Complex Care Needs in Multiple Chronic Conditions: Population Prevalence and Characterization in Primary Care. A Study Protocol

Background:

Chronicity, and particularly complex care needs for people with chronic diseases is one of the main challenges of health systems.

Objective:

To determine the population prevalence of people with chronic diseases and complex care needs and to characterize these needs considering features of health and social complexity in Primary Care.

Design:

Cross-sectional population-based study.

Scope:

Patients who have one or more chronic health conditions from three Primary Care urban centres of a reference population of 43.647 inhabitants older than 14 years old.

Methodology:

Data will be obtained from the review of electronical medical records. Complexity will be defined by: 1) the independent clinical judgment of primary care physicians and nurses and 2) the aid of three complexity domains (clinical and social). Patients with advanced chronic disease and limited life prognosis will be also described.

Conclusions:

This research protocol intends to describe and analyse complex care needs from a primary care professional perspective in order to improve knowledge of complexity beyond multimorbidity and previous consumption of health resources. Knowing about health and social complexity with a more robust empirical basis could help for a better integration of social and health policies and a more proactive and differentiated care approach in this most vulnerable population.

Promoting self-management, health literacy and social capital to reduce health inequalities in older adults living in urban disadvantaged areas: protocol of the randomised controlled trial AEQUALIS

BACKGROUND

Older people living in socio-economic deprived urban areas especially suffer the effects of health inequalities but have been insufficiently targeted. Strategies promoted by local primary health care agents might influence health and social behaviours as intermediate social determinants that are modifiable and thus can potentially mitigate health inequalities. Therefore, we aim to develop and assess the effectiveness of a complex intervention based on a community programme that promotes self-management, health literacy and social capital targeting older people from urban socioeconomically disadvantaged areas in order to improve their self-perceived health as an indicator of health inequality reduction.

METHODS/DESIGN

Design: A pragmatic multicentre, parallel, randomised controlled trial will be implemented in 16 primary health care centres from six urban areas in neighbourhoods with low-socioeconomic level.

TARGET

community-dwelling aged 60 years or above who perceive their health as fair or poor. The programme is called "Sentir-nos Bé" ("Feeling well") and comprises 12 two-hour sessions held once a week in groups of 12-15 people. Group dynamics are designed to promote mutual support, social participation and new knowledge on health literacy and self-management, resulting in meaningful changes in their daily life that positively affect their health and wellbeing. A sample size of 390 participants, randomised to the intervention or the control group, will be needed to detect a clinically relevant benefit in the primary outcome self-perceived health after 3-month intervention. A follow-up will be conducted at 9 months post-intervention. Participants in the control group will receive usual care and remain in a waiting-list to join the programme once the trial ends. A process evaluation will provide greater confidence in the conclusions about the effectiveness of the intervention. Ethics approval: Clinical Investigation Ethics Committee of the IDIAP Jordi Gol (P15/031). Dissemination: Findings will be disseminated through conference presentations and open-access journals.

DISCUSSION

The project will promote the implementation of evidence-based intervention procedures in future health policy strategies targeting older people while considering the social aspects of inequality.

TRIAL REGISTRATION

NCT02733523 . Retrospectively registered. Date of registration: April 11, 2016.

Impact of Medication Adherence on Mortality and Cardiovascular Morbidity: Protocol for a Population-Based Cohort Study

BACKGROUND

Cardiovascular disease (CVD) is a group of disorders of the heart and blood vessels, such as coronary heart disease (CHD), cerebrovascular disease, and peripheral artery disease. CVD is the leading threat to global health, whether measured by mortality, morbidity, or economic cost. Long-term administration of aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers improves survival in patients with stablished coronary heart disease. Nevertheless, adherence to prescribed medication is poor for long-term drug treatment.

OBJECTIVE

We aim to assess the relationship between adherences to the four pharmacological groups recommended for secondary prevention and the clinical outcomes of cardiovascular morbidity and mortality in patients with established CHD according to the level of adherence to these drugs in a population of incident cases of acute coronary syndrome (ACS).

METHODS

Population-based cohort study of patients with a first episode of ACS during 2006-2015 in the Information System for Research in Primary Care (SIDIAP) database. We will estimate adherence to these drugs. The primary endpoint is a composite of all-cause mortality, ACS, and ischaemic stroke. Bivariate analyses will be performed estimating odds ratios for categorical variables and mean differences for continuous variables. Hazard ratios for adherences will be calculated for outcome events using Cox proportional hazard regression models, and proportionality of hazards assumption will be tested.

RESULTS

We expect to estimate adherence to all four study treatments, the incidence of MACE, and to analyze if this incidence is associated with the level of drug adherence.

CONCLUSIONS

We expect to find that adherent patients have a lower risk of the primary endpoints compared with nonadherent patients.

TRIAL REGISTRATION

This study protocol was classified as EPA-OD by the AEMPS (IJG-EST-2017-01-2017-01, 07/04/2017) and registered in the EU PAS register (EUPAS19017, 09/05/2017).

Survival in relation to multimorbidity patterns in older adults in primary care in Barcelona, Spain (2010-2014): a longitudinal study based on electronic health records

BACKGROUND

Several studies have analysed the characteristics of multimorbidity patterns but none have evaluated the relationship with survival. The purpose of this study was to compare survival across older adults with different chronic multimorbidity patterns (CMPs).

METHODS

Prospective longitudinal observational study using electronic health records for 190 108 people aged ≥65 years in Barcelona, Spain (2009-2014). CMPs were identified by cluster analysis. Mortality rates were estimated using the Catalan population structure and individual time at risk. Survival according to CMP (Cox regression) was analysed using hazard ratios (HRs) and 95% confidence intervals (CIs) with stratification by sex and age group (65-79, 80-94) and adjustment for age at onset, deprivation index, number of chronic conditions and invoiced drugs.

RESULTS

The highest mortality rates were observed in men, adults aged 80-94 years, socially disadvantaged quintiles and people prescribed more drugs and with fewer conditions. Using the musculoskeletal pattern as the reference category, men with the digestive-respiratory pattern had a higher risk of death, with adjusted HRs of 6.16 (95% CI 5.37 to 7.06) in the 65-79 age group and 2.62 (95% CI 2.31 to 2.97) in the 80-94 age group. In women, the cardiovascular pattern was associated with the highest risk, with adjusted HRs of 6.34 (95% CI 5.28 to 7.61) in the 65-79 age group and 3.05 (95% CI 2.73 to 3.41) in the 80-94 age group. These patterns were also associated with the highest mortality rates.

CONCLUSIONS

Mortality and survival vary according to CMPs in older adults stratified by sex and age. Our findings are useful for guiding the design and implementation of clinical management strategies.

[Health and determinants of health in second generations of international immigrants: Social inequalities in health since childhood?]

OBJECTIVE

To analyse the social inequalities in health between children and youth population of an immigrant origin from low-income countries and those of native origin in the Basque Country.

METHOD

Cross-sectional descriptive study using data from the Basque Country Health Survey 2013. Variables of health, behaviours and life conditions were used as the outcome variables. Prevalence ratios were calculated using robust Poisson models.

RESULTS

The children with immigrant parents had poorer self-rated health, a higher prevalence of obesity, spent more hours in sedentary activities and lived in households with greater economic difficulties. The differences persisted even after adjusting for social class and educational level of parents.

CONCLUSIONS

A migrant background is a highly relevant axis of health inequalities and has an influence beyond a generation. Given this reality, it is necessary to implement effective and suitable measures to ensure life with good health conditions and to reduce social inequalities in health, not only in childhood but through the entire life cycle.

Statins and new-onset atrial fibrillation in a cohort of patients with hypertension. Analysis of electronic health records, 2006-2015

Hypertension is the most prevalent risk factor for new-onset atrial fibrillation (AF). But few studies have addressed the effect of statins on the incidence of this arrhythmia in patients with hypertension. This study aimed to evaluate the effect of statins on new-onset of this arrhythmia in a hypertensive population, accounting for AF risk. Data from the Information System for the Development of Research in Primary Care was used to recruit a retrospective cohort of ≥55-year-old hypertensive individuals with no ischemic vascular disease, in 2006-2007, followed up through 2015. The effect of initiating statin treatment on new-onset atrial fibrillation was assessed with Cox proportional hazards models adjusted by the propensity score of receiving statin treatment, in the overall study population and stratified by AF risk. Of 100 276 included participants, 9814 initiated statin treatment. The AF incidence per 1000 person-years (95% confidence interval) was 12.5 (12.3-12.8). Statin use associated with a significant (9%) reduction in AF incidence. Differences in absolute AF incidence were higher in the highest AF risk subgroup, and the estimated number needed to treat to avoid one case was 720. The relative effect was poor, similar across groups, and non-significant, as was the association of statins with adverse effects. We found a limited protective effect of statins over new-onset AF in this hypertensive population with no ischemic vascular disease. If there is no further indication, hypertensive patients would not benefit from statin use solely for AF primary prevention.

