Clinical Research in Cardiology

, Volume 103, Issue 3, pp 237–245 | Cite as

Improving care of post-infarct patients: effects of disease management programmes and care according to international guidelines

  • Renee Stark
  • Inge Kirchberger
  • Matthias Hunger
  • Margit Heier
  • Reiner Leidl
  • Wolfgang von Scheidt
  • Christa Meisinger
  • Rolf Holle
Original Paper



Cardiac disease management programmes (CHD-DMPs) and secondary cardiovascular prevention guidelines aim to improve complex care of post-myocardial infarction (MI) patients. In Germany, CHD-DMPs, in addition to incorporating medical care according to guidelines (guideline-care), also ensure regular quarterly follow-up. Thus, our aim was to examine whether CHD-DMPs increase the frequency of guideline-care and whether CHD-DMPs and guideline-care improve survival over 4 years.


The study included 975 post-MI patients, registered by the KORA-MI Registry (Augsburg, Germany), who completed a questionnaire in 2006. CHD-DMP enrolment was reported by physicians. Guideline-care was based on patient reports regarding medical advice (smoking, diet, or exercise) and prescribed medications (statins and platelet aggregation inhibitors plus beta-blockers or renin-angiotensin inhibitors). All-cause mortality until December 31, 2010 was based on municipal registration data. Cox regression analyses were adjusted for age, sex, education, years since last MI, and smoking and diabetes.


Physicians reported that 495 patients were CHD-DMP participants. CHD-DMP participation increased the likelihood of receiving guideline-care (odds ratio 1.55, 95 % CI 1.20; 2.02) but did not significantly improve survival (hazard rate 0.90, 95 % CI 0.64–1.27). Guideline-care significantly improved survival (HR 0.41, 95 % CI 0.28; 0.59). Individual guideline-care components, which significantly improved survival, were beta-blockers, statins and platelet aggregation inhibitors. However, these improved survival less than guideline-care.


This study shows that CHD-DMPs increase the likelihood of guideline care and that guideline care is the important component of CHD-DMPs for increasing survival. A relatively high percentage of usual care patients receiving guideline-care indicate high quality of care of post-MI patients. Reasons for not implementing guideline-care should be investigated.


