Heart Failure and Major Adverse Cardiovascular Events in Atrial Fibrillation Patients: A Retrospective Primary Care Cohort Study.

BACKGROUND: Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with an increased risk of major adverse cardiovascular events (MACE). The main goal was to analyze the links and associations between AF and MACE. METHODS: A multicenter, observational, retrospective, community-based study of a cohort (n = 40,297) of the general population aged 65-95 years between 1 January 2015 and 31 December 2021 without a previous diagnosis of AF or MACE in the Primary Care setting. RESULTS: 2574 people (6.39%) developed a first AF event, resulting in an overall incidence of 8.9/1000 people-years [CI95% 8.6-9.2]. The incidence of MACE among those with AF was 75.1/1000 people-years [CI95% 70.8-79.5], whereas among those without AF, it was 20.6/1000 people-years [CI 95% 20.2-21.1], resulting in a rate ratio of 3.65 [CI 95% 3.43-3.88, p < 0.001]. Besides, the incidence of HF with AF was 40.1 people-years [CI 95% 37.1-43.2], while in the group without AF, it was 8.3 people-years [CI 95% 7.9-8.6, p < 0.001], with a rate ratio of 4.85 [CI 95% 4.45-55.3, p < 0.001]. Before an AF diagnosis, there is already a higher risk of chronic kidney disease, ischemic cardiopathy, and peripheral artery disease. A higher risk of poor nutritional status was detected among those with MACE (49.7% vs. 26.6%, p < 0.001). CONCLUSIONS: AF diagnosis increases the incidence of heart failure fourfold. Additional information is required to establish the connection between AF, major adverse cardiovascular events, and nutritional status.

Risk of Dependency: A Challenge for Health and Social Care Planning-Observational Stroke Cohort.

BACKGROUND: After a stroke, families require the coordinated assistance of health and social care. Currently there is a lack of comprehensive evaluation and assessment tools to identify discharge needs, and there is separate management of health and social resources, and access to these services is variable between regions. OBJECTIVE: The main objective of this study was to assess the factors associated with risk of dependency after stroke and propose a suitable instrument for identifying patients at higher risk. METHODS: This was a 2-year prospective and community study of a stroke cohort. The primary outcome was recognized dependency. The potential predictors were considered in a multivariate regression and area under curve (AUC) to evaluate its discriminative capacity. RESULTS: Overall, 233 stroke survivors were recruited, 49.8% of whom were women, and the average age was 78.1 ± 11.6 years. The total rate of dependency was 31.5 (95% confidence interval [CI] 26.1-37.7) cases/100 person-years. The independent factors associated with dependency outcome were age >80 years (hazard ratio [HR] 2.03, 95% CI 1.32-3.12, P = .001), Pfeiffer score ≥4 (HR 1.82, 95% CI 1.25-1.2.66, P = .002), Barthel score <60 (HR 1.79, 95% CI 1.21-2.66, P = .003), and Charlson score ≥3 (HR 1.49, 95% CI 1.02-2.16, P = .039). The AUC was 0.84 (95% CI 0.79-0.89; P < .001). CONCLUSIONS: Stroke has serious effects on the dependency outcomes. The patient's age, cognitive or physical impairment, and comorbidities as measured on the Pfeiffer score, Barthel Index, and Charlson score identified people at high risk and may ease the integrated role of social and health services.

Mortality and Cardiovascular Complications in Older Complex Chronic Patients with Type 2 Diabetes.

AIMS/INTRODUCTION: Determining the prevalence of diabetes and its cardiovascular complications and all-cause mortality in older chronic complex patients. MATERIALS AND METHODS: We carried out a multicenter retrospective study and included a randomized sample of 932 CCP people. We assessed the prevalence of diabetes according to World Health Organization criteria. Data included demographics and functional, comorbidity, cognitive, and social assessment. RESULTS: The prevalence of diabetes was 53% and average age 81.16 ± 8.93 years. There were no significant differences in the survival of CCP patients with or without DM, with or without ischaemic cardiopathy, and with or without peripheral vascular disease. The prognostic factors of all-cause mortality in patients with DM were age ≥ 80 years [HR 1.47, 95% CI 1.02-2.13, p 0.038], presence of heart failure [HR 1.73, 95% CI 1.25-2.38, p 0.001], Charlson score [HR 1.20, 95% CI 1.06-1.36, p 0.003], presence of cognitive impairment [HR 1.73, 95% CI 1.24-2.40, p 0.001], and no treatment with statins [HR 1.49, 95% CI 1.08-2.04, p 0.038]. CONCLUSIONS: We found high prevalence of DM among CCP patients and the relative importance of traditional risk factors seemed to wane with advancing age. Recommendations may include relaxing treatment goals, providing family/patient education, and enhanced communication strategies.

