Direct Medical Costs of Four Vaccine-Preventable Infectious Diseases in Older Adults in Spain

OBJECTIVE

Protection against vaccine-preventable diseases is especially relevant in older adults due to age-related decline in immunity (immunosenescence). However, adult vaccination remains a challenge with overall low coverage rates, which has an impact on both the patients who have these diseases and the health care system in terms of resource use and costs derived. This study aimed to estimate the direct economic impact of herpes zoster, pneumococcal disease, influenza and pertussis in Spanish adults 45 years and older.

METHODS

Data from 2015 were extracted from two Spanish public databases: the Minimum Basic Data Set for Hospitalisations and the Clinical Database of Primary Care. Codes from the International Classification of Diseases and the International Classification of Primary Care were used to identify and classify the diseases analysed. The variables extracted and calculated were hospitalisation (cases, percentage, length of stay, costs, mortality), primary care (cases, percentage, costs) and referrals (cases, percentage, costs). Results were presented for the age groups 45-64 years, 65-74 years, > 74 years and all ages.

RESULTS

In adults 45 years and older, total costs amounted to €134.1 million in 2015 (i.e. 63.9% of the total direct costs for all age groups): 44.4% due to pneumococcal disease, 39.5% due to influenza, 16.0% due to herpes zoster and 0.1% due to pertussis. Hospitalisations represented 58.1% (€77.9 million) of the total costs, with 15,910 admissions, 144,752 days of hospitalisation and 1170 deaths. Primary care registered 566,556 visits with a cost of €35.0 million, and 269,186 referrals with a cost of €21.1 million.

CONCLUSION

The direct economic burden of herpes zoster, pneumococcal disease, influenza and pertussis in adults 45 years and older was high in Spain, and may be underestimated as it only considered medical assistance and not other applicable direct or indirect costs. Increasing vaccination rates in adults may potentially reduce the economic burden derived from these diseases, although future cost-effectiveness analysis including other disease-related costs, vaccination costs and vaccination effectiveness would be needed.

Cost of illness of invasive meningococcal disease caused by serogroup B Neisseria meningitidis in Spain

INTRODUCTION

Invasive meningococcal disease (IMD) is a severe infectious disease, mainly affecting children under 5 years, associated with long-term physical, neurological and psychological sequelae. In Spain, most IMD cases are caused by meningococcal serogroup B (MenB). This study estimates its economic burden from a societal perspective in Spain.

METHODS

A previously published bottom-up, model-based incidence costing approach by Scholz et al. (2019) to estimate the economic burden of MenB in Germany was adapted to the Spanish setting. Diagnosis and age-related costs for a hypothetical Spanish cohort were calculated over a lifetime horizon. Official Spanish databases, literature and expert opinion were used as data sources. The costs were updated to 2019 prices, and a 3% discount rate was applied. Direct costs related to the acute IMD phase, long-term sequelae, rehabilitation and public health response were considered. Indirect costs included productivity losses and premature mortality and were calculated using the human-capital approach (HCA) and friction-cost approach (FCA). Deterministic and probabilistic sensitivity analyses were also performed.

RESULT

At base-case, the total cost for a cohort of 142 patients (2017-2018 period) was €4.74 million (€33,484/case) using the FCA and €13.14 million (€92,768/case) using the HCA. Direct costs amounted to €4.65 million (€32,765/case). Sequelae costs represented 62.46% of the total cost using the FCA and 77.63% using the HCA. Deterministic sensitivity analysis showed that variation of ± 20% in the input parameter values (population, epidemiology, productivity, costs) had the greatest influence on the base-case results, and the probabilistic sensitivity analysis showed the probability of fitting base-case estimates was > 99%, both for FCA and HCA.

DISCUSSION

MenB IMD is an uncommon but severe disease, with a high economic burden for Spanish society. The elevated costs per IMD case reflect its severity in each patient suffering this disease, especially due to the development of sequelae.

Gas phase Elemental abundances in Molecular cloudS (GEMS) II. On the quest for the sulphur reservoir in molecular clouds: the H2S case

CONTEXT

Sulphur is one of the most abundant elements in the Universe. Surprisingly, sulphuretted molecules are not as abundant as expected in the interstellar medium and the identity of the main sulphur reservoir is still an open question.

AIMS

Our goal is to investigate the H2S chemistry in dark clouds, as this stable molecule is a potential sulphur reservoir.

METHODS

Using millimeter observations of CS, SO, H2S, and their isotopologues, we determine the physical conditions and H2S abundances along the cores TMC 1-C, TMC 1-CP, and Barnard 1b. The gas-grain model Nautilus is used to model the sulphur chemistry and explore the impact of photo-desorption and chemical desorption on the H2S abundance.

RESULTS

Our modeling shows that chemical desorption is the main source of gas-phase H2S in dark cores. The measured H2S abundance can only be fitted if we assume that the chemical desorption rate decreases by more than a factor of 10 when n H > 2 × 104. This change in the desorption rate is consistent with the formation of thick H2O and CO ice mantles on grain surfaces. The observed SO and H2S abundances are in good agreement with our predictions adopting an undepleted value of the sulphur abundance. However, the CS abundance is overestimated by a factor of 5 - 10. Along the three cores, atomic S is predicted to be the main sulphur reservoir.

