The descriptive epidemiology of rheumatoid arthritis in Catalonia: a retrospective study using routinely collected data.

Information on the epidemiology of rheumatoid arthritis (RA) in Southern Europe is scarce. We estimated the age- and gender-adjusted incidence and prevalence of RA in Catalonia using routinely collected primary care records. We identified incident (2009-2012) and prevalent (on 31 December 2012) cases of RA in the SIDIAP database using ICD-10 codes. SIDIAP contains anonymized data from computerized primary care records for about five million adults (>80 % of the population). We estimated age- (5-year groups) and gender-specific, and directly standardized incidence and prevalence of RA and confidence intervals (95% CIs) assuming a Poisson distribution. A total of 20,091 prevalent (among whom 5,796 incident) cases of RA were identified among 4,796,498 study participants observed for up to 4 years. Rates of RA increased with age in both genders, peaking at the age of 65-70 years. Age- and gender-standardized incidence and prevalence rates were 0.20/1,000 person-years (95% CI 0.19-0.20) and 4.17/1,000 (4.11-4.23) respectively. Rheumatoid factor was positive (≥10 IU/mL) in 1,833 (73.9 %) of 2,482 cases tested in primary care. The incidence and prevalence of RA in Catalonia are similar to those of other Southern European regions, and lower than those of northern areas. This data will inform health care planning and resource allocation.

Socio-economic status and the risk of developing hand, hip or knee osteoarthritis: a region-wide ecological study.

OBJECTIVE: To determine the association between socio-economic status (SES) and risk of hand, hip or knee osteoarthritis (OA) at a population level. DESIGN: Retrospective ecological study using the System for the Development of Research in Primary Care (SIDIAP) database (primary care anonymized records for >5 million people in Catalonia (Spain)). Urban residents >15 years old (2009-2012) were eligible. OUTCOMES: Validated area-based SES deprivation index MEDEA (proportion of unemployed, temporary workers, manual workers, low educational attainment and low educational attainment among youngsters) was estimated for each area based on census data as well as incident diagnoses (ICD-10 codes) of hand, hip or knee OA (2009-2012). Zero-inflated Poisson models were fitted to study the association between MEDEA quintiles and the outcomes. RESULTS: Compared to the least deprived, the most deprived areas were younger (43.29 (17.59) vs 46.83 (18.49), years (Mean SD), had fewer women (49.1% vs 54.8%), a higher percentage of obese (16.2% vs 8.4%), smokers (16.9% vs 11.9%) and high-risk alcohol consumption subjects (1.5% vs 1.3%). Compared to the least deprived, the most deprived areas had an excess risk of OA: age-sex-adjusted Incidence Rate Ratio (IRR) 1.26 (1.11-1.42) for hand, 1.23 (1.17-1.29) hip, and 1.51 (1.45-1.57) knee. Adjustment for obesity attenuated this association: 1.06 (0.93-1.20), 1.04 (0.99-1.09), and 1.23 (1.19-1.28) respectively. CONCLUSIONS: Deprived areas have higher rates OA (hand, hip, knee). Their increased prevalence of obesity accounts for a 50% of the excess risk of knee OA observed. Public health interventions to reduce the prevalence of obesity in this population could reduce health inequalities.

Delaying progression to type 2 diabetes among high-risk Spanish individuals is feasible in real-life primary healthcare settings using intensive lifestyle intervention.