[Incidence and preventability of haemorrhagic strokes. Results of the Ebrictus register]. / Incidencia y evitabilidad de los ictus hemorragicos. Resultados del registro Ebrictus.

AIM: To determine the population incidence of intracerebral haemorrhage and its preventable incidence, associated risk factors and prognosis of death and disability. SUBJECTS AND METHODS: We examined a sample of 240 consecutive patients with a first episode of intracerebral haemorrhage between 1st April 2006 and 30th June 2015. The main variables are: NIHSS scale, comorbidity, pharmacological information, Barthel index, Rankin scale, time within therapeutic window, prognosis and destination on hospital discharge. The 'unnecessarily premature and sanitarily avoidable mortality' (MIPSE) classification was applied to define the cases as 'preventable incidence'. RESULTS: The rate of population incidence of haemorrhagic cerebrovascular disease was 23.5 cases per 100,000 inhabitants/year; an exponential increase occurred from the age of 55 years in males and 75 years in females. The rate ratio was 0.682. The preventable incidence would account for 66.6% of all the cases in those under 75 years of age and 22.7% in those aged 75 or over. The chances of survival and functional autonomy were significantly lower in females, and age, anticoagulant treatment, the presence of polymedication and treatment with serotonin reuptake inhibitor antidepressants were factors that were independent of the prognosis. CONCLUSIONS: The incidence of haemorrhagic cerebrovascular disease does not appear to be modified within the period, but just the opposite occurs with the factors associated according to sex and age. According to the MIPSE classification, the preventability of haemorrhagic cerebrovascular disease could be as high as 36%.

TITLE: Incidencia y evitabilidad de los ictus hemorragicos. Resultados del registro Ebrictus.Objetivo. Conocer la incidencia poblacional de la hemorragia intracerebral y su incidencia evitable, factores de riesgo asociados y pronostico de muerte y discapacidad. Sujetos y metodos. Muestra de 240 pacientes consecutivos con un primer episodio de hemorragia intracerebral entre el 1 de abril de 2006 y el 30 de junio de 2015. Las variables principales son: escala NIHSS, comorbilidad, informacion farmacologica, indice de Barthel, escala de Rankin, tiempo en rango terapeutico, pronostico y destino al alta hospitalaria. Se aplico la clasificacion 'mortalidad innecesariamente prematura y sanitariamente evitable' (MIPSE) para definir los casos como 'incidencia evitable'. Resultados. La tasa de incidencia poblacional de enfermedad cerebrovascular hemorragica fue de 23,5 casos por 100.000 habitantes/año; se produjo un incremento exponencial a partir de los 55 años en hombres y 75 años en mujeres. La razon de tasas fue de 0,682. La incidencia evitable significaria el 66,6% de todos los casos en los menores de 75 años y el 22,7% en aquellos con 75 o mas años. La probabilidad de supervivencia y la autonomia funcional fueron significativamente inferiores en las mujeres, y la edad, el tratamiento anticoagulante, la presencia de polimedicacion y el tratamiento con antidepresivos inhibidores de la recaptacion de serotonina fueron factores independientes del pronostico. Conclusiones. No parece que se modifique la incidencia de enfermedad cerebrovascular hemorragica en el periodo, pero si los factores asociados segun sexo y edad. Segun la clasificacion MIPSE, la evitabilidad de la enfermedad cerebrovascular hemorragica seria de hasta un 36%.

[Ebrictus study. Functional results, survival, and potential years of life lost after the first stroke]. / Estudio Ebrictus. Resultados funcionales, supervivencia y años potenciales de vida perdidos después del primer episodio de ictus.

