Effect of comorbidities on survival in patients >80 years of age at onset of renal replacement therapy: data from the ERA-EDTA Registry.

BACKGROUND: The number of elderly patients on renal replacement therapy (RRT) is increasing. The survival and quality of life of these patients may be lower if they have multiple comorbidities at the onset of RRT. The aim of this study was to explore whether the effect of comorbidities on survival is similar in elderly RRT patients compared with younger ones. METHODS: Included were 9333 patients ≥80 years of age and 48 352 patients 20-79 years of age starting RRT between 2010 and 2015 from 15 national or regional registries submitting data to the European Renal Association-European Dialysis and Transplantation Association Registry. Patients were followed until death or the end of 2016. Survival was assessed by Kaplan-Meier curves and the relative risk of death associated with comorbidities was assessed by Cox regression analysis. RESULTS: Patients ≥80 years of age had a greater comorbidity burden than younger patients. However, relative risks of death associated with all studied comorbidities (diabetes, ischaemic heart disease, chronic heart failure, cerebrovascular disease, peripheral vascular disease and malignancy) were significantly lower in elderly patients compared with younger patients. Also, the increase in absolute mortality rates associated with an increasing number of comorbidities was smaller in elderly patients. CONCLUSIONS: Comorbidities are common in elderly patients who enter RRT, but the risk of death associated with comorbidities is less than in younger patients. This should be taken into account when assessing the prognosis of elderly RRT patients.

The association of living donor source with patient and graft survival among kidney transplant recipients in the ERA-EDTA Registry - a retrospective study.

In this study we aimed to compare patient and graft survival of kidney transplant recipients who received a kidney from a living-related donor (LRD) or living-unrelated donor (LUD). Adult patients in the ERA-EDTA Registry who received their first kidney transplant in 1998-2017 were included. Ten-year patient and graft survival were compared between LRD and LUD transplants using Cox regression analysis. In total, 14 370 patients received a kidney from a living donor. Of those, 9212 (64.1%) grafts were from a LRD, 5063 (35.2%) from a LUD and for 95 (0.7%), the donor type was unknown. Unadjusted five-year risks of death and graft failure (including death as event) were lower for LRD transplants than for LUD grafts: 4.2% (95% confidence interval [CI]: 3.7-4.6) and 10.8% (95% CI: 10.1-11.5) versus 6.5% (95% CI: 5.7-7.4) and 12.2% (95% CI: 11.2-13.3), respectively. However, after adjusting for potential confounders, associations disappeared with hazard ratios of 0.99 (95% CI: 0.87-1.13) for patient survival and 1.03 (95% CI: 0.94-1.14) for graft survival. Unadjusted risk of death-censored graft failure was similar, but after adjustment, it was higher for LUD transplants (1.19; 95% CI: 1.04-1.35). In conclusion, patient and graft survival of LRD and LUD kidney transplant recipients was similar, whereas death-censored graft failure was higher in LUD. These findings confirm the importance of both living kidney donor types.

[Health care for patients with multimorbidity. The perception of professionals]. / La atención sanitaria a pacientes con multimorbilidad. La percepción de los profesionales.

OBJECTIVE: To explore the perceptions of health professionals about the characteristics of health care for patients with multimorbidity. DESIGN: Qualitative study of phenomenological trajectory made between January and September 2015 through 3 group interviews and 15 individual interviews. LOCATION: Aragonese Health Service. PARTICIPANTS: Medical and nursing professionals of the Aragon Health Service belonging to various services: Internal Medicine, Primary Care, Emergency and Management. A pharmacist was also included. METHODS: A non-probabilistic intentional sampling was carried out that allowed for the selection of professionals in terms of discourse representation criteria, allowing to know and interpret the phenomenon studied in depth, in its different visions. We interviewed health professionals with different profiles who knew in depth the characteristics of care provided to patients with multimorbidity. The interviews were recorded, transcribed literally and interpreted, through the social analysis of the discourse. RESULTS: Professional culture oriented to individual pathologies, lack of coordination among professionals, high prevalence of multi-prescriptions, Clinical Practice Guidelines oriented to individual pathologies and specialist training focused on individual diseases. CONCLUSIONS: Both the professional culture and the organization of the healthcare system have been oriented towards the attention to individual pathologies, which results in the difficulty to offer a more integrated care to patients with multimorbidity.

