[Recommendations for Primary Health Care for transgender people]

The WHO defines Primary Health Care as essential health care, based on practical, scientifically founded and socially acceptable methods and technologies, made available to all individuals and families in the community, through their full participation, and at a cost that the community and the country can bear, at each and every stage of their development, in a spirit of self-responsibility and self-determination. With the intention of fulfilling the basic objective of caring for and promoting health in all the groups that make up our current society, the need arises to focus on certain groups in which the actions of Primary Care are currently consensual or poorly protocolised, as is the case with the health care of transgender people.

Enhancing patient outcomes: Integrating electronic cardiology consultation in primary care for cancer patients

BACKGROUND

The prevalence of cancer patients with concomitant cardiovascular (CV) disease is on the rise due to improved cancer prognoses. The aim of this study is to evaluate the long-term outcomes of cancer patients referred to a cardiology department (CD) via primary care using e-consultation.

METHODS

We analysed data from cancer patients with prior referrals to a CD between 2010 and 2021 (n = 6889) and compared two care models: traditional in-person consultations and e-consultations. In e-consultation model, cardiologists reviewed electronic health records (e-consultation) to determine whether the demand could be addressed remotely or necessitated an in-person consultation. We used an interrupted time series regression model to assess outcomes during the two periods: (1) time to cardiology consultation, (2) rates of all-cause and CV related hospital admissions and (3) rates of all-cause and CV-related mortality within the first year after the initial consultation or e-consultation at the CD.

RESULTS

Introduction of e-consultation for cancer patients referred to cardiology care led to a 51.8% reduction (95%CI: 51.7%-51.9%) in waiting times. Furthermore, we observed decreased 1-year incidence rates, with incidence rate ratios (iRRs) [IC95%] of .75 [.73-.77] for CV-related hospitalizations, .43 [.42-.44] for all-cause hospitalizations, and .87 [.86-.88] for all-cause mortality.

CONCLUSIONS

Compared to traditional in-person consultations, an outpatient care program incorporating e-consultation for cancer patients significantly reduced waiting times for cardiology care and demonstrated safety, associated with lower rates of hospital admissions.

Estimated Technological Obsolescence of Computed Tomography Equipment

RATIONALE AND OBJECTIVES

To evaluate a model for predicting technological obsolescence of computed tomography (CT) equipment.

MATERIALS AND METHODS

Baseline data consisted of various models of CT scanners that have been on the market since 1974 and represent a technological leap in CT. In documenting the CT scans, a principal component analysis was performed to reduce the number of variables. A Cox regression model was used to calculate the probability of a technology leap.

RESULTS

The CT parameters were divided into three main components: detection system, image resolution, and device performance. Cox regression odds ratios show that a technology leap can be expected as a function of the variables device power (1.457), detection system (0.818), and image resolution (0.964).

CONCLUSION

Our results show that the variables that predict the technological leap in CT are device performance, image resolution, and detection system. The results provide a better understanding of the expected technological changes in CT, which will lead to advances in planning investments in this technology, purchasing and installing equipment in hospitals where this type of technology is not yet available, and renewing the technological base already installed.

Impact of prior use of antiplatelets on COVID-19 susceptibility, progression, and severity: a population-based study

INTRODUCTION AND OBJECTIVES

Hypercoagulability and thromboembolism are processes that arise from severe acute respiratory syndrome coronavirus 2 infection and are responsible for a high degree of coronavirus disease 2019 (COVID-19)-related morbidity and mortality. This study sought to assess the effect of antiplatelet drugs on COVID-19 severity (risk of hospitalization and mortality), susceptibility to severe acute respiratory syndrome coronavirus 2 infection, and progression to severe COVID-19.

METHODS

We conducted a population-based case-control study in a northwestern region of Spain in 2020. The study involved 3060 participants with a positive polymerase chain reaction test who were hospitalized, 26 757 participants with a positive polymerase chain reaction test who were not hospitalized, and 56 785 healthy controls.

