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Primarna zdravstvena zaštita čuvar je ulaza u zdravstveni sustav, a koristeći odgovarajući informacijski sustav, omogućava standardizirani pristup i upravljanje medicinskim i javnozdravstvenim informacijama, bolju horizontalnu i vertikalnu suradnju među razinama zdravstvene zaštite te osigurava jednakost među korisnicima u zdravstvu. Izmjenom načina prikupljanja podataka iz agregiranih izvještaja, putem Centralnog zdravstvenog informacijskog sustava dobiveni su sveobuhvatni, točni i pravodobni podaci te su omogućene detaljnije analize u svrhu podizanja kvalitete i donošenja odluka u zdravstvenom sustavu.

Background Renal damage (RD) is one of the most important contributors to morbidity and mortality in patients with systemic lupus erythematosus (SLE). Objectives We aimed to assess features associated with RD in a group of 90 deceased SLE patients routinely followed-up at our institution, which serves as a national referral center for SLE. Methods We retrospectively analyzed 90 SLE patients (68 females) deceased from 2002 to 2011. All patients were ≥18 years of age at death, fulfilling ≥4/11 classification criteria of the American College of Rheumatology (ACR). We identified patients with RD, as defined by the Systemic Lupus International Collaborating Clinics (SLICC)/ACR index. An extensive set of variables was compared between patients with and without RD (RD and RD-N, respectively): demographics, ACR criteria at diagnosis and cumulatively at death, total damage and its components one year following diagnosis and non-renal damage and its components cumulatively at death, as well as components of the metabolic syndrome, smoking, sicca and Hughes syndrome. Frequencies were compared using the chi-square and Fisher’s exact test, and continuous variables using the t-test and Mann-Whitney U test. Variables associated with RD were analyzed using multivariate logistic regression. Results We identified 25/90 patients who accrued RD over the course of their disease. In the univariate analysis, we found no difference between RD and RD-N patients in any of the following parameters: demographics, total count of ACR criteria at diagnosis and death, as well as damage at one year after diagnosis and cumulative non-renal damage at death. Compared to RD-N patients, RD patients had a higher proportion of malar rash at diagnosis (11/25 vs. 13/65, p=0.021) and a higher cumulative proportion of renal disorder (19/25 vs. 30/65, p=0.011), including proteinuria and urinary casts (17/25 vs. 23/65, p=0.005, for both). RD patients also had a higher proportion of myocardial infarction as an item of cumulative damage (7/25 vs. 6/65, p=0.023) and were more frequently obese (11/25 vs. 15/65, p=0.049). Conversely, hematological disorder and leukopenia at diagnosis were less frequent in RD compared to RD-N patients (4/25 vs. 30/65, p=0.008 and 1/25 vs. 21/65, respectively). In the final multivariate model (adjusted for gender, age at diagnosis and disease duration), malar rash at diagnosis and the cumulative presence of renal disorder (classification criteria of the ACR) were positively associated with RD. Conversely, leukopenia at diagnosis was inversely associated with RD (Figure 1). Conclusion More than a quarter of deceased patients accrued RD. While malar rash at diagnosis may be associated with a higher likelihood of developing RD, early leukopenia may be associated with its lower likelihood in deceased patients. References [1] Davidson A. Nat Rev Rheumatol. 2016;12:143-53. Disclosure of Interests Ivan Padjen: None declared, Marijan Erceg: None declared, Mislav Cerovec: None declared, Miroslav Mayer Speakers bureau: Novartis, Sandoz, Abbvie, Pfizer, Alvogen, Roche, MSD, Octapharma, Ranko Stevanovic: None declared, Branimir Anic Speakers bureau: Novartis, Sandoz, Abbvie, Pfizer, Alvogen, Roche, MSD, Octapharma

Objective:Our aim was to analyze differences between home and office blood pressure (BP) values obtained in epidemiological study and impact on prevalence and distribution of BP categories in a random sample of Croatian population, an original cohort from the EHUH study.Design and method:EHUH study

The aim of this study was to analyse the association of poor self- -perceived health with demographic, socioeconomic and lifestyle factors using data from the European Health Interview Survey. When applying the multiple logistic regression model, two demographic (male sex, older age), all four socioeconomic (low education level, unemployed and retired, living in households with lowest income, poor social support) and only one lifestyle factor (no alcohol consumption) were revealed as associated with poor self-perceived health. The association of socioeconomic factors with self-perceived health among the adult population in Croatia is direct and not mediated exclusively through lifestyle factors., Cilj je ovog rada bio analizirati povezanost samoprocijenjenoga lošeg zdravlja s demografskim i socioekonomskim čimbenicima te životnim stilom na temelju podataka iz Europske zdravstvene ankete. Prilikom primjene modela multiple logističke regresije dva demografska (muškarci, starija dob), sva četiri socioekonomska (niska razina obrazovanja, nezaposleni i umirovljeni, osobe koje žive u kućanstvima s najnižim dohotkom, slaba socijalna podrška) i jedan čimbenik životnoga stila (osobe koje ne piju alkohol) prepoznati su kao povezani sa samoprocijenjenim lošim zdravljem. Povezanost socioekonomskih čimbenika sa samoprocjenom zdravlja među odraslom populacijom u Hrvatskoj izravna je i nije posredovana isključivo kroz životni stil.