CONCLUSIONS

The gaseous H2S abundance is well reproduced, assuming undepleted sulphur abundance and chemical desorption as the main source of H2S. The behavior of the observed H2S abundance suggests a changing desorption efficiency, which would probe the snowline in these cold cores. Our model, however, highly overestimates the observed gas-phase CS abundance. Given the uncertainty in the sulphur chemistry, we can only conclude that our data are consistent with a cosmic elemental S abundance with an uncertainty of a factor of 10.

A sensitive λ 3 mm line survey of L483: A broad view of the chemical composition of a core around a Class 0 object

An exhaustive chemical characterization of dense cores is mandatory to our understanding of chemical composition changes from a starless to a protostellar stage. However, only a few sources have had their molecular composition characterized in detail. Here we present a λ 3 mm line survey of L483, a dense core around a Class 0 protostar, which was observed with the IRAM 30m telescope in the 80-116 GHz frequency range. We detected 71 molecules (140 including different isotopologs), most of which are present in the cold and quiescent ambient cloud according to their narrow lines (FWHM ~0.5 km s-1) and low rotational temperatures (≲10 K). Of particular interest among the detected molecules are the cis isomer of HCOOH, the complex organic molecules HCOOCH3, CH3OCH3, and C2H5OH, a wide variety of carbon chains, nitrogen oxides like N2O, and saturated molecules like CH3SH, in addition to eight new interstellar molecules (HCCO, HCS, HSC, NCCNH+, CNCN, NCO, H2NCO+, and NS+) whose detection has already been reported. In general, fractional molecular abundances in L483 are systematically lower than in TMC-1 (especially for carbon chains), tend to be higher than in L1544 and B1-b, and are similar to those in L1527. Apart from the overabundance of carbon chains in TMC-1, we find that L483 does not have a marked chemical differentiation with respect to starless/prestellar cores like TMC-1 and L1544, although it does chemically differentiate from Class 0 hot corino sources like IRAS 16293-2422. This fact suggests that the chemical composition of the ambient cloud of some Class 0 sources could be largely inherited from the dark cloud starless/prestellar phase. We explore the use of potential chemical evolutionary indicators, such as the HNCO/C3S, SO2/C2S, and CH3SH/C2S ratios, to trace the prestellar/protostellar transition. We also derived isotopic ratios for a variety of molecules, many of which show isotopic ratios close to the values for the local interstellar medium (remarkably all those involving 34S and 33S), while there are also several isotopic anomalies like an extreme depletion in 13C for one of the two isotopologs of c-C3H2, a drastic enrichment in 18O for SO and HNCO (SO being also largely enriched in 17O), and different abundances for the two 13C substituted species of C2H and the two 15N substituted species of N2H+. We report the first detection in space of some minor isotopologs like c-C3D. The exhaustive chemical characterization of L483 presented here, together with similar studies of other prestellar and protostellar sources, should allow us to identify the main factors that regulate the chemical composition of cores along the process of formation of low-mass protostars.

Gas phase Elemental abundances in Molecular cloudS (GEMS): I. The prototypical dark cloud TMC 1

GEMS is an IRAM 30m Large Program whose aim is determining the elemental depletions and the ionization fraction in a set of prototypical star-forming regions. This paper presents the first results from the prototypical dark cloud TMC 1. Extensive millimeter observations have been carried out with the IRAM 30m telescope (3 mm and 2 mm) and the 40m Yebes telescope (1.3 cm and 7 mm) to determine the fractional abundances of CO, HCO+, HCN, CS, SO, HCS+, and N2H+ in three cuts which intersect the dense filament at the well-known positions TMC 1-CP, TMC 1-NH3, and TMC 1-C, covering a visual extinction range from A V ~ 3 to ~20 mag. Two phases with differentiated chemistry can be distinguished: i) the translucent envelope with molecular hydrogen densities of 1-5×103 cm-3; and ii) the dense phase, located at A V > 10 mag, with molecular hydrogen densities >104 cm-3. Observations and modeling show that the gas phase abundances of C and O progressively decrease along the C+/C/CO transition zone (A V ~ 3 mag) where C/H ~ 8×10-5 and C/O~0.8-1, until the beginning of the dense phase at A V ~ 10 mag. This is consistent with the grain temperatures being below the CO evaporation temperature in this region. In the case of sulfur, a strong depletion should occur before the translucent phase where we estimate a S/H ~ (0.4 - 2.2) ×10-6, an abundance ~7-40 times lower than the solar value. A second strong depletion must be present during the formation of the thick icy mantles to achieve the values of S/H measured in the dense cold cores (S/H ~8×10-8). Based on our chemical modeling, we constrain the value of ζ H2 to ~ (0.5 - 1.8) ×10-16 s-1 in the translucent cloud.