Chronic kidney disease in hypertensive subjects ≥60 years treated in Primary Care

BACKGROUND

Hypertension (HT) is the second leading cause of kidney failure. In hypertensive patients with chronic kidney disease (CKD), blood pressure (BP) control is the most important intervention to minimise progression. For CKD diagnosis, standardised creatinine and estimated glomerular filtration rate (eGFR) testing by CKD-EPI is recommended.

OBJECTIVES

To describe the prevalence and factors associated with a moderate decrease in eGFR (by CKD-EPI) and BP control in subjects with HT.

METHODS

Cross-sectional descriptive study in subjects ≥ 60 years included in the SIDIAP plus database with hypertension and standardised serum creatinine and BP tests in the last 2years.

EXCLUSION CRITERIA

eGFR<30, dialysis or kidney transplantation, prior cardiovascular disease, home care. Primary endpoint: eGFR by CKD-EPI formula. Covariates: demographic data, examination, cardiovascular risk factors, heart failure and auricular fibrillation diagnosis, and drugs (antihypertensive agents acting on renal function, antiplatelet and lipid lowering agents). BP control criteria: ≤130/80mmHg in individuals with albuminuria, ≤140/90 in all other subjects.

RESULTS

Prevalence of eGFR <60=18.8%. Associated factors: age, gender, heart failure, albumin/creatinine ratio, auricular fibrillation, smoking, dyslipidaemia, diabetes and obesity. BP control: 66.14 and 63.24% in eGFR≥60 and eGFR <60, respectively (P<.05). Exposure to drugs was higher in eGFR<60.

CONCLUSION

One in 5hypertensive patients without cardiovascular disease ≥60 years in primary care presented with a moderate decrease in eGFR. In addition to age and sex, albuminuria and heart failure were the main associated factors. Despite the increased exposure to drugs, BP control was lower in CKD.

The relationship between bicycle commuting and perceived stress: a cross-sectional study

INTRODUCTION

Active commuting - walking and bicycling for travel to and/or from work or educational addresses - may facilitate daily, routine physical activity. Several studies have investigated the relationship between active commuting and commuting stress; however, there are no studies examining the relationship between solely bicycle commuting and perceived stress, or studies that account for environmental determinants of bicycle commuting and stress. The current study evaluated the relationship between bicycle commuting, among working or studying adults in a dense urban setting, and perceived stress.

METHODS

A cross-sectional study was performed with 788 adults who regularly travelled to work or study locations (excluding those who only commuted on foot) in Barcelona, Spain. Participants responded to a comprehensive telephone survey concerning their travel behaviour from June 2011 through to May 2012. Participants were categorised as either bicycle commuters or non-bicycle commuters, and (based on the Perceived Stress Scale, PSS-4) as either stressed or non-stressed. Multivariate Poisson regression with robust variance models of stress status based on exposures with bicycle commuting were estimated and adjusted for potential confounders.

RESULTS

Bicycle commuters had significantly lower risk of being stressed than non-bicycle commuters (Relative Risk; RR (95% CI)=0.73 (0.60 to 0.89), p=0.001). Bicycle commuters who bicycled 4 days per week (RR (95% CI)=0.42 (0.24 to 0.73), p=0.002) and those who bicycled 5 or more days per week (RR (95% CI)=0.57 (0.42 to 0.77), p<0.001) had lower risk of being stressed than those who bicycled less than 4 days. This relationship remained statistically significant after adjusting for individual and environmental confounders and when using different cut-offs of perceived stress.

CONCLUSIONS

Stress reduction may be an important consequence of routine bicycle use and should be considered by decision makers as another potential benefit of its promotion.

Association between socioeconomic deprivation and colorectal cancer screening outcomes: Low uptake rates among the most and least deprived people

Background

Screening with faecal occult blood tests reduces colorectal cancer-related mortality; however, age, sex and socioeconomic factors affect screening outcomes and could lead to unequal mortality benefits. The aim of this study was to describe the main outcomes of the population-based Barcelona colorectal cancer screening programme (BCRCSP) by deprivation.

Methods

Retrospective study of the eligible population of the first round of the BCRCSP. Participants’ postal addresses were linked with the MEDEA database to obtain the deprivation quintiles (Dq). Chi-squared tests were used to compare proportions across variables and logistic regression was used to estimate the adjusted effects of age, sex and deprivation on uptake, FIT positivity, colonoscopy adherence and advanced neoplasia detection rate.

Results

Overall uptake was 44.7%, higher in Dq2, 3 and 4 (OR 1.251, 1.250 and 1.276, respectively) than in the least deprived quintile (Dq 1), and lowest in Dq5 (OR 0.84). Faecal immunochemical test (FIT) positivity and the percentage of people with detectable faecal haemoglobin below the positivity threshold increased with deprivation. The advanced neoplasia detection rate was highest in Dq4.

Conclusion

Unlike most regions where inequalities are graded along the socioeconomic continuum, inequalities in the uptake of colorectal cancer screening in Spain seem to be concentrated first in the most disadvantaged group and second in the least deprived group. The correlation of deprivation with FIT-positivity and faecal haemoglobin below the positivity threshold is worrying due to its association with colorectal cancer and overall mortality.

Heart failure labelled patients with missing ejection fraction in primary care: prognosis and determinants

Background

It is common to find a high variability in the accuracy of heart failure (HF) diagnosis in electronic primary care medical records (EMR). Our aims were to ascertain (i) whether the prognosis of HF labelled patients whose ejection fraction (EF) was missing in their EMR differed from those that had it registered, and (ii) the causes contributing to the differences in the availability of EF in EMR.

Methods

Retrospective cohort analyses based on clinical records of HF and attended at 52 primary healthcare centres of Barcelona (Spain). Information of 8376 HF patients aged > 40 years followed during five years was analyzed.

Results

EF was available only in 8.5% of primary care medical records. Cumulate incidence for mortality and hospitalization from 1st January 2009 to 31th December 2012 was 37.6%. The highest rate was found in patients with missing EF (HR 1.84, 95% CI 1.68 -1.95) compared to those with preserved EF. Patients hospitalized the previous year and those requiring home healthcare (HR 1.81, 95% Confidence Interval 1.68-1.95 and HR 1.58, 95% CI 1.46-1.71, respectively) presented a higher risk of having an adverse outcome. Older patients, those more socio-economically disadvantaged, obese, requiring home healthcare, and taking loop diuretics were less likely to have an EF registered.

Conclusions

EF is poorly recorded in primary care. HF patients with EF missing at medical records had the worst prognosis. They tended to be older, socio-economically disadvantaged, and more fragile.

Injuries Among Immigrants Treated in Primary Care in Madrid, Spain

This study compared the injury incidence rates by sex in adult immigrant and native population attended in primary care in the Community of Madrid, Spain. Cross-sectional study of injuries registered in the primary care electronic medical record in 2012. Crude and age-adjusted incidence rates by sex, region of birth and type of injury were calculated. Poisson regression was performed. In both sexes, the highest crude injury incidence rate was found in immigrants from North Africa, followed by the native population. After controlling for age and socioeconomic-status, the highest risk of injury in immigrants was observed in burns in women from North-African (79%) and in foreign body injuries in men from Latin America and Caribbean, Sub-Saharan and North Africa and Central and Eastern Europe (61-123%). The analysis by region of origin has identified people from North Africa as a particularly vulnerable group.

Feasibility of an implementation strategy for the integration of health promotion in routine primary care: a quantitative process evaluation

BACKGROUND

Process evaluation is recommended to improve the understanding of underlying mechanisms related to clinicians, patients, context and intervention delivery that may impact on trial or program results, feasibility and transferability to practice. The aim of this study was to assess the feasibility of the Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable") implementation strategy for enhancing the adoption and implementation of an evidence-based health promotion intervention in primary health care.

METHODS

A descriptive study of 2-year implementation indicators for the PVS clinical intervention was conducted in four primary health care centers. A multifaceted collaborative modeling implementation strategy was developed to enhance the integration of a clinical intervention to promote healthy lifestyles into clinical practice. Process indicators were assessed for intervention reach, adoption, implementation, sustainability and their variability at center, practice, and patient levels.

