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Prevalence of chronic diseases and morbidity in primary health care in central Greece: An epidemiological study

  • Markos Minas1Email author,
  • Nikolaos Koukosias1,
  • Elias Zintzaras2,
  • Konstantinos Kostikas1 and
  • Konstantinos I Gourgoulianis1
BMC Health Services Research201010:252

DOI: 10.1186/1472-6963-10-252

Received: 24 April 2010

Accepted: 28 August 2010

Published: 28 August 2010

Abstract

Background

In Greece there is lack of large epidemiological studies regarding morbidity and mortality in primary health care. The aim of the present study was to estimate the prevalence and morbidity of the most common diseases in a large population sample from primary health care.

Methods

Four primary health centres were randomly selected. During one year period, 12 visits were performed in each centre, one per month, in random order and all visitors willing to participate in the study were included. Data on morbidity of each subject were recorded after performing an interview with the participant and checking his medical records, medical history and current medication. Diseases were coded using the international classification of primary care (ICPC) system.

Results

In total 20,299 subjects were recorded. The results revealed significant variations in morbidity between genders and age groups. However, in all age groups, diseases of the circulatory system were most prevalent, followed by endocrine, metabolic, musculoskeletal and respiratory diseases. Osteoporosis was significantly more prevalent in females compared to males, whereas skin and eye disorders were more prevalent in subjects below 65 years old. COPD prevalence was very low compared to worldwide data.

Conclusions

The present study revealed great variations in the prevalence of the diseases between genders and age groups. Our data justify the urgent need for the development of electronic health records that may help in the design of new prevention strategies in primary health care.

Background

Epidemiological data can be useful in the design of new prevention strategies, especially in primary health care [1]. There are worldwide data available regarding the prevalence, morbidity and mortality of chronic diseases. Data from the World Health Organization (WHO) indicate that the most important causes of death are currently ischemic heart disease and cerebrovascular disease [2].

The development of electronic health records, especially in primary care, may help in the identification of the burden of several diseases in each region. The use of such records may be of great importance for health systems, considering that the North Shore Hospital System in Long Island, New York, announced recently that it will pay an incentive of up to $40,000 to each physician in its network who adopts its electronic health record, paying 50% of the cost to physicians who install an electronic health record that communicates with the hospital and 85% of the cost if the physician also shares de-identified data on the quality of care [3].

On the other hand, the International Classification of Primary Care (ICPC) recently celebrated its 21 years. This coding system is very easy and very useful in primary health care [46]. In a recent epidemiological study conducted in Spain, ICPC was used in conjunction with electronic health records, for the estimation of the prevalence of major diseases in the general population [7].

In Greece, the national health system is designed in three levels. Primary health care centres compose the first level which represents the primary health care system. General practitioners are the key component of the primary health care centres. Thus, their role is very important as general practitioners represent the link between public and the national health system. However, the establishment of an integrated primary health care system in Greece is still under development [8].

However, in Greece there is lack of a recording system in primary health care, rendering the design of large epidemiological studies difficult and complex. The aim of this study is to estimate the prevalence and morbidity of ten major chronic diseases in primary health care centres serving a semirural population sample in Thessaly, central Greece. Differences in morbidity between genders as well as between young and elderly were further evaluated.

Methods

Study design

Data collection was performed from January to December 2008. Thessaly is a district in central Greece with four prefectures and seventeen primary health care centres with a total population of 740,115 residents [9] that represents approximately 8% of the total population of Greece. All these primary health care centres are part of the national health system and correspond mainly to rural and semirural population. Four primary health centres were randomly selected to be recorded, one from each prefecture. The primary health care centres selected correspond to a population of 126,843 residents (data derived from local authorities). The study group visited one centre per week in order to visit all selected centres in one month. The centre visited in each of the four weeks of each month was chosen in a random order. Overall, twelve visits were performed in each centre.

Study participants were all subjects over 14 years old who visited primary health care centres for any reason and were willing to participate in the study. A structured questionnaire was completed by the study coordinators upon the arrival of each subject. The study questionnaire included questions about demographics, medical history and current medication for chronic diseases. The study coordinators additionally checked the medical records of each patient, in order to record all chronic diseases in detail.

