Mortality In Primary Care Patients Research Articles

Association between Atrioventricular Block and Mortality in Primary Care Patients: The CODE Study.

ResumoFundamento O bloqueio atrioventricular (BAV) descreve um comprometimento na condução dos átrios para os ventrículos. Embora o curso clínico do BAV tenha sido avaliado, os achados são de países de alta renda e, portanto, não podem ser extrapolados para a população latina.Objetivo Avaliar a associação entre BAV e mortalidade.Métodos Foram incluídos pacientes do estudo CODE (Clinical Outcomes in Digital Electrocardiology), maiores de 16 anos que realizaram eletrocardiograma (ECG) digital de 2010 a 2017. Os ECGs foram relatados por cardiologistas e por software automatizado. Para avaliar a relação entre BAV e mortalidade, foram utilizados o modelo log-normal e as curvas de Kaplan-Meier com valores de p bicaudais < 0,05 considerados estatisticamente significativos.Resultados O estudo incluiu 1.557.901 pacientes; 40,23% eram homens e a média de idade foi de 51,7 (DP ± 17,6) anos. Durante um seguimento médio de 3,7 anos, a mortalidade foi de 3,35%. A prevalência de BAV foi de 1,38% (21.538). Os pacientes com BAV de primeiro, segundo e terceiro graus foram associados a uma taxa de sobrevida 24% (taxa de sobrevida relativa [RS] = 0,76; intervalo de confiança [IC] de 95%: 0,71 a 0,81; p < 0,001), 55% (RS = 0,45; IC de 95%: 0,27 a 0,77; p = 0,01) e 64% (RS = 0,36; IC de 95%: 0,26 a 0,49; p < 0,001) menor quando comparados ao grupo controle, respectivamente. Os pacientes com BAV 2:1 tiveram 79% (RS = 0,21; IC de 95%: 0,08 a 0,52; p = 0,005) menor taxa de sobrevida do que o grupo controle. Apenas Mobitz tipo I não foi associado a maior mortalidade (p = 0,27).Conclusão BAV foi um fator de risco independente para mortalidade geral, com exceção do BAV Mobitz tipo I.

Greater variability in lipid measurements associated with cardiovascular disease and mortality: A 10‐year diabetes cohort study

AimTo examine the associations between variability in lipids and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes based on low‐density lipoprotein‐cholesterol (LDL‐C), the total cholesterol (TC) to high‐density lipoprotein‐cholesterol (HDL‐C) ratio and triglycerides (TG).Materials and methodsA retrospective cohort study included 125 047 primary care patients with type 2 diabetes aged 45‐84 years without CVD during 2008‐2012. The variability of LDL‐C, TC to HDL‐C and TG was determined using the standard deviation of variables in a mixed effects model to minimize regression dilution bias. The associations between variability in lipids and CVD and mortality risk were assessed by Cox regression. Subgroup analyses based on patients’ baseline characteristics were also conducted.ResultsA total of 19 913 CVD events and 15 329 mortalities were recorded after a median follow‐up period of 77.5 months (0.8 million person‐years), suggesting a positive linear relationship between variability in lipids and the risk of CVD and mortality. Each unit increase in the variability of LDL‐C (mmol/L), the TC to HDL‐C ratio and TG (mmol/L) was associated with a 27% (HR: 1.27 [95% CI: 1.20‐1.34]), 31% (HR:1.31 [95% CI: 1.25‐1.38]) and 9% (HR: 1.09 [95% CI: 1.04‐1.15]) increase in the risk of composite endpoint of CVD and mortality, respectively. Age‐specific effects were also found when comparing LDL‐C variability, with patients aged 45‐54 years (HR: 1.70 [95% CI: 1.42‐2.02]) exhibiting a 53% increased risk for the composite endpoints than those aged 75‐84 years (HR: 1.11 [95% CI: 1.01‐1.23]). Similar age effects were observed for both the TC to HDL‐C ratio and TG variability. Significant associations remained consistent among most of the subgroups.ConclusionsVariability in respective lipids are significant factors in predicting CVD and mortality in primary care patients with type 2 diabetes, with the strongest effects related to LDL‐C and the TC to HDL‐C ratio and most significant in the younger age group of patients aged 45‐54 years. Further study is warranted to confirm these findings.

