European expert consensus recommendations on the primary care use of direct oral anticoagulants in patients with venous thromboembolism.

BACKGROUND: Direct oral anticoagulants for the treatment of venous thromboembolism are supported by robust clinical trial evidence. Despite published guidance, general practitioners are faced with increasingly complex decisions and implementation remains sub-optimal in certain real-world scenarios. METHODS: A two stage formal consensus exercise was performed to formulate consensus statements and a summary guide, facilitating optimal management of direct oral anticoagulants in venous thromboembolism patients by generalist physicians across Europe. An online questionnaire distributed to a broad panel (Phase 1), followed by a virtual panel discussion by an expert group (Phase 2) were conducted. Phase 1 statements covered nine management domains, and were developed via a literature review and expert steering committee. Participants rated statements by their level of agreement. Phase 1 responses were collated and analysed prior to discussion and iterative refinement in Phase 2. RESULTS: In total 56 participants from across Europe responded to Phase 1. The majority had experience working as general practitioners. Consensus indicated that direct oral anticoagulants are the treatment of choice for managing patients with venous thromboembolism, at initiation and for extended treatment, with a review at three to six months to re-assess treatment effect and risk profile. Direct oral anticoagulant choice should be based on individual patient factors and include shared treatment choice between clinicians and patients; the only sub-group of patients requiring specific guidance are those with cancer. CONCLUSION: Results demonstrate an appreciation of best practices, but highlight challenges in clinical practice. The patient pathway and consensus recommendations provided, aim to highlight key considerations for general practice decision making, and aid optimal venous thromboembolism treatment.

Seroprevalence against COVID-19 and follow-up of suspected cases in primary health care in Spain

BackgroundDuring the coronavirus disease 2019 (COVID-19) pandemic little information has been available about patients with mild or moderate symptoms attended and followed in the primary care setting, most of whom had an unknown status for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ObjectivesWe aim to measure the seroprevalence of antibodies against SARS-CoV-2 infection in a community sample of asymptomatic individuals and among symptomatic patients (without confirmed diagnosis) followed in a primary care setting. As a secondary objective, we estimated the proportions of symptomatic patients seeing at an emergency department (ED), hospitalized or dying, and identified the most important clinical symptoms associated with a positive infection. MethodsFrom April 21 to April 24 2020, we selected a random sample of 600 individuals stratified by age groups, from a total population of 19,899 individuals from a community area in Barcelona (study population 1). From April 29 to May 5 2020, we also invited all the patients that had been followed by general practitioners (GPs) (study population 2). We used for both populations COVID-19 Rapid lateral flow immunoassay which qualitatively assesses the presence of patient-generated IgG and IgM in approximately 10-15 minutes. The prevalence (95% confidence intervals [CI]) of infection (past and current) was defined as the proportion of individuals with antibody seropositivity. Odds ratios (ORs) for a positive test result were estimated using logistic regression analysis. ResultsThree hundred and eleven asymptomatic individuals from the randomly selected sample accepted to participate in the study. The overall mean age was 43.7 years (SD 21.79, range 1-94) and 55% were women. Seventeen individuals were seropositive for IgM and/or IgG, resulting an overall prevalence of 5,47% (95% CI, 3.44-8.58). Six-hundred and thirty-four symptomatic patients were followed by GPs. The overall mean age was 46.97 years (SD 20.05, range 0-92) and 57.73% were women. Of these, 244 patients (38.49%) were seropositive for IgM and/or IgG. During the follow-up period, 27.13% of symptomatic patients attended the ED, 11.83% were hospitalized and about 2% died. Results of the multivariate logistic regression analysis showed that the OR for a positive test was significantly increased in patients who had fever (>38{degrees}C), ageusia and contact with a patient diagnosed with COVID-19. ConclusionsThe seroprevalence of antibodies against SARS-CoV-2 among asymptomatic individuals in the general population was lower than expected. Approximately 40% of the symptomatic patients followed by GPs during the peak months of the pandemic in Barcelona, were positive. Fever (>38{degrees}C), anosmia, ageusia and contact with a patient diagnosed with COVID-19 were associated with a positive test result.

[Cardiovascular risk factors and Primary Care: evaluation and intervention]. / Factores de riesgo cardiovascular y atención primaria: evaluación e intervención.

There is high prevalence of major cardiovascular risk factors (MCVRF) in Spain, equal or greater than the rest of the countries in Europe, with a tendency to increase, while the their control is in general sub-optimal. In the clinical setting, and in Primary Care clinics in particular, preventive activities and early detection (screening) of MCVRF that are well established by the scientific evidence should be carried out. Smoking should be tackled and treated with decisively, even more so in the context of the favourable current legislation. The measurement of risk factors makes it easy to take decisions in clinical practice, but should not be substituted for clinical judgement, given the limitation of the currently available calculation methods. The concept of overall focus on cardiovascular risks can obtain a reduction of the risk by the synergetic action on the different MCVRF in each individual case. The aim must be to reduce the probability of having a cardiovascular disease in the future, as well as the loss in quality of life, incapacity and associated mortality.