Aim: To determine the prevalence of muscular dystrophy (MD) and spinal muscular atrophy (SMA) in Croatia by use of multiple epidemiological tools. ----- Methods: This epidemiological study collected data from three national patient registries and one database of a non-governmental organization (NGO) of MD and SMA patients. The study involved all individuals who either had undergone hospital treatment for MD or SMA, had consulted their primary health care providers for MD- and SMA-related symptoms, were listed as disabled due to MD or SMA, or were members of the mentioned NGO in 2016. In order to prevent double entries, we created a new database of all living individuals, each with a unique identification number. The prevalence rates for 2016 were calculated by age and sex groups. ----- Results: There were 926 patients diagnosed with MD (544 men). Most men diagnosed with MD were in the age group 10-19, whereas most women were in the age group 50-59. MD prevalence in Croatia was 22.2 per 100 000 population. There were 392 patients diagnosed with SMA (198 men). Most men with SMA were in the age group 50-59, whereas most women were in the age group 60-69. SMA prevalence in Croatia was 9.3 per 100 000 population. ----- Conclusion: SMA prevalence rate in Croatia is similar to SMA prevalence worldwide. However, MD prevalence rate is higher than worldwide estimates. This difference could be attributed to the fact that we could not confirm whether every patient registered in these databases actually met the diagnostic criteria for MD and SMA.

Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up. Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP >140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA2DS2-VASc score and more CKD than non-CKD patients had CHA2DS2-VASc >2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non- CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA2DS2VASc and R2CHA2DS2VASc scores. Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA2DS2VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R2CHA2DS2VASc score was not associated significantly more with CV mortality than CHA2DS2VASc score.

Background Loss to follow-up in the year prior to death may lead to underrecognition and underreporting of systemic lupus erythematosus (SLE) as a cause of death of lupus patients. Objectives We aimed to assess the extent and features associated with loss to follow-up in the year prior to death in a group of 90 deceased SLE patients from our tertiary centre. Methods We retrospectively analysed 90 SLE patients (68 females) followed-up at our centre, deceased from 2002 to 2011. Patients were ≥18 years of age at death and fulfilled ≥4 classification criteria of the American College of Rheumatology (ACR). The cause and place of death were identified by matching patient data from our department’s SLE registry with data from the National Death Database. Patients were considered lost to follow-up in the year prior to death (LTF) if the time span between the last visit to our centre and death exceeded 1 year. Other patients were considered to be under regular follow-up (RGF). An extensive set of parameters was compared between the LTF and RGF groups: demographics, ACR classification criteria, cumulative damage according to the Systemic Lupus International Collaborative Clinics (SLICC)/ACR index, as well as causes of death. Frequencies were compared using the chi-square and Fisher’s exact test, and continuous variables using the t-test and Mann-Whitney U-test. Results We identified 35/90 patients in the LTF group (29 females). The time span between the last visit to our centre and death of LTF patients ranged from >1 to 3 years. Compared to the RGF group, LTF patients were diagnosed at a later age (mean ±SD: 54±15 vs. 44±17 years, p=0.006), while there was no difference in disease duration (median of 11 years, IQR of 5–15 years in the RGF group vs. median of 7 years, IQR of 5–15 years in the LTF group, p=0.285). The LTF and RGF groups did not differ in the count of ACR criteria (median of 5, IQR of 4–6 vs. median of 6, IQR of 5–7, p=0.053) and cumulative damage (median damage of 3, IQR of 2–5 vs. median of 5, IQR of 3–8, p=0.068). Compared to the RGF group, LTF patients had a lower cumulative proportion of pericarditis (1/35 vs.16/55), proteinuria (10/35 vs. 30/55), hemolytic anaemia (1/35 vs. 10/55), thrombocytopenia (5/35 vs. 21/55) and Hughes syndrome (2/35 vs. 13/55) (p RGF patients died more frequently from active lupus compared to their LTF counterparts (24/55 vs. 2/35, p Conclusions A lower proportion of LTF patients exhibited features of active SLE over their disease course. This may have led to underrecognition of SLE as a contributor to death. References [1] Calvo-Alen J, et al. Rheumatology2005;44:1186–9. [2] Abu-Shakra M, Novack V. J Rheumatol2012;39:458–60. Disclosure of Interest None declared

Aim To update the estimate of multiple sclerosis (MS) prevalence in Croatia using multiple epidemiological tools. Methods This level IV, epidemiological study gathered data from three national patient registries and one database of a non-governmental MS patients’ organization. Data were extracted on all individuals who had undergone hospital MS treatment, consulted their primary health care providers about MS-related symptoms, been listed as having MS-related disability, or been members of the mentioned non-governmental organization in 2015. A new database was formed, in which all living individuals were identified using a common identification number to prevent double entries. The prevalence rates in 2015 were calculated by age and sex groups. Results In total, 6160 patients diagnosed with MS were identified (72% women). Most women with MS were 50-59 years old and most men were 40-49 years old. The overall MS prevalence rate was 143.8 per 100 000 population. Conclusion The calculated MS prevalence rate in Croatia in 2015 was more than twice as high as the estimate from 2013. This difference warrants further research into MS epidemiology in Croatia and calls for a rational allocation of funds and human resources to provide adequate care and support to MS patients.

AIM: To assess the causes of early death (ED) and late death (LD) in patients with systemic lupus erythematosus (SLE) and determine the features of deceased SLE patients followed-up in a single Croatian tertiary hospital center, because little if any data on causes of death (CODs) in SLE patients are available for Croatia. ----- METHOD: We identified SLE patients regularly followed-up at the Division of Clinical Immunology and Rheumatology, University Hospital Center Zagreb, who died from 2002 to 2011. Death was ascertained by matching our institutional records with the Croatian National Death Database. Patients were grouped according to their disease duration to ED and LD and compared by demographic characteristics, classification criteria, organ damage, and CODs. ----- RESULTS: We identified 90 patients (68 women), who died at the age of 58±15 years. The most frequent COD category was cardiovascular diseases (40%), followed by infections (33%), active SLE (29%), and malignancies (17%). No significant difference was found between the frequencies of causes of ED and LD, except for stroke, which caused only LD≥10 years after the diagnosis. SLE was reported in death certificates of only 41 of 90 patients. ----- CONCLUSION: Although stroke occurred both in the early and late disease course, it was primarily associated with LD. Given the low proportion of SLE recorded in death certificates of deceased SLE patients, matching of institutional and vital statistics records may be required to assess the true impact of SLE on mortality.

