[A computerised clinical decision-support system for the management of depression in Primary Care]. / Un sistema informatizado de apoyo a las decisiones clínicas para el manejo de la depresión en atención primaria.

Despite its clinical relevance and its importance as a public health problem, there are major gaps in the management of depression. Evidence-based clinical guidelines are useful to improve processes and clinical outcomes. In order to make their implementation easier these guidelines have been transformed into computerised clinical decision support systems. In this article, a description is presented on the basics and characteristics of a new computerised clinical guideline for the management of major depression, developed in the public health system in Catalonia. This tool helps the clinician to establish reliable and accurate diagnoses of depression, to choose the best treatment a priori according to the disease and the patient characteristics. It also emphasises the importance of systematic monitoring to assess the clinical course, and to adjust therapeutic interventions to the patient's needs at all times.

Impact of implementing electronic clinical practice guidelines for the diagnosis, control and treatment of cardiovascular risk factors: A pre-post controlled study.

OBJECTIVE: To evaluate the impact of computerized clinical practice guidelines on the management, diagnosis, treatment, control, and follow-up of the main cardiovascular risk factors: hypertension, hypercholesterolaemia, and type 2 diabetes mellitus. DESIGN: Pre-post controlled study. SETTING: Catalonia, autonomous community located in north-eastern Spain. PARTICIPANTS: Individuals aged 35-74 years assigned to general practitioners of the Catalan Health Institute. INTERVENTION: The intervention group consisted of individuals whose general practitioners had accessed the computerized clinical practice guidelines at least twice a day, while the control group consisted of individuals whose general practitioner had never accessed the computerized clinical practice guidelines platform. MAIN OUTCOMES: The Chi-squared test was used to detect significant differences in the follow-up, control, and treatment variables for all three disorders (hypertension, hypercholesterolaemia, and type 2 diabetes mellitus) between individuals assigned to users and non-users of the computerized clinical practice guidelines, respectively. RESULTS: A total of 189,067 patients were included in this study, with a mean age of 56 years (standard deviation 12), and 55.5% of whom were women. Significant differences were observed in hypertension management, treatment and control; type 2 diabetes mellitus management, treatment and diagnoses, and the management and control of hypercholesterolaemia in both sexes. CONCLUSIONS: Computerized clinical practice guidelines are an effective tool for the control and follow-up of patients diagnosed with hypertension, type 2 diabetes mellitus, and hypercholesterolaemia. The usefulness of computerized clinical practice guidelines to diagnose and adequately treat individuals with these disorders remains unclear.

Population prevalence and control of cardiovascular risk factors: what electronic medical records tell us.

OBJECTIVE: To analyze the prevalence, control, and management of hypertension, hypercholesterolemia, and diabetes mellitus type 2 (DM2). DESIGN: Cross-sectional analysis of all individuals attended in the Catalan primary care centers between 2006 and 2009. LOCATION: History of cardiovascular diseases, diagnosis and treatment of hypertension, hypercholesterolemia, DM2, lipid profile, glycemia and blood pressure data were extracted from electronic medical records. Age-standardized prevalence and levels of management and control were estimated. PARTICIPANTS: Individuals aged 35-74 years using primary care databases. MAIN MEASURES: A total of 2,174,515 individuals were included (mean age 52 years [SD 11], 47% men). RESULTS: Hypertension was the most prevalent cardiovascular risk factor (39% in women, 41% in men) followed by hypercholesterolemia (38% and 40%) and DM2 (12% and 16%), respectively. Diuretics and angiotensin-converting enzyme inhibitors were most often prescribed for hypertension control (<140/90mmHg, achieved in 68% of men and 60% of women treated). Hypercholesterolemia was controlled (low-density lipoprotein cholesterol <130mg/dl) in just 31% of men and 26% of women with no history of cardiovascular disease, despite lipid-lowering treatment, primarily (90%) with statins. The percentage of women and men with DM2 and with glycated hemoglobin <7% was 64.7% and 59.2%, respectively; treatment was predominantly with oral hypoglycemic agents alone (70%), or combined with insulin (15%). CONCLUSIONS: Hypertension was the most prevalent cardiovascular risk factor in the Catalan population attended at primary care centers. About two thirds of individuals with hypertension or DM2 were adequately controlled; hypercholesterolemia control was particularly low.

Impact of the implementation of electronic guidelines for cardiovascular prevention in primary care: study protocol.

