Sobrecarga sentida por la figura del cuidador principal en una cohorte de pacientes pluripatológicos

ObjetivoConocer el perfil del cuidador principal (CP) y los factores relacionados con la sobrecarga sentida, en una cohorte multicéntrica de pacientes pluripatológicos (PP).DiseñoEstudio transversal, multicéntrico.EmplazamientoCuatro zonas básicas de salud del área sanitaria de los Hospitales Universitarios Virgen del Rocío, Sevilla.ParticipantesLa cohorte de PP se generó prospectivamente mediante el censado de todos los pacientes que cumplían los criterios de PP de la Consejería de Salud (2002): aquellos que tienen enfermedades crónicas de dos o más de las 7 categorías clínicas definidas.Mediciones principalesEl perfil del cuidador se determinó a todos los PP. El cansancio del CP se determinó mediante el índice de esfuerzo del cuidador (IEC). Los factores predictores se analizaron mediante los tests de la t de Student, ANOVA y Pearson.Posteriormente se realizó una regresión lineal multivariable paso a paso hacia delante.ResultadosAccedieron a la entrevista 461 (69% de los 662 elegibles) PP; 293 (63,6%) pacientes tenían CP, que en el 88% eran familiares de primer grado (146 [49,7%] de ellos, el cónyuge), de 62±15 años de edad, y el 80%, mujeres. El IEC fue > 7 puntos en el 41,5% y en general fue 5,35±3,5, mayor en los que cuidaban de PP con enfermedades neurológicas (7±3,2 frente a 4,5±3,3; p<0,0001). El IEC se correlacionó directamente con la vulnerabilidad clínica del PP (R=0,37; p<0,001), con el deterioro cognitivo por escala de Pfeiffer (R=0,4; p<0,0001), e inversamente con la situación funcional por índice de Barthel (R=−0,67; p<0,0001). La edad del paciente (p=0,03), su vulnerabilidad clínica (p=0,016) y el deterioro funcional (p<0,0001) y cognitivo (p=0,019) predijeron de forma independiente el IEC.ConclusionesEl perfil del CP de los PP se correspondió con mujeres familiares en primer grado de unos 60 años. Más de la tercera parte estaban sobrecargadas; los factores predictores fueron la edad, la vulnerabilidad clínica y el deterioro funcional y cognitivo del PP.ObjectiveTo determine the profile of the main caregiver (MC) and the factors associated with her/his care burden, in a multi-centre cohort of patients with multiple pathologies (PMP).DesignMulti-centre cross-sectional study.SettingFour health districts in the Virgen del Rocío University Hospitals Health Area, Seville, Spain.ParticipantsThe PMP cohort was created by checking all the patients who satisfied the health department criteria for PMP (2002): patients suffering from chronic diseases in 2 or more of the 7 clinical categories defined.Main measurementsThe profile of PMP caregiver was determined for all patients. The caregiver strain index (CSI) was determined by the index of care stress (ICS). Predictive factors were analysed by the Student t, ANOVA, and Pearson's tests. Multivariate analysis was performed by a forward stepwise linear regression model.ResultsThe interview was attended by 461 (69%) out of 662 eligible PMP. Of these, 293 (63.6%) had an MC whose mean age was 62 (15) years; 80% of them were women. First-degree relatives made up 88% of caregivers, with spouses 49.7% of them (n=146). In 41.5%, the CSI was >7points (mean CSI was 5.35 [3.5]). This was higher in those caring for PMP with neurological illnesses (7 [3.2 vs 4.5 [3.3]; P=.0001).The CSI was compared directly with the medical vulnerability of the PMP (R=0.37; P=.001), cognitive deterioration on the Pfeiffer scale (PS) (R=0.4; P=.0001), and inversely with functional status on Barthel's scale (BS) (R=-0.67; P=.0001). Patient's age (P=.03), his/her medical vulnerability (P=.016) and functional (P<.0001) and cognitive (P=.019) deterioration were independently associated with the CSI.ConclusionsThe profile of the MC of the PMP cohort corresponded mainly to first-degree female relatives around sixty years old. The burden of care was high in more than a third of them. Predictive factors were age, medical vulnerability, and the functional and cognitive deterioration of the PMP

Functional Decline Over 1-year Follow-up in a Multicenter Cohort of Polypathological Patients: A New Approach to Functional Prognostication

SummaryBackgroundLittle is known about the fitness of the available tools in predicting functional decline of polypathological patients (PPs). Our objective was to assess accuracy of the Triage Risk Screening Tool (TRST), the Variable Indicative of Placement risk (VIP) and to develop a specific functional prognostic index adjusted to this population in a multicenter cohort of hospital-based PP.MethodsProspective 12-month follow-up study of PPs from 36 hospitals. Functional decline was defined as loss of ≥20 points on Barthel’s index (BI). Accuracy of TRST/VIP was assessed by calibration/discrimination tests. Development of the new score was performed by dividing into a derivation cohort (constructing the index by logistic regression), and a validation cohort (in which calibration/discrimination of the index were tested).ResultsNine hundred and fifty-eight patients from the 1632 included survived during follow-up. Basal/12-month BI was 85/70, respectively. Mean fall in BI score was 11.7±24 points [353 (36.8%) fell by ≥20 points]. The activities for daily living that declined most frequently were toilet use, grooming, dressing and bathing. TRST/VIP fitted well but their discrimination power was poor (area under the curve=0.49 and 0.46, respectively). A simplified PROFUNCTION index was derived containing seven items (≥85 years, neurological condition, osteoarticular disease, III–IV functional class of dyspnea, ≥4 polypathology categories, basal BI<60, and social problems). Functional decline risk ranged from 21% to 24% in the lowest risk group (0 items) to 38–46% in the highest (4–7 items). Calibration as well as discrimination power (area under the curve=0.56–0.59) of this simplified index were good.ConclusionWe developed and validated a new functional prognostic index specifically focused on these patients with better discrimination power than other tools available