RESULTS

Triflusal seemed to be associated with a significant increase in risk of hospitalization (aOR, 1.97; 95%CI, 1.27-3.04) and susceptibility to infection (OR, 1.45; 95%CI, 1.07-1.96). It also appeared to lead to a nonsignificant increase in the risk of mortality (OR, 2.23; 95%CI, 0.89-5.55) and/or progression to more severe disease stages (OR, 1.42; 95%CI, 0.8-2.51). Aspirin seemed to be associated with a statistically significant decrease in susceptibility to severe acute respiratory syndrome coronavirus 2 infection (OR, 0.92; 95%CI, 0.86-0.98).

CONCLUSIONS

Triflusal use appears to increase the risk of susceptibility to COVID-19 infection and an even higher risk of hospitalization, whereas the other antiplatelets could be associated with a reduction in the risk of the various outcomes or have no effect on risk. These findings could support reconsideration of triflusal prescription in COVID-19 pandemic situations.

Impact of a clinician-to-clinician electronic consultation in heart failure patients with previous hospital admissions

Aims

To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH).

Methods and results

We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4851 were attended in e-consult, and 2230 had previous HFH. Using an interrupted time series regression model, we analysed the impact of incorporating e-consult into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P < 0.001). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840-0.833]), 0.900 [0.862-0.949] for CV and 0.699 [0.678-0.726] for all-cause hospitalizations. There was also lower mortality (iRR [95%CI]: 0.715 [0.657-0.798] due to HF, 0.737 [0.764-0.706] for CV and 0.687 [0.652-0.718] for all-cause). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH.

Conclusion

In patients with HFH, an outpatient care programme that includes an e-consult significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.

Gender differences on healthcare accessibility and outcomes of a electronic inter-clinician consultation program at the cardiology department in a Galician Health Area

AIMS

To assess the longer-term results (hospital admissions and mortality) in women versus men referred to a cardiology department from primary care using an e-consultation in our outpatient care programme.

METHODS

We selected 61,306 patients (30,312 women and 30,994 men) who visited the cardiology service at least once between 2010 and 2021: 69.1% (19,997 women and 20,462 men) were attended in e-consultation (from 2013 to 2021) and 30.9% (8920 women and 9136 men) in in-person consultations (from 2010 to 2012) without gender differences in the proportion of patients attended in each period. Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the healthcare model and evaluated the elapsed time to cardiology care, heart failure (HF), cardiovascular (CV), and all-cause hospital admissions and mortality during the one-year after cardiology consultation.

RESULTS

The introduction of e-consultation substantially decreased waiting times to cardiology care; during the in-person consultation period, the mean delay for cardiology care was 57.9 (24.8) days in men and 55.8 (22.8) days in women. During the e-consultation period, the waiting time to cardiology care was markedly reduced to 9.41 (4.02) days in men and 9.46 (4.18) in women. After e-consultation implantation, there was a significant reduction in the 1-year rate of hospital admissions and mortality, both in women and men iRR [IC 95%]: 0.95 [0.93-0.96] for HF, 0.90 [0.89-0.91] for CV and 0.70 [0.69-0.71] for all-cause hospitalization; and 0.93 [0.92-0.95] for HF, 0.86 [0.86-0.87] for CV and 0.88 [0.87-0.89] for all-cause mortality in women; and 0.91 [0.89-0.92] for HF, 0.90 [0.89-0.91] for CV and 0.72 [0.71-0.73] for all-cause hospitalization; and 0.96 [0.93-0.97] for HF, 0.87 [95% CI: 0.86-0.87] for CV and 0.87 [0.86-0.87] for all-cause mortality, in men.

CONCLUSION

Compared with the in-person consultation period, an outpatient care programme that includes an e-consultation significantly reduced waiting time to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year, without significative gender differences.

Cost Analysis of Magnetic Resonance Imaging and Computed Tomography in Cardiology: A Case Study of a University Hospital Complex in the Euro Region

INTRODUCTION

In recent years, several hospitals have incorporated MRI equipment managed directly by their cardiology departments. The aim of our work is to determine the total cost per test of both CT and MRI in the setting of a Cardiology Department of a tertiary hospital.

