Effectiveness of a clinical practice guideline implementation strategy for patients with anxiety disorders in primary care: cluster randomized trial

<p>Abstract</p> <p>Background</p> <p>Anxiety is a common mental health problem seen in primary care. However, its management in clinical practice varies greatly. Clinical practice guidelines (CPGs) have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit. However, uptake and adherence to their recommendations can be low.</p> <p>Method/design</p> <p>This study involves a community based on cluster randomized trial in primary healthcare centres in the Madrid Region (Spain). The project aims to determine whether the use of implementation strategy (including training session, information, opinion leader, reminders, audit, and feed-back) of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion.</p> <p>The number of patients required is 296 (148 in each arm), all older than 18 years and diagnosed with generalized anxiety disorder, panic disorder, and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). They are chosen by consecutive sampling.</p> <p>The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months. Secondary outcome variables include quality of life (EuroQol 5D), and degree of compliance with the CPG recommendations on treatment, information, and referrals to mental health services. Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis.</p> <p>Discussion</p> <p>There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care. Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care patients receive.</p> <p>Trial registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN83365316">ISRCTN83365316</a></p

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Traumatic stress symptoms among Spanish healthcare workers during the COVID-19 pandemic: a prospective study

Abstract Aim To investigate the occurrence of traumatic stress symptoms (TSS) among healthcare workers active during the COVID-19 pandemic and to obtain insight as to which pandemic-related stressful experiences are associated with onset and persistence of traumatic stress. Methods This is a multicenter prospective cohort study. Spanish healthcare workers (N = 4,809) participated at an initial assessment (i.e., just after the first wave of the Spain COVID-19 pandemic) and at a 4-month follow-up assessment using web-based surveys. Logistic regression investigated associations of 19 pandemic-related stressful experiences across four domains (infection-related, work-related, health-related and financial) with TSS prevalence, incidence and persistence, including simulations of population attributable risk proportions (PARP). Results Thirty-day TSS prevalence at T1 was 22.1%. Four-month incidence and persistence were 11.6% and 54.2%, respectively. Auxiliary nurses had highest rates of TSS prevalence (35.1%) and incidence (16.1%). All 19 pandemic-related stressful experiences under study were associated with TSS prevalence or incidence, especially experiences from the domains of health-related (PARP range 88.4–95.6%) and work-related stressful experiences (PARP range 76.8–86.5%). Nine stressful experiences were also associated with TSS persistence, of which having patient(s) in care who died from COVID-19 had the strongest association. This association remained significant after adjusting for co-occurring depression and anxiety. Conclusions TSSs among Spanish healthcare workers active during the COVID-19 pandemic are common and associated with various pandemic-related stressful experiences. Future research should investigate if these stressful experiences represent truly traumatic experiences and carry risk for the development of post-traumatic stress disorder

Impacto en la salud mental del personal sanitario español de la primera ola de la pandemia COVID-19: un amplio estudio transversal

[EN] Introduction: Healthcare workers are vulnerable to adverse mental health impacts of the COVID-19 pandemic. We assessed prevalence of mental disorders and associated factors during the first wave of the pandemic among healthcare professionals in Spain. Methods: All workers in 18 healthcare institutions (6 AACC) in Spain were invited to web-based surveys assessing individual characteristics, COVID-19 infection status and exposure, and mental health status (May 5 - September 7, 2020). We report: probable current mental disorders (Major Depressive Disorder-MDD- [PHQ-8≥10], Generalized Anxiety Disorder-GAD- [GAD-7≥10], Panic attacks, Posttraumatic Stress Disorder -PTSD- [PCL-5≥7]; and Substance Use Disorder -SUD-[CAGE-AID≥2]. Severe disability assessed by the Sheehan Disability Scale was used to identify probable "disabling" current mental disorders. Results: 9,138 healthcare workers participated. Prevalence of screen-positive disorder: 28.1% MDD; 22.5% GAD, 24.0% Panic; 22.2% PTSD; and 6.2% SUD. Overall 45.7% presented any current and 14.5% any disabling current mental disorder. Workers with pre-pandemic lifetime mental disorders had almost twice the prevalence than those without. Adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (TUS: OR=5.74; 95%CI 2.53-13.03; Mood: OR=3.23; 95%CI:2.27-4.60; Anxiety: OR=3.03; 95%CI:2.53-3.62); age category 18-29 years (OR=1.36; 95%CI:1.02-1.82), caring "all of the time" for COVID-19 patients (OR=5.19; 95%CI: 3.61-7.46), female gender (OR=1.58; 95%CI: 1.27-1.96) and having being in quarantine or isolated (OR= 1.60; 95CI:1.31-1.95). Conclusions: One in seven Spanish healthcare workers screened positive for a disabling mental disorder during the first wave of the COVID-19 pandemic. Workers reporting pre-pandemic lifetime mental disorders, those frequently exposed to COVID-19 patients, infected or quarantined/isolated, female workers, and auxiliary nurses should be considered groups in need of mental health monitoring and support. [ES] Introducción: Los profesionales sanitarios son vulnerables al impacto negativo en salud mental de la pandemia COVID-19. Evaluamos la prevalencia de trastornos mentales y factores asociados durante la primera oleada de la pandemia en sanitarios españoles. Métodos: Se invitó a todos los trabajadores de 18 instituciones sanitarias españolas (6 CCAA) a encuestas en línea evaluando características individuales, estado de infección y exposición a COVID-19 y salud mental (5 Mayo – 7 Septiembre, 2020). Reportamos: probables trastornos mentales actuales (Trastorno depresivo mayor TDD [PHQ-8≥10], Trastorno de ansiedad generalizada TAG [GAD-7≥10], Ataques de pánico, Trastorno de estrés postraumático TEP [PCL-5≥7]; y Trastorno por uso de sustancias TUS [CAGE-AID≥2]. La interferencia funcional grave (Escala de Discapacidad de Sheehan) identificó los probables trastornos “discapacitantes”. Resultados: Participaron 9.138 sanitarios. Prevalencia de cribado positivo: 28,1% TDD; 22,5% TAG, 24,0% Pánico; 22,2% PTE; y 6,2% TUS. En general, el 45,7% presentó algún trastorno mental actual y el 14,5% algún trastorno discapacitante. Los sanitarios con trastornos mentales previos tuvieron el doble de prevalencia que aquellos sin patología mental previa. Ajustando por todas las variables, el trastorno mental incapacitante se asoció positivamente con: trastornos previos (TUS: OR=5.74; 95%CI 2.53-13.03; Ánimo: OR=3.23; 95%CI:2.27-4.60; Ansiedad: OR=3,03; IC 95%: 2,53-3,62); edad 18-29 años (OR=1,36; IC 95%: 1,02-1,82); atender “siempre” a pacientes COVID-19 (OR=5,19; IC 95%: 3,61-7,46), género femenino (OR=1,58; IC 95%: 1,27-1,96) y haber estado en cuarentena o aislado (OR=1,60; IC 95%: 1,31-1,95). Conclusiones: Uno de cada 7 sanitarios españoles presentaron un probable trastorno mental discapacitante durante la primera oleada de COVID-19. Aquéllos con trastornos mentales alguna vez antes de la pandemia, los que están expuestos con frecuencia a pacientes con COVID-19, los infectados o en cuarentena / aislados, las mujeres y las enfermeras auxiliares deben considerarse grupos que necesitan seguimiento y apoyo de su salud mental.This work was supported by Instituto de Salud Carlos III (Ministerio de Ciencia e Innovación)/FEDER (COV20/00711); ISCIII (Sara Borrell, CD18/00049) (PM); FPU (FPU15/05728)); ISCIII (PFIS, FI18/00012); Generalitat de Catalunya (2017SGR452).S

