Sexually transmitted infections, the epidemic that persists after the COVID-19 pandemic: an analysis of the primary care electronic health records covering about 5 million people in Catalonia

BACKGROUND

The aim of our study is to analyse the trends in the diagnosis of sexually transmitted infections (STIs) during the COVID-19 pandemic.

METHODS

We conducted an observational retrospective population-based study using data from primary care electronic health records spanning from January 2016 to December 2022 (involving 5.1 million people older than 14 years). We described the daily number of new STI diagnoses from 2016 to 2022; as well as the monthly accumulation of new STI diagnoses for each year. We compared the monthly averages of new diagnoses in 2019, 2020, 2021 and 2022 using the T-test. Finally, we performed a segmented regression analysis of the daily number of STI diagnoses.

RESULTS

We analysed 200,676 new STI diagnoses. The number of diagnoses abruptly decreased coinciding with the lockdown. Overall in 2020, we observed a reduction of 15%, with higher reductions for specific STIs such as gonorrhoea (-21%), chlamydia (-24%), and HIV (-31%) compared to 2019. Following this drastic drop, which was temporarily associated with the lockdown, we observed a rapid rebound. In 2021, the number of STI diagnoses was similar to that of 2019. Notably, we found a considerable increase in 2022, particularly for non-specific STI, which lack laboratory confirmation (67% increase). HIV was the only STI with a reduction of up to -38% in diagnoses at the end of 2022 compared to 2019.

CONCLUSIONS

After a significant reduction in 2020, the number of STIs recorded in primary care rapidly rebounded, and the current trend is similar to that of 2019, except for HIV. These findings underscore the dynamic impact of the COVID-19 pandemic on STI diagnoses and highlight the importance of ongoing monitoring and public health interventions in the post-pandemic period.

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.

"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.

[SARS-CoV-2 infection in occupational settings in Catalonia.]

OBJECTIVE

The aim of this paper was to estimate the SARS-CoV-2 infection incidence regarding the occupation in Catalonia, globally and in the different waves of the pandemic.

METHODS

We performed a retrospective cohort study. We included all people between 16 and 65 years old with an occupation identified from the sick leave recorded in the primary care electronic health records of the Institut Català de la Salut (ICS) (total n=2,199,745 people). The study period was from March 1^st, 2020 to September 16^th, 2021.

RESULTS

Healthcare workers had the highest incidence, with an age and sex adjusted cumulative rate of 27.7% [95% CI: 27.3%-28.1%]: 29.4% in nursing assistants, 27.3% in medical professions and 26.3% in nursing professionals; followed by the elementary occupations group with an adjusted incidence of 16.9% [95% CI: 16.7%-17%], such as the agricultural laborers (23% [95% CI: 21%-25.1%]) and rural occupations (19.1% [95% CI: 18.3%-19.8%) -especially during the 2020 summer period-, the domestic employees (20.5% [95% CI: 18.9%-22.2%]) and cleaning professionals (17.5% [95% CI: 17.2%-17.9%]).

CONCLUSIONS

Healthcare workers are the hardest hit during the pandemic. On the other hand, the less qualified professions have high incidences, highlighting the different inequities in access to telework, working conditions and other social determinants of health.

Respiratory Syncytial Virus Infections in Young Children Presenting to Primary Care in Catalonia During the COVID-19 Pandemic

We observed an unusual pattern of respiratory syncytial virus (RSV) in children under 5 years in Catalonia (Spain). We observed a near absence of RSV during winter months and a subsequent surge during the late spring. Primary care electronic health records combined with hospital RSV laboratory confirmation could be used to monitor trends of respiratory pathogens.

Association between the reduction of face-to-face appointments and the control of patients with type 2 diabetes mellitus during the Covid-19 pandemic in Catalonia

AIM

To analyse the relation between face-to-face appointments and management of patients with type 2 diabetes mellitus (T2DM) visited in primary care practices (PCP).

METHODS

Retrospective study in 287 primary care practices (PCPs) attending>300,000 patients with T2DM. We analysed the results of 9 diabetes-related indicators of the Healthcare quality standard, comprising foot and retinopathy screening, blood pressure (BP) and glycemic control; and the incidence of T2DM. We calculated each indicator's percentage of change in 2020 with respect to the results of 2019.