The chronic diseases of each subject were identified and coded using the ICPC system [4]. Each disease recorded was included in the respective organic system according to ICPC codes (Table 1). The ten most common and burdensome chronic diseases, based on the main causes of death and disease burden in the United States and the most common diagnoses in primary care, were recorded separately [10]. The study was approved by the Ethics committee of the University Hospital of Larissa and all subjects provided informed consent.
Table 1

ICPC codes for selected diseases and organic systems

A. General

 

B. Blood, lymphatics

 

C. Digestive

 

F. Eye

 

H. Ear

 

K. Circulatory

 

   Elevated blood pressure

K85, K86, K87

   Coronary heart disease

K74, K75

L. Musculoskeletal

 

   Osteoarthritis

L83, L84, L89, L90, L91

   Osteoporosis

L95

N. Neurological

 

P. Psychological

 

   Depression

P03, P76, P78

   Anxiety disorders

P01, P74, P75, P79, P82

R. Respiratory

 

   Asthma

R96

   COPD

R79, R95

T. Endocrine, metabolic and nutritional

 

   Lipid disorder

T93

   Diabetes

T89, T90

U. Urology

 

X. Genital Female

 

Y. Genital male

 

Statistical analysis

Demographic data are presented as median (interquartile range) whereas categorical variables are presented as percentages. Normality of data was estimated with the use of D'Agostino-Pearson normality test. Comparison between medians was performed using Mann-Whitney U test for skewed data. The prevalence was estimated taking into account the cluster design and based on the cluster sample total [11, 12]. The analysis was performed using the proc survey means of SAS v.90 and GraphPad Prism v.5.0. The prevalence of each disease is presented per 10,000 of population.

Results

Demographic data are presented in Table 2. In total, 20,299 subjects were willing to participate in the study (56.4% female). Participants were distributed according to the gender and age group (< 65 years, ≥65 years). According to Table 2, the majority of participants were elderly women. In the age group < 65 years, males were younger than females (48 vs. 51 years old), whereas in the age group ≥65 years old males were older than females (74 vs. 73 years old).
Table 2

Demographic data of the study participants

 

Male

Female

Total

 

< 65 years

≥65 years

Total

< 65 years

≥65 years

Total

 

N

3703

5155

8858

4720

6721

11441

20299

Age

48 (35-58)*

74 (70-79)^

68 (52-75)

51 (36-60)*

73 (69-78)^

68 (55-74)

68 (54-75)

Disease number

       

   0

9 (0.24%)

5 (0.10%)

14 (0.16%)

32 (0.68%)

4 (0.06%)

36 (0.31%)

50

   1

3341 (90.22%)

3732 (72.40%)

7073 (79.85%)

4001 (84.77%)

4522 (67.28%)

8523 (74.50%)

15596

   2

288 (7.78%)

1087 (21.09%)

1375 (15.52%)

544 (11.52%)

1581 (23.53%)

2125 (18.57%)

3500

   3

62 (1.67%)

273 (5.30%)

335 (3.78%)

128 (2.71%)

512 (7.62%)

640 (5.59%)

975

   4

3 (0.09%)

54 (1.05%)

57 (0.64%)

14 (0.30%)

91 (1.35%)

105 (0.92%)

162

   5

0 (0%)

4 (0.06%)

4 (0.05%)

1 (0.02%)

10 (0.15%)

11 (0.1%)

15

   6

0 (0%)

0 (0%)

0 (0%)

0 (0%)

1 (0.01%)

1 (0.01%)

1

*,^ P < 0.0001

Table 2 and Figure 1 present the distribution of participants according to their number of diseases. In all age groups the majority of participants suffered from a single disease, however with several variations. For example, a significant proportion of people ≥65 years old had two or more diseases. Moreover, women had more commonly 2 or more diseases in both age groups.
https://static-content.springer.com/image/art%3A10.1186%2F1472-6963-10-252/MediaObjects/12913_2010_Article_1389_Fig1_HTML.jpg
Figure 1

Distribution of disease numbers between genders and age groups.