RESULTS

Mean rates of adoption by means of active collaboration among the three main professional categories (family physicians, nurses and administrative personnel) were 75% in all centers. Just over half of the patients that attended (n = 11650; 51.9%) were reached in terms of having their lifestyle habits assessed, while more than a third (33.7%; n = 7433) and almost 10% (n = 2175) received advice or a printed prescription for at least one lifestyle change, respectively. Only 3.7% of the target population received a repeat prescription. These process indicators significantly (p < 0.001) varied by center, lifestyle habit and patient characteristics. Sustainability of intervention components changed thorough the implementation period within centers.

CONCLUSIONS

The implementation strategy used showed moderate-to-good performance on process indicators related to adoption, reach, and implementation of the evidence-based healthy lifestyle promotion intervention in the context of routine primary care. Sources of heterogeneity and instability in these indicators may improve our understanding of factors required to attain adequate program adoption and implementation through improved implementation strategies.

Efficiency of "Prescribe Vida Saludable", a health promotion innovation. Pilot phase

OBJECTIVE

"Prescribe Vida Saludable" (PVS) is an organisational innovation designed to optimise the promotion of multiple healthy habits in primary healthcare. It aims to estimate the cost effectiveness and cost-utility of prescribing physical activity in the pilot phase of the PVS programme, compared to the routine clinical practice of promoting physical activity in primary healthcare.

METHODS

An economic evaluation of the quasi-experimental pilot phase of PVS was carried out. In the four control centres, a systematic sample was selected of 194 patients who visited the centre in a single year and who did not comply with physical activity recommendations. In the four intervention centres, 122 patients who received their first physical activity prescription were consecutively enrolled. The costs were evaluated from the perspective of the PVS programme using bottom-up methodology. The effectiveness (proportion of patients who changed their physical activity) as well as the utility were evaluated at baseline and after 3 months. The incremental cost-utility ratio (ICUR) and the incremental cost-effectiveness ratio (ICER) were calculated and a sensitivity analysis was performed with bootstrapping and 1,000 replications.

RESULTS

Information was obtained from 35% of control cases and 62% of intervention cases. The ICUR was €1,234.66/Quality Adjusted Life Years (QALY) and the ICER was €4.12. In 98.3% of the simulations, the ICUR was below the €30,000/QALY threshold.

CONCLUSIONS

The prescription of physical activity was demonstrably within acceptable cost-utility limits in the pilot PVS phase, even from a conservative perspective.

Comorbidities with chronic physical conditions and gender profiles of illness in schizophrenia. Results from PREST, a new health dataset

OBJECTIVE

Using data from a large health dataset, the objectives are to describe the epidemiology of comorbidities with chronic physical conditions in schizophrenia, to identify gender profiles of illness and to discuss findings in the light of previous research.

METHODS

The PREST health database was used which combines high quality and complementary data from numerous public health care resources in the Basque Country (Spain).

RESULTS

A total number of 2,255,406 patients were included in this study and 7331 had a diagnosis of schizophrenia. 55.6% of them had one comorbid condition and 29.3% had 2 or more (e.g. multiple comorbidities). Hypertension (16.8%) was the most prevalent diagnosed comorbid condition in these patients. The risk of having neuropsychiatric disorders including Parkinson (OR up to 47.89), infectious diseases (OR up to 3.31) or diabetes (OR2.23) was increased, while the risk of having cancer (OR down to 0.76) or some cardiovascular conditions (OR down to 0.63) was reduced. Women (both with and without schizophrenia) showed higher percentages of comorbidities than men. A cluster of respiratory diseases was found only in women with schizophrenia (not in men).

CONCLUSIONS

Results confirm partially previous findings and call for a more proactive and comprehensive approach to the health care of patients with schizophrenia. Specific profiles of risks for concrete disorders were identified which could be explained by selective underdiagnoses or higher exposition to risk factors in this group of patients. Results also suggest the need of a more gender oriented approach to health care in schizophrenia.

Use of emergency medical transport and impact on time to care in patients with ischaemic stroke

INTRODUCTION

According to numerous studies, using emergency medical services (EMS) to transport stroke patients to hospitals decreases diagnostic and treatment delays.

OBJECTIVES

To determine the frequency of use of EMS by stroke patients in Bizkaia (Spain), analyse the factors associated with using EMS, and study the impact of EMS on time to care.

METHODS

We gathered data from 545 patients hospitalised for acute ischaemic stroke and recruited consecutively. Data were obtained from the patients' medical histories and interviews with the patients themselves or their companions. We studied the following variables: previous health status, stroke symptoms and severity (NIHSS), type of transport, and time to medical care. Univariate and multivariate analyses were performed to identify factors associated with use of EMS and care delays.

RESULTS

Patients transported to hospital by the EMS accounted for 47.2% of the total. Greater stroke severity, arriving at the hospital at night, and poor functional status at baseline were found to be independently associated with use of EMS. Use of EMS was linked to earlier arrival at the hospital. Door-to-imaging times were shorter in the EMS group; however, this association disappeared after adjusting for stroke severity. Revascularisation was more frequent among patients transported by the EMS.

CONCLUSIONS

EMS transport was associated with shorter prehospital delays. Effective health education programmes should be developed to promote EMS transport for patients with stroke symptoms. In-hospital stroke management should also be improved to reduce time to medical care.

[Influence of postcode on paediatric admissions in Seville]

INTRODUCTION

The postcode (where the home is situated) is an indicator of socioeconomic status and is associated with morbidity, mortality, and the use of health services. The aim of this study was to analyse its effects on paediatric admissions and to determine the rates of the most common causes of paediatric admissions in Seville.

MATHERIAL AND METHODS

An observational cross-sectional study with two analysis units: under 15 year-old "admissions" in public hospitals in Seville (n=2,660) and "city districts" of Seville (n=11). The independent variable analysed was whether the postcode of the admitted patients was within a Regional Government designated "area with social transformation needs". The analysis of the admissions was performed using X²-test, Fisher test and Student-t test, with the description of rates using the calculation of crude and specific rates, and by rate ratio.

RESULTS

Children living in districts with a lower socioeconomic status were on average 7 months younger (P<.001), and they were significantly more likely to be admitted via the emergency department (P<.001). There was no statistical difference detected in either the length of hospital stay or mortality. The crude admission rate ratio was higher in districts with a lower socioeconomic status (1.8), with a higher specific rate ratio detected in admissions due to asthma, respiratory infections, inguinal hernia, and epilepsy/convulsions.

CONCLUSIONS

Paediatric hospital admission rates of the main diagnoses were higher in districts with a lower socioeconomic status. Children living in these districts were more likely to be admitted younger and via the emergency department.

Effectiveness and safety of drugs used for stroke prevention in a cohort of non-valvular atrial fibrillation patients from a primary care electronic database

PURPOSE

The aim of this study was to assess effectiveness and safety of antithrombotics for stroke prevention in non-valvular atrial fibrillation in real-use conditions.

METHODS

We used a population-based retrospective cohort study. Information emerges from SIDIAP, a database containing anonymized information from electronic health records from 274 primary healthcare centres of the Catalan Health Institute, Catalonia (Spain), with a reference population of 5 835 000 people. Population includes all adults with a new diagnosis of non-valvular atrial fibrillation registered in SIDIAP from 2007 to 2012. The main outcome of antithrombotics' effectiveness was stroke. The main outcomes of safety were cerebral and gastrointestinal haemorrhages. We also estimated all-cause mortality. We used multivariable Cox proportional hazard models to examine association between antithrombotic treatment and main outcomes.

RESULTS

We included 22 205 subjects with non-valvular atrial fibrillation; 40.8% initiated on vitamin K antagonists (VKA), 33.4% on antiplatelets and 25.8% untreated. We found stroke-risk reduction with VKA, hazard ratio (HR) 0.72 (95% confidence interval (CI), 0.58-0.91), also seen in patients with CHADS₂  ≥ 2, HR 0.65 (95%CI, 0.49-0.86), and CHA₂ DS₂ -VASc ≥ 2, HR 0.66 (95%CI, 0.52-0.84). We observed a higher risk of digestive bleeding with antiplatelets, HR 1.32 (95%CI, 1.01-1.73). Both VKA and antiplatelets were associated with reduction of all-cause mortality risk; HR 0.55 (95%CI, 0.49-0.62) and HR 0.89 (95%CI, 0.80-0.97), respectively.

