Primary and Community Care Transformation in Post-COVID Era: Nationwide General Practitioner Survey.

Introduction: The health emergency caused by COVID-19 has led to substantial changes in the usual working system of primary healthcare centers and in relations with users. The Catalan Society of Family and Community Medicine designed a survey that aimed to collect the opinions and facilitate the participation of its partners on what the future work model of general practitioners (GPs) should look like post-COVID-19. Methodology: Online survey of Family and Community Medicine members consisting of filiation data, 22 Likert-type multiple-choice questions grouped in five thematic axes, and a free text question. Results: The number of respondents to the questionnaire was 1051 (22.6% of all members): 83.2% said they spent excessive time on bureaucratic tasks; 91.8% were against call center systems; 66% believed that home care is the responsibility of every family doctor; 77.5% supported continuity of care as a fundamental value of patient-centered care; and >90% defended the contracting of complementary tests and first hospital visits from primary healthcare (PHC). Conclusions: The survey responses describe a strong consensus on the identity and competencies of the GP and on the needs of and the threats to the PHC system. The demand for an increase in health resources, greater professional leadership, elimination of bureaucracy, an increase in the number of health professionals, and greater management autonomy, are the axes towards which a new era in PHC should be directed.

CAPPRIC Study-Characterization of Community-Acquired Pneumonia in Spanish Adults Managed in Primary Care Settings.

The real burden of community-acquired pneumonia (CAP) in non-hospitalized patients is largely unknown. This is a 3-year prospective, observational study of ambulatory CAP in adults, conducted in 24 Spanish primary care centers between 2016-2019. Sociodemographic and clinical variables of patients with radiographically confirmed CAP were collected. Pneumococcal etiology was assessed using the Binax Now® test. Patients were followed up for 10 ± 3 days. A total of 456 CAP patients were included in the study. Mean age was 56.6 (±17.5) years, 53.5% were female, and 53.9% had ≥1 comorbidity. Average incidence of CAP was 1.2-3.5 cases per 1000 persons per year. Eighteen patients (3.9%) were classified as pneumococcal CAP. Cough was present in 88.1% of patients at diagnosis and fever in 70.8%. Increased pulmonary density (63.3%) and alveolar infiltrates with air bronchogram (16.6%) were the most common radiographic findings. After 14.6 ± 6.0 days (95% CI = 13.9-15.3), 65.4% of patients had recovered. Hospitalization rate was 2.8%. The most frequently prescribed antibiotics were quinolones (58.7%) and ß-lactams (31.1%). In conclusion, one-third of CAP patients did not fully recover after two weeks of empiric antibiotic therapy and 2.8% required hospitalization, highlighting the significant burden associated with non-hospitalized CAP in Spain.

Evaluación de la validez de las funciones SCORE de bajo riesgo y calibrada para población española en las cohortes FRESCO / Validity assessment of low-risk SCORE function and SCORE function calibrated to the Spanish population in the FRESCO cohorts

Introducción y objetivos. Estudiar la validez de la función SCORE original de bajo riesgo sin y con colesterol unido a lipoproteínas de alta densidad y SCORE calibrada en población española. Métodos. Análisis agrupado con datos individuales de 12 estudios de cohorte de base poblacional. Se incluyó a 30.919 participantes de 40-64 años sin enfermedades cardiovasculares en el momento del reclutamiento, que se siguieron durante 10 años para la mortalidad cardiovascular contemplada en el proyecto SCORE. La validez de las funciones se analizó mediante el área bajo la curva ROC (discriminación) y el test de Hosmer-Lemeshow (calibración), respectivamente. Resultados. Se dispuso de 286.105 personas/año. La mortalidad a 10 años por causas cardiovasculares fue del 0,6%. La razón de casos esperados/observados fue de 9,1, 6,5 y 9,1 en varones y de 3,3, 1,3 y 1,9 en mujeres con las funciones SCORE original de bajo riesgo sin y con colesterol unido a lipoproteínas de alta densidad y SCORE calibrada, respectivamente; diferencias estadísticamente significativas con el test de calibración de Hosmer-Lemeshow entre la mortalidad predicha con SCORE y la observada (p < 0,001 en ambos sexos y en todas las funciones). Las áreas bajo la curva ROC con SCORE original fueron 0,68 en varones y 0,69 en mujeres. Conclusiones. Todas las versiones de las funciones SCORE disponibles en España sobreestiman significativamente la mortalidad cardiovascular observada en la población española. A pesar de la aceptable capacidad de discriminación, la predicción del número de acontecimientos cardiovasculares mortales (calibración) fue significativamente imprecisa (AU)

