Juan Cárdenas-Valladolid

Validation of diabetes mellitus and hypertension diagnosis in computerized medical records in primary health care

BackgroundComputerized Clinical Records, which are incorporated in primary health care practice, have great potential for research. In order to use this information, data quality and reliability must be assessed to prevent compromising the validity of the results.The aim of this study is to validate the diagnosis of hypertension and diabetes mellitus in the computerized clinical records of primary health care, taking the diagnosis criteria established in the most prominently used clinical guidelines as the gold standard against which what measure the sensitivity, specificity, and determine the predictive values.The gold standard for diabetes mellitus was the diagnostic criteria established in 2003 American Diabetes Association Consensus Statement for diabetic subjects. The gold standard for hypertension was the diagnostic criteria established in the Joint National Committee published in 2003.MethodsA cross-sectional multicentre validation study of diabetes mellitus and hypertension diagnoses in computerized clinical records of primary health care was carried out. Diagnostic criteria from the most prominently clinical practice guidelines were considered for standard reference.Sensitivity, specificity, positive and negative predictive values, and global agreement (with kappa index), were calculated. Results were shown overall and stratified by sex and age groups.ResultsThe agreement for diabetes mellitus with the reference standard as determined by the guideline was almost perfect (κ = 0.990), with a sensitivity of 99.53%, a specificity of 99.49%, a positive predictive value of 91.23% and a negative predictive value of 99.98%.Hypertension diagnosis showed substantial agreement with the reference standard as determined by the guideline (κ = 0.778), the sensitivity was 85.22%, the specificity 96.95%, the positive predictive value 85.24%, and the negative predictive value was 96.95%. Sensitivity results were worse in patients who also had diabetes and in those aged 70 years or over.ConclusionsOur results substantiate the validity of using diagnoses of diabetes and hypertension found within the computerized clinical records for epidemiologic studies.

Prevalence of adherence to treatment in homebound elderly people in primary health care: a descriptive, cross-sectional, multicentre study.

AbstractBackground Adherence to the therapeutic plan is one of the most important health issues in terms of treatment efficacy, healthcare costs and patient safety. Unfortunately, homebound elderly patients are especially vulnerable to nonadherence because they have higher morbidity rates combined with cognitive and social problems that hinder their correct use of drugs. The level of therapeutic adherence in homebound elderly people has not been adequately studied. Objective To estimate the prevalence of therapeutic adherence, using the Morisky-Green test, in homebound elderly patients taking polypharmacy (defined as use of four or more drugs), and to study the factors associated with adherence. Methods This was a descriptive, cross-sectional, multicentre study. A total of 327 patients were selected by random start systematic sampling from the total number of homebound patients taking four or more drugs in Healthcare Area 4 of the Madrid Autonomous Region, Spain. Through an in-home survey of patients and their caregivers, information was gathered on sociodemographic data, co-morbidities, number of hospital admissions, responsibility for purchasing and preparation of the medication, level of cognitive impairment (Pfeiffer questionnaire), functional dependence in activities of daily living (Katz Index), knowledge of the disease (Batalla test), adherence to treatment (Morisky-Green test), visual and auditory perception, and caregiver burden (Zarit interview). Results Of the homebound patients, 65.7% (95% CI 60.6, 70.9) had good adherence to treatment. The variables most negatively associated with therapeutic adherence, after adjustment for age, sex, number of drugs, knowledge of the disease, and cognitive function, were a large caregiver burden (odds ratio [OR] 3.09; 95% CI 1.75, 5.48) and impaired hearing (OR 2.00; 95% CI 1.17, 3.40). There was also a trend toward a positive association between nonadherence and patients aged >85 years (OR 1.57; 95% CI 0.93, 2.65) and patients who had nine or more drug prescriptions (OR 1.59; 95% CI 0.96, 2.65). Conclusions Poor therapeutic adherence in homebound elderly patients receiving polypharmacy is a serious problem affecting one of every three individuals concerned, and is directly related to caregiver burden, regardless of age, sex, cognitive status or number of drugs administered.

