Gender Predicts Differences in Acute Ischemic Cardioembolic Stroke Profile: Emphasis on Woman-Specific Clinical Data and Early Outcome-The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry.

Background and Objectives: Acute ischemic cardioembolic stroke (CS) is a clinical condition with a high risk of death, and can lead to dependence, recurrence, and dementia. Materials and Methods: In this study, we evaluated gender differences and female-specific clinical data and early outcomes in 602 women diagnosed with CS from a total of 4600 consecutive acute stroke patients in a single-center hospital stroke registry over 24 years. A comparative analysis was performed in women and men in terms of demographics, cerebrovascular risk factors, clinical data, and early outcomes. Results: In a multivariate analysis, age, hypertension, valvular heart disease, obesity, and internal capsule location were independent variables associated with CS in women. The overall in-hospital mortality rate was similar, but the group of women had a greater presence of neurological deficits and a higher percentage of severe limitation at hospital discharge. After the multivariate analysis, age, altered consciousness, limb weakness, and neurological, respiratory, gastrointestinal, renal, cardiac and peripheral vascular complications were independent predictors related to early mortality in women. Conclusions: Women with CS showed a differential demographic and clinical profile and worse early outcomes than men. Advanced age, impaired consciousness, and medical complications were predictors of stroke severity in women with CS.

Acute Spontaneous Lobar Cerebral Hemorrhages Present a Different Clinical Profile and a More Severe Early Prognosis than Deep Subcortical Intracerebral Hemorrhages-A Hospital-Based Stroke Registry Study.

Acute spontaneous intracerebral hemorrhage (ICH) is the most severe stroke subtype, with a high risk of death, dependence, and dementia. Knowledge about the clinical profile and early outcomes of ICH patients with lobar versus deep subcortical brain topography remains limited. In this study, we investigated the effects of ICH topography on demographics, cerebrovascular risk factors, clinical characteristics, and early outcomes in a sample of 298 consecutive acute ICH patients (165 with lobar and 133 with subcortical hemorrhagic stroke) available in a single-center-based stroke registry over 24 years. The multiple logistic regression analysis shows that variables independently associated with lobar ICH were early seizures (OR 6.81, CI 95% 1.27−5.15), chronic liver disease (OR 4.55, 95% CI 1.03−20.15), hemianopia (OR 2.55, 95% CI 1.26−5.15), headaches (OR 1.90, 95% CI 1.90, 95% IC 1.06−3.41), alcohol abuse (>80 gr/day) (OR 0−10, 95% CI 0.02−0,53), hypertension (OR 0,41, 95% CI 0.23−0−70), sensory deficit (OR 0.43, 95% CI 0.25−0.75), and limb weakness (OR: 0.47, 95% CI 0.24−0.93). The in-hospital mortality was 26.7% for lobar and 16.5% for subcortical ICH. The study confirmed that the clinical spectrum, prognosis, and early mortality of patients with ICH depend on the site of bleeding, with a more severe early prognosis in lobar intracerebral hemorrhage.

Vertigo in Acute Stroke Is a Predictor of Brain Location but Is Not Related to Early Outcome: The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry.

BACKGROUND: Vertigo is an uncommon symptom among acute stroke victims. Knowledge about the clinical profile, the brain location, and the early outcome in stroke patients with cerebrovascular diseases and vertigo remains limited. OBJECTIVES: In this study, the effects of vertigo on cerebral topography and early prognosis in cerebrovascular diseases were investigated. METHODS: A comparative analysis in terms of demographics, risk factors, clinical characteristics, stroke subtypes, cerebral and vascular topography, and early outcome was performed between patients with presence or absence of vertigo on a sample of 3743 consecutive acute stroke patients available from a 24-year ongoing single-center hospital-based stroke registry. RESULTS: Vertigo was present in 147 patients (3.9%). Multiple logistic regression analysis showed that variables independently associated with vertigo were: location in the cerebellum (OR 5.59, CI 95% 3.24-9.64), nausea or vomiting (OR 4.48, CI 95% 2.95-6.82), medulla (OR 2.87, CI 95% 1.31-6.30), pons (OR 2.39, CI 95% 1.26-4.51), basilar artery (OR 2.36, CI 95% 1.33-4.17), ataxia (OR 2.33, CI 95% 1.41-3.85), and headache (OR 2.31, CI 95% 1.53-3.49). CONCLUSION: The study confirmed that the presence of vertigo was not related with increased in-hospital mortality or poor prognosis at hospital discharge. Vertigo is mainly related to non-lacunar vertebrobasilar stroke with topographic localization in the cerebellum and/or brainstem.

Development and validation of a population-based risk stratification model for severe COVID-19 in the general population.

