Cancer diagnosis in primary care after second pandemic year in Catalonia: a time-series analysis of primary care electronic health records covering about 5 million people

BACKGROUND

During the COVID-19 pandemic, the incidence of chronic disease had drastically been reduced due to health care interruptions. The aim of this study is to analyse cancer diagnosis during the last 2 years of the COVID-19 pandemic.

METHODS

Time-series study of cancer diagnoses recorded in primary care settings, using data from the primary care electronic health records from January 2014 to December 2021. We obtained the expected monthly rate per 100,000 inhabitants using a time regression adjusted by trend and seasonality. We additionally compared rates of cancer diagnoses in 2019 with those of 2020 and 2021 using the t-test. We performed the analysis globally, by sex and by type of cancer.

RESULTS

In 2020, the rate of cancer diagnoses had reduced by -21% compared to 2019 (P < 0.05). Greater reductions were observed during the lockdown in early 2020 (>40%) and with some types of cancers, especially prostate and skin cancers (-29.6% and -26.9%, respectively, P < 0.05). Lung cancers presented statistically non-significant reductions in both years. Cancer diagnosis returned to expected around March 2021, and the rate in 2021 was similar to that of 2019 (overall difference of 0.21%, P = 0.967). However, an 11% reduction was still found when comparing the pandemic months of 2020-2021 with pre-pandemic months.

CONCLUSIONS

Although primary care cancer diagnoses in 2021 have returned to pre-pandemic levels, missing diagnoses during the last 2 years have not been fully recovered.

Unravelling the role of the mandatory use of face covering masks for the control of SARS-CoV-2 in schools: a quasi-experimental study nested in a population-based cohort in Catalonia (Spain)

OBJECTIVE

To assess the effectiveness of mandatory use of face covering masks (FCMs) in schools during the first term of the 2021-2022 academic year.

DESIGN

A retrospective population-based study.

SETTING

Schools in Catalonia (Spain).

POPULATION

599 314 children aged 3-11 years attending preschool (3-5 years, without FCM mandate) and primary education (6-11 years, with FCM mandate).

STUDY PERIOD

From 13 September to 22 December 2021 (before Omicron variant).

INTERVENTIONS

A quasi-experimental comparison between children in the last grade of preschool (5 years old), as a control group, and children in year 1 of primary education (6 years old), as an interventional group.

MAIN OUTCOME MEASURES

Incidence of SARS-CoV-2, secondary attack rates (SARs) and effective reproductive number (R*).

RESULTS

SARS-CoV-2 incidence was significantly lower in preschool than in primary education, and an increasing trend with age was observed. Six-year-old children showed higher incidence than 5 year olds (3.54% vs 3.1%; OR 1.15 (95% CI 1.08 to 1.22)) and slightly lower but not statistically significant SAR (4.36% vs 4.59%; incidence risk ratio 0.96 (95% CI 0.82 to 1.11)) and R* (0.9 vs 0.93; OR 0.96 (95% CI 0.87 to 1.09)). Results remained consistent using a regression discontinuity design and linear regression extrapolation approaches.

CONCLUSIONS

We found no significant differences in SARS-CoV-2 transmission due to FCM mandates in Catalonian schools. Instead, age was the most important factor in explaining the transmission risk for children attending school.

"Decline and uneven recovery from 7 common long-term conditions managed in the Catalan primary care after two pandemic years: an observational retrospective population-based study using primary care electronic health records"

BACKGROUND

The incidence of chronic diseases during the COVID-19 pandemic has drastically been reduced worldwide due to disruptions in healthcare systems. The aim of our study is to analyse the trends in the incidence of 7 commonly managed primary care chronic diseases during the last 2 years of the COVID-19 pandemic in Catalonia.

METHODS

We performed an observational retrospective population-based study using data from primary care electronic health records from January 2018 to August 2022 (5.1 million people older than 14 years). We divided the study period into two: a pre-pandemic period (before 14 March 2020) and a pandemic period. We performed a segmented regression analysis of daily incidence rates per 100,000 inhabitants of 7 chronic diseases: type 2 diabetes mellitus (T2DM), asthma, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD), heart failure (HF), hypertension and hypercholesterolemia. In addition, we compared annual incidence between pandemic years (2020, 2021 and 2022) and 2019. Associated incidence rate ratios (IRR) were also calculated. Finally, we estimated the number of expected diagnoses during the pandemic period using data from 2019 and we compared it with the observed data.

RESULTS

We analysed 740,820 new chronic diseases' diagnoses. Daily incidence rates of all 7 chronic diseases were drastically interrupted on 14 March 2020, and a general upward trend was observed during the following months. Reductions in 2020 were around 30% for all conditions except COPD which had greater reductions (IRR: 0.58 [95% CI: 0.57 to 0.6]) and HF with lesser drops (IRR: 0.86 [95% CI: 0.84 to 0.88]). Some of the chronic conditions have returned to pre-pandemic diagnosis levels, except asthma, COPD and IHD. The return to pre-pandemic diagnosis levels compensated for the drops in 2020 for T2DM and HF, but not for hypertension which presented an incomplete recovery. We also observed an excess of hypercholesterolemia diagnoses of 8.5% (95%CI: 1.81% to 16.15%).

CONCLUSIONS

Although primary care has recovered the pre-pandemic diagnosis levels for some chronic diseases, there are still missing diagnoses of asthma, COPD and IHD that should be addressed.

Association between two mass-gathering outdoor events and incidence of SARS-CoV-2 infections during the fifth wave of COVID-19 in north-east Spain: A population-based control-matched analysis

Background

Many countries have resumed mass-gathering events like music festivals, despite the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreading. In this study, we aimed to assess the effect of two mass-gathering outdoor events, held during a peak of SARS-CoV-2 transmission, on COVID-19 incidence.