MATERIALS AND METHODS

The process followed for estimating the costs of CT and MRI tests consists of three phases: (1) Identification of the phases of the testing process; (2) Identification of the resources consumed in carrying out the tests; (3) Quantification and assessment of inputs.

RESULTS

MRI involves higher personnel (EUR 66.03 vs. EUR 49.17) and equipment (EUR 89.98 vs. EUR 33.73) costs, while CT consumes higher expenditures in consumables (EUR 93.28 vs. EUR 22.95) and overheads (EUR 1.64 vs. EUR 1.55). The total cost of performing each test is higher in MRI (EUR 180.60 vs. EUR 177.73).

CONCLUSIONS

We can conclude that the unit cost of each CT and MRI performed in that unit are EUR 177.73 and EUR 180.60, respectively, attributable to consumables in the case of CT and to amortization of equipment and staff time in the case of MRI.

[Impact of the COVID-19 pandemic above a universal electronic consultation program (e-consultation) between general practitioners and cardiologists]

Blackground and objective

Virtual healthcare models, usually between healthcare professionals and patients, have developed strongly during the coronavirus disease 2019 (COVID-19) pandemic, but there are not data of models between clinicians. Our objective is to analyse the impact of the COVID-19 pandemic on the activity and health outcomes of the universal e-consultation program for patient referrals between primary care physicians and the Cardiology Department in our area.

Methods

Patients with at least one e-consultation between 2018 and 2021 were selected. We analysed the impact of the COVID-19 pandemic on activity and waiting time for care, hospitalizations and mortality, taking as a reference the consultations carried out during 2018.

Results

We analysed 25,121 patients. Through logistic regression analysis, it was observed that a shorter delay in care and resolution of the e-consultation without the need for face-to-face care were associated with a better prognosis. The COVID-19 pandemic periods (2019-2020 and 2020-2021) were not associated with worse health outcomes compared to 2018.

Conclusions

The results of our study show a significant reduction in e-consult referrals during the first year of the COVID-19 pandemic with a subsequent recovery in the demand for care without the pandemic periods being associated with worse outcomes. The reduction in the time elapsed for solving the e-consult and no need for in-person visit were associated with better outcomes.

Impact of the COVID-19 pandemic upon a universal electronic consultation program (e-consultation) between general practitioners and cardiologists

BACKGROUND AND OBJECTIVE

Virtual healthcare models, usually between healthcare professionals and patients, have developed strongly during the coronavirus disease 2019 (COVID-19) pandemic, but there are no data corresponding to models between clinicians. An analysis was made of the impact of the COVID-19 pandemic upon the activity and health outcomes of the universal e-consultation program for patient referrals between primary care physicians and the Cardiology Department in our healthcare area.

METHODS

Patients with at least one e-consultation between 2018 and 2021 were selected. We analyzed the impact of the COVID-19 pandemic upon activity and waiting time for care, hospitalizations and mortality, taking as reference the consultations carried out during 2018.

RESULTS

A total of 25,121 patients were analyzed. Logistic regression analysis showed a shorter delay in care and resolution of the e-consultation without the need for face-to-face care to be associated to a better prognosis. The COVID-19 pandemic periods (2019-2020 and 2020-2021) were not associated to poorer health outcomes compared to 2018.

CONCLUSIONS

The results of our study show a significant reduction in e-consultation referrals during the first year of the COVID-19 pandemic, with a subsequent recovery in the demand for care, and without the pandemic periods being associated to poorer outcomes. The reduction in time elapsed for resolving the e-consultations and no need for face-to-face visits were associated to improved outcomes.

Effect of Previous Anticoagulant Treatment on Risk of COVID-19

INTRODUCTION

Little is known about the role played by anticoagulants in COVID-19.

OBJECTIVE

The aim of this study was to assess the impact of previous anticoagulant treatment on risk of hospitalization due to COVID-19, progression to severe COVID-19 and susceptibility to COVID-19 infection.