The shortage of recently approved vaccines against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has highlighted the need for evidence-based tools to prioritize healthcare resources for people at higher risk of severe coronavirus disease (COVID-19). Although age has been identified as the most important risk factor (particularly for mortality), the contribution of underlying comorbidities is often assessed using a pre-defined list of chronic conditions. Furthermore, the count of individual risk factors has limited applicability to population-based "stratify-and-shield" strategies. We aimed to develop and validate a COVID-19 risk stratification system that allows allocating individuals of the general population into four mutually-exclusive risk categories based on multivariate models for severe COVID-19, a composite of hospital admission, transfer to intensive care unit (ICU), and mortality among the general population. The model was developed using clinical, hospital, and epidemiological data from all individuals among the entire population of Catalonia (North-East Spain; 7.5 million people) who experienced a COVID-19 event (i.e., hospitalization, ICU admission, or death due to COVID-19) between March 1 and September 15, 2020, and validated using an independent dataset of 218,329 individuals with COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR), who were infected after developing the model. No exclusion criteria were defined. The final model included age, sex, a summary measure of the comorbidity burden, the socioeconomic status, and the presence of specific diagnoses potentially associated with severe COVID-19. The validation showed high discrimination capacity, with an area under the curve of the receiving operating characteristics of 0.85 (95% CI 0.85-0.85) for hospital admissions, 0.86 (0.86-0.97) for ICU transfers, and 0.96 (0.96-0.96) for deaths. Our results provide clinicians and policymakers with an evidence-based tool for prioritizing COVID-19 healthcare resources in other population groups aside from those with higher exposure to SARS-CoV-2 and frontline workers.

Performance of Three Measures of Comorbidity in Predicting Critical COVID-19: A Retrospective Analysis of 4607 Hospitalized Patients.

BACKGROUND: Comorbidity burden has been identified as a relevant predictor of critical illness in patients hospitalized with coronavirus disease 2019 (COVID-19). However, comorbidity burden is often represented by a simple count of few conditions that may not fully capture patients' complexity. PURPOSE: To evaluate the performance of a comprehensive index of the comorbidity burden (Queralt DxS), which includes all chronic conditions present on admission, as an adjustment variable in models for predicting critical illness in hospitalized COVID-19 patients and compare it with two broadly used measures of comorbidity. MATERIALS AND METHODS: We analyzed data from all COVID-19 hospitalizations reported in eight public hospitals in Catalonia (North-East Spain) between June 15 and December 8 2020. The primary outcome was a composite of critical illness that included the need for invasive mechanical ventilation, transfer to ICU, or in-hospital death. Predictors including age, sex, and comorbidities present on admission measured using three indices: the Charlson index, the Elixhauser index, and the Queralt DxS index for comorbidities on admission. The performance of different fitted models was compared using various indicators, including the area under the receiver operating characteristics curve (AUROCC). RESULTS: Our analysis included 4607 hospitalized COVID-19 patients. Of them, 1315 experienced critical illness. Comorbidities significantly contributed to predicting the outcome in all summary indices used. AUC (95% CI) for prediction of critical illness was 0.641 (0.624-0.660) for the Charlson index, 0.665 (0.645-0.681) for the Elixhauser index, and 0.787 (0.773-0.801) for the Queralt DxS index. Other metrics of model performance also showed Queralt DxS being consistently superior to the other indices. CONCLUSION: In our analysis, the ability of comorbidity indices to predict critical illness in hospitalized COVID-19 patients increased with their exhaustivity. The comprehensive Queralt DxS index may improve the accuracy of predictive models for resource allocation and clinical decision-making in the hospital setting.

Performance of quantitative measures of multimorbidity: a population-based retrospective analysis.

BACKGROUND: Multimorbidity measures are useful for resource planning, patient selection and prioritization, and factor adjustment in clinical practice, research, and benchmarking. We aimed to compare the explanatory performance of the adjusted morbidity group (GMA) index in predicting relevant healthcare outcomes with that of other quantitative measures of multimorbidity. METHODS: The performance of multimorbidity measures was retrospectively assessed on anonymized records of the entire adult population of Catalonia (North-East Spain). Five quantitative measures of multimorbidity were added to a baseline model based on age, gender, and socioeconomic status: the Charlson index score, the count of chronic diseases according to three different proposals (i.e., the QOF, HCUP, and Karolinska institute), and the multimorbidity index score of the GMA tool. Outcomes included all-cause death, total and non-scheduled hospitalization, primary care and ER visits, medication use, admission to a skilled nursing facility for intermediate care, and high expenditure (time frame 2017). The analysis was performed on 10 subpopulations: all adults (i.e., aged > 17 years), people aged > 64 years, people aged > 64 years and institutionalized in a nursing home for long-term care, and people with specific diagnoses (e.g., ischemic heart disease, cirrhosis, dementia, diabetes mellitus, heart failure, chronic kidney disease, and chronic obstructive pulmonary disease). The explanatory performance was assessed using the area under the receiving operating curves (AUC-ROC) (main analysis) and three additional statistics (secondary analysis). RESULTS: The adult population included 6,224,316 individuals. The addition of any of the multimorbidity measures to the baseline model increased the explanatory performance for all outcomes and subpopulations. All measurements performed better in the general adult population. The GMA index had higher performance and consistency across subpopulations than the rest of multimorbidity measures. The Charlson index stood out on explaining mortality, whereas measures based on exhaustive definitions of chronic diagnostic (e.g., HCUP and GMA) performed better than those using predefined lists of diagnostics (e.g., QOF or the Karolinska proposal). CONCLUSIONS: The addition of multimorbidity measures to models for explaining healthcare outcomes increase the performance. The GMA index has high performance in explaining relevant healthcare outcomes and may be useful for clinical practice, resource planning, and public health research.

