Antoni Sicras-Mainar

Perfil de uso de recursos y costes en pacientes que demandan atención por fibromialgia o trastorno de ansiedad generalizada en el ámbito de la atención primaria de salud

OBJECTIVE To determine the use of services and costs in patients with Fibromyalgia (FM) or Generalized Anxiety Disorder (GAD) followed up in Primary Care (PC). DESIGN A retrospective multicenter population-based study. SETTING Five primary care clinics managed by Badalona Health Service. PARTICIPANTS Patients over 18 years seen in the 5 PC centers during the year 2006. Patients with and without GAD/FM were compared. MEASUREMENTS Main outcomes measures were general, case/co-morbidity, health care use and primary care cost (visits, diagnostic/therapeutic tests and drugs). STATISTICAL ANALYSIS logistic regression and ANCOVA (P<.05). RESULTS There was a total of 63,349 patients, 1.4% (95% CI, 0.6%-2.2%) had a diagnosis of FM, and 5.3% (95% CI, 4.5%-6.1%) GAD. The average episodes/year and visits /year was higher in FM group compared to GAD group, with a marked difference observed vs. the reference group (8.3 vs. 7.2 and 4.6 episodes/year; and 12.9 vs. 12.1 and 7.4 visits/year; P <.001). FM was shown to be related to female gender (odds ratio [OR] = 16.8), dyslipidemia (OR = 1.5), and depressive syndrome (OR = 3.9) (P <.001 in all cases). GAD was related to age (OR = 1.1), female gender (OR = 2.2), high blood pressure (OR = 1.3), dyslipidemia (OR=1.2), smoking (OR = 1.4), depressive syndrome (OR = 1.2), and cardiovascular events (OR = 1.3) (P<.02 in all cases). After adjusting for age, gender and co-morbidities, mean annual direct ambulatory cost was 555.58 Euro for the reference group, 817.37 Euro for GAD, and 908.67 Euro for FM (P<.001). CONCLUSIONS Compared with reference group, a considerable use of health resources and costs was observed in patients with FM or TAG in medical practice in PC settings.

C-reactive protein as a marker of cardiovascular disease in patients with a schizophrenia spectrum disorder treated in routine medical practice

OBJECTIVE Interest in cardiovascular diseases (CVD) in schizophrenia has grown recently due to documented incremental mortality. C-reactive protein (CRP) has been assessed as a marker in individuals with CVD and/or at high risk of developing it. However, its role in schizophrenia patients is unknown. The goal of this research was thus to explore the use of CRP as a marker of CVD risk in patients with schizophrenia. METHODS A cross-sectional analysis of the Badalona Serveis Assistencials (BSA) administrative claims database was conducted including all subjects aged>18 years with a diagnosis of schizophrenia spectrum disorder. CRP measurement, sociodemographics, medical history, 10-year CVD risk (Framingham function) and clinical chemistry data were extracted for analysis. RESULTS Seven hundred and five patients (53.0% men, 48.2 [15.8] years, 78.7% on atypicals) met criteria for analysis. Mean 10-year CVD risk was high; 11.9±5.7% and mean CRP levels were 2.6±2.5 mg/L with 30.4% showing above-normative levels (>3 mg/L). After adjusting for age, gender, smoking and presence of neoplasm or inflammatory diseases, CRP was linearly associated with 10-year CVD risk stratified by risk (low, moderate, high/very high): respectively, 2.3 (95% CI: 2.1-2.5), 3.1 (2.6-3.5) and 3.7 (3.2-4.1) mg/L; F=13.5, P<0.001. Patients with known CVD also showed higher CRP levels: 3.7 (2.9-4.5) vs. 2.5 (2.4-2.7) mg/L, P=0.008; and higher probability of above-normal values; odds ratio=4.71 (2.01-11.04), P<0.001. CONCLUSIONS High CRP levels above normative were associated with both known CVD and high/very high 10-year risk of a CVD event in patients with schizophrenia, suggesting CRP could be a marker of CVD in this psychiatric disorder.

