Real-world evidence on heart failure: findings from 25 thousand patients in a portuguese primary care database

Background: Heart failure (HF) is a major health problem in developed coun- tries, accounting for a significant social and economic burden. Published estimates of costs associated with HF patients in the primary care setting are scarce. Purpose: To determine the clinical and demographic characteristics of adult patients with a HF diagnosis in a Portuguese primary care comprehen- sive administrative database and to estimate the associated annual costs per patient. Methods: Population-based study with real data covering a population of 3.6 million patients attending primary care services in a large health region in Portugal. All adult users coded for HF with at least one visit in 2014 were selected. We analyzed patients’ characteristics, comorbidities (anemia, diabetes, hypertension, cere- brovascular disease, atrial fibrillation, ischemic heart disease, cardiomyopathies, valve disease, chronic obstructive pulmonary disease, pulmonary embolism, alco- hol abuse), and resource use in 2014 related to medical tests and cardiovascular diagnostic procedures, visits and cardiovascular or anticoagulant medication. Unit costs estimates were based on national sources. Results: We identied 25,337 patients, with an estimated HF prevalence of 1.4%. This is approximately 30% of number expected according to a previously conducted national community-based epidemiological survey. The difference may be explained by both underdiagnosis and underregistration. Patients with HF are mostly women (58%) and on average 77 ± 11 years old. The large majority of patients (93%) had at least one of the selected comorbidities present, 70% had 2 or more and 38% had 3 or more. About two thirds of patients (65%) had at least one medical test or diagnostic procedure done during 2014. Blood tests, echocardiogram, elec- trocardiogram and chest x-ray were performed in 61%, 16%, 14% and 11% of patients, respectively. The majority of patients (56%) had at least four office visits during one year. Angiotensin-converting enzyme inhibitor or angiotensin receptor blockers, beta-blockers, and aldosterone blockers were prescribed for 80%, 48% and 20% of patients, respectively. Only 12% of patients were prescribed all three drug classes. The average annual cost per patient was estimated at €552 ± 348, of which 54%, 40% and 6% was associated to medications, medical visits and medical tests or diagnostic procedures, respectively. Conclusions: This study provides a characterization of patients with HF in a large population in a primary care setting. Surprisingly 70% of the expected number of patients are either not diagnosed or not registered. HF patients are old, mostly women and characterized by multimorbidity. The average annual cost per patient was estimated to be about €550.info:eu-repo/semantics/publishedVersio

The disease burden of heart failure in Portugal

Objectives: The objective of this study is to estimate the disease burden of Heart Failure (HF) in Portugal for 2014.MethOds: The HF burden was measured in Disability Adjusted Life Years (DALY) resulting from the sum of Years Lost due to Disability (YLD) and Years of Life Lost (YLL) due to premature death. YLL were esti-mated based on the mortality rates reported by the European Detailed Mortality Database. For YLD, the three disability weights (mild moderate and severe) presented by the Global Burden of Disease Study (2015) were considered. Patients in the first class of the New York Heart Association (NYHA) Functional Classification, where considered to have no disability associated to HF. The average total disease duration by age group and the overall incidence were estimated using the software DisMod II, calibrated with the prevalence of NYHA class II-IV, relative risk of mortality and a remission rate of zero. Prevalence was estimated using the microdata of a previously conducted national community-based epidemiological survey while relative risk of mortality came from the international literature. It was assumed that incidence by severity class followed the same pattern as prevalence and that duration was independent from severity.Results: In 2014, HF incident cases in NYHA class II-IV were estimated to be 38,960 (394.74/100,000 inhabitants). The deaths for HF patients amounted to 4,688, 4.7% of overall deaths, with women being responsible for 66.7% of HF mortality. Overall, DALY totaled 21,162, with 53.8% due to YLL and 46.2% due to YLD. Women contributed to most of the overall disease burden in terms of DALY (57.0%) with YLL and YLD estimated at 6.944 and 5.118, respectively.cOnclusiOns:Heart Failure is an important cause of disease burden in Portugal. Heart Failure should be an important target for health policy interventions.info:eu-repo/semantics/publishedVersio

The cost of illness of heart failure in Portugal

Objectives: To estimate direct and indirect costs associated to adult Portuguese patients with heart failure (HF) in 2014.MethOds: A prevalence-based approach was adopted to estimate costs associated to HF. Prevalence in 2014 by the New York Heart Association (NYHA) Functional Classification was estimated using micro-data from a previously conducted national community-based epidemiological survey. Only patients at NYHA classes II-IV were considered to have costs and it was conservatively assumed that patients were either followed in hospital ambu-latory care or in primary care. Primary care costs were estimated using a data-base covering a large population, with records of medications, medical visits and medical tests or diagnostic procedures for 25,337 patients with a HF diagnosis in 2014. Hospital resource consumption was estimated using national DRG microdata. Resource utilization in hospital ambulatory care and in emergency department (ED) episodes was estimated according to experts’ opinion and the national lit-erature, respectively. Unit costs were based on the official NHS tariffs. The indirect costs associated to patients’ absenteeism and early exit from the labour force were based on national sources and conservative assumptions.Results: The class II-IV prevalence rate in the population aged 25+ was estimated at 3.4%, corresponding to 249,592 patients in 2014. HF patients have about 1.1 million medical visits, over 36,000 hospitalizations and approximately 53,000 ED episodes. In 2014, the overall direct and indirect costs were estimated at €289.4M with an average annual cost per patient of €1,159. Medication, medical visits, exams/diagnostic procedures, hospitalization and ED episodes accounted for 29%, 20%, 21%, 26% and 2% of the €244.9M direct costs, respectively. The indirect costs associated to absenteeism and premature exit from the labour market were estimated at €16.4M and €28.1M, respectively.cOnclusiOns: Heart failure is a costly condition and should receive adequate attention from the Portuguese health policy makers.info:eu-repo/semantics/publishedVersio