Impacto clínico y en costes sanitarios de alteraciones de potasio en pacientes con enfermedades cardiovasculares, metabólicas y renales crónicas / Impact on clinical outcomes and health costs of deranged potassium levels in patients with chronic cardiovascular, metabolic, and renal conditions

Introducción y objetivos Las alteraciones de la potasemia son frecuentes en las enfermedades cardiovasculares crónicas. El objetivo del estudio es evaluar las asociaciones de la hiperpotasemia y la hipopotasemia con eventos clínicos y costes sanitarios en pacientes con insuficiencia cardiaca, enfermedad renal crónica, diabetes mellitus, hipertensión y cardiopatía isquémica. Métodos Estudio longitudinal que incluyó a 36.269 pacientes de un Área de Salud que tuvieran al menos una de las afecciones mencionadas. Se utilizaron bases de datos administrativas, hospitalarias y de atención primaria. Se siguió a los participantes entre 2015 y 2017; estos tenían 55 o más años y al menos 1 medición de potasio. Se utilizaron 4 diseños analíticos para evaluar la prevalencia y la incidencia y el uso de inhibidores del sistema renina-angiotensina-aldosterona. Resultados La hiperpotasemia fue 2 veces más frecuente que la hipopotasemia. En los análisis ajustados, la hiperpotasemia se asoció de manera significativa con un mayor riesgo de muerte por todas las causas (HR de los modelos de regresión de Cox entre 1,31 y 1,68) y con un aumento de las probabilidades de que los gastos anuales de atención sanitaria superen el 85% (OR entre 1,21 y 1,29). Las asociaciones fueron aún mayores en los pacientes hipopotasémicos (HR para la muerte por todas las causas, 1,92-2,60; OR para los gastos de atención sanitaria> percentil 85, 1,81-1,85). Conclusiones Se necesitarían estudios experimentales para confirmar si la prevención de los trastornos del potasio reduce la mortalidad y los gastos sanitarios en estas enfermedades crónicas. Hasta entonces, nuestros hallazgos proporcionan conclusiones observacionales sobre la importancia de mantener normales las concentraciones de potasio. (AU)

Introduction and objectives Potassium derangements are frequent among patients with chronic cardiovascular conditions. Studies on the associations between potassium derangements and clinical outcomes have yielded mixed findings, and the implications for health care expenditure are unknown. We assessed the population-based associations between hyperkalemia, hypokalemia and clinical outcomes and health care costs, in patients with chronic heart failure, chronic kidney disease, diabetes mellitus, hypertension, and ischemic heart disease. Methods Population-based, longitudinal study including up to 36 269 patients from a health care area with at least one of the above-mentioned conditions. We used administrative, hospital and primary care databases. Participants were followed up between 2015 and 2017, were aged ≥ 55 years and had at least 1 potassium measurement. Four analytic designs were used to evaluate prevalent and incident cases and the use of renin-angiotensin-aldosterone system inhibitors. Results Hyperkalemia was twice as frequent as hypokalemia. On multivariable-adjusted analyses, hyperkalemia was robustly and significantly associated with an increased risk of all-cause death (HR from Cox regression models ranging from 1.31–1.68) and with an increased odds of a yearly health care expenditure >85th percentile (OR, 1.21–1.29). Associations were even stronger in hypokalemic patients (HR for all-cause death, 1.92–2.60; OR for health care expenditure> percentile 85th, 1.81–1.85). Conclusions Experimental studies are needed to confirm whether the prevention of potassium derangements reduces mortality and health care expenditure in these chronic conditions. Until then, our findings provide observational evidence on the potential importance of maintaining normal potassium levels. (AU)

Cardioembolic stroke: risk factors, clinical features, and early outcome in 956 consecutive patients

ABSTRACT Background: There is little information about the early clinical features of cardioembolic stroke before complementary examinations. Objective: The aim of this study was to identify risk factors, clinical features, and early outcomes of cardioembolic stroke. Methods: Retrospective study based on prospectively collected data available from a university medical center hospital-based stroke registry. Consecutive patients diagnosed with cardioembolic infarction were selected and compared to those diagnosed with an atherothrombotic stroke. Predictors of cardioembolic infarction were assessed by multivariate analysis. Results: From a cohort of 4597 consecutive patients, we studied 956 patients diagnosed with cardioembolic infarction (80 years [standard deviation (SD) 9.14]; 63% women) and 945 with atherothrombotic infarction (77.01 years [SD 9.75]; 49.8% women). The univariate comparative analysis reported that advanced age (≥ 85 years), female gender, atrial fibrillation (AF), ischemic heart disease, and congestive heart failure were significantly more frequent in the cardioembolic group, whereas hypertension, diabetes, peripheral vascular disease, heavy smoking, hyperlipidemia, and previous transient ischemic attack were significant in the atherothrombotic group. In the logistic regression model, AF (odds ratio [OR] 15.75, 95% confidence interval [CI]: 12.14-20.42), ischemic heart disease (OR 3.12, 95% CI: 2.16-4.5), female gender (OR 1.56, 95% CI: 1.22-2.00), and sudden-onset (OR 1.97, 95% CI: 1.54-2.51), were independent significant predictors of cardioembolic stroke. Conclusions: Potential cardioembolic stroke requires a comprehensive evaluation, since early classification and identification through predictors would improve effective management. (REV INVEST CLIN. 2021;73(1):23-30)

Impact on clinical outcomes and health costs of deranged potassium levels in patients with chronic cardiovascular, metabolic, and renal conditions.

