Search

Mònica Monteagudo,1,2 Montse Roset,3 Teresa Rodriguez-Blanco,1,2 Laura Muñoz,4 Marc Miravitlles5 1Primary Care University Research Institute Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; 2Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; 3IMS Health, Barcelona, Spain; 4Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain; 5Pneumology Department, Hospital Universitari Vall d’Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain Objective: To describe and compare demographic and clinical profile of patients newly initiated on aclidinium (ACL) or tiotropium (TIO) and identify factors associated with newly initiated ACL in real-life clinical practice during 2013 in Catalonia.Design: We performed a population-based, retrospective, observational study with data obtained from the Information System for Research Development in Primary Care, a population database that contains information of 5.8 million inhabitants (more than 80% of the Catalan population). Patients over 40 years old, with a recorded diagnosis of COPD and newly initiated treatment with either ACL or TIO during the study period (January to December 2013), were selected. A descriptive analysis of demographic and clinical characteristics was performed, and treatment adherence was also assessed for both cohorts.Results: A total of 8,863 individuals were identified, 4,293 initiated with ACL and 4,570 with TIO. They had a mean age of 69.4 years (standard deviation: 11.3), a median COPD duration of 3 years (interquartile range: 0–8), and 71% were males. Patients treated with ACL were older, with more respiratory comorbidities, a longer time since COPD diagnosis, worse forced expiratory volume in 1 second (% predicted), and with a higher rate of exacerbations during the previous year compared with TIO. It was found that 41.3% of patients with ACL and 62.3% of patients with TIO had no previous COPD treatment. Inhaled corticosteroid and long-acting β2-agonist were the most frequent concomitant medications (32.9% and 32.6%, respectively). Approximately 75% of patients were persistent with ACL or TIO at 3 months from the beginning of treatment, and more than 50% of patients remained persistent at 9 months.Conclusion: Patients initiated with ACL had more severe COPD and were taking more concomitant respiratory medications than patients initiated with TIO. ACL was more frequently initiated as part of triple therapy, while TIO was more frequently initiated as monotherapy. Keywords: COPD, treatment, primary care, adherence

Objective The objective of this study was to investigate incidence and mortality from ischemic stroke in older adults with specific underlying chronic conditions, evaluating the influence of these conditions in developing stroke. Materials & methods Population-based cohort study involving 27,204 individuals ≥60 years old in Southern Catalonia, Spain. All cases of hospitalization from ischemic stroke (confirmed by neuro-imaging) were collected from 01/12/2008 until 30/11/2011. Incidence rates and 30-day mortality were estimated according to age, sex, chronic illnesses, and underlying conditions. Multivariable Cox regression analysis was used to calculate Hazards Ratio ( HR) and estimate the association between baseline conditions and risk of developing stroke. Results Mean incidence rate reached 453 cases per 100,000 person-years. Maximum rates appeared among individuals with history of prior stroke (2926 per 100,000), atrial fibrillation (1815 per 100,000), coronary artery disease (1104 per 100,000), nursing-home residence (1014 per 100,000), and advanced age ≥80 years (1006 per 100,000). Thirty-day mortality was 13% overall, reaching 21% among patients over 80 years. Age [ HR: 1.06; 95% confidence interval ( CI): 1.04-1.07], history of prior stroke ( HR: 5.08; 95% CI: 3.96-6.51), history of coronary artery disease ( HR: 1.65; 95% CI: 1.21-2.25), atrial fibrillation ( HR: 2.96; 95% CI: 2.30-3.81), diabetes mellitus ( HR: 1.55; 95% CI: 1.23-1.95), and smoking ( HR: 1.64; 95% CI: 1.15-2.34) emerged independently associated with an increased risk of ischemic stroke. Conclusion Incidence and mortality from ischemic stroke remains considerable. Apart from age and history of atherosclerosis (prior stroke or coronary artery disease), atrial fibrillation, diabetes, and smoking were the underlying conditions most strongly associated with an increased risk. [ABSTRACT FROM AUTHOR]

Abstract Background Conflicting results have been recently reported evaluating the relationship between pneumococcal vaccination and the risk of thrombotic vascular events. This study assessed the clinical effectiveness of the 23-valent polysaccharide pneumococcal vaccine (PPV23) against acute myocardial infarction and ischaemic stroke in older adults. Methods Population-based prospective cohort study conducted from December 1, 2008 until November 30, 2009, including all individuals ≥ 60 years-old assigned to nine Primary Care Centres in Tarragona, Spain (N = 27,204 individuals). Primary outcomes were hospitalisation for acute myocardial infarction and/or ischaemic stroke. All cases were validated by checking clinical records. The association between pneumococcal vaccination and the risk of each outcome was evaluated by Multivariable Cox proportional-hazard models (adjusted by age, sex, influenza vaccine status, presence of comorbidities and cardiovascular risk factors). Results Cohort members were followed for a total of 26,444 person-years, of which 34% were for vaccinated subjects. Overall incidence rates (per 1000 person-years) were 4.9 for myocardial infarction and 4.6 for ischaemic stroke. In the multivariable analysis, vaccination was associated with a marginally significant 35% lower risk of stroke (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.42-0.99; p = 0.046). We found no evidence for an association between pneumococcal vaccination and reduced risk of myocardial infarction (HR: 0.83; 95% CI: 0.56-1.22; p = 0.347). Conclusions Our data supports a benefit of PPV23 against ischaemic stroke among the general population over 60 years, suggesting a possible protective role of pneumococcal vaccination against some acute thrombotic events.