The estimated prevalence of each system or disease, expressed per 10000 people, is shown in Table 3. The most prevalent diseases overall were circulatory disorders, including arterial hypertension and coronary heart disease. Other diseases with high prevalence were endocrine, metabolic (especially lipid disorders), musculoskeletal and respiratory diseases. Interestingly, osteoarthritis and asthma, two chronic diseases classified in the two latter organic systems, presented low prevalence. It should be mentioned also that the prevalence of chronic obstructive pulmonary disease (COPD) was considerably low compared to other diseases.
Table 3

Estimated prevalence of the recorded diseases

 

N

Estimated prevalence

(per 10,000 residents)

95% CI

A. General

1099

552.0

(471.0 - 633.0)

B. Blood, lymphatics

486

240.6

(175.0 - 306.2)

C. Digestive

1688

844.6

(673.2 - 1016.1)

F. Eye

451

222.8

(167.1 - 278.6)

H. Ear

207

104.8

(45.5 - 164.1)

K. Circulatory

7026

3409.2

(2959.4 - 3860.3)

   Elevated blood pressure

3719

1813.2

(1505.2 - 2121.1)

   Coronary heart disease

2321

1107.2

(710.2 - 1504.2)

L. Musculoskeletal

3150

1551.4

(1448.1 - 1654.7)

   Osteoarthritis

684

340.0

(249.6 - 430.4)

   Osteoporosis

1047

500.7

(403.3 - 598.0)

N. Neurological

975

489.0

(420.4 - 557.6)

P. Psychological

1968

949.9

(669.8 - 1230.0)

   Depression

580

269.1

(79.9 - 458.2)

   Anxiety disorders

376

191.4

(132.4 - 250.4)

R. Respiratory

3122

1548.3

(1353.7 - 1742.9)

   Asthma

103

53.8

(34.2 - 73.4)

   COPD

706

349.6

(277.7 - 421.6)

S. Skin

927

452.7

(381.9 - 523.6)

T. Endocrine, metabolic and nutritional

4058

1945.1

(1641.7 - 2248.5)

   Lipid disorder

2026

960.4

(741.4 - 1179.4)

   Diabetes

1472

714.6

(646.9 - 782.4)

U. Urology

545

268.8

(193.6 - 344.0)

X. Genital Female

242

120.7

(99.4 - 142.1)

Y. Genital male

302

147.5

(114.7 - 180.3)

CI: confidence intervals

Differences between genders

The comparison of the estimated prevalence of the diseases revealed significant differences between the two genders, as presented in Table 4. The most prominent difference is the higher prevalence of the diseases of musculoskeletal system in women, being more than 10-fold higher for osteoporosis. Another important difference is the fact that psychological diseases, especially depression, were more prevalent in females. Circulatory diseases were slightly more prevalent in females, with the exception of coronary heart disease which was slightly more common in males. Another interesting finding is the higher prevalence of COPD compared to asthma in females.
Table 4

Estimated prevalence for each disease according to gender and age group

 

Male

Female

Total

 

< 65 years

≥65 years

Total

< 65 years

≥65 years

Total

 
 

N

Prevalence (95% CI)

N

Prevalence (95% CI)

N

Prevalence (95% CI)

N

Prevalence (95% CI)

N

Prevalence (95% CI)

N

Prevalence (95% CI)

 

A.General

460

1262.5 (1107.5 - 1417.5)

183

358.2 (250.5 - 465.9)

643

738.0 (617.1 - 859.0)

278

591.8 (522.2 - 661.5)

178

275.4 (214.6 - 336.2)

456

407.0 (353.9 - 460.0)

1099

B.Blood, lymphatics

31

85.8 (60.4 - 111.1)

119

246.7 (143.2 - 350.3)

150

173.1 (133.0 - 213.3)

124

256.4 (172.9 - 339.8)

212

322.2 (214.9 - 429.5)

336

292.9 (199.8 - 386.0)

486

C.Digestive

341

937.8 (804.4 - 1071.2)

431

822.9 (585.0 - 1060.7)

772

876.7 (701.1 - 1052.3)

398

859.1 (707.3 - 1010.8)

518

788.5 (582.0 - 995.0)

916

820.4 (642.7 - 998.2)

1688

F.Eye

89

238.8 (157.3 - 320.3)

117

231.1 (178.2 - 284.0)

206

233.1 (173.5 - 292.7)

56

119.0 (114.8 - 123.1)

189

282.0 (188.8 - 375.3)