AIMS/HYPOTHESIS: To assess the feasibility and effectiveness of an active real-life primary care lifestyle intervention in preventing type 2 diabetes within a high-risk Mediterranean population. METHODS: A prospective cohort study was performed in the setting of Spanish primary care. White-European individuals without diabetes aged 45-75 years (n = 2,054) were screened using the Finnish Diabetes Risk Score (FINDRISC) and a subsequent 2 h OGTT. Where feasible, high-risk individuals who were identified were allocated sequentially to standard care, a group-based or an individual level intervention (intensive reinforced DE-PLAN [Diabetes in Europe-Prevention using Lifestyle, Physical Activity and Nutritional] intervention). The primary outcome was the development of diabetes according to WHO criteria. Analyses after 4-year follow-up were performed based on the intention-to-treat principle with comparison of standard care and the combined intervention groups. RESULTS: The standard care (n = 219) and intensive intervention (n = 333) groups were comparable in age (62.0/62.2 years), sex (64.4/68.2% women), BMI (31.3/31.2 kg/m(2)), FINDRISC score (16.2/15.8 points), fasting (5.3/5.2 mmol/l), 2 h plasma glucose (7.1/6.9 mmol/l) and self-reported interest to make lifestyle changes at baseline. Diabetes was diagnosed in 124 individuals: 63 (28.8%) in the standard care group and 61 (18.3%) in the intensive intervention group. During a 4.2-year median follow-up, the incidences of diabetes were 7.2 and 4.6 cases per 100 person-years, respectively (36.5% relative risk reduction, p < 0.005). The number of participants needed to be treated by intensive intervention for 4 years to reduce one case of diabetes was 9.5. CONCLUSIONS/INTERPRETATION: Intensive lifestyle intervention is feasible in a primary care setting and substantially reduces diabetes incidence among high-risk individuals. CLINICAL TRIAL REGISTRATION: ClinicalTrial.gov NCT01519505. FUNDING: Commission of the European Communities, Institute of Health Carlos III, Spanish Ministry of Health and Department of Health, Generalitat de Catalunya.

Shifting from glucose diagnostic criteria to the new HbA(1c) criteria would have a profound impact on prevalence of diabetes among a high-risk Spanish population.

AIM: To investigate changes in the prevalence of diabetes and pre-diabetes by shifting from 2-h plasma glucose and/or fasting plasma glucose diagnostic criteria to the proposed new HbA(1c) -based criteria when applied to a Mediterranean population detected to have a high risk of Type 2 diabetes. METHODS: Individuals without diabetes aged 45-75 years (n = 2287) were screened using the Finnish Diabetes Risk Score questionnaire, a 2-h oral glucose tolerance test plus HbA(1c) test. Prevalence and degree of diagnostic overlap between three sets of criteria (2-h plasma glucose, fasting plasma glucose and HbA(1c) ) and three diagnostic categories (normal, pre-diabetes and diabetes) were calculated. RESULTS: Defining diabetes by a single HbA(1c) measurement resulted in a dramatic decrease in prevalence (1.3%), particularly in comparison with diabetes defined by 2-h plasma glucose (8.6%), but was also significant with regard to fasting plasma glucose (2.8%). A total of 201 screened subjects (8.8%) were classified as having diabetes and 1023 (44.7%) as having pre-diabetes based on at least one of these criteria; among these, the presence of all three criteria simultaneously classified only 21 and 110 individuals respectively, about ten percent of each group. The single overlap index between subjects diagnosed as having diabetes by 2-h plasma glucose/fasting plasma glucose vs. HbA(1c) was 13.9/28%. Similarly, the single overlap index regarding pre-diabetes was 19.2/27.1%. CONCLUSIONS: A shift from the glucose-based diagnosis to the HbA(1c) -based diagnosis for diabetes will reduce diabetes prevalence with a low overall or single degree of overlap between diagnostic categories in this high-risk Spanish population.

[Variations in the application of medical techniques in primary health care]. / Variaciones en la aplicación de técnicas médicas en atención primaria.

