Salud e inmigración en el contexto de esta crisis económica y de valores:el ejemplo de España

Los principales determinantes de la salud de las personas y de las comunidades son sociales y por tanto así deberán ser sus soluciones. En el caso de la población inmigración existe una excepción a esta regla ya que a su llegada por diversos motivos (que pueden resumirse en el 'healthy migration effect') suelen presentar una salud superior a la población que los acoge. No obstante, con el transcurso de los años está salud tiende a deteriorarse. Los Sistemas Sanitarios Públicos de cobertura Universal han demostrado su capacidad de reducir las desigualdades sanitarias. La Unión Europea en diversos documentos ha enfatizado la importancia de garantizar una adecuada atención sanitaria a toda la población incluyendo la inmigrante. España era un referente mundial en este sentido al garantizar la accesibilidad al Sistema Sanitario de todos los inmigrantes independientemente de su situación administrativa. No obstante, a raíz del Real Decreto Ley 12/2012, el Gobierno Español ha excluido a unas 900.000 de este Derecho provocando un grave problema humano, ético y sanitario ante el que distintos colectivos sociales y profesionales han manifestado su oposición

Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial

Background: The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process. Objective: To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care. Methods/design: This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient

Chronic obstructive pulmonary disease (COPD) as a disease of early aging: evidence from the epiChron cohort

Background: Aging is an important risk factor for most chronic diseases. Patients with COPD develop more comorbidities than non-COPD subjects. We hypothesized that the development of comorbidities characteristically affecting the elderly occur at an earlier age in subjects with the diagnosis of COPD. Methods and findings: We included all subjects carrying the diagnosis of COPD (n = 27,617), and a similar number of age and sex matched individuals without the diagnosis, extracted from the 727,241 records of individuals 40 years and older included in the EpiChron Cohort (Aragon, Spain). We compared the cumulative number of comorbidities, their prevalence and the mortality risk between both groups. Using network analysis, we explored the connectivity between comorbidities and the most influential comorbidities in both groups. We divided the groups into 5 incremental age categories and compared their comorbidity networks. We then selected those comorbidities known to affect primarily the elderly and compared their prevalence across the 5 age groups. In addition, we replicated the analysis in the smokers' subgroup to correct for the confounding effect of cigarette smoking. Subjects with COPD had more comorbidities and died at a younger age compared to controls. Comparison of both cohorts across 5 incremental age groups showed that the number of comorbidities, the prevalence of diseases characteristic of aging and network's density for the COPD group aged 56-65 were similar to those of non-COPD 15 to 20 years older. The findings persisted after adjusting for smoking. Conclusion: Multimorbidity increases with age but in patients carrying the diagnosis of COPD, these comorbidities are seen at an earlier age

Primary care utilisation patterns among an urban immigrant population in the Spanish National Health System

<p>Abstract</p> <p>Background</p> <p>There is evidence suggesting that the use of health services is lower among immigrants after adjusting for age and sex. This study takes a step forward to compare primary care (PC) utilisation patterns between immigrants and the native population with regard to their morbidity burden.</p> <p>Methods</p> <p>This retrospective, observational study looked at 69,067 individuals representing the entire population assigned to three urban PC centres in the city of Zaragoza (Aragon, Spain). Poisson models were applied to determine the number of annual PC consultations per individual based on immigration status. All models were first adjusted for age and sex and then for age, sex and case mix (ACG System^®).</p> <p>Results</p> <p>The age and sex adjusted mean number of total annual consultations was lower among the immigrant population (children: IRR = 0.79, p < 0.05; adults: IRR = 0.73, p < 0.05). After adjusting for morbidity burden, this difference decreased among children (IRR = 0.94, p < 0.05) and disappeared among adults (IRR = 1.00). Further analysis considering the PC health service and type of visit revealed higher usage of routine diagnostic tests among immigrant children (IRR = 1.77, p < 0.05) and a higher usage of emergency services among the immigrant adult population (IRR = 1.2, p < 0.05) after adjusting for age, sex and case mix.</p> <p>Conclusions</p> <p>Although immigrants make lower use of PC services than the native population after adjusting the consultation rate for age and sex, these differences decrease significantly when considering their morbidity burden. These results reinforce the 'healthy migration effect' and discount the existence of differences in PC utilisation patterns between the immigrant and native populations in Spain.</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

Multimorbidity among registered immigrants in Norway: the role of reason for migration and length of stay.

