Assessment of pharmacological strategies for management of major depressive disorder and their costs after an inadequate response to first-line antidepressant treatment in primary care.

BACKGROUND: The aim of the study was to determine the most common treatment strategies and their costs for patients with an inadequate response to first-line antidepressant treatment (AD) in primary care. METHOD: A retrospective cohort study of medical records from six primary care centers was conducted. Adults with a major depressive disorder diagnosis, at least 8 weeks of AD treatment after the first prescription, and patient monitoring for 12 months were analyzed. Healthcare (direct cost) and non-healthcare costs (indirect costs; work productivity losses) were described. RESULTS: A total of 2,260 patients were studied. Forty-three percent of patients (N = 965) presented an inadequate response to treatment. Summarizing the different treatment approaches: 43.2% were switched to another AD, 15.5% were given an additional AD, AD dose was increased in 14.6%, and 26.7% remained with the same antidepressant agent. Healthcare/annual costs were 451.2 Euros for patients in remission vs. 826.1 Euros in those with inadequate response, and productivity losses were 991.4 versus 1,842.0 Euros, respectively (p < 0.001). CONCLUSION: Antidepressant switch was the most common therapeutic approach performed by general practitioners in naturalistic practice. A delay in treatment change when no remission occurs and a significant heterogeneity in management of these patients were also found.

[Costs and associated factors with optimal and suboptimal responses to the treatment of major depressive disorder]. / Costes y factores asociados a las respuestas óptima y subóptima al tratamiento del trastorno depresivo mayor en atención primaria.

OBJECTIVE: To evaluate the compliance, persistence and costs of the treatment of major depressive disorder (MDD) in the setting of Primary Care, placing emphasis on the different aspects of those patients with an initial suboptimal response to antidepressant treatment. DESIGN: A retrospective observational study using the population registers of Badalona Healthcare Services. The inclusion criteria consisted of; age ≥18 years, initial episode during 2008-2009, and to be on antidepressant treatment for at least 8 weeks after the first prescription. The follow-up was 12 months. Two study groups were formed, patients with suboptimal response, and remission. MAIN MEASUREMENTS: Sociodemographic data, compliance and adherence to treatment, health costs (direct and indirect). RESULTS: A total of 2,260 subjects were analysed (mean age 58.8 years, 74% women). Just under half (42.7%, 95% CI; 40.0-46.4%) had a suboptimal response to the treatment. These patients had a higher mean age, a higher proportion of women, and pensioners, as well as higher comorbidity, compared to the remission group. They also had poorer compliance percentages (65.1% vs. 67.7%) and treatment persistence at 12 months (31.8% vs. 53.2%), respectively, P<.001. The annual health costs were, 826.1€ for patients with a suboptimal response vs. 451.2€ in patients in remission; loss of productivity 1,842.0€ vs. 991.4€, respectively; P<.001. The factors associated to a suboptimal response were; lack of compliance (OR=1.7), years with the disorder (OR=1.2), age (OR=1.1) and presence of comorbidity (OR=1.1). CONCLUSIONS: The patients with an initial suboptimal response to antidepressant treatment had a higher comorbidity, lower therapeutic compliance, and incurred higher total costs, particularly in losses in work productivity.

[Comparison of three methods for measuring multiple morbidity according to the use of health resources in primary healthcare]. / Comparación entre tres métodos de medida de la multimorbilidad en función del uso de recursos sanitarios en atención primaria.

OBJECTIVE: To compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC). DESIGN: Retrospective study using computerized medical records. SETTING: Thirteen PHC teams in Catalonia (Spain). PARTICIPANTS: Assigned patients requiring care in 2008. MAIN MEASUREMENTS: The socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs. STATISTICAL ANALYSIS: 3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R(2)), p< .05. RESULTS: The study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R(2)=50.4%, the ChI an R(2)=29.2% and BUR an R(2)=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results. CONCLUSIONS: The CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix.

