Primary care indicators for disease burden, monitoring and surveillance of COVID-19 in 31 European countries: Eurodata Study.

BACKGROUND: During the COVID-19 pandemic, the majority of patients received ambulatory treatment, highlighting the importance of primary health care (PHC). However, there is limited knowledge regarding PHC workload in Europe during this period. The utilization of COVID-19 PHC indicators could facilitate the efficient monitoring and coordination of the pandemic response. The objective of this study is to describe PHC indicators for disease surveillance and monitoring of COVID-19's impact in Europe. METHODS: Descriptive, cross-sectional study employing data obtained through a semi-structured ad hoc questionnaire, which was collectively agreed upon by all participants. The study encompasses PHC settings in 31 European countries from March 2020 to August 2021. Key-informants from each country answered the questionnaire. Main outcome: the identification of any indicator used to describe PHC COVID-19 activity. RESULTS: Out of the 31 countries surveyed, data on PHC information were obtained from 14. The principal indicators were: total number of cases within PHC (Belarus, Cyprus, Italy, Romania and Spain), number of follow-up cases (Croatia, Cyprus, Finland, Spain and Turkey), GP's COVID-19 tests referrals (Poland), proportion of COVID-19 cases among respiratory illnesses consultations (Norway and France), sick leaves issued by GPs (Romania and Spain) and examination and complementary tests (Cyprus). All COVID-19 cases were attended in PHC in Belarus and Italy. CONCLUSIONS: The COVID-19 pandemic exposes a crucial deficiency in preparedness for infectious diseases in European health systems highlighting the inconsistent recording of indicators within PHC organizations. PHC standardized indicators and public data accessibility are urgently needed, conforming the foundation for an effective European-level health services response framework against future pandemics.

The role of primary health care in long-term care facilities during the COVID-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study).

BACKGROUND AND AIM: Primary health care (PHC) supported long-term care facilities (LTCFs) in attending COVID-19 patients. The aim of this study is to describe the role of PHC in LTCFs in Europe during the early phase of the pandemic. METHODS: Retrospective descriptive study from 30 European countries using data from September 2020 collected with an ad hoc semi-structured questionnaire. Related variables are SARS-CoV-2 testing, contact tracing, follow-up, additional testing, and patient care. RESULTS: Twenty-six out of the 30 European countries had PHC involvement in LTCFs during the COVID-19 pandemic. PHC participated in initial medical care in 22 countries, while, in 15, PHC was responsible for SARS-CoV-2 test along with other institutions. Supervision of individuals in isolation was carried out mostly by LTCF staff, but physical examination or symptom's follow-up was performed mainly by PHC. CONCLUSION: PHC has participated in COVID-19 pandemic assistance in LTCFs in coordination with LTCF staff, public health officers, and hospitals.

Unique contributions of specific neuropsychiatric symptoms to caregiver burden in informal caregivers family members of patients with dementia.

INTRODUCTION: We aimed to evaluate how the presence of individual neuropsychiatric symptoms in non-institutionalised patients with dementia is associated with caregiver burden of their informal caregivers, family members. METHODS: We performed a cross-sectional study on a total of 131 pairs of one informal caregiver family member and non-institutionalised patient with dementia in a family medicine practices in a city of Zagreb, Croatia. Caregiver measures included Zarit Burden Interview (ZBI) whereas patient measures included Mini mental state examination (MMSE), Barthel index and Neuropsychiatric Inventory Questionnaire (NPI-Q). RESULTS: Total NPI-Q score explained 21% of overall burden. In order of strength of the association, after adjustments for age, sex, MMSE and Barthel index, overall burden was significantly associated with higher NPI-Q scores for agitation/aggression, apathy/indifference, irritability/lability, disinhibition, motor disturbance, appetite/eating, depression/dysphoria, anxiety, elation/euphoria and nighttime behaviours. When evaluating mutually independent contribution of unique NPI-Q symptoms to caregiver burden, agitation/aggression and apathy/indifference remained only two mutually independently associated symptoms, each explaining 5% of overall burden in this context. CONCLUSIONS: Informal caregivers who provide for family members with dementia suffering from agitation/aggression or apathy/indifference should be recognised as under special risk for the development of caregiver burden and considered as candidates for early targeted interventions.