Astrochemical evolution along star formation: Overview of the IRAM Large Program ASAI

Evidence is mounting that the small bodies of our Solar System, such as comets and asteroids, have at least partially inherited their chemical composition from the first phases of the Solar System formation. It then appears that the molecular complexity of these small bodies is most likely related to the earliest stages of star formation. It is therefore important to characterize and to understand how the chemical evolution changes with solar-type protostellar evolution. We present here the Large Program "Astrochemical Surveys At IRAM" (ASAI). Its goal is to carry out unbiased millimeter line surveys between 80 and 272 GHz of a sample of ten template sources, which fully cover the first stages of the formation process of solar-type stars, from prestellar cores to the late protostellar phase. In this article, we present an overview of the surveys and results obtained from the analysis of the 3 mm band observations. The number of detected main isotopic species barely varies with the evolutionary stage and is found to be very similar to that of massive star-forming regions. The molecular content in O- and C- bearing species allows us to define two chemical classes of envelopes, whose composition is dominated by either a) a rich content in O-rich complex organic molecules, associated with hot corino sources, or b) a rich content in hydrocarbons, typical of Warm Carbon Chain Chemistry sources. Overall, a high chemical richness is found to be present already in the initial phases of solar-type star formation.

Discovery of the elusive radical NCO and confirmation of H2NCO+ in space

The isocyanate radical (NCO) is the simplest molecule containing the backbone of the peptide bond, C(=O)-N. This bond has a prebiotic interest since is the one linking two amino acids to form large chains of proteins. It is also present in some organic molecules observed in space such as HNCO, NH2CHO and CH3NCO. In this letter we report the first detection in space of NCO towards the dense core L483. We also report the identification of the ion H2NCO+, definitively confirming its presence in space, and observations of HNCO, HOCN, and HCNO in the same source. For NCO, we derive a column density of 2.2×1012 cm-2, which means that it is only ~5 times less abundant than HNCO. We find that H2NCO+, HOCN and HCNO have abundances relative to HNCO of 1/400, 1/80, and 1/160, respectively. Both NCO and H2NCO+ are involved in the production of HNCO and several of its isomers. We have updated our previous chemical models involving NCO and the production of the CHNO isomers. Taking into account the uncertainties in the model, the observed abundances are reproduced relatively well. Indeed, the detection of NCO and H2NCO+ in L483 supports the chemical pathways to the formation of the detected CHNO isomers. Sensitive observations of NCO in sources where other molecules containing the C(=O)-N subunit have been detected could help in elucidating its role in prebiotic chemistry in space.

Detection of interstellar HCS and its metastable isomer HSC: new pieces in the puzzle of sulfur chemistry

We present the first identification in interstellar space of the thioformyl radical (HCS) and its metastable isomer HSC. These species were detected toward the molecular cloud L483 thanks to observations carried out with the IRAM 30m telescope in the λ 3 mm band. We derive beam-averaged column densities of 7 × 1012 cm-2 for HCS and 1.8 × 1011 cm-2 for HSC, which translate to fractional abundances relative to H2 of 2 × 10-10 and 6 × 10-12, respectively. Although the amount of sulfur locked by these radicals is low, their detection allows to put interesting constraints on the chemistry of sulfur in dark clouds. Interestingly, the H2CS/HCS abundance ratio is found to be quite low, ~ 1, in contrast with the oxygen analogue case, in which the H2CO/HCO abundance ratio is around 10 in dark clouds. Moreover, the radical HCS is found to be more abundant than its oxygen analogue, HCO. The metastable species HOC, the oxygen analogue of HSC, has not been yet observed in space. These observational constraints are confronted with the outcome of a recent model of the chemistry of sulfur in dark clouds. The model underestimates the fractional abundance of HCS by at least one order of magnitude, overestimates the H2CS/HCS abundance ratio, and does not provide an abundance prediction for the metastable isomer HSC. These observations should prompt a revision of the chemistry of sulfur in interstellar clouds.

A prospective study to assess the burden of influenza-related hospitalizations and emergency department visits among children in Bilbao, Spain (2010-2011)

Introduction

This study was undertaken to estimate the burden of morbidity associated with laboratory-confirmed influenza in children below 15 years of age.

Patients and methods

Children presenting with acute respiratory infection and/or isolated fever at the Basurto University Hospital, Bilbao, Spain between November 2010 and May 2011 were included in this study (NCT01592799). Two nasopharyngeal secretion samples were taken from each; one for a rapid influenza diagnostic test in the emergency department, and the second for laboratory analysis using real-time polymerase chain reaction and viral culture.

Results

A total of 501 children were recruited, of whom 91 were hospitalized. Influenza diagnosis was confirmed in 131 children (26.1%); 120 of 410 (29.3%) treated as outpatients and 11 of 91 (12.1%) hospitalized children. A total of 370 of 501 children (73.9%) had no laboratory test positive for influenza. The proportion of subjects with other respiratory viruses was 145/501 (28.9%) cases and co-infection with the influenza virus plus another respiratory virus was detected in 7/501 (1.4%) cases. Influenza virus types were: A (H1N1 and H3N2) 53.2% (67/126); B (Victoria and Yamagata) 46.0% (58/126); A + B 0.8% (1/126). The median direct medical costs associated with each case of laboratory-confirmed influenza was €177.00 (N = 131). No significant differences were observed between the medical costs associated with influenza A and B.