AIM: To determine the mortality, degree of dependence, survival, and years of life lost (YLL) after first episode of stroke. DESIGN: Cohort study. LOCATION: Community based register. PARTICIPANTS: A total of 553 subjects between 15-90 years with a first episode of definitive or transitory stroke were recruited between 01/04/2006 and 31/03/2008. MEASUREMENTS: The analyses were performed with the use of time-to-event methods, according to the intention-to-treat principle. The level of dependency was assessed according to the Barthel Scale one year after stroke; YLL (1-70 years) from the mean life expectancies at birth; survival analysis by Kaplan-Meier's curves, bivariate analysis comparing the variables between patients who had survived and those who died, and Cox's multivariate. RESULTS: The mean age was 73.3 (±11.6 years. The mean time of follow-up was 29.7 ± 13,4 months, during which 26.6% of the patients died. The mean Barthel score fell by >20%, particularly among women. There was moderate or greater dependence in 41.5% (95%CI 30.6-52.8%) of the subjects. The overall accumulative probability of survival was 0.96 (95% CI 0.94-0.97) in the first month and 0.69 (95% CI 0.65-0.72) in the fourth year. The thrombolytic treatment showed a protective effect on mortality, particularly among the women. The main predictive variables were, history of recurrent cardiovascular event (RR 6.7, 95% CI 2.2-21.7) and aging (RR 1.08, 95% CI 1.01-1.2). The average YLL was 11.5/10000/year SD7.2, and higher among men. CONCLUSION: There are differences in functional outcome, mortality, and potential years of life lost by gender. A new cardiovascular event is an independent prognostic factor of survival.

[Characteristics of oral anti-coagulation treatment in high-risk chronic auricular fibrillation]. / Características del tratamiento anticoagulante oral en la fibrilación auricular crónica de alto riesgo.

OBJECTIVE: To calculate the prevalence of chronic auricular fibrillation (CAF), how much of it is considered high-risk (CAFhr) and the degree of coverage with oral anti-coagulation treatment (OAT). DESIGN: Multi-centre descriptive study. SETTING: 9 health districts. The "Terres de l'Ebre" Primary Care Service. PARTICIPANTS: Randomised sample of 375 patients with CAF, of whom 150 met the criteria of CAFh-r during 2002. MAIN MEASUREMENTS: Profile of patients with CAFh-r; coverage with OAT; place of follow-up; presence of vascular complications, and the time relationships between the diagnosis of CAF, vascular complications and the start of OAT. All the INR determinations taken from the patients included in the study were used. RESULTS: There was 2.2% prevalence of CAF (95% CI, 1.4-3.3). 40% of CAF had criteria of CAFh-r. 74.2% were treated with OAT. In 41.7% the diagnosis of CAF coincided with the incidence of some vascular complication. There were no differences between the overall results of the INR obtained in hospital and in PC. The expected efficacy of OAT for thromboembolism prevention in our high-risk sample was 61.12%. CONCLUSIONS: 40% of the CAF are high-risk. In over a third of patients OAT was indicated after a vascular complication linked to an unknown CAF. The INR between 2-3 is similar in PC centres and the corresponding haematology service.

[Cost-effectiveness analysis of self-monitoring of blood glucose in type 2 diabetics]. / Análisis coste-efectividad de la automonitorización de la glucosa sanguínea en diabéticos tipo 2.

