[Organization and costs of stroke care in outpatient settings: Systematic review]. / Organización y costes de la atención extrahospitalaria del ictus. Revisión sistemática de la literatura.

OBJECTIVE: To review the bibliography on stroke costs (ICD-10 code I63) in the field of primary care. DESIGN: Systematic review. DATA SOURCES: PubMed/Medline, ClinicalTrials.gov, Cochrane Reviews, EconLit, and Ovid/Embase between 01/01/2012-12/31/2021 with descriptors included in Medical Subject Heading (MeSH). SELECTION OF STUDIES: Those with a description of the costs of activities carried out in the out-of-hospital setting. Systematic reviews were included; prospective and retrospective observational studies; analysis of databases and total or partial costs of stroke as a disease (COI). Articles were added using the snowball method. The studies were excluded because: a) not specifically related to stroke; b) in editorial or commentary format; c) irrelevant after review of the title and abstract; and d) gray literature and non-academic studies were excluded. DATA EXTRACTION: They were assigned a level of evidence according to the GRADE levels. Direct and indirect cost data were collected. RESULTS AND CONCLUSIONS: Thirty studies, of which 14 (46.6%) were related to post-stroke costs and 12 (40%) to cardiovascular prevention costs. The results show that most of them are retrospective analyzes of different databases of short-term hospital care, and do not allow a detailed analysis of the costs by different segments of services. The possibilities for improvement are centered on primary and secondary prevention, selection and pre-hospital transfer, early discharge with support, and social and health care.

[Differences in the survival after an episode of stroke treated with thrombolytic therapy. Study Ebrictus]. / Diferencias en la supervivencia después de un episodio de ictus tratado con fibrinólisis. Estudio Ebrictus.

OBJECTIVE: To seek if there is gender survival difference among patients treated with thrombolytic therapy. DESIGN: Cohort study. LOCATION: Community based register. PARTICIPANTS: 91 subjects with an episode of stroke collected since April 2006 up to September 2013 and treated with thrombolytic therapy. INTERVENTIONS: Monitoring of vital status. MEASUREMENTS: We collected baseline characteristics in Framingham, Regicor, CHA2DS2-VASc, Essen, NIHSS, Barthel scales and outcomes according to gender; person-time incidence rate; survival analysis by Kaplan-Meier's curves, bivariate analysis between survivors and deaths, and Cox multivariate. RESULTS: 91 patients with middle age 68.02±11.9 years. The men have higher cardiovascular basal risk. The average time of follow-up was 2.95±2.33 years. Incidence rate ratio (IR) shown higher risk in men than in women IR=3.2 (CI 95% 1.2-8.0). The dead cases were older (P=.032); with higher cardiovascular basal risk (P=.040) and more risk of stroke recurrence (P=<.001), with cardiovascular pathology before the stroke (P=.005); more stroke severity (P=.002); and a major fall in the score Barthel one year after the episode (P=.016). The percentage of deaths is significantly higher when the patient is referred by complications to other centres (P=.006) in relation to those referred to home, but just the gender (HR: 1,12; IC 95%: 1,05-1,20) and secondary cardiovascular prevention (HR: 0,13; IC 95%: 0,06-0,28) were associated with higher risk of mortality. CONCLUSIONS: After stroke episode treated with thrombolytic therapy, men have 12% higher risk of dying than women and don't be treated with secondary cardiovascular prevention rise 7.7 times the mortality risk.

[The management of atrial fibrillation and characteristics of its current care in outpatients. AFABE observational study]. / El circuito asistencial de la fibrilación auricular en pacientes ambulatorios: estudio observacional Audit fibrilación auricular en el Baix Ebre.