New Male Users of Lipid-Lowering Drugs for Primary Prevention of Cardiovascular Disease: The Impact of Treatment Persistence on Morbimortality. A Longitudinal Study.

The objective of this study was to analyse persistence to lipid-lowering drug use for primary prevention of cardiovascular disease (CVD) in a new users cohort, to explore all-cause and cardiovascular related morbidity, comorbidity and mortality in this group and, finally, to study the relationship between persistence and morbimortality. We selected subjects who started lipid-lowering treatment for primary prevention of CVD between 1 January 2010 and 31 December 2017 (N = 1424), and classified them as treatment-persistent or -nonpersistent. Bivariate analyses were performed to compare sociodemographic and clinical variables, morbimortality and time to event between groups. The association between morbidities was explored using comorbidity network analysis. The effect of persistence was analysed using logistic regression and Cox survival analyses. Only 38.7% of users were persistent with treatment. Persistent and nonpersistent users had similar sociodemographic and clinical profiles, although differed in age, smoking status, and glycemia. Comorbidity networks revealed that the number of co-occurring diagnoses was higher in nonpersistent than persistent users. Adjusted analyses indicated a protective effect of treatment persistence, especially against major adverse cardiovascular events (MACE), but this effect was not statistically significant. Observational studies are crucial to characterize real-world effectiveness.

Bacteriemias por staphylococcus aureus: factores de riesgo asociados a la resistencia a meticilina / Bacteriemias caused by staphylococcus aureus: risk factors associated to methicillin resistance

INTRODUCCION: el objetivo del trabajo ha sido identificar los factores de riesgo que podrían favorecer la aparición de resistencia a meticilina en aislamientos de Staphylococcus aureus y aquellos que influirían en la mortalidad por las bacteriemias producidas por este patógeno. METODOS: se realizó un estudio observacional de casos y controles en los 57 pacientes diagnosticados de bacteriemia por Staphylococcus aureus en el Hospital de Barbastro. Para el análisis se utilizaron los test estadísticos de Chi cuadrado de Pearson, test de Fisher y regresión logística múltiple. RESULTADOS: del total de bacteriemias, 63,15% correspondieron a Staphylococcus aureus sensible a meticilina y 36,84% a Staphylococcus aureus resistente a meticilina. Se asociaron a resistencia a meticilina, la adquisición nosocomial de la infección, el uso previo de antibióticos y la edad mayor de 65 años. La mortalidad de los casos de bacteriemia por SARM y SAMS fue respectivamente del 28,57% y del 36,11%, siendo estas diferencias estadísticamente no significativas. Todos los aislamientos fueron sensibles in vitro a vancomicina. CONCLUSIONES: en nuestro sector sanitario, las estrategias más efectivas para disminuir la incidencia de bacteriemias por SARM serían el control y uso adecuado de antimicrobianos y la aplicación de programas de prevención de infecciones nosocomiales. En los pacientes con bacteriemia por Staphylococcus aureus, la resistencia a meticilina no se asocia a más mortalidad.

INTRODUCTION: the objective of this work has been to identify the risk factors that could favor the appearance of methicillin resistance in isolates of Staphylococcus aureus (SA) and those that would influence mortality due to bacteremia produced by this pathogen. METHODS: an observational case-control study was carried out in 57 patients diagnosed with bacteremia by SA at the Barbastro's Hospital. Pearson Chi square statistical test, Fisher test and multiple logistic regression were used for the analysis. RESULTS: of the total Bacteriemias, 63.15% corresponded to methicillin-sensitive Staphylococcus aureus (MSSA) and 36.84% to methicillin-resistant Staphylococcus aureus (MRSA). Nosocomial acquisition of the infection, previous use of antibiotics and the age over 65 years, were associated with methicillin resistance. The mortality of cases of MRSA and SAMS bacteremia was 28.57% and 36.1 1% respectively, these differences being statistically not significant. All isolates were sensitive in vitro to vancomycin. CONCLUSIONS: in our health sector, the most effective strategies to reduce the incidence of MRSA bacteremia would be the control and proper use of antimicrobials and the application of nosocomial infection prevention programs. Patients with SA bacteremia, are not associated with more mortality caused by MRSA.

Performance of an easy-to-use prediction model for renal patient survival: an external validation study using data from the ERA-EDTA Registry.