Association between prescription of hypnotics/anxiolytics and mortality in multimorbid and non-multimorbid patients: a longitudinal cohort study in primary care

ObjectivesTo assess the risk of mortality in primary care patients, multimorbid (≥2 chronic conditions) or not, prescribed hypnotics/anxiolytics.DesignA longitudinal cohort studySettingPrimary healthcare in the Reykjavik area.Participants114 084 individuals (aged 10–79...

Cardiovascular risk prevention and all-cause mortality in primary care patients with an abdominal aortic aneurysm.

Perioperative mortality is low for patients undergoing abdominal aortic aneurysm (AAA) repair, but long-term survival remains poor. Although patients diagnosed with AAA have a significant burden of cardiovascular disease and associated risk factors, there is limited understanding of the contribution of cardiovascular risk management to long-term survival. General practice records within The Health Improvement Network (THIN) were examined. Patients with a diagnosis of AAA and at least 1 year of registered medical history were identified from 2000 to 2012. Medical therapies for cardiovascular risk were classified as antiplatelet, statin or antihypertensive agents. Progression to death was investigated using the G-computation formula with time-dependent co-variables to account for differences in exposure to cardiovascular risk-modifying treatments and the confounding between exposure, co-morbidities and death. Some 12 485 patients had a recorded diagnosis of AAA. From 2000 to 2012, prescription of medications that modify cardiovascular risk increased: from 26·6 to 76·7 per cent for statins, from 56·5 to 73·9 per cent for antiplatelet agents and from 75·3 to 84·0 per cent for antihypertensive drugs. Adjusted Kaplan-Meier curves demonstrated a better 5-year survival rate in patients receiving statins (68·4 versus 42·2 per cent), antiplatelet agents (63·6 versus 39·7 per cent) or antihypertensive agents (61·5 versus 39·1 per cent), compared with rates in patients not receiving each therapy. Appropriate risk factor modification could significantly reduce long-term mortality in patients with AAA. In the UK, up to 30 per cent of patients are not currently receiving these medications.

Hyponatremia, all-cause mortality, and risk of cancer diagnoses in the primary care setting: A large population study

BackgroundHyponatremia has been associated with increased all-cause mortality in hospitalized individuals. In this study we examine the risk of all-cause mortality in primary care subjects with hyponatremia, while also exploring the association with subsequent diagnosis of cancer. MethodsRetrospective cohort study on subjects who underwent blood tests, consulting their general practitioner 2000–2012 in Copenhagen, Denmark. Reference range for sodium was 135–145mmol/L, and mild, moderate, and severe hyponatremia were defined as 130–135, 125–129, and <125mmol/L, respectively. Primary outcome was all-cause mortality, and secondary outcomes overall and specific types of cancer diagnoses. ResultsAmong 625,114 included subjects (mean age 49.9 [SD±18.4] years; 43.5% males), 90,926 (14.5%) deaths occurred. All-cause mortality was increased in mild, moderate, and severe hyponatremia (age-adjusted mortality rates [IRs, incidence rates] 26, 30, and 36 per 1000 person-years (py), respectively and incidence rate ratios [IRRs] 1.81 [95% CI: 1.76–1.85], 2.11 [2.00–2.21], and 2.52 [2.26–2.82], respectively) compared with individuals with normonatremia (IR 14 per 1000 py). For the secondary endpoint an increased level-dependent risk was found with lower sodium levels in relation to cancer overall, head and neck cancers, and pulmonary cancer, with severe hyponatremia associated with the highest IRRs (1.77 [1.39–2.24], 5.24 [2.17–12.63]), and 4.99 [3.49–7.15], respectively). ConclusionsAll levels of hyponatremia are associated with all-cause mortality in primary care patients and hyponatremia is linked to an increased risk of being diagnosed with any cancer, particularly pulmonary and head and neck cancers.

Drug Use Severity, Mortality, and Cause of Death in Primary Care Patients With Substance Use Disorders

This article examines the association between drug use severity and mortality in primary care patients with substance use disorders. In 848 individuals with known vital status, severity was low in 32%, intermediate in 38%, or substantial/severe in 30%. Two-year survival was 93% in the low group, 96% in the medium group, and 92% in the high group ( p = .19). The age-adjusted risk of death for the high-severity group was twice that of the medium-risk group (hazard ratio = 2.00, 95% confidence interval = [1.02, 3.93]). Individuals in the high group were more likely to die from accidents than those in the low- or medium-severity groups (50% vs. 20%, p = .021). Compared with low- and medium-severity groups, age at death was 5 years younger in the high-severity group (52 ± 9 vs. 57 ± 6, p = .017). Premature death due to accidental causes in persons with substance use disorders is a persistent yet complex problem.