CONCLUSIONS

This study found a stroke-risk reduction associated with VKA and an increased risk of gastrointestinal bleeding associated with platelet-aggregation inhibitors in comparison with untreated patients. Both antithrombotic groups showed a reduction in all-cause mortality. Copyright © 2016 John Wiley & Sons, Ltd.

[Monitoring social determinants of health]

Public health surveillance is the systematic and continuous collection, analysis, dissemination and interpretation of health-related data for planning, implementation and evaluation of public health initiatives. Apart from the health system, social determinants of health include the circumstances in which people are born, grow up, live, work and age, and they go a long way to explaining health inequalities. A surveillance system of the social determinants of health requires a comprehensive and social overview of health. This paper analyses the importance of monitoring social determinants of health and health inequalities, and describes some relevant aspects concerning the implementation of surveillance during the data collection, compilation and analysis phases, as well as dissemination of information and evaluation of the surveillance system. It is important to have indicators from sources designed for this purpose, such as continuous records or periodic surveys, explicitly describing its limitations and strengths. The results should be published periodically in a communicative format that both enhances the public's ability to understand the problems that affect them, whilst at the same time empowering the population, with the ultimate goal of guiding health-related initiatives at different levels of intervention.

Effectiveness of computerized point-of-care reminders on adherence with multiple clinical recommendations by primary health care providers: protocol for a cluster-randomized controlled trial

BACKGROUND

To determine the effectiveness of reminders compared to no reminders in improving adherence to multiple clinical recommendations measured as the resolution of the clinical condition that motivated the reminder, in a primary care setting with a well-established feedback system.

METHODS/DESIGN

A 12-month, cluster-randomized, controlled clinical trial was designed (randomized by primary care team) to evaluate the impact of computerized reminders. All study participants will continue to receive the usual feedback from the electronic health records system. The control group (well-established feedback) will be compared with reminders and a well-established feedback system. The study will include all general practitioners (3425) and nurses (3262) providing primary care for a population aged 14 years or older in the 282 primary care teams reporting to the Catalan Institute of Health. Up to 10 clinical reminders are offered for each patient, recommending action related to at least one of nine clinical conditions: arterial hypertension, elevated cardiovascular risk, type 2 diabetes mellitus, cerebrovascular accident, ischemic heart disease, heart failure, atrial fibrillation, smoking habit, and hepatitis C. The outcomes are the resolution of the clinical condition that motivated the reminder and the time elapsed between the first reminder message and implementation of the recommended action (months). Due to the obvious correlation between reminders about the same patient, the profile of patients assigned to a particular professional, and the professionals assigned to a particular centre, hierarchical modelling will be used to simultaneously estimate the effect of the study variables at these different levels of analysis. To estimate the impact of the intervention arm, an analysis of adherence to each type of reminder will be carried out, using multi-level logistical regression models at level of the primary care centre. Time to adherence will be estimated by the Kaplan-Meier method and comparisons will be done using the log-rank test.

DISCUSSION

The results of this study could provide new evidence on the impact of computerized reminders at the point of care on adherence to clinical guidelines in primary care with an established feedback system. Trial registration ISRCTN42391639. October 8, 2012.

Trends in socioeconomic inequalities in mortality in small areas of 33 Spanish cities

BACKGROUND

In Spain, several ecological studies have analyzed trends in socioeconomic inequalities in mortality from all causes in urban areas over time. However, the results of these studies are quite heterogeneous finding, in general, that inequalities decreased, or remained stable. Therefore, the objectives of this study are: (1) to identify trends in geographical inequalities in all-cause mortality in the census tracts of 33 Spanish cities between the two periods 1996-1998 and 2005-2007; (2) to analyse trends in the relationship between these geographical inequalities and socioeconomic deprivation; and (3) to obtain an overall measure which summarises the relationship found in each one of the cities and to analyse its variation over time.

METHODS

Ecological study of trends with 2 cross-sectional cuts, corresponding to two periods of analysis: 1996-1998 and 2005-2007. Units of analysis were census tracts of the 33 Spanish cities. A deprivation index calculated for each census tracts in all cities was included as a covariate. A Bayesian hierarchical model was used to estimate smoothed Standardized Mortality Ratios (sSMR) by each census tract and period. The geographical distribution of these sSMR was represented using maps of septiles. In addition, two different Bayesian hierarchical models were used to measure the association between all-cause mortality and the deprivation index in each city and period, and by sex: (1) including the association as a fixed effect for each city; (2) including the association as random effects. In both models the data spatial structure can be controlled within each city. The association in each city was measured using relative risks (RR) and their 95 % credible intervals (95 % CI).

RESULTS

For most cities and in both sexes, mortality rates decline over time. For women, the mortality and deprivation patterns are similar in the first period, while in the second they are different for most cities. For men, RRs remain stable over time in 29 cities, in 3 diminish and in 1 increase. For women, in 30 cities, a non-significant change over time in RR is observed. However, in 4 cities RR diminishes. In overall terms, inequalities decrease (with a probability of 0.9) in both men (RR = 1.13, 95 % CI = 1.12-1.15 in the 1st period; RR = 1.11, 95 % CI = 1.09-1.13 in the 2nd period) and women (RR = 1.07, 95 % CI = 1.05-1.08 in the 1st period; RR = 1.04, 95 % CI = 1.02-1.06 in the 2nd period).

CONCLUSIONS

In the future, it is important to conduct further trend studies, allowing to monitoring trends in socioeconomic inequalities in mortality and to identify (among other things) temporal factors that may influence these inequalities.

Alerts in electronic medical records to promote a colorectal cancer screening programme: a cluster randomised controlled trial in primary care

BACKGROUND

Participation rates in colorectal cancer screening are below recommended European targets.

AIM

To evaluate the effectiveness of an alert in primary care electronic medical records (EMRs) to increase individuals' participation in an organised, population-based colorectal cancer screening programme when compared with usual care.

DESIGN AND SETTING

Cluster randomised controlled trial in primary care centres of Barcelona, Spain.

METHOD

Participants were males and females aged 50-69 years, who were invited to the first round of a screening programme based on the faecal immunochemical test (FIT) (n = 41 042), and their primary care professional. The randomisation unit was the physician cluster (n = 130) and patients were blinded to the study group. The control group followed usual care as per the colorectal cancer screening programme. In the intervention group, as well as usual care, an alert to health professionals (cluster level) to promote screening was introduced in the individual's primary care EMR for 1 year. The main outcome was colorectal cancer screening participation at individual participant level.

RESULTS

In total, 67 physicians and 21 619 patients (intervention group) and 63 physicians and 19 423 patients (control group) were randomised. In the intention-to-treat analysis screening participation was 44.1% and 42.2% respectively (odds ratio 1.08, 95% confidence interval [CI] = 0.97 to 1.20, P = 0.146). However, in the per-protocol analysis screening uptake in the intervention group showed a statistically significant increase, after adjusting for potential confounders (OR, 1.11; 95% CI = 1.02 to 1.22; P = 0.018).

CONCLUSION

The use of an alert in an individual's primary care EMR is associated with a statistically significant increased uptake of an organised, FIT-based colorectal cancer screening programme in patients attending primary care centres.

Development of a cross-cultural deprivation index in five European countries

BACKGROUND

Despite a concerted policy effort in Europe, social inequalities in health are a persistent problem. Developing a standardised measure of socioeconomic level across Europe will improve the understanding of the underlying mechanisms and causes of inequalities. This will facilitate developing, implementing and assessing new and more effective policies, and will improve the comparability and reproducibility of health inequality studies among countries. This paper presents the extension of the European Deprivation Index (EDI), a standardised measure first developed in France, to four other European countries-Italy, Portugal, Spain and England, using available 2001 and 1999 national census data.

METHODS AND RESULTS

The method previously tested and validated to construct the French EDI was used: first, an individual indicator for relative deprivation was constructed, defined by the minimal number of unmet fundamental needs associated with both objective (income) poverty and subjective poverty. Second, variables available at both individual (European survey) and aggregate (census) levels were identified. Third, an ecological deprivation index was constructed by selecting the set of weighted variables from the second step that best correlated with the individual deprivation indicator.

CONCLUSIONS

For each country, the EDI is a weighted combination of aggregated variables from the national census that are most highly correlated with a country-specific individual deprivation indicator. This tool will improve both the historical and international comparability of studies, our understanding of the mechanisms underlying social inequalities in health and implementation of intervention to tackle social inequalities in health.