Objectives: International migration is rapidly increasing worldwide. However, the health status of migrants differs across groups. Information regarding health at arrival and subsequent periodic follow-up in the host country is necessary to develop equitable health care to immigrants. The objective of this study was to determine the impact of the length of stay in Norway and other sociodemographic variables on the prevalence of multimorbidity across immigrant groups (refugees, labour immigrants, family reunification immigrants and education immigrants). Methods: This is a register-based study merging data from the National Population Register and the Norwegian Health Economics Administration database. Sociodemographic variables and multimorbidity across the immigrant groups were compared using Persons’ chi-square test and anova as appropriate. Several binary logistic regression models were conducted. Results: Multimorbidity was significantly lower among labour immigrants (OR (95% CI) 0.23 (0.21–0.26) and 0.45 (0.40–0.50) for men and women, respectively) and education immigrants (OR (95% CI) 0.40 (0.32–0.50) and 0.38 (0.33–0.43)) and higher among refugees (OR (95% CI) 1.67 (1.57–1.78) and 1.83 (1.75–1.92)), compared to family reunification immigrants. For all groups, multimorbidity doubled after a five-year stay in Norway. Effect modifications between multimorbidity and sociodemographic characteristics across the different reasons for migration were observed. Conclusions: Multimorbidity was highest among refugees at arrival but increased rapidly among labour immigrants, especially females. Health providers need to ensure tailor-made preventive and management strategies that take into account pre-migration and post-migration experiences for immigrants in order to address their needs. Objectifs: La migration internationale augmente rapidement dans le monde entier. Cependant, l’état de santé des migrants diffère selon les groupes. Les informations concernant la santé à l'arrivée et le suivi périodique ultérieur dans le pays d'accueil sont nécessaires pour développer des soins de santé équitable pour les immigrés. L'objectif de cette étude était de déterminer l'impact de la durée de séjour en Norvège et d'autres variables sociodémographiques sur la prévalence de la multimorbidité entre les groupes d'immigrés (réfugiés, travailleurs immigrés, immigrés du regroupement familial et immigrés pour des études). Méthodes: Cette étude est basée sur le registre, en fusionnant les données du Registre de la Population et de la base de données de l'Administration Norvégienne d'Economie de la Santé. Les variables sociodémographiques et la multimorbidité entre les groupes d'immigrés ont été comparées à l'aide du chi carré de Persons et de l'analyse de la variance, le cas échéant. Plusieurs modèles de régression logistique binaire ont été appliqués. Resultats: La multimorbidité était significativement plus faible chez les immigrés du travail (OR (IC95%): 0,23 (0,21 à 0,26) et 0,45 (0,40 à 0,50) pour les hommes et les femmes respectivement) et les immigrés pour des études (OR (IC95%): 0,40 (0,32 à 0,50) et 0,38 (0,33 à 0,43)) et plus élevée chez les réfugiés (OR (IC95%): 1,67 (1,57 à 1,78) et 1,83 (1,75 à 1,92)), comparativement aux immigrés de regroupement familial. Pour tous les groupes, la multimorbidité doublait après un séjour de cinq ans en Norvège. Des modifications d'effet entre la multimorbidité et les caractéristiques sociodémographiques selon les différentes raisons de la migration ont été observées. Conclusions: La multimorbidité était la plus élevée chez les réfugiés à l'arrivée, mais augmentait plus rapidement chez les travailleurs immigrés, en particulier chez les femmes. Les prestataires de santé devraient veiller à des stratégies de prévention et de prise en charge appropriées tenant compte des expériences des immigrés en pré- et post-migration afin de répondre à leurs besoins. Objetivos: La migración internacional está aumentando rápidamente a nivel mundial. Sin embargo, el estado de salud de los inmigrantes difiere entre grupos. La información sobre el estado de salud en el momento de llegada y un seguimiento periódico en el país de acogida son necesarios para desarrollar una atención sanitaria equitativa para los inmigrantes. El objetivo de este estudio era determinar el impacto de la longitud de la estadía en Noruega y otras variables sociodemográficas sobre la prevalencia de multimorbilidad en diferentes grupos de inmigrantes (refugiados,inmigrantes laborales, inmigrantes por reunificación familiar e inmigrantes por educación). Métodos: Estudio basado en registros en el que se han juntado datos del Registro Nacional de Población y la base de datos de la Administración de Economía Sanitaria de Noruega. Se compararon las variables sociodemográficas y la multimorbilidad entre los grupos de inmigrantes utilizando el chi cuadrado de Person y la ANOVA. Se realizaron varias regresiones logísticas binarias. Resultados: La multimorbilidad era significativamente menor entre inmigrantes laborales (OR (IC 95%) 0.23 (0.21-0.26) y 0.45 (0.40-0.50) para hombres y mujeres respectivamente) e inmigrantes por educación (OR (IC 95%) 0.40 (0.32-0.50) y 0.38 (0.33-0.43)), y mayor entre los refugiados (OR (IC 95%CI) 1.67 (1.57-1.78) y 1.83 (1.75-1.92)) al compararlo con los inmigrantes por reunificación familiar. Para todos los grupos, la multimorbilidad se doblaba tras cinco años de permanencia en Noruega. Se observaba un efecto de modificación entre la multimorbilidad y las características sociodemográficas en todas las razones por las cuales se había emigrado. Conclusiones: La multimorbilidad era mayor entre los refugiados en el momento de llegar pero aumentaba rápidamente entre inmigrantes laborales, especialmente las mujeres. Los proveedores sanitarios deben asegurar estrategias preventivas y de gestión hechas a medida que tengan en cuenta las experiencias pre-migración y post-migración de los inmigrantes, con el fin de dar respuesta a sus necesidades

