Implications of comorbidity for primary care costs in the UK: a retrospective observational study

Background

Comorbidity is increasingly common in primary care. The cost implications for patient care and budgetary management are unclear.

Aim

To investigate whether caring for patients with specific disease combinations increases or decreases primary care costs compared with treating separate patients with one condition each.

Design

Retrospective observational study using data on 86 100 patients in the General Practice Research Database.

Method

Annual primary care cost was estimated for each patient including consultations, medication, and investigations. Patients with comorbidity were defined as those with a current diagnosis of more than one chronic condition in the Quality and Outcomes Framework. Multiple regression modelling was used to identify, for three age groups, disease combinations that increase (cost-increasing) or decrease (cost-limiting) cost compared with treating each condition separately.

Results

Twenty per cent of patients had at least two chronic conditions. All conditions were found to be both cost-increasing and cost-limiting when co-occurring with other conditions except dementia, which is only cost-limiting. Depression is the most important cost-increasing condition when co-occurring with a range of conditions. Hypertension is cost-limiting, particularly when co-occurring with other cardiovascular conditions.

Conclusion

Three categories of comorbidity emerge, those that are: cost-increasing, mainly due to a combination of depression with physical comorbidity; cost-limiting because treatment for the conditions overlap; and cost-limiting for no apparent reason but possibly because of inadequate care. These results can contribute to efficient and effective management of chronic conditions in primary care.     

Egg Consumption,Cardiovascular Disease and Cardiometabolic Risk Factors: The Interaction with Saturated Fatty Acids. Results from the ATTICA Cohort Study (2002–2012)

Purpose: To examine the association of egg intake with 10-year risk of cardiovascular disease (CVD) and other cardiometabolic risk factors in a sample of individuals of Mediterranean origin. Methods: In 2001–2002, n = 1514 men and n = 1528 women (>18 years old) from the greater Athens area, Greece, were enrolled. Information on any egg intake, eaten as a whole, partly or in recipes was assessed via a validated semi-quantitative food frequency questionnaire. Follow-up for CVD evaluation (2011–2012) was achieved in n = 2020 participants (n = 317 CVD cases). Results: Ranking from lowest (<1 serving/week) to intermediate (1–4 servings/week) and high (4–7 servings/week) egg consumption tertiles, lower CVD incidence was observed (18%, 9% and 8%, respectively, p-for-trend = 0.004). Unadjusted analysis revealed that 1–3 eggs/week and 4–7 eggs/week were associated with a 60% and 75%, respectively, lower risk of developing CVD compared with the reference group (<1 egg/week). When adjusting for sociodemographic, lifestyle and clinical factors, significance was retained only for 1–3 eggs/week (hazard ratio (HR) = 0.53, 95% confidence interval (95% CI) = 0.28, 1.00). When total saturated fatty acid (SFA) intake was taken into account, this inverse association was non-significant. Multi-adjusted analysis revealed that in participants of low SFA intake, 1 serving/day increase in egg intake resulted in 45% lower risk of developing CVD. In the case of higher SFA consumption, only 1–3 eggs/week seemed to protect against CVD (HR = 0.25, 95% CI = 0.07, 0.86). In the case of intermediate cardiometabolic disorders, no significant trend was observed. Conclusions: Overall dietary habits principally in terms of SFA intake may be detrimental to define the role of eggs in cardiac health.     