AIM: To provide insights into the characteristics and management of outpatients when their atrial fibrillation (AF) was first detected: diagnosis, treatment and follow-up in the context of the public health system. DESIGN: AFABE is an observational, multicentre descriptive study with retrospective data collection relating to the practice patterns, management and initial strategies of treatment of patients with diagnosed AF in the context of primary care, emergency and cardiologists of the public health system. SETTING: Primary and Specialist care. Baix Ebre region. Tarragona. Spain. SUBJECTS: A representative sample of 182 subjects > 60-year-old with AF who have been randomized, recruited among the registered patients with AF in 22 primary care centres in the area of the study. MESUREMENTS: Demographic data, comorbidities (AF), CHA2DS2-VASc and HAS_BLED scores, and practice patterns results between Primary Care and referral services. RESULTS: A total of 182 patients were included (mean age 78.5 SD:7.3 years; 50% women). Most patients (68.3% 95%CI; 60.3-76.3) had the first contact in Primary Care, of which 56.3% (95%CI; 45.2-66.0) were sent to Hospital Emergency Department where 72.7% (95%CI: 63.5-79.0) of the oral anticoagulation and 58.4% (95%CI: 49.4-66.9) of antiarrhytmic treatments were started. More than half (55.9%:95%CI; 47.2-64.7, of patients with permanent AF were followed-up by the Cardiology department. CONCLUSIONS: Most patients with newly diagnosed AF made a first contact with Primary Care, but around half were sent to Hospital Emergency departments, where they were treated with an antiarrhythmic and/or oral anticoagulation.

Prognostic Significance of Lung Ultrasound for Heart Failure Patient Management in Primary Care: A Systematic Review.

Background: Heart failure (HF) affects around 60 million individuals worldwide. The primary aim of this study was to evaluate the efficacy of lung ultrasound (LUS) in managing HF with the goal of reducing hospital readmission rates. Methods: A systematic search was conducted on PubMed, Embase, Google Scholar, Web of Science, and Scopus, covering clinical trials, meta-analyses, systematic reviews, and original articles published between 1 January 2019 and 31 December 2023, focusing on LUS for HF assessment in out-patient settings. There is a potential for bias as the effectiveness of interventions may vary depending on the individuals administering them. Results: The PRISMA method synthesized the findings. Out of 873 articles identified, 33 were selected: 19 articles focused on prognostic assessment of HF, 11 centred on multimodal diagnostic assessments, and two addressed therapeutic guidance for HF diagnosis. LUS demonstrates advantages in detecting subclinical congestion, which holds prognostic significance for readmission and mortality during out-patient follow-up post-hospital-discharge, especially in complex scenarios, but there is a lack of standardization. Conclusions: there are considerable uncertainties in their interpretation and monitoring changes. The need for an updated international consensus on the use of LUS seems obvious.

The costs associated with stroke care continuum: a systematic review.

Stroke, a leading cause of death and long-term disability, has a considerable social and economic impact. It is imperative to investigate stroke-related costs. The main goal was to conduct a systematic literature review on the described costs associated with stroke care continuum to better understand the evolution of the economic burden and logistic challenges. This research used a systematic review method. We performed a search in PubMed/MEDLINE, ClinicalTrial.gov, Cochrane Reviews, and Google Scholar confined to publications from January 2012 to December 2021. Prices were adjusted using consumer price indices of the countries in the studies in the years the costs were incurred to 2021 Euros using the World Bank and purchasing power parity exchange rate in 2020 from the Organization for Economic Co-operation and Development with the XE Currency Data API. The inclusion criteria were all types of publications, including prospective cost studies, retrospective cost studies, database analyses, mathematical models, surveys, and cost-of-illness (COI) studies. Were excluded studies that (a) were not about stroke, (b) were editorials and commentaries, (c) were irrelevant after screening the title and abstract,(d) grey literature and non-academic studies, (e) reported cost indicators outside the scope of the review, (f) economic evaluations (i.e., cost-effectiveness or cost-benefit analyses); and (g) studies not meeting the population inclusion criteria. There may be risk of bias because the effects are dependent on the persons delivering the intervention. The results were synthetized by PRISMA method. A total of 724 potential abstracts were identified of which 25 articles were pulled for further investigation. The articles were classified into the following categories: 1)stroke primary prevention, 2) expenditures related to acute stroke care, 3) expenditures for post-acute strokes, and 4) global average stroke cost. The measured expenditures varied considerably among these studies with a global average cost from €610-€220,822.45. Given the great variability in the costs in different studies, we can conclude that we need to define a common system for assessing the costs of strokes. Possible limitations are related to clinical choices exposed to decision rules that trigger decisions alerts within stroke events in a clinical setting. This flowchart is based on the guidelines for acute ischemic stroke treatment but may not be applicable to all institutions.

