Ten-Year Follow-Up of Clinical Governance Implementation in Primary Care: Improving Screening, Diagnosis and Control of Cardiovascular Risk Factors.

Current improvement strategies for the control of cardiovascular risk factors (CRFs) in Europe are based on quality management policies. With the aim of understanding the effect of interventions delivered by primary healthcare systems, we evaluated the impact of clinical governance on cardiovascular health after ten years of implementation in Catalonia. A cohort study that included 1878 patients was conducted in 19 primary care centres (PCCs). Audits that comprised 13 cardiovascular health indicators were performed and general practitioners received periodic (annual, biannual or monthly) feedback about their clinical practice. We evaluated improvement in screening, diagnosis and control of the main CRFs and the effects of the feedback on cardiovascular risk (CR), incidence of cardiovascular disease (CVD) and mortality, comparing baseline data with data at the end of the study (after a 10-year follow-up). The impact of the intervention was assessed globally and with respect to feedback frequency. General improvement was observed in screening, percentage of diagnoses and control of CRFs. At the end of the study, few clinically significant differences in CRFs were observed between groups. However, the reduction in CR was greater in the group receiving high frequency feedback, specifically in relation to smoking and control of diabetes and cholesterol (Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL)). A protective effect of having a cardiovascular event (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.44-0.94) or death (HR = 0.55, 95% CI = 0.35-0.88) was observed in patients from centres where general practitioners received high frequency feedback. Additionally, these PCCs presented improved cardiovascular health indicators and lower incidence and mortality by CVD, illustrating the impact of this intervention.

Persistence in the long term of the effects of a collaborative care programme for depression in primary care.

BACKGROUND: A collaborative care programme for depression in primary care has proven clinical effectiveness over a 12-months period. Because depression tends to relapse and to chronic course, our aim was to determine whether the effectiveness observed in the first year persists during 3 years of monitoring. METHODS: Randomised controlled trial with twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a collaborative care programme with clinical, educational and organisational procedures. Outcomes were monitored by a blinded interviewer at baseline, 12 and 36 months. Clinical outcomes were response to treatment and remission rates, depression severity and health-related quality of life. TRIAL REGISTRATION: ISRCTN16384353. RESULTS: A total of 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 36 months, 137 patients in the intervention group and 97 in the control group were assessed (attrition 31%). The severity of depression (mean Patient Health Questionnaire-9 score) was 0.95 points lower in the intervention group [6.31 versus 7.25; p=0.324]. The treatment response rate was 5.6% higher in the intervention group than in the control group [66.4% versus 60.8%; p=0.379] and the remission rate was 9.2% higher [57.7% versus 48.5%; p=0.164]. No difference reached statistical significance. LIMITATIONS: The number of patients lost (31%) before follow-up may have introduced a bias. CONCLUSIONS: Clinical benefits shown in the first year were not maintained beyond: at 36 months the differences between the control group and the intervention group reduced in all the analysed variables.

Cost-effectiveness analysis of a collaborative care programme for depression in primary care.

BACKGROUND: Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care. METHODS: A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007-2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs). RESULTS: Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane. LIMITATIONS: The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression. CONCLUSIONS: The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation.

Registered prevalence of borderline personality disorder in primary care databases.

OBJECTIVE: Borderline personality disorder (BPD) is a common personality disorder, with a population prevalence of 1.4-5.9%, although the epidemiology of this disorder in primary care is insufficiently known. Our objective was to determine the registered prevalence of BPD in primary care databases and to study the demographic and clinical characteristics of these patients. METHODS: We performed a cross-sectional study of the computerized databases of primary care clinical records. The target population consisted of all adults (≥ 16 years old) registered in the Catalan Health Institute (n = 4,764,729). RESULTS: The prevalence of recorded BPD was 0.017%, and was higher in patients with other mental disorders, particularly substance-abuse disorders (0.161%). These patients had twice as many appointments with the general practitioner as the general population (8.1 vs. 4.4). CONCLUSION: The number of diagnoses of BPD recorded in primary care is extremely low, which contrasts with the available population-based data.

