Preventable hospitalization and access to primary health care in an area of Southern Italy

<p>Abstract</p> <p>Background</p> <p>Ambulatory care-sensitive conditions (ACSC), such as hypertension, diabetes, chronic heart failure, chronic obstructive pulmonary disease and asthma, are conditions that can be managed with timely and effective outpatient care reducing the need of hospitalization. Avoidable hospitalizations for ACSC have been used to assess access, quality and performance of the primary care delivery system. The aims of this study were to quantify the proportion of avoidable hospital admissions for ACSCs, to identify the related patient's socio-demographic profile and health conditions, to assess the relationship between the primary care access characteristics and preventable hospitalizations, and the usefulness of avoidable hospitalizations for ACSCs to monitor the effectiveness of primary health care.</p> <p>Methods</p> <p>A random sample of 520 medical records of patients admitted to medical wards (Cardiology, Internal Medicine, Pneumology, Geriatrics) of a non-teaching acute care 717-bed hospital located in Catanzaro (Italy) were reviewed.</p> <p>Results</p> <p>A total of 31.5% of the hospitalizations in the sample were judged to be preventable. Of these, 40% were for congestive heart failure, 23.2% for chronic obstructive pulmonary disease, 13.5% for angina without procedure, 8.4% for hypertension, and 7.1% for bacterial pneumonia. Preventable hospitalizations were significantly associated to age and sex since they were higher in older patients and in males. The proportion of patients who had a preventable hospitalization significantly increased with regard to the number of hospital admissions in the previous year and to the number of patients for each primary care physician (PCP), with lower number of PCP accesses and PCP medical visits in the previous year, with less satisfaction about PCP health services, and, finally, with worse self-reported health status and shorter length of hospital stay.</p> <p>Conclusion</p> <p>The findings from this study add to the evidence and the urgency of developing and implementing effective interventions to improve delivery of health care at the community level and provided support to the usefulness of avoidable hospitalizations for ACSCs to monitor this process.</p

Effect of SGLT2 inhibitors on stroke and atrial fibrillation in diabetic kidney disease: Results from the CREDENCE trial and meta-analysis

BACKGROUND AND PURPOSE: Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-Analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus. METHODS: CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-Analysis. RESULTS: In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: Total stroke (HRpooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (45 mL/min/1.73 m2]) subgroup (HRpooled, 0.50 [95% CI, 0.31-0.79]). CONCLUSIONS: Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms

Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to 300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m 2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Urban health and prevention and control of vector-borne diseases

Background: This paper presents the overall approach undertaken by the "VEctor boRne DiseAses Scoping reviews" (VERDAS) consortium in response to a call issued by the Vectors, Environment and Society unit of the Special Programme for Research and Training in Tropical Diseases hosted by the World Health Organization. The aim of the project was to undertake a broad knowledge synthesis and identify knowledge gaps regarding the control and prevention of vector-borne diseases in urban settings. Methods: The consortium consists of 14 researchers, 13 research assistants, and one research coordinator from seven different institutions in Canada, Colombia, Brazil, France, Spain, and Burkina Faso. A six-step protocol was developed for the scoping reviews undertaken by the consortium, based on the framework developed by Arksey and O'Malley and improved by Levac et al. In the first step, six topics were identified through an international eDelphi consultation. In the next four steps, the scoping reviews were conducted. The sixth step was the VERDAS workshop held in Colombia in March 2017. Discussion: In this article, we discuss several methodological issues encountered and share our reflections on this work. We believe this protocol provides a strong example of an exhaustive and rigorous process for performing broad knowledge synthesis for any given topic and should be considered for future research initiatives and donor agendas in multiple fields to highlight research needs scientifically

Prioritization of non-recommended clinical activities in Primary Care

Background: To prioritize non-recommended clinical activities in Primary Care (PC), from "Do not do" recommendations listed by the Sociedad Espanola de Medicina de Familia y Comunitaria (Semfyc), according to expert consensus (physicians, nurses and pharmacists).Methods. The consensus for the prioritization of non-recommended practices in PC was performed through an online procedure. We used as a base the list of "do not-do" recommendations of the SEMFYC. We asked the experts to prioritize practices that should be de-adopted in PC, based on four prioritization criteria: frequency of occurrence, cost of the activity, ease of disposal and damage caused, which were scored from one to five, according to their recommendation. Scores were summarized in median and quartile values. Two rounds were necessary to obtain a consensus. A modified e-Delphi technique was used.Results. 34 experts (62%) participated in the first consultation round and prioritized 19 recommendations with a score >= 3.5. These recommendations were again analyzed in a second round, in which 32 panelists agreed to prioritize 17 practices (13 related to prescription, three diagnostic tests, and one clinical analysis). The high priority list included seven practices with values >= 4.1) Prescription of a new drug in elderly patients without having reviewed the previous treatments; 2) Lipid-lowering drugs without calculating the overall cardiovascular risk; 3) Not systematically prescribing gastric protection with proton pump inhibitors to patients consuming Nonsteroidal anti-inflammatory drugs (NSAIDs); 4) Glucose self-analysis in non-insulinized type 2 diabetics; 5) Benzodiazepines in the long term; 6) Bisphosphonates in patients with low risk of fracture; and 7) Antibiotics in lower respiratory tract infections.Conclusion. This study provides information for the prioritization of 17 non-AP activities in which short-term de-adoption would significantly increase the efficiency of the public health system