[Clinical profile and management patterns in outpatients with heart failure in Spain: INCA study]. / Perfil clínico y patrones de manejo en los pacientes con insuficiencia cardíaca atendidos ambulatoriamente en España: estudio INCA (Estudio Insuficiencia Cardíaca).

AIM: To assess clinical characteristics and treatment management of out-patients with chronic heart failure (CHF) in Spain. DESIGN: Cross-sectional study. LOCATION: Primary care (PC) centres and cardiology out-patient clinics. PATIENTS: CHF patients (all had an echocardiography performed). METHODS: Data were collected from consecutive patients who attended clinics (93 cardiologist and 415 PC physicians) with a diagnosis of CHF during June 2006. RESULTS: The study subjects were 2161 CHF patients (1412 PC; 749 Cardiology), with a mean age was 70.9+/-10.6 years and 55.62% were males. Patients followed up in cardiology were younger, the majority were male, had a better functional class, lower ejection fraction, and fewer co-morbidities than those followed up in PC. The most used treatments were drugs that block the renin-angiotensin system (ACEi or ARB) (89.4%) and diuretics (84.91%), followed by beta-blockers (43.96%). Blood pressure (< 130/80 mmHg) was controlled in 24.93% of the patients, and diabetes mellitus in 32.33% of the diabetics (HbA(1c)<6.5%). Both risk factors were significantly better in PC. CONCLUSIONS: The INCA results show different clinical characteristics between patients followed up in the two health care levels. The pharmacological treatment has improved since previous studies and is closer to that recommended in chronic heart failure guidelines. Nevertheless, blood pressure and diabetes mellitus control are still insufficient.

Estudio evaluativo de los costes asistenciales en atención primaria / Evaluative study of medical-care costs in primary care

Objetivo. Estimar los costes reales asistenciales por grupos patológicos de un centro de salud. Diseño. Estudio descriptivo, retrospectivo, realizado a partir de la revisión de historias clínicas informatizadas. Emplazamiento. Centro de salud urbano. Participantes. Todos los pacientes que se visitaron en el centro de salud durante el año 2005. Medidas principales. Se ha calculado el coste asistencial medio en euros por visita diferenciando por profesional, procedimientos y gasto farmacéutico, imputándose a la enfermedad que lo ha generado. Resultados. Las visitas por problemas de los aparatos respiratorio, locomotor, circulatorio y digestivo fueron las más frecuentes. El número medio de visitas por paciente atendido fue de 8,7 ± 9,4, y por paciente adscrito al centro, de 5,9 ± 8,7. Los costes más altos se atribuyen problemas circulatorios (18,96%; intervalo de confianza [IC] del 95%, 18,93-18,99%), del aparato locomotor (11,21%; IC del 95%, 11,18-11,23%), psicológicos (10,69%; IC del 95%, 10,66-10,71%), respiratorios (10,20%; IC del 95%, 10,17-10,22%) y del sistema endocrino-metabólico y nutrición (9,61%; IC del 95%, 9,58-9,63%). El gasto farmacéutico representó el 65% de los costes totales, las visitas al profesional el 33% y los procedimientos, el 2%. El coste total por habitante fue de 239,1 ± 493,6 euros, y por habitante visitado, de 349,5 ± 563,5 euros. Conclusiones. Las enfermedades del aparato circulatorio son, con diferencia, las que tienen un coste asistencial total más alto. Los problemas psicológicos ocupan el segundo lugar desde un punto de vista del gasto farmacéutico y el tercer lugar desde un punto de vista de costes asistenciales totales

Objective. To estimate the real costs of medical care by diagnostic groups at a primary care centre. Design. Descriptive, retrospective study, based on the review of computerized medical records. Setting. Urban primary care centre (PCC). Participants. All patients who attended the PCC during 2005. Main measurements. Mean medical care cost per visit in euros, broken down for health professionals, diagnostic procedures and drugs costs, and stratified by diagnostic groups. Results. The most frequent visits were for pulmonary, locomotor, cardiovascular, and gastro-intestinal conditions. The mean number of visits per patient attended was 8.7 (SD, 9.4); and per patient registered at the centre, 5.9 (8.7). The highest costs were for cardiovascular (18.96%; 95% CI, 18.93%-18.99%), locomotor (11.21%; 95% CI, 11.18%-11.23%), psychological (10.69%, 95% CI, 10.66%-10.71%), pulmonary (10.20%; 95% CI, 10.17%-10.22%) and endocrinal-nutritional (9.61%; 95% CI, 9.58%-9.63%) problems. Drugs expenditure accounted for 65% of the total cost; visits to health professionals, for 33%; and procedures, for 2%. Overall cost per inhabitant was 239.1 (493.6) euros, and per patient attended was 349.5 (563.5). Conclusions. Cardiovascular disease conditions are much the most costly ones in terms of overall medical cost. Psychological conditions are located in second place in terms of pharmaceutical cost; and in third place, in terms of overall medical-care cost