METHODS

We conducted a multiple population-based case-control study in northwest Spain, in 2020, to assess (1) risk of hospitalization: cases were all patients admitted due to COVID-19 with PCR confirmation, and controls were a random matched sample of subjects without a positive PCR; (2) progression: cases were hospitalized COVID-19 subjects, and controls were all non-hospitalized COVID-19 patients; and (3) susceptibility: cases were patients with a positive PCR (hospitalized and non-hospitalized), and the controls were the same as for the hospitalization model. Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using a generalized linear mixed model.

RESULTS

The consumption of antivitamin K and direct-acting anticoagulants apparently was not associated with the risk of progression to severe COVID-19 (OR 0.93 [95% CI 0.74-1.17] and OR 1.04 [95% CI 0.79-1.36], respectively). Antivitamin K anticoagulants were associated with a significantly lower risk of hospitalization (OR 0.77 [95% CI 0.64-0.93]), which, in part, can be explained by a decreased risk of susceptibility to infection (OR 0.83 [95% CI 0.74-0.92]). The use of direct-acting anticoagulants was not associated with the risk of hospitalization, although it also seems to decrease susceptibility (OR 0.85 [95% CI 0.74-0.98]). It has also been observed that low-molecular-weight heparins were associated with an increased risk of progression to severe COVID-19 (OR 1.25 [95% CI 1.01-1.55]).

CONCLUSION

The results of this study have shown that antivitamin K anticoagulants and direct-acting anticoagulants do not increase the risk of progression to more severe stages. Antivitamin K consumption was associated with a lower risk of hospitalization and susceptibility to infection.

The impact of inter-clinician electronic consultation in patients diagnosed with atrial fibrillation in primary care

BACKGROUND

An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Inter-clinician electronic consultations (e-consultations) program for the general practitioner referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care.

OBJECTIVE

To evaluate the effect of a reduced elapsed time to care after a inter-clinician e-consultations program implementation (2013-2019) in comparison with previous in-person consultation (2010-2012) in the outpatient health care management in a Cardiology Department.

METHODOLOGY

We included 10,488 patients with AF from 1 January 2010, to 31 December 2019. Until 2012, all patients attended an in-person consultation (2010-2012). In 2013, we instituted an e-consult program (2013-2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any change in therapy advice from cardiologist was directly implemented in this EPD.

RESULTS

During the e-consultation period (2013-2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010-2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6 ± 8.9 vs. 22.5 ± 8.1 days, p < .001), and an increase of OAC use (61% [95% IC: 19.6%-102.4%], p < .001). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30-.75]) and all-cause mortality (.42 [95% CI: .29-.62]). The OAC reduces the stroke mortality (.15 [95% CI: .06-.39]) and CV mortality (.43 [95% CI: .29-.62]) and all-cause mortality (.23 [95% CI: .17-.31]).

CONCLUSION

A shared EPD-based inter-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke and cardiovascular/all-cause mortality.

Colchicine and risk of hospitalization due to COVID-19: A population-based study

Colchicine is one of the most widely studied and best-known anti-inflammatory treatments. This study aimed to assess the effect of colchicine on risk of hospitalization due to COVID-19; and its effect on susceptibility to and severity of the virus in patients with COVID-19. We carried out a population-based case-control study. The following groups were applied: (1) to assess risk of hospitalization, cases were patients with a positive PCR who were hospitalized due to COVID-19, and controls without a positive PCR; (2) to assess susceptibility to COVID-19, cases were patients with a positive PCR (hospitalized and non-hospitalized), and the same controls; (3) to determine potential severity, cases were subjects with COVID-19 hospitalized, and controls patients with COVID-19 nonhospitalised. Different electronic, linked, administrative health and clinical databases were used to extract data on sociodemographic variables, comorbidities, and medications dispensed. The study covered 3060 subjects with a positive PCR who were hospitalized, 26 757 with a positive PCR who were not hospitalized, and 56 785 healthy controls. After adjustment for sociodemographic variables, comorbidities and other treatments, colchicine did not modify risk of hospitalization due to COVID-19 (adjusted odd ratio [OR] 1.08 [95% confidence interval (CI) 0.76-1.53]), patients' susceptibility to contracting the disease (adjusted OR 1.12 (95% CI 0.91-1.37)) or the severity of the infection (adjusted OR 1.03 [95% CI 0.67-1.59]). Our results would neither support the prophylactic use of colchicine for prevention of the infection or hospitalization in any type of patient, nor justify the withdrawal of colchicine treatment due to a higher risk of contracting COVID-19.