OBJECTIVES: To describe the application of medical techniques (ATM) in Spain and to analyze the relationship with diverse characteristics related to general practitioners and the center of primary health. DESIGN: Multicenter cross-sectional study. SETTING: Three hundred nineteen general practitioners working in primary care centers in the restructured public sector of the Autonomous Communities of Andalusia, Basque Country and Catalonia in Spain. MAIN MEASUREMENTS: Structured and validated questionnaire comprising 100 items in four sections: general characteristics of the physician and health center, task profile, and job satisfaction. The questionnaire was sent by mail to the health center (Andalusia and Basque Country) or to the home (Catalonia). For the analysis an index variable was created from the answers to the questions on AMT. RESULTS: The index variable of AMT obtained a mean value of 10.02 (SD = 4.55). Andalusia obtained the highest value (median: 11.11; SD: 4.33) of the three Autonomous Communities in the study (p =.012). AMT acquired significantly higher values when associated with: masculine sex (sample from the three autonomous communities; p =.046), rural environment, teamwork, availability of basic equipment, fewer patients, and reduced work load. CONCLUSIONS: Index of ATM in Spain is significantly different in the three Spanish communities under study. The quality of the sanitary services evaluated from the dimension of the ATM seems to be much related with demographic characteristics, the readiness in the consultations of scientific-technical stuff and the appropriate time for medical consultations.

Variaciones en la aplicación de técnicas médicas en atención primaria / Variations in the application of medical techniques in primary health care

Objetivo: Describir la aplicación de técnicas médicas (ATM) en tres comunidades autónomas españolas (Andalucía, Cataluña y País Vasco) y analizar sus relaciones con diversas características relacionadas con los médicos de atención primaria y el centro de salud. Diseño: Estudio multicéntrico, transversal. Emplazamiento: Un total de 319 médicos generales que trabajaban en los centros de atención primaria del sector público reformado en las comunidades de Andalucía, País Vasco y Cataluña. Mediciones principales: Cuestionario estructurado y validado de 100 preguntas en cuatro apartados: características generales del profesional y centro de trabajo, perfil de actividad y satisfacción laboral. Éste fue enviado por correo al centro de trabajo (Andalucía y Euskadi) o domicilio particular (Cataluña). Para el análisis se creó una variable índice a partir de las respuestas de las preguntas de ATM. Resultados: La variable índice de ATM obtuvo un valor medio (desviación estándar [DE]) de 10,02 (4,55) y Andalucía el valor más alto (media [DE]: 11,11 [4,33]) de las tres comunidades del estudio (p = 0,012). La variable índice ATM adquiere valores significativamente más altos en relación con: el sexo masculino (muestra de tres comunidades autónomas; p = 0,046), el ámbito rural, el trabajo en equipo, la disponibilidad de equipamiento básico, el número de pacientes más reducido y menor carga asistencial. Conclusiones: Los índices de ATM en España son significativamente distintos en las tres comunidades españolas estudiadas. La calidad de la asistencia sanitaria evaluada desde la dimensión de la ATM parece estar muy relacionada con características demográficas, la disponibilidad en las consultas del material científico-técnico y el tiempo adecuado de las visitas médicas (AU)

Objectives: To describe the application of medical techniques (ATM) in Spain and to analyze the relationship with diverse characteristics related to general practitioners and the center of primary health. Design: Multicenter cross-sectional study. Setting: Three hundred nineteen general practitioners working in primary care centers in the restructured public sector of the Autonomous Communities of Andalusia, Basque Country and Catalonia in Spain. Main measurements: Structured and validated questionnaire comprising 100 items in four sections: general characteristics of the physician and health center, task profile, and job satisfaction. The questionnaire was sent by mail to the health center (Andalusia and Basque Country) or to the home (Catalonia). For the analysis an index variable was created from the answers to the questions on AMT. Results: The index variable of AMT obtained a mean value of 10.02 (SD = 4.55). Andalusia obtained the highest value (median: 11.11; SD: 4.33) of the three Autonomous Communities in the study (p = .012). AMT acquired significantly higher values when associated with: masculine sex (sample from the three autonomous communities; p = .046), rural environment, teamwork, availability of basic equipment, fewer patients, and reduced work load. Conclusions: Index of ATM in Spain is significantly different in the three Spanish communities under study. The quality of the sanitary services evaluated from the dimension of the ATM seems to be much related with demographic characteristics, the readiness in the consultations of scientific-technical stuff and the appropriate time for medical consultations (AU)

Hacia la definición de un conjunto mínimo básico de datos de atención primaria / Towards the definition of a set of basic minimun data in primary care

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Medir la morbilidad en atención primaria / Measuring morbidity in primary care

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[Influence of the unit of analysis on the studies of the factors of primary care resource utilization]. / Influencia de la unidad de análisis en los estudios de utilización de recursos en atención primaria.

