[An update on parathyroid carcinoma]. / Puesta al día: carcinoma paratiroideo.

Parathyroid carcinoma is a rare malignant disease that presents as a sporadic or familial primary hyperparathyroidism (PHP). The latter is associated with some genetic syndromes. It occurs with equal frequency in both sexes, unlike PHP caused by parathyroid adenoma that is more common in women. It should be suspected in cases of severe hypercalcemia, with high parathyroid hormone levels and a palpable cervical mass. Given the difficulty in distinguishing between parathyroid carcinoma and adenoma prior to the surgery, the diagnosis is often made after parathyroidectomy. The only curative treatment is complete surgical resection with oncologic block resection of the primary tumor to ensure free margins. Adjuvant therapies with chemotherapy or radiation therapy do not modify overall or disease-free survival. Recurrences are common and re-operation of resectable recurrent disease is recommended. The palliative treatment of symptomatic hypercalcemia is crucial in persistent or recurrent disease after surgery since morbidity and mortality are more associated with hypercalcemia than with tumor burden.

Puesta al día: carcinoma paratiroideo / An update on parathyroid carcinoma

Parathyroid carcinoma is a rare malignant disease that presents as a sporadic or familial primary hyperparathyroidism (PHP). The latter is associated with some genetic syndromes. It occurs with equal frequency in both sexes, unlike PHP caused by parathyroid adenoma that is more common in women. It should be suspected in cases of severe hypercalcemia, with high parathyroid hormone levels and a palpable cervical mass. Given the difficulty in distinguishing between parathyroid carcinoma and adenoma prior to the surgery, the diagnosis is often made after parathyroidectomy. The only curative treatment is complete surgical resection with oncologic block resection of the primary tumor to ensure free margins. Adjuvant therapies with chemotherapy or radiation therapy do not modify overall or disease-free survival. Recurrences are common and re-operation of resectable recurrent disease is recommended. The palliative treatment of symptomatic hypercalcemia is crucial in persistent or recurrent disease after surgery since morbidity and mortality are more associated with hypercalcemia than with tumor burden.

Recomendaciones para el uso correcto de densitometría ósea en la práctica clínica. Consenso de la Sociedad Chilena de Endocrinología y Diabetes / Guidelines of the Chilean Endocrinology Society for the correct clinical use of bone densitometry

Osteoporosis is a silent and frequent disease, which increases fracture risk. Approximately half of women and one of five men over 50 years old will suffer an osteoporotic fracture throughout their lives. Dual-energy x-ray absorptiometry (DXA) allows a real bone mineral density (BMD) measurement in different parts of the skeleton and is considered the "gold standard" for quantifying osteoporosis with high accuracy and precision. The Board of the Chilean Society of Endocrinology and Diabetes (SOCHED) required from the Bone Disease Study Group to develop a consensus about the "Correct use of bone densitometry in clinical practice in Chilean population". Therefore, we elaborated 25 questions which addressed key aspects about the indications for a DXA scan, and the details of how to perform and report this test. Since some of the evidence obtained was of low quality or inconclusive, we decided to create a multidisciplinary group of national experts in osteoporosis to develop a consensus in this subject. The group consisted of 22 physicians including endocrinologists, gynecologists, geriatricians, radiologists, rheumatologists and nuclear medicine specialists. Using the Delphi methodology to analyze previously agreed questions, we elaborated statements that were evaluated by the experts who expressed their degree of agreement. The final report of this consensus was approved by the SOCHED board.

The clinical characteristics of patients with hip fractures in typical locations and atypical femoral fractures.