Early Diagnosis of Atrial Fibrillation and Stroke Incidence in Primary Care: Translating Measurements into Actions-A Retrospective Cohort Study.

(1) Background: AF-related strokes will triple by 2060, are associated with an increased risk of cognitive decline, and alone or in combination, will be one of the main health and economic burdens on the European population. The main goal of this paper is to describe the incidence of new AF associated with stroke, cognitive decline and mortality among people at high risk for AF. (2) Methods: Multicenter, observational, retrospective, community-based studies were conducted from 1 January 2015 to 31 December 2021. The setting was primary care centers. A total of 40,297 people aged ≥65 years without previous AF or stroke were stratified by AFrisk at 5 years. The main measurements were the overall incidence density/1000 person-years (CI95%) of AF and stroke, prevalence of cognitive decline, and Kaplan-Meier curve. (3) Results: In total, 46.4% women, 77.65 ± 8.46 years old on average showed anAF incidence of 9.9/103/year (CI95% 9.5-10.3), associated with a four-fold higher risk of stroke (CI95% 3.4-4.7), cognitive impairment(OR 1.34 (CI95% 1.1-1.5)), and all-cause mortality (OR 1.14 (CI95% 1.0-1.2)), but there was no significant difference in ischemic heart disease, chronic kidney disease, or peripheral arteriopathy. Unknown AF was diagnosed in 9.4% and of these patients, 21.1% were diagnosed with new stroke. (4) Conclusions: The patients at high AF risk (Q4th) already had an increased cardiovascular risk before they were diagnosed with AF.

Innovative Health and Social Integrated Care Model Effectiveness to Improve Quality Care for Chronic Patients: A Single Group Assignment Clinical Trial.

Background: Patients with chronic disease have become one of the major challenges for health and social protection systems in developed countries. Integrated care models (ICM) have demonstrably improved the quality of care of chronic patients. However, new models of integration need further evaluation of its effectiveness and outcomes. Methods: The ICM studied promoted coordination between the health and social sectors during a 6-month period, through an ad hoc developed application (app) that enabled a constant flow of communication between professionals from both sectors. Patients' quality of life, treatment adherence, chronic patient experience and caregiver overload were assessed by questionnaires at baseline, at the end of the intervention and 6 months post-intervention. Results: The implementation of the new health and social ICM permitted new case detection and medical and social services offered to chronic patients. Furthermore, the quality of life and treatment adherence of patients and caregiver overload were significantly improved. These positive effects lasted at least 6 months after the intervention. Conclusions: Integrated care may facilitate access to care services, increase perceived patient quality of life and treatment adherence. Enhanced access to medical and social services from complex chronic patients may have important implications for caregivers and the care systems who are struggling to adapt to an expanding demand.

Integrated Care Model Salut+Social Assessment by Professionals, Informal Caregivers and Chronic or Social Dependent Patients: A Qualitative Study.

We explored the views of the professionals (from primary care and social services) and users (caregivers and patients) who participated in the clinical trial of the Salut+Social integrated care model to identify the implementation barriers and facilitators, to assess the impact on health and wellbeing and to obtain an assessment of the program. A qualitative descriptive study with a pragmatic, utilitarian approach was performed. Participants were recruited by purposive and convenience sampling. A focus group (FG) and in-depth interviews were conducted with professionals and users, respectively. Thematic content analysis was employed. A total of 11 professionals and 8 users participated in the FG and interviews, respectively. Seven themes were identified: (1) contextualizing the previous scenario; (2) achievements of the program from the professionals' perspective; (3) facilitators and barriers of the integrated care model; (4) proposals for improving the integrated care model; (5) users' assessment of the care received within the program framework; (6) users' perception of the impact on health and wellbeing; (7) users' demands for better care. Professionals reported improved coordination between services and highlighted the need for a protocol for emergencies and to strengthen community orientation. Users proposed more frequent home visits. This study shows the acceptability of the new model by professionals and the users' satisfaction with the care received.

