Background: Demographic aging is a generalised event and the proportion of older adults is increasing rapidly worldwide with chronic pathologies, disability, and complexity of health needs. The intracerebral haemorrhage (ICH) has devastating consequences in high risk people. This study aims to quantify the incidence of ICH in complex chronic patients (CCP).

Methods: This is a multicentre, retrospective and community-based cohort study of 3594 CCPs followed up from 01/01/2013 to 31/12/2017 in primary care without a history of previous ICH episode. The cases were identified from clinical records encoded with ICD-10 (10th version of the International Classification of Diseases) in the e-SAP database of the Catalan Health Institute. The main variable was the ICH episode during the study period. Demographic, clinical, functional, cognitive and pharmacological variables were included. Descriptive and logistic regression analyses were carried out to identify the variables associated with suffering an ICH. The independent risk factors were obtained from logistic regression models, ruling out the variables included in the HAS-BLED score, to avoid duplication effects. Results are presented as odds ratio (OR) and 95% confidence interval (CI). The analysis with the resulting model was also stratified by sex.

Results: 161 (4.4%) participants suffered an ICH episode. Mean age 87±9 years; 55.9% women. The ICH incidence density was 151/10000 person-years [95%CI 127-174], without differences by sex. Related to subjects without ICH, presented a higher prevalence of arterial hypertension (83.2% vs. 74.9%; p=0.02), hypercholesterolemia (55.3% vs. 47.4%, p=0.05), cardiovascular disease (36.6% vs. 28.9%; p=0.03), and use of antiaggregants drugs (64.0% vs. 52.9%; p=0.006). 93.2% had a HAS-BLED score ≥3. The independent risk factors for ICH were identified: HAS-BLED ≥3 [OR 3.54; 95%CI 1.88-6.68], hypercholesterolemia [OR 1.62; 95%CI 1.11-2.35], and cardiovascular disease [OR 1.48 IC95% 1.05-2.09]. The HAS_BLED ≥3 score showed a high sensitivity [0.93 CI95% 0.97-0.89] and negative predictive value [0.98 (CI95% 0.83-1.12)].  

Conclusions:  In the CCP subgroup the incidence density of ICH was 5-60 times higher than that observed in elder and general population. The use of bleeding risk score as the HAS-BLED scale could improve the preventive approach of those with higher risk of ICH.

The cases were identified from clinical records encoded with ICD-10 (10th version of the International Classification of Diseases) in the e-SAP database of the Catalan Health Institute. The Department of Information and New Technologies carried out an automated extraction of the CMBD of hospital discharges and SIRE. All the data were included in an ad hoc repository, which was delivered to the main researcher in a completely anonymous format, supervised and assessed according to the General Data Protection Regulation of Spain/Europe of 1st February 2017. The Catalan Health Plan extensively implemented a case finding system classifying high risk chronic patients into two different categories based on defined criteria and primary care physician judgment: i) Complex chronic patients (CCP, approximately 5% of the population); and, ii) Patients with less than 12 months expected life survival (ACD, approximately 1% of the population). The medical records including the CCP condition were incorporated into the computerised medical record of the Catalan Health Institute in January 2013. This database is managed by primary care professionals, who administer and update it in a specific format called “Shared individual intervention plan” (PIIC, Catalan acronym for Pla d'Intervenció Individualitzat Compartit). Currently, 82% of individuals registered as CCPs have an updated report.