Methods

This was a retrospective, population-based control-matched analysis. The study population included attendees to two outdoor music festivals held in Catalonia (North-East Spain). The primary objective was to compare the incidence of COVID-19 within the 3-to-10 days following the event between attendees and a population-based control group.

Findings

The analysis included 18,275 and 27,347 attendees to the first and second festivals, respectively, and their corresponding controls. The post-festival 7-day cumulative COVID-19 incidence among attendees and controls was 4.14% (95% CI 3.86-4.44) vs. 1.69% (1.51-1.88) for the first festival (RR 2.46; 2.16-2.80), and 2.42% (2.35-2.61) and 1.10% (0.99-1.2) for the second festival (RR 2.19; 1.92-2.51). COVID-19 incidence among immunized individuals was also two-fold higher in attendees than in controls. Previous COVID-19 infection, vaccination, and adequate mask-wearing were significantly associated with a lower risk of COVID-19 infection after the events.

Interpretation

Despite the proven effectiveness of preventive measures such as Ag-RDT screening, mask-wearing and vaccination, caution should be taken when holding these events during a period of high community SARS-CoV-2 transmission.

Funding

Crowdfunding campaign YoMeCorono (https://www.yomecorono.com/) and the Generalitat de Catalunya.

Comparing the Clinical Characteristics and Mortality of Residential and Non-Residential Older People with COVID-19: Retrospective Observational Study

Nursing homes have accounted for a significant part of SARS-CoV-2 mortality, causing great social alarm. Using data collected from electronic medical records of 1,319,839 institutionalised and non-institutionalised persons ≥ 65 years, the present study investigated the epidemiology and differential characteristics between these two population groups. Our results showed that the form of presentation of the epidemic outbreak, as well as some risk factors, are different among the elderly institutionalised population with respect to those who are not. In addition to a twenty-fold increase in the rate of adjusted mortality among institutionalised individuals, the peak incidence was delayed by approximately three weeks. Having dementia was shown to be a risk factor for death, and, unlike the non-institutionalised group, neither obesity nor age were shown to be significantly associated with the risk of death among the institutionalised. These differential characteristics should be able to guide the actions to be taken by the health administration in the event of a similar infectious situation among institutionalised elderly people.

Associations of BNT162b2 vaccination with SARS-CoV-2 infection and hospital admission and death with covid-19 in nursing homes and healthcare workers in Catalonia: prospective cohort study

OBJECTIVE

To determine associations of BNT162b2 vaccination with SARS-CoV-2 infection and hospital admission and death with covid-19 among nursing home residents, nursing home staff, and healthcare workers.

DESIGN

Prospective cohort study.

SETTING

Nursing homes and linked electronic medical record, test, and mortality data in Catalonia on 27 December 2020.

PARTICIPANTS

28 456 nursing home residents, 26 170 nursing home staff, and 61 791 healthcare workers.

MAIN OUTCOME MEASURES

Participants were followed until the earliest outcome (confirmed SARS-CoV-2 infection, hospital admission or death with covid-19) or 26 May 2021. Vaccination status was introduced as a time varying exposure, with a 14 day run-in after the first dose. Mixed effects Cox models were fitted to estimate hazard ratios with index month as a fixed effect and adjusted for confounders including sociodemographics, comorbidity, and previous medicine use.

RESULTS

Among the nursing home residents, SARS-CoV-2 infection was found in 2482, 411 were admitted to hospital with covid-19, and 450 died with covid-19 during the study period. In parallel, 1828 nursing home staff and 2968 healthcare workers were found to have SARS-CoV-2 infection, but fewer than five were admitted or died with covid-19. The adjusted hazard ratio for SARS-CoV-2 infection after two doses of vaccine was 0.09 (95% confidence interval 0.08 to 0.11) for nursing home residents, 0.20 (0.17 to 0.24) for nursing home staff, and 0.13 (0.11 to 0.16) for healthcare workers. Adjusted hazard ratios for hospital admission and mortality after two doses of vaccine were 0.05 (0.04 to 0.07) and 0.03 (0.02 to 0.04), respectively, for nursing home residents. Nursing home staff and healthcare workers recorded insufficient events for mortality analysis.

CONCLUSIONS

Vaccination was associated with 80-91% reduction in SARS-CoV-2 infection in all three cohorts and greater reductions in hospital admissions and mortality among nursing home residents for up to five months. More data are needed on longer term effects of covid-19 vaccines.

Prematurity and ADHD in Childhood: An Observational Register-Based Study in Catalonia

Objective: To evaluate the association between prematurity (by the gestational week [gw]) and ADHD during childhood. Method: Observational, matched cohort study using data from children born in a tertiary-level hospital (Hospital Universitari Vall d'Hebron, Catalonia, Spain) during 1995-2007 and data from the Information System for the Development of Research in Primary Health Care (SIDIAP database, Catalonia, Spain). Results: Prevalence of ADHD increases as gestational age decreases, 12.7% for those born ≤28 gw, compared to 3.2% for those born after the 37 gw. The risk of developing ADHD in the non-premature children tends to increase as the gw decreases (35-36 gw, hazard ratio [HR] = 1.70, 95% confidence interval [CI] [1.19, 2.44]; 33-34 gw, HR = 3.38, 95% CI [2.08, 5.50]; 29-32 gw, HR = 2.37, 95% CI [1.54, 3.63]; and ≤28 gw, HR = 5.57, 95% CI [2.49, 12.46]) Conclusion: Being born preterm is associated with a risk of developing ADHD, also in late preterm children (35-36 gw). Attention when taking care of these infants regarding their mental health must be made.

Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia

BACKGROUND

To analyse the impact of the COVID-19 epidemic and the lockdown measures on the follow-up and control of chronic diseases in primary care.