Abstract Background Low back pain (LBP), with high incidence and prevalence rate, is one of the most common reasons to consult the health system and is responsible for a significant amount of sick leave, leading to high health and social costs. The objective of the study is to assess the cost-effectiveness and cost-utility analysis of a multidisciplinary biopsychosocial educational group intervention (MBEGI) of non-specific sub-acute LBP in comparison with the usual care in the working population recruited in primary healthcare centres. Methods/design The study design is a cost-effectiveness and cost-utility analysis of a MBEGI in comparison with the usual care of non-specific sub-acute LBP. Measures on effectiveness and costs of both interventions will be obtained from a cluster randomised controlled clinical trial carried out in 38 Catalan primary health care centres, enrolling 932 patients between 18 and 65 years old with a diagnosis of non-specific sub-acute LBP. Effectiveness measures are: pharmaceutical treatments, work sick leave (% and duration in days), Roland Morris disability, McGill pain intensity, Fear Avoidance Beliefs (FAB) and Golberg Questionnaires. Utility measures will be calculated from the SF-12. The analysis will be performed from a social perspective. The temporal horizon is at 3 months (change to chronic LBP) and 12 months (evaluate the outcomes at long term). Assessment of outcomes will be blinded and will follow the intention-to-treat principle. Discussion We hope to demonstrate the cost-effectiveness and cost-utility of MBEGI, see an improvement in the patients' quality of life, achieve a reduction in the duration of episodes and the chronicity of non-specific low back pain, and be able to report a decrease in the social costs. If the intervention is cost-effectiveness and cost-utility, it could be applied to Primary Health Care Centres. Trial registration ISRCTN: ISRCTN58719694

Abstract Background The prevalence of smoking in Spain is high in both men and women. The aim of our study was to evaluate the role of gender in the effectiveness of a specific smoking cessation intervention conducted in Spain. Methods This study was a secondary analysis of a cluster randomized clinical trial in which the randomization unit was the Basic Care Unit (family physician and nurse who care for the same group of patients). The intervention consisted of a six-month period of implementing the recommendations of a Clinical Practice Guideline. A total of 2,937 current smokers at 82 Primary Care Centers in 13 different regions of Spain were included (2003-2005). The success rate was measured by a six-month continued abstinence rate at the one-year follow-up. A logistic mixed-effects regression model, taking Basic Care Units as random-effect parameter, was performed in order to analyze gender as a predictor of smoking cessation. Results At the one-year follow-up, the six-month continuous abstinence quit rate was 9.4% in men and 8.5% in women (p = 0.400). The logistic mixed-effects regression model showed that women did not have a higher odds of being an ex-smoker than men after the analysis was adjusted for confounders (OR adjusted = 0.9, 95% CI = 0.7-1.2). Conclusions Gender does not appear to be a predictor of smoking cessation at the one-year follow-up in individuals presenting at Primary Care Centers. ClinicalTrials.gov Identifier NCT00125905.

Abstract Background The 23-valent polysaccharide pneumococcal vaccine (PPV) is currently recommended in elderly and high-risk adults. However, its efficacy in preventing pneumococcal infections remains controversial. This study assessed the clinical effectiveness of vaccination against invasive pneumococcal disease (IPD) among people over 60 years. Methods Population-based case-control study that included 88 case patients over 60 years-old with a laboratory-confirmed IPD (bacteraemic pneumonia, meningitis or sepsis) and 176 outpatient control subjects who were matched by primary care centre, age, sex and risk stratum. Adjusted odds ratios (ORs) for vaccination were calculated using conditional logistic regression, controlling for underlying conditions. Vaccine effectiveness was estimated as (1 - OR) ×100. Results Pneumococcal vaccination rate was significantly lower in cases than in control subjects (38.6% vs 59.1%; p = 0.002). The adjusted vaccine effectiveness was 72% (OR: 0.28; 95% CI: 0.15-0.54) against all IPD and 77% (OR: 0.23; 95% CI: 0.08-0.60) against vaccine-type IPD. Vaccination was significantly effective against all IPD in both age groups: 60-79 years-old (OR 0.32; 95% CI: 0.14-0.74) and people 80 years or older (OR: 0.29; 95% CI: 0.09-0.91). Vaccination appears significantly effective as for high-risk immunocompetent subjects (OR: 0.29; 95% CI: 0.11-0.79) as well as for immunocompromised subjects (OR: 0.12; 95% CI: 0.03-0.53). Conclusion These findings confirm the effectiveness of the 23-valent PPV against IPD, and they also support the benefit of vaccination in preventing invasive infections among high-risk and older people.

Abstract Background Non-specific low back pain is a common cause for consultation with the general practitioner, generating increased health and social costs. This study will analyse the effectiveness of a multidisciplinary intervention to reduce disability, severity of pain, anxiety and depression, to improve quality of life and to reduce the incidence of chronic low back pain in the working population with non-specific low back pain, compared to usual clinical care. Methods/Design A Cluster randomised clinical trial will be conducted in 38 Primary Health Care Centres located in Barcelona, Spain and its surrounding areas. The centres are randomly allocated to the multidisciplinary intervention or to usual clinical care. Patients between 18 and 65 years old (n = 932; 466 per arm) and with a diagnostic of a non-specific sub-acute low back pain are included. Patients in the intervention group are receiving the recommendations of clinical practice guidelines, in addition to a biopsychosocial multidisciplinary intervention consisting of group educational sessions lasting a total of 10 hours. The main outcome is change in the score in the Roland Morris disability questionnaire at three months after onset of pain. Other outcomes are severity of pain, quality of life, duration of current non-specific low back pain episode, work sick leave and duration, Fear Avoidance Beliefs and Goldberg Questionnaires. Outcomes will be assessed at baseline, 3, 6 and 12 months. Analysis will be by intention to treat. The intervention effect will be assessed through the standard error of measurement and the effect-size. Responsiveness of each scale will be evaluated by standardised response mean and receiver-operating characteristic method. Recovery according to the patient will be used as an external criterion. A multilevel regression will be performed on repeated measures. The time until the current episode of low back pain takes to subside will be analysed by Cox regression. Discussion We hope to provide evidence of the effectiveness of the proposed biopsychosocial multidisciplinary intervention in avoiding the chronification of low back pain, and to reduce the duration of non-specific low back pain episodes. If the intervention is effective, it could be applied to Primary Health Care Centres. Trial Registration ISRCTN21392091

Abstract Background Preventive activities carried out in primary care have important variability that makes necessary to know which factors have an impact in order to establish future strategies for improvement. The present study has three objectives: 1) To describe the variability in the implementation of 7 preventive services (screening for smoking status, alcohol abuse, hypertension, hypercholesterolemia, obesity, influenza and tetanus immunization) and to determine their related factors; 2) To describe the degree of control of 5 identified health problems (smoking, alcohol abuse, hypertension, hypercholesterolemia and obesity); 3) To calculate intraclass correlation coefficients. Design Multi-centered cross-sectional study of a randomised sample of primary health care teams from 3 regions of Spain designed to analyse variability and related factors of 7 selected preventive services in years 2006 and 2007. At the end of 2008, we will perform a cross-sectional study of a cohort of patients attended in 2006 or 2007 to asses the degree of control of 5 identified health problems. All subjects older than16 years assigned to a randomised sample of 22 computerized primary health care teams and attended during the study period are included in each region providing a sample with more than 850.000 subjects. The main outcome measures will be implementation of 7 preventive services and control of 5 identified health problems. Furthermore, there will be 3 levels of data collection: 1) Patient level (age, gender, morbidity, preventive services, attendance); 2) Health-care professional level (professional characteristics, years working at the team, workload); 3) Team level (characteristics, electronic clinical record system). Data will be transferred from electronic clinical records to a central database with prior encryption and dissociation of subject, professional and team identity. Global and regional analysis will be performed including standard analysis for primary health care teams and health-care professional level. Linear and logistic regression multilevel analysis adjusted for individual and cluster variables will also be performed. Variability in the number of preventive services implemented will be calculated with Poisson multilevel models. Team and health-care professional will be considered random effects. Intraclass correlation coefficients, standard error and variance components for the different outcome measures will be calculated.

Background: Non-specific low back pain is a common cause for consultation with the general practitioner, generating increased health and social costs. This study will analyse the effectiveness of a multidisciplinary intervention to reduce disability, severity of pain, anxiety and depression, to improve quality of life and to reduce the incidence of chronic low back pain in the working population with non-specific low back pain, compared to usual clinical care.Methods/design: A Cluster randomised clinical trial will be conducted in 38 Primary Health Care Centres located in Barcelona, Spain and its surrounding areas. The centres are randomly allocated to the multidisciplinary intervention or to usual clinical care. Patients between 18 and 65 years old (n = 932; 466 per arm) and with a diagnostic of a non-specific sub-acute low back pain are included. Patients in the intervention group are receiving the recommendations of clinical practice guidelines, in addition to a biopsychosocial multidisciplinary intervention consisting of group educational sessions lasting a total of 10 hours. The main outcome is change in the score in the Roland Morris disability questionnaire at three months after onset of pain. Other outcomes are severity of pain, quality of life, duration of current non-specific low back pain episode, work sick leave and duration, Fear Avoidance Beliefs and Goldberg Questionnaires. Outcomes will be assessed at baseline, 3, 6 and 12 months. Analysis will be by intention to treat. The intervention effect will be assessed through the standard error of measurement and the effect-size. Responsiveness of each scale will be evaluated by standardised response mean and receiver-operating characteristic method. Recovery according to the patient will be used as an external criterion. A multilevel regression will be performed on repeated measures. The time until the current episode of low back pain takes to subside will be analysed by Cox regression.Discussion: We hope to provide evidence of the effectiveness of the proposed biopsychosocial multidisciplinary intervention in avoiding the chronification of low back pain, and to reduce the duration of non-specific low back pain episodes. If the intervention is effective, it could be applied to Primary Health Care Centres.Trial Registration: ISRCTN21392091. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to analyse the impact of comprehensive smoke-free legislation (SFL) on the prevalence and incidence of adult smoking in primary healthcare (PHC) patients from three Spanish regions, overall and stratified by sex., Design: Longitudinal observational study conducted between 2008 and 2013., Setting: 66 PHC teams in Catalonia, Navarre and the Balearic Islands (Spain)., Participants: Population over 15 years of age assigned to PHC teams., Primary and Secondary Outcomes Measures: Quarterly age-standardised prevalence of non-smoker, smoker and ex-smoker and incidence of new smoker, new ex-smoker and ex-smoker relapse rates were estimated with data retrieved from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardised prevalence and incidence rates. Trends were expressed as annual percentage change and average annual percent change., Results: The overall standardised smoker prevalence rate showed a significant downward trend (higher in men than women) and the overall standardised ex-smoker prevalence rate showed a significant increased trend (higher in women than men) in the three regions. Standardised smoker and ex-smoker prevalence rates were higher for men than women in all regions. With regard to overall trends of incidence rates, new smokers decreased significantly in Catalonia and Navarre and similarly in men and women, new ex-smokers decreased significantly and more in men in Catalonia and the Balearic Islands, and ex-smoker relapse increased in Catalonia (particularly in women) and decreased in Navarre., Conclusions: Trends in smoking behaviour in PHC patients remain unchanged after the implementation of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the preceding partial SFL., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex., Methods: Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma ≥ 16 years and coronary disease ≥ 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC)., Results: The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC: -8.00%, 95% CI: -10.46; -5.47) and Navarre (AAPC: -3.66%, 95% CI: -4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia., Conclusion: No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL.

Objective: The aim was to compare multimorbidity patterns identified with the two most commonly used methods: hierarchical cluster analysis (HCA) and exploratory factor analysis (EFA) in a large primary care database. Specific objectives were: (1) to determine whether choice of method affects the composition of these patterns and (2) to consider the potential application of each method in the clinical setting., Design: Cross-sectional study. Diagnoses were based on the 263 corresponding blocks of the International Classification of Diseases version 10. Multimorbidity patterns were identified using HCA and EFA. Analysis was stratified by sex, and results compared for each method., Setting and Participants: Electronic health records for 408 994 patients with multimorbidity aged 45-64 years in 274 primary health care teams from 2010 in Catalonia, Spain., Results: HCA identified 53 clusters for women, with just 12 clusters including at least 2 diagnoses, and 15 clusters for men, all of them including at least two diagnoses. EFA showed 9 factors for women and 10 factors for men. We observed differences by sex and method of analysis, although some patterns were consistent. Three combinations of diseases were observed consistently across sex groups and across both methods: hypertension and obesity, spondylopathies and deforming dorsopathies, and dermatitis eczema and mycosis., Conclusions: This study showed that multimorbidity patterns vary depending on the method of analysis used (HCA vs EFA) and provided new evidence about the known limitations of attempts to compare multimorbidity patterns in real-world data studies. We found that EFA was useful in describing comorbidity relationships and HCA could be useful for in-depth study of multimorbidity. Our results suggest possible applications for each of these methods in clinical and research settings, and add information about some aspects that must be considered in standardisation of future studies: spectrum of diseases, data usage and methods of analysis., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The mortality from all malignant and nonmalignant asbestos-related diseases remains unknown. The authors assessed the incidence and risk factors for all asbestos-related deaths., Methods: The sample included 544 patients from an asbestos-exposed community in the area of Barcelona (Spain), between Jan 1, 1970, and Dec 31, 2006. Competing risk regression through a subdistribution hazard analysis was used to estimate risk factors for the outcomes., Results: Asbestos-related deaths were observed in 167 (30.7%) patients and 57.5% of these deaths were caused by some type of mesothelioma. The incidence rate after diagnosis was 3,600 per 100,000 person-years. In 7.5% of patients death was non-asbestos-related, while pleural and peritoneal mesothelioma were identified in 87 (16.0%) and 18 (3.3%) patients, respectively., Conclusions: Age, sex, household exposure, cumulative nonmalignant asbestos-related disease, and single malignant pathology were identified as risk factors for asbestos-related death. These findings suggest the need to develop a preventive approach to the community and to improve the clinical follow-up process of these patients.

Objective: The aim of this study was to identify multimorbidity patterns in patients from 19 to 44 years attended in primary care in Catalonia in 2010., Design: Cross-sectional study., Setting: 251 primary care centres., Participants: 530,798 people with multimorbidity, aged 19 to 44 years., Main Outcome Measures: Multimorbidity was defined as the coexistence of ≥2 more International Classification system (ICD-10) registered in the electronic health record. Multimorbidity patterns were identified using hierarchical cluster analysis and by sex and age group (19-24 and 25-44)., Results: Of the 882,708 people from initial population, 530,798 (60.1%) accomplished multimorbidity criterion. Mean age was 33.0 years (SD: 7.0) and 53.3% were women. Multimorbidity was higher in the 25-to 44-years-old group with respect the younger group (60.5 vs. 58.1%, p<0.001), being higher in women. Most prevalent cluster in all groups included, among others, by dental caries, smoking, dorsalgia, common cold and other anxiety disorders. For both sexes in the 25-to 44-years-old group appeared the cardiovascular-endocrine-metabolic pattern (obesity, lipid disorders and arterial hypertension)., Conclusions: Multimorbidity affects more than half of persons between 19 to 44-years-old. The most prevalent cluster is formed by grouping common diseases (dental caries, common cold, smoking, anxiety disorders and dorsalgias). Another pattern to highlight is the cardiovascular-endocrine-metabolic pattern in the 25- to 44 years-old group. Knowledge of patterns of multimorbidity in young adults could be used to design individualized preventive strategies., (Copyright © 2015 Elsevier España, S.L.U. All rights reserved.)

Background: This study investigated the burden (incidence, mortality and serotype distribution) of pneumococcal pneumonia among older adults in the region of Tarragona (Spain)., Methods: Population-based cohort study involving 27,204 individuals ≥60 years in Tarragonès county (Southern Catalonia), who were prospectively followed between 01/12/2008 and 30/11/2011. Bacteremic and nonbacteremic (positive sputum culture and/or urinary antigen test) pneumococcal pneumonias were recruited., Results: A total of 125 pneumococcal pneumonias (16 bacteremic and 109 nonbacteremic) was observed. Incidence rates (per 1000 person-years) were 0.21 (95% confidence interval [CI]: 0.13-0.35) for bacteremic cases and 1.45 (95% CI: 1.20-1.75) for nonbacteremic cases. Case-fatality rate was 10.4% (12.5% in bacteremic and 10.1% in nonbacteremic cases). Five serotypes (types 3, 6C, 19A, 22F and 35B) were the most common serotypes, accounting for 64.3% of overall isolated serotypes. 73.1% of cases were due to the strains included in the 23-valent vaccine whereas 53.6% were due to the strains included in the 13-valent vaccine., Conclusion: The burden of pneumococcal pneumonia remains considerable (especially among oldest people and nursing-home residents) despite a publicly funded anti-pneumococcal vaccination program operative for several years., (Copyright © 2015 Elsevier España, S.L.U. All rights reserved.)

Objective: To investigate hospitalizations from pneumococcal pneumonia in older adults with specific underlying chronic conditions, evaluating the influence of these conditions in developing pneumonia., Methods: Population-based cohort study involving 27,204 individuals ≥ 60 years old in Southern Catalonia, Spain. All cases of hospitalization from pneumococcal pneumonia (bacteremic and nonbacteremic) were collected since 01/12/2008 until 30/11/2011. Cox regression was used to calculate hazards ratio (HR) and estimate the association between baseline conditions and the risk of developing pneumococcal pneumonia., Results: Maximum incidences (per 1000 person-years) appeared among patients with history of prior pneumonia (14.6), nursing home residents (12.8), persons with immunodeficiency/asplenia (7.7) and patients with chronic pulmonary disease (7.6). In multivariable analysis, age (HR: 1.05), nursing home residence (HR: 4.59), history of prior pneumonia (HR: 3.58), stroke (HR: 2.50), chronic heart disease (HR: 1.53), chronic pulmonary disease (HR: 4.09), diabetes mellitus (HR: 1.66), smoking (HR: 1.69) and immunosuppressive medication (HR: 1.87) appeared significantly associated with an increased risk of pneumococcal pneumonia., Conclusion: Our data support that nursing home residence, chronic pulmonary disease and immunocompromising conditions are the underlying conditions most strongly associated with an increasing risk of pneumococcal pneumonia in older adults. This data underline the need for better prevention strategies among these persons.

Objective: The purpose of this study was to identify clusters of diagnoses in elderly patients with multimorbidity, attended in primary care., Design: Cross-sectional study., Setting: 251 primary care centres in Catalonia, Spain., Participants: Individuals older than 64 years registered with participating practices., Main Outcome Measures: Multimorbidity, defined as the coexistence of 2 or more ICD-10 disease categories in the electronic health record. Using hierarchical cluster analysis, multimorbidity clusters were identified by sex and age group (65-79 and ≥80 years)., Results: 322,328 patients with multimorbidity were included in the analysis (mean age, 75.4 years [Standard deviation, SD: 7.4], 57.4% women; mean of 7.9 diagnoses [SD: 3.9]). For both men and women, the first cluster in both age groups included the same two diagnoses: Hypertensive diseases and Metabolic disorders. The second cluster contained three diagnoses of the musculoskeletal system in the 65- to 79-year-old group, and five diseases coincided in the ≥80 age group: varicose veins of the lower limbs, senile cataract, dorsalgia, functional intestinal disorders and shoulder lesions. The greatest overlap (54.5%) between the three most common diagnoses was observed in women aged 65-79 years., Conclusion: This cluster analysis of elderly primary care patients with multimorbidity, revealed a single cluster of circulatory-metabolic diseases that were the most prevalent in both age groups and sex, and a cluster of second-most prevalent diagnoses that included musculoskeletal diseases. Clusters unknown to date have been identified. The clusters identified should be considered when developing clinical guidance for this population.

