Physicians' Academy for Cardiovascular Education

DYSIS: Healthcare reimbursement system influences achievement of LDL-c targets

News - Sep. 3, 2013

Restrictive (Germany) Versus an Incentive-Driven (UK) Reimbursement System on LDL-Goal-Achievement in Statin-Treated Patients for Secondary Prevention: Results of DYSIS

Presented at the ESC Congress 2013 by Dr Anselm Kai Gitt (Ludwigshafen, Germany)   


Large differences exist between European countries in the extent to which LDL-c targets are achieved. Diversity of reimbursement systems may explain part of those differences.
The Dyslipidemia International Study (DYSIS) compared to which extent LDL-c targets <100 mg/dl were achieved in Germany, where physicians have a restricted budget for medication costs, and even may be fined when they exceed the budget, with the United Kingdom, where physicians are rewarded based on their performance.

Main results

  • In Germany, 42% of patients reached LDL-c targets, as compared to 79.8% of UK patients.
  • The poten statin atorvastatin was prescribed in 3.9% of German patients (average dose 24.0 mg), as compared to 24.8% in UK patients (average dose 34.2 mg). Simvastatin (less potent) was used in 83.9% of the Germans (average dose 27.2 mg) as opposed to 67.6% of UK patients (average dose 36.6 mg).
    Average doses were significantly lower in Germany as opposed to UK, irrespective of the prescribed statin.


Patients in the United Kingdom are treated with more potent statins and with higher doses than German patients. Physicians in the UK treat more aggressively, possibly as a result of the financial incentive to achieve cholesterol targets. German physicians are more hesitant, possibly because the more potent statins and higher doses are more expensive.
In two countries with a similar accessibility to healthcare and medication, reaching LDL-c targets seems to depend on the type of healthcare reimbursement system. The German system had been developed to limit healthcare costs. It is however unclear whether this effect is actually obtained in the long run, since it is possible that more complications arise.
During the panel discussion at the ESC congress it was remarked that in the UK system, a moment of reflection is automatically built in in treatment decision making, since physicians receive feedback. This may facilitate optimal treatment. The German system does not include such feedback.

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