INTRODUCTION AND OBJECTIVES: Potassium derangements are frequent among patients with chronic cardiovascular conditions. Studies on the associations between potassium derangements and clinical outcomes have yielded mixed findings, and the implications for health care expenditure are unknown. We assessed the population-based associations between hyperkalemia, hypokalemia and clinical outcomes and health care costs, in patients with chronic heart failure, chronic kidney disease, diabetes mellitus, hypertension, and ischemic heart disease. METHODS: Population-based, longitudinal study including up to 36 269 patients from a health care area with at least one of the above-mentioned conditions. We used administrative, hospital and primary care databases. Participants were followed up between 2015 and 2017, were aged ≥ 55 years and had at least 1 potassium measurement. Four analytic designs were used to evaluate prevalent and incident cases and the use of renin-angiotensin-aldosterone system inhibitors. RESULTS: Hyperkalemia was twice as frequent as hypokalemia. On multivariable-adjusted analyses, hyperkalemia was robustly and significantly associated with an increased risk of all-cause death (HR from Cox regression models ranging from 1.31-1.68) and with an increased odds of a yearly health care expenditure >85th percentile (OR, 1.21-1.29). Associations were even stronger in hypokalemic patients (HR for all-cause death, 1.92-2.60; OR for health care expenditure> percentile 85th, 1.81-1.85). CONCLUSIONS: Experimental studies are needed to confirm whether the prevention of potassium derangements reduces mortality and health care expenditure in these chronic conditions. Until then, our findings provide observational evidence on the potential importance of maintaining normal potassium levels.

Temporal trend of cardiorespiratory endurance in urban Catalan high school students over a 20 year period.

BACKGROUND: Physical fitness is considered an important indicator of health in adolescents. However, in recent years several studies in the scientific literature have shown a considerable lower trend and an alarming worsening of the current adolescents' physical condition when comparing with previous decades, especially in urban populations. The aim of the current study was to analyse the temporal trend in cardiorespiratory endurance (CRE) in urban Catalan adolescents over a 20-year period (1999-2019). METHODS: A cross-sectional analysis study considering the 20-m Shuttle Run test (SRT) results obtained in the last 20 years was carried out. 1,701 adolescents between 15 and 16 years old (914 boys and 787 girls) were divided into four groups, corresponding to consecutive periods of five years (Group 1: 1999-2004; Group 2: 2005-2009; Group 3: 2010-2014 and Group 4: 2015-2019). ANOVA was used to test the period effect on CRE and post hoc Bonferroni analysis was performed to test pairwise differences between groups (p < 0.05). RESULTS: Results showed a significantly lower performance in CRE in both sexes. The percentual negative difference was 0.67%, 9.6% and 7% for boys and 5.06%, 14.97% and 9.41% for girls, when comparing the performance in 20-m Shuttle Run test for the first period, respectively. CONCLUSIONS: Results suggest that the physical fitness of Catalan urban adolescents is lower in both sexes when comparing the different analysed periods of time. Therefore, CRE adolescents should be improved in order to help to protect against cardiovascular disease and other health risks in adulthood.

Cardioembolic Stroke: Risk Factors, Clinical Features, and Early Outcome in 956 Consecutive Patients.

BACKGROUND: There is little information about the early clinical features of cardioembolic stroke before complementary examinations. OBJECTIVE: The aim of this study was to identify risk factors, clinical features, and early outcomes of cardioembolic stroke. METHODS: Retrospective study based on prospectively collected data available from a university medical center hospitalbased stroke registry. Consecutive patients diagnosed with cardioembolic infarction were selected and compared to those diagnosed with an atherothrombotic stroke. Predictors of cardioembolic infarction were assessed by multivariate analysis. RESULTS: From a cohort of 4597 consecutive patients, we studied 956 patients diagnosed with cardioembolic infarction (80 years [standard deviation (SD) 9.14]; 63% women) and 945 with atherothrombotic infarction (77.01 years [SD 9.75]; 49.8% women). The univariate comparative analysis reported that advanced age (≥ 85 years), female gender, atrial fibrillation (AF), ischemic heart disease, and congestive heart failure were significantly more frequent in the cardioembolic group, whereas hypertension, diabetes, peripheral vascular disease, heavy smoking, hyperlipidemia, and previous transient ischemic attack were significant in the atherothrombotic group. In the logistic regression model, AF (odds ratio [OR] 15.75, 95% confidence interval [CI]: 12.14-20.42), ischemic heart disease (OR 3.12, 95% CI: 2.16-4.5), female gender (OR 1.56, 95% CI: 1.22-2.00), and sudden-onset (OR 1.97, 95% CI: 1.54-2.51), were independent significant predictors of cardioembolic stroke. CONCLUSIONS: Potential cardioembolic stroke requires a comprehensive evaluation, since early classification and identification through predictors would improve effective management.

