La retinografia ajuda a predir millor el risc del malalt hipertens

L'avaluació dels vasos de la retina és molt útil per al diagnòstic inicial d'hipertensió arterial, ja que ofereix informació per poder determinar millor el risc que tindrà el malalt hipertens i assignar, d'aquesta manera, el tractament més adequat. L'exploració del fons d'ull és el mètode més comú, però sovint es passa per alt degut a les seves condicions especials d'aplicació. Aquest treball proposa la retinografia com a mètode efectiu per fer aquesta avaluació.La evaluación de los vasos de la retina es muy útil en el diagnóstico inicial de la hipertensión arterial, pues ofrece información para pronosticar los factores de riesgo del paciente y asignar un tratamiento adecuado. El fondo de ojo es el método más común, pero debido a las condiciones especiales que requiere a menudo no se aplica. Este trabajo propone la retinografía como una alternativa efectiva

Medication patterns in older adults with multimorbidity : a cluster analysis of primary care patients

Altres ajuts: This manuscript is part of a PhD being undertaken by MGC at the Public Health Department (Departament de Pediatria, d'Obstetrícia i Ginecologia i de Medicina Preventiva) at the Universitat Autònoma de Barcelona. This work was supported by a pre-doctoral grant from Catalan Health Institute in Barcelona; by the Catalan Society of General Practitioners (CAMFiC) and by SIDIAP grant to MGC in 2015; this latter organization allowed us to explore their dataset to obtain the results. The funders had no role in the study design or data collection, analysis, and interpretation, writing of the manuscript, and decision to submit for publication.Background: Older adults suffer from various chronic conditions which make them particularly vulnerable. The proper management of multiple drug use is therefore crucial. The aim of our study was to describe drug prescription and medication patterns in this population. Methods: A cross-sectional study in Barcelona (Spain) using electronic health records from 50 primary healthcare centres. Participants were aged 65 to 94 years, presenting multimorbidity (≥2 chronic diseases), and had been prescribed at least 1 drug for 6 months or longer during 2009. We calculated the prevalence of prescribed drugs and identified medication patterns using multiple correspondence analysis and k-means clustering. Analyses were stratified by sex and age (65-79, 80-94 years). Results: We studied 164,513 patients (66.8% women) prescribed a median of 4 drugs (interquartile range [IQR] = 3-7) in the 65-79 age-group and 6 drugs (IQR = 4-8) in the 80-94 age-group. A minimum of 45.9% of patients aged 65-79 years, and 61.8% of those aged 80-94 years, were prescribed 5 or more drugs. We identified 6 medication patterns, a non-specific one and 5 encompassing 8 anatomical groups (alimentary tract and metabolism, blood, cardiovascular, dermatological, musculo-skeletal, neurological, respiratory, and sensory organ). Conclusions: Drug prescription is widespread among the elderly. Six medication patterns were identified, 5 of which were related to one or more anatomical group, with associations among drugs from different systems. Overall, guidelines do not accurately reflect the situation of the elderly multimorbid, new strategies for managing multiple drug uses are needed to optimize prescribing in these patients

Patrones de multimorbilidad en adultos jóvenes en Cataluña : un análisis de clústeres

Identificar los patrones de multimorbilidad en pacientes de 19-44 años atendidos en atención primaria en Cataluña en el año 2010. Estudio descriptivo transversal. Doscientos cincuenta y un centros de salud. Fueron 530.798 personas con multimorbilidad de 19-44 años. La multimorbilidad fue definida como la coexistencia de ≥2 diagnósticos de la Clasificación Internacional de Enfermedades registrados en la historia clínica informatizada. Los patrones de multimorbilidad fueron identificados a través de un análisis jerárquico de clústeres y descritos por sexo y grupos de edad (19-24 y 25-44 años). De las 882.708 personas de la población inicial, 530.798 (60,1%) presentaron multimorbilidad. La media de edad fue de 33,0 años (DT: 7,0) y el 53,3% fueron mujeres. La multimorbilidad fue más alta en el grupo de 25-44 años respecto al grupo más joven (60,5 vs. 58,1%, p < 0,001), siendo más alta en las mujeres. El clúster más prevalente en todos los estratos estuvo constituido por caries dental, tabaquismo, dorsalgia, resfriado común y otros trastornos de ansiedad. En ambos sexos, en los estratos de 25-44 años apareció el patrón cardiovascular-endocrino-metabólico (obesidad, dislipidemias e hipertensión arterial). La multimorbilidad afecta a más de la mitad de personas entre los 19-44 años de edad. El clúster más prevalente está formado por diagnósticos que agrupan enfermedades comunes (caries dental, resfriado común, tabaquismo, trastornos de ansiedad y dorsalgias). Otro patrón a destacar es el cardiovascular-endocrino-metabólico en el grupo de 25-44. El conocimiento de los patrones de multimorbilidad en adultos jóvenes permitiría un enfoque preventivo