Background: Despite evidence of the benefits of prevention activities, studies have reported only partial integration and great variability of screening in daily clinical practice. The study objectives were: 1) To describe Primary Health Care (PHC) screening for arterial hypertension, dyslipidaemia, obesity, tobacco use, and excessive alcohol consumption in 2008 in 2 regions of Spain, based on electronic health records, and 2) To assess and quantify variability in screening, and identify factors (of patient, general practitioners and PHC team) associated with being screened, that are common throughout the PHC population., Methods: Multicentre, cross-sectional study of individuals aged ≥ 16 years (N = 468,940) who visited the 426 general practitioners (GPs) in 44 PHC teams in Catalonia and Navarre in 2008., Outcomes: screening for hypertension, dyslipidaemia, obesity, tobacco use, and excessive alcohol consumption. Other variables were considered at the individual (sociodemographics, visits, health problems), GP and PHC team (region among others). Individual and contextual factors associated with the odds of being screened and the variance attributable to each level were identified using the SAS PROC GLIMMIX macro., Results: The most prevalent screenings were for dyslipidaemia (64.4%) and hypertension (50.8%); the least prevalent was tobacco use (36.6%). Overall, the odds of being screened were higher for women, older patients, those with more comorbidities, more cardiovascular risk factors, and more frequent office visits, and those assigned to a female GP, a GP with a lower patient load, or a PHC team with a lower percentage of patients older than 65 years. On average, individuals in Navarre were less likely to be screened than those in Catalonia. Hypertension and dyslipidaemia screenings had the least unexplained variability between PHC teams and GPs, respectively, after adjusting for individual and contextual factors., Conclusions: Of the studied screenings, those for obesity, tobacco, and alcohol use were the least prevalent. Attention to screening, especially for tobacco and alcohol, can be greatly improved in the PHC setting.

Aims: To evaluate the efficacy of a school-based educational programme in reducing the incidence and prevalence of smoking in secondary school students (compulsory secondary education: CSE) in Catalonia (Spain)., Design: Cluster-randomized controlled trial., Setting: Schools in the Tarragona Health Care Region of Spain., Participants: All students enrolled in the first year of CSE during the 2007-08 school year in the 29 participating schools (n = 2245); 1583 students completed the follow-up over the 4-year study period (804 and 779 in the control and intervention groups, respectively)., Measures: Self-reported questionnaires were administered during the first quarter of the 2007, 2008, 2009 and 2010 school years. A smoker was defined as 'smoking cigarettes daily or occasionally within the past 30 days'. Multi-level logistic regression analysis was conducted to analyse the prevalence and incidence of smoking between the intervention and control groups., Intervention: A school-based educational programme comprising seven modules, each with a different approach to smoking habits. Each module included activities, work-shops and/or class sessions., Findings: The initial prevalence of smokers in the control and intervention groups who completed the follow-up was 3.9% and 4.2%, respectively. At the end of the study, the prevalence of smokers was 24.4% in the control group and 19.9% in the intervention group. The accumulated incidence of new smokers was 230.57/1000 in the control group and 183.65/1000 in the intervention group. The adjusted odds ratio (OR) comparing the intervention group with the control group was 0.75 [95% confidence interval (CI) = 0.49, 1.15] for smoking prevalence, and 0.74 (95% CI = 0.48, 1.14) for smoking incidence., Conclusions: A school-based educational intervention for secondary school students in Catalonia, Spain was not found to lead to a statistically significant reduction of smoking prevalence and incidence., (© 2015 Society for the Study of Addiction.)

Background: The prevalence of osteoarthritis and knee osteoarthritis in the Spanish population is estimated at 17% and 10.2%, respectively. The clinical guidelines concur that the first line treatment for knee osteoarthritis should be non-pharmacological and include weight loss, physical activity and self-management of pain. Health Coaching has been defined as an intervention that facilitates the achievement of health improvement goals, the reduction of unhealthy lifestyles, the improvement of self-management for chronic conditions and quality of life enhancement. The aim of this study is to analyze the effectiveness, cost-effectiveness and cost-utility of a health coaching intervention on quality of life, pain, overweight and physical activity in patients from 18 primary care centres of Barcelona with knee osteoarthritis., Methods/design: Methodology from the Medical Research Council on developing complex interventions. Phase 1: Intervention modelling and operationalization through a qualitative, socioconstructivist study using theoretical sampling with 10 in-depth interviews to patients with knee osteoarthritis and 4 discussion groups of 8-12 primary care professionals, evaluated using a sociological discourse analysis. Phase 2: Effectiveness, cost-effectiveness and cost-utility study with a community-based randomized clinical trial., Participants: 360 patients with knee osteoarthritis (180 in each group). Randomization unit: Primary Care Centre. Intervention Group: will receive standard care plus 20-hour health coaching and follow-up sessions., Control Group: will receive standard care., Main Outcome Variable: quality of life as measured by the WOMAC index. Data Analyses: will include standardized response mean and multilevel analysis of repeated measures. Economic analysis: based on cost-effectiveness and cost-utility measures. Phase 3: Evaluation of the intervention programme with a qualitative study. Methodology as in Phase 1., Discussion: If the analyses show the cost-effectiveness and cost-utility of the intervention the results can be incorporated into the clinical guidelines for the management of knee osteoarthritis in primary care., Trial Registration: ISRCTN57405925. Registred 20 June 2014.