Conclusion

Almost half of the cases were influenza virus B type. The administration of a vaccine containing influenza A and B types to children below 15 years of age might reduce the overall burden of the illness.

[A prospective study to assess the burden of influenza-related hospitalizations and emergency department visits among children in Bilbao, Spain (2010-2011)]

INTRODUCTION

This study was undertaken to estimate the burden of morbidity associated with laboratory-confirmed influenza in children below 15 years of age.

PATIENTS AND METHODS

Children presenting with acute respiratory infection and/or isolated fever at the Basurto University Hospital, Bilbao, Spain between November 2010 and May 2011 were included in this study (NCT01592799). Two nasopharyngeal secretion samples were taken from each; one for a rapid influenza diagnostic test in the emergency department, and the second for laboratory analysis using real-time polymerase chain reaction and viral culture.

RESULTS

A total of 501 children were recruited, of whom 91 were hospitalized. Influenza diagnosis was confirmed in 131 children (26.1%); 120 of 410 (29.3%) treated as outpatients and 11 of 91 (12.1%) hospitalized children. A total of 370 of 501 children (73.9%) had no laboratory test positive for influenza. The proportion of subjects with other respiratory viruses was 145/501 (28.9%) cases and co-infection with the influenza virus plus another respiratory virus was detected in 7/501 (1.4%) cases. Influenza virus types were: A (H1N1 and H3N2) 53.2% (67/126); B (Victoria and Yamagata) 46.0% (58/126); A+B 0.8% (1/126). The median direct medical costs associated with each case of laboratory-confirmed influenza was €177.00 (N=131). No significant differences were observed between the medical costs associated with influenza A and B.

CONCLUSION

Almost half of the cases were influenza virus B type. The administration of a vaccine containing influenza A and B types to children below 15 years of age might reduce the overall burden of the illness.

EPICOR (long-tErm follow-up of antithrombotic management Patterns In acute CORonary syndrome patients) study: rationale, design, and baseline characteristics

BACKGROUND

There is limited information about patterns of use of newer antithrombotic drugs in patients with acute coronary syndromes (ACS) in a real-life setting. The effectiveness, safety and cost-effectiveness of potential combinations during hospitalization, the duration of therapies, interruptions, or discontinuations as well as their reasons and possible consequences are unknown.

METHODS

EPICOR (NCT01171404) is a prospective, multinational, observational study on patients discharged after a hospitalization for an ACS with 2-year follow-up. The study is designed to describe the patterns of antithrombotic use and to evaluate potential differences in short- and long-term clinical outcomes (ischemic and bleeding events), quality of life and economic impact associated with initial combinations during hospitalization, and treatment duration, discontinuations, or interruptions and their reasons after discharge in different clinical environments.

RESULTS

Between September 1, 2010, and March 31, 2011, 10,568 consecutive patients surviving an ACS (4943 with ST-segment elevation myocardial infarction, and 5625 with non-ST-segment elevation ACS) were enrolled from 555 hospitals in 20 countries from 4 pre-defined regions: Northern Europe (n = 3,782), Southern Europe (n = 2,337), Eastern Europe (n = 2,380), and Latin America (n = 2,069). Pre- and in-hospital management and outcomes were recorded, with a special focus on antithrombotic therapies and ischemic and bleeding events. Changes in antithrombotic treatments and outcomes are currently being registered during the planned 24-month follow-up.

CONCLUSION

EPICOR will show current patterns of antithrombotic use during hospitalization and after discharge in 'real-world' patients with ACS, allowing exploration of potential differences in clinical outcomes, quality of life, and costs related to the different antithrombotic practice patterns.

Factors associated with health-related quality of life in adults with asthma. A cross-sectional study

Background

The measurement of health-related quality of life (HRQoL) is increasingly recognized as an important endpoint, as a reflection of the effects of the disease from a patient perspective. Our aim was to evaluate the factors determining the HRQoL in patients with asthma, according to the EQ-5D questionnaire.

Methods

Patients were included using multi-stage sampling, from Primary Care clinics from all the Autonomous Communities in Spain. The patients included were: over 18 years-old, with a confirmed diagnosis of asthma for at least one year, and had visited a Health Centre in the previous 2 years. The characteristics of the asthma disease, the adherence to treatment, the socio-demographic variables, the smoking habits, and the asthma control were collected using a questionnaire. The influence of the different variables included in the study on the EQ-5D was evaluated using multivariate logistic regression analysis.