Thirty-day suicidal thoughts and behaviors among hospital workers during the first wave of the Spain COVID-19 outbreak

Background: Healthcare workers are a key occupational group at risk for suicidal thoughts and behaviors (STB). We investigated the prevalence and correlates of STB among hospital workers during the first wave of the Spain COVID-19 outbreak (March-July 2020). Methods: Data come from the baseline assessment of a cohort of Spanish hospital workers (n = 5450), recruited from 10 hospitals just after the height of the coronavirus disease 2019 (COVID-19) outbreak (May 5-July 23, 2020). Web-based self-report surveys assessed 30-day STB, individual characteristics, and potentially modifiable contextual factors related to hospital workers' work and financial situation. Results: Thirty-day STB prevalence was estimated at 8.4% (4.9% passive ideation only, 3.5% active ideation with or without a plan or attempt). A total of n = 6 professionals attempted suicide in the past 30 days. In adjusted models, 30-day STB remained significantly associated with pre-pandemic lifetime mood (odds ratio [OR] = 2.92) and anxiety disorder (OR = 1.90). Significant modifiable factors included a perceived lack of coordination, communication, personnel, or supervision at work (population-attributable risk proportion [PARP] = 50.5%), and financial stress (PARP = 44.1%). Conclusions and relevance: Thirty-day STB among hospital workers during the first wave of the Spain COVID-19 outbreak was high. Hospital preparedness for virus outbreaks should be increased, and strong governmental policy response is needed to increase financial security among hospital workers

“Gaining or losing”: The importance of the perspective in primary care health services valuation

<div><p>Rationale and objectives</p><p>Economic theory classifies an intervention as socially beneficial if the total Willingness to Pay (WTP) of those who gain exceeds the total Willingness to accept (WTA) of those who are harmed. This paper examines the differences in health system users’ valuation of a health care service in primary care setting based on the WTP and WTA perspectives, discussing the impact of personal and service variables, including risk attitudes, on these disparities.</p><p>Method</p><p>Six hundred and sixty two subjects who asked for care in health centres in the Region of Madrid (Spain) were interviewed, using the contingent valuation method to estimate WTP and WTA. Patient sociodemographic characteristics, health needs, satisfaction with the service and risk attitude and behaviour under risk (measured by self-reported scales and lottery games respectively) were collected. Generalised Linear Models were used to estimate the association between the explanatory variables and the WTA/WTP ratio.</p><p>Results</p><p>We obtained the WTA/WTP ratio for 570 subjects (mean 1.66 CI 95%: 1.53–1.79; median 1, interquartile range 1–2). People with higher education or in high social groups expressed WTA values closest to WTP. The opposite occurred in patients with the greatest health needs or who were born abroad. Self-reported expression of risk aversion appeared also related to increases in the WTA/WTP ratio. Satisfaction with the service evaluated was the most influential factor in the WTA/WTP ratio.</p><p>Conclusion</p><p>Health need, difficulty in obtaining substitutes and satisfaction with the service could serve for profiling people averse to loss for health care services in primary care setting. Self-reported expression of risk aversion could also be related to increases in the WTA/WTP ratio. This would mean that these characteristics should be taken into account both in the design and implementation of new healthcare interventions, as in the making decision for disinvestment.</p></div