Effectiveness, safety and costs of thromboembolic prevention in patients with non-valvular atrial fibrillation: phase I ESC-FA protocol study and baseline characteristics of a cohort from a primary care electronic database

PURPOSE

Atrial fibrillation is the most common arrhythmia. Its management aims to reduce symptoms and to prevent complications through rate and rhythm control, management of concomitant cardiac diseases and prevention of related complications, mainly stroke. The main objective of Effectiveness, Safety and Costs in Atrial Fibrillation (ESC-FA) study is to analyse the drugs used for the management of the disease in real-use conditions, particularly the antithrombotic agents for stroke prevention. The aim of this work is to present the study protocol of phase I of the ESC-FA study and the baseline characteristics of newly diagnosed patients with atrial fibrillation in Catalonia, Spain.

PARTICIPANTS

The data source is System for the Improvement of Research in Primary Care (SIDIAP) database. The population included are all patients with non-valvular atrial fibrillation diagnosis registered in the electronic health records during 2007-2012.

FINDINGS TO DATE

A total of 22,585 patients with non-valvular atrial fibrillation were included in the baseline description. Their mean age was 72.8 years and 51.6% were men. The most commonly prescribed antithrombotics were vitamin K antagonists (40.1% of patients) and platelet aggregation inhibitors (32.9%); 25.3% had not been prescribed antithrombotic treatment. Age, gender, comorbidities and co-medication at baseline were similar to those reported for previous studies.

FUTURE PLANS

The next phase in the ESC-FA study will involve assessing the effectiveness and safety of antithrombotic treatments, analysing stroke events and bleeding episodes' rates in our patients (rest of phase I), describing the current management of the disease and its costs in our setting, and assessing how the introduction of new oral anticoagulants changes the stroke prevention in non-valvular atrial fibrillation.

Impact of primary care nursing workforce characteristics on the control of high-blood pressure: a multilevel analysis

OBJECTIVE

To determine the impact of Primary Health Care (PHC) nursing workforce characteristics and of the clinical practice environment (CPE) perceived by nurses on the control of high-blood pressure (HBP).

DESIGN

Cross-sectional analytical study.

SETTING

Administrative and clinical registries of hypertensive patients from PHC information systems and questionnaire from PHC nurses.

PARTICIPANTS

76,797 hypertensive patients in two health zones within the Community of Madrid, North-West Zone (NWZ) with a higher socioeconomic situation and South-West Zone (SWZ) with a lower socioeconomic situation, and 442 reference nurses. Segmented analyses by area were made due to their different socioeconomic characteristics.

PRIMARY OUTCOME MEASURE

Poor HBP control (adequate figures below the value 140/90 mm Hg) associated with the characteristics of the nursing workforce and self-perceived CPE.

RESULTS

The prevalence of poor HBP control, estimated by an empty multilevel model, was 33.5% (95% CI 31.5% to 35.6%). In the multilevel multivariate regression models, the perception of a more favourable CPE was associated with a reduction in poor control in NWZ men and SWZ women (OR=0.99 (95% CI 0.98 to 0.99)); the economic immigration conditions increased poor control in NWZ women (OR=1.53 (95% CI 1.24 to 1.89)) and in SWZ, both men (OR=1.89 (95% CI 1.43 to 2.51)) and women (OR=1.39 (95% CI 1.09 to 1.76)). In all four models, increasing the annual number of patient consultations was associated with a reduction in poor control (NWZ women: OR=0.98 (95% CI0.98 to 0.99); NWZ men: OR=0.98 (95% CI 0.97 to 0.99); SWZ women: OR=0.98 (95% CI 0.97 to 0.99); SWZ men: OR=0.99 (95% CI 0.97 to 0.99).

CONCLUSIONS

A CPE, perceived by PHC nurses as more favourable, and more patient-nurse consultations, contribute to better HBP control. Economic immigration condition is a risk factor for poor HBP control. Health policies oriented towards promoting positive environments for nursing practice are needed.

Early (1-year) Discontinuation of Different Anti-osteoporosis Medications Compared: A Population-Based Cohort Study

Although a number of reports suggest very low persistence with oral bisphosphonates, there is limited data on persistence with other anti-osteoporosis medications. We compare rates of early discontinuation (in the first year) with all available outpatient anti-osteoporosis drugs in Catalonia, Spain. We conducted a population-based retrospective cohort study using data from the SIDIAP database. SIDIAP contains computerized primary care records and pharmacy dispensing data for >80 % of the population of Catalonia (>5 million people). All SIDIAP participants starting an anti-osteoporosis drug between 1/1/2007 and 30/06/2011 (with 2 years wash-out) were included. We modelled persistence as the time between first prescription and therapy discontinuation (refill gap of at least 6 months) using Fine and Gray survival models with competing risk for death. We identified 127,722 patients who started any anti-osteoporosis drug in the study period. The most commonly prescribed drug was weekly alendronate (N = 55,399). 1-Year persistence ranges from 40 % with monthly risedronate to 7.7 % with daily risedronate, and discontinuation was very common [from 49.5 % (monthly risedronate) to 84.4 % (daily risedronate)] as was also switching in the first year of therapy [from 2.8 % (weekly alendronate) to 10 % (daily alendronate)]. Multivariable-adjusted models showed that only monthly risedronate had better one-year persistence than weekly alendronate and teriparatide equivalent, whilst all other therapies had worse persistence. Early discontinuation with available anti-osteoporosis oral drugs is very common. Monthly risedronate, weekly alendronate, and daily teriparatide are the drugs with the best persistence, whilst daily oral drugs have 40-60 % higher first-year discontinuation rates compared to weekly alendronate.

Is utilization of health services for HIV patients equal by socioeconomic status? Evidence from the Basque country

Introduction

Access to ART and health services is guaranteed under universal coverage to improve life expectancy and quality of life for HIV patients. However, it remains unknown whether patients of different socioeconomic background equally use different types of health services.

Methods

We use one-year (2010–2011) data on individual healthcare utilization and expenditures for the total population (N = 2262698) of the Basque Country. We observe the prevalence of HIV and use OLS regressions to estimate the impact on health utilization of demographic, socioeconomic characteristics, and health status in such patients.

Results

HIV prevalence per 1000 individuals is greater the lower the socioeconomic status (0.784 for highest; 2.135 for lowest), for males (1.616) versus females (0.729), and for middle-age groups (26–45 and 46–65). Health expenditures are 11826€ greater for HIV patients than for others, but with differences by socioeconomic group derived from a different mix of services utilization (total cost of 13058€ for poorest, 14960€ for richest). Controlling for health status and demographic variables, poor HIV patients consume more on pharmaceuticals; rich in specialists and hospital care. Therefore, there is inequity in health services utilization by socioeconomic groups.

Conclusions

Equity in health provision for HIV patients represents a challenge even if access to treatment is guaranteed. Lack of information in poorer individuals might lead to under-provision while richer individuals might demand over-provision. We recommend establishing accurate clinical guidelines with the appropriate mix of health provision by validated need for all socioeconomic groups; promoting educational programs so that patients demand the appropriate mix of services, and stimulating integrated care for HIV patients with multiple chronic conditions.

Social inequalities in a population based colorectal cancer screening programme in the Basque Country

BACKGROUND

While it is known that a variety of factors (biological, behavioural and interventional) play a major role in the health of individuals and populations, the importance of the role of social determinants is less clear. The effect of social inequality on population-based screening for colorectal cancer (CRC) could limit the value of such programmes. The present study aims to determine whether such inequalities exist.

METHODS

Data was obtained from the population-based screening programme administered in the Autonomous Community of the Basque Country, Spain, with a target population aged 50 to 69, first invited to participate between 2009 and 2011. The magnitude of inequality was analysed using the odds ratio (taking the least disadvantaged socioeconomic quintile as the reference population), the population attributable risk and the relative index of inequality, based on the regression, which is the ratio of the rates in the most and least disadvantaged socioeconomic groups.

RESULTS

The target population comprised 242,394 people, with the test kit successfully sent to 95.1 % (230,510). The overall response rate was 64.3 % (67.1 in women and 61.4 % men). Among women, the highest participation was in the third quintile (71.5 %) and the lowest in the first - the least disadvantaged (65.7 %). The lowest and highest rates of people with identified lesions were in the second and fourth quintiles (14.7/1000 and 17.0/1000 respectively). Among men, the response rate was lowest in the fifth - most disadvantaged - quintile (60.2 %). The highest rate of identified lesions was in the fifth quintile; 38 % higher than the first (55.7/1000 compared to 41.0/1000).