METHODS

Retrospective study in 288 primary care practices (PCP) of the Catalan Institute of Health. We analysed the results of 34 indicators of the Healthcare quality standard (EQA), comprising different types: treatment (4), follow-up (5), control (10), screening (7), vaccinations (4) and quaternary prevention (4). For each PCP, we calculated each indicator's percentage of change in February, March and April 2020 respective to the results of the previous month; and used the T-Student test for paired data to compare them with the percentage of change in the same month of the previous year. We defined indicators with a negative effect those with a greater negative change or a lesser positive change in 2020 in comparison to 2019; and indicators with a positive effect those with a greater positive change or a lesser negative change.

RESULTS

We observed a negative effect on 85% of the EQA indicators in March and 68% in April. 90% of the control indicators had a negative effect, highlighting the control of LDL cholesterol with a reduction of - 2.69% (95%CI - 3.17% to - 2.23%) in March and - 3.41% (95%CI - 3.82% to - 3.01%) in April; and the control of blood pressure with a reduction of - 2.13% (95%CI - 2.34% to - 1.9%) and - 2.59% (95%CI - 2.8% to - 2.37%). The indicators with the greatest negative effect were those of screening, such as the indicator of diabetic foot screening with a negative effect of - 2.86% (95%CI - 3.33% to - 2.39%) and - 4.13% (95%CI - 4.55% to - 3.71%) in March and April, respectively. Only one vaccination indicator, adult Measles-Mumps-Rubella vaccine, had a negative effect in both months. Finally, among the indicators of quaternary prevention, we observed negative effects in March and April although in that case a lower inadequacy that means better clinical outcome.

CONCLUSIONS

The COVID-19 epidemic and the lockdown measures have significantly reduced the results of the follow-up, control, screening and vaccination indicators for patients in primary care. On the other hand, the indicators for quaternary prevention have been strengthened and their results have improved.

Primary Care Doctor Characteristics That Determine the Use of Teleconsultations in the Catalan Public Health System: Retrospective Descriptive Cross-Sectional Study

BACKGROUND

eConsulta is a tele-consultation service involving doctors and patients, and is part of Catalonia's public health information technology system. The service has been in operation since the end of 2015 as an adjunct to face-to-face consultations. A key factor in understanding the barriers and facilitators to the acceptance of the tool is understanding the sociodemographic characteristics of general practitioners who determine its use.

OBJECTIVE

This study aimed to analyze the sociodemographic factors that affect the likelihood of doctors using eConsulta.

METHODS

A retrospective cross-sectional analysis of administrative data was used to perform a multivariate logistic regression analysis on the use of eConsulta in relation to sociodemographic variables.

RESULTS

The model shows that the doctors who use eConsulta are 45-54 years of age, score higher than the 80th percentile on the quality of care index, have a high degree of accessibility, are involved in teaching, and work on a health team in a high socioeconomic urban setting.

CONCLUSIONS

The results suggest that certain sociodemographic characteristics associated with general practitioners determine whether they use eConsulta. These results must be taken into account if its deployment is to be encouraged in the context of a public health system.

Effectiveness of electronic point-of-care reminders versus monthly feedback to improve adherence to 10 clinical recommendations in primary care: a cluster randomized clinical trial

BACKGROUND

Numerous studies have analyzed the effectiveness of electronic reminder interventions to improve different clinical conditions, and most have reported a small to moderate effect. Few studies, however, have analyzed reminder systems targeting multiple conditions, and fewer still have compared electronic point-of-care reminders systems with other forms of feedback designed to improve delivery of care.

METHODS

We performed an unblinded cluster randomized clinical trial to compare the effectiveness of an electronic point-of-care reminder system with that of a well-established system providing monthly feedback on adherence to clinical recommendations. The control group received monthly feedback only while the intervention group received monthly feedback in addition to on-screen point-of-care reminders for 10 clinical conditions. The study targeted all physicians and nurses at the 283 primary care centers managed by the Institut Català de la Salut (approximately 6600 professionals).

RESULTS

Following exclusions and randomization, 132 primary care centers (328,728 patients with reminders) were assigned to the intervention group while 137 centers (317,117 patients with reminders) were randomized to the control group. A 20.6% improvement (OR 1.29, 95% CI: 1.25-1.34) in reminder resolution rates was observed in the intervention group. Results varied according to the clinical condition. The most effective reminder was screening for diabetic retinopathy (OR 1.51, 95% CI:1.46-1.57) while the least effective reminders were measurement of glycated hemoglobin (OR: 1.10, 95% CI: 1.07-1.13) and smoking cessation encouragement (OR 1.12, 95% CI: 1.09-1.16).

CONCLUSIONS

Electronic point-of-care reminders were more effective than the existing monthly feedback system at resolving the 10 clinical situations. However, more studies are needed to investigate the variations of the effect observed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42391639, 08/10/2012. Retrospectively registered.

Effectiveness of computerized point-of-care reminders on adherence with multiple clinical recommendations by primary health care providers: protocol for a cluster-randomized controlled trial

BACKGROUND

To determine the effectiveness of reminders compared to no reminders in improving adherence to multiple clinical recommendations measured as the resolution of the clinical condition that motivated the reminder, in a primary care setting with a well-established feedback system.