Results

A total of 2,125 patients were finally included (57.7% females, mean age 48 years). The response rate was 95.4%. Some factors showed a considerable detrimental effect on the HRQoL of asthmatics. Advanced age, lower educational level and poor control of asthma are significantly associated with a worse quality of life in all the dimensions assessed by the EQ-5D scale. The baseline severity of the asthma, and having been admitted to hospital are related to a worse quality of life in 5 of the 6 dimensions analyzed.

Conclusion

In our study, we could identify some factors related to quality of life in asthma patients. The most important were advanced age, lower education level, and poor control of the asthma.

Factors associated with health-related quality of life in adults with asthma. A cross-sectional study

Background: The measurement of health-related quality of life (HRQoL) is increasingly recognized as an important endpoint, as a reflection of the effects of the disease from a patient perspective. Our aim was to evaluate the factors determining the HRQoL in patients with asthma, according to the EQ-5D questionnaire. Methods: Patients were included using multi-stage sampling, from Primary Care clinics from all the Autonomous Communities in Spain. The patients included were: over 18 years-old, with a confirmed diagnosis of asthma for at least one year, and had visited a Health Centre in the previous 2 years. The characteristics of the asthma disease, the adherence to treatment, the socio-demographic variables, the smoking habits, and the asthma control were collected using a questionnaire. The influence of the different variables included in the study on the EQ-5D was evaluated using multivariate logistic regression analysis. Results: A total of 2,125 patients were finally included (57.7% females, mean age 48 years). The response rate was 95.4%. Some factors showed a considerable detrimental effect on the HRQoL of asthmatics. Advanced age, lower educational level and poor control of asthma are significantly associated with a worse quality of life in all the dimensions assessed by the EQ-5D scale. The baseline severity of the asthma, and having been admitted to hospital are related to a worse quality of life in 5 of the 6 dimensions analyzed. Conclusion: In our study, we could identify some factors related to quality of life in asthma patients. The most important were advanced age, lower education level, and poor control of the asthma.

Structured management strategy based on the Gastro-oesophageal Reflux Disease (GERD) Questionnaire (GerdQ) vs. usual primary care for GERD: pooled analysis of five cluster-randomised European studies

BACKGROUND

Response to treatment among primary care patients with gastro-oesophageal disease (GERD) is variable.

AIM

The GERD Management Project (GMP) evaluated the effectiveness of a structured management approach to GERD vs. standard treatment (usual care).

METHODS

Data from five cluster-randomised clinical trials in adult primary care patients with symptoms of GERD were pooled. The structured pathway was based on the self-administered GERD Questionnaire (GerdQ) and was compared with standard treatment.

RESULTS

1734 patients were enrolled (structured treatment, n=834; standard treatment, n=900). The difference in the mean GerdQ score change from baseline favoured the structured pathway (-0.61; 95% CI: -0.88, -0.34; p<0.001). The odds ratio for an indication for treatment revision at the end of follow-up (structured vs. standard treatment) was 0.39 (95% CI: 0.29, 0.52; p=0.001).

CONCLUSIONS

Management of primary care patients with GERD can be improved by systematic stratification of patients using a patient management tool such as the GerdQ.

Excess risk attributable to traditional cardiovascular risk factors in clinical practice settings across Europe - The EURIKA Study

Background

Physicians involved in primary prevention are key players in CVD risk control strategies, but the expected reduction in CVD risk that would be obtained if all patients attending primary care had their risk factors controlled according to current guidelines is unknown. The objective of this study was to estimate the excess risk attributable, firstly, to the presence of CVD risk factors and, secondly, to the lack of control of these risk factors in primary prevention care across Europe.

Methods

Cross-sectional study using data from the European Study on Cardiovascular Risk Prevention and Management in Daily Practice (EURIKA), which involved primary care and outpatient clinics involved in primary prevention from 12 European countries between May 2009 and January 2010. We enrolled 7,434 patients over 50 years old with at least one cardiovascular risk factor but without CVD and calculated their 10-year risk of CVD death according to the SCORE equation, modified to take diabetes risk into account.

Results

The average 10-year risk of CVD death in study participants (N = 7,434) was 8.2%. Hypertension, hyperlipidemia, smoking, and diabetes were responsible for 32.7 (95% confidence interval 32.0-33.4), 15.1 (14.8-15.4), 10.4 (9.9-11.0), and 16.4% (15.6-17.2) of CVD risk, respectively. The four risk factors accounted for 57.7% (57.0-58.4) of CVD risk, representing a 10-year excess risk of CVD death of 5.66% (5.47-5.85). Lack of control of hypertension, hyperlipidemia, smoking, and diabetes were responsible for 8.8 (8.3-9.3), 10.6 (10.3-10.9), 10.4 (9.9-11.0), and 3.1% (2.8-3.4) of CVD risk, respectively. Lack of control of the four risk factors accounted for 29.2% (28.5-29.8) of CVD risk, representing a 10-year excess risk of CVD death of 3.12% (2.97-3.27).

Conclusions

Lack of control of CVD risk factors was responsible for almost 30% of the risk of CVD death among patients participating in the EURIKA Study.

