The impact of frailty on admission to home care services and nursing homes: eight-year follow-up of a community-dwelling, older adult, Spanish cohort.

BACKGROUND: Frailty in older adults is a common multidimensional clinical entity, a state of vulnerability to stressors that increases the risk of adverse outcomes such as functional decline, institutionalization or death. The aim of this study is to identify the factors that anticipate the future inclusion of community-dwelling individuals aged ≥70 years in home care programmes (HC) and nursing homes (NH), and to develop the corresponding prediction models. METHODS: A prospective cohort study was conducted in 23 primary healthcare centers located in Catalonia, Spain, with an eight-year follow-up (2005-2013). The cohort was made up of 616 individuals. Data collection included a baseline multidimensional assessment carried out by primary health care professionals. Outcome variables were collected during follow-up by consulting electronic healthcare records, and the Central Registry of Catalonia for mortality. A prognostic index for a HC and NH at 8 years was estimated for each patient. Death prior to these events was considered a competing risk event, and Fine-Gray regression models were used. RESULTS: At baseline, mean age was 76.4 years and 55.5% were women. During follow-up, 19.2% entered a HC program, 8.2% a NH, and 15.4% died without presenting an event. Of those who entered a NH, 31.5% had previously been in a HC program. Multivariate models for a HC and NH showed that the risk of a HC entry was associated with older age, dependence on the Instrumental Activities of Daily Living, and slow gait measured by Timed-up-and-go test. An increased risk of being admitted to a NH was associated with older age, dependence on the Instrumental Activities of Daily Living, number of prescriptions, and the presence of social risk. CONCLUSIONS: Prognostic models based on comprehensive geriatric assessments can predict the need for the commencement of HC and NH admission in community-dwelling older adults. Our findings underline the necessity to measure functional capacity, mobility, number of prescriptions, and social aspects of older adults in primary healthcare centers. In such a setting they can be offered longitudinal holistic assessments so as to benefit from preventive actions in order to remain independent in the community for as long as possible.

Effectiveness and cost-effectiveness of Improving clinicians' diagnostic and communication Skills on Antibiotic prescribing Appropriateness in patients with acute Cough in primary care in CATalonia (the ISAAC-CAT study): study protocol for a cluster randomised controlled trial.

BACKGROUND: Despite their marginal benefit, about 60% of acute lower respiratory tract infections (ALRTIs) are currently treated with antibiotics in Catalonia. This study aims to evaluate the effectiveness and efficiency of a continuous disease-focused intervention (C-reactive protein [CRP]) and an illness-focused intervention (enhancement of communication skills to optimise doctor-patient consultations) on antibiotic prescribing in patients with ALRTIs in Catalan primary care centres. METHODS/DESIGN: A cluster randomised, factorial, controlled trial aimed at including 20 primary care centres (N = 2940 patients) with patients older than 18 years of age presenting for a first consultation with an ALRTI will be included in the study. Primary care centres will be identified on the basis of socioeconomic data and antibiotic consumption. Centres will be randomly assigned according to hierarchical clustering to any of four trial arms: usual care, CRP testing, enhanced communication skills backed up with patient leaflets, or combined interventions. A cost-effectiveness and cost-utility analysis will be performed from the societal and national healthcare system perspectives, and the time horizon of the analysis will be 1 year. Two qualitative studies (pre- and post-clinical trial) aimed to identify the expectations and concerns of patients with ALRTIs and the barriers and facilitators of each intervention arm will be run. Family doctors and nurses assigned to the interventions will participate in a 2-h training workshop before the inception of the trial and will receive a monthly intervention-tailored training module during the year of the trial period. Primary outcomes will be antibiotic use within the first 6 weeks, duration of moderate to severe cough, and the quality-adjusted life-years. Secondary outcomes will be duration of illness and severity of cough measured using a symptom diary, healthcare re-consultations, hospital admissions, and complications. Healthcare costs will be considered and expressed in 2021 euros (year foreseen to finalise the study) of the current year of the analysis. Univariate and multivariate sensitivity analyses will be carried out. DISCUSSION: The ISAAC-CAT project will contribute to evaluate the effectiveness and efficiency of different strategies for more appropriate antibiotic prescribing that are currently out of the scope of the actual clinical guidelines. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03931577.

Repeated Renal Biopsy - A Predictive Tool to Assess the Probability of Renal Flare in Lupus Nephritis.

BACKGROUND: How one responds to treatment of lupus nephritis (LN) is based on clinical features, but the activity in renal biopsy (RB) is uncertain. We have described the therapeutic decisions after performing a repeated RB on the assessment of response to intravenous cyclophosphamide (IC) and the possible prognostic role of this repeated RB. METHODS: Clinical, laboratory and histological features at the initial RB and repeated RB were analyzed in 35 patients. RESULTS: Data in the initial versus the repeated RB were serum creatinine 1.23 ± 1.08 and 0.96 ± 0.45 mg/dl (p < 0.05), glomerular filtration rate <60 ml/min in 12 and 5% patients and proteinuria 4.1 ± 2.8 vs. 0.6 1.1 g/day (p < 0.05). Significant differences were detected in hematuria, nephrotic syndrome and serological immune features. Complete renal remission was reached in 60% (n = 21) at the time of the repeated RB, partial remission in 31.4% (n = 11), and no response IC in 8.6% (n = 3). Nine patients showed proliferative forms in the repeated RB, 3 of them had proteinuria <1 g/day. Just after the repeated RB, 34.3% increased or started a new immunosuppressive therapy, 17.1% remained with the same complementary IST, and 14.3% decreased or stopped it. In the follow-up post repeated RB, 34.5% without active lesions showed a renal flare versus 77.8% with active lesions (p = 0.04). The mean time was 120 and 45 months, respectively. CONCLUSION: A repeated biopsy in LN distinguishes patients in true remission from those in apparent remission. By doing this, we can identify patients who could benefit from intensified treatment and for whom unnecessary treatment methods can be modified or eliminated.

[Statistical methods to analyze risk with spatial distribution patterns]. / Métodos estadísticos para analizar el riesgo con patrones de distribución espacial.

The development of the geographic information systems has improved the interest in analyzing the characteristics of the population, taking into account the place where they live. The health of the population, measured as the risk of morbidity or mortality, is conditioned by the variety of risk factors characteristic of the region which cannot be measured. Analysis of spatial models considers the dependence of the health indicators between close regions. This dependence is due to the existence of the risk factors that are not measured but are shared by the region. Thus, the spatial distribution of these indicators depends on the geographic pattern of these risk factors. In this study, some limitations of the standardized methods and the Poisson regression used to model the spatiality are discussed and the advantages of the spatial models are shown. The methodology is illustrated by the insulin-dependent diabetes type 1 data from Catalonia during 1989 and 1998.