Introduction and objectives. To assess the validity of the original low-risk SCORE function without and with high-density lipoprotein cholesterol and SCORE calibrated to the Spanish population. Methods. Pooled analysis with individual data from 12 Spanish population-based cohort studies. We included 30 919 individuals aged 40 to 64 years with no history of cardiovascular disease at baseline, who were followed up for 10 years for the causes of death included in the SCORE project. The validity of the risk functions was analyzed with the area under the ROC curve (discrimination) and the Hosmer-Lemeshow test (calibration), respectively. Results. Follow-up comprised 286 105 persons/y. Ten-year cardiovascular mortality was 0.6%. The ratio between estimated/observed cases ranged from 9.1, 6.5, and 9.1 in men and 3.3, 1.3, and 1.9 in women with original low-risk SCORE risk function without and with high-density lipoprotein cholesterol and calibrated SCORE, respectively; differences were statistically significant with the Hosmer-Lemeshow test between predicted and observed mortality with SCORE (P < .001 in both sexes and with all functions). The area under the ROC curve with the original SCORE was 0.68 in men and 0.69 in women. Conclusions. All versions of the SCORE functions available in Spain significantly overestimate the cardiovascular mortality observed in the Spanish population. Despite the acceptable discrimination capacity, prediction of the number of fatal cardiovascular events (calibration) was significantly inaccurate (AU)

Validity Assessment of Low-risk SCORE Function and SCORE Function Calibrated to the Spanish Population in the FRESCO Cohorts.

INTRODUCTION AND OBJECTIVES: To assess the validity of the original low-risk SCORE function without and with high-density lipoprotein cholesterol and SCORE calibrated to the Spanish population. METHODS: Pooled analysis with individual data from 12 Spanish population-based cohort studies. We included 30 919 individuals aged 40 to 64 years with no history of cardiovascular disease at baseline, who were followed up for 10 years for the causes of death included in the SCORE project. The validity of the risk functions was analyzed with the area under the ROC curve (discrimination) and the Hosmer-Lemeshow test (calibration), respectively. RESULTS: Follow-up comprised 286 105 persons/y. Ten-year cardiovascular mortality was 0.6%. The ratio between estimated/observed cases ranged from 9.1, 6.5, and 9.1 in men and 3.3, 1.3, and 1.9 in women with original low-risk SCORE risk function without and with high-density lipoprotein cholesterol and calibrated SCORE, respectively; differences were statistically significant with the Hosmer-Lemeshow test between predicted and observed mortality with SCORE (P < .001 in both sexes and with all functions). The area under the ROC curve with the original SCORE was 0.68 in men and 0.69 in women. CONCLUSIONS: All versions of the SCORE functions available in Spain significantly overestimate the cardiovascular mortality observed in the Spanish population. Despite the acceptable discrimination capacity, prediction of the number of fatal cardiovascular events (calibration) was significantly inaccurate.

Interaction between cardiovascular risk factors and body mass index and 10-year incidence of cardiovascular disease, cancer death, and overall mortality.

The effect of above-normal body mass index (BMI) on health outcomes is controversial because it is difficult to distinguish from the effect due to BMI-associated cardiovascular risk factors. The objective was to analyze the impact on 10-year incidence of cardiovascular disease, cancer deaths and overall mortality of the interaction between cardiovascular risk factors and BMI. We conducted a pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79years old at basal examination. Body mass index was measured at baseline being the outcome measures ten-year cardiovascular disease, cancer and overall mortality. Multivariable analyses were adjusted for potential confounders, considering the significant interactions with cardiovascular risk factors. We included 54,446 individuals (46.5% with overweight and 27.8% with obesity). After considering the significant interactions, the 10-year risk of cardiovascular disease was significantly increased in women with overweight and obesity [Hazard Ratio=2.34 (95% confidence interval: 1.19-4.61) and 5.65 (1.54-20.73), respectively]. Overweight and obesity significantly increased the risk of cancer death in women [3.98 (1.53-10.37) and 11.61 (1.93-69.72)]. Finally, obese men had an increased risk of cancer death and overall mortality [1.62 (1.03-2.54) and 1.34 (1.01-1.76), respectively]. In conclusion, overweight and obesity significantly increased the risk of cancer death and of fatal and non-fatal cardiovascular disease in women; whereas obese men had a significantly higher risk of death for all causes and for cancer. Cardiovascular risk factors may act as effect modifiers in these associations.

Risk of Cause-Specific Death in Individuals With Diabetes: A Competing Risks Analysis.