Clinical validity of a population database definition of remission in patients with major depression.

BACKGROUND: Major depression (MD) is one of the most frequent diagnoses in Primary Care. It is a disabling illness that increases the use of health resources. AIM: To describe the concordance between remission according to clinical assessment and remission obtained from the computerized prescription databases of patients with MD in a Spanish population. DESIGN: multicenter cross-sectional. The population under study was comprised of people from six primary care facilities, who had a MD episode between January 2003 and March 2007. A specialist in psychiatry assessed a random sample of patient histories and determined whether a certain patient was in remission according to clinical criteria (ICPC-2). Regarding the databases, patients were considered in remission when they did not need further prescriptions of AD for at least 6 months after completing treatment for a new episode. Validity indicators (sensitivity [S], specificity [Sp]) and clinical utility (positive and negative probability ratio [PPR] and [NPR]) were calculated. The concordance index was established using Cohen's kappa coefficient. Significance level was p < 0.05. RESULTS: 133 patient histories were reviewed. The kappa coefficient was 82.8% (confidence intervals [CI] were 95%: 73.1 - 92.6), PPR 9.8% and NPR 0.1%. Allocation discrepancies between both criteria were found in 11 patients. S was 92.5% (CI was 95%: 88.0 - 96.9%) and Sp was 90.6% (CI was 95%: 85.6 - 95.6%), p < 0.001. Reliability analysis: Cronbach's alpha: 90.6% (CI was 95%: 85.6 - 95.6%). CONCLUSIONS: Results show an acceptable level of concordance between remission obtained from the computerized databases and clinical criteria. The major discrepancies were found in diagnostic accuracy.

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases.

BACKGROUND: The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments. METHODS/DESIGN: We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness.The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization.The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50).The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. STATISTICAL ANALYSIS: multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05.

Metabolic syndrome in outpatients receiving antipsychotic therapy in routine clinical practice: a cross-sectional assessment of a primary health care database.

OBJECTIVE: To determine the prevalence of metabolic syndrome (MS) in outpatients treated with antipsychotics included in a primary-health-care database. METHODS: A cross-sectional study was carried out assessing an administrative outpatients claim-database from 5 primary-health-centers. Subjects on antipsychotics for more than 3 months were included. The control group was formed by the outpatients included in the database without exposition to any antipsychotic drugs. MS was defined according to the modified NCEP-ATP III criteria, and required confirmation of at least 3 of the 5 following components: body mass index >28.8 kg/m(2), triglycerides >150 mg/ml, HDL-cholesterol <40 mg/ml (men)/<50mg/ml (women), blood pressure >130/85 mmHg, and fasting serum glucose >110 mg/dl. RESULTS: We identified 742 patients [51.5% women, aged 55.1 (20.7) years] treated with first- or second-generation antipsychotics during 27.6 (20.3) months. Controls were 85.286 outpatients [50.5% women, aged 45.5 (17.7) years]. MS prevalence was significantly higher in subjects on antipsychotics: 27.0% (95% CI, 23.8-30.1%) vs. 14.4% (14.1-14.6%); age- and sex-adjusted OR=1.38 (1.16-1.65, P<0.001). All MS components, except high blood pressure, were significantly more prevalent in the antipsychotic group, particularly body mass index >28.8 kg/m(2): 33.0% (29.6-36.4%) vs. 17.8% (17.6-18.1%), adjusted OR=1.63 (1.39-1.92, P<0.001), and low HDL-cholesterol levels: 48.4% (44.8-52.0%) vs. 29.3% (29.0-29.6%); adjusted OR=1.65 (1.42-1.93, P<0.001). Compared with the reference population, subjects with schizophrenia or bipolar disorder (BD), but not dementia, showed a higher prevalence of MS. CONCLUSIONS: Compared with the general outpatient population, the prevalence of MS was significantly higher in patients with schizophrenia or BD treated with antipsychotics.