Soft clustering using real-world data for the identification of multimorbidity patterns in an elderly population: Cross-sectional study in a Mediterranean population

The aim of this study was to identify, with soft clustering methods, multimorbidity patterns in the electronic health records of a population =65 years, and to analyse such patterns in accordance with the different prevalence cut-off points applied. Fuzzy cluster analysis allows individuals to be linked simultaneously to multiple clusters and is more consistent with clinical experience than other approaches frequently found in the literature.Peer ReviewedPostprint (published version

Multimorbidity patterns in the elderly : a prospective cohort study with cluster analysis

This manuscript constitutes a part of the PhD thesis of MGC in the Public Health Department of the Universitat Autònoma de Barcelona. This work was supported by a pre-doctoral grant from Catalan Health Institute in Barcelona; by the Catalan Society of General Practitioners (CAMFiC) and by SIDIAP grant to MGC in 2015; this latter organization allowed us to explore their dataset to obtain the results. The funders had no role in the study design or data collection, analysis, and interpretation, writing of the manuscript, and decision to submit for publication.Multimorbidity is the coexistence of more than two chronic diseases in the same individual; however, there is no consensus about the best definition. In addition, few studies have described the variability of multimorbidity patterns over time. The aim of this study was to identify multimorbidity patterns and their variability over a 6-year period in patients older than 65 years attended in primary health care. A cohort study with yearly cross-sectional analysis of electronic health records from 50 primary health care centres in Barcelona. Selected patients had multimorbidity and were 65 years of age or older in 2009. Diagnoses (International Classification of Primary Care, second edition) were extracted using O'Halloran criteria for chronic diseases. Multimorbidity patterns were identified using two steps: 1) multiple correspondence analysis and 2) k-means clustering. Analysis was stratified by sex and age group (65-79 and ≥80 years) at the beginning of the study period. Analysis of 2009 electronic health records from 190,108 patients with multimorbidity (59.8% women) found a mean age of 71.8 for the 65-79 age group and 84.16 years for those over 80 (Standard Deviation [SD] 4.35 and 3.46, respectively); the median number of chronic diseases was seven (Interquartil range [IQR] 5-10). We obtained 6 clusters of multimorbidity patterns (1 nonspecific and 5 specifics) in each group, being the specific ones: Musculoskeletal, Endocrine-metabolic, Digestive/Digestive-respiratory, Neurological, and Cardiovascular patterns. A minimum of 42.5% of the sample remained in the same pattern at the end of the study, reflecting the stability of these patterns. This study identified six multimorbidity patterns per each group, one nonnspecific pattern and five of them with a specific pattern related to an organic system. The multimorbidity patterns obtained had similar characteristics throughout the study period. These data are useful to improve clinical management of each specific subgroup of patients showing a particular multimorbidity pattern. The online version of this article (10.1186/s12877-018-0705-7) contains supplementary material, which is available to authorized users

The burden of cardiovascular morbidity in a European Mediterranean population with multimorbidity : a cross-sectional study