245

215.2 (155.1 - 275.3)

451

H.Ear

58

155.5 (90.2 - 220.7)

31

66.6 (23.9 - 109.4)

89

105.0 (50.9 - 159.1)

78

158.4 (56.9 - 260.0)

40

61.9 (12.8 - 111.0)

118

104.7 (31.3 - 178.2)

207

K.Circulatory

715

1940.0 (1730.1 - 2149.9)

2445

4700.9 (4485.4 - 4916.4)

3160

3532.6 (3186.1 - 3879.1)

890

1892.2 (1494.8 - 2289.6)

2976

4344.2 (3959.3 - 4729.2)

3866

3311.7 (2775.2 - 3848.1)

7026

   Elevated blood pressure

389

1062.6 (868.6 - 1256.5)

1096

2105.5 (1743.4 - 2467.5)

1485

1665.3 (1362.0 - 1968.5)

589

1251.2 (1006.4 - 1496.0)

1645

2422.7 (2087.1 - 2758.2)

2234

1926.8 (1595.3 - 2258.4)

3719

   Coronary heart disease

225

608.7 (369.6 - 847.7)

959

1817.3 (1351.9 - 2282.6)

1184

1308.9 (890.7 - 1727.2)

179

380.8 (148.0 - 613.6)

958

1354.4 (946.4 - 1762.5)

1137

949.3 (562.4 - 1336.2)

2321

L.Musculoskeletal

416

1122.3 (1047.1 - 1197.5)

457

886.9 (826.0 - 947.8)

873

988.0 (926.4 - 1049.6)

795

1696.8 (1491.5 - 1902.0)

1482

2216.7 (2017.8 - 2415.6)

2277

1990.4 (1795.6 - 2185.3)

3150

   Osteoarthritis

60

163.3 (131.8 - 194.7)

121

234.5 (171.9 - 297.0)

181

203.1 (158.4 - 247.7)

145

315.4 (238.3 - 392.5)

358

537.7 (366.9 - 708.5)

503

447.2 (316.8 - 577.6)

684

   Osteoporosis

11

27.6 (0 - 55.7)

37

68.8 (36.3 - 101.3)

48

51.0 (20.3 - 81.7)

300

629.3 (499.4 - 759.3)

699

1014.4 (911.7 - 1117.1)

999

850.3 (712.8 - 987.8)

1047

N.Neurological

122

328.9 (284.5 - 373.2)

278

545.2 (426.0 - 664.5)

400

456.1 (393.7 - 518.6)

216

466.6 (391.3 - 542.0)

359

550.6 (462.5 - 638.7)

575

515.4 (434.5 - 596.4)

975

P.Phychological

321

873.9 (696.7 - 1051.1)

396

733.3 (472.5 - 994.1)

717

792.3 (571.6 - 1031.1)

498

1074.1 (726.5 - 1241.7)

753

1078.6 (758.1 - 1399.0)

1251

1075.5 (752.5 - 1398.5)

1968

   Depression

42

111.3 (21.4 - 201.3)

115

201.2 (39.9 - 362.6)

157

165.0 (30.3 - 299.7)

141

305.2 (104.7 - 505.7)

282

379.4 (129.9 - 628.9)

423

349.9 (117.5 - 582.2)

580

   Anxiety disorders

77

212.1 (125.1 - 299.0)

68

128.5 (77.6 - 179.3)

145

168.5 (120.5 - 216.5)

115

248.5 (162.9 - 334.2)

116

179.7 (102.9 - 256.5)

231

209.1 (137.1 - 281.2)

376

R.Respiratory

717

1887.6 (1529.3 - 2245.9)

780

1548.0 (1316.7 - 1779.4)

1497

1692.3 (1503.0 - 1881.7)

937

1969.7 (1646.7 - 2292.6)

688

1029.0 (996.3 - 1061.6)

1625

1436.4 (1234.6 - 1638.3)

3122

   Asthma

15

40.6 (20.5 - 60.8)

14

29.6 (4.0 - 55.2)

29

33.9 (16.2 - 51.7)

40

87.4 (58.7 - 116.1)

34

57.4 (23.9 - 90.9)

74

69.4 (41.1 - 97.6)

103

   COPD

71

188.3 (144.1 - 232.5)