BACKGROUND: The electronic medical records software of the Catalan Institute of Health has recently incorporated an electronic version of clinical practice guidelines (e-CPGs). This study aims to assess the impact of the implementation of e-CPGs on the diagnosis, treatment, control and management of hypercholesterolaemia, diabetes mellitus type 2 and hypertension. METHODS: Eligible study participants are those aged 35-74 years assigned to family practitioners (FPs) of the Catalan Institute of Health. Routinely collected data from electronic primary care registries covering 80% of the Catalan population will be analysed using two approaches: (1) a cross-sectional study to describe the characteristics of the sample before e-CPG implementation; (2) a controlled before-and-after study with 1-year follow-up to ascertain the effect of e-CPG implementation. Patients of FPs who regularly use the e-CPGs will constitute the intervention group; the control group will comprise patients assigned to FPs not regularly using the e-CPG. The outcomes are: (1) suspected and confirmed diagnoses, (2) control of clinical variables, (3) requests for tests and (4) proportions of patients with adequate drug prescriptions. RESULTS: This protocol should represent a reproducible process to assess the impact of the implementation of e-CPGs. We anticipate reporting results in late 2013. CONCLUSION: This project will assess the effectiveness of e-CPGs to improve clinical decisions and healthcare procedures in the three disorders analysed. The results will shed light on the use of evidence-based medicine to improve clinical practice of FPs.

Validity of an adaptation of the Framingham cardiovascular risk function: the VERIFICA Study.

BACKGROUND: To assess the reliability and accuracy of the Framingham coronary heart disease (CHD) risk function adapted by the Registre Gironí del Cor (REGICOR) investigators in Spain. METHODS: A 5-year follow-up study was completed in 5732 participants aged 35-74 years. The adaptation consisted of using in the function the average population risk factor prevalence and the cumulative incidence observed in Spain instead of those from Framingham in a Cox proportional hazards model. Reliability and accuracy in estimating the observed cumulative incidence were tested with the area under the curve comparison and goodness-of-fit test, respectively. RESULTS: The Kaplan-Meier CHD cumulative incidence during the follow-up was 4.0% in men and 1.7% in women. The original Framingham function and the REGICOR adapted estimates were 10.4% and 4.8%, and 3.6% and 2.0%, respectively. The REGICOR-adapted function's estimate did not differ from the observed cumulated incidence (goodness of fit in men, p = 0.078, in women, p = 0.256), whereas all the original Framingham function estimates differed significantly (p<0.001). Reliabilities of the original Framingham function and of the best Cox model fit with the study data were similar in men (area under the receiver operator characteristic curve 0.68 and 0.69, respectively, p = 0.273), whereas the best Cox model fitted better in women (0.73 and 0.81, respectively, p<0.001). CONCLUSION: The Framingham function adapted to local population characteristics accurately and reliably predicted the 5-year CHD risk for patients aged 35-74 years, in contrast with the original function, which consistently overestimated the actual risk.

Un sistema informatizado de apoyo a las decisiones clínicas para el manejo de la depresión en atención primaria / A computerised clinical decision-support system for the management of depression in Primary Care

A pesar de su relevancia clínica y de su importancia como problema de salud pública existen importantes deficiencias en el abordaje de la depresión. Las guías clínicas basadas en la evidencia son útiles para mejorar los procesos y los resultados clínicos, y para facilitar su implementación se ha ensayado su transformación en sistemas informatizados de apoyo a las decisiones clínicas. En este artículo se describen los fundamentos y principales características de una nueva guía clínica informatizada para el manejo de la depresión mayor desarrollada en el sistema sanitario público de Cataluña. Esta herramienta ayuda al clínico a establecer diagnósticos de depresión fiables y precisos, a elegir el tratamiento idóneo a priori según las características de la enfermedad y del propio paciente, y enfatiza en la importancia de un seguimiento sistemático para evaluar la evolución clínica y adecuar las intervenciones terapéuticas a las necesidades del paciente en cada momento

Despite its clinical relevance and its importance as a public health problem, there are major gaps in the management of depression. Evidence-based clinical guidelines are useful to improve processes and clinical outcomes. In order to make their implementation easier these guidelines have been transformed into computerised clinical decision support systems. In this article, a description is presented on the basics and characteristics of a new computerised clinical guideline for the management of major depression, developed in the public health system in Catalonia. This tool helps the clinician to establish reliable and accurate diagnoses of depression, to choose the best treatment a priori according to the disease and the patient characteristics. It also emphasises the importance of systematic monitoring to assess the clinical course, and to adjust therapeutic interventions to the patient's needs at all times