Retrospective epidemiological study for the characterization of community- acquired pneumonia and pneumococcal pneumonia in adults in a well-defined area of Badalona (Barcelona, Spain)

BackgroundCommunity-acquired pneumonia (CAP) has large impact on direct healthcare costs, especially those derived from hospitalization. This study determines impact, clinical characteristics, outcome and economic consequences of CAP in the adult (≥18 years) population attended in 6 primary-care centers and 2 hospitals in Badalona (Spain) over a two-year period.MethodsMedical records were identified by codes from the International Classification of Diseases in databases (January 1st 2008-December 31st 2009).ResultsA total of 581 patients with CAP (55.6% males, mean age 57.5 years) were identified. Prevalence: 0.64% (95% CI: 0.5%-0.7%); annual incidence: 3.0 cases/1,000 inhabitants (95% CI: 0.2-0.5). Up to 241 (41.5%) required hospitalization. Hospital admission was associated (p<0.002) with liver disease (OR=5.9), stroke (OR=3.6), dementia (OR=3.5), COPD (OR=2.9), diabetes mellitus (OR=1.9) and age (OR=1.1 per year). Length of stay (4.4±0.3 days) was associated with PSI score (β=0.195), in turn associated with age (r=0.827) and Charlson index (r=0.497). Microbiological tests were performed in all inpatients but only in 35% outpatients. Among patients with microbiological tests, results were positive in 51.7%, and among them, S pneumoniae was identified in 57.5% cases. Time to recovery was 29.9±17.2 days. Up to 7.5% inpatients presented complications, 0.8% required ICU admission and 19.1% readmission. Inhospital mortality rate was 2.5%. Adjusted mean total cost was €2,332.4/inpatient and €698.6/outpatient (p<0.001). Patients with pneumococcal CAP (n=107) showed higher comorbidity and hospitalization (76.6%), higher PSI score, larger time to recovery and higher overall costs among inpatients.ConclusionsStrategies preventing CAP, thus reducing hospital admissions could likely produce substantial costs savings in addition to the reduction of CAP burden.

Prevalence of metabolic syndrome according to the presence of negative symptoms in patients with schizophrenia

Background Metabolic syndrome (MetS) is one of the primary reasons for increased mortality in patients with schizophrenia. The mechanisms involved in its pathogenesis are not well understood. Objective To estimate the prevalence of MetS in adult outpatients with schizophrenia according to the presence or absence of negative symptoms. Materials and methods A retrospective cohort study using electronic medical records was conducted. The Positive and Negative Syndrome Scale negative-symptom factor (N1–N4, N6, G7, and G16) was used as a framework for characterizing negative symptoms. MetS was defined using the National Cholesterol Education Program Adult Treatment Panel III diagnostic criteria. An analysis of covariance model was used for correction, with significance at P<0.05. Results One or more negative symptoms were present in 52.5% of a sample of 1,120 patients (mean age 46.8 years, men 58.4%). Dyslipidemia (48.7%), hypertension (38.2%), and diabetes mellitus (19.3%) were the most frequent comorbidities. The overall prevalence of MetS was 38.6% (95% confidence interval 35.7%–41.5%), and was significantly higher in those patients with negative symptoms (43.9% versus 34.9%, P=0.002). MetS was significantly associated with the presence of negative symptoms, age, and physical comorbidity (odds ratios 1.6, 1.2, and 1.2, respectively; P<0.05). Conclusion A sedentary lifestyle and lack of physical exercise due to negative symptomatology may contribute to MetS development. Further studies are necessary to confirm this association and the underlying pathophysiological mechanisms.

Asociación entre el grado de control de la hipertensión arterial, la comorbilidad y los costes en personas de más de 30 años durante el año 2006

Fundamento. La hipertension arterial (HTA) es uno de los principales motivos de consulta de los centros de atencion primaria (AP). El objetivo del estudio fue determinar la asociacion entre el grado de control de la HTA, la comorbilidad y los costes directos en atencion primaria. Metodos. Diseno retrospectivo-multicentrico. Se incluyo a sujetos mayores de 30 anos pertenecientes a cinco equipos de AP (ano 2006). Criterios: buen control (<140/90, y <130/80 mmHg en personas diabeticas y presencia de enfermedad cardiovascular [ECV]). Principales medidas: generales, ECV, indice de Charlson, casuistica/comorbilidad (Adjusted Clinical Groups), parametros clinicos y costes directos (fijos/semifijos y variables [medicamentos, pruebas y derivaciones]). Analisis de regresion logistica y de ANCOVA para la correccion del modelo, p<0,05. Resultados. La prevalencia de HTA fue del 26,5% (edad media: 67,1 anos; varones: 43,5%). El buen control fue del 52,0% (IC: 51,2-52,8%). El mal control tuvo una relacion independiente con la diabetes (OR=3,8), el ECV (OR=2,2) y los varones (OR=1,2), p<0,001. El promedio/unitario/ano del coste directo corregido fue de 1.202,13 vs. 1.183,55 € (p=0,032). Conclusiones. Los pacientes en situacion de mal control muestran una mayor carga de morbilidad y un similar coste sanitario.

