Highlights and Shadows of the Integrated Cardiological Care System in Poland: A Statin Discontinuation ‘Stress Test’.

Despite a widely available interventional cardiology system, Poland faced challenges in achieving satisfactory one-year survival rates for patients with acute myocardial infarction (AMI). In response to this concern, a dedicated system of coordinated care 'KOS-Zawal' was introduced. It addresses the challenge of fragmented health delivery for high risk patients. In order to bridge the gaps and assure the continuity of follow-up, it uses the principle of vertical integration, creating close links between tertiary, secondary and primary care. There is an evidence that this approach is leading to positive outcomes. However, the long-term effectiveness of this system remains incompletely evaluated. Therefore, a detailed examination of its ability to prevent statin therapy discontinuation was deemed necessary for the purpose of this study. Statins are widely used in lifelong manner for this purpose of the secondary prevention in high cardiovascular risk patients. However, their use is subject to poor adherence and often discontinuation by patients, whose motivation to use these drugs is often very limited. This leads to adverse cardiovascular events, hospitalizations, deaths, and profound economic consequences. Therefore, the aim of this study was to analyse the extent of statin therapy discontinuation among high-risk coronary artery disease (CAD) patients in Poland and check whether the coordinated care system lowers the chances of this discontinuation. Methods: The analysis utilized a countrywide dataset of dispensing data from the national payer organization - Polish National Health Fund - and covered the period March 1, 2022 - February 28, 2023. Discontinuation was defined as a 60-day-long period without drug possession. Inclusion criteria were 1. AMI within last 24 months; 2. Percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) within last 24 months; 3. Participation in coordinated care ‚KOS-Zawał’ within last 12 months. Results: Analysis identified 218,549 patients in total, of whom 136,327 were post-AMI, 181,422 post-PCI/CABG, and 29,296 were covered by coordinated care ‚KOS-Zawal’ (with significant overlap among the subgroups). Coordinated care proved to be effective in lowering the risk of statin discontinuation: in post-AMI patients those covered by coordinated care vs non-covered discontinued in 12.6% and 23.7%, respectively (P<0.001), similar effect was found in post PCI/CABG patients (12.2% vs 16.7%, P<0.01). On the other hand, statin discontinuation was observed in 1/5, 1/6 and 1/8 of post-AMI, post-PCI/CABG, and coordinated care patients. Conclusion: The results affirm the efficacy of a coordinated care system in mitigating the risk of statin discontinuation among high-risk patients. However, they also underscore a significant disparity between the recommended statin therapy and its execution, with a substantial 12% of patients experiencing discontinuation within the coordinated care setting. Therefore, there is an urgent need for system-wide interventions to address this problem. Efforts should be directed towards further fine-tuning of the ‚KOS-Zawał’ system, ensuring better coordination, vertical flow of information, and long-term patient involvement. The strategic adoption of digital solutions by all stakeholders appears to be a advisable approach to address existing challenges. Introducing a dedicated alerting system for both prescribers and patients could also prove highly beneficial.