Effectiveness of a multi-component programme for managing depression in primary care: a cluster randomized trial. The INDI project.

BACKGROUND: There are significant shortcomings in the management and clinical outcomes of depressed patients. The objective is to assess the effectiveness of a multi-component programme to improve the management of depression in primary care. METHODS: This is a cluster-randomized controlled trial, conducted between June 2007 and June 2010. Twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a multi-component programme with clinical, educational and organizational procedures including primary care nurses working as case-managers. Outcomes were monitored by a blinded interviewer at 0, 3, 6 and 12 months. TRIAL REGISTRATION: ISRCTN16384353, at http://isrctn.org. RESULTS: In total, 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 12 months, 302 patients were assessed, 172 in the intervention group and 130 in the control group. The severity of depression (mean Patient Health Questionnaire-9 score) was 1.76 points lower in the intervention group [7.15 vs. 8.78, 95% CI=-3.53 to 0.02, p=0.053]. The treatment response rate was 15.4% higher in the intervention group than in the controls [66.9% vs. 51.5%, odds ratio 1.9, 95% CI=1.2 to 3.1, p=0.011)], and the remission rate was 13.4% higher [48.8% vs. 35.4%, odds ratio 1.8, 95% CI=1.1 to 2.9, p=0.026)]. LIMITATIONS: Unblinded physicians diagnosed depression in their patients and decided whether to include them in the study, so we cannot discount a hidden selection bias. CONCLUSIONS: The programme for managing depression leads to better clinical outcomes in patients with major depression in primary care settings.

Actitudes y opiniones de los médicos de familia frente a la depresión: una aproximación con el Depression Attitudes Questionnaire (DAQ) / Attitudes and opinions of family doctors on depression: application of the Depression Attitudes Questionnaire (DAQ)

ObjetivoDescribir las actitudes de los médicos de Atención Primaria hacia la depresión.DiseñoEstudio transversal basado en la aplicación de un cuestionario estandarizado.Emplazamiento y participantes112 médicos de Atención Primaria de los 20 Centros de Salud de la Dirección de Atención Primaria Tarragona-Reus (Institut Català de la Salut).MedicionesSe usó una adaptación española del Depression Attitudes Questionnaire.ResultadosEl 88,4% está de acuerdo en que hay un aumento en la presencia de pacientes depresivos en los últimos años. Aproximadamente la mitad de los médicos opinan que la depresión en Atención Primaria a menudo se debe a adversidades de la vida, pero el 72,3% reconoce el carácter biológico en los casos de depresión severa. El 81,2% cree que los antidepresivos usados en Atención Primaria son eficaces y la mayoría valora la psicoterapia como una opción terapéutica útil. Existe acuerdo en el papel de la enfermería en la atención al paciente deprimido y se reconoce el papel de la derivación al psiquiatra cuando no se obtiene un resultado satisfactorio en Atención Primaria. El 64,3% de los médicos consideran que el manejo de los pacientes deprimidos es duro, aunque el 57,1% se sienten cómodos y solamente el 19,7% consideran que esta dedicación no es gratificante.ConclusionesSe halla, en general, una favorable predisposición hacia el manejo de la depresión en Atención Primaria donde pueden establecerse y fructificar iniciativas formativas y organizativas para mejorar los resultados de la depresión(AU)