Real-World Epidemiology of Potassium Derangements Among Chronic Cardiovascular, Metabolic and Renal Conditions: A Population-Based Analysis.

BACKGROUND: The aims of the present analysis are to estimate the prevalence of five key chronic cardiovascular, metabolic and renal conditions at the population level, the prevalence of renin-angiotensin-aldosterone system inhibitor (RAASI) medication use and the magnitude of potassium (K+) derangements among RAASI users. METHODS AND RESULTS: We used data from more than 375,000 individuals, 55 years of age or older, included in the population-based healthcare database of the Catalan Institute of Health between 2015 and 2017. The conditions of interest were chronic heart failure (CHF), chronic kidney disease (CKD), diabetes mellitus, ischemic heart disease and hypertension. RAASI medications included angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists (MRAs) and renin inhibitors. Hyperkalemia was defined as K+ levels >5.0 mEq/L and hypokalemia as K+ <3.5 mEq/L. The prevalence of chronic cardiovascular, metabolic and renal conditions was high, and particularly that of hypertension (prevalence ranging from 48.2% to 48.9%). The use of at least one RAASI medication was almost ubiquitous in these patients (75.2-77.3%). Among RAASI users, the frequency of K+ derangements, mainly of hyperkalemia, was very noticeable (12% overall), particularly in patients with CKD or CHF, elderly individuals and users of MRAs. Hypokalemia was less frequent (1%). CONCLUSION: The high prevalence of K+ derangements, and particularly hyperkalemia, among RAASI users highlights the real-world relevance of K+ derangements, and the importance of close monitoring and management of K+ levels in routine clinical practice. This is likely to benefit a large number of patients, particularly those at higher risk.

Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak.

Digital health technologies offer significant opportunities to reshape current health care systems. From the adoption of electronic medical records to mobile health apps and other disruptive technologies, digital health solutions have promised a better quality of care at a more sustainable cost. However, the widescale adoption of these solutions is lagging behind. The most adverse scenarios often provide an opportunity to develop and test the capacity of digital health technologies to increase the efficiency of health care systems. Catalonia (Northeast Spain) is one of the most advanced regions in terms of digital health adoption across Europe. The region has a long tradition of health information exchange in the public health care sector and is currently implementing an ambitious digital health strategy. In this viewpoint, we discuss the crucial role digital health solutions play during the coronavirus disease (COVID-19) pandemic to support public health policies. We also report on the strategies currently deployed at scale during the outbreak in Catalonia.

Performance of Comprehensive Risk Adjustment for the Prediction of In-Hospital Events Using Administrative Healthcare Data: The Queralt Indices.

BACKGROUND: Accurate risk adjustment is crucial for healthcare management and benchmarking. PURPOSE: We aimed to compare the performance of classic comorbidity functions (Charlson's and Elixhauser's), of the All Patients Refined Diagnosis Related Groups (APR-DRG), and of the Queralt Indices, a family of novel, comprehensive comorbidity indices for the prediction of key clinical outcomes in hospitalized patients. MATERIAL AND METHODS: We conducted an observational, retrospective cohort study using administrative healthcare data from 156,459 hospital discharges in Catalonia (Spain) during 2018. Study outcomes were in-hospital death, long hospital stay, and intensive care unit (ICU) stay. We evaluated the performance of the following indices: Charlson's and Elixhauser's functions, Queralt's Index for secondary hospital discharge diagnoses (Queralt DxS), the overall Queralt's Index, which includes pre-existing comorbidities, in-hospital complications, and principal discharge diagnosis (Queralt Dx), and the APR-DRG. Discriminative ability was evaluated using the area under the curve (AUC), and measures of goodness of fit were also computed. Subgroup analyses were conducted by principal discharge diagnosis, by age, and type of admission. RESULTS: Queralt DxS provided relevant risk adjustment information in a larger number of patients compared to Charlson's and Elixhauser's functions, and outperformed both for the prediction of the 3 study outcomes. Queralt Dx also outperformed Charlson's and Elixhauser's indices, and yielded superior predictive ability and goodness of fit compared to APR-DRG (AUC for in-hospital death 0.95 for Queralt Dx, 0.77-0.93 for all other indices; for ICU stay 0.84 for Queralt Dx, 0.73-0.83 for all other indices). The performance of Queralt DxS was at least as good as that of the APR-DRG in most principal discharge diagnosis subgroups. CONCLUSION: Our findings suggest that risk adjustment should go beyond pre-existing comorbidities and include principal discharge diagnoses and in-hospital complications. Validation of comprehensive risk adjustment tools such as the Queralt indices in other settings is needed.