METHODS/DESIGN

A 12-month, cluster-randomized, controlled clinical trial was designed (randomized by primary care team) to evaluate the impact of computerized reminders. All study participants will continue to receive the usual feedback from the electronic health records system. The control group (well-established feedback) will be compared with reminders and a well-established feedback system. The study will include all general practitioners (3425) and nurses (3262) providing primary care for a population aged 14 years or older in the 282 primary care teams reporting to the Catalan Institute of Health. Up to 10 clinical reminders are offered for each patient, recommending action related to at least one of nine clinical conditions: arterial hypertension, elevated cardiovascular risk, type 2 diabetes mellitus, cerebrovascular accident, ischemic heart disease, heart failure, atrial fibrillation, smoking habit, and hepatitis C. The outcomes are the resolution of the clinical condition that motivated the reminder and the time elapsed between the first reminder message and implementation of the recommended action (months). Due to the obvious correlation between reminders about the same patient, the profile of patients assigned to a particular professional, and the professionals assigned to a particular centre, hierarchical modelling will be used to simultaneously estimate the effect of the study variables at these different levels of analysis. To estimate the impact of the intervention arm, an analysis of adherence to each type of reminder will be carried out, using multi-level logistical regression models at level of the primary care centre. Time to adherence will be estimated by the Kaplan-Meier method and comparisons will be done using the log-rank test.

DISCUSSION

The results of this study could provide new evidence on the impact of computerized reminders at the point of care on adherence to clinical guidelines in primary care with an established feedback system. Trial registration ISRCTN42391639. October 8, 2012.

Socioeconomic status and its association with the risk of developing hip fractures: a region-wide ecological study

PURPOSE

To determine the association between socioeconomic deprivation (SES) and hip fracture risk.

METHODS

Retrospective cohort study using a population-based database (primary care records) of over 5 million people. Eligibility: all living subjects registered during the period 2009-2012 and resident in an urban area.

MEASURES

a validated SES composite index (proportion of unemployed, temporary workers, manual workers, low educational attainment and low educational attainment among youngsters) estimated for each area based on census data.

OUTCOME

incident hip fracture rates as coded in medical records using ICD-10 codes.

STATISTICS

zero-inflated Poisson models fitted to study the association between SES quintiles and hip fracture risk, adjusted for age, sex, obesity, smoking and alcohol consumption.

RESULTS

Compared to the most deprived, wealthy areas had a higher hip fracture incidence (age- and sex-adjusted incidence 38.57 (37.14-40.00) compared to 34.33 (32.90-35.76) per 10,000 person-years). Similarly, most deprived areas had a crude and age- and sex-adjusted lower risk of hip fracture, RR of 0.71 (0.65-0.78) and RR of 0.90 (0.85-0.95), respectively, compared to wealthiest areas. The association was attenuated and no longer significant after adjustment for obesity: RR 0.96 (0.90-1.01). Further adjustment for smoking and high alcohol consumption did not make a difference.

CONCLUSION

Wealthiest areas have an almost 30% increased risk of hip fracture compared to the most deprived. Differences in age-sex composition and a higher prevalence of obesity in deprived areas could explain this higher risk.

The descriptive epidemiology of rheumatoid arthritis in Catalonia: a retrospective study using routinely collected data

Information on the epidemiology of rheumatoid arthritis (RA) in Southern Europe is scarce. We estimated the age- and gender-adjusted incidence and prevalence of RA in Catalonia using routinely collected primary care records. We identified incident (2009-2012) and prevalent (on 31 December 2012) cases of RA in the SIDIAP database using ICD-10 codes. SIDIAP contains anonymized data from computerized primary care records for about five million adults (>80 % of the population). We estimated age- (5-year groups) and gender-specific, and directly standardized incidence and prevalence of RA and confidence intervals (95% CIs) assuming a Poisson distribution. A total of 20,091 prevalent (among whom 5,796 incident) cases of RA were identified among 4,796,498 study participants observed for up to 4 years. Rates of RA increased with age in both genders, peaking at the age of 65-70 years. Age- and gender-standardized incidence and prevalence rates were 0.20/1,000 person-years (95% CI 0.19-0.20) and 4.17/1,000 (4.11-4.23) respectively. Rheumatoid factor was positive (≥10 IU/mL) in 1,833 (73.9 %) of 2,482 cases tested in primary care. The incidence and prevalence of RA in Catalonia are similar to those of other Southern European regions, and lower than those of northern areas. This data will inform health care planning and resource allocation.

Linking of primary care records to census data to study the association between socioeconomic status and cancer incidence in Southern Europe: a nation-wide ecological study

BACKGROUND

Area-based measures of economic deprivation are seldom applied to large medical records databases to establish population-scale associations between deprivation and disease.

OBJECTIVE

To study the association between deprivation and incidence of common cancer types in a Southern European region.

METHODS

Retrospective ecological study using the SIDIAP (Information System for the Development of Research in Primary Care) database of longitudinal electronic medical records for a representative population of Catalonia (Spain) and the MEDEA index based on urban socioeconomic indicators in the Spanish census. Study outcomes were incident cervical, breast, colorectal, prostate, and lung cancer in 2009-2012. The completeness of SIDIAP cancer recording was evaluated through linkage of a geographic data subset to a hospital cancer registry. Associations between MEDEA quintiles and cancer incidence was evaluated using zero-inflated Poisson regression adjusted for sex, age, smoking, alcoholism, obesity, hypertension, and diabetes.

RESULTS

SIDIAP sensitivity was 63% to 92% for the five cancers studied. There was direct association between deprivation and lung, colorectal, and cervical cancer: incidence rate ratios (IRR) 1.82 [1.64-2.01], IRR 1.60 [1.34-1.90], IRR 1.22 [1.07-1.38], respectively, comparing the most deprived to most affluent areas. In wealthy areas, prostate and breast cancers were more common: IRR 0.92 [0.80-1.00], IRR 0.91 [0.78-1.06]. Adjustment for confounders attenuated the association with lung cancer risk (fully adjusted IRR 1.16 [1.08-1.25]), reversed the direction of the association with colorectal cancer (IRR 0.90 [0.84-0.95]), and did not modify the associations with cervical (IRR 1.27 [1.11-1.45]), prostate (0.74 [0.69-0.80]), and breast (0.76 [0.71-0.81]) cancer.