AimTo describe the attitudes of General Practitioners (GPs) towards depression in Primary Health Care Centres.DesignCross-sectional study based on the application of a standard questionnaire.Setting and participantsA total of 112 GPs from all of the 20 Primary Health Care Centres in the Tarragona-Reus Primary Care Area (Catalan Health Institute).MeasurementsA Spanish adaptation of Depression Attitudes Questionnaire was used.ResultsA total of 88.4% of doctors agreed there was an increase in the number of depressive patients in recent years. Around half of the GPs thought that depression in Primary Health Care Centres are due to the adversities of life, but 72.3% considers that there is a biological root in severe depressions. A large majority (81.2%) of doctors believed that antidepressants used in Primary Care are efficient and the majority values psychotherapy as a useful therapeutic option. There is an agreement in the role of nursing staff when attending depressed patients. The role of psychiatric referral when a satisfactory result is not obtained in Primary Care is recognised. Although 64.3% of doctors consider that dealing with depressed patients is hard work, but 57.1% feel comfortable and only 19.7% think it is an unpleasant job.ConclusionsIn general, there is a favourable predisposition to deal with depression in Primary Care where training and organisational initiatives can be introduced to improve clinical outcomes of depression in Primary Care(AU)

Comparative efficacy of two primary care interventions to assist withdrawal from long term benzodiazepine use: a protocol for a clustered, randomized clinical trial.

BACKGROUND: Although benzodiazepines are effective, long-term use is not recommended because of potential adverse effects; the risks of tolerance and dependence; and an increased risk of hip fractures, motor vehicle accidents, and memory impairment. The estimated prevalence of long-term benzodiazepine use in the general population is about 2,2 to 2,6%, is higher in women and increases steadily with age. Interventions performed by General Practitioners may help patients to discontinue long-term benzodiazepine use. We have designed a trial to evaluate the effectiveness and safety of two brief general practitioner-provided interventions, based on gradual dose reduction, and will compare the effectiveness of these interventions with that of routine clinical practice. METHODS/DESIGN: In a three-arm cluster randomized controlled trial, general practitioners will be randomly allocated to: a) a group in which the first patient visit will feature a structured interview, followed by visits every 2-3 weeks to the end of dose reduction; b) a group in which the first patient visit will feature a structured interview plus delivery of written instructions to self-reduce benzodiazepine dose, or c) routine care. Using a computerized pharmaceutical prescription database, 495 patients, aged 18-80 years, taking benzodiazepine for at least 6 months, will be recruited in primary care health districts of three regions of Spain (the Balearic Islands, Catalonia, and Valencia). The primary outcome will be benzodiazepine use at 12 months. The secondary outcomes will include measurements of anxiety and depression symptoms, benzodiazepine dependence, quality of sleep, and alcohol consumption. DISCUSSION: Although some interventions have been shown to be effective in reducing benzodiazepine consumption by long-term users, the clinical relevance of such interventions is limited by their complexity. This randomized trial will compare the effectiveness and safety of two complex stepped care interventions with that of routine care in a study with sufficient statistical power to detect clinically relevant differences. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN13024375.

[Attitudes and opinions of family doctors on depression: application of the Depression Attitudes Questionnaire (DAQ)]. / Actitudes y opiniones de los médicos de familia frente a la depresión: una aproximación con el Depression Attitudes Questionnaire (DAQ).

AIM: To describe the attitudes of General Practitioners (GPs) towards depression in Primary Health Care Centres. DESIGN: Cross-sectional study based on the application of a standard questionnaire. SETTING AND PARTICIPANTS: A total of 112 GPs from all of the 20 Primary Health Care Centres in the Tarragona-Reus Primary Care Area (Catalan Health Institute). MEASUREMENTS: A Spanish adaptation of Depression Attitudes Questionnaire was used. RESULTS: A total of 88.4% of doctors agreed there was an increase in the number of depressive patients in recent years. Around half of the GPs thought that depression in Primary Health Care Centres are due to the adversities of life, but 72.3% considers that there is a biological root in severe depressions. A large majority (81.2%) of doctors believed that antidepressants used in Primary Care are efficient and the majority values psychotherapy as a useful therapeutic option. There is an agreement in the role of nursing staff when attending depressed patients. The role of psychiatric referral when a satisfactory result is not obtained in Primary Care is recognised. Although 64.3% of doctors consider that dealing with depressed patients is hard work, but 57.1% feel comfortable and only 19.7% think it is an unpleasant job. CONCLUSIONS: In general, there is a favourable predisposition to deal with depression in Primary Care where training and organisational initiatives can be introduced to improve clinical outcomes of depression in Primary Care.