[Patterns of health services use and costs in patients with mental disorders in primary care]. / Costes y patrón de uso de servicios en pacientes que demandan atención por problemas mentales en asistencia primaria.

OBJECTIVES: To determine the pattern of services use and costs of patients requiring care for mental disorders (MD) in primary care in the context of routine clinical practice. METHODS: We performed a retrospective study of patients older than 15 consulting primary care at least once for MD, attended by 5 primary care teams in 2004. A comparative group was formed with the remaining outpatients without MD. The main measurements were age, gender, case-mix/comorbidity and health resource utilization and corresponding outpatient costs (drugs, diagnostic tests and visits). Multiple logistic regression analysis and ANCOVA models were applied. RESULTS: A total of 64,072 patients were assessed, of which 11,128 had some type of MD (17.4%; 95% CI, 16.7-18.1). Patients consulting for MD had a greater number of health problems (6.7 vs. 4.7; p < 0.0001) and higher resource consumption, mainly all-type medical visits/patient/year (10.7 vs. 7.2; p < 0.0001). The mean annual cost per patient was higher for patients with MD (851.5 vs. 519.2 euros; p < 0.0001), and this difference remained significant after adjusting by age, sex and comorbidities, with a differential cost of euros 72.7 (95% CI, 59.2-85.9). All components of outpatient management costs were significantly higher in the MD group. CONCLUSIONS: Outpatients seeking care for some type of MD had a high number of comorbidities and showed greater annual cost per patient in the primary care setting.

[Economic evaluation of desvenlafaxine in the treatment of major depressive disorder in Spain]. / Evaluación económica de la desvenlafaxina en el tratamiento de la depresión mayor en España.

INTRODUCTION: The objective of this analysis was to evaluate the clinical and economic value of the use of 50mg-desvenlafaxine compared to the usual care (mix of duloxetine and venlafaxine) in the outpatient treatment of major depressive disorder after first line treatment failure (relapse) in Spain. MATERIALS AND METHODS: A Markov model was used to follow up a cohort of major depressive disorder patients for one year after failure of first-line treatment with a serotonin-specific reuptake inhibitor and estimate outcome measures (percentage remission and depression-free days) and accrued and direct costs incurred during outpatient treatment of major depressive disorder. In order to obtain the efficacy data related to the treatment alternatives, a literature review of clinical trials was performed. A panel of clinical experts validated the use of clinical resources employed in the estimation of economic outcomes together with model assumptions. The analysis was performed in 2014 from the perspective of the National Health System. RESULTS: Due to fewer discontinuations, initiating second line treatment with desvenlafaxine was associated with more depression-free days and a higher percentage of patients in remission versus usual care: 1.7 days and 0.5%, respectively. This was translated into lower drug and events management costs, and an overall cost reduction of €108 for the National Health System. CONCLUSIONS: In patients who have not responded to a first-line serotonin-specific reuptake inhibitor therapy, desvenlafaxine-50mg was clinically similar in effectiveness, but a less costly option, compared with a weighted average of duloxetine and venlafaxine for the second-line treatment of major depressive disorder patients from a payer (National Health System) perspective in Spain.

Influence of the CYP2D6 isoenzyme in patients treated with venlafaxine for major depressive disorder: clinical and economic consequences.

