[Translated article] Therapeutic management, adherence, and clinical outcomes of heart failure in Andalucía. ANDALIC Protocol.

Heart failure is a prevalent syndrome with high mortality rates, representing a significant economic burden in terms of healthcare. The lack of systematic information about the treatment and adherence of patients with heart failure limits the understanding of these aspects and potentially the improvement of clinical outcomes. OBJECTIVE: To describe the clinical characteristics, therapeutic management, adherence, persistence, and clinical results, as well as the association between these variables, in a cohort of patients with heart failure in Andalusia. DESIGN: This study will be an observational, population-based, retrospective cohort study. Data of patients discharged from an Andalusian hospital with a diagnosis of heart failure between 2014 and 2023 will be extracted from the Andalusian population health database. ANALYSIS: The statistical analysis will incorporate the following strategies: (1) Descriptive analysis of the characteristics of the population cohort, adherence measures, and clinical outcomes. (2) Bivariate analyses to study the association of covariates with adherence, persistence, and clinical results. (3) Multivariate logistic regression and Cox regression analysis including relevant covariates. (4) To evaluate changes over time, multivariate Poisson regression models will be used. By conducting this comprehensive study, we aim to gain valuable insights into the clinical characteristics, treatment management, and adherence of heart failure patients in Andalusia, as well as to identify factors that may influence clinical outcomes. These findings could be critical both for the development of optimised strategies that improve medical care and quality of life of patients and for mitigating the health burden of HF in the region.

Therapeutic management, adherence, and clinical outcomes of heart failure in Andalucía. ANDALIC Protocol. / Manejo terapéutico, adherencia y resultados clínicos de la insuficiencia cardiaca en Andalucía. Protocolo ANDALIC.

Heart failure is a prevalent syndrome with high mortality rates, representing a significant economic burden in terms of healthcare. The lack of systematic information about the treatment and adherence of patients with heart failure limits the understanding of these aspects and potentially the improvement of clinical outcomes. OBJECTIVE: To describe the clinical characteristics, therapeutic management, adherence, persistence and clinical results, as well as the association between these variables, in a cohort of patients with heart failure in Andalusia. DESIGN: This study will be an observational, population-based, retrospective cohort study. Data of patients discharged from an Andalusian hospital with a diagnosis of heart failure between 2014 and 2023 will be extracted from the Andalusian population health database. ANALYSIS: The statistical analysis will incorporate the following strategies: 1) Descriptive analysis of the characteristics of the population cohort, adherence measures, and clinical outcomes. 2) Bivariate analyses to study the association of covariates with adherence, persistence and clinical results. 3) Multivariate logistic regression and Cox regression analysis including relevant covariates. 4) To evaluate changes over time, multivariate Poisson regression models will be used. By conducting this comprehensive study, we aim to gain valuable insights into the clinical characteristics, treatment management, and adherence of heart failure patients in Andalusia, as well as to identify factors that may influence clinical outcomes. These findings could be critical both for the development of optimized strategies that improve medical care and quality of life of patients and for mitigating the health burden of HF in the region.

Multimorbidity Profiles and Infection Severity in COVID-19 Population Using Network Analysis in the Andalusian Health Population Database.

Identifying the population at risk of COVID-19 infection severity is a priority for clinicians and health systems. Most studies to date have only focused on the effect of specific disorders on infection severity, without considering that patients usually present multiple chronic diseases and that these conditions tend to group together in the form of multimorbidity patterns. In this large-scale epidemiological study, including primary and hospital care information of 166,242 patients with confirmed COVID-19 infection from the Spanish region of Andalusia, we applied network analysis to identify multimorbidity profiles and analyze their impact on the risk of hospitalization and mortality. Our results showed that multimorbidity was a risk factor for COVID-19 severity and that this risk increased with the morbidity burden. Individuals with advanced cardio-metabolic profiles frequently presented the highest infection severity risk in both sexes. The pattern with the highest severity associated in men was present in almost 28.7% of those aged ≥ 80 years and included associations between cardiovascular, respiratory, and metabolic diseases; age-adjusted odds ratio (OR) 95% confidence interval (1.71 (1.44-2.02)). In women, similar patterns were also associated the most with infection severity, in 7% of 65-79-year-olds (1.44 (1.34-1.54)) and in 29% of ≥80-year-olds (1.35 (1.18-1.53)). Patients with mental health patterns also showed one of the highest risks of COVID-19 severity, especially in women. These findings strongly recommend the implementation of personalized approaches to patients with multimorbidity and SARS-CoV-2 infection, especially in the population with high morbidity burden.