Objective: The aim of this study was to obtain data on prevalence and awareness of hypertension, cardiovascular risk factors, and life-style habits in individuals (aged 18 years or older) participating in the 2017 World Hypertension Day in Croatia. Design and method: Blood pressure (BP) was measured at 26 sites in 5 cities in Croatia. Along with BP measurement, a short questionnaire on hypertension awareness/salt intake/smartphone use was completed in the time of the interview. The average of two BP measurements, taken in seated position after a few minutes rest by a validated oscillometric device (Omron M6) was recorded. BP measurements were performed from 10 AM to 2 PM in hospital open points, central squares and pharmacies. BP was measured by physicians, trained nurses, pharmacist or medical students. This action was organized and supported by the Croatian Society of Hypertension. Results: A total of 2175 subjects, 873 (40.1%) men, 1211 (59.9%) women were examined. Men were older, had higher BP, BMI and waist circumference (64.7 (13.9)vs.61.8 (14.5) ; 142.9/85.4 (19.8/11.7)vs.136.3/82.9 (21.2/11.3) ; 28.3 (4.4)vs.26.7 (5.4) ; 103 (12.2)vs.92.8 (15.7), respectively). Proportion of patients with BMI over 25 and 25–30 kg/m2 was 32.4% and 20% respectively. In the whole group there were 53.4% subjects with BP 140/90 mmHg or higher (women vs.men 54.1% vs.45.9%, p < 0.001), 68.4% were aware of hypertension (men vs. women 66.9% vs.67.8%, p > 0.05). Positive family history (FH) for hypertension, stroke and myocardial infarction was found in 46.7%, 17.9% and 23.5% subjects respectively. FH was more frequently positive in women than in men (51.0% vs.40.3%, p < 0.001 ; 20.3% vs.14.3%, p = 0.008, 26% vs.19.6%, p = 0.01). We failed to find association between BP values and positive FH. There were 18.7% smokers (more women never smoked 66.5% vs.57.1%, p < 0.001), average pack- years was 5. Only 9.4% of population declared regular physical activity (more than twice per week), and 49.7% were never physically active (no gender differences). Conclusions: Prevalence of subjects with BP values in hypertensive ranges is high, awareness is insufficient, and high proportion of subjects is obese and physically inactive. There is an urgent need of education not only hypertensives but general population as a true measure of primordial prevention.

Objective:Our aim was to analyze mortality data in random sample of Croatian population, an original cohort from the EHUH study.Design and method:EHUH study is nation-wide survey on prevalence, treatment and control of hypertension in Croatia. In 2001–2003 a random sample of 1267 subjects were enrol

Background Systemic lupus erythematosus (SLE) is frequently not reported in death certificates of lupus patients, despite its known role as an underlying and/or immediate cause of death. Possible reasons may be insufficient access to patients' medical records at time of death (including details on their medical history) and/or physicians' unawareness of the contribution of SLE to death. Objectives We aimed to analyze the extent and predictors of non-reporting of SLE in death certificates of 90 deceased SLE patients regularly followed-up in a routine academic setting at our Department. Methods We retrospectively observed 90 SLE patients (68 females) deceased within the 2002– 2011 period. All patients were ≥18 years of age and Croatian residents at the time of death, fulfilling ≥4 classification criteria of the American College of Rheumatology (ACR). We identified patients with SLE listed as a cause of death in the death certificate. An extensive set of variables was compared between patients with and without SLE reported in the certificate: demographics, ACR criteria at time of death and damage according to the Systemic Lupus Erythematosus International Collaborating Clinics (SLICC)/ACR index and its components at the time of death. We also compared the proportion of in-hospital deaths and autopsies performed. Frequencies were compared using the χ2 and Fisher's exact test, and continuous variables using the t-test and Mann-Whitney U test. Variables associated with reporting of SLE in the death certificate in the univariate analysis were included in a multivariate logistic regression model. Results SLE was reported in death certificates of 41/90 (46%) patients. Patients with SLE not reported in their death certificates were older at death (62±14 vs. 53±15 years) and diagnosis (53±14 vs 42±18 years) and had a longer time from their last visit at our Department to death (0.80±1.00 vs. 0.34±0.66 years), compared to patients with SLE listed in the death certificate (p

Cardiovascular comorbidities are a major contributor of damage in patients with SLE. They are driven by classical, as well as SLE-related risk factors, i.e. disease activity and immunosuppressive treatment. We aimed to analyze cardiovascular damage (CVD) in a group of 90 deceased SLE patients regularly followed-up in a routine academic setting at our Department, and to identify features associated with accrual of CVD. We retrospectively observed 90 SLE patients (68 females) deceased within the 2002– 2011 period. All patients were ≥18 years of age and Croatian residents at the time of death, fulfilling ≥4 classification criteria of the American College of Rheumatology (ACR). We identified patients with CVD, including the following components of the Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage index: cardiovascular damage as defined by the index (cardiac damage), peripheral vascular damage, cerebrovascular accident, pulmonary infarction, bowel infarction and avascular necrosis. An extensive set of variables was compared between patients with and without CVD: demographics, ACR criteria at diagnosis and death, damage (according to the SLICC/ACR index) and its components one year following diagnosis and at the time of death, disease activity at diagnosis (according to the European Consensus Lupus Activity Measurements index, ECLAM), as well as features of the metabolic syndrome, smoking and immunosuppressive treatment. Frequencies were compared using the χ2 and Fisher's exact test, and continuous variables using the t-test and Mann-Whitney U test. Variables associated with CVD in the univariate analysis were included in a multivariate logistic regression model. We identified 63/90 patients with CVD, including 46/63 (73%) with cardiac damage, 19/63 (30%) with peripheral vascular damage, 21/63 (33%) with cerebrovascular accident, 4/63 (6%) with bowel infarction, 14/63 (22%) with avascular necrosis and a single patient with pulmonary infarction (Figure 1). Patients with CVD had a higher disease duration at time of death compared to patients without CVD (12±8 vs. 7±6 years), as well as higher cumulative proportions of hematologic disorder (60/63 vs. 15/27), lymphopenia (48/63 vs. 10/27), pulmonary damage (19/63 vs. 1/27), fractures (25/63 vs. 2/27), higher overall damage (6.0±3.0 vs. 2.4±2.0) and a higher proportion of secondary antiphospholipid syndrome (14/63 vs. 1/27) (p

Objectives Hearing impairment and specific language disorder are two entities that seriously affect language acquisition in children and reduce their communication skills. These children require specific treatment and higher levels of care than healthy children. Their language abilities also strongly influence parent–child interactions. The purpose of our study was to evaluate the health-related quality of life (HRQOL) of the parents of hearing-impaired children and the parents of children with speech difficulties (specific language disorder). Methods Our study subjects included 349 parents (182 mothers and 167 fathers) of preschool-aged children with receptive expressive language disorder and 131 parents (71 mothers and 60 fathers) of children with severe hearing impairment. A control group was composed of 146 parents (82 mothers and 64 fathers) of healthy children of the same age. HRQOL was assessed using the SF-36 questionnaire. Results For all groups of parents, the mothers had poorer scores compared with the fathers, but large differences were apparent depending on the child's impairment. In the control group, the scores of the mothers were significantly lower than the fathers’ scores in only two (of eight) health domains. In contrast, the scores were lower in three domains for the mothers of speech-impaired children and in six domains for the mothers of hearing-impaired children, representing the greatest difference between the parents. When compared with the control group, both the mothers and fathers of speech-impaired children scored significantly worse in five health domains. Fathers of hearing-impaired children scored significantly worse than controls in three health domains. The lowest scores, indicating the poorest HRQOL, were observed for mothers of hearing-impaired children, who obtained significantly lower scores than the control mothers in all health domains except the emotional role. Conclusions The parents of preschool-aged speech-and hearing-impaired children experience poorer HRQOL than parents of healthy children of the same age. Mothers of hearing-impaired children are especially affected, demonstrating a negative impact in almost all health domains.

Objective:Inter-arm blood pressure (BP) difference is associated with higher cardiovascular (CV) risk and increased mortality. The aim of this study was to obtain data on prevalence of inter-arm difference and association with all-caused and cardiovascular (CV) mortality in a random sample of Croati

Objective:Our aim was to analyze gender differences in all-cause and cardiovascular (CV) mortality in a random sample of Croatian population, an original cohort from the EH-UH study.Design and method:EH-UH study is a nation-wide survey on prevalence, treatment and control of hypertension in Croatia.

Objective:Our aim was to analyze the association of obesity with all-cause and cardiovascular (CV) mortality in a random sample of Croatian population, an original cohort from the EH-UH study.Design and method:EH-UH study is a nation-wide survey on prevalence, treatment and control of hypertension i

Objective:Our aim was to analyze association of visit-to-visit blood pressure variability (BPV) with comorbidity and mortality in random sample of Croatian population, an original cohort from the EHUH study.Design and method:EHUH study is nation-wide survey on prevalence, treatment and control of hy

Objective:The aim of this study was to assess the association of chronic kidney disease (CKD) with all-cause and cardiovascular (CV) mortality in patients surviving their first ischemic stroke and enrolled in the Croatian part of the ESH Stroke Survey.Design and method:The cohort consisted of 292 co

Background Causes of death (CODs) of patients with systemic lupus erythematosus (SLE) comprise active SLE and comorbidities that develop as a result of SLE and immunosuppressive therapy: infections, cardiovascular disease and malignant tumors. Active disease and infections are typical causes of early death, while cardiovascular disease typically causes late death. However, COD frequencies depend on the source population and data ascertainment method. Objectives To identify and compare causes of early and late death of SLE patients deceased during a ten-year period. Methods We retrospectively identified SLE patients followed-up by our Department, deceased between 2002 and 2011, and included patients with ≥4 classification criteria of the American College of Rheumatology (ACR), ≥18 years of age and Croatian residency at the time of death. Death and causes of death were retrospectively identified using patient medical records, as well as death certificates and autopsy reports, when available. We also matched data on all SLE patients that visited our Department from 2002 to 2011 with the National Mortality Database. We classified CODs into five categories: active SLE, cardiovascular disease, infection, malignant tumor and other. More than one COD category was possible in a single patient. We compared the frequencies of each COD category between patients deceased within and after 5 years following diagnosis (early vs. late death). Frequencies were compared using the χ 2 and Fisher9s exact test, and continuous variables using the t-test and Mann-Whitney U test. The study was approved by the local ethics committee. Results We identified 90 deceased patients (68 females, 22 males; 21 in the early death group (EDG), 69 in the late death group (LDG)). EDG patients were older than LDG patients at diagnosis (mean age±SD: 56±15 vs. 46±17 years; p=0.005), but there was no difference between the age at death (mean age±SD: 58±15 years for all patients). Patients were followed-up for a median of 10 years (IQR: 5–15 years). LDG patients fulfilled a higher number of ACR criteria compared to EDG patients (median, IQR: 6, 5–7 vs. 5, 4–6; p=0.018). No difference between COD category frequencies was detected between EDG and LDG. Nevertheless, infections and active SLE were leading causes of early death (9/21 and 8/21, respectively), while cardiovascular disease was the most frequent cause of late death (30/69), followed by infection and active SLE (21/69 and 18/69, respectively)(Table). SLE was mentioned in the death-related medical records of only 41/90 patients. Conclusions Infections and active SLE are leading causes of early death, while cardiovascular disease is the most frequent cause of late death in SLE. Lack of recording of SLE in death-related medical records requires matching of clinical data with a complementary source, such as a population-based mortality database, to identify deceased SLE patients. References Nossent J et al. Lupus 2007;16:309–17. Disclosure of Interest None declared

The Republic of Croatia is a Parliamentary Republic with a population of 4.2 million people that sits on the Adriatic coast within Central Europe. Gross domestic product is approximately 60% of the European Union average, which in turn, limits health service spending. The health system is funded through universal health insurance administered by the Croatian Health Insurance Fund based on the principles of social solidarity and reciprocity. The children of Croatia are guaranteed access to universal primary, hospital, and specialist care provided by a network of health institutions. Pediatricians and school medicine specialists provide comprehensive preventive health care for both preschool and school-aged children. Despite the Croatian War of Independence in the late 20th century, indicators of child health and measures of health service delivery to children and families are steadily improving. However, similar to many European countries, Croatia is experiencing a rise in the "new morbidities" and is responding to these new challenges through a whole society approach to promote healthy lifestyles and insure good quality of life for children.

The aim of this paper is to determine the differences in the outpatient consumption of cardiovascular drugs between Croatian regions: the City of Zagreb and Lika-Senj County. The data on the number of packages and the purchase price for each drug have been obtained from all pharmacies in Lika-Senj County and all pharmacies in the City of Zagreb. Defined daily doses/1000 inhabitants/day (DDD/1000/day) was calculated for every drug in accordance with its code name and Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) index of the World Health Organization (WHO) for 2007. For drug combinations without defined daily doses, equivalent doses (ED) were used. The quality of drug prescribing within the group of cardiovascular drugs was assessed using the Drug Utilization (DU90%) method and the adherence of the DU90% segment to the guidelines for prescribing individual drug groups. The statistical significance of differences in results between the City of Zagreb and Lika-Senj County was tested using the chi-square test at the level of statistical significance p0.05. The comparison of the share of the five most often prescribed drug groups in Lika-Senj County has shown statistically significant differences when compared to the City of Zagreb (chi2 = 28.93, df = 4, p0.001). The total outpatient consumption of cardiovascular drugs in the City of Zagreb and Lika-Senj County differs significantly. The consumption, quality of prescribing drugs and cost/DDD in the City of Zagreb is higher than in Lika-Senj County; in the City of Zagreb, newer and more expensive drugs are prescribed to a higher extent.

BACKGROUND & AIMS: Undernutrition is a common and aggravating problem in people suffering from various chronic diseases as well as a source of material costs. The aim of this study was to investigate the prevalence of disease-related undernutrition among adults in Croatia in the year 2012, as well as the cost of undernutrition associated with tumour cachexia, chronic pancreatitis, inflammatory bowel disease, hepatic encephalopathy, chronic obstructive pulmonary disease, chronic renal insufficiency requiring dialysis, cerebrovascular insult, pressure ulcers, and femoral fractures in the elderly. ----- METHODS: A cost-of-illness analysis was conducted, including direct costs only. The study employed the dominant cost-of-illness method, which restricts the summation of medical expenditure to the disease of interest. The bottom-up, prevalence-based approach was used. The budget holder perspective was employed, and data sources include the list of reimbursed drugs, clinical opinions, and literature. ----- RESULTS: The prevalence of disease-related undernutrition in people over the age of 20 in Croatia in the year 2012 was estimated to be 33.7/1000. The total cost of adult malnutrition for selected diagnoses was 97.35 million EUR, accounting for 3.38% of the total Croatian national health care budget. The largest share was used for medications (43%), followed by 34% for hospitalizations, 13% for community health nursing, while parenteral and enteral nutrition contributed with 6% and 1% respectively. The average cost per patient was estimated at 1640.48 EUR. ----- CONCLUSIONS: The cost of malnutrition for the selected diagnoses in Croatia was substantial. These health costs will increase due to population ageing, which calls for undernutrition screening in people at risk as well as for effective approaches in nutrition supplementation.

Disease related malnutrition (DRM) and its risk are still highly prevalent in some patient populations, depending on patients' diagnoses and age, setting and assessment tools used. DRM is associated with increased morbidity and mortality, decreased QOL, frequent hospitalizations and increased health care costs. Moreover, the economic and human costs of malnutrition are avoidable. The purpose of the study is to estimate cost of DRM in Croatia by assessing direct costs related to hospitalizations, drug consumption, outpatient care in selected illnesses (IBD, gastric and lung cancers, chronic renal impairment and COPB). Selection was based on most evidential relations and available data. Secondary objective was to calculate and compare the total and per capita medical expenditures for people with DRM and identify cost saving potential.