Prevalencia del déficit de atención e hiperactividad en personas adultas según el registro de las historias clínicas informatizadas de atención primaria / Prevalence in adults of attention deficit hyperactivity disorder using the medical records of primary care

Fundamento:El TDAH en adultos no es infrecuente y, según datos epidemiológicos recientes, tiene una prevalencia poblacional del 3-4%. Sin embargo, existe un gran desconocimiento sobre este trastorno entre los médicos, particularmente en atención primaria. El objetivo de este trabajo es determinar la prevalencia del diagnóstico registrado de TDAH en adultos y la proporción de pacientes con prescripción farmacológica para este trastorno en atención primaria. Métodos:Se trata de un estudio transversal sobre las bases de datos de las historias clínicas electrónicas de atención primaria. La población diana son los adultos (18-44 años) adscritos a centros de salud del Instituto Catalán de la Salud (n=2.452.107). Hemos obtenido la proporción de pacientes con diagnóstico de TDAH (código F90/CIE-10) en la lista de problemas activos, y la proporción de pacientes con prescripción activa de un fármaco específico para el TDAH en adultos: metilfenidato, metilfenidato de liberación prolongada o atomoxetina. Resultados:La prevalencia de TDAH registrado es del 0,04% (0,07% en hombres; 0,02% en mujeres). Los pacientes con prescripción para TDAH son el 0,07% (0,08% en hombres; 0,05% en mujeres). El 32,05% de los TDAH tenían prescripción específica. Conclusión:El diagnóstico en adultos de TDAH y el tratamiento específico son extremadamente bajos en atención primaria. Estos resultados contrastan con los datos poblacionales: el TDAH registrado es 1/85 de la prevalencia poblacional(AU)

Background:ADHD in adults is not uncommon and, according to recent epidemiological data, has a population prevalence of 3-4%. However, there is major unawareness of this disorder among doctors, particularly in primary care. The aim of this study is to determine the prevalence of the diagnosis of ADHD recorded in adults and the proportion of patients with drug prescriptions for this disorder in primary care. Methods:This is a cross-sectional study on databases of computerised primary care medical records. The target population is adults (18-44 years) assigned to primary care centres of the Catalan Health Institute (n = 2,452,107). We obtained the proportion of patients with ADHD (F90/ICD-10 code) registered as active problem, and the proportion of patients with a specific prescription for ADHD in adults: methylphenidate, methylphenidate extended release or atomoxetine. Results:The prevalence of recorded ADHD is 0.04% (0.07% in men, 0.02% in women). The percentage of patients with a specific prescription for ADHD is 0.07% (0.08% in men, 0.05% in women). 32.05% of ADHD patients had specific prescription. Conclusion:The diagnosis of ADHD in adults and specific treatment are extremely low in primary care. These results contrast with population data: registered ADHD is 1/85 of the population prevalence(AU)

Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain.

The aim of the present study was to assess reproducibility and relative validity of a self-administered FFQ used in the PREDIMED Study, a clinical trial for primary prevention of CVD by Mediterranean diet in a population at high cardiovascular risk. The FFQ was administered twice (FFQ1 and FFQ2) to explore reproducibility at 1 year. Four 3 d dietary records (DR) were used as reference to explore validity; participants therefore recorded their food intake over 12 d in the course of 1 year. The degree of misclassification in the FFQ was also evaluated by a contingency table of quintiles comparing the information from the FFQ2 and the DR. A total of 158 men and women (aged 55-80 years) were asked not to modify their dietary habits during the study period. Reproducibility for food groups, energy and nutrient intake, explored by the Pearson correlation coefficient (r) ranged 0.50-0.82, and the intraclass correlation coefficient (ICC) ranged from 0.63 to 0.90. The FFQ2 tended to report higher energy and nutrient intake than the DR. The validity indices of the FFQ in relation to the DR for food groups and energy and nutrient intake ranged (r) from 0.24 to 0.72, while the range of the ICC was between 0.40 and 0.84. With regard to food groups, 68-83 % of individuals were in the same or adjacent quintile in both methods, a figure which decreased to 55-75 % for energy and nutrient intake. We concluded that FFQ measurements had good reproducibility and a relative validity similar to those of FFQ used in other prospective studies.