The impact of ageing on the future costs and burden of heart failure in Portugal

Objectives: To estimate, the impact of population ageing on the costs and burden of Heart Failure (HF) in Portugal over a twenty-year horizon, between 2014 and 2034. MethOds: HF costs were estimated using a prevalence-based approach. Costs and disability were assumed zero for patients in class I of the New York Heart Association (NYHA) Functional Classification. The prevalence rate was estimated using microdata from a previous epidemiological survey. Average direct costs per patient were estimated using: 1) a primary care national database with records of 25,337 patients registered with HF; 2) National DRG microdata; 3) expert panel; 4) national literature, reports and legislation. Indirect costs associated to patients’ absenteeism and early exit from the labour force were considered. The burden was measured in Disability Adjusted Life Years (DALY) resulting from the sum of Years Lost due to Disability (YLD) and Years of Life Lost (YLL) due to premature death. For YLL, mortality rates reported in the European Detailed Mortality Database were considered. For YLD, disease duration and the overall incidence were estimated using the software DisMod II. Disability weights were retrieved from published literature. Population ageing was carried out by a shift-share analysis using the official demographic projections. Results: Considering only population ageing on a 20-year horizon, HF prevalence (class II-IV) is expected to increase by 25%, reaching over 312,000 patients in 2034. Total costs in 2014 and 2034 are estimated, respectively, at €289M and €364M (at today’s prices), with an increase in the costs per inhabitant of 34%. In 2034, total DALY are expected to be 25% higher than in 2014, from 21,162 to 26,521. The contribution of YLL will increase from 54% to 61%. cOnclusiOns: Population ageing will substantially increase the burden of HF in Portugal. Health policy makers should consider new strategies to deal with this problem.info:eu-repo/semantics/publishedVersio

Atrial fibrillation’s burden of disease in Portugal

Copyright © 2013 Published by Elsevier Inc.Objectives: To estimate the Disability Adjusted Life-Years (DALY) attributable to Atrial Fibrillation (AF) during 2010 in Portugal, including both AF and AF related stroke.info:eu-repo/semantics/publishedVersio

A Aterosclerose nos Cuidados de Saúde Primários: Estudo da Vida Real

Introduction and objectives: To characterize patients with atherosclerosis, a disease with a high socioeconomic impact, in the Lisbon and Tagus Valley Health Region. Methods: A cross-sectional observational study was carried out through the Lisbon and Tagus Valley Regional Health Administration primary health care database, extracting data on the clinical and demographic characteristics and resource use of adult primary health care users with atherosclerosis during 2016. Different criteria were used to define atherosclerosis (presence of clinical manifestations, atherothrombotic risk factors and/or consumption of drugs related to atherosclerosis). Comparisons between different subpopulations were performed using parametric tests. Results: A total of 318 692 users were identified, most of whom (n=224 845 users; 71%) had no recorded clinical manifestations. The subpopulation with clinical manifestations were older (72.0±11.5 vs. 71.3±11.0 years), with a higher proportion of men (58.0% vs. 45.9%), recorded hypertension (78.3% vs. 73.5%) and dyslipidemia (55.8% vs. 53.5%), and a lower proportion of recorded obesity (18.2% vs. 20.8%), compared to those without clinical manifestations (p<0.001). Mean blood pressure, LDL-C and glycated hemoglobin values were lower in the subpopulation with manifestations (142/74 vs. 146/76 mmHg, 101 vs. 108 mg/dl, and 6.80 vs. 6.84%, respectively; p<0.001). Each user with atherosclerosis attended 4.1±2.9 face-to-face medical consultations and underwent 8.6±10.0 laboratory test panels, with differences in subpopulations with and without clinical manifestations (4.4±3.2 vs. 4.0±2.8 and 8.3±10.3 vs. 8.7±9.8, respectively; p<0.001). Conclusions: About one in three adult primary health care users with atherosclerosis have clinical manifestations. The results suggest that control of cardiovascular risk factors is suboptimal in patients with atherosclerosis.info:eu-repo/semantics/publishedVersio

Cost and burden of hypercholesterolemia In Portugal

Copyright © 2014 Published by Elsevier Inc.Hypercholesterolemia is a risk factor for ciculatory diseases. This study estimates the impact of hypercholesterolemia on populations’ health levels and its economic impact in Portugal.info:eu-repo/semantics/publishedVersio