OBJECTIVE: Compare the cost-effectiveness of self-monitoring of blood glucose (MBG) with your non-use. DESIGN: Descriptive and retrospective study covering the period 1995-97 in the 597 type-2 diabetes patients: 286 practicing MBG on a stable basis and 311 not doing so. All are registered in seven health districts in the territorial ambit of Tortosa Primary Care. Were quantified the direct costs in relation to consumption of reagent strips for the practice of MBG, outpatients visits in your primary care center, derivations to specialist of reference and complementary test according to recommendations of the European NIDDM Policy Group in the population user of MBG and no-user; the annual cost increment, the average annual cost and the total annual cost in the population user of MBG and in the application of a ideal model of quantitative and qualitative cover according to clinical recommendations of the Gedaps; and the cost-effectiveness. RESULTS: While the 78% of the total diabetic population satisfy some clinical indication for prescribing MBG, only the 42.5% practice the MBG. The consumption of reagent strips rising of 8% to 15% of the global cost of the diabetic population. In the application of the ideal model of cover, this cost increase up the 30% of global cost. The effectiveness obtained, an 27%, not are significantly different in the population user of MBG and no user. The cost-effectiveness in the user of MBG increased of 210.789 ptes/year to 213.148 ptes/year; and no-user of 162.019 ptes/year to 162.051 ptes/year. The application of ideal model of cover and the gain of an effectiveness near to possible level of efficiency imply an descent average of cost-effectiveness of approximately 60%: 78.904 ptes/year in user MBG and 54.682 ptes/year in no-user. CONCLUSIONS: 1. We choose in the presents conditions the option of no-user MBG. 2. The average cost-effectiveness per diabetic patient will increase by the needs of accommodate the therapy to new standards of metabolic control. 3. Are clear opportunity for the improve the management and to motivate an efficient use of technology associate to defects of public sanitary market. 4. The model of ideal cover associated to greater effectiveness are necessary for to unify the economic and clinic efficiency.

[Blood glucose self-monitoring (BGSM): an evaluation of its prescription and results in type-2 diabetes. The Research Group in Primary Care of Tortosa]. / Automonitorización de la glucosa sanguínea (MGS): evaluación de su prescripción y resultados en la diabetes tipo 2. Grup de Recerca en Atenció Primària Tortosa.

OBJECTIVES: To investigate the results of metabolic control among type-2 diabetics who practise self-monitoring of their blood glucose (MBG) and compare them with those who do not; the adequacy of MBG prescription according to clinical criteria and frequency of use; and to analyse the presence of factors predicting metabolic control. DESIGN: Descriptive and retrospective study covering 1995, 1996 and 1997. SETTING: The seven health districts in the territorial ambit of Tortosa Primary Care. PATIENTS: 597 type-2 diabetes patients were evaluated: 286 practising MBG, and 311 not doing so. All of them belonged to the health districts reference population. The sample was systematized and stratified by health districts in order to obtain data through a pre-designed data collection form. MEASUREMENTS AND MAIN RESULTS: 41.06% of diabetics practised MBG on a stable basis, without any significant differences showing in either HbA1c percentage, in any of the biological variables defining metabolic control in relation to the practice or otherwise of MBG, or in its frequency. An inverse relationship (p = 0.012) between the frequency of MBG and age was shown. Some clinical indication for prescribing MBG existed in 78.22% of the total diabetic population. In the diabetic population using MBG, inappropriate use of quantity was 54.89% (84.07% by too little, 15.92% in excess). Only 37.9% displayed quantitative and qualitative concordance simultaneously. The logistic model applied to the total diabetic population predicted 73.19% metabolic control with the variables of BMI (OR = 1.0542). Karnofsky index (OR = 0.9768) and presence of macroangiopathy (OR = 0.4249). CONCLUSIONS: 1. The practice of MBG is questionable, since the effectiveness found was not superior. 2. There is an imbalance between the real practice of MBG according to the clinical recommendations and consumption, which tends to be deficient. 3. The results do not seem to depend so much on MBG practice as on other linked circumstances which cannot be modified by MBG practice.

[The evaluation of the self-financing capacity within the territorial compass of a primary care management]. / Evaluación de la capacidad de autofinanciación en el ámbito territorial de una dirección de atención primaria. GRAP Tortosa.

OBJECTIVE: The main objective of this study is to calculate the point of financial balance in the geographical setting of the Tortosa PC Area, to evaluate the business results, and to reflect on the side-effects and potential problems of self-management. DESIGN: Retrospective and descriptive study. SETTING: The units studied were the seven base health districts operating during 1997. MEASUREMENTS AND MAIN RESULTS: The products or services considered for the calculation of income are included in the Order of 29/9/97. The overall result meant a deficit of 0.019 milliards. Pharmaceutical prescription accounted for 58.45% of the total cost. 96.26% of the total activity was products or services undertaken in the PCC, where 95.95% of the income was obtained. All the points of balance, except for in-home activity of nursing personnel, were above the activity recorded. The products with greatest volume were the most profitable overall for the business. CONCLUSIONS: 1. The overall result meant a subsidy to running costs of 0.019 milliards. 2. If it did not occur otherwise, our systems for recording activity would have to be adapted to the products financed and accountancy information at the operational unit level. 3. Given that what is measured can be improved, we can identify problems and synergically involve the clinics in improving service efficiency and at the same time achieving a higher level of responsibility for services in a new context of self-management both for each operational unit and overall. 4. Defining the point of financial balance has to enable a framework of target incentives to be established by means of simultaneous information on cost and profit elements in the activity undertaken.