OBJECTIVE: To identify the characteristics of the patient that influence a different cost of his care, specifically, the different behaviour of these factors depending on the unit considered: encounter, episode or patient. METHODS: Observational study with the voluntary participation of 13 physicians (9 general practitioners and 4 paediatricians) and nursing staff. During 7 months all diagnoses and interventions to a sample of attended patients were gathered. The cost of care was calculated and aggregated depending on the three units, and four models of multiple lineal regression were built with the following explanatory variables: age, gender, morbidity (ambulatory diagnosis groups), comorbidity and psychosocial conditions. RESULTS: 1,868 adult patients (more than 14 years) made 11.146 consults which belong to 4,772 episodes. The 895 paediatric patients made 6,254 consults that belonged to 3,416 episodes. Morbidity is the variable that shows a major increase in all units. Overall, the capacity to explain cost variations are: 0.03 for the encounter, 0.14 for the episode and 0.44 for the patient. CONCLUSIONS: The patients variables considered in the study explain very little the resource utilization of the encounter, more the episode, and rather more the patient. Those results indicate that the assessment or comparison of the effectiveness, efficiency, or quality of the encounters will be very difficult considering only the commonly used variables to control the patient factors. The patient classification systems that group with a similar complexity that use the visits as the unit, should, consequently, consider additional variables of the process of care in contrast with the others units. This have implications in the collection and availability of the information.

[A patient classification system for our primary care: the ambulatory care groups (ACGs)]. / Un sistema de clasificación de pacientes para nuestra atención primaria: los "ambulatory care groups" (ACGs).

OBJECTIVES: The ambulatory care groups (ACGs) were developed at the Johns Hopkins University in 1987 and they differ from other systems because their longitudinal approach and its capability to describe the case-mix of a population of reference. This paper describes the ACGs and assess its potential application to spanish primary care (PC). METHODS: Observational study with the voluntary participation of 13 physicians (general practitioner and paediatrician) and nursing staff. During six months all diagnoses and interventions to a sample of attended patients were gathered. RESULTS: The first stage in grouping involves ascribing one of the 34 ambulatory diagnostic groups (ADGs) to each of the health problems attended. The second stage involves, after several intermediates steps, assigning one of the 51 ACGs to each patient. The total number of episodes was 7,559 (input), the number of patients (output) 2,467, the ICD codes with error 292, and the number of patients with ICD codes with error 278. With 5 ACGs we classify 44% of all the patients and with 10 ACGs, 64% of all them. Only two ACGs were empty. The article explores the potential applications of the system in spanish PC: for provider financing when a capitation payment component were introduced, utilization review and quality assurance when we compare several providers or populations, and research interested to link the process and its outcomes. CONCLUSIONS: Among the various patients classification system for grouping ambulatory care, the ambulatory care groups (ACGs) appear as the method with more potentialities to PC in Spain. The ACGs should be validated before been applied and its adaption to a more suitable PC classification of diagnoses would assists its extension.

[The reasons for consultation and active problems. A key for the understanding of information in primary care]. / Motivos de consulta y problemas activos. Una clave para la comprensión de la información en atención primaria.

The aim of this work is to assess the major differences found in the information content of the registers in primary care according to whether the registration includes the Reason (s) For Encounter (as ascertained by the professional) or the Active Health Problem (s). The information used is based on an observational study of a representative sample of the consultations to eight general practitioners from the Principate of Andorra. The study was performed during the period of May-June 1989. 547 consultations are analysed. A better specificity and information content is observed when both approaches are registered. Active Health Problems seem to be barely related to Reasons for Encounter and it seems that they could have as much, if no more. Influence in the process of care, than the RFEs it selves.