Trends in Hypertension Prevalence, Awareness, Treatment and Control in an Adult Type 2 Diabetes Spanish Population between 2003 and 2009

In patients with type 2 diabetes, the prevalence of hypertension is higher than in non-diabetic subjects. Despite the high cardiovascular risk involving hypertension in these patients, its prevalence and control are not well known. The aims of this study were: to estimate the hypertension prevalence, awareness, treatment and control in Spanish adults with type 2 diabetes attended in Primary Care; and to analyse its time trend from 2003 to 2009. A serial cross-sectional study from 2003 to 2009 was performed in 21 Primary Care Centres in Madrid. The study population comprised all patients with diagnosed type 2 diabetes in their computerised medical history. Overall annual prevalence during the period 2003–2009 was calculated from and according to sex and age groups. Linear trend tests, regression lines and coefficients of determination were used. In 2003 89.78% (CI 87.92–91.64) of patients with type 2 diabetes suffered hypertension and 94.76% (CI: 92.85–96.67) in 2009. This percentage was greater for women and for patients over 65 years old. 30% of patients suffered previously undiagnosed hypertension in 2003 and 23.1% in 2009. 97% of diagnosed patients received pharmacological treatment and 28.79% reached the blood pressure objective in 2009. The average number of antihypertensive drugs taken was 2.72 in 2003 and 3.27 in 2009. Only 5.2% of patients with type 2 diabetes show blood pressure levels below 130/80 mmHg. Although significant improvements have been achieved in the diagnosis and control of hypertension in people with type 2 diabetes, these continue to remain far from optimum.

Effectiveness of Standardized Nursing Care Plans in Health Outcomes in Patients with Type 2 Diabetes Mellitus: A Two-Year Prospective Follow-Up Study

Background Implementation of a standardized language in Nursing Care Plans (SNCP) allows for increased efficiency in nursing data management. However, the potential relationship with patientś health outcomes remains uncertain. The aim of this study was to evaluate the effectiveness of SNCP implementation, based on North American Nursing Diagnosis Association (NANDA) and Nursing Interventions Classification (NIC), in the improvement of metabolic, weight, and blood pressure control of Type 2 Diabetes Mellitus (T2DM) patients. Methods A two-year prospective follow-up study, in routine clinical practice conditions. 31 primary health care centers (Spain) participated with 24,124 T2DM outpatients. Data was collected from Computerized Clinical Records; SNCP were identified using NANDA and NIC taxonomies. Descriptive and ANCOVA analyses were conducted. Results 18,320 patients were identified in the Usual Nursing Care (UNC) group and 5,168 in the SNCP group. At the two-year follow-up, the SNCP group improved all parameters except LDL cholesterol and diastolic blood pressure. We analyzed data adjustming by the baseline value for these variables and variables with statistically significant differences between groups at baseline visit. Results indicated a lowering of all parameters except HbA1c, but a statistically significant reduction was only observed with diastolic blood pressure results. However, the adjusted reduction of diastolic blood pressure is of little clinical relevance. Greater differences of control values for diastolic blood pressure, HbA1c, LDL-cholesterol and Body Mass Index were found in the SNCP group, but only reached statistical significance for HbA1c. A greater proportion of patients with baseline HbA1c ≥7 decreased to <7% at the two-year follow-up in the SNCP group than in the UNC group (16.9% vs. 15%; respectively; p = 0.01). Conclusions Utilization of SNCP was helpful in achieving glycemic control targets in poorly controlled patients with T2DM (HbA1c ≥7%). Diastolic blood pressure results were slightly improved in the SNCP group compared to the UNC group. Trial Registration ClinicalTrials.gov NCT01482481

Effect of depression on mortality and cardiovascular morbidity in type 2 diabetes mellitus after 3 years follow up. The DIADEMA study protocol