Heritage-specific oral microbiota in Indigenous Australian dental calculus

Background and objectivesAboriginal Australians and Torres Strait Islanders (hereafter respectfully referred to as Indigenous Australians) experience a high burden of chronic non-communicable diseases (NCDs). Increased NCD risk is linked to oral diseases mediated by the oral microbiota, a microbial community influenced by both vertical transmission and lifestyle factors. As an initial step towards understanding the oral microbiota as a factor in Indigenous health, we present the first investigation of oral microbiota in Indigenous Australian adults.MethodologyDental calculus samples from Indigenous Australians with periodontal disease (PD; n = 13) and non-Indigenous individuals both with (n = 19) and without PD (n = 20) were characterized using 16S ribosomal RNA gene amplicon sequencing. Alpha and beta diversity, differentially abundant microbial taxa and taxa unique to different participant groups were analysed using QIIME2.ResultsSamples from Indigenous Australians were more phylogenetically diverse (Kruskal–Wallis H = 19.86, P = 8.3 × 10⁻⁶), differed significantly in composition from non-Indigenous samples (PERMANOVA pseudo-F = 10.42, P = 0.001) and contained a relatively high proportion of unique taxa not previously reported in the human oral microbiota (e.g. Endomicrobia). These patterns were robust to stratification by PD status. Oral microbiota diversity and composition also differed between Indigenous individuals living in different geographic regions.Conclusions and implicationsIndigenous Australians may harbour unique oral microbiota shaped by their long relationships with Country (ancestral homelands). Our findings have implications for understanding the origins of oral and systemic NCDs and for the inclusion of Indigenous peoples in microbiota research, highlighting the microbiota as a novel field of enquiry to improve Indigenous health.     

Blood flow changes in the trapezius muscle and overlying skin following transcutaneous electrical nerve stimulation

BACKGROUND AND PURPOSE: Various researchers have studied the effects of transcutaneous electrical nerve stimulation (TENS) on hemodynamics. The purpose of this study was to examine the effects of TENS on local blood flow in the trapezius muscle and overlying skin. SUBJECTS: Thirty-three women who were healthy, aged 25 to 55 years, were randomly assigned to receive 1 of 3 different modes of TENS. METHODS: Skin and muscle blood flow were monitored noninvasively using a new application of photoplethysmography for 15 minutes of TENS applied at high frequency (80 Hz) and sensory-level intensity and at low frequency (2 Hz) and motor-level intensity and for 15 minutes after stimulation. Subliminal 80-Hz TENS was used as a control. Blood flow was monitored simultaneously on stimulated and nonstimulated shoulders. RESULTS: Blood flow in the trapezius muscle, but not skin blood flow, increased significantly with motor-level 2-Hz TENS, whereas no increase occurred with sensory-level 80-Hz TENS or subliminal 80-Hz TENS. DISCUSSION AND CONCLUSION: Muscle contractions induced by motor-level 2-Hz TENS appear to be a prerequisite for increasing blood flow in the trapezius muscle. However, high stimulation intensity may prevent increased blood flow in the overlying skin.     

Association of Helicobacter pylori infection with cardiovascular disease--is it just a myth?

Objective

To test the hypothesis that Helicobacter pylori infection is associated with a higher rate of documented cardiovascular disease (CVD) in subjects undergoing elective upper gastrointestinal endoscopy.

Methods

202 consecutive patients (median age 60 years, 101 men) were studied. H. pylori infection was established by a rapid urease test in a gastric tissue sample (CLO test) and by histological examination of gastric mucosa from the stomach antrum and body. CVD was documented by completion of the Rose questionnaire. The association of H. pylori infection with CVD was determined by multivariate logistic regression modelling after adjusting for potential confounding factors.

Results

A total of 104 (51.5%) subjects were found H. pylori positive. Forty patients had a confirmed history of CVD. Multiple logistic regression analysis verified the strong associations of CVD with established risk factors of atherosclerotic disease but not with H. pylori infection.

Conclusion

Our findings suggest that there is no association of H. pylori infection with CVD. Eradication of H. pylori to prevent CVD is not warranted.     

Gastrointestinal manifestations of essential mixed cryoglobulinemia

A patient with essential mixed cryoglobulinemia (EMC) presented initially with gastric ulcers and, six months later, with a lesion of the ileum, mild stricture of the transverse colon, and stricture of the sigmoid colon with deep ulceration. The initial diagnosis was Crohn's disease, but pathologic examination of the resected sigmoid lesion showed vasculitis secondary to EMC. Patients with EMC can present with gastrointestinal manifestations mimicking Crohn's disease. A review and classification of the gastrointestinal manifestations of EMC are presented.