Comorbilidad de la depresión mayor con otros trastornos mentales comunes en pacientes de atención primaria / Comorbidity of major depression with other common mental disorders in primary care patients

Introducción: La comorbilidad psiquiátrica influye en el impacto, el pronóstico y el manejo de la depresión.Objetivos: Determinar la prevalencia de otros trastornos mentales comunes en pacientes con depresión mayor y analizar sus relaciones de comorbilidad.Diseño: Estudio transversal en doble fase: a) cribado (test de Zung), y b) entrevista psiquiátrica estandarizada.Emplazamiento: 10 centros de salud de la provincia de Tarragona.Pacientes: Se cribó a 906 pacientes consecutivos. En la segunda fase fueron evaluados los 209 pacientes con resultado positivo y 97 con resultado negativo (1/7 aleatorio).Análisis: En el análisis estadístico se usaron ponderaciones atendiendo al muestreo en doble fase. Se determinó la frecuencia con que la distimia, el trastorno de ansiedad generalizada, el trastorno de pánico y el trastorno desomatización se presentabanconcomitantemente con la depresión mayor. Se compararon las características de los pacientes deprimidos según diversos grados de comorbilidad.Resultados: En el 45,7%(intervalo de confianza [IC] del 95%, 32,8–59,2) de los pacientes con depresión mayor coexistía un trastorno mental más, dos en el 19,9% (IC del 95%, 13,7–27,9) y tres trastornos mentales más en el 8,3%(IC del 95%, 4,5–14,8). El trastorno deansiedad generalizada estaba presente en el 55,2% de los deprimidos(IC del 95%, 41,6–68), el trastorno de pánico en el 33,8% (IC del 95%, 21,1–47,1), la distimia en el 15,7% (IC del 95%, 10,3–23,4) y el trastorno de somatización en el 6,6% (IC del 95%, 3,3–12,8). En los grupos de pacientes con comorbilidad la depresión fue más severa y con mayor impacto funcional. No hubo diferencias en las variables relacionadas con el manejo clínico.Conclusiones: La comorbilidad psiquiátrica de la depresión es común en atención primaria. En la mayoría de los pacientes deprimidos coexisten otros trastornos, frecuentemente de ansiedad(AU)

AimsTo determine the prevalence of other common mental disorders in patients with major depression and to analyse their associated comorbidities.SettingsTen health centres in the province of Tarragona.PatientsA total of 906 consecutive patients were screened. In the second stage, the 209 patients who gave a positive result and 97 patients who gave a negative result (1/7 at random) were evaluated.AnalysisThe statistical analysis used weights that took into account the two-stage sampling. The frequency with which dysthymia, generalised anxiety disorder, panic disorder and somatisation disorder presented concomitantly with major depression was determined. The characteristics of the depressed patients were compared for different degrees of comorbidity.ResultsIn 45.7% (95% CI, 32.8–59.2) of patients with major depression there was one other coexisting mental disorder, in 19.9% (95% CI, 13.7–27.9) two more mental disorders and in 8.3% (95% CI, 4.5–14.8) three more mental disorders. Generalised anxiety disorder was present in 55.2% of depressed patients (95% CI, 41.6–68), panic disorder in 33.8% (95% CI, 21.1–47.1), dysthymia in 15.7% (95% CI, 10.3–23.4) and somatisation disorder in 6.6% (95% CI, 3.3-12.8). In the groups of patients with comorbidity, the depression was more severe and had a greater functional impact. There were no differences in the clinical management variables.ConclusionsPsychiatric comorbidity of depression is common in primary care. Most depressed patients suffer from other disorders, often anxiety(AU)

[Comorbidity of major depression with other common mental disorders in primary care patients]. / Comorbilidad de la depresión mayor con otros trastornos mentales comunes en pacientes de atención primaria.