BackgroundType 2 diabetes mellitus and depression are highly prevalent diseases that are associated with an increased risk of cardiovascular disease and mortality. There is evidence about a bidirectional association between depressive symptoms and type 2 diabetes mellitus. However, prognostic implications of the joint effects of these two diseases on cardiovascular morbidity and mortality are not well-known.Method/designA three-year, observational, prospective, cohort study, carried out in Primary Health Care Centres in Madrid (Spain). The project aims to analyze the effect of depression on cardiovascular events, all-cause and cardiovascular mortality in patients with type 2 diabetes mellitus, and to estimate a clinical predictive model of depression in these patients.The number of patients required is 3255, all them with type 2 diabetes mellitus, older than 18 years, who regularly visit their Primary Health Care Centres and agree to participate. They are chosen by simple random sampling from the list of patients with type 2 diabetes mellitus of each general practitioner.The main outcome measures are all-cause and cardiovascular mortality and cardiovascular morbidity; and exposure variable is the major depressive disorder.There will be a comparison between depressed and not depressed patients in all-cause mortality, cardiovascular mortality, coronary artery disease and stroke using the Chi-squared test. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors that might alter the effect recorded will be taken into account in this analysis. To assess the effect of depression on the mortality, a survival analysis will be used comparing the two groups using the log-rank test. The control of potential confounding variables will be performed by the construction of a Cox regression model.DiscussionOur study’s main contribution is to evaluate the increase in the risk of cardiovascular morbidity and mortality, in depressed Spanish adults with type 2 diabetes mellitus attended in Primary Health Care Setting. It would also be useful to identify subgroups of patients for which the interventions could be more beneficial.

Influenza vaccination in people with type 2 diabetes, coverage, predictors of uptake, and perceptions. Result of the MADIABETES cohort a 7years follow up study.

OBJECTIVES We aim to determine influenza vaccination uptake among people with diabetes included in the MADIABETES cohort study in order to identify predictors of uptake and to analyze reasons for adherence and non-adherence with vaccination. METHODS Using data from the MADIABETES Study we conducted a retrospective case record form based study without controls. We included outpatients with type 2 diabetes mellitus. Information was obtained from computerized clinical records and by telephone survey. The main dependent variables were influenza vaccination uptake in the year 2013 and the reason for receiving or refusing vaccination. RESULTS Overall, 65.7% had received the influenza vaccine in 2013. The mean number of influenza vaccines received from 2007 to 2013 was 3.24 (SD1.15), although 19.23% had not received any influenza vaccine and 23.3% had been vaccinated against pneumococcus. The variables that increased the probability of being vaccinated were inclusion in the age-based recommendation (⩾60years), having a chronic respiratory disease, previous pneumococcal vaccination, higher number of visits to the general practitioner, higher number of influenza vaccines, and longer time since diabetes diagnosis. A higher mean glycated haemoglobin value in 2013 was associated with a reduced probability of vaccination. Most patients (90%) agreed to be vaccinated following their physicians advice because of their age or their chronic conditions. The most common reason for refusal among men was the belief that they were not at risk (41.6% vs. 29.79% in women); the most common reason for refusal among women was fear of adverse reactions (32.53% vs. 20.23% in men). CONCLUSIONS The uptake of influenza vaccination among diabetic patients in the present study was below desirable levels. The main barrier to vaccination was lack of knowledge regarding the need for and risks and advantages of influenza vaccination. Healthcare professionals should educate and encourage influenza vaccination among people with diabetes.

Predictors of Adherence to Multiple Clinical Preventive Recommendations among Adults with Diabetes in Spain.

Objective This study aims to describe adherence to seven clinical preventive services among Spanish adults with diabetes, to compare adherence with people without diabetes and to identify predictor of adherence to multiple practices among adults with diabetes. Design Cross-sectional study based on data obtained from the European Health Survey for Spain 2009 and the Spanish National Health Survey 2011. We analyzed those aged 40-69 years (n= 20,948). Diabetes status was self-reported. The study variables included adherence to blood pressure (BP) checkup, cholesterol measurement, influenza vaccination, dental examination, fecal occult blood test (FOBT), mammography and cytology. Independent variables included socio-demographic characteristics, variables related to health status and lifestyle factors. Results The study sample included 1,647 subjects with diabetes and 19,301 without. Over 90% had measured their BP and cholesterol in the last year, 44.4% received influenza immunization, 36.4% had a dental checkup within the year and only 8.1% underwent a FOBT. Among diabetic women 75.4% had received a mammography and 52.4% a cytology in the recommended periods. The adherence to BP and cholesterol measurements and influenza vaccination was significantly higher among those suffering diabetes and cytology and dental checkup were lower. Only 63.4% of people with diabetes had fulfilled half or more of the recommended practices. Female sex, higher educational level, being married or cohabiting, higher number of chronic conditions and number of physician visits increased the adherence to multiple preventive practices. For each unhealthy lifestyle reported the probability of having a higher adherence level decreased. Conclusions Acceptable adherence is found for BP and cholesterol checkups and mammography. Unacceptably low rates were found for influenza vaccine, dental care, cytology and FOBT. Moreover, preventive services are provided neither equitably nor efficiently so future research needs to identify individual and organizational factors that allow interventions to reach these subjects with diabetes.