No Association of 25-Hydroxyvitamin D With Exacerbations in Primary Care Patients With COPD

Cross-sectional studies suggest an association of 25-hydroxyvitamin D with exacerbations in patients with COPD, but longitudinal evidence from cohort studies is scarce. The aim of this study was to assess the association of serum 25-hydroxyvitamin D with exacerbations and mortality in primary care patients with COPD. In the main analysis, we included 356 patients with COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages II-IV, free from exacerbations for ≥ 4 weeks) from a prospective cohort study in Dutch and Swiss primary care settings. We used negative binomial and Cox regression to assess the association of 25-hydroxyvitamin D with (centrally adjudicated) exacerbations and mortality, respectively. Baseline mean ± SD serum 25-hydroxyvitamin D concentration was 15.5 ± 8.9 ng/dL, and 274 patients (77.0%) had 25-hydroxyvitamin D deficiency (< 20 ng/dL). Compared with patients with severe 25-hydroxyvitamin D deficiency (< 10 ng/dL, n = 106 [29.8%]), patients with moderately deficient (10-19.99 ng/dL, n = 168 [47.2%]) and insufficient (20-29.99 ng/dL, n = 58 [16.3%]) concentrations had the same risk for exacerbations (incidence rate ratio, 1.01 [95% CI, 0.77-1.57] vs 1.00 [95% CI, 0.62-1.61], respectively). In patients with desirable concentrations (> 30 ng/dL, n = 24 [6.7%]), the risk was lower, although not significantly (incidence rate ratio, 0.72 [95% CI, 0.37-1.42]). In patients taking vitamin D supplements, using different cutoffs for 25-hydroxyvitamin D or competing risk models did not materially change the results. We did not find a statistically significant association of 25-hydroxyvitamin D concentration with mortality. This longitudinal study in a real-world COPD population that carefully minimized misclassification of exacerbations and the influence of confounding did not show an association of 25-hydroxyvitamin D with exacerbations and mortality.

Recognition of depression and anxiety and their association with quality of life, hospitalization and mortality in primary care patients with heart failure - study protocol of a longitudinal observation study.

BackgroundInternational disease management guidelines recommend the regular assessment of depression and anxiety in heart failure patients. Currently there is little data on the effect of screening for depression and anxiety on the quality of life and the prognosis of heart failure (HF). We will investigate the association between the recognition of current depression/anxiety by the general practitioner (GP) and the quality of life and the patients’ prognosis.Methods/DesignIn this multicenter, prospective, observational study 3,950 patients with HF are recruited by general practices in Germany. The patients fill out questionnaires at baseline and 12-month follow-up. At baseline the GPs are interviewed regarding the somatic and psychological comorbidities of their patients. During the follow-up assessment, data on hospitalization and mortality are provided by the general practice. Based on baseline data, the patients are allocated into three observation groups: HF patients with depression and/or anxiety recognized by their GP (P+/+), those with depression and/or anxiety not recognized (P+/−) and patients without depression and/or anxiety (P−/−). We will perform multivariate regression models to investigate the influence of the recognition of depression and/or anxiety on quality of life at 12 month follow-up, as well as its influences on the prognosis (hospital admission, mortality).DiscussionWe will display the frequency of GP-acknowledged depression and anxiety and the frequency of installed therapeutic strategies. We will also describe the frequency of depression and anxiety missed by the GP and the resulting treatment gap. Effects of correctly acknowledged and missed depression/anxiety on outcome, also in comparison to the outcome of subjects without depression/anxiety will be addressed. In case results suggest a treatment gap of depression/anxiety in patients with HF, the results of this study will provide methodological advice for the efficient planning of further interventional research.