Morbimortalidad y consumo de recursos asociados tras síndrome coronario agudo en una población española

OBJECTIVES To describe the management of patients suffering acute coronary syndrome (ACS) and to determine its clinical and economic consequences in a Spanish population. METHODS A multicenter, retrospective claim database study including patient medical records from 6 primary care centers, two hospitals and two years of follow-up was carried out. Patients ≥30 years, suffering a first acute coronary syndrome (ACS), between 2003 and 2007, were included. Groups: acute coronary syndrome with and without ST segment elevation. VARIABLES socio-demographic, co-morbidities, metabolic syndrome (MS), biochemical parameters, drugs, cumulative incidence (total mortality and cardiovascular events (CVE: including myocardial infarction, stroke and peripheral artery disease) and total costs. STATISTICAL ANALYSIS logistic regression, Kaplan-Meier curves and ANCOVA; (P<.05). RESULTS A total of 1020 patients were included. Mean age: 69 years; males: 65%. Groups: ST segment elevation ACS (N=632; 62%). Co-morbidities: hypertension (56%), dyslipidemia (46%) and diabetes (38%). Prevalence of MS: 59% (CI 95%: 56-62%). All biochemical parameters had improved after two years of follow-up. The average total cost per patient was €14,069 (87% direct costs; 13% productivity loss costs). Direct costs: primary care (20%), specialty care (67%); hospitalization costs represented 63% of total costs. The average total cost for patients presenting more than one CVE was 22,750€ vs 12,380€ for those patients who suffered only one (P<.001). Cumulative incidence: total mortality 14%; CVE: 16%. CONCLUSIONS In the current clinical practice, and despite the clinical efforts carried out, patients with an ACS are still at a high risk of suffering further CVE, representing a high cost burden to the health care system.

Impact of morbidity, resource use and costs on maintenance of remission of major depression in Spain: a longitudinal study in a population setting

OBJECTIVE To determinate the impact of comorbidity, resource use and cost (healthcare and lost productivity) on maintenance of remission of major depressive disorder in a Spanish population setting. METHODS We performed an observational, prospective, multicenter study using population databases. The inclusion criteria were age > or = 18 years, first depressive episode between January 2003 and March 2007, with antidepressant prescription >60 days after the first prescription and a follow-up of at least 18 months (study: 12 months; continuation: 6 months). Two subgroups were considered: patients with/without remission. MAIN MEASURES sociodemographic data, episodes, resource utilization bands, healthcare costs (direct) and lost productivity (indirect). Logistic regression and analysis of covariance (Bonferroni correction) were used for analysis. RESULTS A total of 4,572 patients were analyzed and 54.6% (95% confidence interval: 53.2-56.0%) were considered in remission. Patients in remission were younger (52.6 vs. 60.7), with a lower proportion of women (71.7% vs. 78.2%), and showed less general morbidity (6.2 vs. 7.7 episodes/year), lower resource utilization bands/year (2.7 vs. 3.0), fewer sick leave days (31.0 vs. 38.5) and shorter treatment duration (146.6 vs. 307.7 days); p<0.01. Lack of remission was associated with fibromyalgia (odds ratio [OR]=2.5), thyroid alterations (OR=1.3) and hypertension (OR=1.2); p<0.001. The annual healthcare cost was euro706.0 per patient in remission vs. euro1,108.3 without remission (p <0.001) and lost productivity was euro1,631.5 vs. euro2,024.2, respectively (p <0.001). CONCLUSIONS Patients not achieving remission showed higher morbidity, resources use, healthcare costs and, especially, productivity losses.

Cost analysis of adding pregabalin or gabapentin to the management of community‐treated patients with peripheral neuropathic pain