Introduction: Burnout is a very prevalent type of stress among health professionals. It affects their well-being, performance, and attitude toward patients. This study assessed the effectiveness of a training program for primary health care professionals designed to reduce burnout and mood disturbance, increase empathy, and develop mindfulness., Methods: Pragmatic randomized controlled trial with pre- and postintervention measurements of 68 primary health care professionals (43 in the intervention and 25 in the control group) in Spain. The intervention consisted of presentations of clinically relevant topics, mindfulness-based coping strategies, mindfulness practice, yoga, and group discussions (8 sessions of 2.5 hours per week plus a 1-day session of 8 hours). Outcome measures included the Maslach Burnout Inventory, Profile of Mood States, Jefferson Scale of Physician Empathy, Baer's Five Facets Mindfulness Questionnaire, and a questionnaire on changes in personal habits and mindfulness practice. Measurements were performed at baseline and after 8 weeks., Results: The intervention group improved in the 4 scales measured. The magnitude of the change was large in total mood disturbance (difference between groups -7.1; standardized effect-size [SES] 1.15) and mindfulness (difference between groups 11; SES 0.9) and moderate in the burnout (difference between groups -7; SES 0.74) and empathy scales (difference between groups 5.2; SES 0.71). No significant differences were found in the control group., Discussion: Our study supports the use of mindfulness-based programs as part of continuing professional education to reduce and prevent burnout, promote positive attitudes among health professionals, strengthen patient-provider relationships, and enhance well-being., (© 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.)

Background: Cerebrovascular benefits using the 23-valent pneumococcal polysaccharide vaccine (PPV23) are controversial. This study assessed clinical effectiveness of PPV23 in preventing ischemic stroke in people older than 60 years., Methods: We conducted a population-based cohort study involving 27,204 individuals of 60 years or older in Tarragona, Spain, who were prospectively followed from December 01, 2008, until November 30, 2011. Outcomes were neuroimaging-confirmed ischemic stroke, 30-day mortality from stroke, and all-cause death. Pneumococcal vaccination effectiveness was evaluated by Cox regression analyses, estimating hazard ratios (HRs) adjusted for age, sex, comorbidities, and influenza vaccine status., Results: Cohort members were followed for a total of 76,033 person-years, of which 29,065 were for vaccinated subjects. Overall, 343 cases of stroke, 45 deaths from stroke, and 2465 all-cause deaths were observed. Pneumococcal vaccination did not alter the risk of stroke (multivariable HR: 1.04; 95% confidence interval [CI]: .83-1.30; P=.752), death from stroke (HR: 1.14; 95% CI: .61-2.13; P=.686), and all-cause death (HR: .97; 95% CI: .89-1.05; P=.448). In analyses focused on people with and without a history of cerebrovascular disease, the PPV23 did not emerge effective in preventing any analyzed event, but influenza vaccine emerged independently associated with a reduced risk of death from stroke (HR: .51; 95% CI: .28-.93; P=.029) and all-cause death (HR: .73; 95% CI: .67-.81; P<.001)., Conclusions: Our data support that the PPV23 does not provide benefit against ischemic stroke, but it also supports a beneficial effect of influenza vaccine in reducing specific- and all-cause mortality risk in the general population older than 60 years., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: The burden of chronic conditions and multimorbidity is a growing health problem in developed countries. The study aimed to determine the estimated prevalence and patterns of multimorbidity in urban areas of Catalonia, stratified by sex and adult age groups, and to assess whether socioeconomic status and use of primary health care services were associated with multimorbidity., Methods: A cross-sectional study was conducted in Catalonia. Participants were adults (19+ years) living in urban areas, assigned to 251 primary care teams., Main Outcome: multimorbidity (≥2 chronic conditions). Other variables: sex (male/female), age (19-24; 25-44; 45-64; 65-79; 80+ years), socioeconomic status (quintiles), number of health care visits during the study., Results: We included 1,356,761 patients; mean age, 47.4 years (SD: 17.8), 51.0% women. Multimorbidity was present in 47.6% (95% CI 47.5-47.7) of the sample, increasing with age in both sexes but significantly higher in women (53.3%) than in men (41.7%). Prevalence of multimorbidity in each quintile of the deprivation index was higher in women than in men (except oldest group). In women, multimorbidity prevalence increased with quintile of the deprivation index. Overall, the median (interquartile range) number of primary care visits was 8 (4-14) in multimorbidity vs 1 (0-4) in non-multimorbidity patients. The most prevalent multimorbidity pattern beyond 45 years of age was uncomplicated hypertension and lipid disorder. Compared with the least deprived group, women in other quintiles of the deprivation index were more likely to have multimorbidity than men until 65 years of age. The odds of multimorbidity increased with number of visits in all strata., Conclusions: When all chronic conditions were included in the analysis, almost 50% of the adult urban population had multimorbidity. The prevalence of multimorbidity differed by sex, age group and socioeconomic status. Multimorbidity patterns varied by life-stage and sex; however, circulatory-endocrine-metabolic patterns were the most prevalent multimorbidity pattern after 45 years of age. Women younger than 80 years had greater prevalence of multimorbidity than men, and women's multimorbidity prevalence increased as socioeconomic status declined in all age groups. Identifying multimorbidity patterns associated with specific age-related life-stages allows health systems to prioritize and to adapt clinical management efforts by age group.

