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Damià Valero-Bover,1,2 David Monterde,2,3 Gerard Carot-Sans,1,2 Miguel Cainzos-Achirica,4,5 Josep Comin-Colet,6– 8 Emili Vela,1,2 Montse Clèries,1,2 Júlia Folguera,1,2 Sònia Abilleira,9 Miquel Arrufat,3 Yolanda Lejardi,3 Òscar Solans,2,10 Toni Dedeu,11 Marc Coca,1,2 Pol Pérez-Sust,1 Caridad Pontes,1,2,12 Jordi Piera-Jiménez1,2,13 1Catalan Health Service, Barcelona, Spain; 2Digitalization for the Sustainability of the Healthcare System (DS3) – Institut d’Investigacions Biomèdiques de Bellvitge (IDIBELL), Barcelona, Spain; 3Catalan Institute of Health, Barcelona, Spain; 4Center for Outcomes Research, Houston Methodist, Houston, TX, USA; 5Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore, MD, USA; 6Cardiology Department, Bellvitge University Hospital (IDIBELL), Barcelona, Spain; 7Department of Medicine, University of Barcelona, Hospitalet de Llobregat, Barcelona, Spain; 8CIBER Cardiovascular (CIBERCV), L’Hospitalet de Llobregat, Barcelona, Spain; 9CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; 10Health Department, eHealth Unit, Barcelona, Spain; 11WHO European Centre for Primary Health Care, Almaty, Kazakhstan; 12Department of Pharmacology, Autonomous University of Barcelona, Barcelona, Spain; 13Faculty of Informatics, Telecommunications and Multimedia, Universitat Oberta de Catalunya, Barcelona, SpainCorrespondence: Jordi Piera-Jiménez, Catalan Health Service, Gran Via de les Corts Catalanes 587, Barcelona, 08007, Spain, Tel +34 93 403 85 85, Email jpiera@catsalut.catPurpose: To assess the contribution of age and comorbidity to the risk of critical illness in hospitalized COVID-19 patients using increasingly exhaustive tools for measuring comorbidity burden.Patients and Methods: We assessed the effect of age and comorbidity burden in a retrospective, multicenter cohort of patients hospitalized due to COVID-19 in Catalonia (North-East Spain) between March 1, 2020, and January 31, 2022. Vaccinated individuals and those admitted within the first of the six COVID-19 epidemic waves were excluded from the primary analysis but were included in secondary analyses. The primary outcome was critical illness, defined as the need for invasive mechanical ventilation, transfer to the intensive care unit (ICU), or in-hospital death. Explanatory variables included age, sex, and four summary measures of comorbidity burden on admission extracted from three indices: the Charlson index (17 diagnostic group codes), the Elixhauser index and count (31 diagnostic group codes), and the Queralt DxS index (3145 diagnostic group codes). All models were adjusted by wave and center. The proportion of the effect of age attributable to comorbidity burden was assessed using a causal mediation analysis.Results: The primary analysis included 10,551 hospitalizations due to COVID-19; of them, 3632 (34.4%) experienced critical illness. The frequency of critical illness increased with age and comorbidity burden on admission, irrespective of the measure used. In multivariate analyses, the effect size of age decreased with the number of diagnoses considered to estimate comorbidity burden. When adjusting for the Queralt DxS index, age showed a minimal contribution to critical illness; according to the causal mediation analysis, comorbidity burden on admission explained the 98.2% (95% CI 84.1– 117.1%) of the observed effect of age on critical illness.Conclusion: Comorbidity burden (when measured exhaustively) explains better than chronological age the increased risk of critical illness observed in patients hospitalized with COVID-19.Keywords: COVID-19, comorbidities, comorbidity burden, risk assessment, hospitalized patients, case-mix tool

