No abstract
Spain has been a parliamentary monarchy since 1978. Political devolution to regional governments has been incrementally implemented over the last 30 years. Thus, the political organization of the Spanish state is made up of the central state and 17 highly decentralized regions (termed Comunidades Autónomas, that is, Autonomous Communities) with their respective governments and parliaments (Figure 1). With a population of 46,468,102 (December 2016), Spain covers 505,370 km 2 and has the third largest surface area in Western Europe (Table 1). The fertility rate is one of the lowest in the EU (1.27 children per woman in 2014). The inflow of migrant population, especially in the last decade, has had a demographic impact in rejuvenating a population that is otherwise rapidly ageing. Life expectancy in Spain is one of the highest in Europe: 85.5 for women and 82.8 for men in 2015. The top three causes of death in Spain since 1970 have been: cardiovascular diseases, cancer and respiratory diseases, albeit there has been a steady decrease in the actual mortality rates from these causes. Still, mortality rates for these causes are among the lowest in the WHO European Region. Maternal and child health indicators (neonatal, perinatal and maternal mortality rates) have experienced a dramatic improvement, current rates scoring below European averages. Regarding lifestyle factors affecting health status, the proportion of daily smokers has been declining, though regular alcohol consumption is quite widespread and hazardous drinking affects some 7% of men and 3% of women. Obesity and overweight is increasing, doubling the 1987 rate for adult population to reach 15.6%.
Being initiated under Chancellor Bismarck in 1883, Germany's social statutory insurance is one of the earliest systems offering formal healthcare coverage for employed people as a part of a social security system. Since then, ever-changing environmental factors put continuous pressure on the functioning of the system: 1. the population grew to today approximately 82 million inhabitants, 2. scientific and medical progress has allowed the growth of an active healthcare industry, which today is an important pillar of the German economy, 3. better access to healthcare has increased longevity to a life expectancy at birth of 83.1 for women and 78.2 for men [1], 4. many otherwise deadly diseases can now be cured or controlled as chronic diseases, and 5. at the same time, the birth rate went down to currently about 1.5 children per woman (2015) [1] and therefore, a decreasing number of younger working people have to bear the increasing bill of total social security cost. Due to all these developments, healthcare expenditure has been continuously increasing to today about 11.3% of the German Gross Domestic Product (GDP) [2] and throughout the ongoing dynamics, the German healthcare system has experienced many revisions and changes over the years. Particular events were the split of Germany into two politically and economically strictly separated parts in 1949 and the reunification into the current Nation with the capital of Berlin in 1990. During these 50 years, the eastern part (about 1/3 of the territory; today 5 states plus Berlin) as "German Democratic Republic" was under the rule of the socialist Union of Soviet Socialist Republics (USSR) and the Western part (Federal Republic of Germany with 10 states) under temporary control of the 3 other victorious powers (USA, UK, France) favoring a democratic political system of social market economy. The reunification of the two healthcare systems after 1990 was driven by the social statutory insurance system established in the West. Figure 1 summarized facts and numbers about Germany.
Objective While some studies have evaluated the prescribing patterns of clopidogrel in combination with proton-pump inhibitors (PPI) before and after the FDA safety communication, none have assessed the prescribing patterns of histamine-2 receptor antagonists (H2RAs), one alternative to PPIs, during the same time period. This study aims to assess the trends in the concomitant use of clopidogrel with H2RAs or PPIs between 2007 and 2014 using the National Health and Nutrition Examination Survey (NHANES) database. Methods This was a secondary data analysis of survey participants who reported being 20 years of age or older and taking clopidogrel at the time of survey interview. The primary outcomes measured were the independent use of H2RAs or PPIs over 2007-2014. Logistic regression analyses compared H2RA and PPI use over time, while controlling for sociodemographics, insurance coverage, history of cardiovascular disease and history of smoking. Key findings 7.5% of study participants were on H2RAs while 26.3% were on PPIs. Except for the use of private health insurance, there were no statistical differences in covariates across the study period. H2RA use increased numerically from 2007 to 2014 by 5.6 percentage points (P = 0.118). PPI use decreased numerically from 2007 to 2010 by 5.9 percentage points but increased thereafter by 6 percentage points through 2014 (P = 0.488). The use of pantoprazole significantly increased (P = 0.005) while the use of lansoprazole significantly decreased (P = 0.008). The use of other PPIs over time did not change significantly (P > 0.05).Conclusions Overall H2RA and PPI use did not change among adults taking clopidogrel from 2007 through 2014. Prescribers must consider acid reducing agents that will not interact with clopidogrel. Future studies should evaluate the use of PPIs and H2RAs with dual antiplatelet therapy and in patients with a high risk of gastrointestinal bleeding.
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