Has the COVID-19 pandemic wiped out the seasonality of outpatient antibiotic use and influenza activity? A time-series analysis from 2014 to 2021.

OBJECTIVE: To assess the influence of the emergence of severe acute respiratory syndrome coronavirus 2 and the implementation of public health measures on the seasonality of outpatient antibiotic use and their possible association with the incidence of influenza. METHODS: We performed a time-series ecological study in 1516 primary care centres of Andalusia, Spain, comparing the coronavirus disease 2019 period (April 2020 to March 2021) with the 6 previous years. We assessed the number of packs and defined daily doses per 1000 inhabitants of antibacterials and key antibiotics commonly used for acute respiratory tract infections and the number of influenza-positive cases per 100 000 inhabitants. We calculated the correlation between variables and analyzed the seasonal patterns and differences in quarterly antibiotic use. RESULTS: For all quarters, a significant correlation was observed between influenza activity and antibiotic use (Spearman's r = 0.94; p < 0.001). Before the pandemic period, both variables presented similar seasonal patterns. After the start of the pandemic, influenza activity was suppressed and the pattern of antibiotic use flattened into a straight line (R2 = 0.96; p = 0.022) with a quarterly change of 3.9% (p = 0.007). Total antibiotic use and antibiotics used for treating acute respiratory tract infections showed significant reductions in all quarters compared to the previous year (p < 0.01). DISCUSSION: The coronavirus disease 2019 pandemic has strongly influenced the seasonality of antibiotic use in primary care. The decline in respiratory viruses, among which the influenza virus is a major player that may act as a proxy for general prevalence, is proposed as a reason for the flattening of the seasonal fluctuations of outpatient antibiotic use in our region.

[Impact assessment on data protection in research projects]. / La evaluación de impacto en protección de datos en los proyectos de investigación.

Recent changes in European regulations for personal data protection still allow the use of health data for research purposes, but they have set the Impact Assessment on Data Protection as an instrument for reflection and risk analysis in the process of data processing. The publication of a guide for facilitates this impact assessment, although it is not directly applicable to research projects. Experience in a specific project is detailed, showing how the context of the treatment becomes relevant with respect to the data characteristics. Carrying out an impact assessment is an opportunity to ensure compliance with the principles of data protection in an increasingly complex environment with greater ethical challenges.

[Health promotion and prevention in the economic crisis: the role of the health sector. SESPAS report 2014]. / Promoción de la salud y prevención en tiempos de crisis: el rol del sector sanitario. Informe SESPAS 2014.

This article reviews trends in lifestyle factors and identifies priorities in the fields of prevention and health promotion in the current economic recession. Several information sources were used, including a survey of 30 public health and primary care experts. Between 2006 and 2012, no significant changes in lifestyle factors were detected except for a decrease in habitual alcohol drinking. There was a slight decrease in the use of illegal drugs and a significant increase in the use of psychoactive drugs. Most experts believe that decision-making about new mass screening programs and changes in vaccination schedules needs to be improved by including opportunity cost analysis and increasing the transparency and independence of the professionals involved. Preventive health services are contributing to medicalization, but experts' opinions are divided on the need for some preventive activities. Priorities in preventive services are mental health and HIV infection in vulnerable populations. Most experts trust in the potential of health promotion to mitigate the health effects of the economic crisis. Priority groups are children, unemployed people and other vulnerable groups. Priority interventions are community health activities (working in partnership with local governments and other sectors), advocacy, and mental health promotion. Effective tools for health promotion that are currently underused are legislation and mass media. There is a need to clarify the role of the healthcare sector in intersectorial activities, as well as to acknowledge that social determinants of health depend on other sectors. Experts also warn of the consequences of austerity and of policies that negatively impact on living conditions.

[Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method]. / Análisis del tratamiento quirúrgico más apropiado para la colecistitis aguda mediante aplicación del método RAND/UCLA.

INTRODUCTION: Acute cholecystitis (AC) is a common indication for cholecystectomy. Local circumstances and certain patient characteristics lead to high failure rates and complications in laparoscopic cholecystectomy (LC), and despite the experience gained, we still do not have a detailed list of indications which could minimise them. MATERIAL AND METHOD: We used the RAND/UCLA Appropriateness Method (RAM) to evaluate 2 options, LC and open cholecystectomy (OC). An expert panel analysed its suitability after a literature review, a consensus meeting, and 2 rounds of scores on different clinical situations. The score of each scenario was analysed to establish the appropriateness level of each option. RESULTS: At the end of the meeting there were 64 defined scenarios, with an agreement being reached on the indications in 67.18% of them. In 86.04% of the scenarios, the agreement was due to the appropriateness of the indications. When cholecystectomy was indicated, it was always by laparoscopy, while it was only occasionally by laparotomy. In patients with less than 72 h of onset, LC was always considered appropriate when there was sepsis, or even without this if the ultrasound data showed complicated AC. CONCLUSIONS: There is still uncertainty as regards the management of AC, especially as regards the timing of the operation and the surgical approach, particularly in frail patients and with a clinical onset greater than 72 h. The RAND method can help to make decisions on the appropriateness of different therapeutic options.

[Portable coagulometer devices in the monitoring and control of oral anticoagulation therapy: a systematic review]. / Dispositivos de coagulometría portátil en el seguimiento y control ambulatorio de la terapia anticoagulante oral: revisión sistemática.

OBJECTIVE: To compare portable coagulometer devices and conventional coagulometers. The clinical validity will be estimated via anticoagulation control (maintenance of therapeutic range), patient satisfaction, thrombotic or haemorrhagic events and mortality. Analytical validity will be studied in quality control terms. DESIGN: Systematic review. DATA SOURCES: MEDLINE and EMBASE databases, CRD, Cochrane, EMEA, FDA, EuroScan and the ClinicalTrials.gov. METHODS: Inclusion criteria were studied in patients on anticoagulation therapy who used portable coagulometer devices. In an additional undertaking, the comparison with lab references was looked for, in order to evaluate the effectiveness. The quality of selected studies was assessed according to CASPe check-list. As meta-analysis was not possible, a qualitative synthesis was made. RESULTS: Four evaluation reports and 7 systematic reviews were selected (two of them with meta-analysis). After these, 22 original articles were included for this review and they had high or very high score for CASPe check-list (≥7/10). Almost all of the studies found very high correlations between portable coagulometer devices and conventional coagulometers (r>90), and clinical advantages such as lower incidence of thromboembolism events. Three systematic reviews showed a lower mortality index. CONCLUSIONS: The analytical-validity related articles show that portable coagulometers have an equivalent effectiveness to conventional coagulometers. Studies that include patient-reported outcomes show that self-monitoring patients, by means of portable coagulometers, have better analytical measurement results and fewer rates of thromboembolic events. Survival was analysed in very few studies; nevertheless, all of these show lower mortality. Similarly, the minority of selected articles includes economic evaluations, although they suggest a better cost-effectiveness of portable coagulometers compared to the conventional mode.

Effectiveness of laparoscopic surgery for gallstones and common bile duct lithiasis: a systematic overview / Efectividad de la cirugía laparoscópica para colecistolitiasis y coledocolitiasis: revisión global de la evidencia

The aim of the present study was to evaluate the available evidence on the effectiveness of laparoscopic surgery for treating gallstones and common bile duct lithiasis (CBDL). A systematic overview was performed. Medline, EMBASE and The Cochrane Library were searched (1998-2008). Systematic reviews (SR), clinical practice guidelines (CPG), randomised clinical trials (RCT) and observational studies were included. Internal validity and overall quality of the evidence were assessed. The available evidence was classified according to the Oxford Centre for Evidence Based Medicine proposal. 87 studies were included in this review (12 SR, 23 RCT, 3 CPG, 13 cohort studies, 3 cross-sectional studies, 2 case and control studies and 31 case series). Compared with open cholecystectomy, laparoscopic cholecystectomy (LC) is associated with shorter operating time, shorter hospital stay and better quality of life (high quality evidence). The use of antibiotic prophylaxis does not appear to reduce the infection rate in low-risk patients (high quality evidence). Although many techniques have been advocated to perform LC their effectiveness is as yet inconclusive (low-quality evidence). Two-stage surgery is the most appropriate strategy for high-risk patients with CBDL (high-quality evidence). Mortality is similar to open surgery, as the effectiveness is similar to that of endoscopic treatment (high-quality evidence). As a conclusion we can state that the evidence concerning the effectiveness of laparoscopic surgery for gallstones and CBDL is scarce and of low methodological quality and that better quality studies are warranted to assess these techniques more adequately.

El objetivo del presente estudio fue evaluar la evidencia disponible respecto de la efectividad de la cirugía laparoscópica en el tratamiento de la colelitiasis y la litiasis de la vía biliar (LVBP). Para ello, se realizó una revisión global de la evidencia disponible. Se realizaron búsquedas en las bases de datos MEDLINE, EMBASE y The Cochrane Library (1998-2008). Se incluyeron guías de práctica clínica (GPC), revisiones sistemáticas (RS), ensayos clínicos con asignación aleatoria (EC) y estudios observacionales. Se valoró la validez interna y la calidad global de los estudios. Los datos disponibles y la evidencia generada se clasificaron en base a la propuesta del Centro de Oxford de Medicina Basada en la Evidencia. 87 estudios fueron incluidos en esta revisión (3 GPC, 12 RS, 23 EC, 13 estudios de cohortes, 3 estudios transversales, 2 estudios de casos y de controles y 31 series de casos). En comparación con la colecistectomía abierta, la colecistectomía laparoscópica (CL) se asocia con menor tiempo operatorio y estancia hospitalaria y mejor calidad de vida (evidencia de alta calidad). El uso de profilaxis antibiótica no parece reducir la tasa de infección en pacientes de bajo riesgo (evidencia de alta calidad). Aunque se han descrito numerosas técnicas para realizar una CL, su eficacia no es aún concluyente (evidencia de baja calidad). La cirugía en dos etapas es la estrategia más adecuada para los pacientes de alto riesgo con LVBP (evidencia de alta calidad). La mortalidad del tratamiento laparoscópico de la LVBP es similar a la de la cirugía abierta; y como su eficacia es similar a la del tratamiento endoscópico (evidencia de alta calidad). Se puede concluir señalando que la evidencia disponible respecto de la efectividad de la cirugía laparoscópica para el tratamiento de la colelitiasis y la LVBP es escasa y de baja calidad metodológica; y que se requieren estudios de mejor calidad para valorar de forma más apropiada estas técnicas.

Isolated limb perfusion for malignant melanoma: systematic review on effectiveness and safety.

BACKGROUND: Isolated limb perfusion (ILP) involves the administration of chemotherapy drugs directly into a limb involved by locoregional metastases. Unresectable locally advanced melanoma of the limbs represents one of the clinical settings in which ILP has demonstrated benefits. METHODS: A systematic review of the literature on ILP for patients with unresectable locally advanced melanoma of the limbs was conducted. MEDLINE, EMBASE, and Cochrane database searches were conducted to identify studies fulfilling the following inclusion criteria: hyper- or normothermic ILP with melphalan with or without tumor necrosis factor (TNF) or other drugs providing valid data on clinical response, survival, or toxicity. To allocate levels of evidence and grades of recommendation the Scottish Intercollegiate Guidelines Network system was used. RESULTS: Twenty-two studies including 2,018 ILPs were selected with a clear predominance of observational studies (90.90%) against experimental studies (9.10%). The median complete response rate to ILP was of 58.20%, with a median overall response rate of 90.35%. ILP with melphalan yielded a median complete response rate of 46.50%, against a 68.90% median complete response rate for melphalan plus TNF ILP. The median 5-year overall-survival rate was 36.50%, with a median overall survival interval of 36.70 months. The Wieberdink IV and V regional toxicity rates were 2.00% and 0.65%, respectively. CONCLUSIONS: ILP is effective in achieving clinical responses in patients with unresectable locally advanced melanoma of the limbs. The disease-free and overall survival rates provided by ILP are acceptable. ILP is safe, with a low incidence of severe regional and systemic toxicity.

Is FDG-PET suitable for evaluating neoadjuvant therapy in non-small cell lung cancer? Evidence with systematic review of the literature.