Background: An easy-to-use prediction model for long-term renal patient survival based on only four predictors [age, primary renal disease, sex and therapy at 90 days after the start of renal replacement therapy (RRT)] has been developed in The Netherlands. To assess the usability of this model for use in Europe, we externally validated the model in 10 European countries. Methods: Data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry were used. Ten countries that reported individual patient data to the registry on patients starting RRT in the period 1995-2005 were included. Patients <16 years of age and/or with missing predictor variable data were excluded. The external validation of the prediction model was evaluated for the 10- (primary endpoint), 5- and 3-year survival predictions by assessing the calibration and discrimination outcomes. Results: We used a data set of 136 304 patients from 10 countries. The calibration in the large and calibration plots for 10 deciles of predicted survival probabilities showed average differences of 1.5, 3.2 and 3.4% in observed versus predicted 10-, 5- and 3-year survival, with some small variation on the country level. The concordance index, indicating the discriminatory power of the model, was 0.71 in the complete ERA-EDTA Registry cohort and varied according to country level between 0.70 and 0.75. Conclusions: A prediction model for long-term renal patient survival developed in a single country, based on only four easily available variables, has a comparably adequate performance in a wide range of other European countries.

Renal replacement therapy in Europe: a summary of the 2013 ERA-EDTA Registry Annual Report with a focus on diabetes mellitus.

BACKGROUND: This article provides a summary of the 2013 European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD). METHODS: In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people. RESULTS: In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5-61.3] and 50.6% (95% CI 49.9-51.2) for patients with DM as the cause of ESRD.

Non-adherence to antihypertensive medication: The role of mental and physical comorbidity.

BACKGROUND: Multiple parameters influence adherence to drug treatment, including socio-economic, healthcare, condition, therapy, and patient-related factors. However, studies of the impact of patient-related factors, particularly regarding comorbid conditions, have produced conflicting results. OBJECTIVES: To analyse the association between mental and physical comorbidity and non-adherence to antihypertensive medication in patients attending primary care, after including a comprehensive range of chronic comorbidities and potential confounders. METHODS: Cross-sectional study of 113,397 adults with a diagnosis of hypertension in 2010 assigned to the public health service of a region in northeastern Spain. Pharmacy billing records were linked to data from electronic health records at individual level. Non-adherence was defined as an antihypertensive medication possession ratio (MPR) <80%. Multivariable logistic regression models were used to estimate the odds ratio for non-adherence. Potential predictors included mental and physical comorbidity, age, sex, blood pressure level, nationality, rurality, polypharmacy, and number of visits to the GP and to different specialties. RESULTS: One fifth of the study population showed poor adherence levels. Female sex, younger age, foreign nationality, living in a rural area, low blood pressure levels, polypharmacy, and mental comorbidity were positively and significantly associated with non-adherence. Conversely, non-adherence was negatively and significantly associated with the presence of cardiovascular risk factors and higher annual rates of GP visits. CONCLUSION: The majority of patient-related determinants identified here (e.g., the presence of mental comorbidity, polypharmacy, foreign nationality) underscores the need for a patient- rather than a disease-centred care approach, as well as adequate physician-patient communication.

[Perceptions of patients and health professionals about the quality of care provided to chronic obstructive pulmonary disease patients]. / Percepciones de pacientes y profesionales sobre la calidad de la atención a personas con enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To explore the understanding and knowledge of patients and health professionals about factors that influence the quality of care provided in Primary Care to people with Chronic Obstructive Pulmonary Disease (COPD). DESIGN: Qualitative study performed between February and March 2010. LOCATION: Primary Care Centers. PARTICIPANTS: Medical and nursing professionals and patients with COPD. METHODS: Non-probabilistic intentional sampling with representation criterion of the discourse. Two group (focus group) and 6 individual interviews were performed. The interviews were recorded, literally transcribed and interpreted by social discourse analysis. RESULTS: Patients neither identify properly the symptomatology nor they assume the COPD importance until advanced states. The lacks of knowledge about the evolution of the disease and the impact on quality of life hinders the necessary changes. Professionals reports problems with performing spirometry. Among doctors, scepticism regarding to the effectiveness of the interventions aimed at change of behaviour is identified. The existence of Clinical Guides, the improvement of the coordination between professionals and the alignment of priorities between managers and professionals stand out as organizational factors. CONCLUSIONS: The identified factors suggest the possibility of improving the health care through improved communication to motivate them to take the recommended changes and to increase the adherence to treatments. To this effect, the awareness and training of professionals, the healthcare coordination, the implementation of Clinical Guides and the use of indicators in a process of quality assessment.

