Effectiveness of a multidisciplinary BIOPSYCHOSOCIAL intervention for non-specific SUBACUTE low back pain in a working population : a cluster randomized clinical trial

BACKGROUND: Low back pain (LBP) is a multifactorial condition with individual and societal impact that affects populations globally. Current guidelines for the treatment of LBP recommend pharmacological and non-pharmacological strategies. The aim of this study was to compare usual clinical practice with the effectiveness of a biopsychosocial multidisciplinary intervention in reducing disability, severity of pain and improving quality of life in a working population of patients with subacute (2-12 weeks), non-specific LBP. METHODS: Longitudinal cluster randomized clinical trial conducted in 39 Primary Health Care Centres (PHCC) of Barcelona, with patients aged 18-65 years (n = 501; control group = 239; 26 PHCC, intervention group = 262; 13 PHCC). The control group received usual clinical care. The intervention group received usual clinical care plus a biopsychosocial multidisciplinary intervention, which consisted of physiotherapy, cognitive-behavioural therapy and medication. The main outcomes were changes in the Roland Morris Disability Questionnaire (RMDQ), and the minimal clinically important differences. Secondary outcomes were changes in the McGill Pain (MGPQ) and Quality of Life (SF-12) questionnaires. Assessment was conducted at baseline, 3 and 12 months. Analysis was by intention-to-treat and analyst-blinded. Multiple imputations were used. RESULTS: Of the 501 enrolled patients, 421 (84%) provided data at 3 months, and 387 (77.2%) at 12 months. Mean age was 46.8 years (SD: 11.5) and 64.7% were women. In the adjusted analysis of the RMDQ outcome, only the intervention group showed significant changes at 3 months (- 1.33 points, p = 0.005) and at 12 months (- 1.11 points, p = 0.027), but minimal clinically important difference were detected in both groups. In the adjusted analysis of the RMDQ outcome, the intervention group improvement more than the control group at 3 months (- 1.33 points, p = 0.005) and at 12 months (- 1.11 points, p = 0.027). The intervention group presented a significant difference. Both groups presented a minimal clinically important difference, but more difference in the intervention group. The intervention group presented significant differences in the MGPQ scales of current pain intensity and VAS scores at 3 months. No statistically significant differences were found in the physical and mental domains of the SF-12. CONCLUSIONS: A multidisciplinary biopsychosocial intervention in a working population with non-specific subacute LBP has a small positive impact on disability, and on the level of pain, mainly at short-term, but no difference on quality of life. TRIAL REGISTRATION: ISRCTN21392091 (17 oct 2018) (Prospectively registred

Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review.

BACKGROUND: Emergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization. METHODOLOGY/PRINCIPAL FINDINGS: We conducted electronic searches using free text and Medical Subject Headings on PubMed and The Cochrane Library to identify studies of ED visits, re-visits and mortality. We performed complementary searches of grey literature, manual searches and direct contacts with experts. We included studies that investigated the effectiveness of interventions designed to reduce ED visits and the following study designs: time series, cross-sectional, repeated cross-sectional, longitudinal, quasi-experimental studies, and randomized trial. We excluded studies on specific conditions, children and with no relevant outcomes (ED visits, re-visits or adverse events). From 2,348 potentially useful references, 48 satisfied the inclusion criteria. We classified the interventions in mutually exclusive categories: 1) Interventions addressing the supply and accessibility of services: 25 studies examined efforts to increase primary care physicians, centers, or hours of service; 2) Interventions addressing the demand for services: 6 studies examined educational interventions and 17 examined barrier interventions (gatekeeping or cost). CONCLUSIONS/SIGNIFICANCE: The evidence suggests that interventions aimed at increasing primary care accessibility and ED cost-sharing are effective in reducing ED use. However, the rest of the interventions aimed at decreasing ED utilization showed contradictory results. Changes in health care policies require rigorous evaluation before being implemented since these can have a high impact on individual health and use of health care resources. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO. Identifier: CRD420111253