UNLABELLED: The pathophysiology of atypical fractures is unknown. We compared characteristics of patients with atypical femoral fractures and hip fractures in typical locations of the femur. Patients with atypical fracture reported a longer duration of use of bisphosphonates, had higher body mass index, and higher total hip bone mineral density. Further studies are needed. INTRODUCTION: This study aims to describe the characteristics of patients with typical and atypical fractures of the femur assessed in a tertiary care osteoporosis center. METHODS: We abstracted clinical, laboratory, and radiographic data on subjects with a history of a low-impact fracture at the femur and/or hip (confirmed by review of radiograph and/or radiology report) from January 2008 to October 2011. Available radiographs were reviewed and fracture categorized as typical or atypical by a radiologist blinded to the original diagnosis. RESULTS: Radiology reports were available for 72 subjects: 40 hip fractures in typical locations (typical fracture), 16 atypical femoral fracture (atypical fracture), and 16 were excluded. While both those with typical and atypical fractures reported taking bisphosphonates at the time of fracture, duration of use was longer with atypical fractures (104.2±42.0 months) compared with typical (71.1±62.8 months) (p=0.04). Body mass index (BMI) was higher in patients with atypical fractures (26.2±3.2 kg/m2) than in those with typical (23.1±4.3 kg/m2) (p=0.006). Total bone mineral density (BMD) was higher in patients with atypical fracture (0.795±0.102) versus typical (0.686±0.130) (p=0.003) Previous history of cancer was reported by 7 of 16 patients with atypical and 7 of 40 patients with typical fracture (p=0.04). CONCLUSIONS: Compared to those with typical fractures, patients with atypical fracture report a longer duration of use of bisphosphonates, higher BMI, and higher total hip BMD. Future studies should examine if these differences contribute to the pathophysiology of atypical fractures.

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

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

Obtaining the mean relative weights of the cost of care in Catalonia (Spain): retrospective application of the adjusted clinical groups case-mix system in primary health care.

OBJECTIVE: The study aims to obtain the mean relative weights (MRWs) of the cost of care through the retrospective application of the adjusted clinical groups (ACGs) in several primary health care (PHC) centres in Catalonia (Spain) in routine clinical practice. METHODS: This is a retrospective study based on computerized medical records. All patients attended by 13 PHC teams in 2008 were included. The principle measurements were: demographic variables (age and sex), dependent variables (number of diagnoses and total costs), and case-mix or co-morbidity variables (International Classification of Primary Care). The costs model for each patient was established by differentiating the fix costs from the variable costs. In the bivariate analysis, the Student's t, analysis of variance, chi-squared, Pearson's linear correlation and Mann-Whitney-Wilcoxon tests were used. In order to compare the MRW of the present study with those of the United States (US), the concordance [intraclass correlation coefficient (ICC) and concordance correlation coefficient (CCC)] and the correlation (coefficient of determination: R²) were measured. RESULTS: The total number of patients studied was 227,235, and the frequentation was 5.9 visits/habitant/year) and with a mean diagnoses number of 4.5 (3.2). The distribution of costs was €148.7 million, of which 29.1% were fixed costs. The mean total cost per patient/year was €654.2 (851.7), which was considered to be the reference MRW. Relationship between study-MRW and US-MRW: ICC was 0.40 [confidential interval (CI) 95%: 0.21-0.60] and the CCC was 0.42 (CI 95%: 0.35-0.49). The correlation between the US MRW and the MRW of the present study can be seen; the adjusted R² value is 0.691. The explanatory power of the ACG classification was 36.9% for the total costs. The R² of the total cost without considering outliers was 56.9%. CONCLUSIONS: The methodology has been shown appropriate for promoting the calculation of the MRW for each category of the classification. The results provide a possible practical application in PHC clinical management.

Adaptive capacity of the Adjusted Clinical Groups Case-Mix System to the cost of primary healthcare in Catalonia (Spain): a observational study.