RESULTS

Indicators' results were reduced in 2020 compared to 2019, highlighting the indicators of foot and retinopathy screening (-51.6% and -25.7%, respectively); the glycemic control indicator (-21.2%); the BP control indicator (-33.7%) and the incidence of T2DM (-25.6%). Conversely, the percentage of type 2 diabetes patients with HbA1c > 10% increased by 34%. PCPs with<11 weekly face-to-face appointments offered per professional had greater reductions than those PCPs with more than 40. For instance, a reduction of -60.7% vs -38.2% (p-value < 0.001) in the foot screening's indicator; -27.5% vs -12.5% (p-value < 0.001) in glycemic control and -40.2 vs -24.3% (p-value < 0.001) in BP control.

CONCLUSIONS

Reducing face-to-face visits offered may impact T2DM patients' follow-up and thus worsen their control.

Impact of the COVID-19 pandemic and related control measures on cancer diagnosis in Catalonia: a time-series analysis of primary care electronic health records covering about five million people

OBJECTIVE

Cancer care has been disrupted by the response of health systems to the COVID-19 pandemic, especially during lockdowns. The objective of our study is to evaluate the impact of the pandemic on the incidence of cancer diagnoses in primary care.

DESIGN

Time-series study of malignant neoplasms and diagnostic procedures, using data from the primary care electronic health records from January 2014 to September 2020.

SETTING

Primary care, Catalonia, Spain.

PARTICIPANTS

People older than 14 years and assigned in one of the primary care practices of the Catalan Institute of Health with a new diagnosis of malignant neoplasm.

MAIN OUTCOME MEASURES

We obtained the monthly expected incidence of malignant neoplasms using a temporary regression, where the response variable was the incidence of cancer from 2014 to 2018 and the adjustment variables were the trend and seasonality of the time series. Excess or lack of malignant neoplasms was defined as the number of observed minus expected cases, globally and stratified by sex, age, type of cancer and socioeconomic status.

RESULTS

Between March and September 2020 we observed 8766 (95% CI 4135 to 13 397) fewer malignant neoplasm diagnoses, representing a reduction of 34% (95% CI 19.5% to 44.1%) compared with the expected. This underdiagnosis was greater in individuals aged older than 64 years, men and in some types of cancers (skin, colorectal, prostate). Although the reduction was predominantly focused during the lockdown, expected figures have not yet been reached (40.5% reduction during the lockdown and 24.3% reduction after that).

CONCLUSIONS

Reduction in cancer incidence has been observed during and after the lockdown. Urgent policy interventions are necessary to mitigate the indirect effects of the COVID-19 pandemic and related control measures on other diseases and some strategies must be designed in order to reduce the underdiagnosis of cancer.

Influence of organization and demographic characteristics of primary care practices on continuity of care: analysis of a retrospective cohort from 287 primary care practices covering about 6 million people in Catalonia

Background

There is evidence that an ongoing patient-physician relationship is associated with improved health outcomes and more efficient health systems. The main objective of this study is to describe the continuity of care in primary healthcare in Catalonia (Spain) and to analyze whether the organization of primary care practices (PCP) or their patients’ sociodemographic characteristics play a role in its continuity of care.

Methods

Four indices were used to measure continuity of care: Usual Provider Index (UPC), Modified Modified Continuity Index (MMCI), Continuity of Care Index (COC), and Sequential Continuity Index (SECON). The study was conducted on 287 PCP of the Catalan Institute of Health (Institut Català de la Salut—ICS). Each continuity of care index was calculated at the patient level (3.2 million patients and 35.5 million visits) and then aggregated at the PCP level. We adjusted linear regression models for each continuity index studied, considering the result of the index as an independent variable and demographic and organizational characteristics of the PCP as explanatory variables. Pearson correlation tests were used to compare the four continuity of care indices.

Results

Indices’ results were: UPC: 70,5%; MMCI: 73%; COC: 53,7%; SECON: 60,5%. The continuity of care indices had the highest bivariate correlation with the percentage of appointments booked with an assigned health provider (VISUBA variable: the lower the value, the higher the visits without an assigned health provider, and thus an organization favoring immediate consultation). Its R² ranged between 56 and 63%, depending on the index. The multivariate model which explained better the variability of continuity of care indices (from 49 to 56%) included the variables VISUBA and rurality with a direct relationship; while the variables primary care physician leave days and training practices showed an inverse relationship.

Conclusion

Study results suggest that an organization of primary care favoring immediate consultation is related to a lower continuity of patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01414-y.