Experiencias de las personas con sintomatología neuropsicológica de covid persistente en Cataluña: un estudio fenomenológico

Resumen: Objetivo: Describir las vivencias de las personas con sintomatología neuropsicológica asociada al COVID persistente, así como las barreras que estas suponen en su día a día y las estrategias que se desarrollan para abordarlas. Diseño: Estudio cualitativo descriptivo de orientación fenomenológica interpretativa. Emplazamiento: Centros de Atención Primaria del Área Metropolitana Norte de Barcelona y el Hospital Universitario Germans Trias i Pujol (Badalona), España. Participantes: 34 personas adultas con síntomas neuropsicológicos persistentes de COVID-19 (>12 semanas desde el inicio de la enfermedad). Método: Se realizaron entrevistas individuales en profundidad siguiendo un guion de preguntas abiertas que permite poner de manifiesto sus narrativas alrededor de su vivencia de la sintomatología neuropsicológica asociada al COVID persistente. Éstas fueron transcritas y analizadas siguiendo los preceptos del análisis fenomenológico interpretativo (IPA). Resultados: Se identificaron 3 clústeres que detallan el impacto vital de la COVID persistente y su sintomatología neuropsicológica: COVID persistente como ruptura y cambio de vida; estrategias de afrontamiento; y (re)conocimiento de la nueva subjetividad. Conclusiones: De los relatos de las participantes y la literatura existente emerge la relevancia de integrar críticamente los aprendizajes de síndromes análogos como la fibromialgia y la fatiga crónica, así como involucrar a pacientes en el diseño y la implementación, incluso a nivel de la consulta, de prácticas clínicas que den a conocer estas secuelas neuropsicológicas (psicoeducación) tanto a otros pacientes como a cuidadores y profesionales. De esta forma, se facilitaría un mayor y mejor abordaje psicológico especializado y reducir el estigma que aún acompaña la dolencia. Abstract: Objective: To describe the experiences of people living with neuropsychological symptomatology associated with long-COVID, as well as identifying the barriers they encounter in their daily lives and the strategies they develop to deal with them. Design: Descriptive qualitative study following an interpretative phenomenological perspective. Location: Primary Care Centres in the Northern Metropolitan Area of Barcelona and the Germans Trias i Pujol University Hospital (Badalona), Spain. Participants: 34 adults with any persistent neuropsychological symptoms of COVID-19 (>12 weeks since disease onset). Method: In-depth individual interviews were conducted following a script of open-ended questions to elicit their narratives around the research objective. Results: 3 clusters detailing the life impact of long-COVID and its neuropsychological symptomatology were identified: long-COVID as life-breaking and life-changing; coping strategies; and (ac)knowledge (of) the emerging subjectivity. Conclusions: From the participants’ accounts and the existing literature emerges the relevance of critically integrating lessons learned from analogous syndromes such as fibromyalgia and chronic fatigue, as well as involving patients in the design and implementation (even at the consultation level) of clinical practices that raise awareness of these neuropsychological sequelae (psychoeducation) both to other patients and to caregivers and professionals. This would facilitate a greater and better specialised psychological approach and reduce the stigma that still accompanies the condition

Flow of articles through the literature review process.

<p>Flow of articles through the literature review process.</p

Comparación entre tres métodos de medida de la multimorbilidad en función del uso de recursos sanitarios en atención primaria