Frequent attenders in general practice and immigrant status in Norway: a nationwide cross-sectional study

Objective. To compare the likelihood of being a frequent attender (FA) to general practice among native Norwegians and immigrants, and to study socioeconomic and morbidity factors associated with being a FA for natives and immigrants. Design, setting and subjects. Linked register data for all inhabitants in Norway with at least one visit to the general practitioner (GP) in 2008 (2 967 933 persons). Immigrants were grouped according to their country of origin into low- (LIC), middle- (MIC), and high-income countries (HIC). FAs were defined as patients whose attendance rate ranked in the top 10% (cut-off point > 7 visits). Main outcome measures. FAs were compared with other GP users by means of multivariate binary logistic analyses adjusting for socioeconomic and morbidity factors. Results. Among GP users during the daytime, immigrants had a higher likelihood of being a FA compared with natives (OR (95% CI): 1.13 (1.09–1.17) and 1.15 (1.12–1.18) for HIC, 1.84 (1.78–1.89) and 1.66 (1.63–1.70) for MIC, and 1.77 (1.67–1.89) and 1.65 (1.57–1.74) for LIC for men and women respectively). Pregnancy, middle income earned in Norway, and having cardiologic and psychiatric problems were the main factors associated with being a FA. Among immigrants, labour immigrants and the elderly used GPs less often, while refugees were overrepresented among FAs. Psychiatric, gastroenterological, endocrine, and non-specific drug morbidity were relatively more prevalent among immigrant FA compared with natives. Conclusion. Although immigrants account for a small percentage of all FAs, GPs and policy-makers should be aware of differences in socioeconomic and morbidity profiles to provide equality of health care

Patterns of pharmaceutical use for immigrants to Spain and Norway: a comparative study of prescription databases in two European countries

Background: Although equity in health care is theoretically a cornerstone in Western societies, several studies show that services do not always provide equitable care for immigrants. Differences in pharmaceutical consumption between immigrants and natives are explained by variances in predisposing factors, enabling factors and needs across populations, and can be used as a proxy of disparities in health care use. By comparing the relative differences in pharmacological use between natives and immigrants from the same four countries of origin living in Spain and Norway respectively, this article presents a new approach to the study of inequity in health care. Methods: All purchased drug prescriptions classified according to the Anatomical Therapeutic Chemical (ATC) system in Aragon (Spain) and Norway for a total of 5 million natives and nearly 100,000 immigrants for one calendar year were included in this cross-sectional study. Age and gender adjusted relative purchase rates for immigrants from Poland, China, Colombia and Morocco compared to native populations in each of the host countries were calculated. Direct standardisation was performed based on the 2009 population structure of the OECD countries. Results: Overall, a significantly lower proportion of immigrants in Aragon (Spain) and Norway purchased pharmacological drugs compared to natives. Patterns of use across the different immigrant groups were consistent in both host countries, despite potential disparities between the Spanish and Norwegian health care systems. Immigrants from Morocco showed the highest drug use rates in relation to natives, especially for antidepressants, “pain killers” and drugs for peptic ulcer. Immigrants from China and Poland showed the lowest use rates, while Colombians where more similar to host countries. Conclusions: The similarities found between the two European countries in relation to immigrants’ pharmaceutical use disregarding their host country emphasises the need to consider specific immigrant-related features when planning and providing healthcare services to this part of the population. These results somehow remove the focus on inequity as the main reason to explain differences in purchase between immigrants and natives