[The quality of professional life and the pride in working in public health. The results of a survey]. / La calidad de vida profesional y el orgullo de trabajar en la sanidad pública. Resultados de una encuesta.

OBJECTIVE: To find what factors explain best the pride of belonging to a public health enterprise. DESIGN: A descriptive crossover study. SETTING: One primary care CHS. PARTICIPANTS: Staff of 363 from Tortosa's Primary Care administrative staff. MEASUREMENTS AND MAIN RESULTS: All the employees were sent a self-filling questionnaire on the quality of their professional life. 232 returned the questionnaire filled in (63.9%). They showed an average value for the overall quality of professional life (5.40 +/- 2.09). The general profile covered the following perceptions taken together: sufficient intrinsic motivation; in a work-place with sufficient responsibility, training and social support; associated with enough work-load; with some emotional support from the managers; having some inconveniences caused by work. The pride in belonging to the CHS was high (6.86 +/- 2.50), with those over 45 giving a significantly higher average reply. Among doctors, pride was significantly lower. The multiple regression model identified three significant variables which explained 67.5% of the variability in the pride of belonging to the CHS: recognition of effort, being properly trained for their current job and length of service. CONCLUSIONS: a) Professionals are quite proud of belonging to the CHS. b) Their perception of the quality of professional life is average.

[Evaluation of the effectiveness of metabolic self-control through direct dispensation of diagnostic strips to type 2 diabetic patients]. / Evaluación de la efectividad en el autocontrol metabólico mediante la dispensación directa de tiras diagnósticas a los diabéticos tipo 2.

OBJECTIVE: To perform an evaluation of the effectiveness of diagnostic strips in metabolic control by type 2 diabetics. DESIGN: A crossover, observational study. SETTING: Primary Health Care. PATIENTS: A sample of 400 histories at a Primary Care Centre (PCC), representative of Diabetes 2 patients who used reactive strips directly dispensed at PCCs as a method of home self-analysis of their disease, was evaluated. They were monitored in 1995 and 1996 in the seven health districts in the Primary Care region of Tortosa. MEASUREMENTS AND MAIN RESULTS: The use of reactive strips was considered effective if the data recorded in the PCC histories satisfied the criteria for acceptable metabolic control, as defined by the GEDAPS, for the previous year of monitoring, or for at least three months if the period of use of the strips was under a year. Mean annual cost and consumption per diabetic, and the evolution of these over the study period, were calculated. CONCLUSIONS: Direct dispensing of reactive strips led to an important annual increase in cost (+46.59%) and consumption (+89.25%), but acceptable effectiveness was not demonstrated (1.10%).

[Use of the resources in the diagnosis and control of diabetes mellitus in a rural area]. / Uso de los medios de diagnóstico y control del diabético en una zona rural.

The clinical records of 135 diabetics from the Amposta rural area were reviewed and distributed in two groups: Group A consisted of four rural nuclei; each of them had a population of less than 1000 and a team of basic health care, and their overall population was 2967 with 88 recognized diabetics. Group B consisted of a rural nucleus with a population of 3337, served by three basic health care teams and administrative support; the number of diabetics was 47. The prevalences of type I (2.62% and 1.1%) and type II diabetes (35.91% and 17.18% were compared in the groups A and B, respectively. Also were compared the use of the available resources for the evaluation of the degree of metabolic compensation and for the detection of complications; and the use of the clinical record during the first year of operation of the basic health area. The results showed a significant difference in the prevalence of diabetes (p less than 0.001), in the use of resources both for the evaluation of metabolic compensation (p less than 0.001) and for the detection of complications (p less than 0.001), and in the quality of the clinical record (p less than 0.001).