BACKGROUND: Antidepressant drugs are the mainstay of drug therapy for sustained remission of symptoms. However, the clinical results are not encouraging. This lack of response could be due, among other causes, to factors that alter the metabolism of the antidepressant drug. OBJECTIVE: to evaluate the impact of concomitant administration of CYP2D6 inhibitors or substrates on the efficacy, tolerability and costs of patients treated with venlafaxine for major depressive disorder in clinical practice. METHODS: We designed an observational study using the medical records of outpatients. Subjects aged ≥ 18 years who started taking venlafaxine during 2008-2010 were included. Three study groups were considered: no combinations (reference), venlafaxine-substrate, and venlafaxine-inhibitor. The follow-up period was 12 months. The main variables were: demographic data, comorbidity, remission (Hamilton <7), response to treatment, adverse events and costs. The statistical analysis included logistic regression models and ANCOVA, with p values <0.05 considered significant. RESULTS: A total of 1,115 subjects were recruited. The mean age was 61.7 years and 75.1% were female. Approximately 33.3% (95% CI: 30.5 to 36.1) were receiving some kind of drug combination (venlafaxine-substrate: 23.0%, and venlafaxine-inhibitor: 10.3%). Compared with the venlafaxine-substrate and venlafaxine-inhibitor groups, patients not taking concomitant drugs had a better response to therapy (49.1% vs. 39.9% and 34.3%, p<0.01), greater remission of symptoms (59.9% vs. 50.2% and 43.8%, p<0.001), fewer adverse events (1.9% vs. 7.0% and 6.1%, p<0.05) and a lower mean adjusted cost (€2,881.7 vs. €4,963.3 and €7,389.1, p<0.001), respectively. All cost components showed these differences. CONCLUSIONS: The patients treated with venlafaxine alone showed a better response to anti-depressant treatment, greater remission of symptoms, a lower incidence of adverse events and lower healthcare costs.

[Impact of morbidity, resource use and costs on maintenance of remission of major depression in Spain: a longitudinal study in a population setting]. / Impacto de la morbilidad, uso de recursos y costes en el mantenimiento de la remisión de la depresión mayor en España: estudio longitudinal de ámbito poblacional.

OBJECTIVE: To determinate the impact of comorbidity, resource use and cost (healthcare and lost productivity) on maintenance of remission of major depressive disorder in a Spanish population setting. METHODS: We performed an observational, prospective, multicenter study using population databases. The inclusion criteria were age > or = 18 years, first depressive episode between January 2003 and March 2007, with antidepressant prescription >60 days after the first prescription and a follow-up of at least 18 months (study: 12 months; continuation: 6 months). Two subgroups were considered: patients with/without remission. MAIN MEASURES: sociodemographic data, episodes, resource utilization bands, healthcare costs (direct) and lost productivity (indirect). Logistic regression and analysis of covariance (Bonferroni correction) were used for analysis. RESULTS: A total of 4,572 patients were analyzed and 54.6% (95% confidence interval: 53.2-56.0%) were considered in remission. Patients in remission were younger (52.6 vs. 60.7), with a lower proportion of women (71.7% vs. 78.2%), and showed less general morbidity (6.2 vs. 7.7 episodes/year), lower resource utilization bands/year (2.7 vs. 3.0), fewer sick leave days (31.0 vs. 38.5) and shorter treatment duration (146.6 vs. 307.7 days); p<0.01. Lack of remission was associated with fibromyalgia (odds ratio [OR]=2.5), thyroid alterations (OR=1.3) and hypertension (OR=1.2); p<0.001. The annual healthcare cost was euro706.0 per patient in remission vs. euro1,108.3 without remission (p <0.001) and lost productivity was euro1,631.5 vs. euro2,024.2, respectively (p <0.001). CONCLUSIONS: Patients not achieving remission showed higher morbidity, resources use, healthcare costs and, especially, productivity losses.

Comparison of escitalopram vs. citalopram and venlafaxine in the treatment of major depression in Spain: clinical and economic consequences.