Clinical evolution of chronic renal patients with HIV infection in replacement therapy.

Patients on renal replacement therapy (RRT) infected with the human immunodeficiency virus (HIV) are a special group with growing interest. In order to study the epidemiological data of HIV+ patients on RRT in Spain, we collected individual information from 2004-2011 (period of use of highly active antiretroviral therapy [HAART] in the Autonomous Communities of Andalusia, Aragon, Asturias, Catalonia, Valencia, Castilla la Mancha, Castilla León, Galicia, Madrid, La Rioja and the Basque Country, comprising 85% of the Spanish population. A total of 271 incident and 209 prevalent patients were analysed. They were compared with the remaining patients on RRT during the same period. The annual incidence was 0.8 patients per one million inhabitants, with a significant increase during the follow-up period. The proportion of prevalent HIV+ patients was 5.1 per 1,000 patients on RRT (95% confidence interval [CI] 4.4-5.8. Although glomerular diseases constituted the majority of cases (42%), diabetic nephropathy was the cause in 14% of patients. The nation-wide totals for these percentages were 13 and 25%, respectively. Compared to the total of patients in treatment, the risk of death was significantly higher in the HIV+ group: hazard ratio (HR) adjusted for age, sex and diabetes was 2.26 (95% CI 1.74 - 2.91). Hepatitis C coinfection increased the risk of death in the HIV+ group (HR 1.77; 95% CI 1.10 - 2.85). The probability of kidney transplantation in HIV+ was only 17% after 7 years, comparing with total RTT patients (HR 0.15; 95% CI: 0.10-0.24). Despite the use of HAART, the incidence of HIV+ patients on dialysis has increased; their mortality still exceeds non-HIV patients, and they have a very low rate of transplantation. It is necessary to further our knowledge of this disease in order to improve results.

A Spanish version for the new ERA-EDTA coding system for primary renal disease.

BACKGROUND: The European Renal Association and the European Dialysis and Transplant Association (ERA-EDTA) have issued an English-language new coding system for primary kidney disease (PKD) aimed at solving the problems that were identified in the list of "Primary renal diagnoses" that has been in use for over 40 years. PURPOSE: In the context of Registro Español de Enfermos Renales (Spanish Registry of Renal Patients, [REER]), the need for a translation and adaptation of terms, definitions and notes for the new ERA-EDTA codes was perceived in order to help those who have Spanish as their working language when using such codes. METHODS: Bilingual nephrologists contributed a professional translation and were involved in a terminological adaptation process, which included a number of phases to contrast translation outputs. Codes, paragraphs, definitions and diagnostic criteria were reviewed and agreements and disagreements aroused for each term were labelled. Finally, the version that was accepted by a majority of reviewers was agreed. RESULTS: A wide agreement was reached in the first review phase, with only 5 points of discrepancy remaining, which were agreed on in the final phase. CONCLUSIONS: Translation and adaptation into Spanish represent an improvement that will help to introduce and use the new coding system for PKD, as it can help reducing the time devoted to coding and also the period of adaptation of health workers to the new codes.

Renal replacement therapy in Europe: a summary of the 2012 ERA-EDTA Registry Annual Report.

BACKGROUND: This article summarizes the 2012 European Renal Association-European Dialysis and Transplant Association Registry Annual Report (available at www.era-edta-reg.org) with a specific focus on older patients (defined as ≥65 years). METHODS: Data provided by 45 national or regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. Individual patient level data were received from 31 renal registries, whereas 14 renal registries contributed data in an aggregated form. The incidence, prevalence and survival probabilities of patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT) and renal transplantation rates for 2012 are presented. RESULTS: In 2012, the overall unadjusted incidence rate of patients with ESRD receiving RRT was 109.6 per million population (pmp) (n = 69 035), ranging from 219.9 pmp in Portugal to 24.2 pmp in Montenegro. The proportion of incident patients ≥75 years varied from 15 to 44% between countries. The overall unadjusted prevalence on 31 December 2012 was 716.7 pmp (n = 451 270), ranging from 1670.2 pmp in Portugal to 146.7 pmp in the Ukraine. The proportion of prevalent patients ≥75 years varied from 11 to 32% between countries. The overall renal transplantation rate in 2012 was 28.3 pmp (n = 15 673), with the highest rate seen in the Spanish region of Catalonia. The proportion of patients ≥65 years receiving a transplant ranged from 0 to 35%. Five-year adjusted survival for all RRT patients was 59.7% (95% confidence interval, CI: 59.3-60.0) which fell to 39.3% (95% CI: 38.7-39.9) in patients 65-74 years and 21.3% (95% CI: 20.8-21.9) in patients ≥75 years.