326

640.6 (545.9 - 735.4)

397

451.9 (392.7 - 511.0)

79

172.7 (120.8 - 224.7)

230

332.3 (212.0 - 452.5)

309

269.4 (184.3 - 354.5)

706

S.Skin

286

779.3 (671.5 - 887.2)

158

294.2 (208.2 - 380.2)

444

497.1 (429.4 - 564.7)

290

612.7 (526.7 - 698.7)

193

273.2 (178.5 - 367.8)

483

418.0 (330.2 - 505.7)

927

T.Endocrine, metabolic and nutitional

413

1096.5 (941.4 - 1251.5)

1183

2268.6 (2018.8 - 2518.3)

1596

1770.2 (1556.5 - 1983.8)

712

1476.0 (1124.8 - 1827.3)

1750

2525.0 (2214.5 - 2834.5)

2462

2080.4 (1696.6 - 2464.2)

4058

   Lipid disorder

233

620.6 (520.3 - 720.9)

572

1092.5 (1005.7 - 1179.3)

805

892.9 (791.4 - 994.4)

358

723.9 (401.0 - 1046.8)

863

1223.8 (954.8 - 1492.8)

1221

1010.9 (698.7 - 1323.0)

2026

   Diabetes

137

362.6 (282.5 - 442.6)

474

925.3 (774.5 - 1076.0)

611

680.9 (587.1 - 774.6)

208

435.1 (354.1 - 516.1)

653

698.2 (938.8 - 997.6)

861

741.7 (678.9 - 804.4)

1472

U.Urology

96

255.4 (165.0 - 345.8)

131

262.7 (152.0 - 373.4)

227

259.0 (158.2 - 359.8)

140

290.9 (220.6 - 361.1)

178

264.0 (218.4 - 309.7)

318

276.2 (220.0 - 332.5)

545

X.Genital Female

-

-

-

-

-

-

122

261.2 (196.0 - 326.4)

124

179.8 (153.3 - 206.3)

246

217.4 (180.6 - 254.3)

246

Y.Genital male

50

140.3 (96.8 - 183.7)

252

470.4 (373.1 - 567.8)

302

333.9 (254.0 - 413.8)

-

-

-

-

-

 

302

CI: Confidence interval. Estimated prevalence corresponds to each gender and age group and is expressed per 10000 residents

Differences between age groups

Significant differences in the prevalence of the diseases between the young and the elderly were observed (Table 4). Of great importance were the differences in the general diseases, the diseases of the skin and the respiratory diseases, which were more prevalent in younger patients. In contrast, circulatory disorders were more prevalent in the elderly. Surprisingly, psychological disorders had similar overall prevalence in both genders and in both age groups, whereas anxiety disorders were more prevalent in the younger.

The differences between genders in each age group were not very prominent. In younger patients, circulatory diseases had similar prevalence between males and females, whereas coronary heart disease was significantly more prevalent in males. The same pattern was observed in the elderly, but with a more blunted difference. Musculoskeletal diseases were more prevalent in females in both age groups; however, the difference in the elderly was more prominent. Interestingly, the prevalence of COPD was similar in the two genders of the younger group, whereas it was more prevalent in elderly males compared to females.

Discussion

The results of the present study indicate that circulatory and metabolic diseases represent the most important causes of morbidity in the general population visiting primary health care centres, followed by endocrine, metabolic, musculoskeletal and respiratory diseases. Significant variations in the prevalence of diseases between genders and age groups were observed. Our results support the fact that in Greece there is an unmet need for the development of a recording system in primary health care, in order the pattern of diseases in specific areas and age groups to be identified and effective strategies for the prevention and management of individual patients to be implemented.

The primary health care facilities of the National Health System in Greece are located mainly in rural areas. However, recently the first urban primary health centre was introduced in the Greek health care system, and Mariolis et al. showed that there are variations between urban and rural primary health centres [13]. The primary health centres selected for this study correspond to a rural and semirural population, since there are no urban primary health care centres in Thessaly.