INTRODUCTION: Psychiatric comorbidity affects the impact, the prognosis and the management of depression. AIMS: To determine the prevalence of other common mental disorders in patients with major depression and to analyse their associated comorbidities. DESIGN: Two-stage cross-sectional study: a) screening (Zung's Self-Rating Depression Scale); b) a standardised psychiatric interview. SETTINGS: Ten health centres in the province of Tarragona. PATIENTS: A total of 906 consecutive patients were screened. In the second stage, the 209 patients who gave a positive result and 97 patients who gave a negative result (1/7 at random) were evaluated. ANALYSIS: The statistical analysis used weights that took into account the two-stage sampling. The frequency with which dysthymia, generalised anxiety disorder, panic disorder and somatisation disorder presented concomitantly with major depression was determined. The characteristics of the depressed patients were compared for different degrees of comorbidity. RESULTS: In 45.7% (95% CI, 32.8-59.2) of patients with major depression there was one other coexisting mental disorder, in 19.9% (95% CI, 13.7-27.9) two more mental disorders and in 8.3% (95% CI, 4.5-14.8) three more mental disorders. Generalised anxiety disorder was present in 55.2% of depressed patients (95% CI, 41.6-68), panic disorder in 33.8% (95% CI, 21.1-47.1), dysthymia in 15.7% (95% CI, 10.3-23.4) and somatisation disorder in 6.6% (95% CI, 3.3-12.8). In the groups of patients with comorbidity, the depression was more severe and had a greater functional impact. There were no differences in the clinical management variables. CONCLUSIONS: Psychiatric comorbidity of depression is common in primary care. Most depressed patients suffer from other disorders, often anxiety.

Relevance of casual undetected hyperglycemia among high-risk individuals for developing diabetes.

To assess the relevance of unrecognized hyperglycemia among high-risk subjects for developing diabetes a cross-sectional study was carried out. Subjects aged 40-75 years with (high-risk group) and without (control group) history of impaired glucose metabolism underwent a 2h-oral glucose tolerance test (OGTT). All individuals with diabetes diagnostic criteria and all controls with glucose abnormalities at OGTT were excluded. An individualized 48-h continuous glucose monitoring (CGM) calibrated by fasting plasma glucose was performed. The microdialysis-based biosensor recordings were computerized in order to identify continuous glucose profiles. Of the 121 monitored subjects, 104 were finally analyzed (56.7% female, 57.8 years, BMI=29.2, A1C=4.9%, HOMA index=2.5). Glucose profiles corresponded to 31 controls (29.8%), 32 high-risk individuals with normal OGTT (30.8%) and 41 (39.4%) with hyperglycemia at OGTT. The recordings defined as hyperglycemia (fasting >or=6.1 mmol/l, non-fasting >or=7.8 mmol/l) appeared during an average of 1.4h, 4.9h and 7.6h (3.9%, 13.9% and 19% of the CGM time), respectively. The highest percentage of impaired CGM registers corresponded to the fasting period. Nevertheless, the longest duration corresponded to the non-fasting period. The CGM evidenced a relevant degree of casual undetected hyperglycaemia among high-risk individuals.

[Continuous glucose monitoring in high-risk subjects for developing type 2 diabetes]. / Registro continuo de glucosa en sujetos con alto riesgo de diabetes tipo 2.