Validación clínica de 2 agrupadores de morbilidad en el ámbito de atención primaria / Clinical validation of 2 morbidity groups in the primary care setting

INTRODUCCIÓN: Los grupos de morbilidad ajustados (GMA) y los clinical risk groups (CRG) son herramientas de estratificación poblacional basada en la morbilidad que permiten clasificar a los pacientes en categorías mutuamente excluyentes. OBJETIVO: Comparar la estratificación, según niveles de complejidad, proporcionada por los GMA con la de los CRG y con la realizada ad-hoc por los evaluadores. DISEÑO: Muestra aleatoria por estratos de riesgo de morbilidad. Emplazamiento: Cataluña. PARTICIPANTES: Cuarenta médicos de atención primaria emparejados 2 a 2. INTERVENCIONES: Cada pareja de evaluadores tuvo que validar 25 historias. Mediciones principales: Se evaluó la concordancia entre evaluadores, y entre los evaluadores y los resultados obtenidos por los 2 agrupadores de morbilidad con el índice kappa, la sensibilidad, la especificidad, el valor predictivo positivo y el negativo. RESULTADOS: La concordancia entre evaluadores se situó alrededor del valor kappa 0,75 (valor medio = 0,67), entre los GMA y los evaluadores fue similar (valor medio = 0,63), y más elevada que para los CRG (valor medio = 0,35). Los profesionales otorgaron una puntuación de 7,5 a la bondad de ambos agrupadores, aunque para los estratos de mayor complejidad, según asignación de los profesionales, los GMA obtuvieron mejores puntuaciones que los CRG. Los profesionales prefirieron mayoritariamente los GMA frente a los CRG. Estas diferencias se incrementaron con el aumento de la complejidad de los pacientes según el criterio clínico. Globalmente, se encontró menos de un 2% de errores graves de clasificación proporcionada por ambos agrupadores. CONCLUSIÓN: Los profesionales consideraron que ambos agrupadores clasificaban adecuadamente a la población, aunque los GMA tienen un mejor comportamiento en los estratos que los profesionales identifican como de mayor complejidad. Además, en la mayoría de los casos, los evaluadores clínicos prefirieron los GMA

INTRODUCTION: Adjusted Morbidity Groups (GMAs) and the Clinical Risk Groups (CRGs) are population morbidity based stratification tools which classify patients into mutually exclusive categories. Objetive: To compare the stratification provided by the GMAs, CRGs and that carried out by the evaluators according to the levels of complexity. DESIGN: Random sample stratified by morbidity risk. LOCATION: Catalonia. PARTICIPANTS: Forty paired general practitioners in the primary care, matched pairs. INTERVENTIONS: Each pair of evaluators had to review 25 clinical records. Main outputs: The concordance by evaluators, and between the evaluators and the results obtained by the 2 morbidity tools were evaluated according to the kappa index, sensitivity, specificity, and positive and negative predicted values. RESULTS: The concordance between general practitioners pairs was around the kappa value 0.75 (mean value = 0.67), between the GMA and the evaluators was similar (mean value = 0.63), and higher than for the CRG (mean value = 0.35). The general practitioners gave a score of 7.5 over 10 to both tools, although for the most complex strata, according to the professionals' assignment, the GMA obtained better scores than the CRGs. The professionals preferred the GMAs over the CRGs. These differences increased with the complexity level of the patients according to clinical criteria. Overall, less than 2% of serious classification errors were found by both groupers. CONCLUSION: The evaluators considered that both grouping systems classified the studied population satisfactorily, although the GMAs showed a better performance for more complex strata. In addition, the clinical raters preferred the GMAs in most cases

[Clinical validation of 2 morbidity groups in the primary care setting]. / Validación clínica de 2 agrupadores de morbilidad en el ámbito de atención primaria.

INTRODUCTION: Adjusted Morbidity Groups (GMAs) and the Clinical Risk Groups (CRGs) are population morbidity based stratification tools which classify patients into mutually exclusive categories. OBJETIVE: To compare the stratification provided by the GMAs, CRGs and that carried out by the evaluators according to the levels of complexity. DESIGN: Random sample stratified by morbidity risk. LOCATION: Catalonia. PARTICIPANTS: Forty paired general practitioners in the primary care, matched pairs. INTERVENTIONS: Each pair of evaluators had to review 25 clinical records. MAIN OUTPUTS: The concordance by evaluators, and between the evaluators and the results obtained by the 2 morbidity tools were evaluated according to the kappa index, sensitivity, specificity, and positive and negative predicted values. RESULTS: The concordance between general practitioners pairs was around the kappa value 0.75 (mean value=0.67), between the GMA and the evaluators was similar (mean value=0.63), and higher than for the CRG (mean value=0.35). The general practitioners gave a score of 7.5 over 10 to both tools, although for the most complex strata, according to the professionals' assignment, the GMA obtained better scores than the CRGs. The professionals preferred the GMAs over the CRGs. These differences increased with the complexity level of the patients according to clinical criteria. Overall, less than 2% of serious classification errors were found by both groupers. CONCLUSION: The evaluators considered that both grouping systems classified the studied population satisfactorily, although the GMAs showed a better performance for more complex strata. In addition, the clinical raters preferred the GMAs in most cases.

Predictive clinical features of cardioembolic infarction in patients aged 85 years and older.

OBJECTIVE: To assess predictive clinical factors of cardioembolic infarction in very old patients (85 years of age and older). METHODS: Prospective hospital-based stroke registry ("The Sagrat Cor Hospital of Barcelona Stroke Registry") is an acute-care teaching hospital in Barcelona, Catalonia, Spain. From 956 first-ever cardioembolic stroke patients included in the stroke registry over a 24-year period, 639 were younger than 85 years of age and 317 were 85 years or older (mean age: 88.9 years). Demographics, clinical characteristics, risk factors and early outcome were compared. Predictors of cardioembolic infarction in the oldest age group were assessed by multivariate analyses. RESULTS: In a logistic regression model based on demographics, risk factors, clinical features and complications, female gender (odds ratio [OR] = 1.74, 95% confidence interval [CI]: 1.27-2.39), heart failure (OR = 2.27, 95% CI: 1.46-3.56), altered consciousness (OR = 1.76, 95% CI: 1.28-2.42), and infectious complications (OR = 2.01, 95% CI: 1.39-2.91) were predictors of cardioembolic stroke in the oldest age group. By contrast, heavy smoking, heart valve disease, hypertension, headache, early seizures, sensory deficit, and involvement of the posterior cerebral artery were independently associated with cardioembolic stroke in the younger group. CONCLUSIONS: Identification of a differential clinical profile of cardioembolic stroke between patients aged 85 years or more and those younger than 85 years helps clinicians to the optimal management of ischemic infarction in the oldest segment of the population.

Five-Year Incidence of Hospital-Based Emergencies Related to Acute Recreational Intoxication in Minors.

BACKGROUND: Alcohol or other drug (AOD) intoxication in minors is a public health challenge. We characterized underage patients admitted to an emergency department (ED) with acute, recreational AOD intoxication. METHODS: We conducted a 5-year (2012 to 2016) analysis of minors admitted to the only hospital-based pediatric ED in an urban area. Episodes of AOD intoxication were selected using ICD-9-CM diagnostic codes. Sociodemographics, substance use and clinical characteristics, laboratory parameters, and discharge dispositions were collected through the revision of clinical charts. RESULTS: A total of 266 admissions related to recreational AOD intoxication in 258 patients occurred during the study period. Among the 258 patients, 127 (49.2%) were men, median age 16 years [IQR: 15 to 17 years], and 234 (90.7%) of episodes were alcohol-related. At admission, 202/256 (78.9%) patients had a Glasgow Coma Scale ≥ 13 points, the median systolic and diastolic blood pressure was 109 mmHg (IQR: 101 to 118 mmHg) and 67 mmHg (IQR: 60 to 73 mmHg), respectively, and the median blood glucose level was 112 mg/dl (IQR: 99 to 127 mg/dl). Only 72/258 (27.9%) patients underwent urine screening (22/72 (30.5%) were positive for cannabis), and only 30/258 (11.6%) were tested for blood ethanol (median: 185 mg/dl, IQR: 163 to 240 mg/dl). There was a trend in admissions occurring early in the morning of weekend days, and 249 (96.5%) patients were discharged home the day of admission. CONCLUSIONS: Though the severity of AOD intoxication seems to be mild to moderate, assessment of substance exposure is low and may underestimate polydrug use in underage populations.

Optimización de la gestión del dolor postoperatorio basado en una nueva herramienta tecnológica. Mapa del dolor / Optimization of postoperative pain management based on a new technological tool. Pain map

Introducción: En el año 2005 el Ministerio de Sanidad, Servicios Sociales e Igualdad (MSSSI) impulsó y promovió la Estrategia de Seguridad del Paciente del Sistema Nacional de Salud (SNS), en colaboración con las comunidades autónomas, que integraba las aportaciones de los profesionales sanitarios y de los pacientes a través de sus organizaciones. Uno de los objetivos de las prácticas seguras era la necesidad de prevención y control del dolor en el adulto y en el niño, incluyéndose la gestión de este en los estándares de calidad. En el Hospital Universitario Germans Trias i Pujol (HUGTIP), en el año 2016 se inició la elaboración de los indicadores que se querían evaluar para una mejor detección y eficiencia terapéutica del dolor agudo intrahospitalario de cualquier área y que finalizó con el diseño y creación de lo que denominamos "Mapa del dolor". El objetivo fue diseñar una herramienta que, a través de la variable clínica dolor, permitiera mejorar la visualización de esta y extraer los datos estadísticos de los indicadores defi nidos para una óptima gestión del dolor dentro de un hospital universitario de tercer nivel. Material y método: Análisis descriptivo de la herramienta que denominamos "Mapa del dolor" en el Hospital Universitario Germans Trias i Pujol (HUGTiP) durante el año 2016. Se incluyeron todos los pacientes ingresados en los que el registro de dolor se realizó a través de la historia clínica informatizada GacelaCare(R). Considerando el dolor como 5.ª constante, la variable principal fue el registro de la intensidad del dolor mediante la escala visual analógica (EVA) o escala verbal numérica (EVN) en cada turno de enfermería. El procedimiento de creación de la herramienta para la elaboración del denominado "Mapa del dolor" se realizó con la colaboración del Departamento de Sistemas de Información del HUGTiP, junto con miembros de la Unidad del Dolor. Resultados: El "Mapa del dolor" se fundamenta en el registro de la intensidad del dolor mediante la escala visual analógica (EVA) o escala verbal numérica (EVN) por turno de enfermería, acción previa imprescindible por parte de enfermería. Permite visualizar en la pantalla los registros de la intensidad del dolor de todos los pacientes hospitalizados de manera simultánea y en tiempo real. El "Mapa del dolor" identifi ca los registros con distintos colores a modo de semáforo del dolor, en color verde marca los valores de EVN entre 1-3 (dolor leve), en color naranja EVN entre 4-6 (dolor moderado) y en color rojo EVN entre 7-10 (dolor intenso); asimismo señala con una franja de color morado aquellos pacientes operados el día anterior, facilitando el control del dolor durante las primeras 24 horas postoperatorias. La explotación estadística de los registros informatizados de dolor permite obtener resultados de los indicadores relacionados con su gestión, previamente defi nidos por nuestro hospital. Discusión: El "Mapa del dolor" es una herramienta innovadora que permite desarrollar con garantías la efi ciencia de las unidades de dolor agudo de bajo coste