OBJECTIVE: Diabetes is a common cause of shortened life expectancy. We aimed to assess the association between diabetes and cause-specific death. RESEARCH DESIGN AND METHODS: We used the pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79 years old. Diabetes status was self-reported or defined as glycemia >125 mg/dL at baseline. Vital status and causes of death were ascertained by medical records review and linkage with the official death registry. The hazard ratios and cumulative mortality function were assessed with two approaches, with and without competing risks: proportional subdistribution hazard (PSH) and cause-specific hazard (CSH), respectively. Multivariate analyses were fitted for cardiovascular, cancer, and noncardiovascular noncancer deaths. RESULTS: We included 55,292 individuals (15.6% with diabetes and overall mortality of 9.1%). The adjusted hazard ratios showed that diabetes increased mortality risk: 1) cardiovascular death, CSH = 2.03 (95% CI 1.63-2.52) and PSH = 1.99 (1.60-2.49) in men; and CSH = 2.28 (1.75-2.97) and PSH = 2.23 (1.70-2.91) in women; 2) cancer death, CSH = 1.37 (1.13-1.67) and PSH = 1.35 (1.10-1.65) in men; and CSH = 1.68 (1.29-2.20) and PSH = 1.66 (1.25-2.19) in women; and 3) noncardiovascular noncancer death, CSH = 1.53 (1.23-1.91) and PSH = 1.50 (1.20-1.89) in men; and CSH = 1.89 (1.43-2.48) and PSH = 1.84 (1.39-2.45) in women. In all instances, the cumulative mortality function was significantly higher in individuals with diabetes. CONCLUSIONS: Diabetes is associated with premature death from cardiovascular disease, cancer, and noncardiovascular noncancer causes. The use of CSH and PSH provides a comprehensive view of mortality dynamics in a population with diabetes.

Rationale and design of the DP-TRANSFERS project: diabetes prevention-transferring findings from European research to society in Catalonia.

BACKGROUND: Compelling evidence has been accumulated to support the effectiveness of intensive lifestyle intervention in delaying progression to Type 2 diabetes even in people identified as being at high risk determined by the Finnish diabetes risk score. The DE-PLAN-CAT project (diabetes in Europe-prevention using lifestyle, physical activity and nutritional intervention-Catalonia) evidenced that intensive lifestyle intervention was feasible and cost-effective on a short scale in real-life primary care settings, at least over 4 years. However, transferring such lifestyle interventions to society remains the major challenge of research in the field of diabetes prevention. METHODS/DESIGN: The derived DP-TRANSFERS (diabetes prevention-transferring findings from European research to society) is a large scale national programme aimed at translating a tailored lifestyle intervention to the maximum of primary care centres where feasible through a core proposal agreed with all the partners. The method is built upon a 3-step (screening, intervention and follow-up) real-life, community-wide structure on the basis of a dual intensity lifestyle intervention (basic and continuity modules) and supported by a 4-channel transfer strategy (institutional relationships, facilitators' workshops, collaborative groupware and programme WEB page). Participation will initially cover nine health departments (7 million inhabitants) through nine coordinating centres located in metropolitan (3.2 million), semi-urban (2.9 million) and rural (0.9 million) areas from which it is expected accessing 25 % of all primary care settings, equivalent to 90 associated centres (1.6-1.8 million people) with an estimate of 0.32 million participants aged 45-75 years at high risk of future development of diabetes. To ascertain sustainability, effect, satisfaction and quality of the translation programme statistical analyses will be performed from both the entire population (facilitators and participants) and a stratified representative sample obtained by collecting data from at least 920 participants. DISCUSSION: The DP-TRANSFERS will use a strategy of approach to society consistent with the impact of the disease and the fast accessibility provided by primary care settings in Catalonia. Both the widespread effect of the lifestyle intervention and the translational process itself could be assessed.

Derivation and validation of a set of 10-year cardiovascular risk predictive functions in Spain: the FRESCO Study.

OBJECTIVE: To derive and validate a set of functions to predict coronary heart disease (CHD) and stroke, and validate the Framingham-REGICOR function. METHOD: Pooled analysis of 11 population-based Spanish cohorts (1992-2005) with 50,408 eligible participants. Baseline smoking, diabetes, systolic blood pressure (SBP), lipid profile, and body mass index were recorded. A ten-year follow-up included re-examinations/telephone contact and cross-linkage with mortality registries. For each sex, two models were fitted for CHD, stroke, and both end-points combined: model A was adjusted for age, smoking, and body mass index and model B for age, smoking, diabetes, SBP, total and HDL cholesterol, and for hypertension treatment by SBP, and age by smoking and by SBP interactions. RESULTS: The 9.3-year median follow-up accumulated 2973 cardiovascular events. The C-statistic improved from model A to model B for CHD (0.66 to 0.71 for men; 0.70 to 0.74 for women) and the combined CHD-stroke end-points (0.68 to 0.71; 0.72 to 0.75, respectively), but not for stroke alone. Framingham-REGICOR had similar C-statistics but overestimated CHD risk. CONCLUSIONS: The new functions accurately estimate 10-year stroke and CHD risk in the adult population of a typical southern European country. The Framingham-REGICOR function provided similar CHD prediction but overestimated risk.