Share of and Absolute Costs of Informal Care in Five Subpopulations of Outpatients with Dementia in Croatia: A Latent Profile Analysis.

BACKGROUND: High heterogeneity exists in estimates of the share of and absolute costs of informal care (IC) for individuals diagnosed with dementia. OBJECTIVE: To assess the differences in the share of and absolute costs of IC between subpopulations defined by latent profiles of activities of daily living (ADLs), neuropsychiatric symptoms, and global cognitive functioning. METHODS: We performed a nested cross-sectional analysis of data collected from 2019-2021 at the Zagreb-Zapad Health Center, Zagreb, Croatia, from a sample of patients and their caregivers. The outcome was the share of costs of IC in the total costs of care estimated using the Resource Utilization in Dementia questionnaire. We used latent profile analysis of six principal components of the Alzheimer's Disease Cooperative Study ADLs inventory, Neuropsychiatric Inventory and Mini-Mental State Examination, and conducted the analysis using beta and quantile regression. RESULTS: We enrolled 240 patients with a median age of 74 years; 78% were women. The annual cost for treatment and care for one patient was 11,462 (95% confidence interval 9,947; 12,976) EUR. After the adjustment for covariates, five latent profiles were significantly associated with the share of costs and absolute cost of IC. The adjusted annual costs of IC ranged from 2,157 EUR, with a share of 53% in the first latent profile, to 18,119 EUR, with a share of 78% in the fifth latent profile. CONCLUSION: The population of patients with dementia was heterogeneous, and there were relatively large differences in the share and absolute costs of IC between particular subpopulations.

Vaccine uptake in caregivers family members and patients with dementia and relationship with severity of dementia and caregiver burden: a cross-sectional study.

We cross sectionally evaluated COVID-19 and seasonal flu vaccination rates among 94 dyads consisting of informal caregiver family member and non-institutionalized patient with dementia observed in family-medicine practice in Zagreb, Croatia. COVID-19 vaccination rates in caregivers (78.7%) and patients with dementia (82.9%) were significantly higher than in general population. Caregiver and patient COVID-19 vaccination status (CVS) did not correlate. Among caregivers, seasonal flu vaccination (P = 0.004) but no other investigated factors related to caregiving or dementia severity showed significant association with CVS. Among patients with dementia, CVS was significantly associated with lower number of caregiver hours dedicated per week (P = 0.017), higher caregiver SF-36 role emotional HRQoL (P = 0.017), younger patient age (P = 0.027), higher MMSE (P = 0.030), higher Barthel index (P = 0.006), absence of neuropsychiatric symptoms of agitation and aggression (P = 0.031), lower overall caregiver burden (P = 0.034), lower burden of personal strain (P = 0.023) and lower burden of frustration (P = 0.016). Caregiving and severity of dementia-related factors significantly affect patient, but not caregiver CVS.

Predictors of Health-Related Quality of Life in Informal Caregivers of Dementia Patients in Zagreb, Croatia, a Cross Sectional Study.

We aimed to estimate health-related quality of life (HRQoL) in family-member caregivers of patients with dementia in Croatia and to assess relevant predictors. A cross-sectional study in family medicine practices in Zagreb (Health Care Center Zagreb-West) was performed in period 10/2017-9/2018 and included 131 dyads consisting of a patient with dementia and one dominant informal caregiver. Patient measures included Mini-mental-state-examination (MMSE), Barthel-index and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Caregiver measures included 36-Item Short-Form-Health-Survey (SF-36), Zarit-Burden-Interview (ZBI) and structured questionnaire regarding general information on caregiver and patient. SF-36 is a reliable instrument to estimate HRQoL (Cronbach α ≥0.79 for all domains). Caregiver HRQoL was higher than reported in Croatian population in physical functioning (PF), role physical (RP), general health (GH), social functioning (SF) and role emotional (RE) domains. More pronounced neuropsychiatric symptoms in patient with dementia were associated with caregiver's lower HRQoL in vitality (VT) and mental health (MH) domains. Caregivers with higher caregiver burden assessed by ZBI had lower HRQoL in RP, bodily pain (BP), GH, VT, SF, RE and MH domains. In multivariate analyses, higher caregiver's burden was independent predictor of lower HRQoL in RP, VT, RE and MH domains. Neuropsychiatric symptoms and use of day-care service were recognized as independent predictors of lower HRQoL (in PF, BP and GH, SF, RE domains, respectively). Neuropsychiatric symptoms and caregiver burden are associated with HRQoL in caregivers of patients with dementia. Interventions including psychological support and learning of skills necessary to tackle individual problems may help in improvement of HRQoL.

