Evolución de la relación entre atención primaria y especializada 1992-2001: estudio Delphi

ObjetivoValorar la tendencia en la relación de atención primaria (AP) y especializada (hospital) en 2 momentos diferentes de la reforma sanitaria, al inicio (1992) y tras una fase de consolidación (2001).DiseñoEstudio cualitativo basado en la técnica Delphi modificada.EmplazamientoComunidad Valenciana.ParticipantesSe seleccionó a un total de 196 profesionales de la Comunidad Valenciana (103 coordinadores de AP, 43 directores médicos hospitalarios y de AP, y 50 jefes de servicio de medicina interna/urgencias).ResultadosSe enviaron 196 cuestionarios, con una tasa de respuesta del 38%. Desde AP los problemas se mantienen, con un empeoramiento en la desmotivación del personal sanitario (+1,34), la falta de visión integral del paciente (+1,10) y la masificación asistencial (+1,06), y un mejoría en la presencia de especialistas de ambulatorio no integrados (–1,32). Desde el ámbito hospitalario empeora la falta de visión integral del paciente (+0,51), pero destaca la mejoría generalizada de los problemas, sobre todo la falta de comunicación y diálogo (–1,14). Las soluciones que aumentan su demanda desde AP son una historia clínica única informatizada (+1,50), la elaboración de protocolos comunes (+0,86) y las rotaciones periódicas de los médicos de AP (MAP) por servicios hospitalarios (+0,85), con una disminución de las derivaciones burocráticas a AP (–0,60) y la necesidad de especialistas en AP como consultores (–0,36). Desde el ámbito hospitalario, todas las soluciones disminuyen su valoración y entre ellas destaca facilitar el acceso de MAP para el seguimiento de los pacientes ingresados (–2,44) y la realización de guardias hospitalarias por MAP (–2,30).ConclusionesLos problemas y las soluciones siguen siendo los mismos que en 1992, pero en AP se observa una tendencia a empeorar y en el ámbito hospitalario se detecta una visión más positiva.AimTo evaluate the trends in the inter-professional relationship between primary health care (PHC) and secondary care (hospital) at 2 different moments of the health reform, at its start in 1992 and after a phase of consolidation (2001).DesignObservational study based on modified Delphi technique.SettingValencia Community, Spain.ParticipantsOne hundred and ninety six professionals from Valencia Community were selected (103 PH centre administrators, 43 hospital and PC medical directors, and 50 heads of internal medicine or emergency services).ResultsOne hundred and ninety six questionnaires were sent out, with a response rate of 38%. In PHC problems remained the same, but the following got worse: “lack of motivation” (+1.34), “lack of overall vision of patients” (+1.10), and “overuse of medical services” (+1.06). The existence of non-integrated out-patient specialists got better (–1.32). In hospitals, “lack of overall vision of patients” got worse (+0.51), but in general problems got better, especially in “lack of communication and dialogue” (–1.14). PC increased its demand for “a single computerized clinical record” (+1.50), drawing up of common protocols (+0.86), and periodic rotations of PC doctors through hospitals (+0.85), but bureaucratic referrals to PC (–0.60) and the need for specialists in PC as consultants (-0.36) diminished. In hospitals all solutions showed lower scores, particularly access of PC doctors to monitoring of admitted patients (–2.44) and PC doctors doing hospital cover (–2.30).ConclusionsProblems and solutions from PHC and hospitals remain the same, but there is a trend to the worse in PHC, whereas in hospitals the trend is more positive

Gestión clínica de la consulta: previsibilidad y contenido clínico (estudio SyN-PC)