OBJECTIVE To compare the cost of adding either pregabalin or gabapentin to the management of community-treated patients with peripheral neuropathic pain (PNP). METHODS A retrospective observational study was conducted using medical records from a Spanish health care provider claims database. Patients receiving health care for PNP, above 18 years and for which either pregabalin or gabapentin was initiated between 2006 and 2008 were included. Economic evaluation included health care resource utilization costs and costs due to sick leave. RESULTS A total of 1163 patients with PNP were eligible for analysis: 764 were prescribed pregabalin and 399 gabapentin in addition to current pain therapy. Mean age was 59.2 years and 62.2% were female. Concomitant use of analgesics was higher in the gabapentin cohort (3.2 vs. 2.7; P = 0.003), mainly due to non-steroidal anti-inflammatory drugs (74.9% vs. 69.5%; P = 0.018) and opioids (27.7% vs. 17.9%; P = 0.031). Adjusted total costs per patient was lower in pregabalin-treated patients (€2514 vs. €3241; P = 0.003), due to less sick leave (€1067 vs. €1633; P = 0.018) and lower health care costs (€1447 vs. €1609; P = 0.004). The higher acquisition cost of pregabalin (€351 vs. €191; P < 0.001) was largely compensated with lower costs in medical visits, physiotherapy, hospital stays and concomitant analgesics. CONCLUSIONS In community-treated patients with PNP, total costs were considerably less for those patients initiated with pregabalin therapy than for those patients starting gabapentin add-on therapy. The relatively higher treatment acquisition cost of pregabalin was largely compensated by the overall lower costs for the other components of health care resources and sick leave, thus reducing the economic impact on the health care providers budget and society.

Clinical validity of a population database definition of remission in patients with major depression

BackgroundMajor depression (MD) is one of the most frequent diagnoses in Primary Care. It is a disabling illness that increases the use of health resources. Aim: To describe the concordance between remission according to clinical assessment and remission obtained from the computerized prescription databases of patients with MD in a Spanish population.MethodsDesign: multicenter cross-sectional. The population under study was comprised of people from six primary care facilities, who had a MD episode between January 2003 and March 2007. A specialist in psychiatry assessed a random sample of patient histories and determined whether a certain patient was in remission according to clinical criteria (ICPC-2). Regarding the databases, patients were considered in remission when they did not need further prescriptions of AD for at least 6 months after completing treatment for a new episode. Validity indicators (sensitivity [S], specificity [Sp]) and clinical utility (positive and negative probability ratio [PPR] and [NPR]) were calculated. The concordance index was established using Cohens kappa coefficient. Significance level was p < 0.05.Results133 patient histories were reviewed. The kappa coefficient was 82.8% (confidence intervals [CI] were 95%: 73.1 - 92.6), PPR 9.8% and NPR 0.1%. Allocation discrepancies between both criteria were found in 11 patients. S was 92.5% (CI was 95%: 88.0 - 96.9%) and Sp was 90.6% (CI was 95%: 85.6 - 95.6%), p < 0.001. Reliability analysis: Cronbachs alpha: 90.6% (CI was 95%: 85.6 - 95.6%).ConclusionsResults show an acceptable level of concordance between remission obtained from the computerized databases and clinical criteria. The major discrepancies were found in diagnostic accuracy.

Relationship between obesity and antipsychotic drug use in the adult population: a longitudinal, retrospective claim database study in Primary Care settings.

Objective To describe the association between obesity and the use of antipsychotic drugs (APDs) in adult outpatients followed-up on in five Primary Care settings. Methods A longitudinal, retrospective design study carried out between July 2004 and June 2005, in patients who were included in a claim database and for whom an APD treatment had been registered. A body mass index (BMI) <30 kg/m2 was defined as obesity. The main measurements were: use of APDs, demographics, medical background and co-morbidities, and clinical parameters. Logistic regression analysis and ANCOVA with Bonferroni adjustment were applied to correct the model. Results A total of 42,437 subjects (mean age: 50.8 (18.4) years; women: 54.5%; obesity: 27.3% [95% confidence intervals (CI), 26.9%–27.7%]) were analyzed. A total of 1.3% of the patients were receiving APDs, without statistical differences in distribution by type of drug (typical: 48.8%; atypical: 51.2%). Obesity was associated with the use of APDs [OR = 1.5 (CI: 1.3–1.8)], hypertension [OR = 2.4 (CI: 2.2–2.5)], diabetes [OR = 1.4 (CI: 1.3–1.5)] and dyslipidemia [OR = 1.3 (CI: 1.2–1.4)], p < 0.0001 in all cases. BMI was significantly higher in subjects on APDs; 28.8 vs. 27.3 kg/m2, p = 0.002, and remained higher after adjusting by age and sex (mean difference 0.4 (CI: 0.1–0.7), p < 0.01). After adjusting by age, sex and the Charlson index, obese subjects generated higher average annual total costs than nonobese subjects; 811 (CI: 787–835) vs. 694 (CI: 679–709), respectively, p < 0.001. Conclusions Obesity was associated with the use of APDs, regardless of the type of drug, and with the presence of hypertension, diabetes and dyslipidemia. Obesity was also associated with substantially higher health care costs.