OBJECTIVES: To describe the adaptive capacity of the Adjusted Clinical Groups (ACG) system to the cost of care in primary healthcare centres in Catalonia (Spain). DESIGN: Retrospective study (multicentres) conducted using computerised medical records. SETTING: 13 primary care teams in 2008 were included. PARTICIPANTS: All patients registered in the study centres who required care between 1 January and 31 December 2008 were finally studied. Patients not registered in the study centres during the study period were excluded. OUTCOME MEASURES: Demographic (age and sex), dependent (cost of care) and case-mix variables were studied. The cost model for each patient was established by differentiating the fixed and variable costs. To evaluate the adaptive capacity of the ACG system, Pearson's coefficient of variation and the percentage of outliers were calculated. To evaluate the explanatory power of the ACG system, the authors used the coefficient of determination (R(2)). RESULTS: The number of patients studied was 227 235 (frequency: 5.9 visits per person per year), with a mean of 4.5 (3.2) episodes and 8.1 (8.2) visits per patient per year. The mean total cost was €654.2. The explanatory power of the ACG system was 36.9% for costs (56.5% without outliers). 10 ACG categories accounted for 60.1% of all cases and 19 for 80.9%. 5 categories represented 71% of poor performance (N=78 887, 34.7%), particularly category 0300-Acute Minor, Age 6+ (N=26 909, 11.8%), which had a coefficient of variation =139% and 6.6% of outliers. CONCLUSIONS: The ACG system is an appropriate manner of classifying patients in routine clinical practice in primary healthcare centres in Catalonia, although improvements to the adaptive capacity through disaggregation of some categories according to age groups and, especially, the number of acute episodes in paediatric patients would be necessary to reduce intra-group variation.

Comparación entre tres métodos de medida de la multimorbilidad en función del uso de recursos sanitarios en atención primaria / Comparison of three methods for measuring multiple morbidity according to the use of health resources in primary healthcare

Objetivo: Comparar 3 diferentes métodos de medida de la multimorbilidad en función del uso de recursos sanitarios (coste de la asistencia) en atención primaria (AP). Diseño: Estudio retrospectivo realizado a partir de registros médicos informatizados. Emplazamiento: En 13 equipos de AP de Cataluña. Participantes: Pacientes adscritos que demandaron atención durante el año 2008. Medidas principales: Variables sociodemográficas, de comorbilidad y de coste. Los métodos de comparación fueron: a) índice de comorbilidad combinado (ICC): se elaboró un índice propio a partir de las puntuaciones de episodios agudos y crónicos; b) índice de Charlson (iCh), y c) índices de casuística de los Adjusted Clinical Groups: bandas de utilización de recursos (BUR). El modelo de costes se estableció diferenciando los costes fijos (funcionamiento de los centros) y los variables. Análisis estadístico: se desarrollaron 3 modelos de regresión lineal para evaluar la capacidad explicativa de cada medida de comorbilidad; que se compararon a partir del coeficiente de determinación (R2), p<0,05. Resultados: Se seleccionaron 227.235 pacientes; el promedio/unitario del coste de la asistencia fue de 654,2 €. El ICC explica un R2=50,4%, el iCh un R2=29,2% y las BUR un R2=39,7% de la variabilidad del coste. El comportamiento del ICC es aceptable, no obstante con puntuaciones bajas (entre 1 y 3 puntos) no se consiguen resultados tan concluyentes. Conclusiones: El ICC se muestra como un sencillo y posible predictor del coste de la asistencia en AP en situación de práctica clínica habitual. De confirmarse estos resultados posibilitarían una mejora en la comparación de la casuística(AU)

Objective: To compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC). Design: Retrospective study using computerized medical records. Setting: Thirteen PHC teams in Catalonia (Spain). Participants: Assigned patients requiring care in 2008. Main measurements: The socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs. Statistical analysis: 3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R2), p< .05. Results: The study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R2=50.4%, the ChI an R2=29.2% and BUR an R2=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results. Conclusions: The CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix(AU)

[Comparison of three methods for measuring multiple morbidity according to the use of health resources in primary healthcare]. / Comparación entre tres métodos de medida de la multimorbilidad en función del uso de recursos sanitarios en atención primaria.