Metabolic syndrome as a cardiovascular disease risk factor: patients evaluated in primary care.

To estimate the prevalence of metabolic syndrome (MS) in a population receiving attention in primary care centers (PCC) we selected a random cohort of ostensibly normal subjects from the registers of 5 basic-health area (BHA) PCC. Diagnosis of MS was with the WHO, NCEP and IDF criteria. Variables recorded were: socio-demographic data, CVD risk factors including lipids, obesity, diabetes, blood pressure and smoking habit and a glucose tolerance test outcome. Of the 720 individuals selected (age 60.3 +/- 11.5 years), 431 were female, 352 hypertensive, 142 diabetic, 233 pre-diabetic, 285 obese, 209 dyslipemic and 106 smokers. CVD risk according to the Framingham and REGICOR calculation was 13.8 +/- 10% and 8.8 +/- 9.8%, respectively. Using the WHO, NCEP and IDF criteria, MS was diagnosed in 166, 210 and 252 subjects, respectively and the relative risk of CVD complications in MS subjects was 2.56. Logistic regression analysis indicated that the MS components (WHO set), the MS components (IDF set) and the female gender had an increased odds ratio for CVD of 3.48 (95CI%: 2.26-5.37), 2.28 (95%CI: 1.84-4.90) and 2.26 (95%CI: 1.48-3.47), respectively. We conclude that MS and concomitant CVD risk is high in ostensibly normal population attending primary care clinics, and this would necessarily impinge on resource allocation in primary care.

Relevance of casual undetected hyperglycemia among high-risk individuals for developing diabetes.

To assess the relevance of unrecognized hyperglycemia among high-risk subjects for developing diabetes a cross-sectional study was carried out. Subjects aged 40-75 years with (high-risk group) and without (control group) history of impaired glucose metabolism underwent a 2h-oral glucose tolerance test (OGTT). All individuals with diabetes diagnostic criteria and all controls with glucose abnormalities at OGTT were excluded. An individualized 48-h continuous glucose monitoring (CGM) calibrated by fasting plasma glucose was performed. The microdialysis-based biosensor recordings were computerized in order to identify continuous glucose profiles. Of the 121 monitored subjects, 104 were finally analyzed (56.7% female, 57.8 years, BMI=29.2, A1C=4.9%, HOMA index=2.5). Glucose profiles corresponded to 31 controls (29.8%), 32 high-risk individuals with normal OGTT (30.8%) and 41 (39.4%) with hyperglycemia at OGTT. The recordings defined as hyperglycemia (fasting >or=6.1 mmol/l, non-fasting >or=7.8 mmol/l) appeared during an average of 1.4h, 4.9h and 7.6h (3.9%, 13.9% and 19% of the CGM time), respectively. The highest percentage of impaired CGM registers corresponded to the fasting period. Nevertheless, the longest duration corresponded to the non-fasting period. The CGM evidenced a relevant degree of casual undetected hyperglycaemia among high-risk individuals.

[Continuous glucose monitoring in high-risk subjects for developing type 2 diabetes]. / Registro continuo de glucosa en sujetos con alto riesgo de diabetes tipo 2.

BACKGROUND AND OBJECTIVE: To assess the relevance of unrecognised hyperglycaemia among high-risk subjects for developing type 2 diabetes. SUBJECTS AND METHOD: Cross-sectional multicentre study in primary care. Subjects aged 40 to 75 years with previous evidence of impaired glucose metabolism were screened according to the World Health Organization rules by means of an oral glucose tolerance test (OGTT). Those with diabetes diagnostic criteria were excluded. An individualized 48-h ambulatory continuous glucose monitoring (CGM) calibrated by plasma values (Glucoday) was performed. Data from biosensor activity were computerized in order to identify hyperglycaemic records. RESULTS: 50 out of 64 screened subjects were included and evaluated; there were 30 female (60%). Mean age was 59 years; body mass index, 30.9; HbA1c, 5.3%, and HOMA, 2.8. Regarding the CGM results, 9 whole registers (18%) were rejected because of technical problems and 41 continuous profiles (72%) were analysed, corresponding to 17 (41.5%) subjects with normal OGTT and 24 (58.5%) with non-diabetic hyperglycaemia on OGTT. Mean CGM time with hyperglycaemia (fasting > or = 6.1 mmol/l or non-fasting > or = 7.8 mmol/l) accounted for 5.8 h, a 17.2% of the effective register per subject (33.8 h). Both groups matched the World Health Organization diabetes diagnostic interval (fasting > or = 7 mmol/l or non-fasting > or = 11.1 mmol/l): 1.1 h of effective register (3.6%) and 1.2 h (3.3%), respectively. CONCLUSIONS: The CGM evidenced a high degree of unrecognised hyperglycaemia among high-risk individuals. Therefore, casual plasma glucose measurements should be recommended to achieve early screening.