Disease management Coronary disease Secondary prevention 



The KORA research platform (KORA, Cooperative Research in the Region of Augsburg) was initiated and financed by the Helmholtz Zentrum München—German Research Center for Environmental Health, which is funded by the German Federal Ministry of Education and Research and by the State of Bavaria. The survival analysis was part of the project “Medium term effects of Disease Management Programs for Coronary Heart Disease” funded by the Federal Association of Statutory Regional Health Funds (AOK Bundesverband). We thank all members of the Helmholtz Zentrum München who are involved in the conduct of the study. Furthermore, we wish to thank the field staff in Augsburg, especially Claudia Greschik, Dorothea Lukitsch, and Gisela Sietas.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Federal Ministry of Health Mortality statistics. Available from URL: Accessed on 01.08.2012
  2. 2.
    WHO (2012) Global atlas on cardiovascular disease prevention and control available on Accessed 08.07.2013
  3. 3.
    Smith SC Jr, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz HM, Mosca L, Pasternak RC, Pearson T, Pfeffer MA, Taubert KA (2006) AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation 113(19):2363–2372. doi: 10.1161/CIRCULATIONAHA.106.174516 PubMedCrossRefGoogle Scholar
  4. 4.
    Federal Insurance Agency Basic facts of disease management programs in Germany, Accessed 2 Aug 2012
  5. 5.
    Federal Joint Committee Directives regarding disease management programs in Germany, (see page 1552 regarding CHD-DMP). Accessed November 6, 2012 2012
  6. 6.
    Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, Albus C, Benlian P, Boysen G, Cifkova R, Deaton C, Ebrahim S, Fisher M, Germano G, Hobbs R, Hoes A, Karadeniz S, Mezzani A, Prescott E, Ryden L, Scherer M, Syvanne M, Scholte op Reimer WJ, Vrints C, Wood D, Zamorano JL, Zannad F, European Association for Cardiovascular P, Rehabilitation, Guidelines ESCCfP (2012) European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth joint task force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 33(13):1635–1701. doi: 10.1093/eurheartj/ehs092 PubMedCrossRefGoogle Scholar
  7. 7.
    Zeymer U, Junger C, Zahn R, Bauer T, Bestehorn K, Senges J, Gitt A (2011) Effects of a secondary prevention combination therapy with an aspirin, an ACE inhibitor and a statin on 1-year mortality of patients with acute myocardial infarction treated with a beta-blocker. Support for a polypill approach. Curr Med Res Opin 27(8):1563–1570. doi: 10.1185/03007995.2011.590969 PubMedCrossRefGoogle Scholar
  8. 8.
    Federal Statistics Office Annual German Population on December 31st of each year, Accessed 2 Aug 2012
  9. 9.
    Federal Statistics Office Prevalence of coronary heart disease diagnosed by a physician based on patient reports, Accessed 2 Aug 2012
  10. 10.
    Miksch A, Laux G, Ose D, Joos S, Campbell S, Riens B, Szecsenyi J (2010) Is there a survival benefit within a German primary care-based disease management program? Am J Manag Care 16(1):49–54. doi: 12562 PubMedGoogle Scholar
  11. 11.
    Drabik A, Buscher G, Thomas K, Graf C, Muller D, Stock S (2012) Patients with type 2 diabetes benefit from primary care-based disease management: a propensity score matched survival time analysis. Popul Health Manag 15(4):241–247. doi: 10.1089/pop.2011.0063 PubMedCrossRefGoogle Scholar
  12. 12.
    Gapp O, Schweikert B, Meisinger C, Holle R (2008) Disease management programmes for patients with coronary heart disease—an empirical study of German programmes. Health Policy 88(2–3):176–185. doi: 10.1016/j.healthpol.2008.03.009 PubMedCrossRefGoogle Scholar
  13. 13.
    Holle R, Happich M, Lowel H, Wichmann HE, Group MKS (2005) KORA—a research platform for population based health research. Gesundheitswesen 67(Suppl 1):S19–S25. doi: 10.1055/s-2005-858235 PubMedCrossRefGoogle Scholar
  14. 14.
    Kirchberger I, Heier M, Kuch B, Wende R, Meisinger C (2011) Sex differences in patient-reported symptoms associated with myocardial infarction (from the population-based MONICA/KORA Myocardial Infarction Registry). Am J Cardiol 107(11):1585–1589. doi: 10.1016/j.amjcard.2011.01.040 PubMedCrossRefGoogle Scholar
  15. 15.
    Hostetter JC, Ghaffari S (2003) Should everyone with a recent myocardial infarction receive a beta-blocker and an ACE inhibitor? Clevel Clin J Med 70(1):46–48CrossRefGoogle Scholar
  16. 16.
    Leidl R, Reitmeir P (2011) A value set for the EQ-5D based on experienced health states: development and testing for the German population. Pharmacoeconomics 29(6):521–534. doi: 10.2165/11538380-000000000-00000 PubMedCrossRefGoogle Scholar
  17. 17.
    Horton NJ, Lipsitz SR (2001) Multiple imputation in practice: comparison of software packages for regression models with missing variables. Am Stat 55(3):244–254CrossRefGoogle Scholar
  18. 18.
    Schunk M, Stark R, Reitmeir P, Rathmann W, Meisinger C, Holle R (2011) Improvements in type 2 diabetes care? Pooled analysis of survey data in southern Germany (KORA) from 1999-2008. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 54(11):1187–1196. doi: 10.1007/s00103-011-1364-4 PubMedCrossRefGoogle Scholar
  19. 19.