David Monterde,1,2 Gerard Carot-Sans,2,3 Miguel Cainzos-Achirica,4,5 Sònia Abilleira,1,6 Marc Coca,2,3 Emili Vela,2,3 Montse Clèries,2,3 Damià Valero-Bover,2,3 Josep Comin-Colet,7– 9 Luis García-Eroles,2,3 Pol Pérez-Sust,3 Miquel Arrufat,1 Yolanda Lejardi,1 Jordi Piera-Jiménez2,3,10 1Catalan Institute of Health, Barcelona, Spain; 2Digitalization for the Sustainability of the Healthcare System (DS3), Sistema de Salut de Catalunya, Barcelona, Spain; 3Servei Català de la Salut, Barcelona, Spain; 4Center for Outcomes Research, Houston Methodist, Houston, TX, USA; 5Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore, MD, USA; 6CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; 7Department of Cardiology, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain; 8Bioheart-Cardiovascular Diseases Research Group (Idibell), L’Hospitalet de Llobregat, Barcelona, Spain; 9Department of Clinical Sciences, School of Medicine, Universität de Barcelona - UB, L’Hospitalet de Llobregat, Barcelona, Spain; 10Open Evidence Research Group, Universitat Oberta de Catalunya, Barcelona, SpainCorrespondence: Jordi Piera-JiménezServei Català de la Salut (CatSalut), Travessera de les Corts, 131-159 (Edifici Olímpia), Barcelona, 08028, SpainTel +34 634283110Email jpiera@catsalut.catBackground: Comorbidity burden has been identified as a relevant predictor of critical illness in patients hospitalized with coronavirus disease 2019 (COVID-19). However, comorbidity burden is often represented by a simple count of few conditions that may not fully capture patients’ complexity.Purpose: To evaluate the performance of a comprehensive index of the comorbidity burden (Queralt DxS), which includes all chronic conditions present on admission, as an adjustment variable in models for predicting critical illness in hospitalized COVID-19 patients and compare it with two broadly used measures of comorbidity.Materials and Methods: We analyzed data from all COVID-19 hospitalizations reported in eight public hospitals in Catalonia (North-East Spain) between June 15 and December 8 2020. The primary outcome was a composite of critical illness that included the need for invasive mechanical ventilation, transfer to ICU, or in-hospital death. Predictors including age, sex, and comorbidities present on admission measured using three indices: the Charlson index, the Elixhauser index, and the Queralt DxS index for comorbidities on admission. The performance of different fitted models was compared using various indicators, including the area under the receiver operating characteristics curve (AUROCC).Results: Our analysis included 4607 hospitalized COVID-19 patients. Of them, 1315 experienced critical illness. Comorbidities significantly contributed to predicting the outcome in all summary indices used. AUC (95% CI) for prediction of critical illness was 0.641 (0.624– 0.660) for the Charlson index, 0.665 (0.645– 0.681) for the Elixhauser index, and 0.787 (0.773– 0.801) for the Queralt DxS index. Other metrics of model performance also showed Queralt DxS being consistently superior to the other indices.Conclusion: In our analysis, the ability of comorbidity indices to predict critical illness in hospitalized COVID-19 patients increased with their exhaustivity. The comprehensive Queralt DxS index may improve the accuracy of predictive models for resource allocation and clinical decision-making in the hospital setting.Keywords: comorbidity, multimorbidity, COVID-19, hospitalization, risk

Background: The incidence of chronic diseases during the COVID-19 pandemic has drastically been reduced worldwide due to disruptions in healthcare systems. The aim of our study is to analyse the trends in the incidence of 7 commonly managed primary care chronic diseases during the last 2 years of the COVID-19 pandemic in Catalonia., Methods: We performed an observational retrospective population-based study using data from primary care electronic health records from January 2018 to August 2022 (5.1 million people older than 14 years). We divided the study period into two: a pre-pandemic period (before 14 March 2020) and a pandemic period. We performed a segmented regression analysis of daily incidence rates per 100,000 inhabitants of 7 chronic diseases: type 2 diabetes mellitus (T2DM), asthma, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD), heart failure (HF), hypertension and hypercholesterolemia. In addition, we compared annual incidence between pandemic years (2020, 2021 and 2022) and 2019. Associated incidence rate ratios (IRR) were also calculated. Finally, we estimated the number of expected diagnoses during the pandemic period using data from 2019 and we compared it with the observed data., Results: We analysed 740,820 new chronic diseases' diagnoses. Daily incidence rates of all 7 chronic diseases were drastically interrupted on 14 March 2020, and a general upward trend was observed