BACKGROUND AND OBJECTIVE: To assess the relevance of unrecognised hyperglycaemia among high-risk subjects for developing type 2 diabetes. SUBJECTS AND METHOD: Cross-sectional multicentre study in primary care. Subjects aged 40 to 75 years with previous evidence of impaired glucose metabolism were screened according to the World Health Organization rules by means of an oral glucose tolerance test (OGTT). Those with diabetes diagnostic criteria were excluded. An individualized 48-h ambulatory continuous glucose monitoring (CGM) calibrated by plasma values (Glucoday) was performed. Data from biosensor activity were computerized in order to identify hyperglycaemic records. RESULTS: 50 out of 64 screened subjects were included and evaluated; there were 30 female (60%). Mean age was 59 years; body mass index, 30.9; HbA1c, 5.3%, and HOMA, 2.8. Regarding the CGM results, 9 whole registers (18%) were rejected because of technical problems and 41 continuous profiles (72%) were analysed, corresponding to 17 (41.5%) subjects with normal OGTT and 24 (58.5%) with non-diabetic hyperglycaemia on OGTT. Mean CGM time with hyperglycaemia (fasting > or = 6.1 mmol/l or non-fasting > or = 7.8 mmol/l) accounted for 5.8 h, a 17.2% of the effective register per subject (33.8 h). Both groups matched the World Health Organization diabetes diagnostic interval (fasting > or = 7 mmol/l or non-fasting > or = 11.1 mmol/l): 1.1 h of effective register (3.6%) and 1.2 h (3.3%), respectively. CONCLUSIONS: The CGM evidenced a high degree of unrecognised hyperglycaemia among high-risk individuals. Therefore, casual plasma glucose measurements should be recommended to achieve early screening.

Registro continuo de glucosa en sujetos con alto riesgo de diabetes tipo 2 / Continuous glucose monitoring in high-risk subjects for developing type 2 diabetes

Fundamento y objetivo: Evidenciar la hiperglucemia inadvertida en sujetos con alto riesgo de diabetes tipo 2. Sujetos y método: Estudio transversal multicéntrico en atención primaria. Se seleccionó a sujetos de 40-75 años con antecedentes de hiperglucemia no diabética a los que se cribó mediante una prueba de tolerancia oral a la glucosa (PTOG), excluyendo a aquellos con criterios de diabetes según la Organización Mundial de la Salud. Se desarrolló un registro continuo de la glucosa (RGC) individualizado y ambulatorio de 48 h mediante un biosensor subcutáneo (GlucoDay®) calibrado por la glucemia plasmática. Se informatizó la actividad del biosensor para evidenciar posibles registros de hiperglucemia. Resultados: Se efectuó el RCG a 50 de 64 sujetos seleccionados, de los que 30 eran mujeres. El índice de masa corporal medio fue de 30,9 kg/m2; la hemoglobina glucosilada del 5,3%, y el índice HOMA de 2,8, descartando 9 perfiles completos (18%) por problemas técnicos. Se evaluaron 41 RCG (82%) pertenecientes a 17 sujetos con PTOG normal (41,5%) y a 24 (58,5%) con PTOG alterada. Por término medio, se obtuvieron registros de hiperglucemia (basal é 6,1 mmol/l o no basal é 7,8 mmol/l) durante 5,8 h, un 17,2% del tiempo total de registro efectivo (33,8 h). La hiperglucemia en el intervalo de diabetes (basal é 7 mmol/l o no basal é 11,1 mmol/l) concurrió durante el 3,6% del tiempo (1,2 h) y el 3,3% (1,1 h), respectivamente. Conclusiones: El RCG evidenció índices altos de hiperglucemia no reconocida en sujetos de riesgo. Este hallazgo indica que medir la glucemia en cualquier momento del día incrementaría la detección de anomalías glucídicas