CONCLUSIONS

Deprivation is associated differently with the occurrence of various cancer types. These results provide evidence that MEDEA is a useful, area-based deprivation index for analyses of the SIDIAP database. This information will be useful to improve screening programs, cancer prevention and management strategies, to reach patients more effectively, particularly in deprived urban areas.

Effectiveness of an intervention designed to optimize statins use: a primary prevention randomized clinical trial

BACKGROUND

Although hypercholesterolemia is considered a cardiovascular risk factor, in isolation it is not necessarily sufficient cause for a cardiovascular event. To improve event prediction, cardiovascular risk calculators have been developed; the REGICOR calculator has been validated for use in our population. The objective of this project is to develop an intervention with general practitioners (GPs) and evaluate its impact on prescription adequacy of cholesterol-lowering drugs in primary prevention of cardiovascular disease and in controlling the costs associated with this disease.

METHODS

This nonblinded, cluster-randomized clinical trial analyzes data from primary care electronic medical records (ECAP) and other databases. Inclusion criteria are patients aged 35 to 74 years with no known cardiovascular disease and a new prescription for cholesterol-lowering drugs during the 2-year study period. Dependent variables include the following: RETIRA, defined as new cholesterol-lowering drugs initiated during the year preceding the intervention, considered inadequate, and withdrawn during the study period; EVITA, defined as new cholesterol-lowering drugs initiated during the study period and considered inadequate; COST, defined as the total cost of inadequate new treatments prescribed; and REGISTER, defined as the recording of cardiovascular risk factors. Independent variables include the GP's quality-of-care indicators and randomly assigned study group (intervention vs control), patient demographics, and clinical variables. Aggregated descriptive analysis will be done at the GP level and multilevel analysis will be performed to estimate the intervention effect, adjusted for individual and GP variables.

DISCUSSION

The study objective is to generate evidence about the effectiveness of implementing feedback information programs directed to GPs in the context of Primary Care. The goal is to improve the prescription adequacy of lipid-lowering therapies for primary prevention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01997671. November 28, 2013.

Prescription in patients with chronic heart failure and multimorbidity attended in primary care

BACKGROUND

Multimorbidity and polypharmacy pose challenges to improving the quality of care.

OBJECTIVES

To determine the association between prescription of recommended treatment in ambulatory patients with chronic heart failure and multiple comorbidities and hospitalisation events.

DESIGN

A population-based retrospective cohort study in Catalonia (north-east Spain).

PARTICIPANTS

We included 7173 newly registered patients with chronic heart failure (59% women; mean [SD] age 76.3 [10.7] years). Patients were selected from the electronic patient records of primary care practices and followed for three years.

OUTCOME MEASURES

Prescription of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs) and beta-blockers (BBs).

RESULTS

Prescription of ACEI/ARBs in patients managed in primary care without a hospitalisation event during the follow-up rose from 50.8 to 83.5% for 0 and ≥4 comorbidities, respectively, and for ACEI/ARBs and BB from 13.1 to 30.6% for 0 and ≥4 comorbidities respectively. Patients with a hospitalisation event were treated more often (ACEI/ARBs or 1.47 [1.17 to 1.85]; ACEI/ARBs and BB or 1.41 [1.17 to 1.69]). Comorbid conditions receiving more treatment were hypertension (ACEI/ARBs or 3.75 [3.33 to 4.22]; ACEI/ARBs and BB or 1.40 [1.23 to 1.59]), diabetes mellitus (ACEI/ARBs or 1.79 [1.57 to 2.04]; ACEI/ARBs and BB or 1.33 [1.18 to 1.49]) and ischaemic heart disease (ACEI/ARBs or 1.25 [1.10 to 1.42]; ACEI/ARBs and BB or 3.01 [2.68 to 3.38]).

CONCLUSION

Prescription of recommended treatment in patients with chronic heart failure increased as the number of comorbidities increased. Family physicians can provide equivalent care to more complex patients and those less complex, according to the number of comorbidities.

Construction and validation of a scoring system for the selection of high-quality data in a Spanish population primary care database (SIDIAP)

BACKGROUND

Computerised databases of primary care clinical records are widely used for epidemiological research. In Catalonia, the Information System for the Development of Research in Primary Care (SIDIAP) aims to promote the development of research based on high-quality validated data from primary care electronic medical records.

OBJECTIVE

The purpose of this study is to create and validate a scoring system (Registry Quality Score, RQS) that will enable all primary care practices (PCPs) to be selected as providers of researchusable data based on the completeness of their registers.

METHODS

Diseases that were likely to be representative of common diagnoses seen in primary care were selected for RQS calculations. The observed/expected cases ratio was calculated for each disease. Once we had obtained an estimated value for this ratio for each of the selected conditions we added up the ratios calculated for each condition to obtain a final RQS. Rate comparisons between observed and published prevalences of diseases not included in the RQS calculations (atrial fibrillation, diabetes, obesity, schizophrenia, stroke, urinary incontinence and Crohn's disease) were used to set the RQS cutoff which will enable researchers to select PCPs with research-usable data.

RESULTS

Apart from Crohn's disease, all prevalences were the same as those published from the RQS fourth quintile (60th percentile) onwards. This RQS cut-off provided a total population of 1 936 443 (39.6% of the total SIDIAP population).

CONCLUSIONS

SIDIAP is highly representative of the population of Catalonia in terms of geographical, age and sex distributions. We report the usefulness of rate comparison as a valid method to establish research-usable data within primary care electronic medical records.

Primary health care utilization by immigrants as compared to the native population: a multilevel analysis of a large clinical database in Catalonia

BACKGROUND

Immigration is a relevant public health issue and there is a great deal of controversy surrounding its impact on health services utilization.

OBJECTIVE

To determine differences between immigrants and non-immigrants in the utilization of primary health care services in Catalonia, Spain.