Assessing the adverse events costs of comparable regimens (sunitinib vs bevacizumab) in context of budget impact analysis in Croatian setting. Authors have assessed costs and outcomes of bevacizumab and sunitinib via systematic review, performed in January 2011. Survival rates, incidence and prevalence was assessed via Croatian National Cancer Registry, and the model was verified with Monte Carlo simulations. Direct drug, adverse events and treatment costs were calculated in kuna/per patient yearly according to price listings of National Institute for Health Insurance. Local data was verified with structured interviews gathered with Croatian oncologists (N=6) involved in this indication in their daily practice. Focus of the analysis was the drug cost and the adverse events treatment cost. Sunitinib has showed costly side effects such as neutropenia, trombocitopenia, hypothiroidism and cardiovascular complications. The cost of adverse events (aforementioned) for sunitinib per patient yearly is 3.904 HRK (535 EUR), whereas for bevacizumab is 1.404 HRK (192 EUR). Bevacizumab demonstrated significantly lower adverse events costs than sunitinib. Overall budget impact (from payers perspective) when bevacizumab is introduced equals -29.753, 52 HRK (-4075 EUR) of savings yearly per patient. At current costs, head to head drug price comparison demonstrates that bevacizumab is less costly, demonstrating dominant ability to reduce costs due to less frequent and less costly adverse events, whereas in budget impact context introducing bevacizumab brings savings.

The role of general practitioner/family physician (GP/FP) in disease prevention and health promotion is strongly supported by research and health policies. The position of GPs/FPs in the health care system and their close, sustained contact with their patients and local community makes preventive care an integral part of GP/FP routine work. The spectrum of caring for patients in general practice/family medicine is actually very large, going from intervention on health care determinants to palliative care. The prevention-related activities are more or less present at each step of this "healthcare continuum". The significant gaps between GP/FP knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention. We describe the role of GP/FP in preventive care and report data on preventive care activities in the Croatian Family Medicine Service. More objective evidence is needed to see what GPs/FPs actually do in practice. For this reason, it is critical that GPs/FPs systematically record the most relevant preventive and health promotion activities that they perform. Furthermore, their performance of the preventive program should be regularly monitored, evaluated and professionally and financially validated. We present the preventive program based on these principles in Family Medicine Service proposed by the Ministry of Health and Social Welfare Working Group on Reform of Primary Health Care.

One of the main conceptual changes in the 20th century medicine is the inclusion of social dimension. The “golden era” of Parson’s medical model (1), which uses the “active-passive” dichotomy to describe the positions and expectations of physicians and patients, is over. Physicians’ supremacy has slowly and systematically been challenged by the emergence of third party stakeholders, development of new media sources, strengthening of the civil society, and democratization of information, which all have contributed to the development of the patients’ active role in the healing processes (2). The rise of medical consumerism has stimulated the medical authorities to react with a new ideological policy: the patient- oriented medicine, insisting on the partnership in the diagnostic and therapeutic processes, and viewing the patient as a person with biological, psychological, social, and spiritual needs (2).

The primary goal of this research is to compare risks and occurrence of HIV infection in Osijek-Baranja and Zadar County. Several chosen socioeconomic factors controlled by sex and age were investigated including level of education, employment and marital status of the free-of charge voluntary counseling and testing center (VCT) customers in the towns of Osijek and Zadar and their risk behaviors for acquiring HIV. Bivariate analysis of the differences between the customers from Osijek and Zadar showed statistically significant differences in the following variables: gender, education, number of VCT clients who use intravenous drugs (IDU), promiscuous behavior, number of homosexual clients, mode of receiving information on the VCT services, marital and partnership status, having children, inclination towards homosexual and bisexual relations, the main reasons for not using condoms, injecting drugs (IDU) needle sharing and the occurrence of hepatitis C. The analysis showed that significantly more males were counseled and tested in the city of Osijek, significantly less hepatitis C positive persons and promiscuity among all behavioral risk factors more often. A higher number of the customers of the VCT in the city of Osjek were "in permanent" relationship. Strategic management of health and health care, methods of comparing regional and national standardized indicators can provide valuable information about setting the focus, choosing priorities and establishing a good economic policy at the micro level. This study clearly established the dimensions of problems in HIV/AIDS prevention onto which it should be influenced through regional and local measures and actions. The indexes measured indicate which special initiatives and programs should be focused and set up as priorities in particular regions. The determined differences point to the need for a regional approach to HIV/AIDS prevention in purpose of improving preventive activities according to most common risk behaviors. Even though Croatia is a relatively small country, it has many regional and local features which need to be taken into consideration when developing prevention programs and activities.