Altres ajuts: European Regional Development Fund (IP12/00427)Cardiovascular diseases are highly represented in multimorbidity patterns. Nevertheless, few studies have analysed the burden of these diseases in the population with multimorbidity. The objective of this study was to identify and describe the cardiovascular diseases among the patients with multimorbidity. We designed a cross-sectional study in patients ≥19 years old assigned to 251 primary health care centres in Catalonia, Spain. The main outcome was cardiovascular morbidity burden, defined as the presence of one or more of 24 chronic cardiovascular diseases in multimorbid patients (≥2 chronic conditions). Two groups were defined, with and without multimorbidity; the multimorbidity group was further divided into cardiovascular and non-cardiovascular subgroups. The secondary outcomes were: modifiable major cardiovascular risk factors (smoking, hypertension, hypercholesterolaemia, diabetes) and cardiovascular risk score (REGICOR, Registre Gironí del Cor). Other variables analysed were: sex, age (19-24, 25-44, 45-64, 65-79, and 80+ years), number of chronic diseases, urban setting, active toxic habits (smoking and alcohol), physical parameters and laboratory tests. A total of 1,749,710 individuals were included (mean age, 47.4 years [SD: 17.8]; 50.7 % women), of which nearly half (46.8 %) had multimorbidity (95 % CI: 46.9-47.1). In patients with multimorbidity,, the cardiovascular burden was 54.1 % of morbidity (95 % CI: 54.0-54.2) and the four most prevalent cardiovascular diseases were uncomplicated hypertension (75.3 %), varicose veins of leg (20.6 %), "other" heart disease (10.5 %) and atrial fibrillation/flutter (6.7 %). In the cardiovascular morbidity subgroup, 38.2 % had more than one cardiovascular disease. The most prevalent duet and triplet combinations were uncomplicated hypertension & lipid disorder (38.8 %) and uncomplicated hypertension & lipid disorder & non-insulin dependent diabetes (11.3 %), respectively. By age groups, the same duet was the most prevalent in patients aged 45-80 years and in men aged 25-44 years. In women aged 19-44, varicose veins of leg & anxiety disorder/anxiety was the most prevalent; in men aged 19-24, it was uncomplicated hypertension & obesity. Patients with multimorbidity showed a higher cardiovascular risk profile than the non-multimorbidity group. More than 50 % percent of patients with multimorbidity had cardiovascular diseases, the most frequent being hypertension. The presence of cardiovascular risk factors and the cardiovascular risk profile were higher in the multimorbidity group than the non-multimorbidity group. Hypertension, diabetes and dyslipidaemia constituted the most prevalent multimorbidity pattern

Exploring dementia management attitudes in primary care: a key informant survey to primary care physicians in 25 European countries

Background: Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment. Methods: Key informant survey. Setting: Primary care practices across 25 European countries. Subjects: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. Main outcome measures: Two by two contingency tables with odds ratios and 95 confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs' attitude of "trying to establish a diagnosis of dementia on their own". Results: Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95 CI 2.28-5.23). Conclusions: Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe

Relationship between efficiency and clinical effectiveness indicators in an adjusted model of resource consumption : a cross-sectional study

Background: Adjusted clinical groups (ACG®) have been widely used to adjust resource distribution; however, the relationship with effectiveness has been questioned. The purpose of the study was to measure the relationship between efficiency assessed by ACG® and a clinical effectiveness indicator in adults attended in Primary Health Care Centres (PHCs). Methods: Research design: cross-sectional study. Subjects: 196, 593 patients aged >14 years in 13 PHCs in Catalonia (Spain). Measures: Age, sex, PHC, basic care team (BCT), visits, episodes (diagnoses), and total direct costs of PHC care and co-morbidity as measured by ACG® indicators: Efficiency indices for costs, visits, and episodes (costs EI, visits EI, episodes EI); a complexity or risk index (RI); and effectiveness measured by a general synthetic index (SI). The relationship between EI, RI, and SI in each PHC and BCT was measured by multiple correlation coefficients (r). Results: In total, 56 of the 106 defined ACG® were present in the study population, with five corresponding to 44.5% of the patients, 11 to 68.0% of patients, and 30 present in less than 0.5% of the sample. The RI in each PHC ranged from 0.9 to 1.1. Costs, visits, and episodes had similar trends for efficiency in six PHCs. There was moderate correlation between costs EI and visits EI (r = 0.59). SI correlation with episodes EI and costs EI was moderate (r = 0.48 and r = −0.34, respectively) and was r = −0.14 for visits EI. Correlation between RI and SI was r = 0.29. Conclusions: The Efficiency and Effectiveness ACG® indicators permit a comparison of primary care processes between PHCs. Acceptable correlation exists between effectiveness and indicators of efficiency in episodes and costs

Unburdening dementia a basic social process grounded theory – based on a primary care physician survey from 25 countries

OBJECTIVE: To explore dementia management from a primary care physician perspective.DESIGN: One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist.SETTING: Twenty-five European General Practice Research Network member countries.SUBJECTS: Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories.MAIN OUTCOME MEASURES: Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines.RESULTS: Unburdening dementia - a basic social process - explained physicians' dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients - 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories.CONCLUSIONS: Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders. Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief - often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders