Primary and Community Care Transformation in Post-COVID Era: Nationwide General Practitioner Survey.

Introduction: The health emergency caused by COVID-19 has led to substantial changes in the usual working system of primary healthcare centers and in relations with users. The Catalan Society of Family and Community Medicine designed a survey that aimed to collect the opinions and facilitate the participation of its partners on what the future work model of general practitioners (GPs) should look like post-COVID-19. Methodology: Online survey of Family and Community Medicine members consisting of filiation data, 22 Likert-type multiple-choice questions grouped in five thematic axes, and a free text question. Results: The number of respondents to the questionnaire was 1051 (22.6% of all members): 83.2% said they spent excessive time on bureaucratic tasks; 91.8% were against call center systems; 66% believed that home care is the responsibility of every family doctor; 77.5% supported continuity of care as a fundamental value of patient-centered care; and >90% defended the contracting of complementary tests and first hospital visits from primary healthcare (PHC). Conclusions: The survey responses describe a strong consensus on the identity and competencies of the GP and on the needs of and the threats to the PHC system. The demand for an increase in health resources, greater professional leadership, elimination of bureaucracy, an increase in the number of health professionals, and greater management autonomy, are the axes towards which a new era in PHC should be directed.

Depressive symptom severity is a major risk factor for frailty in community-dwelling older adults with depression. A prospective study.

BACKGROUND: Depression and frailty are closely related, but the mechanisms by which depressed older adults are at an increased risk of becoming frail are still not well understood. AIM: To assess socioeconomic and depression-related risk factors for frailty in older adults with depression. METHODS: Observational and prospective cohort study, with 12-month follow-up, of nonfrail community-dwelling subjects aged ≥70 years old with depression. The main study factors were clinical characteristics of depression, including symptom severity (Hamilton Depression Rating Scale), accompanying anxiety and cognitive symptoms, pharmacological treatment, and social factors including educational level, income, housing conditions and living circumstances, and social network. Frailty status was established according to Fried criteria. RESULTS: We recruited and analysed 216 subjects (mean age 76.5 years; 74% women), 65 (30%) of whom were lost to follow-up. Annual incidence of frailty was 23.2 new cases/100 persons. Age, female gender, osteoarthritis, pain, number of medications, major depression, first-degree family history of depression, depressive symptom severity, low educational level, and low-income level were risk factors for frailty. The multivariate analysis showed that age (odds ratio [OR] = 1.16; 95% confidence interval [CI]: 1.04-1.29), visual analogue scale (VAS)-pain (OR = 1.25; 95% CI: 1.01-1.55), and severe or very severe depressive symptoms (OR = 37.36; 95% CI: 2.68-518.53) were significantly associated with incident frailty at 12 months of follow-up. CONCLUSIONS: Both clinical and social characteristics are risk factors for frailty, but severity of depressive symptoms had the highest independent effect on frailty in depressed aged subjects. Frailty requires a multidisciplinary approach that pays special attention to pain and depressed mood.

Primary Care Professionals' Self-Efficacy Surrounding Advance Care Planning and Its Link to Sociodemographics, Background and Perceptions: A Cross-Sectional Study.

Primary care (PC) professionals have been considered the most appropriate practitioners for leading Advance care planning (ACP) processes with advanced chronic patients. AIM: To explore how PC doctors' and nurses' self-efficacy surrounding ACP is linked to their sociodemographic characteristics, background and perceptions of ACP practices. METHODS: A cross-sectional study was performed. Sociodemographics, background and perceptions about ACP in practice were collected using an online survey. The Advance Care Planning Self-Efficacy Spanish (ACP-SEs) scale was used for the self-efficacy measurement. STATISTICAL ANALYSIS: Bivariate, multivariate and backward stepwise logistic regression analyses were performed to identify variables independently related to a higher score on the ACP-SEs. RESULTS: N = 465 participants, 70.04% doctors, 81.47% female. The participants had a mean age of 46.45 years and 66.16% had spent >15 years in their current practice. The logistic regression model showed that scoring ≤ 75 on the ACP-SEs was related to a higher score on feeling sufficiently trained, having participated in ACP processes, perceiving that ACP facilitates knowledge of preferences and values, and perceiving that ACP improves patients' quality of life. CONCLUSION: Professionals with previous background and those who have a positive perception of ACP are more likely to feel able to carry out ACP processes with patients.

Psychosocial factors associated with frailty in the community-dwelling aged population with depression. A cross-sectional study.

OBJECTIVE: There is a two-way relationship between frailty and depression, but the mechanisms by which one may influence the other are not well understood. The objective of this study was to evaluate the relationship between psychosocial factors and frailty in community-dwelling aged populations with depression. DESIGN: Observational cross-sectional study. SITE: 5 primary care centres. PARTICIPANTS: Community-dwelling subjects with depression aged ≥70 years. MAIN MEASUREMENTS: Frailty status was established according to Fried criteria, depression and depression severity were evaluated by DSM-IV criteria and the Hamilton Depression Rating Scale, respectively, and psychosocial factors were assessed using the Gijón Social-Familial Evaluation Scale and ad hoc questionnaires. RESULTS: Recruited were 338 subjects (mean age 77.2 years), 82% women and 36.1% rated as frail. A dose-response relationship was observed between depression severity and frailty risk. Widowhood was a risk factor for frailty, while a higher educational level, home internet, stairs in the home, and an active social life had a protective effect. A multivariate analysis showed that age, number of drugs, and depression severity were independent risk factors for frailty, while an active social life was a protective factor. The severity of depressive symptoms showed higher association with frailty than other clinical and socio-demographic characteristics. CONCLUSIONS: In depressed elderly subjects, frailty is associated with psychologiocal factors such as the intensity of depressive symptoms and with social factors such as education level, widowhood, loneliness, and limited social life. More research is required to better understand the modifiable psychological risk factors for frailty.

Relative Validity of a Method Based on a Smartphone App (Electronic 12-Hour Dietary Recall) to Estimate Habitual Dietary Intake in Adults.

BACKGROUND: Accurate dietary assessment is key to understanding nutrition-related outcomes and for estimating the dietary change in nutrition-based interventions. When researching the habitual consumption of selected food groups, it is essential to be aware of factors that could possibly affect reporting accuracy. OBJECTIVE: This study aimed to evaluate the relative validity of the current-day dietary recall, a method based on a smartphone app called electronic 12-hour dietary recall (e-12HR), to categorize individuals according to habitual intake, in the whole sample of adults and in different strata thereof. METHODS: University students and employees over 18 years recorded the consumption of 10 selected groups of food using e-12HR during 28 consecutive days. During this period, they also completed 4 dietary records. Once the period was finished, the subjects then completed a food frequency questionnaire (FFQ) and a usability-rating questionnaire for e-12HR. The food group intakes estimated by the e-12HR app, the dietary records, and the FFQ were categorized into sextiles: less than once a week, once or twice a week, 3-4 times a week, 5-6 times a week, once or twice a day, and 3 or more times a day. The 10 selected groups with e-12HR were compared with 4 dietary records and an FFQ reference method, in the whole sample and in different strata thereof: age (years): <25 and ≥25; gender: females and males; occupation: students and employees; smoking: no and yes; physical activity (minutes/week): ≥150 and <150; and body mass index (kg/m2): <25 and ≥25. The association between the different methods was assessed using Spearman correlation coefficient (SCC). Cross-classification and kappa statistic were used as a measure of agreement between the different methods. RESULTS: In total, 203 participants completed the study (56.7% [115/203] women, and 43.3% [88/203] men). For all food groups and all participants, the mean SCC for e-12HR versus FFQ was 0.67 (≥0.62 for all strata). On average, 50.7% of participants were classified into the same category (≥47.0% for all strata) and 90.2% within the nearest category (≥88.6% for all strata). Mean weighted kappa was 0.49 (≥0.44 for all strata). For e-12HR versus RDs, mean SCC was 0.65 (≥0.57 for all strata). On average, 50.0% of participants were classified into the same category (≥47.0% for all strata) and 88.2% within the nearest category (≥86.1% for all strata). Mean weighted kappa was 0.50 (≥0.44 for all strata). CONCLUSIONS: The results indicate that e-12HR generated categories of dietary intake highly comparable with the 2 reference methods in the whole sample and in different strata thereof. The inclusion of photographs to facilitate estimation of the servings consumed generated correlation/agreement data between e-12HR and the FFQ that were similar to a previous study using an older version of the app, which did not include photographs.

[Find your 1%: prevalence and mortality of a community cohort of people with advanced chronic disease and palliative needs]. / Busca tu 1%: prevalencia y mortalidad de una cohorte comunitaria de personas con enfermedad crónica avanzada y necesidades paliativas.

OBJECTIVE: To determine the prevalence and profiles of people with advanced chronic diseases in Primary Care and to analyse the elements related to their mortality in order to orient strategies for improvement in this level of care. DESIGN: An observational, analytical and prospective study during 3 years conducted on a cohort of patients with palliative needs. LOCATION: Three Primary Care teams of Osona (Catalonia). PARTICIPANTS: A total of 251 people identified as advanced patients using a systematic population-based strategy that included the NECPAL tool. MAIN MEASUREMENTS: Basic demographic and clinical profile (age, gender, type of residence, health stratification level and main disease); date, place, and cause of eventual deaths. RESULTS: 1% of the adult Primary Care population suffer from advanced diseases, of which 56.6% are women, and with a median age of 85 years. Dementia or advanced frailty is observed in 49.3%, and only 13.7% have cancer. Just under one-quarter (24.3%) live in nursing homes. The accumulated mortality at 3 years is 62.1%, with a median survival of 23 months. Factors significantly associated with the likelihood of dying are cancer, female gender, and over-aging. Patients died at their home (47.3%), in an intermediate care hospital (37.2%), or in an acute care hospital (15.5%), depending on certain explanatory factors. CONCLUSIONS: The prevalence and characteristics of advanced community-based disease coincide with that reported in the literature. Potentially, Primary Care is the reference level of care for these patients, especially if it incorporates nursing homes as a usual field of practice.

[Every week counts: Use of health services and related costs of a community-based cohort of people with advanced chronic diseases]. / Cada semana cuenta: uso de dispositivos sanitarios y costes relacionados de una cohorte comunitaria de personas con enfermedades crónicas avanzadas.

OBJECTIVE: To describe the use of health resources of people with advanced chronicity, quantifying and characterizing its cost to suggest improvements in health care models. DESIGN: Observational, analytical and prospective study during 3 years of a cohort of people with advanced chronicity. LOCATION: Three primary care teams (EAP) of Osona, Cataluña. PARTICIPANTS: 224 people identified as advanced patients through a systematic population strategy. MAIN MEASUREMENTS: Age, sex, type of home, end-of-life trajectory; use, type and cost of resources in primary care, emergencies, palliative teams or hospitalization (in acute or intermediate care). RESULTS: Patients made an average of 1.1 admissions per year (average stay=6 days), 74% in intermediate care hospitals. They lived in the community 93.4% of time, carrying out 1 weekly contact with the EAP (45.1% home care). The average daily cost was 19.4euros, the main chapters were intermediate care hospitalizations (36.5%), EAP activity (29.4%) and admissions in acute hospitals (28.6%). Factors determining a potential lower cost are frailty/dementia as trajectory (p<0.001), living in a nursing-home facility (p<0.001) and over-aging (p<0.001). There are certain differences in the behavior of the EAP related to the global cost and to community resources (p<0.05). CONCLUSIONS: Consumption in intermediate hospitalization and primary care is more relevant than stays in acute care centers. Nursing-homes and home-care strategies are important to attend effectively and efficiently, especially when primary care teams get ready for it.

Is there any alternative to traditional food frequency questionnaire for evaluating habitual dietary intake?

INTRODUCTION: Dietary assessment methods are an important instrument for nutrition research. Food frequency questionnaires (FFQs) have been the most frequently used dietary assessment tool in epidemiological and intervention studies. There is a great necessity for new methods of determination of habitual dietary intake that overcome the limitations of these traditional methods. OBJECTIVES: The objectives of the present study were to develop a new method, based on an application for mobile phones called e-EPIDEMIOLOGY, designed to record individual consumption data about a short series of foods/drinks, and to compare data collected using this tool with those obtained from a previously validated short paper FFQ. METHODS: University students over 18 years recorded the consumption of certain foods/drinks using e-EPIDEMIOLOGY during 28 consecutive days and then filled out a short paper FFQ at the end of the study period. To evaluate the agreement between both methods, Spearman's correlation coefficient, cross-classification analysis and a weighted kappa statistic were used. RESULTS: One hundred and nineteen participants completed the study (71.4% female and 28.6% male). The mean Spearman's correlation coefficients for food/drink group intake between the two methods was 0.73. The mean percentage of participants cross-classified into categories of "exact agreement + adjacent" was 91.6%. The average weighted kappa statistic was 0.60. CONCLUSIONS: The results indicate that e-EPIDEMIOLOGY has good agreement with the previously validated FFQ short paper. However, it was noted that further testing of e-EPIDEMIOLOGY is required to establish its wider utility.

Quality improvement in palliative care services and networks: preliminary results of a benchmarking process in Catalonia, Spain.

BACKGROUND: A wide range of palliative care services has been implemented in Catalonia over the past 20 years. Quantitative and qualitative differences in the organization of palliative care services between districts and settings can result in wide variability in the quality of these services, and their accessibility. METHODS: We implemented a benchmark methodology to compare dimensions of care and organization, to identify aspects requiring improvement, and to establish indicators to measure progress. The overall aim was to generate a consensus document for submission to the Department of Health (DoH) of the Government of Catalonia. RESULTS: A Steering Committee convoked a meeting in Barcelona (Catalonia, Spain) and representatives (n = 114) of all the 37 districts within our health care remit (rural, urban, intermediate, and metropolitan) and settings of the health care system (hospitals, social health centers, community, and nursing homes) attended and took part in plenary sessions and workshops to define areas that, in their experience, were considered weak. Twenty-one consensus recommendations achieving high levels of consensus were generated for submission to the DoH. These included the formal definition of the model of care and organization of palliative care services at all levels in the region, the implementation of measures for improvement in different settings and scenarios, systems for continuous care, and facilities for the continuing training of health care personnel. These proposals have since been implemented in a trial region and, depending on the outcomes, will be applied throughout our health service. CONCLUSION: We conclude that benchmark methodology is valuable in acquiring data for use in improving palliative care organization for patients' benefit.

Health-related quality-of-life of care-givers as a predictor of nursing-home placement of patients with dementia.

Care-giver health-related quality-of-life (QoL) as a predictor of nursing-home placement of family-member patients with dementia was evaluated (using the SF-36 questionnaire) in 181 care providers (78% females; mean age 63 years) at the start and at the end of 12 months of follow-up. The patients and their carers were evaluated at home or at the local Primary Health-care Centers (n = 37) in the area of Barcelona (Catalunya, Spain). Data were evaluated using logistic regression analysis with nursing-home placement of patients as the main outcome measure, and the care-givers' QoL, demographic, medical, social and cognitive variables as covariates. The incidence rate of nursing-home placement was 10.5% (95%CI: 6.4-15.9). Carers of patients who had not been placed in a nursing home had better QoL scores, even after controlling for potential confounding factors. The adjusted odds ratio of being admitted to a nursing home was 6.4 (95%CI: 2.1-19.0) for patients cared-for by relatives who rated their health as being much worse compared with the previous year. The care-giver's poor health-related QoL significantly influenced rates of nursing-home admission of patients in their care.

Health-related quality of life in carers of patients with dementia.

BACKGROUND: Carers of patients with dementia experience high levels of stress that can adversely affect their health and well-being. OBJECTIVE: Our aim was to assess the health-related quality of life of carers of patients with dementia compared with an age- and gender-matched sample from the general population. METHODS: A cross-sectional study was conducted in 37 primary health care centres in Catalonia, Spain. Carers (n = 181; 78% females, mean age 63 years) of patients with dementia together with a random sample of 543 individuals from the general population, matched for age and gender, were assessed with the SF-36 questionnaire, which is a generic measure of health status. RESULTS: With the exception of physical function category, seven of the scales showed lower scores for females in the carer group. The most important differences were observed in the emotional role [95% confidence interval (CI) -37.7 to -3.6], mental health (95% CI -21.0 to -1.6) and bodily pain (95% CI -37.7 to -8.6) categories. In contrast, male carers had higher scores in the physical function category (95% CI 2.2-19.4), and no differences were observed on the other scales. CONCLUSION: Female carers of patients with dementia experienced a seriously decreased quality of life level compared with their contemporaries in the general population.