Clinical predictors of poor outcomes among patients with nonvariceal upper gastrointestinal bleeding in Europe

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency associated with substantial morbidity and mortality. Despite advances in endoscopic and pharmacological treatment during the past two decades, the incidence of mortality associated with NVUGIB has remained relatively constant.

AIM

To report outcomes and predictive factors for bleeding continuation/re-bleeding and mortality of NVUGIB in clinical practice in different European countries.

METHODS

This observational, retrospective cohort study (NCT00797641; ENERGIB) was conducted in Belgium, Greece, Italy, Norway, Portugal, Spain and Turkey. Eligible patients were hospitalised (new admissions or inpatients), presenting with overt NVUGIB with endoscopy from 1 October to 30 November, 2008. Patients were managed according to routine care, and data regarding bleeding continuation/re-bleeding, pharmacological treatment, surgery and mortality during 30-days after the initial bleed were collected. A multivariate analysis of clinical factors predictive of poor outcomes was conducted.

RESULTS

Overall, 2660 patients (64.7% men; mean age 67.7 years) were evaluable. Significant differences across countries in bleeding continuation/re-bleeding (range: 9-15.8%) or death (2.5-8%) at 30 days were explained by clinical factors (number of comorbidities, age > 65 years, history of bleeding ulcers, in-hospital bleeding, type of lesion or type of concomitant medication). Other factors (country, size of hospital, profile of team managing the event, or endoscopic/pharmacological therapy received) did not affect these outcomes. Similar predictors were observed in patients with high-risk stigmata.

CONCLUSION

Differences in the outcomes of nonvariceal upper gastrointestinal bleeding in clinical practice across some European countries are explained mainly by patient-related factors, and not by management factors.

[Use of health resources and loss of productivity in gastroesophageal reflux disease: results of a cross-sectional study in a primary care setting in Spain]

OBJECTIVE

To evaluate healthcare resource use and productivity in patients with gastro-esophageal reflux disease (GERD) and the influence of disease severity on these two factors.

DESIGN

Sub-analysis of the Spanish population of a multinational study with a 4-month retrospective period for the identification and selection of patients, and a clinical visit to obtain clinical information and data on use of healthcare resources, carried out between October 2007 and January 2008.

POPULATION

A total of 477 patients attending a Primary Care centre, with a medical consultation for GERD.

MAIN VARIABLES

Use of healthcare resources, changes in productivity based on the Work Productivity and Activity Impairment Questionnaire for GERD patients (WPAI-GERD).

RESULTS

Despite having received pharmacological treatment at the baseline visit, after a median of 5.1 months follow-up (range 2.1-8.1), up to 15.9% (95% CI; 12.8-19.5) patients still showed clinically relevant GERD symptoms. Direct medical costs per year associated with diagnostic tests and medical consultations in patients with or without clinically relevant GERD symptoms were 666 € (SD: 2,097 €) and 370 € (SD: 2,060 €), respectively. The mean annual cost of reduced productivity (17%) was 5,316 € (SD: 8,615 €). This cost was 4 times higher for patients with clinically relevant GERD symptoms than for patients with no relevant symptoms (15,188 € [SD: 11,206 €] vs 3,926 € [SD: 7,232 €]).

CONCLUSION

Patients with GERD use significant healthcare resources, attributable to associated medical costs and marked reduction in productivity, even though they receive pharmacological treatment.

Factors associated with a higher prevalence of work disability among asthmatic patients

OBJECTIVE

To study asthma-related absenteeism in the asthmatic population in Spain and to identify some risk factors for absenteeism.

METHODS

A cross-sectional study was performed on patients who had been diagnosed with asthma in the primary care setting at least 1 year before the start of this study. A questionnaire was designed that included socio-demographic and clinical variables. The time absent from work in the previous year was self-reported by the patients.

RESULTS

More than 25% of the asthmatic population in Spain took sick leave during the previous year. Visits to a general practitioner or to the emergency department are the factors associated with the greatest risk of absenteeism.

CONCLUSIONS

Absenteeism is common within the asthmatic population in Spain. The authors of this study believe that some of the determining factors could be modified by the health-care system.

Structured management strategy versus usual care for gastroesophageal reflux disease: rationale for pooled analysis of five European cluster-randomized trials

BACKGROUND

Gastroesophageal reflux disease (GERD) has a major impact at the primary care level and there is a need to evaluate whether the diagnosis and therapeutic management of GERD in Europe needs to be improved.

METHODS

This project was designed to test the hypothesis that a new primary care management strategy would improve outcomes for patients with GERD, compared with usual care, in Europe. The analysis pools five separate cluster-randomized studies conducted in Austria, Italy, Norway, Spain and Sweden. These studies used a strategy based on the self-administered GerdQ questionnaire to stratify adult patients with symptoms of heartburn or regurgitation according to the frequency and impact of symptoms. A score of ≥8 indicates a high probability of suffering GERD. Patients with a GerdQ impact score ≤2 were treated with generic proton-pump inhibitors according to local guidance, and patients with an impact score ≥3 were treated with esomeprazole 40 mg once daily.