Geochronological and thermometric evidence of unusually hot fluids in an Alpine fissure of Lauzière granite (Belledonne, Western Alps)

A multi-method investigation into Lauzière granite, located in the external Belledonne massif of the French Alps, reveals unusually hot hydrothermal conditions in vertical open fractures (Alpine-type clefts). The host-rock granite shows sub-vertical mylonitic microstructures and partial retrogression at temperatures of &lt;&thinsp;400&thinsp;∘C during Alpine tectonometamorphism. Novel zircon fission-track (ZFT) data in the granite give ages at 16.3&thinsp;±&thinsp;1.9 and 14.3&thinsp;±&thinsp;1.6&thinsp;Ma, confirming that Alpine metamorphism was high enough to reset the pre-Alpine cooling ages and that the Lauzière granite had already cooled below 240–280&thinsp;∘C and was exhumed to &lt;&thinsp;10&thinsp;km at that time. Novel microthermometric data and chemical compositions of fluid inclusions obtained on millimetric monazite and on quartz crystals from the same cleft indicate early precipitation of monazite from a hot fluid at T&thinsp;&gt;&thinsp;410&thinsp;∘C, followed by a main stage of quartz growth at 300–320&thinsp;∘C and 1.5–2.2&thinsp;kbar. Previous Th-Pb dating of cleft monazite at 12.4&thinsp;±&thinsp;0.1&thinsp;Ma clearly indicates that this hot fluid infiltration took place significantly later than the peak of the Alpine metamorphism. Advective heating due to the hot fluid flow caused resetting of fission tracks in zircon in the cleft hanging wall, with a ZFT age at 10.3&thinsp;±&thinsp;1.0&thinsp;Ma. The results attest to the highly dynamic fluid pathways, allowing the circulation of deep mid-crustal fluids, 150–250&thinsp;∘C hotter than the host rock, which affect the thermal regime only at the wall rock of the Alpine-type cleft. Such advective heating may impact the ZFT data and represent a pitfall for exhumation rate reconstructions in areas affected by hydrothermal fluid flow.</p

Subversion of early innate antiviral responses during antibody-dependent enhancement of Dengue virus infection induces severe disease in immunocompetent mice

Dengue is a mosquito-borne disease caused by one of four serotypes of Dengue virus (DENV-1–4). Epidemiologic and observational studies demonstrate that the majority of severe dengue cases, dengue hemorrhagic fever and dengue shock syndrome (DHF/DSS), occurs predominantly in either individuals with cross-reactive immunity following a secondary heterologous infection or in infants with primary DENV infections born from dengue-immune mothers, suggesting that B-cell-mediated and antibody responses impact on disease evolution. We demonstrate here that B cells play a pivotal role in host responses against primary DENV infection in mice. After infection, μMT[superscript −/−] mice showed increased viral loads followed by severe disease manifestation characterized by intense thrombocytopenia, hemoconcentration, cytokine production and massive liver damage that culminated in death. In addition, we show that poly and monoclonal anti-DENV-specific antibodies can sufficiently increase viral replication through a suppression of early innate antiviral responses and enhance disease manifestation, so that a mostly non-lethal illness becomes a fatal disease resembling human DHF/DSS. Finally, treatment with intravenous immunoglobulin containing anti-DENV antibodies confirmed the potential enhancing capacity of subneutralizing antibodies to mediate virus infection and replication and induce severe disease manifestation of DENV-infected mice. Thus, our results show that humoral responses unleashed during DENV infections can exert protective or pathological outcomes and provide insight into the pathogenesis of this important human pathogen

HIV-1-Transmitted Drug Resistance and Transmission Clusters in Newly Diagnosed Patients in Portugal Between 2014 and 2019

Objective: To describe and analyze transmitted drug resistance (TDR) between 2014 and 2019 in newly infected patients with HIV-1 in Portugal and to characterize its transmission networks. Methods: Clinical, socioepidemiological, and risk behavior data were collected from 820 newly diagnosed patients in Portugal between September 2014 and December 2019. The sequences obtained from drug resistance testing were used for subtyping, TDR determination, and transmission cluster (TC) analyses. Results: In Portugal, the overall prevalence of TDR between 2014 and 2019 was 11.0%. TDR presented a decreasing trend from 16.7% in 2014 to 9.2% in 2016 (p for-trend = 0.114). Multivariate analysis indicated that TDR was significantly associated with transmission route (MSM presented a lower probability of presenting TDR when compared to heterosexual contact) and with subtype (subtype C presented significantly more TDR when compared to subtype B). TC analysis corroborated that the heterosexual risk group presented a higher proportion of TDR in TCs when compared to MSMs. Among subtype A1, TDR reached 16.6% in heterosexuals, followed by 14.2% in patients infected with subtype B and 9.4% in patients infected with subtype G. Conclusion: Our molecular epidemiology approach indicates that the HIV-1 epidemic in Portugal is changing among risk group populations, with heterosexuals showing increasing levels of HIV-1 transmission and TDR. Prevention measures for this subpopulation should be reinforced.info:eu-repo/semantics/publishedVersio