Establishing research priorities in prevention and control of vector-borne diseases in urban areas : a collaborative process

Background: In 2015, following a call for proposals from the Special Programme for Research and Training in Tropical Diseases (TDR), six scoping reviews on the prevention and control of vector-borne diseases in urban areas were conducted. Those reviews provided a clear picture of the available knowledge and highlighted knowledge gaps, as well as needs and opportunities for future research. Based on the research findings of the scoping reviews, a concept mapping exercise was undertaken to produce a list of priority research needs to be addressed. Methods: Members of the six research teams responsible for the "VEctor boRne DiseAses Scoping reviews" (VERDAS) consortium's scoping reviews met for 2 days with decision-makers from Colombia, Brazil, Peru, Pan-American Health Organization, and World Health Organization. A total of 11 researchers and seven decision-makers (from ministries of health, city and regional vector control departments, and vector control programs) completed the concept mapping, answering the question: "In view of the knowledge synthesis and your own expertise, what do we still need to know about vector-borne diseases and other infectious diseases of poverty in urban areas?" Participants rated each statement on two scales from 1 to 5, one relative to 'priority' and the other to 'policy relevance', and grouped statements into clusters based on their own individual criteria and expertise. Results: The final map consisted of 12 clusters. Participants considered those entitled "Equity", "Technology", and "Surveillance" to have the highest priority. The cluster considered the most important concerns equity issues, confirming that these issues are rarely addressed in research on vector-borne diseases. On the other hand, the "Population mobility" and "Collaboration" clusters were considered to be the lowest priority but remained identified by participants as research priorities. The average policy relevance scores for each of the 12 clusters were roughly the same as the priority scores for all clusters. Some issues were not addressed during the brain-storming. This is the case for governance and for access and quality of care. Conclusions: Based on this work, and adopting a participatory approach, the concept mapping exercise conducted collaboratively with researchers from these teams and high-level decision-makers identified research themes for which studies should be carried out as a priority

Urban health and prevention and control of vector-borne diseases

Background: In 2015, following a call for proposals from the Special Programme for Research and Training in Tropical Diseases (TDR), six scoping reviews on the prevention and control of vector-borne diseases in urban areas were conducted. Those reviews provided a clear picture of the available knowledge and highlighted knowledge gaps, as well as needs and opportunities for future research. Based on the research findings of the scoping reviews, a concept mapping exercise was undertaken to produce a list of priority research needs to be addressed. Methods: Members of the six research teams responsible for the "VEctor boRne DiseAses Scoping reviews" (VERDAS) consortium's scoping reviews met for 2 days with decision-makers from Colombia, Brazil, Peru, Pan-American Health Organization, and World Health Organization. A total of 11 researchers and seven decision-makers (from ministries of health, city and regional vector control departments, and vector control programs) completed the concept mapping, answering the question: "In view of the knowledge synthesis and your own expertise, what do we still need to know about vector-borne diseases and other infectious diseases of poverty in urban areas?" Participants rated each statement on two scales from 1 to 5, one relative to 'priority' and the other to 'policy relevance', and grouped statements into clusters based on their own individual criteria and expertise. Results: The final map consisted of 12 clusters. Participants considered those entitled "Equity", "Technology", and "Surveillance" to have the highest priority. The cluster considered the most important concerns equity issues, confirming that these issues are rarely addressed in research on vector-borne diseases. On the other hand, the "Population mobility" and "Collaboration" clusters were considered to be the lowest priority but remained identified by participants as research priorities. The average policy relevance scores for each of the 12 clusters were roughly the same as the priority scores for all clusters. Some issues were not addressed during the brain-storming. This is the case for governance and for access and quality of care. Conclusions: Based on this work, and adopting a participatory approach, the concept mapping exercise conducted collaboratively with researchers from these teams and high-level decision-makers identified research themes for which studies should be carried out as a priority