Impact of implementing electronic clinical practice guidelines for the diagnosis, control and treatment of cardiovascular risk factors: A pre-post controlled study / Impacto de la implementación de las guías de práctica clínica electrónicas en el diagnóstico, control y tratamiento de los factores de riesgo cardiovascular: un estudio pre-post controlado

Objective: To evaluate the impact of computerized clinical practice guidelines on the management, diagnosis, treatment, control, and follow-up of the main cardiovascular risk factors: hypertension, hypercholesterolaemia, and type 2 diabetes mellitus. Design: Pre-post controlled study. Setting: Catalonia, autonomous community located in north-eastern Spain. Participants: Individuals aged 35-74 years assigned to general practitioners of the Catalan Health Institute. Intervention: The intervention group consisted of individuals whose general practitioners had accessed the computerized clinical practice guidelines at least twice a day, while the control group consisted of individuals whose general practitioner had never accessed the computerized clinical practice guidelines platform Main outcomes: The Chi-squared test was used to detect significant differences in the follow-up, control, and treatment variables for all three disorders (hypertension, hypercholesterolaemia, and type 2 diabetes mellitus) between individuals assigned to users and non-users of the computerized clinical practice guidelines, respectively. Results: A total of 189,067 patients were included in this study, with a mean age of 56 years (standard deviation 12), and 55.5% of whom were women. Significant differences were observed in hypertension management, treatment and control; type 2 diabetes mellitus management, treatment and diagnoses, and the management and control of hypercholesterolaemia in both sexes. Conclusions: Computerized clinical practice guidelines are an effective tool for the control and follow-up of patients diagnosed with hypertension, type 2 diabetes mellitus, and hypercholesterolaemia. The usefulness of computerized clinical practice guidelines to diagnose and adequately treat individuals with these disorders remains unclear (AU)

Objetivo: Evaluar el impacto de las guías de práctica clínica electrónicas en el manejo, diagnóstico, tratamiento, control y seguimiento de los factores de riesgo cardiovascular mayores: hipertensión, hipercolesterolemia, diabetes mellitus tipo 2. Diseño: Estudio pre-post controlado. Emplazamiento: Cataluña, comunidad autónoma situada al noreste de España. Participantes: Individuos de 35-74 años asignados a médicos de familia del Institut Català de la Salut. Intervención: El grupo de intervención estaba formado por pacientes asignados a médicos de familia que accedían al menos 2 veces al día a las guías de práctica clínica electrónicas. El grupo de control estaba formado por las personas asignadas a médicos de familia que nunca habían accedido. Medidas de resultado: Se realizaron pruebas de ji al cuadrado para detectar diferencias significativas en el seguimiento, control y tratamiento de la hipertensión, hipercolesterolemia y diabetes mellitus tipo 2 entre los individuos asignados al grupo de usuarios y los no usuarios de las guías. Resultados: Se incluyeron 189.067 individuos, con una edad media de 56 años (desviación estándar 12), de los cuales el 55,5% eran mujeres. Se encontraron diferencias estadísticamente significativas en el manejo, tratamiento y control de la hipertensión; en el manejo, tratamiento y diagnóstico de la diabetes mellitus tipo 2, y en el manejo y control de la hipercolesterolemia en ambos sexos. Conclusiones: Las guías de práctica clínica electrónicas son una herramienta efectiva para el control y seguimiento de los pacientes con hipertensión, hipercolesterolemia y diabetes mellitus tipo 2. La utilidad de las guías de práctica clínica electrónicas en el diagnóstico y adecuación del tratamiento sigue en discusión (AU)

Population prevalence and control of cardiovascular risk factors: What electronic medical records tell us / Prevalencia y control de factores de riesgo cardiovascular en la población general: ¿qué nos dice la historia clínica electrónica?