Age and gender differences in the prevalence and patterns of multimorbidity in the older population.

BACKGROUND: The coexistence of several chronic diseases in one same individual, known as multimorbidity, is an important challenge facing health care systems in developed countries. Recent studies have revealed the existence of multimorbidity patterns clustering systematically associated distinct clinical entities. We sought to describe age and gender differences in the prevalence and patterns of multimorbidity in men and women over 65 years. METHODS: Observational retrospective multicentre study based on diagnostic information gathered from electronic medical records of 19 primary care centres in Aragon and Catalonia. Multimorbidity patterns were identified through exploratory factor analysis. We performed a descriptive analysis of previously obtained patterns (i.e. cardiometabolic (CM), mechanical (MEC) and psychogeriatric (PG)) and the diseases included in the patterns stratifying by sex and age group. RESULTS: 67.5% of the aged population suffered two or more chronic diseases. 32.2% of men and 45.3% of women were assigned to at least one specific pattern of multimorbidity, and 4.6% of men and 8% of women presented more than one pattern simultaneously. Among women over 65 years the most frequent pattern was the MEC pattern (33.3%), whereas among men it was the CM pattern (21.2%). While the prevalence of the CM and MEC patterns decreased with age, the PG pattern showed a higher prevalence in the older age groups. CONCLUSIONS: Significant gender differences were observed in the prevalence of multimorbidity patterns, women showing a higher prevalence of the MEC and PG patterns, as well as a higher degree of pattern overlapping, probably due to a higher life expectancy and/or worse health. Future studies on multimorbidity patterns should take into account these differences and, therefore, the study of multimorbidity and its impact should be stratified by age and sex.

Renal replacement therapy in Europe-a summary of the 2010 ERA-EDTA Registry Annual Report.

BACKGROUND: This study provides a summary of the 2010 European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at www.era-edta-reg.org). METHODS: This report includes data on renal replacement therapy (RRT) using data from the national and regional renal registries in 29 countries in Europe and bordering the Mediterranean Sea. Individual patient data were received from 27 registries, whereas 18 registries contributed data in aggregated form. We present incidence and prevalence of RRT, transplant rates, survival probabilities and expected remaining lifetimes. The latter two are solely based on individual patient records. RESULTS: In 2010, the overall incidence rate of RRT for end-stage renal disease (ESRD) among all registries reporting to the ERA-EDTA Registry was 123 per million population (pmp) (n = 91 798). The highest incidence rate was reported by Turkey (252pmp) and the lowest reported by Montenegro (21 pmp). The overall prevalence of RRT for ESRD at 31 December 2010 among all registries reporting to the ERA-EDTA Registry was 741 pmp (n = 551 005). The prevalence varied from 124 pmp in Ukraine to 1580 pmp in Portugal. The overall number of renal transplantations performed in 2010 among all registries was 29.2 pmp (n = 21 740). The highest overall transplant rate was reported from Spain, Cantabria (73 pmp), whereas the highest transplant rate for living donor kidneys was reported from the Netherlands (28 pmp). For patients who started RRT between 2001 and 2005, the unadjusted 5-year patient survival on RRT was 46.2% [95% confidence interval (CI) 46.0-46.3], and on dialysis 38.6% (95% CI 38.5-38.8). The unadjusted 5-year patient survival after the first renal transplantation performed between 2001 and 2005 was 86.6% (95% CI 86.1-87.1) for deceased donor kidneys and 94.1% (95% CI 93.4-94.8) for living donor kidneys.

Multimorbidity, polypharmacy, referrals, and adverse drug events: are we doing things well?