Impact of Cognitive Impairment in a Multicentric Cohort of Polypathological Patients

Background: Little is known about the prevalence and impact of cognitive impairment in polypathological patients (PPs). Objectives: To assess the prevalence of cognitive impairment (CI) and delirium, their associated risk factors, and their impact on survival of a multicenter population of PPs. Methods: Prospective cohort study. Descriptive analysis of the prevalence, main clinical features of PPs with basal CI (by means of Short Portable Mental Status Questionnaire), and delirium (Confusion Assessment Method); and bivariate as well as multivariate assessment of the factors associated with both conditions. Survival analysis after 12 months follow-up by means of Kaplan–Meier curves, and multivariate analysis of mortality risk factors in PPs with CI, and those with delirium. Results: CI was present in 39% [28% mild to moderate (3–7 errors), and 11% severe (≥ 8 errors)] of the 1434 PPs assessed [in the remaining 11% (n=198) delirium was detected]; only 26% of them had been previously diagnosed with dementia. One-year mortality was 46%/31.4% in those with/without CI [p 2 mg/dL [p=0.003; RR=7.8 (2–26)], and polypharmacy [p=0.0019; RR=3.1 (1.2–8.1)]. Conclusion: CI, as well as delirium, is common in PPs. Both play a deleterious role in 12-month survival. A systematic cognitive assessment as well as prevention and early detection of delirium should be included in the clinical care of all PPs

Concordance between the Clinical Definition of Polypathological Patient versus Automated Detection by Means of Combined Identification through ICD-9-CM Codes

It is unknown whether the digital application of automated ICD-9-CM codes recorded in the medical history are useful for a first screening in the detection of polypathological patients. In this study, the objective was to identify the degree of intra- and inter-observer concordance in the identification of in-patient polypathological patients between the standard clinical identification method and a new automatic method, using the basic minimum data set of ICD-9-CM codes in the digital medical history. For this, a cross-sectional multicenter study with 1518 administratively discharged patients from Andalusian hospitals during the period of 2013&#8722;2014 has been carried out. For the concordance between the clinical definition of a polypathological patient and the polypathological patient classification according to ICD-9-CM coding, a 0.661 kappa was obtained (95% confidence interval (CI); 0.622&#8722;0.701) with p &lt; 0.0001. The intraclass correlation coefficient between both methods for the number of polypathological patient categories was 0.745 (95% CI; 0.721&#8722;0.768; p &lt; 0.0001). The values of sensitivity, specificity, positive-, and negative predictive values of the automated detection using ICD-9-CM coding were 78%, 88%, 78%, and 88%, respectively. As conclusion, the automatic identification of polypathological patients by detecting ICD-9-CM codes is useful as a screening method for in-hospital patients

A Personalized Ontology-Based Decision Support System for Complex Chronic Patients: Retrospective Observational Study.

Due to an increase in life expectancy, the prevalence of chronic diseases is also on the rise. Clinical practice guidelines (CPGs) provide recommendations for suitable interventions regarding different chronic diseases, but a deficiency in the implementation of these CPGs has been identified. The PITeS-TiiSS (Telemedicine and eHealth Innovation Platform: Information Communications Technology for Research and Information Challenges in Health Services) tool, a personalized ontology-based clinical decision support system (CDSS), aims to reduce variability, prevent errors, and consider interactions between different CPG recommendations, among other benefits. The aim of this study is to design, develop, and validate an ontology-based CDSS that provides personalized recommendations related to drug prescription. The target population is older adult patients with chronic diseases and polypharmacy, and the goal is to reduce complications related to these types of conditions while offering integrated care. A study scenario about atrial fibrillation and treatment with anticoagulants was selected to validate the tool. After this, a series of knowledge sources were identified, including CPGs, PROFUND index, LESS/CHRON criteria, and STOPP/START criteria, to extract the information. Modeling was carried out using an ontology, and mapping was done with Health Level 7 Fast Healthcare Interoperability Resources (HL7 FHIR) and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT; International Health Terminology Standards Development Organisation). Once the CDSS was developed, validation was carried out by using a retrospective case study. This project was funded in January 2015 and approved by the Virgen del Rocio University Hospital ethics committee on November 24, 2015. Two different tasks were carried out to test the functioning of the tool. First, retrospective data from a real patient who met the inclusion criteria were used. Second, the analysis of an adoption model was performed through the study of the requirements and characteristics that a CDSS must meet in order to be well accepted and used by health professionals. The results are favorable and allow the proposed research to continue to the next phase. An ontology-based CDSS was successfully designed, developed, and validated. However, in future work, validation in a real environment should be performed to ensure the tool is usable and reliable