Trends in the Prevalence of Depression in Hospitalized Patients with Type 2 Diabetes in Spain: Analysis of Hospital Discharge Data from 2001 to 2011

Background This study aims to describe trends in the prevalence of depression among hospitalized patients with type 2 diabetes in Spain, 2001–2011. Methods We selected patients with a discharge diagnosis of type 2 diabetes using national hospital discharge data. Discharges were grouped by depression status. Prevalence of depression globally and according to primary diagnoses based on the Charlson comorbidity index (CCI) were analyzed. We calculated length of stay (LOHS) and in-hospital mortality (IHM). Multivariate analysis was adjusted by age, year and comorbidity. Results From 2001 to 2011, 4,723,338 discharges with type 2 diabetes were identified (4.93% with depression). Prevalence of depression in diabetic patients increased from 3.54% in 2001 to 5.80% in 2011 (p<0.05). The prevalence of depression was significantly higher in women than in men in each year studied and increased from 5.22% in 2001 to 9.24% in 2011 (p<0.01). The highest prevalence was observed in the youngest age group (35–59 years). The median LOHS decreased significantly over this period. Men with diabetes and depression had higher IHM than women in all the years studied (p<0.05). Older age and greater comorbidity were significantly associated with a higher risk of dying, among diabetic patients with concomitant depression. Conclusions Prevalence of depression increased significantly among hospitalized diabetic patients from 2001 to 2011 even if the health profile and LOHS have improved over this period. Programs targeted at preventing depression among persons with diabetes should be reinforced in Spain.

Body mass index and all-cause mortality among type 2 diabetes mellitus patients: Findings from the 5-year follow-up of the MADIABETES cohort

PURPOSE To analyse the association between body mass index (BMI) and all-cause mortality in a 5-year follow-up study with Spanish type 2 diabetes mellitus (T2DM) patients, seeking gender differences. METHODS 3443 T2DM outpatients were studied. At baseline and annually, patients were subjected to anamnesis, a physical examination, and biochemical tests. Data about demographic and clinical characteristics was also recorded, as was the treatment each patient had been prescribed. Mortality records were obtained from the Spanish National Institute of Statistics. Survival curves for BMI categories (Gehan-Wilcoxon test) and a multivariate Cox proportional hazard analysis were performed to identify adjusted Hazard Ratios (HRs) of mortality. RESULTS Mortality rate was 26.38 cases per 1000patient-years (95% CI, 23.92-29.01), with higher rates in men (28.43 per 1000patient-years; 95% CI, 24.87-32.36) than in women (24.31 per 1000patient-years; 95% CI, 21.02-27.98) (p=0.079). Mortality rates according to BMI categories were: 56.7 (95% CI, 40.8-76.6), 28.4 (95% CI, 22.9-34.9), 24.8 (95% CI, 21.5-28.5), 21 (95% CI, 16.3-26.6) and 23.7 (95% CI, 14.3-37) per 1000person-years for participants with a BMI of <23, 23-26.8, 26.9-33.1, 33.2-39.4, and >39.4kg/m2, respectively. The BMI values associated with the highest all-cause mortality were <23kg/m2, but only in males [HR: 2.78 (95% CI, 1.72-4.49; p<0.001)], since in females this association was not significant [HR: 1.14 (95% CI, 0.64-2.04; p=0.666)] (reference category for BMI: 23.0-26.8kg/m2). Higher BMIs were not associated with higher mortality rates. CONCLUSIONS In an outpatient T2DM Mediterranean population sample, low BMI predicted all-cause mortality only in males.

Standardized nursing care plans in patients with type 2 diabetes mellitus: Are they effective in the long-term?

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