CONCLUSIONS

Sex and socioeconomic group influence the rate of participation in the CRC programme and the rate of lesions found in the participants. Any public health programme is morally and ethically obliged to strive for equity and effectiveness. Improving participation of men and socially disadvantaged groups should be taken in account.

Suicide in Portugal: Spatial determinants in a context of economic crisis

This study compares the existing statistical association between suicide mortality and the characteristics of places of residence (municipalities), before and during the current economic crisis, in Portugal. We found that (1) the traditional culture-based North/South pattern of suicidal behaviour has faded away, while the socioeconomic urban/rural divide has become more pronounced; (2) suicide is associated with higher levels of rurality and material deprivation; and (3) recent shifts in suicidal trends may result from the current period of crisis. Strategies targeting rural areas combined with public policies that address area deprivation may have important implications for tackling suicide.

The Origin of Variation in Primary Care Process and Outcome Indicators: Patients, Professionals, Centers, and Health Districts

Healthcare providers are often evaluated by studying variability in their indicators. However, the usefulness of this analysis may be limited if we do not distinguish the variability attributable to health professionals and organizations from that associated with their patients.Our objectives are to describe the main process and outcome indicators of primary healthcare services, analyzing the contribution to variability in these indicators from different levels: individual, health professional, health center, and health district.This is a cross-sectional study that includes all.All the individuals covered by the public Basque Health Service (children [age 0-13], n = 247,493; adults [≥14 years old], n = 1,959,682) over a 12-month period.We calculated the number of visits to primary care doctors, number of referrals, prescription costs, and potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSCs). Using multilevel analysis, we determined the percentage of variance attributable to each level.After adjusting for the characteristics of patients (demographic, socioeconomic, and morbidity), doctors (panel size), health center (size, staff satisfaction, demographic structure of the community), and health district, the variance in the indicators was mainly attributable to differences between patients, independently of the attending health professional, the center, or the healthcare organization, both in children (94.21% for visits to the doctor; 96.66% for referrals; 98.57% for prescription costs; 90.02% for potentially avoidable hospitalizations for ACSCs) and in adults (88.10%; 96.26%; 97.92%; and 93.77%, respectively).The limited contribution of health professionals and organizations to variability in indicators should be taken into account when performing evaluations and planning quality improvement strategies.

Incidence of severe hypoglycaemic episodes in patients with type 2 diabetes in the Basque country: impact on healthcare costs

BACKGROUND

Hypoglycaemia is an acute complication of diabetes mellitus which poses a serious threat. This study aims to describe the annual rate of people suffering episodes of severe hypoglycaemia and to estimate the healthcare costs for individuals who have suffered such events.

METHODS

A descriptive study involving all patients with type 2 diabetes (T2DM) from the Basque Country (period: 1/09/2010 to 31/08/2011) aged ≥35 years (N = 134,413). The rate of hypoglycaemic episodes treated in hospitals (Accident and Emergency and in-patient services) was calculated using an algorithm based on diagnostics and laboratory tests. The variables recorded included demographic, comorbidity (diagnoses categorised using the Adjusted Clinical Groups case-mix system) and socioeconomic variables (deprivation index of the area of residence). The annual healthcare cost for people with T2DM who suffered those episodes was compared with those who did not by regression analysis.

RESULTS

The incidence of hypoglycaemia in the Basque Country was 0.56 %. This percentage was higher among women and people with a lower socioeconomic status. These episodes were associated with age and high values of glycosylated haemoglobin (HbA1c) > 7 %. Adjusting for the other variables, on average, people who suffered hypoglycaemia accounted for an additional €2509 in annual healthcare costs.

CONCLUSIONS

Hypoglycaemia has high morbi-mortality and a major economic impact. As such, health services must monitor its appearance and promote specific actions, especially in the higher risk sub-populations.

Variability in potentially preventable hospitalisations: an observational study of clinical practice patterns of general practitioners and care outcomes in the Basque Country (Spain)

OBJECTIVES

To explain the variability in the frequency of potentially preventable hospitalisations (ambulatory care sensitive conditions, ACSCs) based on factors at multiple levels (individual, health professional, health centre and health district), and specifically using resource efficiency indicators for general practitioners (GPs).

DESIGN

Cross-sectional study. We analysed primary care electronic health records and hospital discharge data using multilevel mixed models.

SETTING

Primary care network of the Basque Health Service (Spain).

PARTICIPANTS

All the residents in the Basque Country ≥14 years of age, covered by the public healthcare system (n=1,959,682), and all the GPs (n=1193) and health centres (n=130).

MAIN OUTCOME MEASURES

Individuals admitted for ACSCs, over a 12- month period.

RESULTS

Admissions for ACSCs were less frequent among patients who were female, middle-aged or from the highest socioeconomic classes. The health centre variables considered and GP list size were not found to be significant. After adjusting for the variables studied including morbidity, the risk of hospital admission was higher among individuals under the care of GPs with greater than expected numbers of patient visits and prescribing costs (OR=1.27 (95% CI 1.18 to 1.37); 1.16 (1.08 to 1.25)), and who make fewer referrals than the mean among their colleagues (OR=1.33 (1.22 to 1.44)).

CONCLUSIONS

When assessing activities and procedure indicators in primary care, we should also define outcome-based criteria. Specifically, GPs who are repeatedly visited by their patients, have higher prescribing costs and are more reluctant to refer patients to specialists obtain poorer outcomes.

Lung cancer and urbanization level in a region of Southern Europe: influence of socio-economic and environmental factors

BACKGROUND

This study analysed the distribution of lung cancer deaths in areas with different urbanization levels in the Madrid Region and whether such differences persisted when deprivation and air pollution were considered.

METHODS

This was a population-based cross-sectional study covering lung cancer deaths (2001-07). The exposure indicators were: a deprivation index based on 2001 census data; and the daily mean NO2 measurement (2002-07), both at the census tract level. Analysis was stratified by sex and age group and the Poisson regression models were applied to obtain rate ratios (RRs).

RESULTS

After adjustment for age, deprivation index and NO2, mortality was similar in the city and Greater Madrid areas and lower in the rural area for the over-64 age group (RR: 0.84 in men and RR: 0.66 in women, with respect to the city of Madrid), and significantly lower in the Greater Madrid area (RR: 0.84 in men and RR: 0.74 in women) and in the rural area (RR: 0.73 in men and RR: 0.51 in women) with respect to the city of Madrid for the under-65 age group.

CONCLUSIONS

The most urbanized areas of the Madrid Region are characterized by higher lung cancer mortality.

Trends in socioeconomic inequalities in preventable mortality in urban areas of 33 Spanish cities, 1996-2007 (MEDEA project)

Background

Preventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996–2001 and 2002–2007.

Methods

We analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used.

Results

Preventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996–2001 and 10.9 in 2002–2007), though not so clearly among women (3.3% in 1996–2001 and 2.9% in 2002–2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities.

Conclusions

Preventable mortality decreased between the 1996–2001 and 2002–2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process.

Residential proximity to major roads and term low birth weight: the roles of air pollution, heat, noise, and road-adjacent trees

BACKGROUND

Maternal residential proximity to roads has been associated with adverse pregnancy outcomes. However, there is no study investigating mediators or buffering effects of road-adjacent trees on this association. We investigated the association between mothers' residential proximity to major roads and term low birth weight (LBW), while exploring possible mediating roles of air pollution (PM(2.5), PM(2.5-10), PM(10), PM(2.5) absorbance, nitrogen dioxide, and nitrogen oxides), heat, and noise and buffering effect of road-adjacent trees on this association.

METHODS

This cohort study was based on 6438 singleton term births in Barcelona, Spain (2001-2005). Road proximity was measured as both continuous distance to and living within 200 m from a major road. We assessed individual exposures to air pollution, noise, and heat using, respectively, temporally adjusted land-use regression models, annual averages of 24-hour noise levels across 50 m and 250 m, and average of satellite-derived land-surface temperature in a 50-m buffer around each residential address. We used vegetation continuous fields to abstract tree coverage in a 200-m buffer around major roads.

RESULTS

Living within 200 m of major roads was associated with a 46% increase in term LBW risk; an interquartile range increase in heat exposure with an 18% increase; and third-trimester exposure to PM(2.5), PM(2.5-10), and PM10 with 24%, 25%, and 26% increases, respectively. Air pollution and heat exposures together explained about one-third of the association between residential proximity to major roads and term LBW. Our observations on the buffering of this association by road-adjacent trees were not consistent between our 2 measures of proximity to major roads.