OBJETIVOS: Analizar la prevalencia, control y manejo de la hipertensión arterial, hipercolesterolemia y diabetes mellitus tipo 2. DISEÑO: Análisis transversal de todos los individuos atendidos en centros de atención primaria entre 2006 y 2009.Emplazamiento: Se extrajo de la historia clínica electrónica los antecedentes de enfermedad cardiovascular, el diagnóstico y tratamiento de la hipertensión arterial, hipercolesterolemia, diabetes mellitus tipo 2, el perfil lipídico, la glicemia y la presión arterial. Las prevalencias ylas variables de manejo y control se estandarizaron por edad. Participantes: Individuos de 35 a 74 años registrados en las bases de datos de atención primaria. Mediciones principales: Se analizaron registros de 2.174.515 de individuos (47% hombres, edad media 52 años (DE 11)). RESULTADOS: La hipertensión arterial fue el factor de riesgo más prevalente (39% en mujeres y 41% en hombres), seguido de la hipercolesterolemia (38% y 40%) y la diabetes mellitus tipo 2 (12% y 16%), respectivamente. Los diuréticos y los inhibidores de la enzima convertidora de angiotensina fueron los fármacos más frecuentemente recetados para el control de la presión arterial (68% de hombres y 60% de mujeres presentaron valores <140/90 mmHg). Sólo el 31% de los hombres y el 26% de las mujeres sin antecedentes de enfermedad cardiovascular presentaron hipercolesterolemia controlada (colesterol de las lipoproteínas de baja densidad <130 mg/dl),a pesar del porcentaje de tratamiento con estatinas (90%). EL porcentaje de mujeres y hombres con diabetes mellitus tipo 2 y hemoglobina glicada <7% era de 64.7% y 59.2%, respectivamente; el tratamiento se realizó predominantemente con antidiabéticos orales únicamente (70%) o asociados con insulina (15%). CONCLUSIONES: La hipertensión arterial fue el factor de riesgo cardiovascular más prevalente en población catalana atendida en centros de atención primaria. Alrededor de dos tercios de los individuos con hipertensión arterial o diabetes mellitus tipo 2 estaban adecuadamente controlados; mientras que el control de la hipercolesterolemia fue especialmente bajo

OBJECTIVE: To analyze the prevalence, control, and management of hypertension, hypercholesterolemia, and diabetes mellitus type 2 (DM2). DESIGN: Cross-sectional analysis of all individuals attended in the Catalan primary care centers between 2006 and 2009.LocationHistory of cardiovascular diseases, diagnosis and treatment of hypertension, hypercholesterolemia, DM2, lipid profile, glycemia and blood pressure data were extracted from electronic medical records. Age-standardized prevalence and levels of management and control were estimated. Participants: Individuals aged 35-74 years using primary care databases. Main measures: A total of 2,174,515 individuals were included (mean age 52 years [SD 11], 47% men). RESULTS: Hypertension was the most prevalent cardiovascular risk factor (39% in women, 41% in men) followed by hypercholesterolemia (38% and 40%) and DM2 (12% and 16%), respectively. Diuretics and angiotensin-converting enzyme inhibitors were most often prescribed for hypertension control (<140/90 mmHg, achieved in 68% of men and 60% of women treated). Hypercholesterolemia was controlled (low-density lipoprotein cholesterol <130 mg/dl) in just 31% of men and 26% of women with no history of cardiovascular disease, despite lipid-lowering treatment, primarily (90%) with statins. The percentage of women and men with DM2 and with glycated hemoglobin <7% was 64.7% and 59.2%, respectively; treatment was predominantly with oral hypoglycemic agents alone (70%), or combined with insulin (15%). CONCLUSIONS: Hypertension was the most prevalent cardiovascular risk factor in the Catalan population attended at primary care centers. About two thirds of individuals with hypertension or DM2 were adequately controlled; hypercholesterolemia control was particularly low

[Estimating cardiovascular risk in Spain using different algorithms]. / Rendimiento de la estimación del riesgo cardiovascular en España mediante la utilización de distintas funciones.

INTRODUCTION AND OBJECTIVES: Although its incidence is low, cardiovascular disease is the most common cause of morbidity and mortality in Spain. A number of different algorithms can be used to calculate cardiovascular disease risk for primary prevention, but their ability to identify patients who will experience a cardiovascular event is not well understood. The objective of this study was to compare the results of using the original Framingham algorithm and two adaptations for low-risk countries: the REGICOR (Registre Gironí del cor) and SCORE (Systematic COronary Risk Evaluation) algorithms. METHODS: All cardiovascular events during 5-year follow-up in a cohort of patients without coronary disease in nine autonomous Spanish regions were recorded. The levels of different cardiovascular risk factors were measured between 1995 and 1998. Participants were considered high-risk if their 10-year risk was >or=20% with the Framingham algorithm, >or=10%, >or=15% or >or=20% with REGICOR, and >or=5% with SCORE. RESULTS: In total, 180 (3.1%) coronary events (112 in men and 68 in women) occurred among the 5732 (57.3% female) participants during follow-up. Of these, 43 died from cerebrovascular disease, and 24 had a non-coronary vascular event. The REGICOR algorithm had the highest positive predictive value for coronary and cardiovascular disease in all age groups. Moreover, with a 10-year risk limit of 10%, it classified less of the population aged 35-74 years as high-risk (i.e., 12.4%) than the Framingham algorithm (i.e., 22.4%). The SCORE and Framingham algorithms classified 8.4% and 16.6% of the population aged 35-64 years, respectively, as having a high cardiovascular disease risk; with REGICOR, the figure was 7.5%. CONCLUSIONS: The REGICOR adapted algorithm was the best predictor of cardiovascular events and classified a smaller proportion of the Spanish population aged 35-74 years as high risk than alternative algorithms.