[Minimum sets of data in primary care: an exploration of their feasibility]. / Conjuntos mínimos de datos en atención primaria: una exploración de su factibilidad.

OBJECTIVE: To evaluate the different "costings" of several different strategies for gathering a Minimum Set of Data (MSD) at the Primary Care level. DESIGN: A simulation study using a hypothetical MSD with 16 items together with the findings on demand and interventions made by General Physicians in an observational study in Andorra. Different gathering strategies were applied using these data and with the MSD register covering visits as the starting-point. Measurement of the "costing" or work-load involved in the gathering and transmission of each of the items was carried out by means of a nominal group. SITE. General and paediatric consulting-rooms. PATIENTS OR OTHERS PARTICIPANTS: The simulation was carried out among the catchment population of PAMEM and used data on what was done in 1988. MAIN MEASUREMENTS AND RESULTS: Strategies based on sampling of visits or individuals are those which show a greater reduction in cost (99.3% and 98.1% respectively). Sampling individuals additionally allows for the MSD to be added to during periods of illness. Other options with their respective results are: "gathering information from alternative sources", with a reduction of 22%, "reduction of the number of data to record", with 20% reduction and "separation of stable information" with 18%. CONCLUSIONS: The systematic collection of data on each visit has important and much more efficient alternatives. The choice of one of them will depend on how feasible it is to introduce, on the available resources and above all on objectives.

[Suitability of the practice of recording only the main health problem in primary care]. / La idoneidad del registro exclusivo del problema de salud principal en atención primaria.

OBJECTIVE: To analyse if recording only the main health problem (P) can reflect in a valid way the totality of health problems (P+S) cared for and all the actions generated by a consultation. DESIGN: Using a representative sample of the patients seen at the centre over a three-month period, information on P+S was gathered, P was identified and the actions generated by each one of the problems were recorded. Health problems were codified through CIPSAP-2-D and grouping diagnoses. SITE. General Medicine service in a Primary Care Centre. PATIENTS AND OTHERS PARTICIPANTS: All the General Medical physicians at the Centre took part in the study by collecting data on the consultations established by the sampling. MAIN MEASUREMENTS AND RESULTS: Frequency and order among the first 25 P+S and P problems were compared, as was the percentage of secondary problems encountered. Out of 559 consultations examined, Diabetes, Dislepemia and an irritated? Colon stood out as under-represented. Acute infections of the Upper Respiratory Tract, Conjunctivitis and ??Queratitis were over-represented. As for the activity generated, 83.1% corresponded to P, although there was great variability among the problems according to the percentage of secondary problems according to the percentage of secondary problems. CONCLUSIONS: Recording only the main health problem can be a valid instrument for providing an initial view of problems seen.

[Minimum data sets in ambulatory care]. / Conjuntos mínimos de datos en la atención ambulatoria.

A sensible and rational approach is necessary in order to match the growing requirements of information on the ambulatory care sector characterised by a big deal of complexity and variability. This must be applied to any initiative attempting to obtain any degree of harmonization in ambulatory care data sets. This paper summarises a conceptual aspect of the work undertaken by the project Measurement Characterization and Control of Ambulatory Care in Europe (McACE) sponsored by the Commission of the European Communities under the exploratory phase of the Advanced Informatics in Medicine (AIM) programme. Our approach places in the first priority the efficiency when assessing the information needs of the different actors trying to make a balanced approach between the costs of collecting and processing a specific item and its use. For this we performed a conceptual validation of the term Minimum Basic Data Set and its potential application to the Ambulatory Care Sector. It is suggested its substitution by the term Minimum Data Set as a part of a practical tool for promoting the harmonization of the information in ambulatory care.