during the following months. Reductions in 2020 were around 30% for all conditions except COPD which had greater reductions (IRR: 0.58 [95% CI: 0.57 to 0.6]) and HF with lesser drops (IRR: 0.86 [95% CI: 0.84 to 0.88]). Some of the chronic conditions have returned to pre-pandemic diagnosis levels, except asthma, COPD and IHD. The return to pre-pandemic diagnosis levels compensated for the drops in 2020 for T2DM and HF, but not for hypertension which presented an incomplete recovery. We also observed an excess of hypercholesterolemia diagnoses of 8.5% (95%CI: 1.81% to 16.15%)., Conclusions: Although primary care has recovered the pre-pandemic diagnosis levels for some chronic diseases, there are still missing diagnoses of asthma, COPD and IHD that should be addressed., (© 2023. The Author(s).)

Introduction: SARS-CoV-2 seroprevalence studies are currently being recommended and implemented in many countries. Forming part of the COVID-19 monitoring and evaluation plan of the Catalan Government Health Department, our network aims to initiate a primary healthcare sentinel monitoring system as a surrogate of SARS-CoV-2 exposure in the Barcelona Metropolitan Area., Methods and Analysis: The seroCAP is a serial cross-sectional study, which will be performed in the Barcelona Metropolitan Area to estimate antibodies against SARS-CoV-2. From February 2021 to March 2022, the detection of serum IgG antibodies against SARS-CoV-2 trimeric spike protein will be performed on a monthly basis in blood samples collected for diverse clinical purposes in three reference hospitals from the three Barcelona healthcare areas (BCN areas). The samples (n=2588/month) will be from patients attended by 30 primary healthcare teams at 30 basic healthcare areas (BHA). A lab software algorithm will systematically select the samples by age and sex. Seroprevalence will be estimated and monitored by age, sex, BCN area and BHA. Descriptive and cluster analysis of the characteristics and distribution of SARS-CoV-2 infections will be performed. Sociodemographic, socioeconomic and morbidity-associated factors will be determined using logistic regression. We will explore the association between seroprevalence, SARS-CoV-2 confirmed cases and the implemented measures using interrupted time series analysis., Ethics and Dissemination: Ethical approval was obtained from the University Institute Foundation for Primary Health Care Research Jordi Gol i Gurina ethics committee. An informed consent is not required regarding the approval of the secondary use of biological samples within the framework of the COVID-19 pandemic. A report will be generated quarterly. The final analysis, conclusions and recommendations will be shared with the stakeholders and communicated to the general public. Manuscripts resulting from the network will be submitted for publication in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To analyse the relation between face-to-face appointments and management of patients with type 2 diabetes mellitus (T2DM) visited in primary care practices (PCP)., Methods: Retrospective study in 287 primary care practices (PCPs) attending>300,000 patients with T2DM. We analysed the results of 9 diabetes-related indicators of the Healthcare quality standard, comprising foot and retinopathy screening, blood pressure (BP) and glycemic control; and the incidence of T2DM. We calculated each indicator's percentage of change in 2020 with respect to the results of 2019., Results: Indicators' results were reduced in 2020 compared to 2019, highlighting the indicators of foot and retinopathy screening (-51.6% and -25.7%, respectively); the glycemic control indicator (-21.2%); the BP control indicator (-33.7%) and the incidence of T2DM (-25.6%). Conversely, the percentage of type 2 diabetes patients with HbA1c > 10% increased by 34%. PCPs with<11 weekly face-to-face appointments offered per professional had greater reductions than those PCPs with more than 40. For instance, a reduction of -60.7% vs -38.2% (p-value < 0.001) in the foot screening's indicator; -27.5% vs -12.5% (p-value < 0.001) in glycemic control and -40.2 vs -24.3% (p-value < 0.001) in BP control., Conclusions: Reducing face-to-face visits offered may impact T2DM patients' follow-up and thus worsen their control., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper: [XC has acted as consultant, research support or speaker’s bureau for AstraZeneca, Boehringer Ingelheim, Lilly, Novartis, Novo Nordisk and Sanofi Diabetes, Sanofi Pasteur and Esteve. The rest of the authors did not declare any competing interests]., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: To analyse the impact of the COVID-19 epidemic and the lockdown measures on the follow-up and control of chronic diseases in primary care., Methods: Retrospective study in 288 primary care practices (PCP) of the Catalan Institute of Health. We analysed the results of 34 indicators of the Healthcare quality standard (EQA), comprising different types: treatment (4), follow-up (5), control (10), screening (7), vaccinations (4) and quaternary prevention (4). For each PCP, we calculated each indicator's percentage of change in February, March and April 2020 respective to the results of the previous month; and used the T-Student test for paired data to compare them with the percentage of change in the same month of the previous year. We defined indicators with a negative effect those with a greater negative change or a lesser positive change in 2020 in comparison to 2019; and indicators with a positive effect those with a greater positive change or a lesser negative change., Results: We observed a negative effect on 85% of the EQA indicators in March and 68% in April. 90% of the control indicators had a negative effect, highlighting the control of LDL cholesterol with a reduction of - 2.69% (95%CI - 3.17% to - 2.23%) in March and - 3.41% (95%CI - 3.82% to - 3.01%) in April; and the control of blood pressure with a reduction of - 2.13% (95%CI - 2.34% to - 1.9%) and - 2.59% (95%CI - 2.8% to - 2.37%). The indicators with the greatest negative effect were those of screening, such as the indicator of diabetic foot screening with a negative effect of - 2.86% (95%CI - 3.33% to - 2.39%) and - 4.13% (95%CI - 4.55% to - 3.71%) in March and April, respectively. Only one vaccination indicator, adult Measles-Mumps-Rubella vaccine, had a negative effect in both months. Finally, among the indicators of quaternary prevention, we observed negative effects in March and April although in that case a lower inadequacy that means better clinical outcome., Conclusions: The COVID-19 epidemic and the lockdown measures have significantly reduced the results of the follow-up, control, screening and vaccination indicators for patients in primary care. On the other hand, the indicators for quaternary prevention have been strengthened and their results have improved.

Aims: This paper is a report of a study to assess the feasibility and efficacy of a programme of nurse management for patients requesting same day consultation for minor illnesses in primary care., Background: The efficacy of such programmes has been demonstrated in randomized studies but there is little information on these programmes in highly populated areas., Methods: Patients seeking same day consultation for one of 23 preselected minor illnesses (16 for adults, 7 for paediatric patients) from March 2009 to April 2010 were seen by trained nurses who followed predefined algorithms. If signs of alarm were detected, patients were referred to a general practitioner., Findings: A total of 629,568 consultations were performed, 575,189 in adults and 54,379 in paediatric patients. Case resolution was achieved in 61.8% of adult and 75.6% of paediatric patients. In adults, the highest resolution rates (>90%) were obtained for burns, skin injury and emergency contraception, and the lowest for lower urinary symptoms (46.7%), sore throat (45.7%), pink eye (45.5%) and upper respiratory symptoms (41.4%). In paediatric patients, the highest resolution rates (>90%) were obtained for stomach cramps and burns and the lowest for cough (36.2%). A return to consultation during a 7-day period for the same reason as the first consultation was low, 4% for adults and 2.4% for paediatric patients., Conclusion: An extended programme of nurse management for same day consultation of patients with minor illnesses showed an acceptably high rate of resolution and low rate of return to consultation. The application of such programmes in extensive areas is feasible and effective., (© 2011 Blackwell Publishing Ltd.)