CONCLUSION

An increased risk of term LBW associated with proximity to major roads was partly mediated by air pollution and heat exposures.

Linking of primary care records to census data to study the association between socioeconomic status and cancer incidence in Southern Europe: a nation-wide ecological study

BACKGROUND

Area-based measures of economic deprivation are seldom applied to large medical records databases to establish population-scale associations between deprivation and disease.

OBJECTIVE

To study the association between deprivation and incidence of common cancer types in a Southern European region.

METHODS

Retrospective ecological study using the SIDIAP (Information System for the Development of Research in Primary Care) database of longitudinal electronic medical records for a representative population of Catalonia (Spain) and the MEDEA index based on urban socioeconomic indicators in the Spanish census. Study outcomes were incident cervical, breast, colorectal, prostate, and lung cancer in 2009-2012. The completeness of SIDIAP cancer recording was evaluated through linkage of a geographic data subset to a hospital cancer registry. Associations between MEDEA quintiles and cancer incidence was evaluated using zero-inflated Poisson regression adjusted for sex, age, smoking, alcoholism, obesity, hypertension, and diabetes.

RESULTS

SIDIAP sensitivity was 63% to 92% for the five cancers studied. There was direct association between deprivation and lung, colorectal, and cervical cancer: incidence rate ratios (IRR) 1.82 [1.64-2.01], IRR 1.60 [1.34-1.90], IRR 1.22 [1.07-1.38], respectively, comparing the most deprived to most affluent areas. In wealthy areas, prostate and breast cancers were more common: IRR 0.92 [0.80-1.00], IRR 0.91 [0.78-1.06]. Adjustment for confounders attenuated the association with lung cancer risk (fully adjusted IRR 1.16 [1.08-1.25]), reversed the direction of the association with colorectal cancer (IRR 0.90 [0.84-0.95]), and did not modify the associations with cervical (IRR 1.27 [1.11-1.45]), prostate (0.74 [0.69-0.80]), and breast (0.76 [0.71-0.81]) cancer.

CONCLUSIONS

Deprivation is associated differently with the occurrence of various cancer types. These results provide evidence that MEDEA is a useful, area-based deprivation index for analyses of the SIDIAP database. This information will be useful to improve screening programs, cancer prevention and management strategies, to reach patients more effectively, particularly in deprived urban areas.

Changes in social inequalities in disability-free life expectancy in Southern Europe: the case of the Basque Country

BACKGROUND

Health expectancy is a useful tool to monitor health inequalities. The evidence about the recent changes in social inequalities in healthy expectancy is relatively scarce and inconclusive, and most studies have focused on Anglo-Saxon and central or northern European countries. The objective of this study was to analyse the changes in socioeconomic inequalities in disability-free life expectancy in a Southern European population, the Basque Country, during the first decade of the 21st century.

METHODS

This was an ecological cross-sectional study of temporal trends on the Basque population in 1999-2003 and 2004-2008. All-cause mortality rate, life expectancy, prevalence of disability and disability free-life expectancy were calculated for each period according to the deprivation level of the area of residence. The slope index of inequality and the relative index of inequality were calculated to summarize and compare the inequalities in the two periods.

RESULTS

Disability free-life expectancy decreased as area deprivation increased both in men and in women. The difference between the most extreme groups in 2004-2008 was 6.7 years in men and 3.7 in women. Between 1999-2003 and 2004-2008, socioeconomic inequalities in life expectancy decreased, and inequalities in disability-free expectancy increased in men and decreased in women.

CONCLUSIONS

This study found important socioeconomic inequalities in health expectancy in the Basque Country. These inequalities increased in men and decreased in women in the first decade of the 21st century, during which the Basque Country saw considerable economic growth.

Air pollution and human fertility rates

BACKGROUND

Some reports have suggested effects of air pollution on semen quality and success rates of in vitro fertilization (IVF) in humans and lower fertility rates in mice. However, no studies have evaluated the impact of air pollution on human fertility rates.

AIMS

We assessed the association between traffic related air pollution and fertility rates in humans in Barcelona, Spain (2011-2012). We hypothesized that higher air pollution levels would be associated with lower fertility rates.

METHODS

We calculated the general fertility rate which is the number of live births per 1000 women between the ages of 15 and 44 years per census tract. We used land use regression (LUR) modeling to estimate the air pollution concentrations (particulate matter, NO2/NOx) per census tract. We used Besag-York-Mollié models to quantify the relationship between air pollution and fertility rates with adjustment for a number of potential confounders such as maternal age and area level socio-economic status.

RESULTS

We found a statistically significant reduction of fertility rates with an increase in traffic related air pollution levels, particularly for the coarse fraction of particulate matter (IRR=0.87 95% CI 0.82, 0.94 per IQR).

CONCLUSION

This is the first study in humans to show an association between reduced fertility rates and higher traffic related air pollution levels.

Prevalence of depression in adults with type 2 diabetes in the Basque Country: relationship with glycaemic control and health care costs

Background

The aim of the study was to estimate the prevalence of depression in the population diagnosed with diabetes type 2 and to test the hypothesis that the presence of depression in such cases was associated with a) worse glycaemic control, and b) higher healthcare costs.

Methods

We conducted a cross-sectional analysis, from 1st September 2010 to 31st August 2011, among patients with type 2 diabetes aged 35 years and over in the Basque Country. It was identified how many of them had also depression. The database included administrative individual level information on age, sex, healthcare costs, other comorbidities, and values of glycaemic control (HbA_1c). Deprivation index variable was used as socioeconomic measure and, to observe the coexistent pathologies, all the patients diagnoses were categorized by Adjusted Clinical Groups. We used a measure of association, a logistic and a linear regression for analysis.

Results

12.392 (9.8%) of type 2 diabetes patients were diagnosed with depression, being the prevalence 5.2% for males and 15.1% for females. This comorbidity was higher among the most deprived population. There was no association between the presence of depression and glycaemic control. We estimated that the comorbidity average cost per patient/year was 516€ higher than in patients with just type 2 diabetes (P < 0.001) adjusted by the other covariates.

Conclusions

We did not find any relationship between depression and glycaemic control in patients with type 2 diabetes. However, the comorbidity was associated with significantly high healthcare costs compared to that of type 2 diabetes occurring alone, after adjusting by other illness. Thus, there is a need of more precise recognition, screening and monitoring of depression among diabetic population. Evidence-based treatment for depression should be included in type 2 diabetes clinical guidelines.

Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study

Background

The burden of chronic conditions and multimorbidity is a growing health problem in developed countries. The study aimed to determine the estimated prevalence and patterns of multimorbidity in urban areas of Catalonia, stratified by sex and adult age groups, and to assess whether socioeconomic status and use of primary health care services were associated with multimorbidity.

Methods

A cross-sectional study was conducted in Catalonia. Participants were adults (19+ years) living in urban areas, assigned to 251 primary care teams. Main outcome: multimorbidity (≥2 chronic conditions). Other variables: sex (male/female), age (19–24; 25–44; 45–64; 65–79; 80+ years), socioeconomic status (quintiles), number of health care visits during the study.

Results

We included 1,356,761 patients; mean age, 47.4 years (SD: 17.8), 51.0% women. Multimorbidity was present in 47.6% (95% CI 47.5-47.7) of the sample, increasing with age in both sexes but significantly higher in women (53.3%) than in men (41.7%). Prevalence of multimorbidity in each quintile of the deprivation index was higher in women than in men (except oldest group). In women, multimorbidity prevalence increased with quintile of the deprivation index. Overall, the median (interquartile range) number of primary care visits was 8 (4–14) in multimorbidity vs 1 (0–4) in non-multimorbidity patients. The most prevalent multimorbidity pattern beyond 45 years of age was uncomplicated hypertension and lipid disorder. Compared with the least deprived group, women in other quintiles of the deprivation index were more likely to have multimorbidity than men until 65 years of age. The odds of multimorbidity increased with number of visits in all strata.

Conclusions

When all chronic conditions were included in the analysis, almost 50% of the adult urban population had multimorbidity. The prevalence of multimorbidity differed by sex, age group and socioeconomic status. Multimorbidity patterns varied by life-stage and sex; however, circulatory-endocrine-metabolic patterns were the most prevalent multimorbidity pattern after 45 years of age. Women younger than 80 years had greater prevalence of multimorbidity than men, and women’s multimorbidity prevalence increased as socioeconomic status declined in all age groups. Identifying multimorbidity patterns associated with specific age-related life-stages allows health systems to prioritize and to adapt clinical management efforts by age group.