A clinician-to-clinician universal electronic consultation programme at the cardiology department of a Galician healthcare area improves healthcare accessibility and outcomes in elderly patients

Aim

We aimed to assess the longer-term results (accessibility, and hospital admissions and mortality) in elderly patients referred to a cardiology department (CD) from primary care using an e-consultation in outpatient care.

Methods

We included 9,963 patients &gt;80 years from January 1, 2010, to December 31, 2019. Until 2012, all patients were attended in an in-person consultation (2010-2012). In 2013, we instituted an e-consult programme (2013-2019) for all primary care referrals to cardiologists that preceded patient’s in-person consultation when considered. We used an interrupted time series (ITS) regression approach to investigate the impact of the e-consultation on (1) cardiovascular hospital admissions and mortality. We also analyzed (2) total number and referral rate (population-adjusted referred rate) in both periods, and (3) the accessibility was measured as number of consultations and variation according to distance from municipality and reference hospital.

Results

During the e-consultation, the demand of care increased (12·8 ± 4·3% vs 25·5 ± 11·1% per 1,000 inhabitants, p &lt; 0·001) and referrals from different areas were equalized. After the implementation of e-consultation, we observed that the increasing of hospital admissions and mortality were stabilised (incidence rate ratio [iRR]: 1·351 [95% CI, 0·787, 2·317], p = 0·874) and (iRR: 1·925 [95% CI: 0·889, 4·168], p = 0·096), respectively. The geographic variabilities in hospital admissions and mortality seen during the in-person consultation were stabilized after e-consultation implementation.

Conclusions

Implementation of a clinician-to-clinician e-consultation program in the outpatient care was associated with improved accessibility to cardiology healthcare in elderly patients. After e-consultations were implemented, the hospital admissions and mortality were stabilised.

A universal electronic consultation programme at the cardiology department after general practitioner referrals to improve healthcare accessibility and outcomes in elderly patients

Background

The on-line healthcare models are an opportunity to improve the accessibility and efficiency in clinical assistance, however, analyses of the effects of outpatient care on healthcare quality, including safety, are limited, particularly in vulnerable populations such as elderly patients 1. The care of elderly patients (generally &gt;80 years) is usually characterized as having more chronic pathologies, particularly more cardiovascular diseases, resulting in having a worse risk profile 2. However, this group is also usually characterized by problems with functionality and dependency that can increase difficulties in moving from their homes to health care centres, particularly in areas of great geographical dispersion such as in our study 3.

The healthcare systems that have integrated electronic clinical records between different assistance levels provide an electronic consultation (e-consultation) as a first step of ambulatory care for all general practitioner (GP) referrals. Healthcare systems that include an e-consultation have already shown favorable health outcomes and reduced displacement of the population served 4,5 and could also improve accessibility to outpatient care, although there are not results to demonstrate its safety in this particular group of high-risk patients.

Purpose

We aimed to assess the accessibility and health outcomes (hospital admissions and mortality) in elderly patients referred to a cardiology department (CD) from primary care after inclusion of an e-consultation in outpatient care.

Methods

We included 9,963 patients &gt;80 years old referred to the CD from January 1st, 2010, to December 31st, 2019. In 2013, we instituted an e-consultation programme (2013–2019) for all primary care referrals to cardiologists that preceded patient in-person consultations when considered. We compared both models (in-person consultation and e-consultation) using I: an interrupted time series regression on delay time, hospital admission, and mortality, II: the accessibility measured as population-adjusted referred rate in both periods, and III: analysing the changes in each municipality in delay time, hospital admission and mortality.