Background: The benefits of using the 23-valent pneumococcal polysaccharide vaccine (PPV23) are controversial. This study assessed clinical effectiveness of PPV23 in preventing community-acquired pneumonia (CAP) among the general population aged ≥ 60 years., Methods: This was a population-based cohort study involving 27 204 individuals aged ≥ 60 years in Tarragona, Spain, who were prospectively followed from 1 December 2008 until 30 November 2011. Primary outcomes were hospitalization for pneumococcal CAP (bacteremic and nonbacteremic cases) and all-cause CAP. All CAP cases were radiographically confirmed and validated by checking clinical records. Cox regression was used to evaluate the association between pneumococcal vaccination and the risk of each outcome., Results: Cohort members were followed for a total of 76 033 person-years (29 065 person-years for vaccinated subjects). Incidence rates (per 1000 person-years) were 0.21 for bacteremic pneumococcal CAP (0.14 vs 0.26 among vaccinated and unvaccinated subjects, respectively), 1.45 for nonbacteremic pneumococcal CAP (1.46 vs 1.44), and 7.51 for all-cause CAP (7.19 vs 7.71). In primary analyses including all cohort members, PPV23 did not appear to be effective against any analyzed outcome. However, a beneficial effect emerged in sensitive and stratified analyses. After multivariable adjustments, as compared with those never vaccinated, recent vaccination with PPV23 (<5 years ago) was associated with reduced risks of bacteremic pneumococcal CAP (hazard ratio [HR], 0.38; 95% confidence interval [CI], .09-1.68), nonbacteremic pneumococcal CAP (HR, 0.52; 95% CI, .29-.92), overall pneumococcal CAP (HR, 0.49; 95% CI, .29-.84), and all-cause CAP (HR, 0.75; 95% CI, .58-.98)., Conclusions: Our data support a protective effect of recent PPV23 vaccination (within previous 5 years) against both pneumococcal and all-cause CAP.

Background: Concurrent diseases, multiple pathologies and multimorbidity patterns are topics of increased interest as the world's population ages. To explore the impact of multimorbidity on affected patients and the consequences for health services, we designed a study to describe multimorbidity by sex and life-stage in a large population sample and to assess the association with acute morbidity, area of residency and use of health services., Methods: A cross-sectional study was conducted in Catalonia (Spain). Participants were 1,749,710 patients aged 19+ years (251 primary care teams)., Primary Outcome: Multimorbidity (≥2 chronic diseases). Secondary outcome: Number of new events of each acute disease. Other variables: number of acute diseases per patient, sex, age group (19-24, 25-44, 45-64, 65-79, and 80+ years), urban/rural residence, and number of visits during 2010., Results: Multimorbidity was present in 46.8% (95% CI, 46.7%-46.8%) of the sample, and increased as age increased, being higher in women and in rural areas. The most prevalent pair of chronic diseases was hypertension and lipid disorders in patients older than 45 years. Infections (mainly upper respiratory infection) were the most common acute diagnoses. In women, the highest significant RR of multimorbidity vs. non-multimorbidity was found for teeth/gum disease (aged 19-24) and acute upper respiratory infection. In men, this RR was only positive and significant for teeth/gum disease (aged 65-79). The adjusted analysis showed a strongly positive association with multimorbidity for the oldest women (80+ years) with acute diseases and women aged 65-79 with 3 or more acute diseases, compared to patients with no acute diseases (OR ranged from 1.16 to 1.99, p < 0.001). Living in a rural area was significantly associated with lower probability of having multimorbidity. The odds of multimorbidity increased sharply as the number of visits increased, reaching the highest probability in those aged 65-79 years., Conclusions: Multimorbidity is related to greater use of health care services and higher incidence of acute diseases, increasing the burden on primary care services. The differences related to sex and life-stage observed for multimorbidity and acute diseases suggest that further research on multimorbidity should be stratified according to these factors.

Background and Objective: The best strategy to achieve optimal integrated management to patients with chronic obstructive pulmonary disease (COPD) in primary care (PC) is not clear. We aimed to evaluate the effectiveness of an intervention in PC based on an integrated programme, which combines diverse strategies directed at health professionals to improve quality of life and clinical outcomes of their patients with COPD. We compared the outcome with results from standard practice., Methods: A prospective, multicentre, quasi-experimental study and a 12-month follow up was performed. Intervention consisted of an integrated education programme in PC. The main outcome variable was the change in total score of the St. George's Respiratory Questionnaire (SGRQ) at the end of follow up between the control and intervention group., Results: A total of 801 patients participated in the study with a mean age of 70.2 years and a mean FEV1 (% predicted) of 55%. At 1-year follow up, the SGRQ score did not significantly differ. Although the intervention group showed an improvement in dietary, exercise and smoking habits, there was an increase in reported exacerbations and hospital admissions (P < 0.001)., Conclusions: Implementation of an integrated education programme in a PC setting, which combines diverse strategies directed at health professionals, did not achieve the expected changes in quality of life measured by SGRQ at 1-year follow up. Nonetheless, this study observed an improvement in patients' lifestyle choices, even though this did not result in a significant change in the clinical evolution or heath status over 12 months., (© 2013 The Authors. Respirology © 2013 Asian Pacific Society of Respirology.)