RESULTS

In total, 2400 patients were enrolled across the five studies. The protocols were modified by individual countries according to their local guidelines/requirements. In Norway, the new management strategy was compared with traditional routine endoscopy and 24-hour pH-metry, and encompassed proton-pump inhibitor reimbursement restrictions. Outcome measures differed by country, but included control of GERD symptoms, self-rated health status and work productivity, treatment changes, specialist referrals and physician adherence. GERD-related use of healthcare resources was also evaluated.

CONCLUSION

The pooled analysis will determine whether a locally adapted primary care management strategy for GERD, using GerdQ as a patient-tailored diagnostic and therapeutic evaluation tool, is beneficial compared with usual care across five countries with different standard approaches to GERD management and control.

[Study of the clinical profile and management of patients with gastroesophageal reflux disease in primary care in Spain]

OBJECTIVE

To assess the clinical profile and management of patients with gastroesophageal reflux disease (GERD) in primary care.

METHODS

A multinational, multicenter study was performed comprising a 4-month retrospective phase for the screening, selection and assessment of patients who had consulted for any GERD-related cause (index visit), and a cross-sectional phase in which clinical data were recorded and the following questionnaires were administered: the Reflux Disease Questionnaire and the Gastroesophageal Reflux Disease Impact Scale (GIS).

RESULTS

Among the 24 participating Spanish centers, 2.7% of the patients (95% CI: 2.6-2.9) had consulted at least once because of GERD. Approximately 50% of the patients showed frequent (2 or more days a week) or moderate to severe symptoms of heartburn, acid regurgitation or chest pain. Although the patients received effective pharmacological treatment at the index visit, clinically relevant GERD symptoms persisted in 16% after a median follow-up of 5 months. These symptoms were associated with a strong disease impact as evaluated with the GIS.

CONCLUSION

GERD represents a substantial burden for primary care physicians. Although effective drugs are used for the treatment of this condition, clinically relevant symptoms persist in a substantial proportion of patients.

[Validation of the Reflux Disease Questionnaire (RDQ) and Gastrointestinal Impact Scale (GIS) in patients with gastroesophageal reflux disease in the Spanish population]

OBJECTIVES

To assess the feasibility, reliability, validity and sensitivity of changes in the Reflux Disease Questionnaire (RDQ) and the Gastrointestinal Impact Scale (GIS).

MATERIAL AND METHODS

An observational, prospective, multicenter study was conducted in primary care centers on two visits (baseline and 16 days later) in a sample of patients with a diagnosis of gastroesophageal reflux disease (GERD) or suspicion of GERD requiring a therapeutic intervention (sensitivity to change group, n=230) and in another sample of patients with clinically controlled GERD (reliability group, n=51).

RESULTS

The RDQ questionnaire and GIS scale, both overall and for each domain, showed a Cronbach's alpha of greater than or equal to 0.70. All RDQ domains and the total score, as well as the total GIS score and impact dimension, showed a high correlation between the baseline evaluation and that performed 16 days later in stable patients. The RDQ and GIS showed very high correlations between the total scores and those of the quality of life in reflux and dyspepsia (QOLRAD) (-0.73 and 0.80, respectively), a reflux- and dyspepsia-specific quality of life scale, and a high correlation with the gastrointestinal symptoms rating scale (GSRS) (0.54 and -0.55, respectively), a general scale of gastrointestinal symptoms. Both the RDQ questionnaire and the GIS scale showed significant changes with a high effect size on improvement responses.

CONCLUSIONS

The RDQ and GIS questionnaires show very good psychometric properties, making them suitable for use in primary care.

Screening for bipolar disorder in a Spanish sample of outpatients with current major depressive episode

OBJECTIVE

Bipolar spectrum disorders often go unrecognised and undiagnosed or misdiagnosed. One of the underlying reasons is the poor recognition of bipolar disorder among patients presenting depressive episodes. The specific aim of this study was to estimate the Mood Disorder Questionnaire (MDQ) rate of positive screens for bipolar disorder in a Spanish sample of outpatients with a current major depressive episode and compare it with their current psychiatric diagnosis. The study was designed to address this specific question.

METHOD

971 consecutively outpatients with a current DSM-IV TR diagnosis of a major depressive episode entered this cross-sectional study. Study measures included sociodemographic and clinical data, Clinical Global Impression of Severity of Illness Scale (CGI-S), Hamilton Depression Scale (HAMD) and MDQ.

RESULTS

905 patients fulfilled criteria to be included in the analysis. All of them presented with a current major depressive episode. 74.3% (n=671) of the patients had received a diagnosis of unipolar depression and 25.7% (n=232) of bipolar disorder by a psychiatrist. Using a MDQ of 7-or-more-item threshold, the global positive screen rate for bipolar disorder was 41.3% (n=373). From the 671 patients with previous unipolar depression diagnosis, 161 (24%) screened positive for bipolar disorder with MDQ, whereas in 232 patients diagnosed of bipolar disorder, 212 (91.4%) screened positive for bipolar disorder.