ObjetivoDescribir la actividad asistencial en función de la naturaleza de la consulta (previsibilidad) y las necesidades de los pacientes (contenido clínico). Analizar la relación con las características de la consulta, del paciente y del centroDiseñoEstudio observacional descriptivo multicéntricoEmplazamientoAtención primaria. Área 17 de la Conselleria de Sanidad de la Comunidad Valenciana. Población de 197.316 habitantes. Trece centros de saludParticipantesRecogida de información en tiempo real por un observador externo. Muestreo aleatorio estratificado de 2.051 pacientes que ocasionaron 3.008 motivos de consulta médicaMediciones principalesConsulta previsible (Pr): se puede prever su contenido (revisiones, recogida de resultados). Consulta imprevisible (Ip): no podemos prever su contenido (problemas agudos) y surgen inesperadamente. Engloba la consulta urgente. Consulta administrativa (Ad): tareas burocráticas (recetas, partes de confirmación, certificados). Consulta asistencial (As): prevenir, diagnosticar y tratar la enfermedad, o realizar seguimiento de ésta. Variables del paciente, el centro y la consultaResultadosEl 60% (n=1.809; IC del 95%, 58,69–61,59%) de los motivos fueron previsibles y el 40% (n=1.199; IC del 95%, 36,6–43,12%), imprevisibles. El 50% (n=1.509; IC del 95%, 47,26–53,06%) fueron consultas asistenciales y el 50% (n=1.499; IC del 95%, 46,34–53,39%), administrativas. El 40% (n=1.189; IC del 95%, 37,78–41,28%) fueron previsibles-administrativas y tan sólo un 21% (n=620; IC del 95%, 19,16– 22,06%) resultaron de carácter previsible-asistencial. El 30% (n=889; IC del 95%, 27,92–31,18%) fueron de carácter imprevisible–asistencial y el 10% (n=310; IC del 95%, 9,22– 11,4%), imprevisibles-administrativas. En los pacientes con un único motivo, el 48% (n=577; IC del 95%, 44,25–52,05%) fueron consultas previsibles-administrativas. Los centros docentes o informatizados tienen menos carga de consultas previsibles-administrativas. Éstas aumentan con la edad del paciente y con la presión asistencialConclusionesCasi un 40% de los motivos de consulta son previsibles-administrativos, lo que implica una gestión clínica inadecuada. Sería necesaria una intervención que permitiera liberar tiempo médico consumido en asuntos burocráticos para dedicarlo a la tarea asistencial propiamente dichaObjectivesTo describe care activity as a function of the nature of the consultation (predictability) and the needs of the patients (clinical content). To analyse the relationship of these with the characteristics of the consultation, of the patient and of the centreDesignMulti-centre, descriptive, observational study.SettingPrimary care. Area 17 of the Health Department of the Community of Valencia, with 197 316 inhabitants and 12 health centresParticipantsInformation gathering in real time by outside observer. Stratified randomised sampling of 2051 patients who gave rise to 3008 reasons for medical consultationMain measurementsPredictable consultations (Pr): their content can be foreseen (check-ups, picking up results). Unpredictable consultations (Unp): we cannot predict their content (acute problems may arise unexpectedly). These include urgent consultations. Administrative consultations (Ad): bureaucratic tasks (prescriptions, repeat sick-notes, sick certificates). Care consultations (Car): prevention, diagnosis and treatment of the illness, or monitoring of it. Variables here are the patient, the doctor and the consultationResults60% (1809) (95% CI, 58.69%–61.59%) of the reasons were Pr and 40% (1199) (95% CI, 36.6%–43.12%) were Unp. 50% (1509) (95% CI, 47.26%–53.06%) were Car, and 50% Ad (1499) (95% CI, 46.34%–53.39%). 40% (1189) (95% CI, 37.78%–41.28%) were Pr-Ad and only 21% (620) (95% CI, 19.16%–22.06%) were Pr-Car. 30% (889) (95% CI, 27.92%–31.18%) were Unp–Car, and 10% (310) (95% CI, 9.22%– 11.4%) Unp-Ad. 48% of patients with a single reason for attendance were Pr-Ad (577) (95% CI, 44.25%–52.05). Teaching centres and computerised ones had less Pr-Ad load. Pr-Ad consultations increased with patient´s age and with case-load.ConclusionsAlmost 40% of the reasons for consultation are Pr-Ad, which implies inadequate clinical management. An intervention is needed to free up medical time consumed by bureaucratic questions, so that this time can be devoted fully to health-care task

A randomized clinical trial to determine the effect of angiotensin inhibitors reduction on creatinine clearance and haemoglobin in heart failure patients with chronic kidney disease and anaemia