Divergences on expected pneumonia cases during the COVID-19 epidemic in Catalonia: a time-series analysis of primary care electronic health records covering about 6 million people

BACKGROUND

Pneumonia is one of the complications of COVID-19. Primary care electronic health records (EHR) have shown the utility as a surveillance system. We therefore analyse the trends of pneumonia during two waves of COVID-19 pandemic in order to use it as a clinical surveillance system and an early indicator of severity.

METHODS

Time series analysis of pneumonia cases, from January 2014 to December 2020. We collected pneumonia diagnoses from primary care EHR, a software system covering > 6 million people in Catalonia (Spain). We compared the trend of pneumonia in the season 2019-2020 with that in the previous years. We estimated the expected pneumonia cases with data from 2014 to 2018 using a time series regression adjusted by seasonality and influenza epidemics.

RESULTS

Between 4 March and 5 May 2020, 11,704 excess pneumonia cases (95% CI: 9909 to 13,498) were identified. Previously, we identified an excess from January to March 2020 in the population older than 15 years of 20%. We observed another excess pneumonia period from 22 october to 15 november of 1377 excess cases (95% CI: 665 to 2089). In contrast, we observed two great periods with reductions of pneumonia cases in children, accounting for 131 days and 3534 less pneumonia cases (95% CI, 1005 to 6064) from March to July; and 54 days and 1960 less pneumonia cases (95% CI 917 to 3002) from October to December.

CONCLUSIONS

Diagnoses of pneumonia from the EHR could be used as an early and low cost surveillance system to monitor the spread of COVID-19.

Filling the gaps in the characterization of the clinical management of COVID-19: 30-day hospital admission and fatality rates in a cohort of 118 150 cases diagnosed in outpatient settings in Spain

BACKGROUND

Currently, there is a missing link in the natural history of COVID-19, from first (usually milder) symptoms to hospitalization and/or death. To fill in this gap, we characterized COVID-19 patients at the time at which they were diagnosed in outpatient settings and estimated 30-day hospital admission and fatality rates.

METHODS

This was a population-based cohort study.

Data were obtained from Information System for Research in Primary Care (SIDIAP)-a primary-care records database covering >6 million people (>80% of the population of Catalonia), linked to COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) tests and hospital emergency, inpatient and mortality registers. We included all patients in the database who were ≥15 years old and diagnosed with COVID-19 in outpatient settings between 15 March and 24 April 2020 (10 April for outcome studies). Baseline characteristics included socio-demographics, co-morbidity and previous drug use at the time of diagnosis, and polymerase chain reaction (PCR) testing and results.

Study outcomes included 30-day hospitalization for COVID-19 and all-cause fatality.

RESULTS

We identified 118 150 and 95 467 COVID-19 patients for characterization and outcome studies, respectively. Most were women (58.7%) and young-to-middle-aged (e.g. 21.1% were 45-54 years old). Of the 44 575 who were tested with PCR, 32 723 (73.4%) tested positive. In the month after diagnosis, 14.8% (14.6-15.0) were hospitalized, with a greater proportion of men and older people, peaking at age 75-84 years. Thirty-day fatality was 3.5% (95% confidence interval: 3.4% to 3.6%), higher in men, increasing with age and highest in those residing in nursing homes [24.5% (23.4% to 25.6%)].

CONCLUSION

COVID-19 infections were widespread in the community, including all age-sex strata. However, severe forms of the disease clustered in older men and nursing-home residents. Although initially managed in outpatient settings, 15% of cases required hospitalization and 4% died within a month of first symptoms. These data are instrumental for designing deconfinement strategies and will inform healthcare planning and hospital-bed allocation in current and future COVID-19 outbreaks.

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.

Substrate-controlled Michael additions of chiral ketones to enones

Substrate-controlled Michael additions of the titanium(IV) enolate of lactate-derived ketone 1 to acyclic α,β-unsaturated ketones in the presence of a Lewis acid (TiCl4 or SnCl4) provide the corresponding 2,4-anti-4,5-anti dicarbonyl compounds in good yields and excellent diastereomeric ratios. Likely, the nucleophilic species involved in such additions are bimetallic enolates that may add to enones through cyclic transition states. Finally, further studies indicate that a structurally related β-benzyloxy chiral ketone can also participate in such stereocontrolled conjugate additions.

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.

A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care

AIMS

To compare the effectiveness of care delivered by nurses to the usual care delivered by general practitioners, in adult patients requesting same day appointments in primary care practices in Catalonia (Spain).