OBJECTIVE: To compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC). DESIGN: Retrospective study using computerized medical records. SETTING: Thirteen PHC teams in Catalonia (Spain). PARTICIPANTS: Assigned patients requiring care in 2008. MAIN MEASUREMENTS: The socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs. STATISTICAL ANALYSIS: 3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R(2)), p< .05. RESULTS: The study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R(2)=50.4%, the ChI an R(2)=29.2% and BUR an R(2)=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results. CONCLUSIONS: The CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix.

Utilidad de la PTH intraoperatoria como predictor de curación quirúrgica en hiperparatiroidismo primario / Usefulness of intraoperative parathormone measurement to predict surgical cure in primary hyperparathyroidism

Background: The aim of the surgical treatment of primary hyperparathyroidism (PHPT) is to achieve its complete cure, evidenced by normal serum calcium in the postoperative period. Measurement of intraoperative serum parathormone (PTH) can be useful to predict complete cure of the disease. Aim: To assess the usefulness of intraoperative PTH measurement to predict complete cure of PHPT Material and methods: Serum PTH was measured to all patients operated for PHPT between 2003 and 2008, before and five and ten minutes after the excision of the parathyroid gland causing the disease. The criteria for complete cure were normal serum calcium at 24 hours and 6 months after surgery and the pathological confirmation of parathyroid gland excision. Results: Eighty-eight operated patients, aged 58±15 years (72 females) were studied. Sixty four percent were asymptomatic and their preoperative serum calcium was 11.6± 1.2 mg/dl. A normal serum calcium was achieved in 86 patients (98 percent) at 24 hours and 50 of 52 patients followed for six months (96 percent). The pathological study disclosed an adenoma in 69 (78 percent), and multiglandular disease in 16 (18 percent), a parathyroid cancer in one and a normal gland in one patient. Intraoperative PTH predicted early and definitive cure in 97 percent and 100 percent of patients with a single adenoma, respectively. Among patients with multiglandular disease, the predictive figures were 94 percent and 100 percent, respectively. Conclusions: Intraoperative PTH measurement efficiently predicts early and definitive surgical cure of PHPT.

Increase of bone resorption and the parathyroid hormone in postmenopausal women in the long-term after Roux-en-Y gastric bypass.

BACKGROUND: The effects of Roux-en-Y Gastric Bypass (RYGB) on bone in the long-term remains unclear. We assessed bone metabolism and bone mineral density (BMD) 1 to 5 years after RYGB. METHODS: We designed a retrospective cohort study in 26 postmenopausal women (58.0+/-3.9 years old) with RYGB 3.5+/-1.1 years before (body mass index (BMI) 29.5+/-3.8 kg/m2, presurgery 43.6+/-5.5 kg/m2) and 26 nonoperated women (57.5+/-4.7 years old, BMI 29.2+/-4.1 kg/m2) matched by age and BMI. The main measures were BMD, serum carboxy telopeptide (CTx), total alkaline phosphatases (ALP), parathyroid hormone (PTH), 25-hydroxyvitamin D (25OHD), and ghrelin. RESULTS: RYGB group, compared to nonoperated women, had higher CTx (0.71+/-0.21 vs. 0.43+/-0.15 ng/ml; P<0.01) and PTH (68.3+/-35 vs. 49.4+/-16 pg/ml; P=0.02). There were no differences between RYGB and nonoperated women in: calcium and vitamin D intake (759+/-457 vs. 705+/-460 mg/day; 176+/-160 vs. 111+/-86 UI/day), ghrelin (763+/-336 vs. 621+/-274 pg/ml), ALP (101+/-22 vs. 94+/-25 UI/l), 25OHD (18.8+/-7.6 vs. 17.4 +/- 5.9 ng/ml), lumbar spine BMD (1.059+/-0.32 vs. 1.071+/-0.207 g/cm2), or femoral neck BMD (0.892+/-0.109 vs. 0.934+/-1.1 g/cm2). CONCLUSIONS: RYGB is associated to high bone resorption and hyperparathyroidism prevalence in postmenopausal women in the long-term. This occurs independently of the intake of calcium, vitamin D status, or ghrelin and does not seem to affect BMD after RYGB.