METHODS

Population based, cross-sectional, multicentre study. We used the information from 16 primary health care centres in an area near Barcelona, Spain. We conducted a multilevel analysis for the year 2008 to compare primary health care services utilization between all immigrants aged 15 or more and a sample of non-immigrants, paired by age and sex.

RESULTS

Overall, immigrants living in Spain used health services more than non-immigrants (Incidence Risk Ratio (IRR) 1.16 (95% Confidence Interval (CI): 1.15-1.16) and (IRR 1, 26, 95% CI: 1.25-1.28) for consultations with GPs and referrals to specialized care, respectively. People coming from the Maghreb and the rest of Africa requested the most consultations involving a GP and nurses (IRR 1.34, 95% CI: 1.33-1.36 and IRR 1.06, 95% CI: 1.03-1.44, respectively). They were more frequently referred to specialized care (IRR 1.44, 95% CI: 1.41-1.46) when compared to Spaniards. Immigrants from Asia had the lowest numbers of consultations with a GP and referrals (IRR 0.76, 95% CI: 0.66-0.88 and IRR 0.76, 95% CI: 0.61-0.95, respectively.

CONCLUSION

On average, immigrants living in Catalonia used the health services more than non-immigrants. Immigrants from the Maghreb and other African countries showed the highest and those from Asia the lowest, number of consultations and referrals to specialized care.

Incidence and prevalence of juvenile idiopathic arthritis in Catalonia (Spain)

OBJECTIVE

To ascertain the incidence and prevalence of juvenile idiopathic arthritis (JIA) in Catalonia (autonomous region in northeast Spain), examined according to the currently established disease subtypes.

METHODS

Before initiating the study, we conducted an educational programme on paediatric rheumatology, addressed to all general paediatricians in Catalonia. A 2-year (2004-2006), prospective, population-based study was then carried out to determine the incidence of JIA. Prospective and retrospective data retrieval was performed to calculate prevalence. The International League of Associations for Rheumatology (ILAR, Edmonton revision) classification criteria were applied.

RESULTS

Over the study period, 145 new cases of JIA were diagnosed. The mean annual incidence was 6.9/10⁵ children aged less than 16 years (range 5.8-8.1 years; 9.0 years for girls and 4.8 years for boys). On separate analysis of patients ≤ 6 and > 6 years, the distribution in younger children was found to be similar for both girls and boys, whereas in older children, most girls belonged to the oligoarthritis and polyarthritis subgroups, and boys to the enthesitis-related arthritis and undifferentiated subgroups. The calculated prevalence of JIA (31 October 2006) was 39.7 (36.1-43.7)/10⁵ children younger than 16. The relative risk of girls having JIA was 2.1 [95% confidence interval (CI) 1.7-2.7, p < 0.001]. In 70% of patients, the diagnosis was established before the age of 7. Subgroup distribution of prevalent cases mirrored that of incident cases.

CONCLUSION

This is the first population-based study on the epidemiology of JIA in Catalonia. Incidence and prevalence rates are lower than those reported for several areas in Nordic countries of Europe. Oligoarthritis was the most common subtype.

Multivisceral resection for colon cancer: analysis of prognostic factors

BACKGROUND/AIMS

To assess outcome of multivisceral resection in colon cancer patients and to identify predictors of survival.

METHODS

One hundred and thirteen consecutive patients with primary locally advanced colon cancer infiltrating adjacent organs undergoing multivisceral resection between 1998 and 2007 were reviewed. Overall survival and disease-free survival were analyzed by the Kaplan-Meier method. The relative risk for clinical outcome was obtained using a Cox multivariate model.

RESULTS

The median follow-up was 74.9 months. Fifty-two patients had sigmoid tumors and 48 involvement of the small intestine. Complications occurred in 54 patients. The diagnosis was conventional adenocarcinoma in 94 patients. R0 resection was achieved in 96 patients (85%). Eighty-three patients received postoperative adjuvant therapy. The operative mortality was 7.1% (8 patients). Sixty-seven patients died at follow-up. Of the 46 patients who were alive, 38 were free of disease. In 73 patients with pT4a disease, 42 patients died (57.5%) and of the 31 survivors, recurrence was documented in 6. Hematochezia and adjuvant chemotherapy were independent factors of favorable outcome and grade G3 and tumor stage III-IV of poor survival.

CONCLUSION

Hematochezia and adjuvant chemotherapy were associated with a better survival, and poorly differentiated tumors and stage IV disease with a poor survival.

Preoperative chemotherapy plus surgery versus surgery plus adjuvant chemotherapy versus surgery alone in early-stage non-small-cell lung cancer

PURPOSE

To address whether preoperative chemotherapy plus surgery or surgery plus adjuvant chemotherapy prolongs disease-free survival compared with surgery alone among patients with resectable non-small-cell lung cancer.

PATIENTS AND METHODS

In this phase III trial, 624 patients with stage IA (tumor size > 2 cm), IB, II, or T3N1 were randomly assigned to surgery alone (212 patients), three cycles of preoperative paclitaxel-carboplatin followed by surgery (201 patients), or surgery followed by three cycles of adjuvant paclitaxel-carboplatin (211 patients). The primary end point was disease-free survival.

RESULTS

In the preoperative arm, 97% of patients started the planned chemotherapy, and radiologic response rate was 53.3%. In the adjuvant arm, 66.2% started the planned chemotherapy. Ninety-four percent of patients underwent surgery; surgical procedures and postoperative mortality were similar across the three arms. Patients in the preoperative arm had a nonsignificant trend toward longer disease-free survival than those assigned to surgery alone (5-year disease-free survival 38.3% v 34.1%; hazard ratio [HR] for progression or death, 0.92; P = .176). Five-year disease-free survival rates were 36.6% in the adjuvant arm versus 34.1% in the surgery arm (HR 0.96; P = .74).