Trial registration: EudraCT: 2008-008480-10[Abstract] Background. Chronic kidney disease is a common comorbidity in elderly patients with heart failure. Evidence supports the use of angiotensin inhibitors for patients with heart failure. However, there is little evidence with which to assess the risk and benefits of this treatment in elderly patients with renal dysfunction. Objective. To determine the efficacy and safety of angiotensin inhibitor reduction in patients with heart failure, chronic kidney disease and anaemia. Study design. Open randomized controlled clinical trial. Setting. Complexo Hospitalario Universitario A Coruña (Spain). Patients. Patients ≥ 50 years old, with heart failure, haemoglobin (Hb) < 12 mg/dl and creatinine clearance <60 ml/min/1.73 m2 admitted to hospital, in treatment with angiotensin inhibitors. Informed consent and Ethical Review Board approval were obtained. Intervention. A 50% reduction of angiotensin inhibitor dose of the basal treatment on admission (n = 30) in the intervention group. Control group (n = 16) with the standard basal dose. Main outcome measure. Primary outcome was difference in Hb (gr/dl), creatinine clearance (ml/min/1.73 m2) and protein C (mg/dl) between admission and 1–3 months after discharge. Secondary outcome was survival at 6–12 months after discharge. Results. Patients in the intervention group experienced an improvement in Hb (10.62–11.47 g/dl), creatinine clearance (32.5 ml/min/1.73 m2 to 42.9 ml/min/1.73 m2), and a decrease in creatinine levels (1.98–1.68 mg/dl) and protein C (3.23 mg/dl to 1.37 mg/dl). There were no significant differences in these variables in the control group. Survival at 6 and 12 months in the intervention and control group was 86.7% vs. 75% and 69.3% vs. 50%, respectively. Conclusion. The reduction of the dose of angiotensin inhibitors in the intervention group resulted in an improvement in anaemia and kidney function, decreased protein C and an increased survival rate

Clinical inertia in poorly controlled elderly hypertensive patients: a cross-sectional study in Spanish physicians to ascertain reasons for not intensifying treatment

Background Clinical inertia, the failure of physicians to initiate or intensify therapy when indicated, is a major problem in the management of hypertension and may be more prevalent in elderly patients. Overcoming clinical inertia requires understanding its causes and evaluating certain factors, particularly those related to physicians. Objective The objective of our study was to determine the rate of clinical inertia and the physician-reported rea- sons for it. Conclusion Physicians provided reasons for not intensi- fying treatment in poorly controlled patients in only 30 % of instances. Main reasons for not intensifying treatment were borderline BP values, co-morbidity, suspected white coat effect, or perceived difficulty achieving target. nJCI was associated with high borderline BP values and car- diovascular diseas

Randomized Clinical Trial to Determine the Effectiveness of CO-Oximetry and Anti-Smoking Brief Advice in a Cohort of Kidney Transplant Patients who Smoke

[Abstract] Background: measure the efficacy of exhaled carbon monoxide (CO) measurement plus brief advisory sessions to reduce smoking exposure and smoking behaviour in kidney transplant recipients. Methods: Randomized, controlled, open-label clinical trial at a Spanish hospital.Smoking kidney transplant recipients giving their consent to participate were randomized to control (brief advice, n=63) or intervention group (brief advisory session plus measuring exhaled CO, n=59). Measurements: Sociodemographic characteristics, cardiovascular risk factors, treatment, rejection episodes, infections, self-reported smoking, drug use, level of dependence and motivation to stop smoking (Fagerström's and Richmond's test) and stage of change (Prochaska and DiClemente's Stages). Efficacy was assessed at 3, 6, 9 and 12 months as: cotinine test, CO levels in exhaled air, nicotine dependence, motivational stages of change, motivation to stop smoking, pattern of tobacco use and smoking cessation rates. Logistic regression models were computed. Results: At 12 months of follow-up, differences were found in exhaled CO between the intervention and control group(6.1±6.8vs.10.2±9.7ppm;p=0.028). Carboxyhemoglobin levels were lower in the intervention group as well as the positive cotinine test (1.2±1.2%vs.2.0±2.4%;p=0.039),(53.4%vs.74.2%). At 12 months, intervention reduces the probability of a positive urine test by 28%. Conclusions: Co-oximetry is a clinically relevant intervention for reduction of tobacco exposure in kidney transplant recipients.Instituto de Salud Carlos III; PI11 /0135