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases.

BACKGROUND: The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments. METHODS/DESIGN: We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness.The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization.The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50).The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. STATISTICAL ANALYSIS: multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05.

Treating patients with fibromyalgia in primary care settings under routine medical practice: a claim database cost and burden of illness study.

INTRODUCTION: The objective of this study was to analyze health care and non-health care resource utilization under routine medical practice in a primary care setting claims database and to estimate the incremental average cost per patient per year of fibromyalgia syndrome (FMS) compared with a reference population. METHODS: A 12-month cross-sectional and retrospective study was completed using computerized medical records from a health provider database. Analyses were conducted from the perspective of the provider and from the viewpoint of society. Health care and non-health care resource utilization included drugs, complementary tests, all types of medical visits, referrals, hospitalizations, sick leave, and early retirement because of disability due to FMS. Patients with a diagnosis of FMS in accordance with ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) criteria were included in the analysis if they had at least one claim for FMS during the 12 months prior to the end of May 2007. A non-FMS comparison group was also created with the remaining subjects. RESULTS: Of the 63,526 patients recruited for the study, 1,081 (1.7%) (96.7% of whom were women, 54.2 [10.1] years old) met the criteria for FMS. After an adjustment for age and gender, FMS subjects used significantly more health care resources than the reference population and had more sick leave and the percentage of subjects with premature retirement was also significantly higher (P < 0.001 in all cases). As a result, FMS subjects showed an incremental adjusted per-patient per-year total cost of 5,010 euro (95% confidence interval [CI] 3,494 to 6,076, +153%, P < 0.001) on average compared with non-FMS subjects. Significantly higher differences were observed in both health care and non-health care adjusted costs: 614 euro (404 to 823, +66%) and 4,394 euro (3,373 to 5,420, +189%), respectively (P < 0.001 in both cases). Annual drug expenditure per patient on average was considerably higher in FMS patients, 230 euro (124 to 335, +64%, P < 0.001), than the reference group. CONCLUSIONS: Under routine medical practice, patients with FMS were associated with considerably higher annual total costs in the primary care setting compared with the reference population.

[Usefulness of intraoperative parathormone measurement to predict surgical cure in primary hyperparathyroidism]. / Utilidad de la PTH intraoperatoria como predictor de curación quirúrgica en hiperparatiroidismo primario.

BACKGROUND: The aim of the surgical treatment of primary hyperparathyroidism (PHPT) is to achieve its complete cure, evidenced by normal serum calcium in the postoperative period. Measurement of intraoperative serum parathormone (PTH) can be useful to predict complete cure of the disease. AIM: To assess the usefulness of intraoperative PTH measurement to predict complete cure of PHPT. MATERIAL AND METHODS: Serum PTH was measured to all patients operated for PHPT between 2003 and 2008, before and five and ten minutes after the excision of the parathyroid gland causing the disease. The criteria for complete cure were normal serum calcium at 24 hours and 6 months after surgery and the pathological confirmation of parathyroid gland excision. RESULTS: Eighty-eight operated patients, aged 58+/-15 years (72 females) were studied. Sixty four percent were asymptomatic and their preoperative serum calcium was 11.6+/- 1.2 mg/dl. A normal serum calcium was achieved in 86 patients (98%) at 24 hours and 50 of 52 patients followed for six months (96%). The pathological study disclosed an adenoma in 69 (78%), and multiglandular disease in 16 (18%), a parathyroid cancer in one and a normal gland in one patient. Intraoperative PTH predicted early and definitive cure in 97% and 100% of patients with a single adenoma, respectively. Among patients with multiglandular disease, the predictive figures were 94% and 100%, respectively. CONCLUSIONS: Intraoperative PTH measurement efficiently predicts early and definitive surgical cure of PHPT.