Rendimiento de la estimación del riesgo cardiovascular en España mediante la utilización de distintas funciones / Estimating cardiovascular risk in Spain using different algorithms

Introducción y objetivos. A pesar de que presentan una baja incidencia, las enfermedades cardiovasculares son la causa más frecuente de morbimortalidad en España. Se dispone de diversas funciones para calcular el riesgo cardiovascular en la prevención primaria, cuya capacidad para identificar a los pacientes que desarrollarán acontecimientos cardiovasculares es poco conocida. Comparamos el rendimiento de las funciones de Framingham original, adaptada de REGICOR (Registre Gironí del Cor) y SCORE (Systematic COronary Risk Evaluation) para países de bajo riesgo. Métodos. Se registraron todos los acontecimientos cardiovasculares en un seguimiento de 5 años de una cohorte sin enfermedad coronaria en 9 comunidades autónomas. Se midieron los factores de riesgo cardiovascular entre 1995 y 1998. Se consideró que el riesgo era elevado a los 10 años en ≥ 20% para Framingham, ≥ 10, ≥ 15 y ≥ 20% para REGICOR y ≥ 5% para SCORE. Resultados. Se produjeron 180 (3,1%) acontecimientos coronarios (112 en varones y 68 en mujeres) en las 5.732 personas (57,3% de mujeres) en las que se realizó el seguimiento. Se produjo muerte cerebrovascular en 43 personas, así como 24 acontecimientos vasculares no coronarios. Con la función REGICOR se obtuvo el mayor valor predictivo positivo para enfermedad coronaria y cardiovascular a cualquier edad, y, tomando un límite de 10% de riesgo a los 10 años, se clasificó a menos población de alto riesgo de 35-74 años (12,4%) que con la función de Framingham (22,4%). SCORE y Framingham clasificaron al 8,4 y al 16,6% de la población de 35-64 años como de alto riesgo cardiovascular y REGICOR, al 7,5%. Conclusiones. La función adaptada de REGICOR es la opción aplicable hasta los 74 años que muestra el mejor equilibrio en la capacidad de clasificación de riesgo de acontecimientos cardiovasculares. Su aplicación permite la clasificación de alto riesgo a individuos con un perfil más adecuado para ser candidatos a tratamiento hipolipemiante (AU)

Introduction and objectives. Although its incidence is low, cardiovascular disease is the most common cause of morbidity and mortality in Spain. A number of different algorithms can be used to calculate cardiovascular disease risk for primary prevention, but their ability to identify patients who will experience a cardiovascular event is not well understood. The objective of this study was to compare the results of using the original Framingham algorithm and two adaptations for low-risk countries: the REGICOR (Registre Gironí del cor) and SCORE (Systematic COronary Risk Evaluation) algorithms. Methods. All cardiovascular events during 5-year follow-up in a cohort of patients without coronary disease in nine autonomous Spanish regions were recorded. The levels of different cardiovascular risk factors were measured between 1995 and 1998. Participants were considered high-risk if their 10-year risk was ≥20% with the Framingham algorithm, ≥10%, ≥15% or ≥20% with REGICOR, and ≥5% with SCORE. Results. In total, 180 (3.1%) coronary events (112 in men and 68 in women) occurred among the 5732 (57.3% female) participants during follow-up. Of these, 43 died from cerebrovascular disease, and 24 had a non-coronary vascular event. The REGICOR algorithm had the highest positive predictive value for coronary and cardiovascular disease in all age groups. Moreover, with a 10-year risk limit of 10%, it classified less of the population aged 35-74 years as high-risk (i.e., 12.4%) than the Framingham algorithm (i.e., 22.4%). The SCORE and Framingham algorithms classified 8.4% and 16.6% of the population aged 35-64 years, respectively, as having a high cardiovascular disease risk; with REGICOR, the figure was 7.5%. Conclusions. The REGICOR adapted algorithm was the best predictor of cardiovascular events and classified a smaller proportion of the Spanish population aged 35-74 years as high risk than alternative algorithms (AU)