Peripheral Arterial Disease as an Independent Predictor for Excess Stroke Morbidity and Mortality in Primary-Care Patients: 5-Year Results of the getABI Study

Background:There is controversial evidence with regard to the significance of peripheral arterial disease (PAD) as an indicator for future stroke risk. We aimed to quantify the risk increase for mortality and morbidity associated with PAD. Methods:In an open, prospective, noninterventional cohort study in the primary care setting, a total of 6,880 unselected patients ≧65 years were categorized according to the presence or absence of PAD and followed up for vascular events or deaths over 5 years. PAD was defined as ankle-brachial index (ABI) <0.9 or history of previous peripheral revascularization and/or limb amputation and/or intermittent claudication. Associations between known cardiovascular risk factors including PAD and cerebrovascular mortality/events were analyzed in a multivariate Cox regression model. Results:During the 5-year follow-up [29,915 patient-years (PY)], 183 patients had a stroke (incidence per 1,000 PY: 6.1 cases). In patients with PAD (n = 1,429) compared to those without PAD (n = 5,392), the incidence of all stroke types standardized per 1,000 PY, with the exception of hemorrhagic stroke, was about doubled (for fatal stroke tripled). The corresponding adjusted hazard ratios were 1.6 (95% confidence interval, CI, 1.1–2.2) for total stroke, 1.7 (95% CI 1.2–2.5) for ischemic stroke, 0.7 (95% CI 0.2–2.2) for hemorrhagic stroke, 2.5 (95% CI 1.2–5.2) for fatal stroke and 1.4 (95% CI 0.9–2.1) for nonfatal stroke. Lower ABI categories were associated with higher stroke rates. Besides high age, previous stroke and diabetes mellitus, PAD was a significant independent predictor for ischemic stroke. Conclusions:The risk of stroke is substantially increased in PAD patients, and PAD is a strong independent predictor for stroke.

Depression, Posttraumatic Stress Disorder, and Mortality

To determine whether a history of depression and/or posttraumatic stress disorder (PTSD) is associated with all-cause mortality in primary care patients over an average of 2 years. Patients from seven Department of Veterans Affairs medical centers completed mailed questionnaires. Depression and PTSD status were determined from patient self-report of a prior diagnosis and/or electronic administrative data. Date of death was ascertained from Veterans Health Information Systems and Technology Architecture and the Department of Veterans Affairs' Beneficiary Identification and Records Locator System. Among 35,715 primary care patients, those with a history of depression without a history of PTSD (n = 6876) were at increased risk of death over an average of 2 years compared with patients with neither depression nor PTSD after adjustment for demographic variables, health behaviors, and medical comorbidity (hazard ratio (HR) = 1.17; 95% Confidence Interval (CI) = 1.06-1.28). However, patients with a history of PTSD without a history of depression (n = 748) were not at increased risk of death compared with patients with neither depression nor PTSD (HR = 0.84; 95% CI = 0.63-1.13). Patients with a history of both (n = 3762) were at increased risk of death after adjustment for demographic factors, although not after additional adjustment for health behaviors and medical comorbidity (HR = 0.90; 95% CI = 0.78-1.04). In a large sample of veterans, a prior diagnosis of depression, but not PTSD, was associated with an increased risk of death over an average of 2 years after adjusting for age, demographic variables, health behaviors, and medical comorbidity.

Using electronic medical records to predict mortality in primary care patients with heart disease

To identify high-risk patients with heart disease by using data stored in an electronic medical record system to predict six-year mortality. Retrospective cohort study. Academic primary care general internal medicine practice affiliated with an urban teaching hospital with a state-of-the-art electronic medical record system. Of 2,434 patients with evidence of ischemic heart disease or heart failure or both who visited an urban primary care practice in 1986, half were used to derive a proportional hazards model, and half were used to validate it. Mortality from any cause within six years of inception date. Model discrimination was assessed with the C statistic, and goodness-of-fit was measured with a calibration curve and Hosmer-Lemeshow statistic. Of these patients 82% had evidence of ischemic heart disease, 53% heart failure, and 35% both conditions. Mean survival among the 653 (27%) who died was 2.8 years; mean follow-up among survivors was 5.0 years. Those with both heart conditions had the highest mortality rate (45% at 6 years), followed by isolated heart failure (39%) and ischemic heart disease (18%). Of 300 potential predictive characteristics, 100 passed a univariate screen and were submitted to maltivariable proportional hazards regression. Twelve variables contributed independent predictive information: age, weight, more than one previous hospitalization for heart failure, and nine conditions indicated on diagnostic tests and problem lists. No drug treatment variables were independent predictors. The model C statistic was 0.76 in the derivation sample of patients and 0.74 in a randomly selected validation sample, and it was well calibrated. Patients in the lowest and highest quartiles of risk differed more than five-fold in their average risk. Routine clinical data stored in patients electronic medical records are capable of predicting mortality among patients with heart disease. This could allow increasingly scarce health care resources to be focused on those at highest mortality risk.