Uloga liječnika opće/obiteljske medicine u prevenciji bolesti i promociji zdravlja potvrđena je rezultatima istraživanja te u zdravstvenoj politici. S obzirom na položaj liječnika opće/obiteljske medicine u zdravstvenom sustavu i njegov bliski, trajni kontakt s populacijom koja ga je izabrala te s lokalnom zajednicom u kojoj djeluje, razumljivo je da je liječniku opće/obiteljske medicine preventivni rad uključen kao neodvojivi dio redovitog, uobičajenog rada u praksi. Skrb za bolesnika u općoj medicini je kompleksna i proteže se od intervencija u determinantama zdravlja do palijativne skrbi. Preventivne aktivnosti su više ili manje prisutne na svakom odsječku tog procesa. Postoji značajan raskorak između znanja liječnika opće/obiteljske medicine i postojeće prakse u korištenju na znanstvenim dokazima utemeljenih preporuka za aktivnosti u promociji zdravlja i prevenciji bolesti. Opisali smo ulogu liječnika opće obiteljske medicine u preventivnom radu i prikazali podatke o preventivnima aktivnostima u službi obiteljske medicine u Hrvatskoj. Za pravu ocjenu preventivnog rada obiteljskih liječnika potrebno je raspolagati objektivnim na znanstvenim dokazima utemeljenim podacima koji će pokazati što obiteljski liječnici rade u praksi. Zbog toga je nužno da liječnici sistematski bilježe i evaluiraju relevantne preventivne aktivnosti i aktivnosti koje provode u promociji zdravlja, a da se njihovo izvršenje programa redovito prati, evaluira te profesionalno i financijski vrednuje. Prema tim je principima Stručna radna skupina za koordinaciju, praćenje i usmjeravanje reforme u obiteljskoj medicini Ministarstva zdravstva i socijalne skrbi Republike Hrvatske izradila program preventivnih aktivnosti u obteljskoj medicini koji je prikazan u ovom radu, The role of general practitioner/family physician (GP/FP) in disease prevention and health promotion is strongly supported by research and health policies. The position of GPs/FPs in the health care system and their close, sustained contact with their patients and local community makes preventive care an integral part of GP/FP routine work. The spectrum of caring for patients in general practice/family medicine is actually very large, going from intervention on health care determinants to palliative care. The prevention-related activities are more or less present at each step of this “healthcare continuum”. The significant gaps between GP/FP knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention. We describe the role of GP/FP in preventive care and report data on preventive care activities in the Croatian Family Medicine Service. More objective evidence is needed to see what GPs/FPs actually do in practice. For this reason, it is critical that GPs/FPs systematically record the most relevant preventive and health promotion activities that they perform. Furthermore, their performance of the preventive program should be regularly monitored, evaluated and professionally and financially validated. We present the preventive program based on these principles in Family Medicine Service proposed by the Ministry of Health and Social Welfare Working Group on Reform of Primary Health Care.

In isolated human communities infectious diseases often occur in unusual forms and reveal unexpected patterns of spread. This is not due to differences in biological characteristics of affected populations or infectious agents, but rather a consequence of specific changes in conditions under which the epidemics occur in isolated populations. The aim of this study was to analyze the patterns of the occurrence of salmonellosis, streptococcal angina, varicellae and scabies in 10 Croatian islands (Krk, Cres, Losinj, Rab, Pag, Brac, Hvar, Korcula, Vis and Lastovo) and in the entire Croatian population between 1989 and 1998. The four investigated diseases were selected based on: (1) sufficient number of cases each year the islands to warrant appropriate analysis of occurrence patterns; (2) different pathogenic mechanisms which include alimentary and respiratory bacterial infection, highly contagious viral infection and parasitic disease. The comparison of standardized rates of infection between the island populations and Croatian general population revealed large differences. In the islands the epidemics were less frequent in time, but of much greater intensity, especially in smaller and very isolated communities. Factors such as specific food and water supply, ecologic peculiarities, sociodemographic structure and population subdivision could have contributed to the determination of epidemic patterns in human isolates.

Health emergency service teams play an important role in the management of patients with acute coronary syndrome. They have to be educated, equipped, skilful and supported by the entire health care system. The role of county health center in the management of patients with acute coronary syndrome is illustrated in the article, based on the experience acquired at Medimurje County Health Center from Cakovec. The reformed Health Center activities including organization, coordination and linking of teams, population health monitoring at the local level, epidemiologic surveillance, education (active and passive, on both sides of college chair), joint diagnostic and other services, and quality control are discussed in detail. In contrast to a bureaucratic and formal one, a real and innovative reform should take account of necessary changes in the management and organization, not just in standards, rights and obligations. The management protocol for acute coronary syndrome patients is described: setting the main objective (acute coronary disease morbidity and mortality reduction), setting short-term and long-term specific goals, adoption of strategy based on the main objective (education, completion and particular programs pursuit, connecting, collaboration, quality assurance through clinical guidelines and protocols) and other elements, including dignity, leadership, teamwork, adoption and implementation of patient management protocols.

Even the most socially aware countries in the World have noticed the gap increase between the poorest and the richest population groups. The purpose of this study was to investigate the presence of inequity and to identify main barriers for equitable health care utilization by economic status, region and area of living, controlled for health needs in the Croatian adult population. The data from the Croatian Adult Health Survey 2003 were used in this study. The results show that among the respondents with higher health needs, those with economic status above average had higher proportion of regular annual general practitioner and medical specialist visits. In contrast, highly frequent visits to physician were more common in respondents who were below average economic status. Economically worse-off women, regardless on their health care needs reported gynecologist visits less regularly than the better-off women. Long waiting and the large distance from the health care facilities were the most commonly reported barriers in health care utilization. High expenses were present as the main barrier at dentist and inpatient health services utilization. Suburban and rural settlements were more burdened with long distance from the health care facilities and high expenses for all health services, aggravated by the long waiting time for visits to GP. Respondents from the urban settings reported long waiting time and unkindness of the health personnel as the main barriers. The results of this study clearly show the main barriers in the equitable health care delivery to Croatia population from the health care users perspective.