[Influence of morbidity, metabolic control, and use of resources in subjects with cardiovascular risk in the primary care setting]. / Influencia de la morbilidad, control metabólico y uso de recursos de los sujetos en situación de riesgo cardiovascular en el ámbito de la atención primaria de salud.

OBJECTIVE: To determine the comorbidity, the therapeutic objectives, and economic impact in subjects with cardiovascular risk in primary care (PC). DESIGN: Multicentre, cross-sectional study. SETTING: Five urban PC centres, Spain. PARTICIPANTS: Patients over 55 years seen during the year 2006. Compared according to the presence/absence of a cardiovascular event (CVE). MEASUREMENTS: Demographics, cardiovascular/general comorbidity (adjusted clinical groups), Charlson index, clinical parameters, multiple drugs and semi-fixed direct costs (operational) and variables (tests, referrals, drugs). A logistical regression and ANCOVA analysis was performed to correct the models. SPSSWIN Program (P< .05). RESULTS: Of 24 410 patients, 15.4% (CI, 14.9-15.9) had a CVE. The subjects with a CVE showed a higher mortality (4.0% vs 1.8%) and general morbidity (8.1 vs 6.4 episodes) (P< .001). The CVE had an independent association in males (OR=2.7), Charlson index (OR=2.1), dyslipaemia (OR=1.5), depression (OR=1.4), age (OR=1.3), arterial hypertension (OR=1.2) and diabetes (OR=1.1) (P< .005). In primary prevention worse average cholesterols were obtained (211.6 vs 192.4 mg/dL), while in secondary prevention blood glucose was worse (111.3 vs 104.2 mg/dL; P< .001). The average corrected direct costs were euro1543.55 versus euro1027.65, respectively (P< .001). These differences were maintained in all the cost components. CONCLUSIONS: The presence of a CVE is associated with higher comorbidity, causing an increase in costs. The achievement of therapeutic control objectives could be improved, in primary prevention as well as in secondary. Intervention strategies should be increased to modify life styles in these patients.

Influencia de la morbilidad, control metabólico y uso de recursos de los sujetos en situación de riesgo cardiovascular en el ámbito de la atención primaria de salud / Influence of morbidity, metabolic control, and use of resources in subjects with cardiovascular risk in the primary care setting

Objetivo. Determinar la comorbilidad, los objetivos terapéuticos y el impacto económico de sujetos en situación de riesgo cardiovascular en atención primaria (AP). Diseño. Estudio multicéntrico y transversal. Emplazamiento. Cinco centros de AP urbanos. Participantes. Pacientes mayores de 55 años atendidos durante el año 2006, comparados en función de la presencia/ausencia de episodios cardiovasculares (ECV). Mediciones. Demográficas, comorbilidad cardiovascular/general (Adjusted Clinical Groups), índice de Charlson, parámetros clínicos, polifarmacia y costes directos semifijos (funcionamiento) y variables (pruebas, derivaciones, fármacos). Se efectuó un análisis de regresión logística y de ANCOVA para la corrección de los modelos con el programa SPSSWIN (p < 0,05). Resultados. Se incluyeron en el estudio 24.410 pacientes. Un 15,4% (intervalo de confianza [IC], 14,9-15,9) presentaron algún ECV. Los sujetos con ECV presentaron una mortalidad (el 4,0 frente al 1,8%) y una morbilidad general (8,1 frente a 6,4 episodios) superiores (p < 0,001). El ECV tuvo una relación independiente en varones (odds ratio [OR] = 2,7), índice de Charlson (OR = 2,1), dislipemia (OR = 1,5), depresión (OR = 1,4), edad (OR = 1,3), hipertensión arterial (OR = 1,2) y diabetes (OR = 1,1) (p < 0,005). En prevención primaria se obtuvieron unos peores promedios de colesterol (211,6 frente a 192,4 mg/dl), mientras que en prevención secundaria fueron los de glucemia (111,3 frente a 104,2 mg/dl; p < 0,001). El promedio de los costes directos corregidos fue de 1.543,55 frente a 1.027,65 €, respectivamente (p < 0,001). Estas diferencias se mantuvieron en todos los componentes del coste. Conclusiones. La presencia de ECV se asocia con una mayor comorbilidad, lo que ocasiona un incremento de los costes. La consecución de los objetivos terapéuticos de control debería mejorarse, tanto en el ámbito de la prevención primaria como en el de la secundaria. Se deberían potenciar estrategias de intervención sobre la modificación de los estilos de vida en estos pacientes