Sociodemographic characteristics and chronic medical conditions as risk factors for herpes zoster: a population-based study from primary care in Madrid (Spain)

The objectives of this study were to estimate incidence density rates (IDR) of herpes zoster (HZ) and to analyze the association with sociodemographic characteristics and selected chronic medical conditions. The study cohort consisted of the adult population included in the Public Health System of the Autonomous Community of Madrid, Spain on 1/10/2009 (5 244 402 persons). Data source were electronic medical records from primary care between 1/10/2009-31/12/2012. Individual socioeconomic status (SES) was inferred by geocoding. Poisson regression analyses were stratified by sex, to identify factors associated with HZ. We identified 81 541 incident cases of HZ (61.7% in women and 46.5% in the group aged 60 and over). IDR was 4.11 per 1000 person-years in men and 5.95 in women. IDR were higher with age, in autochthonous population, those with lower SES and in patients with immunodeficiencies. After adjustment, higher incidence rate ratios were found with age, autochthonous origin, lower SES, and in patients with HIV-infection/AIDS (3.20, CI95% 2.90-3.53 in men and 2.98, CI95% 2.58-3.45 in women), and other immunodeficiencies (1.57, CI95% 1.41-1.75 and 1.65, CI95% 1.50-1.80). COPD, asthma, DM, ischemic heart disease, other cardiovascular diseases, and cancer were also associated with an increased incidence of HZ. We conclude that older, autochthonous patients with lower SES and with certain underlying medical conditions had a higher probability of suffering HZ. Electronic databases are useful for estimating the incidence of HZ, and for finding associations with sociodemographic and clinical characteristics. Identifying unrecognized risk factors for HZ, such as asthma or cardiovascular diseases, is crucial to interpret the epidemiology of HZ, to target vaccination programs and to monitor their effect.

The effects of an urban renewal project on health and health inequalities: a quasi-experimental study in Barcelona

BACKGROUND

In the last decade, the Neighbourhoods Law in Catalonia (Spain) funded municipalities that presented urban renewal projects within disadvantaged neighbourhoods focusing on physical, social and economic improvements. The objective of the study was to evaluate the effects of this law on the health and health inequalities of residents in the intervened neighbourhoods in the city of Barcelona.

METHODS

A quasi-experimental predesign and postdesign was used to compare adult residents in five intervened neighbourhoods with eight non-intervened comparison neighbourhoods with similar socioeconomic characteristics. The Barcelona Health Survey was used for studying self-rated and mental health in pre (2001, 2006) and post (2011) years. Poisson regression models stratified by sex were used to compute prevalence ratios comparing 2011 with 2006, and later stratified by social class, to study health inequalities.

RESULTS

The intervened neighbourhoods had a significant decrease in poor self-rated health in both sexes while no significant changes occurred in the comparison group. When stratified by social class, a significant improvement was observed in poor self-rated health in the manual group of the intervened neighbourhoods in both sexes, resulting in a decrease in self-rated health inequalities. Similar results were observed in poor mental health of women, while in men, poor mental health worsens in both neighbourhood groups but mostly in the comparison group.

CONCLUSIONS

The Neighbourhoods Law had a positive effect on self-rated health and seems to prevent poor mental health increases in both sexes and especially among manual social classes.

Trends in socioeconomic inequalities in amenable mortality in urban areas of Spanish cities, 1996-2007

Background

While research continues into indicators such as preventable and amenable mortality in order to evaluate quality, access, and equity in the healthcare, it is also necessary to continue identifying the areas of greatest risk owing to these causes of death in urban areas of large cities, where a large part of the population is concentrated, in order to carry out specific actions and reduce inequalities in mortality. This study describes inequalities in amenable mortality in relation to socioeconomic status in small urban areas, and analyses their evolution over the course of the periods 1996–99, 2000–2003 and 2004–2007 in three major cities in the Spanish Mediterranean coast (Alicante, Castellón, and Valencia).

Methods

All deaths attributed to amenable causes were analysed among non-institutionalised residents in the three cities studied over the course of the study periods. Census tracts for the cities were grouped into 3 socioeconomic status levels, from higher to lower levels of deprivation, using 5 indicators obtained from the 2001 Spanish Population Census. For each city, the relative risks of death were estimated between socioeconomic status levels using Poisson’s Regression models, adjusted for age and study period, and distinguishing between genders.

Results

Amenable mortality contributes significantly to general mortality (around 10%, higher among men), having decreased over time in the three cities studied for men and women. In the three cities studied, with a high degree of consistency, it has been seen that the risks of mortality are greater in areas of higher deprivation, and that these excesses have not significantly modified over time.

Conclusions

Although amenable mortality decreases over the time period studied, the socioeconomic inequalities observed are maintained in the three cities. Areas have been identified that display excesses in amenable mortality, potentially attributable to differences in the healthcare system, associated with areas of greater deprivation. Action must be taken in these areas of greater inequality in order to reduce the health inequalities detected. The causes behind socioeconomic inequalities in amenable mortality must be studied in depth.

Can an alert in primary care electronic medical records increase participation in a population-based screening programme for colorectal cancer? COLO-ALERT, a randomised clinical trial

BACKGROUND

Colorectal cancer is an important public health problem in Spain. Over the last decade, several regions have carried out screening programmes, but population participation rates remain below recommended European goals. Reminders on electronic medical records have been identified as a low-cost and high-reach strategy to increase participation. Further knowledge is needed about their effect in a population-based screening programme. The main aim of this study is to evaluate the effectiveness of an electronic reminder to promote the participation in a population-based colorectal cancer screening programme. Secondary aims are to learn population's reasons for refusing to take part in the screening programme and to find out the health professionals' opinion about the official programme implementation and on the new computerised tool.

METHODS/DESIGN

This is a parallel randomised trial with a cross-sectional second stage.

PARTICIPANTS

all the invited subjects to participate in the public colorectal cancer screening programme that includes men and women aged between 50-69, allocated to the eleven primary care centres of the study and all their health professionals. The randomisation unit will be the primary care physician. The intervention will consist of activating an electronic reminder, in the patient's electronic medical record, in order to promote colorectal cancer screening, during a synchronous medical appointment, throughout the year that the intervention takes place. A comparison of the screening rates will then take place, using the faecal occult blood test of the patients from the control and the intervention groups. We will also take a questionnaire to know the opinions of the health professionals. The main outcome is the screening status at the end of the study. Data will be analysed with an intention-to-treat approach.

DISCUSSION

We expect that the introduction of specific reminders in electronic medical records, as a tool to facilitate and encourage direct referral by physicians and nurse practitioners to perform colorectal cancer screening will mean an increase in participation of the target population. The introduction of this new software tool will have good acceptance and increase compliance with recommendations from health professionals.

TRIAL REGISTRATION

Clinical Trials.gov identifier NCT01877018.

Prevalence and costs of multimorbidity by deprivation levels in the basque country: a population based study using health administrative databases

Background

Multimorbidity is a major challenge for healthcare systems. However, currently, its magnitude and impact in healthcare expenditures is still mostly unknown.

Objective

To present an overview of the prevalence and costs of multimorbidity by socioeconomic levels in the whole Basque population.

Methods

We develop a cross-sectional analysis that includes all the inhabitants of the Basque Country (N = 2,262,698). We utilize data from primary health care electronic medical records, hospital admissions, and outpatient care databases, corresponding to a 4 year period. Multimorbidity was defined as the presence of two or more chronic diseases out of a list of 52 of the most important and common chronic conditions given in the literature. We also use socioeconomic and demographic variables such as age, sex, individual healthcare cost, and deprivation level. Predicted adjusted costs were obtained by log-gamma regression models.

Results

Multimorbidity of chronic diseases was found among 23.61% of the total Basque population and among 66.13% of those older than 65 years. Multimorbid patients account for 63.55% of total healthcare expenditures. Prevalence of multimorbidity is higher in the most deprived areas for all age and sex groups. The annual cost of healthcare per patient generated for any chronic disease depends on the number of coexisting comorbidities, and varies from 637 € for the first pathology in average to 1,657 € for the ninth one.

Conclusion

Multimorbidity is very common for the Basque population and its prevalence rises in age, and unfavourable socioeconomic environment. The costs of care for chronic patients with several conditions cannot be described as the sum of their individual pathologies in average. They usually increase dramatically according to the number of comorbidities. Given the ageing population, multimorbidity and its consequences should be taken into account in healthcare policy, the organization of care and medical research.