Introduction: In 2005, the Ministry of Health, Social Services and Equality (MSSSI) promoted the Patient Safety Strategy of the National Health System (SNS), in collaboration with the Autonomous Communities, which integrated the contributions of health professionals and patients through their organizations. One of the objectives of safe practices was the need for prevention and control of pain in adults and children, including management of the same in quality standards. At the Germans Trias and Pujol University Hospital (HUGTIP) in 2016, the development of the indicators that were intended to be evaluated for better detection and therapeutic effi ciency of acute in-hospital pain in any area ended with the design and creation of what we call as "pain map". The objective was to design a tool that, through the clinical pain variable, could improve the visualization of pain and extract statistical data from the defi ned indicators for optimal pain management in a university hospital of the third level. Material and method: Descriptive analysis of the tool we call pain map at the Germans Trias and Pujol University Hospital during 2016. The population was all patients admitted to hospital units where the pain registry was made through the GacelaCare(R) computerized medical record. The main variable was the recording of pain intensity using the Visual Analogue Scale (VAS) or Numeric Verbal Scale (NVA) by nursing shift considering pain as the 5th constant. The tool creation procedure was carried out with the collaboration of the hospital information systems department together with members of the Pain Unit for the elaboration of the so-called pain map. Results: The pain map is based on the previous action required by nursing which is the recording of the intensity of pain using the Visual Analogue Scale (VAS) or Numerical Verbal Scale (NVA) in turn considering pain as the 5th constant. The map allows to visualize on the screen the registers of the pain intensity of all hospitalized patients simultaneously and in real time. The pain map identifi es with different colors as a traffi c light of pain. In green color, the EVN values are between 0-3 (mild pain), orange EVN between 4 and 6 (moderate pain) and red color between 7 and 10 (intense pain). Likewise, it indicates with a purple band those patients operated on the previous day, facilitating pain control during the fi rst 24 postoperative hours. The statistical exploitation of computerized pain registers allows obtaining results of the quality indicators related to pain management defi ned by our hospital. Discussion: The pain map is an innovative tool that allows the development of low-cost Acute Pain Units to be guaranteed with effi ciency

Validez de los grupos de morbilidad ajustados respecto a los clinical risk groups en el ámbito de la atención primaria / Validity of adjusted morbidity groups with respect to clinical risk groups in the field of primary care

Objetivo: Comparar el rendimiento referente a la bondad de ajuste y el poder explicativo de 2agrupadores de morbilidad en el ámbito de la atención primaria (AP): los grupos de morbilidad ajustados (GMA) y los clinical risk groups (CRG). Diseño: Estudio transversal. Emplazamiento: Ámbito de la AP del Instituto Catalán de la Salud (ICS), Cataluña, España. Participantes: Población asignada a centros de AP del ICS para el año 2014. Mediciones principales: Se analizan 3 indicadores de interés, como son el ingreso urgente, el número de visitas y el gasto en farmacia. Se aplica un análisis estratificado por centros ajustando modelos lineales generalizados a partir de las variables edad, sexo y agrupador de morbilidad para explicar cada una de las 3 variables de interés. Las medidas estadísticas para analizar el rendimiento de los distintos modelos aplicados son el índice de Akaike, el índice de Bayes y la seudovariabilidad explicada mediante cambio de deviance. Resultados: Los resultados muestran que en el ámbito de la AP del ICS el poder explicativo de los GMA es superior al ofrecido por los CRG, especialmente para el caso de las visitas y el gasto en farmacia. Conclusiones: El rendimiento de los GMA en el ámbito de la AP del ICS es superior al mostrado por los CRG

Objective: To compare the performance in terms of goodness of fit and explanatory power of 2 morbidity groupers in primary care (PC): adjusted morbidity groups (AMG) and clinical risk groups (CRG). Design: Cross-sectional study. Location: PC in the Catalan Institute for the Health (CIH), Catalonia, Spain. Participants: Population allocated in primary care centers of the CIH for the year 2014. Main measurements: Three indicators of interest are analyzed such as urgent hospitalization, number of visits and spending in pharmacy. A stratified analysis by centers is applied adjusting generalized lineal models from the variables age, sex and morbidity grouping to explain each one of the 3 variables of interest. The statistical measures to analyze the performance of the different models applied are the Akaike index, the Bayes index and the pseudo-variability explained by deviance change. Results: The results show that in the area of the primary care the explanatory power of the AMGs is higher to that offered by the CRGs, especially for the case of the visits and the pharmacy. Conclusions: The performance of GMAs in the area of the CIH PC is higher than that shown by the CRGs