affect approximately 50% of all CHD patients. MD act as particularly strong barriers to treatment adherence and impede efforts to lifestyle change, resulting in a two-fold greater morbidity and mortality risk in CHD. Guidelines on prevention of CHD have recommended routine screening for MD and adequate treatment for at-risk patients. However, there is currently no empirical evidence indicating whether these recommendations have been implemented in the clinical practice.

Research questions:

1.

What is the prevalence of MD in CHD?

2.

Are actions of MD detection and treatment taken? Are these actions consistent with guidelines on prevention of CHD?

3.

What is the quality of life and satisfaction with healthcare in CHD patients with MD?

4.

Do the assessment and treatment of MD correspond to CHD patients´ needs and preferences?

5.

What are the experiences of physicians who treat their CHD patients according to the guidelines?

6.

What are the barriers for a correct implementation of guideline-based diagnostic and treatment?

7.

What is the status quo of the administrative epidemiology, resource use, costs and trajectories of care associated with patients with CHD and MD?

Method:

Participants: Four hundred patients (50% women, 30% with congestive heart failure) will be recruited in cardiologic clinics, cardiologic practices, and rehabilitation clinics. Further, 350 relatives of the CHD patients and 80 physicians (e.g., GPs, cardiologists, psychotherapists and members of rehabilitation clinics) will be recruited.

Material:

Quantitative: Quantitative research in CHD patients, relatives and physicians will assess patients’ trajectories and quality of care, barriers to guideline based care, healthcare preferences, quality of life, presence of MD, disease severity and received healthcare.

Further utilized questionnaires are:

1.

Patient Assessment of Care for Chronic Conditions (PACIC),

2.

EURO-Quality of Life 5D questionnaire (EQ-5D),

3.

Hospital Anxiety and Depression Scale (HADS), and

4.

Demenz-Detection (DemTect).

If the HADS-score is above eight, the Structured Clinical Interview for DSM-IV (SKID-I) will be conducted to assess psychiatric symptoms and disorders. If the DemTect score is between 9 – 16 points, the Consortium to Establish a Registry for Alzheimer’s Disease test battery (CERAD-Plus) will be assessed. If the DemTect score is eight and lower, the Mini-Mental Status Examination (MMSE) to assess dementia will be utilized.

All available relatives are asked to fill out the Functional Activities Questionnaire (FAQ).

Qualitative: Regarding focus groups, physicians will be analysed to explore the collectively shared patterns of interpretation of the various professions. Sixty face-to-face interviews are carried out – selected as triads (patient, relative and physician).

Secondary data analysis – statutory health insurance data (SHI): Secondary data will be allocated by four health insurances in Germany, which will contain the trajectories of care and utilized payments patients have used from 2011 – 2015. This data will be analyzed to determine administrative epidemiology, resource use, costs and trajectories of care.

Procedure: All patients will be given the questionnaires. If the HADS and/or the DemTect is positive, a second personal appointment will be arranged to assess the patients with the SKID-I and/or the CERADPlus for a valid diagnosis. The subsample for the interviews and focus groups will be randomly contacted at a third time-point.

Analysis: Analysis of the quantitative data will include descriptive statistics, exploratory analysis (e.g., regression analysis), sub-group analysis and multivariate analyses to identify predictors of features of quality of healthcare. The results of the secondary analysis of the health insurance data will be compared to the quantitative data from this study. Qualitative data will be subject to content analysis, including an analysis of patterns of perception and interpretation.

Discussion and practical implications: Our vision is to create value for the patient through social innovations, paying attention to both quality of healthcare and costs. The multimethodal and multiperspective approach of MenDis-CHD will provide analysis tools to enable care providers to redesign care pathways and to understand the barriers to and facilitators of change towards patient-centeredness. Restructuring complex care for vulnerable CHD patients is very much needed because there is evidence that these patients are underserved and often get lost in the transition between multi-professional and multi-institutional care providers.