ResumenObjetivoComparar 3 diferentes métodos de medida de la multimorbilidad en función del uso de recursos sanitarios (coste de la asistencia) en atención primaria (AP).DiseñoEstudio retrospectivo realizado a partir de registros médicos informatizados.EmplazamientoEn 13 equipos de AP de Cataluña.ParticipantesPacientes adscritos que demandaron atención durante el año 2008.Medidas principalesVariables sociodemográficas, de comorbilidad y de coste. Los métodos de comparación fueron: a) índice de comorbilidad combinado (ICC): se elaboró un índice propio a partir de las puntuaciones de episodios agudos y crónicos; b) índice de Charlson (iCh), y c) índices de casuística de los Adjusted Clinical Groups: bandas de utilización de recursos (BUR). El modelo de costes se estableció diferenciando los costes fijos (funcionamiento de los centros) y los variables. Análisis estadístico: se desarrollaron 3 modelos de regresión lineal para evaluar la capacidad explicativa de cada medida de comorbilidad; que se compararon a partir del coeficiente de determinación (R2), p<0,05.ResultadosSe seleccionaron 227.235 pacientes; el promedio/unitario del coste de la asistencia fue de 654,2 €. El ICC explica un R2=50,4%, el iCh un R2=29,2% y las BUR un R2=39,7% de la variabilidad del coste. El comportamiento del ICC es aceptable, no obstante con puntuaciones bajas (entre 1 y 3 puntos) no se consiguen resultados tan concluyentes.ConclusionesEl ICC se muestra como un sencillo y posible predictor del coste de la asistencia en AP en situación de práctica clínica habitual. De confirmarse estos resultados posibilitarían una mejora en la comparación de la casuística.AbstractObjectiveTo compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC).DesignRetrospective study using computerized medical records.SettingThirteen PHC teams in Catalonia (Spain).ParticipantsAssigned patients requiring care in 2008.Main measurementsThe socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs. Statistical analysis: 3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R2), p< .05.ResultsThe study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R2=50.4%, the ChI an R2=29.2% and BUR an R2=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results.ConclusionsThe CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix

Effectiveness of a multidisciplinary BIOPSYCHOSOCIAL intervention for non-specific SUBACUTE low back pain in a working population: a cluster randomized clinical trial

Abstract Background Low back pain (LBP) is a multifactorial condition with individual and societal impact that affects populations globally. Current guidelines for the treatment of LBP recommend pharmacological and non-pharmacological strategies. The aim of this study was to compare usual clinical practice with the effectiveness of a biopsychosocial multidisciplinary intervention in reducing disability, severity of pain and improving quality of life in a working population of patients with subacute (2–12 weeks), non-specific LBP. Methods Longitudinal cluster randomized clinical trial conducted in 39 Primary Health Care Centres (PHCC) of Barcelona, with patients aged 18–65 years (n = 501; control group = 239; 26 PHCC, intervention group = 262; 13 PHCC). The control group received usual clinical care. The intervention group received usual clinical care plus a biopsychosocial multidisciplinary intervention, which consisted of physiotherapy, cognitive-behavioural therapy and medication. The main outcomes were changes in the Roland Morris Disability Questionnaire (RMDQ), and the minimal clinically important differences. Secondary outcomes were changes in the McGill Pain (MGPQ) and Quality of Life (SF-12) questionnaires. Assessment was conducted at baseline, 3 and 12 months. Analysis was by intention-to-treat and analyst-blinded. Multiple imputations were used. Results Of the 501 enrolled patients, 421 (84%) provided data at 3 months, and 387 (77.2%) at 12 months. Mean age was 46.8 years (SD: 11.5) and 64.7% were women. In the adjusted analysis of the RMDQ outcome, only the intervention group showed significant changes at 3 months (− 1.33 points, p = 0.005) and at 12 months (− 1.11 points, p = 0.027), but minimal clinically important difference were detected in both groups. In the adjusted analysis of the RMDQ outcome, the intervention group improvement more than the control group at 3 months (− 1.33 points, p = 0.005) and at 12 months (− 1.11 points, p = 0.027). The intervention group presented a significant difference. Both groups presented a minimal clinically important difference, but more difference in the intervention group. The intervention group presented significant differences in the MGPQ scales of current pain intensity and VAS scores at 3 months. No statistically significant differences were found in the physical and mental domains of the SF-12. Conclusions A multidisciplinary biopsychosocial intervention in a working population with non-specific subacute LBP has a small positive impact on disability, and on the level of pain, mainly at short-term, but no difference on quality of life. Trial registration ISRCTN21392091 (17 oct 2018) (Prospectively registred). </jats:sec