A validation of the Croatian version of Zarit Burden Interview and clinical predictors of caregiver burden in informal caregivers of patients with dementia: a cross-sectional study.

AIM: To validate the Croatian version of the Zarit Burden Interview (ZBI) and to investigate the predictors of perceived burden. METHODS: This cross-sectional study involved 131 dyads of one informal caregiver family member and one patient with dementia visiting primary care practices (Health Care Center Zagreb-West; 10/2017-9/2018). Patient-related data were collected with the Mini-Mental-State-Examination, Barthel-index, and Neuropsychiatric-Inventory-Questionnaire (NPI-Q); caregiver-related data with the ZBI, and general information on caregivers and patients with a structured questionnaire. Principal-axis-factoring with varimax-rotation was used for factor analysis. RESULTS: The caregivers' mean age was 62.1±13 years. They were mostly women (67.9%) and patients' children (51.1%). Four dimensions of ZBI corresponding to personal strain, frustration, embarrassment, and guilt were assessed and explained 56% variance of burden. Internal consistency of ZBI (α=0.87) and its dimensions (α1=0.88, α2=0.83, α3=0.72, α4=0.75) was good. Stronger cognitive and functional impairment of patients was associated only with personal strain, whereas more pronounced neuropsychiatric symptoms and the need for daily care were associated with more dimensions. Longer caregiver education suppressed embarrassment and promoted guilt. Guilt was higher in younger caregivers, caregivers of female patients, patients' children, and non-retired caregivers. In multivariate analysis significant predictors of higher overall burden were male sex of the patient, higher NPI-Q, the need for daily-care services, shorter duration of caregiving, non-spouse relationship, higher number of hours caring per-week, and anxious-depressive symptoms in a caregiver. CONCLUSION: The Croatian version of ZBI is reliable and valid. Our data confirm that ZBI is a multidimensional construct. Caregivers may benefit from individually tailored interventions.

The development and appraisal of a tool designed to find patients harmed by falsely labelled, falsified (counterfeit) medicines.

BACKGROUND: Falsely labelled, falsified (counterfeit) medicines (FFCm's) are produced or distributed illegally and can harm patients. Although the occurrence of FFCm's is increasing in Europe, harm is rarely reported. The European Directorate for the Quality of Medicines & Health-Care (EDQM) has therefore coordinated the development and validation of a screening tool. METHODS: The tool consists of a questionnaire referring to a watch-list of FFCm's identified in Europe, including symptoms of their use and individual risk factors, and a scoring form. To refine the questionnaire and reference method, a pilot-study was performed in 105 self-reported users of watch-list medicines. Subsequently, the tool was validated under "real-life conditions" in 371 patients in 5 ambulatory and in-patient care sites ("sub-studies"). The physicians participating in the study scored the patients and classified their risk of harm as "unlikely" or "probable" (cut-off level: presence of ≥2 of 5 risk factors). They assessed all medical records retrospectively (independent reference method) to validate the risk classification and documented their perception of the tool's value. RESULTS: In 3 ambulatory care sites (180 patients), the tool correctly classified 5 patients as harmed by FFCm's. The positive and negative likelihood ratios (LR+/LR-) and the discrimination power were calculated for two cut-off levels: a) 1 site (50 patients): presence of two risk factors (at 10% estimated health care system contamination with FFCm's): LR + 4.9/LR-0, post-test probability: 35%; b) 2 sites (130 patients): presence of three risk factors (at 5% estimated prevalence of use of non-prescribed medicines (FFCm's) by certain risk groups): LR + 9.7/LR-0, post-test probability: 33%. In 2 in-patient care sites (191 patients), no patient was confirmed as harmed by FFCm's. The physicians perceived the tool as valuable for finding harm, and as an information source regarding risk factors. CONCLUSIONS: This "decision aid" is a systematic tool which helps find in medical practice patients harmed by FFCm's. This study supports its value in ambulatory care in regions with health care system contamination and in certain risk groups. The establishment of systematic communication between authorities and the medical community concerning FFCm's, current patterns of use and case reports may sustain positive public health impacts.