CONCLUSION

In early-stage patients, no statistically significant differences in disease-free survival were found with the addition of preoperative or adjuvant chemotherapy to surgery. In this trial, in which the treatment decision was made before surgery, more patients were able to receive preoperative than adjuvant treatment.

Prognostic significance of vascular endothelial growth factor and cyclooxygenase-2 in patients with rectal cancer treated with preoperative radiotherapy

PURPOSE

To analyze the prognostic value of cyclooxygenase-2 (COX-2) and vascular endothelial growth factor (VEGF) in patients with locally advanced rectal cancer treated with preoperative radiotherapy.

METHODS

Eighty-one patients with locally advanced rectal cancer were studied. All patients received preoperative pelvic radiotherapy. Forty-seven patients received concomitant chemotherapy. Surgical resection was performed 4-8 weeks later in all patients. Immunohistochemical examination of COX-2 and VEGF was performed on the preirradiation diagnostic biopsies. An immunohistochemical score established from the extension and intensity of the markers was used for analysis. The log-rank test and proportional hazards regression analysis were used to calculate the probability that the biomarkers were associated with patient outcome.

RESULTS

COX-2 expression was positive in 38 tumors (51%) while VEGF expression was positive in 43 (57%). The only clinicopathological parameter significantly associated with COX-2 or VEGF expression was performance status. None of the 2 markers were found to predict treatment response. There was no statistically significant correlation between COX-2 and VEGF. Univariate analysis identified pathological stage (pT, pN) as prognostic for disease-free survival. When VEGF expression was analyzed, disease-free survival was reduced among patients with VEGF-positive tumors (p = 0.047). This was specifically related to metastases-free survival (p = 0.016). These results were not observed for COX-2. After multivariate analysis, the pT and pN stage remained as independent prognostic factors.

CONCLUSIONS

VEGF-positive expression is an indicator of poor disease-free survival, specifically linked to distant metastasis. More aggressive treatment strategies are warranted in pT3-4 and pN1-2 rectal cancer patients.

Short postal questionnaire and selective clinical examination combined with repeat mailing and telephone reminders as a method of follow-up in hernia surgery

BACKGROUND

We assessed the usefulness of a short postal questionnaire and selective clinical examination combined with repeat mailing and telephone reminders for quality assessment in hernia surgery.

METHODS

All patients (n = 1153) who underwent tension-free hernioplasty through an open preperitoneal approach between 1999 and 2003 received a six-item questionnaire with a covering letter and a stamped addressed envelope. Nonresponders received two successive new questionnaires and a telephone call.

RESULTS

A total of 841 (72.9%) patients returned questionnaires after three reminders (512 after the first mailing, 205 after the second, and 124 after the third). Positive questionnaire answers were documented for 152 (18.1%) of repairs and negative answers for 689 (81.9%). Of the 152 patients who answered "yes" to either of the questions regarding recurrence and/or current pain, 91 declined clinical appointments, 24 could not be contacted by phone, and 37 underwent physical examination. Of the 312 patients who did not return the questionnaire, eight had died, 124 did not want to be visited, and 180 could not be located. The recurrence rate was 2.7% and the chronic pain rate 5.9%.

CONCLUSIONS

Repeat mailing was a useful strategy to improve response to self-administered postal questionnaires on hernia surgery quality assessment. However, contacting the group that responded with positive questionnaire answers was a poorly effective way to encourage subjects to come for a physical examination.

Hepatitis B virus genotypes and G1896A precore mutation in 486 Spanish patients with acute and chronic HBV infection

This study aims to determine the prevalence of hepatitis B virus (HBV) genotypes (A-F) and their association with the G1896A precore mutation in 486 patients positive for HBV surface antigen. Genotypes were determined by RFLP and precore mutation by real-time PCR. Genotypes D (48.1%) and A (39.5%) were the most common, followed by F (4.1%) and B, C and E (<1%). The A to D ratio (A:D) was 1.4 in HBeAg+ chronic hepatitis B (CHB), 0.6 in HBeAg- CHB and 1.4 in HBeAg- inactive carriers. Distribution of these genotypes was different between HBeAg+ CHB and HBeAg- CHB (P = 0.02), and between HBeAg- CHB and HBeAg- inactive carriers (P = 0.009). Genotype A was the most prevalent in HBeAg+ CHB with elevated alanine aminotransferase (ALT) (68.6%) and genotype D in HBeAg+ CHB with fluctuating ALT (60.7%). There was a difference in genotype prevalence between chronic and acute infection (P = 0.03). The precore mutant correlated with high levels of HBV-DNA in genotype d HBeAg- CHB. Genotype D is not as highly prevalent in Spanish patients as would be expected in a Mediterranean area. The unequal prevalence of genotypes between acute and chronic infection suggests that genotype A is associated with a higher tendency to cause chronic infection.

Genotype-phenotype correlation for pulmonary function in cystic fibrosis

BACKGROUND

Since the CFTR gene was cloned, more than 1000 mutations have been identified. To date, a clear relationship has not been established between genotype and the progression of lung damage. A study was undertaken of the relationship between genotype, progression of lung disease, and survival in adult patients with cystic fibrosis (CF).

METHODS

A prospective cohort of adult patients with CF and two CFTR mutations followed up in an adult cystic fibrosis unit was analysed. Patients were classified according to functional effects of classes of CFTR mutations and were grouped based on the CFTR molecular position on the epithelial cell surface (I-II/I-II, I-II/III-V). Spirometric values, progression of lung disease, probability of survival, and clinical characteristics were analysed between groups.

RESULTS

Seventy four patients were included in the study. Patients with genotype I-II/I-II had significantly lower current spirometric values (p < 0.001), greater loss of pulmonary function (p < 0.04), a higher proportion of end-stage lung disease (p < 0.001), a higher risk of suffering from moderate to severe lung disease (odds ratio 7.12 (95% CI 1.3 to 40.5)) and a lower probability of survival than patients with genotype I-II/III, I-II/IV and I-II/V (p < 0.001).