Outcomes of nonagenarians after transcatheter aortic valve implantation

Introduction and objectives: Nonagenarians are a fast-growing age group among cardiovascular patients, especially with aortic stenosis, but data about their prognosis after transcatheter aortic valve implantation (TAVI) is scarce. The objective of our study is to analyze the baseline characteristics of nonagenarians treated with TAVI and determine whether age = 90 years is associated with a worse prognosis compared to non-nonagenarian patients. Methods: We included all patients =75 years enrolled in the multicenter prospective Spanish TAVI registry between 2009 and 2018. Patients < 75 years were excluded. Results: A total of 8073 elderly patients (= 75 years) from 46 Spanish centers were enrolled in the Spanish TAVI registry; 7686 were between = 75 and < 90 years old (95.2%), and 387 were nonagenarian patients (4.79%). A gradual increase of nonagenarians was observed. The transfemoral access was used in 91.6% of the cases, predominantly among the nonagenarian patients (91.4% vs 95.1%, P = .01). Nonagenarians were more likely to die during their hospital stay (4.3% vs 7.0% among nonagenarians, P = .01). However, no difference was seen in the all-cause mortality rates reported at the 1-year follow-up (8.8% vs 11.3%, P =.07). In the multivariate analysis, age = 90 years was not independently associated with a higher adjusted all-cause mortality rate (HR, 1.37, 95%CI, 0.91–1.97, P = .14). The baseline creatinine levels, and the in-hospital bleeding complications were all associated with a worse long-term prognosis in nonagenarians treated with TAVI. Conclusions: Nonagenarians are a very high-risk and growing population with severe AS in whom TAVI may be a safe and effective strategy. Careful patient selection by the TAVI heart team is mandatory to achieve maximum efficiency in this population where the baseline kidney function and bleeding complications may determine the long-term prognosis after TAVI. © 2021 Sociedad Española de Cardiología. Published by Permanyer Publications

Physician Perception of Blood Pressure Control and Treatment Behavior in High-Risk Hypertensive Patients: A Cross-Sectional Study

Objective: We examined physician perception of blood pressure control and treatment behavior in patients with previous cardiovascular disease and uncontrolled hypertension as defined by European Guidelines. Methods: A cross-sectional study was conducted in which 321 primary care physicians throughout Spain consecutively studied 1,614 patients aged ≥18 years who had been diagnosed and treated for hypertension (blood pressure ≥140/90 mmHg), and had suffered a documented cardiovascular event. The mean value of three blood pressure measurements taken using standardized procedures was used for statistical analysis. Results: Mean blood pressure was 143.4/84.9 mmHg, and only 11.6% of these cardiovascular patients were controlled according to 2007 European Guidelines for Hypertension Management target of <130/80 mmHg. In 702 (49.2%) of the 1426 uncontrolled patients, antihypertensive medication was not changed, and in 480 (68.4%) of these cases this was due to the physicianś judgment that blood pressure was adequately controlled. In 320 (66.7%) of the latter patients, blood pressure was 130-139/80-89 mmHg. Blood pressure level was the main factor associated (inversely) with no change in treatment due to physician perception of adequate control, irrespective of sociodemographic and clinical factors. Conclusions: Physicians do not change antihypertensive treatment in many uncontrolled cardiovascular patients because they considered it unnecessary, especially when the BP values are only slightly above the guideline target. It is possible that the guidelines may be correct, but there is also the possibility that the care by the physicians is appropriate since BP <130/80 mmHg is hard to achieve, and recent reviews suggest there is insufficient evidence to support such a low BP targetFunding for this study was obtained from RECORDATI ESPAÑA, S.L through an unrestricted grant. Krista Lundelin has a ‘‘Rio Hortega’’ research training contract (Expediente CM10/00327) from the Ministry of Science and Innovation (Instituto de Salud Carlos III), Spain Governmen

Impacto de la pandemia de COVID en la salud mental de la población general y de los trabajadores sanitarios.