Results

During the e-consult period, the demand of care increased (12.8±4.3% vs 25.5±11.1% per 1,000 inhabitants, p&lt;0.001), delay for care was reduced (−0.094 days; 95% CI [−0.063, −0.140], p&lt;0.001), and age-dependent delay disappeared. After the implementation of e-consults, hospital admission (incidence rate ratio [iRR]: 1.351 [95% CI, 0.787, 2.317], p=0.874), Figure 1, and mortality (iRR: 1.925 [95% CI: 0.889, 4.168], p=0.096) stabilised with a slight downward trend, Figure 2.

Conclusion

Implementation of e-consultations in the outpatient care programme in CD was associated with improved access to cardiology healthcare in elderly patients. After the implementation of the e-consultation, hospital admissions and mortality were stabilised and showed a slight non-significant downward trend.

Funding Acknowledgement

Type of funding sources: None.

Impact of a universal electronic consultation program at the cardiology service of a galician health area on hospital admissions and on the accessibility and equity of healthcare services

Background

The implementation of integrated electronic medical record projects between healthcare levels allows all healthcare professionals access to all the clinical information of patients, which is a key factor in optimizing the management of healthcare resources, facilitating the communication between professionals and avoiding medical acts that do not add value, always from the premise of safety and quality for patients [1]. The benefits that telemedicine models can bring in reducing waiting times and the role they can play in organizing the growing demand for care have been described [2,3]. A matter of concern is the lack of accessibility for patients who live further away from their reference hospital centers, not only from a management point of view but also from a clinical point of view, since they are patients who are usually admitted with more complications and therefore could have a worse prognosis.

Purpose

To assess the impact on accessibility to healthcare provision and hospital admissions of an outpatient care management program that includes an e-consultation through an integrated medical record.

Patients and methods

It was registered the epidemiological and clinical data available from the 41,258 patients referred from January 1, 2010 to December 31, 2019, from Primary Care to the Cardiology Service of a health area, in which all doctors share the same electronic medical record. The municipality where the patients live and the admissions for cardiovascular causes in any hospital service during the first year after consultation in the Cardiology Service was recorded.

Results

After the e-consultation was implemented, the demand for care increased in all municipalities (7.2±2.4 vs 10.1±4.8 rates per 1,000 habitants-year, p&lt;0.001). In general, higher delay times were recorded in the regional hospital area, the furthest patients; the spatial effects also were similar in both periods; however, these differences were lower in the e-consultation period than in the in-person consultation period, Figure 1. Also, during the single act consultation period, we observed a progressive reduction in the delay to cardiology consultation which was markedly reduced after the implementation of the e-consultation. The interrupted time series analysis showed that the number of hospital admissions during the period of the Single Act Consultation has increased at approximately 1.1% per month (RR: 1,011 [IC95%: 1.003–1.018]), and after the implementation of the E-Consultation, this upward trend is stabilized in mean with a constant trend (RR: 1.011*0.989 ∼ 1), Figure 2.

Conclusions

The implementation of an e-consultation in the outpatient management model increases the demand for care and improves accessibility to health care for patients furthest from the referral hospital. After the implementation of the e-consultation, the upward trend of hospital admissions observed during the single act period, was stabilized with a slight downward trend.

Funding Acknowledgement

Type of funding sources: None.

Longer-Term Results of a Universal Electronic Consultation Program at the Cardiology Department of a Galician Healthcare Area

BACKGROUND

Telemedicine models play a key role in organizing the growing demand for care and healthcare accessibility, but there are no described longer-term results in health care. Our objective is to assess the longer-term results (delay time in care, accessibility, and hospital admissions) of an electronic consultation (e-consultation) outpatient care program.

METHODS

Epidemiological and clinical data were obtained from the 41 258 patients referred by primary care to the cardiology department from January 1, 2010, to December 31, 2019. Until 2012, all patients were attended in an in-person consultation (2010-2012). In 2013, we instituted an e-consultation program (2013-2019) for all primary care referrals to cardiologists that preceded patients' in-person consultations when considered. We used an interrupted time series regression approach to investigate the impact of the e-consultation on (1) delay time (days) in care and (2) hospital admissions. We also analyzed (3) total number and referral rate (population-adjusted referred rate) in both periods (in-person consultation and e-consultation), and (4) the accessibility was measured as number of consultations and variation according to distance from municipality and reference hospital.