BACKGROUND

Same day appointments conducted by nurses are characterized by high patient satisfaction and a high resolution index. The profile of nursing and the organization of primary care services in our country differ from other countries.

DESIGN

Multicentre, randomized, unblinded clinical trial with two parallel groups.

METHODS

Patients were randomized to an intervention group (seen by nurses trained to respond to low complexity problems) or a control group (seen by the general practitioner) using an automatic probabilistic function.

SETTING

38 primary care practices in Catalonia, 142 general practitioners and 155 nurses participated. Population study: ≥ 18-year-old patients who requested a same day consultation. Recruitment period: January-May, 2009. Of the 1,461 randomized patients, 92.5% completed the study.

MAIN OUTCOME MEASURES

resolution of symptoms and patient satisfaction 2 weeks after the visit.

RESULTS

Seven hundred and fifty-three patients were assigned to the intervention group and 708 to the control group. Nurses successfully solved 86.3% of the cases. We did not observe any differences in resolution of symptoms or patient satisfaction between the groups.

CONCLUSIONS

Nurses trained specifically to resolve acute health problems of low complexity give comparable quality of care to that provided by general practitioners in terms of resolution of the problem 15 days after the visit and in patient satisfaction with the visit.

[Cognitive, phonemic or temporal processing?]

INTRODUCTION

Cognitive, temporal and phonemic processing are different terms applied to language and, in particular, reading- writing processing.

OBJECTIVE

To test whether temporal, phonemic, and cognitive processing are interrelated. Methods. After medical screening, 36 subjects with phonemic difficulties, 7 to 14 years-old, boy/ girl ratio of 2:1, were selected with phonemic processing tests. For every subject, two normal controls were also selected with the same phonemic tests. DN:CAS cognitive battery for diagnosing of cognitive processing was administered to the subjects and both subjects and controls were examined with an acoustic temporal processing test made in laboratory. This consisted of two kinds of items, syllables with transition period of 40 milliseconds and another longer one. Proportions and means were statistically analyzed. Factorial analysis was applied to scores in DN:CAS and syllabic acoustic tests.

RESULTS

When compared to the controls, the subjects made more errors in the acoustic test (z=6.73; p<0.000). The DN:CAS mean obtained by the subjects was lower than the standardized group (t=6.73; p=0.001). The factorial analysis accounting for 77% of the variance identified the acoustic test as a sequential processing test.

CONCLUSIONS

Arguments are presented that suggest that phonemic, temporal, and cognitive processing may be different expressions of the same central neurological mechanism regardless of the age. This implies diagnostic and therapeutic considerations. On the other hand, the acoustic test is suggested as a useful test in assessing cognitive function.

Safety of intramuscular influenza vaccine in patients receiving oral anticoagulation therapy: a single blinded multi-centre randomized controlled clinical trial

Background

Influenza vaccines are recommended for administration by the intramuscular route. However, many physicians use the subcutaneous route for patients receiving an oral anticoagulant because this route is thought to induce fewer hemorrhagic side effects. Our aim is to assess the safety of intramuscular administration of influenza vaccine in patients on oral anticoagulation therapy.

Methods

Design: Randomised, controlled, single blinded, multi-centre clinical trial. Setting: 4 primary care practices in Barcelona, Spain. Participants: 229 patients on oral anticoagulation therapy eligible for influenza vaccine during the 2003–2004 season. Interventions: intramuscular administration of influenza vaccine in the experimental group (129 patients) compared to subcutaneous administration in the control group (100 patients). Primary outcome: change in the circumference of the arm at the site of injection at 24 hours. Secondary outcomes: appearance of local reactions and pain at 24 hours and at 10 days; change in INR (International Normalized Ratio) at 24 hours and at 10 days. Analysis was by intention to treat using the 95% confidence intervals of the proportions or mean differences.

Results

Baseline variables in the two groups were similar. No major side effects or major haemorrhage during the follow-up period were reported. No significant differences were observed in the primary outcome between the two groups. The appearance of local adverse reactions was more frequent in the subcutaneous administration group (37,4% vs. 17,4%, 95% confidence interval of the difference 8,2% to 31,8%).

Conclusion

This study shows that the intramuscular administration route of influenza vaccine in patients on anticoagulant therapy does not have more side effects than the subcutaneous administration route.

Registration number

NCT00137579 at clinicaltrials.gov