Reliability and validity of the Croatian version of Consultation and Relational Empathy (CARE) Measure in primary care setting.

AIM: To translate the Consultation and Relational Empathy (CARE) Measure into Croatian and validate the Croatian version of the questionnaire. METHODS: A cross-sectional study was conducted in July 2011 in 8 general practices (GP) in Croatia. Following two stages of translation, back-translation, and pilot testing, the Croatian version of the CARE was tested on 568 consecutive patients. RESULTS: Face validity was high, the number of missing values was low (9%), and the internal consistency (Cronbach's alpha) was 0.77. A principal component analysis of 10 CARE Measure items extracted two components with eigenvalues >1. These two components explained 43.6% of the total instrument variance. CONCLUSION: The Croatian version of the CARE Measure had acceptable reliability and face validity, but its intended component structure was not reproduced and further research is needed to understand its dimensionality.

[Concomitant use of statins and cytochrome P 450 inhibitors in Croatia]. / Ucestalost istodobne primjene statina s inhibitorima citokroma P 450 u Hrvatskoj.

It is known that coadministration of a statin and certain drugs that inhibit cytochrome P-450 may inhibit catabolism of statin, resulting in an increased concentration of statin in the blood and consequently, increased risk of certain side effects, e.g. myopathy. The aim of this study was to establish, for the first time, how many patients in Croatia concomitantly take statins with other drugs, and which drugs. Also, the aim was to determine how often statins are administered concomitantly with cytochrome P-450 inhibitors, and how many patients taking statin are therefore at increased risk of interactions and/or side effects. The data were collected from general practitioners' health records all over Croatia during July and August 2004. The data for patients who were prescribed any statin between June 1, 2003 and June 1, 2004 were analysed. The records of 882 patients were analysed, 446 (50.6%) women, 422 (47.8%) men and 14 (1.6%) of unidentified sex. The average age of women on statin was 65 years and of men 60 years. Of 882 patients, 772 patients (82%) were taking at least one more drug concurrently with statin. Of that number, 24% of patients concomitantly were taking one more drug, 20% two more drugs, 16% three more drugs, 10% four more drugs, 8% five more drugs and 3% six more drugs. The average number of other drugs prescribed together with statin was 2.1 +/- 1.59 in men and 2.2 +/- 1.71 in women. The average age of patients who were taking another drug together with a statin did not significantly differ from that of patients receiving only statin. There were regional differences in the number of drugs prescribed together with a statin. In Osijek, the average number of drugs prescribed with a statin was 2.4 +/- 1.80, in Zagreb 2.2 +/- 1.64, in Rijeka 2.0 +/- 1.60, and in Split 1.8 +/- 1.44. The number of drugs prescribed with a statin in rural areas was 2.0 +/- 1.58, in urban areas 2.1 +/- 1.63 and in semi-urban areas 2.8 +/- 1.85. The therapeutic groups of drugs that are most frequently prescribed with a statin in Croatia are ACE inhibitors and their fixed combinations (32%), beta-receptor blockers and their fixed combinations (23%), selective calcium channel blockers (18%), anxiolytics (18%), vasodilators and organic nitrates (16%), antirheumatic drugs (11%), oral antidiabetics (11%), vitamin K antagonists, analgesics-antipyretics, diuretics (10%), antibiotics (8%), and angiotensin II antagonists and their fixed combinations (5%). All other drugs accounted for less than 5%. Four percent of the patients take cytochrome P-450 inhibitors concomitantly with a statin. The most frequently used drug is verapamil, combination of verapamil and trandolapril, clarithromycin and diltiazem. Consequently, 3% of men and 5% of women are at increased risk of side effects. This sex difference is, however, not statistically significant. Patients between 70 and 74 years of age taking statins are in Croatia at the highest risk of interactions because 8% of them take concomitantly cytochrome P 450 inhibitors.