    Stark RG, Schunk MV, Meisinger C, Rathmann W, Leidl R, Holle R, Grp KS (2011) Medical care of type 2 diabetes in German disease management programmes: a population-based evaluation. Diabetes Metab Res 27(4):383–391CrossRefGoogle Scholar
  20. 20.
    Jolly K, Bradley F, Sharp S, Smith H, Thompson S, Kinmonth AL, Mant D (1999) Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. BMJ 318(7185):706–711PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Khunti K, Stone M, Paul S, Baines J, Gisborne L, Farooqi A, Luan X, Squire I (2007) Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial. Heart 93(11):1398–1405. doi: 10.1136/hrt.2006.106955 PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Law MR, Watt HC, Wald NJ (2002) The underlying risk of death after myocardial infarction in the absence of treatment. Arch Intern Med 162(21):2405–2410PubMedCrossRefGoogle Scholar
  23. 23.
    Kuch B, Heier M, von Scheidt W, Kling B, Hoermann A, Meisinger C (2008) 20-year trends in clinical characteristics, therapy and short-term prognosis in acute myocardial infarction according to presenting electrocardiogram: the MONICA/KORA AMI Registry (1985-2004). J Intern Med 264(3):254–264. doi: 10.1111/j.1365-2796.2008.01956.x PubMedCrossRefGoogle Scholar
  24. 24.
    McAlister FA, Lawson FM, Teo KK, Armstrong PW (2001) Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 323(7319):957–962PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Murphy AW, Cupples ME, Smith SM, Byrne M, Byrne MC, Newell J (2009) Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial. BMJ 339:b4220. doi: 10.1136/bmj.b4220 PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Bailey TC, Noirot LA, Gage BF, Li X, Shannon WD, Waterman B, Sinha S, Bouselli DA, Reichley RM, Goldberg AC, Dunagan WC (2006) Improving adherence to coronary heart disease secondary prevention medication guidelines at a community hospital. AMIA Annual Symposium proceedings/AMIA Symposium AMIA Symposium:850Google Scholar
  27. 27.
    Tickoo S, Fonarow GC, Hernandez AF, Liang L, Cannon CP (2008) Weekend/holiday versus weekday hospital discharge and guideline adherence (from the American Heart Association’s get with the guidelines—coronary artery disease database). Am J Cardiol 102(6):663–667. doi: 10.1016/j.amjcard.2008.04.053 PubMedCrossRefGoogle Scholar
  28. 28.
    Ctt C Cholesterol Treatment Trialists’ (2012) The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet. doi: 10.1016/S0140-6736(12)60367-5 Google Scholar
  29. 29.
    Law MR, Morris JK, Wald NJ (2009) Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 338:b1665. doi: 10.1136/bmj.b1665 PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Antithrombotic Trialists C, Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R, Buring J, Hennekens C, Kearney P, Meade T, Patrono C, Roncaglioni MC, Zanchetti A (2009) Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 373(9678):1849–1860. doi: 10.1016/S0140-6736(09)60503-1 CrossRefGoogle Scholar
  31. 31.
    Estruch R, Ros E, Salas-Salvado J, Covas MI, Corella D, Aros F, Gomez-Gracia E, Ruiz-Gutierrez V, Fiol M, Lapetra J, Lamuela-Raventos RM, Serra-Majem L, Pinto X, Basora J, Munoz MA, Sorli JV, Martinez JA, Martinez-Gonzalez MA, Investigators PS (2013) Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 368(14):1279–1290. doi: 10.1056/NEJMoa1200303 PubMedCrossRefGoogle Scholar
  32. 32.
    Danaei G, Tavakkoli M, Hernan MA (2012) Bias in observational studies of prevalent users: lessons for comparative effectiveness research from a meta-analysis of statins. Am J Epidemiol 175(4):250–262. doi: 10.1093/aje/kwr301 PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Joos S, Rosemann T, Heiderhoff M, Wensing M, Ludt S, Gensichen J, Kaufmann-Kolle P, Szecsenyi J (2005) ELSID-Diabetes study-evaluation of a large scale implementation of disease management programmes for patients with type 2 diabetes. Rationale, design and conduct—a study protocol [ISRCTN08471887]. BMC Public Health 5:99. doi: 10.1186/1471-2458-5-99 PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Azaouagh A, Churzidse S, Konorza T, Erbel R (2011) Arrhythmogenic right ventricular cardiomyopathy/dysplasia: a review and update. Clinical Res Cardiol Off J Ger Cardiac Soc 100(5):383–394. doi: 10.1007/s00392-011-0295-2 CrossRefGoogle Scholar
  35. 35.
    Dabiri Abkenari L, Theuns DA, Valk SD, Van Belle Y, de Groot NM, Haitsma D, Muskens-Heemskerk A, Szili-Torok T, Jordaens L (2011) Clinical experience with a novel subcutaneous implantable defibrillator system in a single center. Clin Res Cardiol Off J Ger Cardiac Soc 100(9):737–744. doi: 10.1007/s00392-011-0303-6 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Renee Stark
    • 1
  • Inge Kirchberger
    • 2
  • Matthias Hunger
    • 1
  • Margit Heier
    • 2
  • Reiner Leidl
    • 1
    • 3
  • Wolfgang von Scheidt
    • 4
  • Christa Meisinger
    • 2
  • Rolf Holle
    • 1
  1. 1.Institute for Health Economics and Healthcare ManagementHelmholtz Zentrum MünchenMunichGermany
  2. 2.Institute of Epidemiology IIHelmholtz Zentrum MünchenMunichGermany
  3. 3.Department of Health Economics and Health Care Management, Munich School of ManagementUniversity of MunichMunichGermany
  4. 4.Department of Internal Medicine I - CardiologyCentral Hospital of AugsburgAugsburgGermany

Personalised recommendations