Objective. To determine the comorbidity, the therapeutic objectives, and economic impact in subjects with cardiovascular risk in primary care (PC). Design. Multicentre, cross-sectional study. Setting. Five urban PC centres, Spain. Participants. Patients over 55 years seen during the year 2006. Compared according to the presence/absence of a cardiovascular event (CVE). Measurements. Demographics, cardiovascular/general comorbidity (adjusted clinical groups), Charlson index, clinical parameters, multiple drugs and semi-fixed direct costs (operational) and variables (tests, referrals, drugs). A logistical regression and ANCOVA analysis was performed to correct the models. SPSSWIN Program (P<.05). Results. Of 24 410 patients, 15.4% (CI, 14.9-15.9) had a CVE. The subjects with a CVE showed a higher mortality (4.0% vs 1.8%) and general morbidity (8.1 vs 6.4 episodes) (P<.001). The CVE had an independent association in males (OR=2.7), Charlson index (OR=2.1), dyslipaemia (OR=1.5), depression (OR=1.4), age (OR=1.3), arterial hypertension (OR=1.2) and diabetes (OR=1.1) (P<.005). In primary prevention worse average cholesterols were obtained (211.6 vs 192.4 mg/dL), while in secondary prevention blood glucose was worse (111.3 vs 104.2 mg/dL; P<.001). The average corrected direct costs were €1543.55 versus €1027.65, respectively (P<.001). These differences were maintained in all the cost components. Conclusions. The presence of a CVE is associated with higher comorbidity, causing an increase in costs. The achievement of therapeutic control objectives could be improved, in primary prevention as well as in secondary. Intervention strategies should be increased to modify life styles in these patients

[Relationship among the degree of control of arterial hypertension, comorbidity and costs in individuals over age 30 during 2006]. / Asociación entre el grado de control de la hipertensión arterial, la comorbilidad y los costes en personas de más de 30 años durante el año 2006.

BACKGROUND: Arterial hypertension is one of the main reasons for primary care consultations. This study is aimed at determining the relationship among the degree to which arterial hypertension is controlled, comorbidity and the direct costs in primary care. METHODS: Retrospective, multi-centre design. Subjects over 30 years of age pertaining to five primary care teams (2006) were included. CRITERIA: good control (<140/90 and <130/80 mmHg in diabetics and those with cardiovascular disease [CVD]. Main general measurements, CVD, Charlson index, casuistic/comorbidity (Adjusted Clinical Groups), clinical parameters and direct costs (fixed/semifixed and variable costs) [medications, tests and referrals]) Logic regression and ANCOVA for correcting the model, p<0.05. RESULTS: The prevalence of arterial hypertension was 26.5% (mean age: 67.1 years; males: 43.5%). Good control totalled 52.0% (CI: 51.2-52.8%). Poor control was independently related to diabetes (Odds Ratio=3.8), CVD (Odds Ratio=2.2) and males (Odds Ratio=1.2), p<0.001. The average/direct unit cost/year was 1,202.13 Euro vs. 1,183.55 Euro (p=0.032). CONCLUSIONS: Those individuals whose arterial hypertension was poorly controlled displayed a greater burden of morbidity and a similar healthcare cost in comparison to those under good control.