Background and objective: To assess the relevance of unrecognised hyperglycaemia among high-risk subjects for developing type 2 diabetes. Subjects and method: Cross-sectional multicentre study in primary care. Subjects aged 40 to 75 years with previous evidence of impaired glucose metabolism were screened according to the Word Health Organization rules by means of an oral glucose tolerance test (OGTT). Those with diabetes diagnostic criteria were excluded. An individualized 48-h ambulatory continuous glucose monitoring (CGM) calibrated by plasma values (Glucoday®) was performed. Data from biosensor activity were computerized in order to identify hyperglycaemic records. Results: 50 out of 64 screened subjects were included and evaluated; there were 30 female (60%). Mean age was 59 years; body mass index, 30.9; HbA1c, 5.3%, and HOMA, 2.8. Regarding the CGM results, 9 whole registers (18%) were rejected because of technical problems and 41 continuous profiles (72%) were analysed, corresponding to 17 (41.5%) subjects with normal OGTT and 24 (58.5%) with non-diabetic hyperglycaemia on OGTT. Mean CGM time with hyperglycaemia (fasting é 6.1 mmol/l or non-fasting é 7.8 mmol/l) accounted for 5.8 h, a 17.2% of the effective register per subject (33.8 h). Both groups matched the World Health Organization diabetes diagnostic interval (fasting é 7 mmol/l or non-fasting é 11.1 mmol/l): 1.1 h of effective register (3.6%) and 1.2 h (3.3%), respectively. Conclusions: The CGM evidenced a high degree of unrecognised hyperglycaemia among high-risk individuals. Therefore, casual plasma glucose measurements should be recommended to achieve early screening

The overdiagnosis of depression in non-depressed patients in primary care.

BACKGROUND: The underdiagnosis of depression is an important research topic. Nevertheless, overdiagnosis has not been given the importance it deserves by research into the ability of family physicians to diagnose depression correctly. OBJECTIVES: To identify the factors that determine the overdiagnosis of depression by family physicians and to evaluate the clinical significance of this error. DESIGN: Two-phase cross-sectional study. SETTING: Primary care centres in Tarragona (Spain). METHODS: In the first phase, we screened 906 consecutive patients using Zung's self-rating depression scale (SDS). In the second phase, all the 209 patients with a positive screening and 97 patients with a negative screening (1 out of 7 randomly) were given the Structured Clinical Interview for DSM-IV Disorders, a series of questionnaires, and the family physician judged whether depression was present. In the 186 patients for whom there were no criteria of major depression or dysthymia, the association of various variables with the physicians' overdiagnosis of depression was analysed. RESULTS: The rate of diagnosis of depression in non-depressed patients was 26.5% (95% CI: 19.0-33.9). The factors associated independently with overdiagnosis were the SDS score (OR: 1.05; 95% CI: 1.01-1.10), the Global Assessment of Functioning score (OR: 0.95; 95% CI: 0.90-0.99), previous history of depression (OR: 2.66; 95% CI: 1.12-6.30) and presence of generalized anxiety (OR: 0.42; 95% CI: 0.18-0.97). CONCLUSION: Family physicians classify as depressed those patients who do not have the formal signs of depression but who do have antecedents of this disorder or a psychological distress that may be prodromal of future depressive episodes.

Prevalence and determinants of depressive disorders in primary care practice in Spain.

OBJECTIVE: Depressive disorders are considered to be a public health problem. Primary health care plays an important role in the treatment of such disorders. Our aim is to determine the prevalence and determinant factors of major depression and dysthymia in consecutive primary care attenders. METHOD: The study took place in medical consultations in 10 Primary Care Centers in Tarragona (Spain). It was designed as a two-phase cross-sectional study. In the first phase we screened 906 consecutive patients according to Zung's Self-Rating Depression Scale. In the second phase the 209 patients whose results were positive and 97 patients whose results were negative (1/7 chosen at random) were given the Structured Clinical Interview for DSM-IV Axis I Disorders, plus a series of questionnaires. We evaluated the link between major depression and dysthymia and several sociodemographic and clinical variables using non-conditional logistic regression. RESULTS: Weighted prevalence was 14.3% (CI 95%: 11.2-17.4) for major depression and 4.8% (CI 95%: 2.8-6.8) for dysthymia. Independently linked to the presence of major depression were female sex, panic disorder, generalized anxiety disorder, frequency of primary care visits, and clinical presentation in the form of explicitly psychosocial symptoms as opposed to exclusively somatic symptoms. Independently linked to the presence of dysthymia were age, generalized anxiety disorder and psychosocial symptoms. CONCLUSION: In our area, depressive disorders in primary care attenders are very common. General practitioners should be aware of this fact so that these disorders can be detected and treated correctly.