BACKGROUND: Neoadjuvant therapy response assessment is crucial in patients with non-small cell lung cancer (NSCLC). FDG-PET has emerged as a valuable tool for defining therapy response assessment in other tumours. AIM: To systematically review publications appearing in the literature describing induction therapy response assessment with FDG-PET in NSCLC. METHODS: We performed a bibliographic search and selected only prospective studies in order to include the highest levels of evidence. RESULTS: Nine of 497 potentially relevant publications were selected. The ranges of sensitivity, specificity, positive predictive value and negative predictive value for primary tumour response assessment were 80-100%, 0-100%, 42.9-100%, and 66.7-100%, respectively. Pooling data for N2 restaging after neoadjuvant response the overall sensitivity was 63.8% (95% CI, 53.3-73.7%) and overall specificity was 85.3% (95% CI, 80.4-89.4%). CONCLUSION: The results of the analysis do not support the use of FDG-PET as the only re-assessment tool for mediastinal lymph node evaluation for routine clinical use. FDG-PET seems to predict primary tumour response to induction therapy but it could not be shown by pooling analysis.

Interventions to promote the use of advance directives: an overview of systematic reviews.

OBJECTIVE: To identify, appraise and synthesise the results of systematic reviews of the literature (SRLs) that examines the effectiveness of interventions to increase advance directive (AD) completion rate. METHODS: Narrative review of the literature-an overview of SRLs focused on interventions to improve patients' AD completion rate. RESULTS: Seven SRLs were located. A wide range of interventions was identified in order to determine their influence on the AD completion rate. CONCLUSION: The most effective method of increasing the use of ADs is the combination of informative material and repeated conversations over clinical visits. The use of passive informative material in isolation does not significantly increase AD completion rates. However, when interactive informative interventions are employed, the AD completion rate increases and the majority of the studies identify multiple sessions as the most effective method for direct interaction between patients and health care professionals. PRACTICE IMPLICATIONS: The progressive ageing of the population and the provision of quality care during the process of ageing and dying, have given rise to the Governments' interest in developing moral autonomy and regulating tools as ADs. In order to put legislation into practice it is necessary to set up successful interventions to expand ADs use.

18F-fluorodeoxiglucose positron emission tomography for the evaluation of neoadjuvant therapy response in esophageal cancer: systematic review of the literature.

UNLABELLED: Neoadjuvant treatment is a relatively new therapeutic approach for locally advanced esophageal cancer. Response assessment is crucial for the treatment of these patients. Cross sectional imaging has traditionally being used as the elective method of response assessment. Recently, 18F fluorodeoxyglucose- positron emission tomography (FDG-PET) has emerged as a new valuable tool defining therapy response assessment in other tumors. AIM: We systematically reviewed the increasing number of publications appearing in the literature analyzing the utility of FDG-PET in the evaluation of neoadjuvant therapy response assessment. METHODS: We performed a bibliographic search according to the COSI protocol and selected only prospective studies to achieve the highest levels of evidence. Quality assessment was defined with the QUADAS questionnaire. RESULTS: Eight of 237 potentially relevant publications were selected for the analysis. Ranged sensitivity, specificity, positive predictive value, and negative predictive value for primary tumor response assessment were 27.3% to 93.3%, 41.7% to 95.2%, 70.8% to 93.3% and 71.4% to 93.5%, respectively, and for N restaging, 16.0% to 67.5%, 85.7% to 100%, 33% to 100% and 91.7% to 93.3%, respectively. The heterogeneity of the publications ruled out the possibility of meta-analysis. FDG-PET is more precise compared with computed tomography in the evaluation of induction therapy response assessment. CONCLUSION: FDG-PET seems to be the best available imaging modality for neoadjuvant therapy response assessment in esophageal cancer. But more prospective studies with larger populations are needed to confirm the power of this imaging tool in this aim and to determine the best analytical interpretation method and threshold to differentiate responders from nonresponding patients.

[Out-patient determination of glycosylated haemoglobin in the monitoring and control of diabetes mellitus: systematic review of the literature]. / Determinación ambulatoria de glucohemoglobina en el seguimiento y el control de la diabetes mellitus: revisión sistemática de la literatura.