STUDY OBJECTIVE: Population based study to determine the clinical consequences and economic impact of using escitalopram (ESC) vs. citalopram (CIT) and venlafaxine (VEN) in patients who initiate treatment for a new episode of major depression (MD) in real life conditions of outpatient practice. METHODS: Observational, multicenter, retrospective study conducted using computerized medical records (administrative databases) of patients treated in six primary care centers and two hospitals between January 2003 and March 2007. STUDY POPULATION: patients >20 years of age diagnosed with a new episode of MD who initiate treatment with ESC, CIT or VEN who had not received any antidepressant treatment within the previous 6 months, and were followed for 18 months or more. MAIN VARIABLES: socio-demographic variables, remission (defined as a patient completing 6 months of therapy), comorbidity, annual health care costs (medical visits, diagnostic and therapeutic tests, hospitalizations, emergency room and psychoactive drugs prescribed) and non-health care costs (productivity losses at work, mainly sick leave and disability). STATISTICAL ANALYSES: logistic regression and ANCOVA models. RESULTS: A total of 965 patients (ESC = 131; CIT = 491; VEN = 343) were identified and met study criteria. ESC-treated patients were younger, with a higher proportion of males, and had a lower specific comorbidity (p < 0.01). ESC-treated patients achieved higher remission rates compared to CIT (58.0% vs. 38.3%) or VEN patients (32.4%), p < 0.001, and had lower productivity work losses compared to VEN patients (32.7 vs. 43.8 days), p = 0.042. No differences in productivity work losses were observed between ESC and CIT patients. Compared to the ESC group, higher costs in average/unit of psychoactive drugs were found in the VEN group (€643.00), p = 0.003, whereas no differences were observed between the ESC and CIT groups (€294.70 vs. €265.20). In the corrected model, total costs (health care and non-health care cost) were lower with ESC (€2276.20) compared to CIT (€3093.80), p = 0.047 and VEN (€3801.20), p = 0.045. CONCLUSIONS: ESC appears to be dominant in the treatment of new MD episodes when compared to CIT and VEN, resulting in higher remission rates and lower total costs.

[Use of resources and costs profile in patients with fibromyalgia or generalized anxiety disorder in primary care settings]. / Perfil de uso de recursos y costes en pacientes que demandan atención por fibromialgia o trastorno de ansiedad generalizada en el ámbito de la atención primaria de salud.

OBJECTIVE: To determine the use of services and costs in patients with Fibromyalgia (FM) or Generalized Anxiety Disorder (GAD) followed up in Primary Care (PC). DESIGN: A retrospective multicenter population-based study. SETTING: Five primary care clinics managed by Badalona Health Service. PARTICIPANTS: Patients over 18 years seen in the 5 PC centers during the year 2006. Patients with and without GAD/FM were compared. MEASUREMENTS: Main outcomes measures were general, case/co-morbidity, health care use and primary care cost (visits, diagnostic/therapeutic tests and drugs). STATISTICAL ANALYSIS: logistic regression and ANCOVA (P<.05). RESULTS: There was a total of 63,349 patients, 1.4% (95% CI, 0.6%-2.2%) had a diagnosis of FM, and 5.3% (95% CI, 4.5%-6.1%) GAD. The average episodes/year and visits /year was higher in FM group compared to GAD group, with a marked difference observed vs. the reference group (8.3 vs. 7.2 and 4.6 episodes/year; and 12.9 vs. 12.1 and 7.4 visits/year; P <.001). FM was shown to be related to female gender (odds ratio [OR] = 16.8), dyslipidemia (OR = 1.5), and depressive syndrome (OR = 3.9) (P <.001 in all cases). GAD was related to age (OR = 1.1), female gender (OR = 2.2), high blood pressure (OR = 1.3), dyslipidemia (OR=1.2), smoking (OR = 1.4), depressive syndrome (OR = 1.2), and cardiovascular events (OR = 1.3) (P<.02 in all cases). After adjusting for age, gender and co-morbidities, mean annual direct ambulatory cost was 555.58 Euro for the reference group, 817.37 Euro for GAD, and 908.67 Euro for FM (P<.001). CONCLUSIONS: Compared with reference group, a considerable use of health resources and costs was observed in patients with FM or TAG in medical practice in PC settings.

Relationship between obesity and antipsychotic drug use in the adult population: a longitudinal, retrospective claim database study in Primary Care settings.