Effectiveness of the integrated care model Salut+Social in patients with chronic conditions: A mixed methods study protocol.

INTRODUCTION: Integrated care models aim to provide solutions to fragmentation of care by improving coordination. This study will evaluate the effectiveness of a new integrated care model (Salut + Social), which will promote the coordination and communication between social and healthcare services in southern Catalonia (Spain) to improve quality of life, adherence to treatment and access to medical services for patients with chronic conditions, and also to reduce caregiver burden. Additionally, we will evaluate the experience of caregivers, health professionals and social workers with the new model implemented. METHODS AND ANALYSIS: A clinical trial using mixed methodology will be carried out. The intervention consists of improving the coordination between the social and healthcare sectors during a 6-month period, by means of information and communication technology (ICT) tools that operate as an interface for the integrated care model. The study subjects are primary care patients with chronic health and social conditions that can benefit from a collaborative and coordinated approach. A sample size of 141 patients was estimated. Questionnaires that assess quality of life, treatment adherence, medical service and caregiver burden will be used at baseline and at 6, 9, and 12 months after the beginning of the study. The principal variable is quality of life. For statistical analysis, comparisons of means and proportions at different time points will be performed. A discussion group and semi-structured interviews will be conducted with the aim of improving the care model taking into account the opinions of professionals and caregivers. A thematic content analysis will be carried out. ETHICS AND DISSEMINATION: This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P17/100). Articles will be published in international, peer-reviewed scientific journals. TRIAL REGISTRATION: Clinical-Trials.gov: NCT04164160.

Sex Differences in Long-Term Survival after a First Stroke with Intravenous Thrombolysis: Ebrictus Study.

BACKGROUND: A number of large trials have confirmed the benefits of thrombolysis in acute stroke, but there are gender differences. We sought to examine the relationship between sex and outcome after thrombolysis. METHODS: This was a prospective cohort study including 1,272 incident ischemic strokes (597 in women) from April 1, 2006 to December 31, 2014. Statistical approaches were used for analyzing survival outcomes and their relationship with thrombolysis therapy. RESULTS: The death rates were lower (p = 0.003) in the thrombolysis therapy group with an incidence ratio of 0.57 (95% CI 0.39-0.83). 113 (8.8%) patients (53 women) received thrombolysis. They were significantly younger (69.2 ± 12.7 vs. 73.9 ± 12.5 years; p < 0.001), had higher NIHSS score (12.7 ± 6.3 vs. 7.3 ± 7.0; p < 0.001), spent more days in hospital (10.4 ± 8.3 vs. 8.3 ± 7.9; p < 0.001), and had a higher average Barthel score at discharge (85.5 ± 24.4 vs. 79.2 ± 28.6; p = 0.023). The male/female incidence ratio showed a significant decrease (p = 0.01) in the incidence of mortality in women and a better Barthel score. The thrombolysis improved the survival in the overall group with thrombolysis versus without thrombolysis (p = 0.028), in women versus in men with thrombolysis (p = 0.023), and in women with thrombolysis versus in those without thrombolysis (p < 0.001) but not in men with thrombolysis versus in those without thrombolysis (p = 0.743). The protective factors as regards mortality were thrombolysis therapy (95% CI 0.37-0.80; p = 0.002), Barthel score ≥ 60 (95% CI 0.81-0.94; p = 0.002), and cardiovascular secondary prevention 1 year after stroke (0.13, 95% CI 0.06-0.28). CONCLUSIONS: The stroke death rates were lower in women after thrombolysis treatment and suggest significant benefit for women in this setting. The overall benefit on survival of the patients treated with thrombolysis might be explained by the beneficial effect of the thrombolysis on the women.