BACKGROUND: The consequences of multimorbidity include polypharmacy and repeated referrals for specialised care, which may increase the risk of adverse drug events (ADEs). AIM: The objective of this study was to analyse the influence of multimorbidity, polypharmacy, and multiple referrals on the frequency of ADEs, as an indicator of therapeutic safety, in the context of a national healthcare system. DESIGN AND SETTING: This was a multicentre, retrospective, observational study of 79 089 adult patients treated during 2008 in primary care centres. METHOD: The explanatory patient variables sex, age, level of multimorbidity, polypharmacy, number of primary care physician visits, and number of different specialties attended were analysed. The response variable was the occurrence of ADEs. Logistic regression models were used to identify associations among the analysed variables. RESULTS: The prevalence of individuals with at least one ADE was 0.88%. Multivariate analysis identified the following variables as risk factors for the occurrence of ADE in descending order of effect size: multimorbidity level (odds ratio [OR]Veryhigh/Low = 45.26; ORHigh/Low = 17.58; ORModerate/Low = 4.25), polypharmacy (OR = 1.34), female sex (OR = 1.31), number of different specialties (OR = 1.20), and number of primary care physician visits (OR = 1.01). Age, however, did not show statistical significance (OR = 1.00; 95% confidence interval = 0.996 to 1.005). CONCLUSION: The results of this study demonstrate that multimorbidity is strongly related to the occurrence of ADEs, insofar as it requires the intervention of multiple specialties and the prescription of multiple medications. Further research should shed light on the causal pathway between multimorbidity and increased risk of adverse events.

[Variations in the prescription of antibiotics among primary care areas in the autonomous region of Aragon, Spain]. / Variabilidad de la prescripción de antibióticos en atención primaria de los sectores sanitarios de Aragón.

BACKGROUND: Resistance to antibacterial drugs can be contained by judicious utilization, so we must know about its use. The objective is to describe the prevalence of antibiotic consumption and the variability in the use of antibiotics among outpatients in the different health areas of Aragon. METHODS: Study of the prescription of antibiotics in the health areas of Aragon in 2008. Data were extracted from the Aragon Pharmaceutical Consumption Database, a complete register of all dispensed prescriptions. Prescription rates per 1000 individuals adjusted by sex and age were calculated using a direct and indirect standardization method. The subgroups utilization were calculated in Defined Daily Dose per 1000 inhabitants per day (DID). In the variation analysis were used: extremal quotient (EQ), coefficient of variation (CV), weighted coefficient of variation (CVw). RESULTS: The adjusted rate of antibiotic varied between 279,8 and 382 per 1000 inhabitants, showing a CVw=0,12. The utilization rate in women was 364.9 per 1,000 and in men 300.0 per 1,000. Cephalosporins have a EQ=2,42 and CVw=0,37; and quinolones have EQ=1,84 and CVw=0,22. CONCLUSIONS: The utilization rate was higher in women than men. The higher variability in the prescription of antibiotics among health areas in Aragon was in cephalosporins and quinolones.

Does the pharmacy expenditure of patients always correspond with their morbidity burden? Exploring new approaches in the interpretation of pharmacy expenditure.

BACKGROUND: The computerisation of primary health care (PHC) records offers the opportunity to focus on pharmacy expenditure from the perspective of the morbidity of individuals. The objective of the present study was to analyse the behaviour of pharmacy expenditure within different morbidity groups. We paid special attention to the identification of individuals who had higher values of pharmacy expenditure than their morbidity would otherwise suggest (i.e. outliers). METHODS: Observational study consisting of 75,574 patients seen at PHC centres in Zaragoza, Spain, at least once in 2005. Demographic and disease variables were analysed (ACG 8.1), together with a response variable that we termed 'total pharmacy expenditure per patient'. Outlier patients were identified based on boxplot methods, adjusted boxplot for asymmetric distributions, and by analysing standardised residuals of tobit regression models. RESULTS: The pharmacy expenditure of up to 7% of attendees in the studied PHC centres during one year exceeded expectations given their morbidity burden. This group of patients was responsible for up to 24% of the total annual pharmacy expenditure. There was a significantly higher number of outlier patients within the low-morbidity band which matched up with the higher variation coefficient observed in this group (3.2 vs. 2.0 and 1.3 in the moderate- and high-morbidity bands, respectively). CONCLUSIONS: With appropriate validation, the methodologies of the present study could be incorporated in the routine monitoring of the prescribing profile of general practitioners. This could not only enable evaluation of their performance, but also target groups of outlier patients and foster analyses of the causes of unusually high pharmacy expenditures among them. This interpretation of pharmacy expenditure gives new clues for the efficiency in utilisation of healthcare resources, and could be complementary to management interventions focused on individuals with a high morbidity burden.