In 2006, the Croatian Ministry of Science, Education, and Sports has completed the review process of more than 3000 research proposals for the new 5-year funding cycle (2007-2011). The grant submission process was similar to the procedure used by the European Commission (Framework Programmes, FP). The new grant program encouraged the formation of national-level consortia, which linked several research projects from different institutions into greater and more efficient programs, and favored the projects with international collaboration. It also ensured greater attention to ethical aspects of the submitted proposals (1). Aside from some persisting problems such as excessive length of the review process, which took 10 months, and high overall success rate, which was over 70% after the first call, the new process nevertheless represented a substantial improvement over previous practices in terms of transparency, supporting web-based technology, and the attention it paid to ethical aspects of the proposed research. The most interesting outcome of this process were a few rare and genuine attempts to synchronize and coordinate several institutions within the country into larger “research programs.” Such clusters of research groups aim to become competitive at the European level and join the successful consortia within the new FP7. There is hope that they could serve as examples that could increase the international impact of the Croatian scientific production, which was heavily affected during and after the war years (1991-1995). One of the best examples is “The Croatian National Biobank,” a consortium now linking more than 20 research projects, either awarded or presently under review, from all four Medical Schools in Croatia, several teaching hospitals, and public health institutes. It is coordinated from the recently founded Croatian Centre for Global Health, based at the University of Split School of Medicine (2). In its infancy, the national Biobank will rely on 3 large resources that should ensure and maintain its international competitiveness: 1) “10 001 Dalmatians” study of Croatian island isolates; 2) a hospital-based DNA bank with thousands of cases with most common complex diseases; and 3) a large cohort from general population to serve as a control sample. The first resource is an internationally already recognized study of genetic and environmental determinants of health and disease in genetic-isolate island populations from Dalmatia, Croatia. This effort, aiming to recruit 10 001 examinees, has developed during the recent years, in collaboration mainly with the scientists from Scotland, but also from Sweden, The Netherlands, Italy, and Germany. In the period 2001-2007, it already received substantial competitive funding from The Croatian Government, European FP6, UK Medical Research Council, UK Royal Society, The Wellcome Trust, US National Institutes of Health, and The British Council. This “flagship” of the post-war Croatian science has had 3 publications in one of the leading journals in the field of genetics, Nature Genetics (3-5) and several more articles in other high-impact genetics journals (6-13). The project has also contributed to the characterization of the two indigenous Mendelian genetic disorders (14,15). In 2006, the Croatian Medical Journal devoted a theme issue, with 17 articles, to the results arising from this research program (16,17). The second resource, planned as a large and important building block of the Croatian National Biobank, is a network of hospital-based registries of patients with specific diseases. The project, which received ethical approval of the ethics committee of the Sisters of Mercy University Hospital in Zagreb, aims to create a large DNA bank of up to 20 000 cases of complex chronic diseases by 2011. To achieve this, participating hospitals and public health institutes will form several national registries of diseases of unknown etiology and without preventable risk factors, such as amyotrophic lateral sclerosis, multiple sclerosis, diabetes type 1, specific early-onset cancers, and a spectrum of childhood illnesses. In addition, cases of the most common complex diseases, which form the greatest share of the overall disease burden in the Croatian population, will be collected: myocardial infarction; cerebral stroke; breast, lung, and colorectal cancer; type 2 diabetes; depression; schizophrenia; renal stones and gallstones; gout; eye diseases; Parkinson and Alzheimer diseases; osteoporosis; rheumatoid arthritis; and others. Finally, a representative sample of several thousands of individuals from general Croatian population will be collected from many of the participating institutions as a control population for the two resources described above. This will be a “targeted sample,” which will correspond closely to the demographic characteristics of the Croatian population. It will also be DNA-based. In this sample, information on the lifestyle, habits, exposure to health risks, health attitudes, and medical history will be documented using standard and internationally validated questionnaires. The main aim of the research within the Croatian National Biobank will be to discover and illuminate the nature of the relationships between: 1) genomic sequence and sophisticated circulating metabolites; 2) circulating metabolites and quantitative biological traits of relevance to human health and disease; and 3) quantitative biological traits and human diseases of complex etiology. The Croatian National Biobank will take into consideration 4 general levels of complexity involved in the development of human diseases: 1) genomics level; 2) “metabolomics” level (including proteomics, glycomics, and lipidomics); 3) level of intermediate quantitative traits (eg, blood pressure, forced expiratory capacity, cholesterol levels, etc.); and 4) endpoint that results in a complex disease phenotype. It will probably be easier to demonstrate and explore the associations between “neighboring” levels of complexity, while the associations across the levels will be more likely to be weak and of relatively small effect size. At each of these levels, modifiers such as environmental, cultural, socio-economic, and psychological influences can also play an important role. The interactions between those “outside” influences and biological factors will also be studied. Figure 1 shows the structure of the Croatian National Biobank, presenting all contributing resources. The central resource will be a databank of 10 001 examinees collected at the Croatian Centre for Global Health in Split, Croatia. In these healthy examinees, genome scanning will be performed (using dense genome-wide scans with hundreds of thousands of genomic markers), followed by sequencing. In addition, hundreds of metabolites will be measured in plasma of all individuals, based on high-throughput technologies such as mass-spectrometry and high-performance liquid chromatography. This will involve proteomics, glycomics, and lipidomics measurements (“metabolomics”). Genetic sequence variants and structural genetic variants will then be associated with changes in the levels of individual metabolites and the effects of metabolite changes on complex quantitative traits will also be assessed. Eventually, public health relevance of identified genetic variants that could be used in genetic testing, metabolites that could potentially represent disease markers, and quantitative traits that could represent significant health risks will then be assessed in large collections of diseased individuals and controls from the general population. The diseased individuals will be approached in participating hospitals, while the examinees for the control sample will be recruited through a network of collaborating institutions (such as the National Institute for Public Health and 4 University Medical Schools in all parts of Croatia) (Figure 1). Figure 1 Schematic representation of the resources that will contribute to The Croatian Biobank in the future. HPLC – high-performance liquid chromatography. More than 150 Croatian researchers from a variety of scientific backgrounds and disciplines will also be involved in this project and will continuously seek and expand their international collaborations. This should ensure sustainable growth of the program and its lasting international competitiveness. We hope that the Croatian National Biobank could substantially increase international visibility and productivity of Croatian biomedical research in the 21st century.