Results from the Registry of Atrial Fibrillation (AFABE): Gap between Undiagnosed and Registered Atrial Fibrillation in Adults--Ineffectiveness of Oral Anticoagulation Treatment with VKA.

OBJECTIVE: This study aimed to examine the effectiveness of the use of oral anticoagulation (OAC) medication, recommended by national guidelines for stroke prevention but reportedly underused in AF patients with moderate to high stroke risk. METHOD: A multicentre and cross-sectional study of undiagnosed AF among out-of-hospital patients over 60 years old was carried out, visiting 3,638 patients at primary health centres or at home for AF diagnosis using the IDC-10 classification. The main outcome measures were CHA2DS2VASC, HAS-BLED scores, cardiovascular comorbidity, pharmacological information, TTR, and SAMe-TT2R2 scores. RESULTS: The main findings were undiagnosed AF in 26.44% of cases; 31.04% registered with AF but not using OAC despite 95.6% having a CHA2DS2VASC ≥ 2 score; a risk of bleeding in important subgroups using OAC without indication (37.50% CHA2DS2VASC < 2 score); the use of OAC with TTR < 60% (33.1%), of whom 47.6% had a HAS-BLED score ≥3. Thus, 35.4% of the expected AF prevalence achieved an optimal time in the therapeutic range. CONCLUSIONS: The expected AF prevalence was 10.9% (n 5267), but the registered prevalence was 7.5% (n 3638). Only 35.04% (CI = 95%, 33.7-36.3) of AF patients treated with vitamin K antagonists (VKAs) achieve the goal of TTR > 60%.

Atrial Fibrillation and Cardiovascular Comorbidities, Survival and Mortality: A Real-Life Observational Study.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac tachyarrhythmia encountered in clinical practice affecting up to 10% of the population over 60 years old and its prevalence rises with age. The main goals were to characterize the AF patient population after the initial diagnosis of AF and to determine overall survival. METHODS: It is a real-life observational study of 269 subjects with an AF diagnosis over 60 years old randomly selected. The collected variables were: sociodemographic, cardiovascular complications/comorbidities (CVCs) included in the CHA2DS2-VASc and HAS_BLED scores, drug assigned as clinical treatment, mean range INR and CVCs and death dates (all-cause mortality). The survival curve and the risk of death were assessed using Kaplan-Meier survival curve and comparisons with log-rank. RESULTS: The average following time was 6.2 ± 3.7 years (0.2-20.4). Eleven point five percent died. Sixty-five point four percent had some CVCs. There were no differences in the overall incidence of CVCs by gender. The survival probability was 0.86 ± DE 0.03 among men and 0.90 ± DE 0.04 among women without differences. Thirty-six point eight percent (95% CI: 30.8 - 42.7) were diagnosed vascular complications before AF diagnosis, being ischemic cardiopathy (24.2%) and ischemic stroke (23.2%) the most frequent. The mortality is higher (P < 0.036) among those who suffered ≥ 3 vascular complications and significantly lower among those treated with statins (P = 0.032). After AF diagnosis, the most frequent was the cardiac heart failure (46.7%), significantly higher among women (P = 0.037). The mortality is significantly lower in those treated with OAC (P = 0.003). CONCLUSIONS: AF is associated with ischemic heart disease, ischemic stroke and congestive heart failure, but the average mortality age is not different from the global population in Spain and Catalonia.

Prevalence of undiagnosed atrial fibrillation and of that not being treated with anticoagulant drugs: the AFABE study.