La pandemia de COVID-19 cumplirá próximamente 3 años de evolución con consecuencias catastróficas y bien conocidas en la salud física y la mortalidad de los habitantes del planeta. Sus consecuencias sobre la salud mental han sido igualmente enormes y su análisis se ha llevado a cabo en momentos distintos de la pandemia y con enfoques lógicamente parciales. Por otro lado, las condiciones para alterar la salud mental de los individuos y de los grupos que la pandemia ha supuesto han sido diferentes en distintos lugares. El patronato de la Fundación de Ciencias de la Salud se planteó, en su momento, una serie de preguntas sobre las consecuencias sobre la salud mental de la pandemia de COVID-19 tanto en la población general, con o sin buena salud mental previa, como sobre el colectivo de trabajadores sanitarios. Muy particularmente, preocupaban esas consecuencias en la población española. Por ello, se reunió a una serie de expertos en distintas materias relacionadas con el tema que han tratado de ir dando respuesta a dichas preguntas a la luz de la evidencia científica y de su propia opinión y experiencia. Tras la exposición del tema, en cada una de las preguntas y con la discusión de todo el grupo, se llegó a una conclusión de consenso que trataba de resumir el estado del arte sobre el tema. El documento que sigue a continuación es el resultado de ese proceso. Todos los autores han revisado el manuscrito final y han dado su aprobación al mismo. El documento está dividido en una primera parte que evalúa el impacto de la pandemia en la salud mental de la población general y una segunda sobre su impacto en los sanitarios

FUMEPOC: Early detection of chronic obstructive pulmonary disease in smokers

<p>Abstract</p> <p>Background</p> <p>Currently is not feasible using conventional spirometry as a screening method in Primary Care especially among smoking population to detect chronic obstructive pulmonary disease in early stages. Therefore, the FUMEPOC study protocol intends to analyze the validity and reliability of Vitalograph COPD-6 spirometer as simpler tool to aid screening and diagnosis of this disease in early stages in primary care surgery.</p> <p>Methods / Design</p> <p>Study design: An observational, descriptive study of diagnostic tests, undertaken in Primary Care and Pneumology Outpatient Care Centre at San Juan Hospital and Elda Hospital. All smokers attending the primary care surgery and consent to participate in the study will undergo a test with Vitalograph COPD-6 spirometer. Subsequently, a conventional spirometry will be performed in the hospital and the results will be compared with those of the Vitalograph COPD-6 test.</p> <p>Discussion</p> <p>It is difficult to use the spirometry as screening for early diagnose test in real conditions of primary care clinical practice. The use of a simpler tool, Vitalograph COPD-6 spirometer, can help in the early diagnose and therefore, it could improve the clinical management of the disease.</p

Identification of TNF-α and MMP-9 as potential baseline predictive serum markers of sunitinib activity in patients with renal cell carcinoma using a human cytokine array

BACKGROUND: Several drugs are available to treat metastatic renal-cell carcinoma (MRCC), and predictive markers to identify the most adequate treatment for each patient are needed. Our objective was to identify potential predictive markers of sunitinib activity in MRCC. METHODS: We collected sequential serum samples from 31 patients treated with sunitinib. Sera of six patients with extreme phenotypes of either marked responses or clear progressions were analysed with a Human Cytokine Array which evaluates 174 cytokines before and after treatment. Variations in cytokine signal intensity were compared between both groups and the most relevant cytokines were assessed by ELISA in all the patients. RESULTS: Twenty-seven of the 174 cytokines varied significantly between both groups. Five of them (TNF-alpha, MMP-9, ICAM-1, BDNF and SDF-1) were assessed by ELISA in 21 evaluable patients. TNF-alpha and MMP-9 baseline levels were significantly increased in non-responders and significantly associated with reduced overall survival and time-to-progression, respectively. The area under the ROC curves for TNF-alpha and MMP-9 as predictive markers of sunitinib activity were 0.83 and 0.77. CONCLUSION: Baseline levels of TNF-alpha and MMP-9 warrant further study as predictive markers of sunitinib activity in MRCC. Selection of patients with extreme phenotypes seems a valid method to identify potential predictive factors of response