RESULTS

During the e-consultation, the demand increased (7.2±2.4% versus 10.1±4.8% per 1000 inhabitants, P<0.001), and referrals from different areas were equalized. The reduction in delay to consultation during the in-person consultation (-0.96 [95% CI, -0.951 to -0.966], P<0.001) was maintained with e-consultations (-0.064 [95% CI, 0.043-0.085], P<0.001). After the implementation of e-consultation, we observed that the increasing of hospital admission observed in the in-person consultation (incidence rate ratio, 1.011 [95% CI, 1.003-1.018]), was stabilized (incidence rate ratio, 1.000 [95% CI, 0.985-1.015]; P=0.874).

CONCLUSIONS

Implementing e-consultations in the outpatient management model may improve accessibility of care for patients furthest from the referral hospital. After e-consultations were implemented, the upward trend of hospital admissions observed during the in-person consultation period was stabilized with a slight downward trend.

Universal electronic consultation (e-consultation) program of a cardiology service. Long-term results

INTRODUCTION AND OBJECTIVES

Many health systems have initiated electronic consultation (e-consultation) programs, although little is known about their impact on accessibility, safety, and satisfaction. The aim of this study was to assess the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation and to compare it with a one-time face-to-face consultation model.

METHODS

We selected patients who visited the cardiology service at least once between 2010 and 2019. Using an interrupted time series regression model, we analyzed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated waiting times, emergency services, hospital admissions, and mortality.

RESULTS

We analyzed 47 377 patients: 61.9% were attended in e-consultation and 38.1% in one-time face-to-face consultations. The waiting time for care was shorter in the e-consultation model (median [IQR]: 7 [5-13] days) than in the face-to-face model (median [IQR]: 33 [14-81] days), P<.001. The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times, which held steady at around 9 days, although with slight oscillations. Patients evaluated via e-consultation had fewer hospital admissions (0.9% vs 1.2%, P=.0017) and lower mortality (2.5% vs 3.9%, P<.001).

CONCLUSIONS

An outpatient care program that includes an e-consultation reduced waiting times significantly and was safe, with a lower rate of hospital admissions and mortality in the first year.

[Analysis on the impact of the introduction of a quality management plan of the diabetes care process in a Health Area of Galicia (Spain)]

OBJECTIVE

To analyse the impact of a management plan for the diabetes process on the level of control of HbA1c and the rate of hypoglycaemia.

MATERIAL AND METHODS

The Health Area had a catchment population of 446,603. An anti-diabetic drug prescription (29,705 patients) was used to select diabetic patients. The variables recorded were: percentage of patients with HbA1c <8% and the hypoglycaemia rate before and after implementation of the quality program.

RESULTS

The prevalence of diabetes was 11.8%, with 71.3% of them receiving some pharmacological treatment. In the year 2016, in the Integrated Health Area of Santiago de Compostela (Spain), 59.6% (95% CI: 57.9% -61.2%) of the patients had an HbA1c of less than 8%. After the implementation of the quality program, there was an increase in the number of controlled patients, reaching 63.6% (IRQ: 16.0%) in 2017, and 63.8% (95% CI: 62.5% - 65.2%) in 2018. The annual rate of hypoglycaemia increased non-significantly from 2.8 (95% CI: 2.22-3.35) in 2016, to 2.94 (95% CI: 2.35-2.35) in 2017 (P=.083), and 3.0 (95% CI: 2.44-3.56) in 2018 (P=.399).

CONCLUSIONS

The implementation of the diabetes process management program enabled the level of control of HbA1c to be improved, as well as increase the percentage of patients who undergo regular check-ups, without increasing hypoglycaemia.