INTRODUCTION AND OBJECTIVES: Atrial fibrillation constitutes a serious public health problem because it can lead to complications. Thus, the management of this arrhythmia must include not only its treatment, but antithrombotic therapy as well. The main goal is to determine the proportion of cases of undiagnosed atrial fibrillation and the proportion of patients not being treated with oral anticoagulants. METHODS: A multicenter, population-based, retrospective, cross-sectional, observational study. In all, 1043 participants over 60 years of age were randomly selected to undergo an electrocardiogram in a prearranged appointment. Demographic data, CHA2DS2-VASc and HAS-BLED scores, international normalized ratio results, and reasons for not receiving oral anticoagulant therapy were recorded. RESULTS: The overall prevalence of atrial fibrillation was 10.9% (95% confidence interval, 9.1%-12.8%), 20.1% of which had not been diagnosed previously. In the group with known atrial fibrillation, 23.5% of those with CHA2DS2-VASc≥2 were not receiving oral anticoagulant therapy, and 47.9% had a HAS-BLED score≥3. The odds ratio for not being treated with oral anticoagulation was 2.04 (95% confidence interval, 1.11-3.77) for women, 1.10 (95% confidence interval, 1.05-1.15) for more advanced age at diagnosis, and 8.61 (95% confidence interval 2.38-31.0) for a CHA2DS2-VASc score<2. Cognitive impairment (15.2%) was the main reason for not receiving oral anticoagulant therapy. CONCLUSIONS: The prevalence of previously undiagnosed atrial fibrillation in individuals over 60 years of age is 20.1%, and 23.5% of those who have been diagnosed receive no treatment with oral anticoagulants.

[The stroke care system in Terres de l'Ebre, Spain, after the implementation of the Stroke Code model: Ebrictus Study]. / La atención sanitaria del ictus en el área Terres de l'Ebre desde la implantación del Código Ictus: Estudio Ebrictus.

BACKGROUND AND OBJECTIVE: We aimed to know the characteristics of the urgent stroke assistance system, the Stroke Code (SC) model, 2 years after its implementation through testing the specific impact on several result indicators on individuals with a first stroke. PATIENTS AND METHOD: Prospective study of a cohort who suffered a first stroke episode, 15 to 89-year-old. Several clinical indicators were selected to evaluate results according to the SC and an analysis survival for Kaplan-Meier's curves was made as well as a bivariate analysis between dead and surviving patients. Data were collected by a community based registry. RESULTS: A total of 380 patients ≤80-year-aged were enrolled and the SC was activated in 54.3% (CI95%: 49,0-59.3), 77% at the hospital. An 80% of the therapeutic window was wasted before arrival to hospital. In 13.9% (CI95%: 9,2-19,8) thrombolysis was used. The immediate mortality was 9.9% (CI95%: 7.5-12.5). CONCLUSIONS: The implantation of the SC is a system that improved the welfare chain of stroke in the whole territory, but its activation in the area of primary care was low.

[Primary and secondary cardiovascular prevention results in patients with stroke: relapse risk and associated survival (Ebrictus study)]. / Resultados de prevención cardiovascular primaria y secundaria en pacientes con ictus: riesgo de recurrencia y supervivencia asociada (estudio Ebrictus).

INTRODUCTION: The prevalence and cardiovascular risk factors control (CVRF) are determining to suffer a stroke and its relapse which arise the mortality and disability. AIM: To estimate the incidence of the first episode of ictus and describe the results in primary and secondary cardiovascular prevention. PATIENTS AND METHODS: Observational and prospective study of a fix cohort of 130,649 people, 15-90-year-old assigned to participants centers between 01/04/2006 and 31/03/2008. Community based register. Analyses were performed with the use of time-to-event methods, included Cox's multivariate on survival, risk of it's relapse; the CVRF diagnosed and it's relative risk (RR); cardiovascular risk. RESULTS: 553 patients were enrolled (48,8% female), average age 73.3 ± 11.6 years with the first episode of stroke. After the episode, the hypertension (74.9% vs 88.7%), atrial fibrillation (9.9% vs 16%) and dislipemia (37.8% vs 49.8%) increased significantly as well its control. The 47% (95% CI = 42.8-51.2) of the cases had high risk of relapsing. In the 15.7% of the patients happened relapse of cardiovascular event, 48.3% of which were stroke. The main predictors variables were history of recurrent cardiovascular event (RR = 6.7; 95% CI = 2.2-21.7) and the aging (RR = 1,08; 95% CI = 1.01-1.2). CONCLUSION: The cardiovascular secondary prevention seems to be more effective both in CVRF's detection and its control and is extremely important to get better results of survival.