CONCLUSIONS

The presence of class I or II mutations on both chromosomes is associated with worse respiratory disease and a lower probability of survival.

[Longitudinal study of hospital readmission for congestive heart failure in Cataluña. 1996-1999]

BACKGROUND

This study is aimed at describing the readmission phenomenon for heart failure patients and identifying some of their related clinical factors by means of a follow-up study with administrative data.

METHODS

Longitudinal study of readmissions due to heart failure (HF) among a population > or = age 65 in Catalonia throughout the 1996-1999 period. Information source: Minimum Basic Set of Data of Hospital Discharges from the Catalan Health Service. Definition of HF, etiological or precipitating cause, and comorbility by means of a ICD-9 discharge release codes combination. Analysis units "patient with HF" and an index population or cohort".

STATISTICS

Survival analysis (Kaplan-Meier and Log-rank test) and regression models (Cox).

RESULTS

The follow-up populations, comprised of 16,919 patients, generated 44,283 admissions (61.8%). The length of time free of readmissions (Mean "ME" in months) and the comparison of the survival curves is statistically significant with lower values in the following categories: 'age 65-74' (ME = 21.6 months); 'male' (23.3); 'healthcare region 6' (16.3); 'reference hospital' (22.9) and 'pure COPD related to the HF (17.7),. The highest risk of readmission, adjusted by the other variables under study, has been found for 'pure COPD' [RR = 1.03, (95% CI: 1.02-1.04), p < 0.001], and ischaemic heart disease [RR = 1.03, (95% CI: 1.01-1.05), p = 0.003].

CONCLUSIONS

This study reveals the clinical complexity and patterns of utilization of hospitals on the part of patients with heart failure, identifying that those having COPD or ischaemic heart disease being top-priority groups for care intervention and thus revealing the potential which administrative data has for clinical planning and management.

Peripheral neuropathy associated with monoclonal IgG of undetermined significance: clinical, electrophysiologic, pathologic and therapeutic study of 14 cases

Fourteen patients with peripheral neuropathy and monoclonal IgG of undetermined significance are reported with a retrospective study of the clinical features, electrophysiologic and sural nerve biopsy findings. There were two groups. Five patients had a relapsing chronic sensorimotor polyneuropathy with clinical (5/5), electrophysiologic (4/5) and pathologic (5/5) features compatible with chronic inflammatory demyelinating polyneuropathies (CIDP). The nine others had a slowly progressive sensory (5/9) (SPNP) or sensorimotor (4/9) (SMPNP) axonal polyneuropathy. Four patients of the first group were treated with intravenous human immunoglobulin (400 mg/kg/day for five days) with significant clinical improvement. The motor conduction velocities and distal latencies of two of these patients improved following treatment, thus matching the clinical improvement. Our results on peripheral nerve biopsies confirm the differentiation of patients with CIDP from those with SMPNP and SPNP. There was no specific immunologic serologic reactivity in any of the cases.

Chronic inflammatory demyelinating polyneuropathy associated with dysglobulinemia: a peripheral nerve biopsy study in 18 cases

The possible occurrence of chronic inflammatory demyelinating polyneuropathy (CIDP) in association with an identified dysglobulinemic status is recognized and a causal relationship between the two has been suggested. We had the opportunity to study 18 patients presenting with CIDP and dysglobulinemia. This was an IgG monoclonal gammopathy (IgG MG) in 8 cases, an IgM monoclonal gammopathy (IgM MG) in 8, an IgG-IgM biclonal gammopathy in 1 case and an IgM monoclonal cryoglobulinemia in another. A peripheral nerve biopsy specimen was available for all patients and the morphological findings in these specimens in the cases of CIDP with IgG MG or cryoglobulin did not differ from those without, whereas characteristic features were observed in the cases of CIDP with IgM MG and anti-myelin associated glycoprotein activity.

[Case of superficial hemosiderosis of the central nervous system treated with trientine]

A 58-year-old woman, with recurrent headaches, exhibited cerebellar alaxic gait, anosmia, deafness and a pyramidal syndrome, with a progressive onset. In cerebrospinal fluid there was erythrocytes and siderophages. MRI on T2-weighted images revealed a marginal hypo-intensity, leading to the diagnostic of superficial siderosis of the central nervous system. None haemorragic lesion was found. The patient was given Trientine. Unfortunately she worsened on later examinations.

[Multineuritis in essential hypereosinophilia syndrome]

A 72-old-man with a dramatic weight loss, exhibited a mononeuritis multiplex of subacute onset, and myalgia. There was hypoesthesia and weakness on median and ulnar nerves bilaterally, and weakness on left femoral nerve. Electrodiagnostical studies showed an axonal pattern of neuropathy. There was a considerable hypereosinophilia on blood count without any aetiologia found on exhaustive explorations. The idiopathic hypereosinophilic syndrome with a mononeuritis multiplex was suggested. Histological findings were an acute myelino-axonal degeneration with endoneural oedema, without vasculitis nor eosinophil cell on nerve-biopsy. Dramatic improvement occurred with corticosteroids and immunosuppressive treatment.

[Localized muscular hypertrophy in a familial form of sarcoidosis]

Muscular hypertrophy, rarely reported in muscular sarcoidosis, is usually associated with the myositic, myopathic and nodular types. We report a case with an isolated localised muscular hypertrophy simulating a tumor formation developed after repetitive efforts, in a familial context of sarcoidosis. MRI shows muscular high intensity lesions in the thighs and calves, and after treatment, central areas of low intensity signal. Muscular biopsy confirms diagnosis of sarcoidosis. Gallium-67 scintigraphy shows systemic extension of disease. This case highlights the usefulness of recent imaging techniques in diagnostic strategy and follow up.