Registro continuo de glucosa en sujetos con alto riesgo de diabetes tipo 2 / Continuous glucose monitoring in high-risk subjects for developing type 2 diabetes

Fundamento y objetivo: Evidenciar la hiperglucemia inadvertida en sujetos con alto riesgo de diabetes tipo 2. Sujetos y método: Estudio transversal multicéntrico en atención primaria. Se seleccionó a sujetos de 40-75 años con antecedentes de hiperglucemia no diabética a los que se cribó mediante una prueba de tolerancia oral a la glucosa (PTOG), excluyendo a aquellos con criterios de diabetes según la Organización Mundial de la Salud. Se desarrolló un registro continuo de la glucosa (RGC) individualizado y ambulatorio de 48 h mediante un biosensor subcutáneo (GlucoDay®) calibrado por la glucemia plasmática. Se informatizó la actividad del biosensor para evidenciar posibles registros de hiperglucemia. Resultados: Se efectuó el RCG a 50 de 64 sujetos seleccionados, de los que 30 eran mujeres. El índice de masa corporal medio fue de 30,9 kg/m2; la hemoglobina glucosilada del 5,3%, y el índice HOMA de 2,8, descartando 9 perfiles completos (18%) por problemas técnicos. Se evaluaron 41 RCG (82%) pertenecientes a 17 sujetos con PTOG normal (41,5%) y a 24 (58,5%) con PTOG alterada. Por término medio, se obtuvieron registros de hiperglucemia (basal é 6,1 mmol/l o no basal é 7,8 mmol/l) durante 5,8 h, un 17,2% del tiempo total de registro efectivo (33,8 h). La hiperglucemia en el intervalo de diabetes (basal é 7 mmol/l o no basal é 11,1 mmol/l) concurrió durante el 3,6% del tiempo (1,2 h) y el 3,3% (1,1 h), respectivamente. Conclusiones: El RCG evidenció índices altos de hiperglucemia no reconocida en sujetos de riesgo. Este hallazgo indica que medir la glucemia en cualquier momento del día incrementaría la detección de anomalías glucídicas

Background and objective: To assess the relevance of unrecognised hyperglycaemia among high-risk subjects for developing type 2 diabetes. Subjects and method: Cross-sectional multicentre study in primary care. Subjects aged 40 to 75 years with previous evidence of impaired glucose metabolism were screened according to the Word Health Organization rules by means of an oral glucose tolerance test (OGTT). Those with diabetes diagnostic criteria were excluded. An individualized 48-h ambulatory continuous glucose monitoring (CGM) calibrated by plasma values (Glucoday®) was performed. Data from biosensor activity were computerized in order to identify hyperglycaemic records. Results: 50 out of 64 screened subjects were included and evaluated; there were 30 female (60%). Mean age was 59 years; body mass index, 30.9; HbA1c, 5.3%, and HOMA, 2.8. Regarding the CGM results, 9 whole registers (18%) were rejected because of technical problems and 41 continuous profiles (72%) were analysed, corresponding to 17 (41.5%) subjects with normal OGTT and 24 (58.5%) with non-diabetic hyperglycaemia on OGTT. Mean CGM time with hyperglycaemia (fasting é 6.1 mmol/l or non-fasting é 7.8 mmol/l) accounted for 5.8 h, a 17.2% of the effective register per subject (33.8 h). Both groups matched the World Health Organization diabetes diagnostic interval (fasting é 7 mmol/l or non-fasting é 11.1 mmol/l): 1.1 h of effective register (3.6%) and 1.2 h (3.3%), respectively. Conclusions: The CGM evidenced a high degree of unrecognised hyperglycaemia among high-risk individuals. Therefore, casual plasma glucose measurements should be recommended to achieve early screening