[Impact of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on COVID-19 in a western population. CARDIOVID registry]

Introducción y objetivos

La Organización Mundial de la Salud calificó la enfermedad por coronavirus (COVID-19) como una pandemia global. No está claro si el tratamiento previo con inhibidores de la enzima de conversión de la angiotensina (IECA) y antagonistas de los receptores de angiotensina (ARA-II) tiene un impacto en el pronóstico de los pacientes infectados con COVID-19. El objetivo fue evaluar la implicación clínica del tratamiento previo con IECA/ARA-II en el pronóstico de la COVID-19.

Métodos

Estudio observacional, retrospectivo, unicéntrico, de cohortes basado en todos los habitantes del área de salud. El análisis de los resultados principales (mortalidad, insuficiencia cardiaca, hospitalización, ingreso en la unidad de cuidados intensivos (UCI) y eventos cardiovasculares agudos mayores [un compuesto de mortalidad e insuficiencia cardiaca]), se ajustó mediante modelos de regresión logística multivariada y modelos de coincidencia de puntaje de propensión.

Resultados

De una población total, 447.979 habitantes, 965 pacientes (0,22%), fueron diagnosticados de infección por COVID-19, 210 (21,8%) estaban bajo tratamiento con IECA o ARA-II en el momento del diagnóstico. El tratamiento con IECA/ARA-II (combinado e individualmente) no tuvo efecto sobre la mortalidad (OR = 0,62; IC95%, 0,17-2,26; p = 0,486), insuficiencia cardiaca (OR = 1,37; IC95%, 0,39-4,77; p = 0,622), tasa de hospitalización (OR = 0,85; IC95%, 0,45-1,64; p = 0,638), ingreso en UCI (OR = 0,87; IC95%, 0,30-2,50; p = 0,798) y cardiopatía aguda grave eventos (OR = 1,06; IC95%, 0,39-2,83; p = 0,915). En el análisis del subgrupos de pacientes que requirieron hospitalización, el efecto se mantuvo neutral.

Conclusiones

El tratamiento previo con IECA/ARA-II en pacientes con COVID-19 no tuvo efecto sobre la mortalidad, la aparición de insuficiencia cardíaca, ni en la necesidad de hospitalización ni ingreso en UCI. La supresión de IECA/ARA-II en pacientes con COVID-19 no estaría justificada en ningún caso, de acuerdo a las recomendaciones actuales de las sociedades científicas y las agencias gubernamentales.

Impact of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on COVID-19 in a western population. CARDIOVID registry

Introduction and objectives

Coronavirus disease (COVID-19) has been designated a global pandemic by the World Health Organization. It is unclear whether previous treatment with angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) affects the prognosis of COVID-19 patients. The aim of this study was to evaluate the clinical implications of previous treatment with ACEI/ARB on the prognosis of patients with COVID-19 infection.

Methods

Single-center, retrospective, observational cohort study based on all the inhabitants of our health area. Analyses of main outcomes (mortality, heart failure, hospitalization, intensive care unit [ICU] admission, and major acute cardiovascular events [a composite of mortality and heart failure]) were adjusted by multivariate logistic regression and propensity score matching models.

Results

Of the total population, 447 979 inhabitants, 965 patients (0.22%) were diagnosed with COVID-19 infection, and 210 (21.8%) were under ACEI or ARB treatment at the time of diagnosis. Treatment with ACEI/ARB (combined and individually) had no effect on mortality (OR, 0.62; 95%CI, 0.17-2.26; P = .486), heart failure (OR, 1.37; 95%CI, 0.39-4.77; P = .622), hospitalization rate (OR, 0.85; 95%CI, 0.45-1.64; P = .638), ICU admission (OR, 0.87; 95%CI, 0.30-2.50; P = .798), or major acute cardiovascular events (OR, 1.06; 95%CI, 0.39-2.83; P = .915). This neutral effect remained in a subgroup analysis of patients requiring hospitalization.

Conclusions

Previous treatment with ACEI/ARB in patients with COVID-19 had no effect on mortality, heart failure, requirement for hospitalization, or ICU admission. Withdrawal of ACEI/ARB in patients testing positive for COVID-19 would not be justified, in line with current recommendations of scientific societies and government agencies.