CONCLUSIONS

The MDQ showed a positive screen rate for bipolar disorder in 24% of patients with a previous diagnosis of unipolar disorder and a current major depressive episode. Screening tools like MDQ could contribute to increase detection of bipolar disorder in patients with depression. Early diagnosis of bipolar disorder may have important clinical and therapeutic implications in order to improve the illness course and the long-term functional outcome.

The "Seroquel" Outcomes Study (SOS): Efficacy and tolerability of quetiapine in a long-term, naturalistic study of patients with schizophrenia

Objective. The "Seroquel" Outcomes Study (SOS) aimed to assess the efficacy and tolerability of quetiapine in patients with schizophrenia in the clinical practice setting. Methods. A 6-month, non-comparative, open-label study in adults with schizophrenia in a standard care setting in Spain. Outpatients received flexibly dosed quetiapine. Efficacy was evaluated using the Brief Psychiatry Rating Scale (BPRS) and the Clinical Global Impression (CGI) scale. BPRS response was defined as≥30% decrease from baseline. Tolerability was assessed using the Simpson-Angus Scale (SAS) and a modified Udvalg for Kliniske Undersogelser (UKU) side-effects scale. Results. A total of 2029 patients enrolled. Significant changes from baseline to Month 6 were recorded for BPRS total and subscale scores (P<0.001). Compared with doses of≥600 mg/day, doses of<400 mg/day were a strong predictor of a lower response rate (OR 0.62; 95% CI: 0.48, 0.82) and higher withdrawal rate (OR 3.3; 95% CI: 2.5, 4.4). Mean change in weight was minimal (+0.4 kg). Somnolence (26.7%), asthenia (12.5%), and constipation (9.8%) were the most common adverse events. Conclusion. Quetiapine was found to improve symptoms of schizophrenia, as indicated by a significant decrease in BPRS scores, and was well tolerated by patients in clinical practice.

A 6-month prospective observational study on the effects of quetiapine on sexual functioning

OBJECTIVE

The aim of this study was to assess the long-term impact of quetiapine on sexual functioning of patients with schizophrenia treated in a real practice setting.

METHODS

This was a multicenter, noncomparative, open-label, and naturalistic study conducted in outpatients with a diagnosis of schizophrenia or schizophreniform disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Patients were evaluated at baseline, day 15, and at the end of months 1, 3, and 6 using the Brief Psychiatry Rating Scale, the Clinical Global Impression Severity and Improvement Scales, and the Psychotropic-Related Sexual Dysfunction Questionnaire. All primary effectiveness analyses were based on the intent-to-treat sample and consisted primarily of last-observation-carried-forward analysis of Psychotropic-Related Sexual Dysfunction Questionnaire, Brief Psychiatry Rating Scale, and Clinical Global Impression Improvement of Illness Scale.

RESULTS

Eighty-six patients were recruited by 19 investigators, and 82 patients were included in the intent-to-treat sample. Psychotropic-Related Sexual Dysfunction Questionnaire total scores for the patients decreased progressively and significantly from baseline to the study end point. When only patients who initiated quetiapine treatment without being switched from another antipsychotic (n = 28) were included in the intent-to-treat analysis, Psychotropic-Related Sexual Dysfunction Questionnaire scores remained almost unchanged throughout the study. Sexual dysfunction rates, defined as a change in the score of any item greater than 0, were 3.7%, 2.4%, 2.4%, and 4.9% for decreased libido, delayed ejaculation/orgasm, lack of ejaculation/orgasm, and difficulties with erection/lubrication, respectively. Overall, quetiapine was efficacious and well tolerated.

CONCLUSION

Despite the limitations of the design, our results suggest that quetiapine shows a low frequency of sexual dysfunction during long-term treatment of patients with schizophrenia or schizophreniform disorder in the clinical practice setting.

[The cost of type 2 diabetes in Spain: the CODE-2 study]

OBJECTIVE

To estimate the cost of providing health care to patients with type 2 diabetes, by differentiating costs of the disease, costs of complications, and other unrelated health costs.

METHODS

Data on resource use were retrospectively collected from medical records and personal interviews in 29 primary health care centers in Spain. Patients were randomly selected from each center's diabetes registry.

RESULTS

We evaluated 1004 patients (561 women) with a mean age of 67.42 years and a mean disease duration of 10.07 years. A total of 50.9% had no complications, 17.7% had macrovascular complications only, 19.5% had microvascular complications only and 11.9% presented both types of complication. The annual health cost per patient was 1305.15 euros. Of this cost, 28.6% (373.27 euros) was directly related to diabetes control, 30.51% (398.20 euros) was related to complications of the disease, and 40.89% (533.68 euros) was unrelated. The mean cost of patients with no complications was 883 euros compared with 1403 euros for those with microvascular complications, 2022 euros for those with macrovascular complications and 2133 euros for patients with both types of complication.

CONCLUSIONS

Because of the high cost of treating type 2 diabetes and its complications, preventive measures should be implemented and control of the disease should be improved to reduce the costs associated with chronic complications.