The distribution of the diseases estimated in this study is similar with worldwide data. Data from WHO indicate that cardiovascular disease and diabetes mellitus are important causes for morbidity and mortality worldwide [2] and cardiovascular diseases are the leading cause of death worldwide, especially in women. In low and middle income countries of Europe in the age group of 15-59 years old, two thirds of all deaths are associated with cardiovascular diseases, cancer and other non-communicable diseases [2]. It is estimated that the global cardiovascular deaths will increase to 11.8 million in 2030 [2]. Data from the present study are in accordance with these data, since the results of this study indicate that the diseases of the circulatory system are the most prevalent in all age groups, both in males and females.

Another important group of diseases of high prevalence in the Greek population are neuropsychiatric disorders. Mental disorders are an important source of lost years of healthy life among women 15 to 44 years old [2]. Moreover, neuropsychiatric disorders have been observed also in the 16.5% of a representative sample of South African adults [14]. Our data indicate that the prevalence of depression is higher in women compared to men, in accordance with previous studies.

Recent data from a Spanish population have shown that the prevalence of chronic health problems in general practice was higher in women and increased with age [7], a finding similar to the present study. Arterial hypertension was the most prevalent disease in the Spanish study [7], and this was also the case in two other studies from Italy and Sweden [15, 16]. It is important to be noticed that these studies were performed in primary care, since data from secondary and tertiary care are additionally needed for the correct estimation of the disease prevalence [16]. A previous study in a random nationwide sample of adult Greek population has also indicated that self-reported arterial hypertension represents a significant public health problem [17].

One important difference between the present and the Spanish study is that COPD is more prevalent in Spain compared to our sample of Greek population [7]. The prevalence of COPD depends on the smoking pattern of each country [18], despite the fact that there is an increasing number of studies showing high rates of COPD in non-smokers [19]. There is a high prevalence of smoking in urban areas of Greece [20], which is lower in rural areas [21]. The fact that smoking rates are lower in the rural areas recorded in the present study, in combination with the underdiagnosis of COPD in Greece [22] may account for this discrepancy.

Several regions worldwide present a totally different pattern of diseases compared to our findings. For example, data from African studies indicate that the major causes of death in sub Saharan regions were communicable, maternal and perinatal conditions [23]. Despite the fact that in these regions the pattern of morbidity and mortality is entirely different, a rise in non communicable diseases has been recently observed [14].

Epidemiologic data depend on the presence of recording systems. Several studies have emphasized the usefulness of electronic health records in physicians' practice. The development of a new pan-Canadian network for primary health care has been recently announced [24]. However, there is not adequate adoption of these records, even in US hospitals [25], and the proportion of physicians that use them remains very low, even in primary care settings [3]. The absence of epidemiologic data on many chronic diseases in Greece renders the conduction of large epidemiologic studies in general population imperative, in order to design new strategies in primary care.

Despite the large number of participants, the present study presents several limitations. Firstly, due to geographic reasons, our sample may present significant differences compared to the general population. Data from Eurostat indicate that in Greece the proportion of the population aged > 65 years old is 18.6% [26], whereas in this study patients ≥65 years old represent over 50% of our sample. On the other hand the selected primary health care centres correspond to rural and semirural areas, with possible differences in the distribution of the population compared to urban areas. However, it should be mentioned that our study population represents approximately 16% of the population of the area that corresponds to the health care centres involved. Another possible bias is that the participation in the study was voluntary after invitation. Although there are no data on the morbidity of the subjects that were not willing to participate, the large number of participants, as well as the large number and the random order of visits in each health centre may minimize this factor. The additional evaluation of the patients' health records may have further diminished the inaccurate recording of chronic diseases.

Conclusions

In conclusion, the burden of chronic diseases in Greece seems to be similar with the burden observed in Europe, and especially in the middle and high income countries. Arterial hypertension, diabetes mellitus, diseases of the circulatory system and depression seem to be the most prevalent diseases. The present study revealed great variations in the prevalence of the diseases between genders and age groups. Our data justify the urgent need for the development of electronic health records that may help in the design of new prevention strategies in primary health care.

Abbreviations

COPD: 

Chronic Obstructive Pulmonary Disease

ICPC: 

International Classification of Primary Care

WHO: 

World Health Organization.

Declarations

Acknowledgements

None

Authors’ Affiliations

(1)
Respiratory Medicine Department, University of Thessaly Medical School
(2)
Department of Biomathematics, University of Thessaly Medical School

References

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