OBJECTIVE: To describe the association between obesity and the use of antipsychotic drugs (APDs) in adult outpatients followed-up on in five Primary Care settings. METHODS: A longitudinal, retrospective design study carried out between July 2004 and June 2005, in patients who were included in a claim database and for whom an APD treatment had been registered. A body mass index (BMI) <30 kg/m(2) was defined as obesity. The main measurements were: use of APDs, demographics, medical background and co-morbidities, and clinical parameters. Logistic regression analysis and ANCOVA with Bonferroni adjustment were applied to correct the model. RESULTS: A total of 42,437 subjects (mean age: 50.8 (18.4) years; women: 54.5%; obesity: 27.3% [95% confidence intervals (CI), 26.9%-27.7%]) were analyzed. A total of 1.3% of the patients were receiving APDs, without statistical differences in distribution by type of drug (typical: 48.8%; atypical: 51.2%). Obesity was associated with the use of APDs [OR = 1.5 (CI: 1.3-1.8)], hypertension [OR = 2.4 (CI: 2.2-2.5)], diabetes [OR = 1.4 (CI: 1.3-1.5)] and dyslipidemia [OR = 1.3 (CI: 1.2-1.4)], p < 0.0001 in all cases. BMI was significantly higher in subjects on APDs; 28.8 vs. 27.3 kg/m(2), p = 0.002, and remained higher after adjusting by age and sex (mean difference 0.4 (CI: 0.1-0.7), p < 0.01). After adjusting by age, sex and the Charlson index, obese subjects generated higher average annual total costs than nonobese subjects; 811 (CI: 787-835) vs. 694 (CI: 679-709), respectively, p < 0.001. CONCLUSIONS: Obesity was associated with the use of APDs, regardless of the type of drug, and with the presence of hypertension, diabetes and dyslipidemia. Obesity was also associated with substantially higher health care costs.

[Influence of morbidity and the use of health resources in patients who require care for generalised anxiety disorder in the primary health care setting]. / Influencia de la morbilidad y uso de recursos en pacientes que demandan atención por trastorno de ansiedad generalizada en el ámbito de la atención primaria de salud.

OBJECTIVE: To evaluate the co-morbidity, health care use, economical impact, and availability of effective treatments used in generalised anxiety disorder (GAD) patients in a primary care setting (PCS). METHOD: A retrospective multicentre population-based study. SETTING: Five primary care clinics managed by Badalona Serveis Assistencials S.A., Barcelona, Spain. PARTICIPANTS: Outpatient records of patients over 18 years managed at 5 PCSs during 2006. Patients with and without GAD were compared. In GAD patients, 4 groups were established for comparison, according to pharmacological prescription. MEASUREMENTS: Main outcomes measures were general, reason/co-morbidity, health care use and primary care cost (visits, diagnostic/therapeutic tests, and drugs). We counted work absenteeism as an indirect cost. Pharmacological prescription was studied according to evidence-based recommendations and Spanish health-approved indications. The statistical analysis included a multivariate model: logistic regression, analysis of covariance (ANCOVA), P< .05. RESULTS. Of the 65 767 patients included, 4.6% (95% confidence interval [CI], 3.9-5.3) had GAD. Patients with/without GAD, the average episode/year was 6.1 versus 4.7 and attendance/year 10.0 versus 7.6; P< .001. GAD was associated with women (odds ratio [OR], 1.8), dyslipidemia (OR, 1.2), smoking (OR, 1.4), depression (OR, 1.2), and cerebrovascular accident (OR, 1.6) (P< .02). The mean direct cost/year adjusted by age, gender and morbidity load was euro686 versus euro557 (P< .001). GAD was associated with higher directs costs. The recommended treatment was followed in 40.1% of total patients (95% CI, 38.4-41.8). CONCLUSIONS: Patients with GAD have greater co-morbidity and higher direct costs in PCS. Means designed to improve the recognition and treatment of these patients should be established in the PCS.