OBJECTIVE: To compare out-patient determination of HbA(1c) with lab figures, by measuring metabolic control, quality of life and hypoglycaemia episodes, in adults with type-1 or -2 diabetes mellitus. DESIGN: Systematic review. DATA SOURCES: MEDLINE (1966-August 2006), EMBASE (2000-August 2006), bases held by the Center for Reviews and Dissemination (DARE, INAHTA, NHS-EED), Cochrane Library (number 3, 2006), European Medication Agency, Food and Drug Administration and the European Network of Emerging Technologies. A manual search was made in Point of Care and in the register of trials, (ClinicalTrials.gov). METHODS: Inclusion criteria were studies with type-1 or -2 diabetics who used portable out-patient devices and with comparison with lab references. Studies of minors, of any other kind of diabetes, of patients without a portable device and where the comparator did not include reference methods were excluded. Those that a priori met the criteria were recovered fully. A quality analysis was run according to the CASPe programme criteria and data were extracted with specific formulae. As meta-analysis was not possible, a qualitative synthesis was made. RESULTS: Twenty publications were selected. The values of most devices correlated well (R(2)=0.85 and R(2)=0.059; P< .001). Some studies described increase in glycaemia control, with drop in HbA(1c) of 0.1%-1.5% (P< .01); therapy control was more intense (95% CI, 0.95-1.52) and visits to the doctor decreased. CONCLUSIONS: Out-patient evaluations are rapid and comfortable, increasing patients' metabolic control. However, they possess certain limitations.

[Efficacy and safety of inhaled insulin in diabetes mellitus treatment]. / Eficacia y seguridad de la insulina inhalada en el tratamiento de la diabetes mellitus.

OBJECTIVE: To evaluate the efficacy and safety of inhaled insulin. DESIGN: Systematic review. DATA SOURCES: Reference data bases, MEDLINE (1999 to November 2005) and EMBASE (2000 to November 2005), the CENTRAL base (Cochrane Library), the European Drug Agency, the Food and Drug Administration, the International Network of Technology Evaluation Agencies, the European Network for Early Detection (EuroScan), and various research registers. STUDIES: Eight clinical trials were recovered. Studies not comparing inhaled with subcutaneous insulin and those that did not measure metabolic control or satisfaction and quality of life were excluded. DATA EXTRACTION: Critical reading using the methods proposed by the CASPe programme. RESULTS: The difference between the 2 groups in mean values of descent of glycosylated haemoglobin was -0.07% (95% CI, -0.32 to 0.17) for type-2 diabetics; and between 0.16% (95% CI, -0.01 to 0.32) and -0.16% (95% CI, -0.34 to 0.01) in type-1 diabetics. Hypoglucaemias per subject-month were similar (between 0.83 and 1.57 in type-2 diabetics and between 8.6 and 9.9 in type-1 diabetics). Quality of life and satisfaction were favourable to the intervention group (P< .05). Secondary effects were comparable except in the appearance of cough (21%-27% in inhaled and 2%-7% in subcutaneous insulin). CONCLUSIONS: Inhaled insulin is comparable to subcutaneous insulin in metabolic control, the number of hypoglucaemias and side-effects. However, the trials reviewed showed certain problems of internal and external validity. Studies with longer follow-up are needed, in order to evaluate possible lung disorders.

[Incorporation of cardiac rehabilitation programs and their characteristics in the Spanish National Health Service]. / Incorporation of cardiac rehabilitation programs and their characteristics in the Spanish National Health Service.

OBJECTIVES: To estimate the degree of incorporation of cardiac rehabilitation in the Spanish National Health Service, to describe the characteristics of the programs, and to report on the opinions of those responsible for them regarding their progress. PATIENTS AND METHOD: Cardiac rehabilitation centers were identified from different sources. A questionnaire which included items about coverage, resources, activities and services, selection of patients, and opinions was mailed to the heads of all units. RESULTS: Twelve public centers with cardiac rehabilitation programs were identified. Cardiac rehabilitation was offered to 53% of all eligible patients. All units treated patients with myocardial infarction, 64% treated those with heart failure; and 60% high risk patients. Approximately 10-19% of all patients were women. The physicians involved most frequently in programs were cardiologists; nonmedical professionals who participated most often were physiotherapists, and 64% of all units had a staff psychologist. Phase II rehabilitation was provided by all units, and phase III treatment was provided mainly by units that operated in coordination with out-patient services (45%). All units provided physical exercise training and counseling about the disease and risk factors, and 73% of them provided psychological support. The main reasons cited for providing rehabilitation were its efficacy and ability to prevent illness; and the main barriers to more widespread use were lack of resources and support. About three-fourths (73%) of all doctors interviewed thought that primary health care centers could play an important role in rehabilitation programs. CONCLUSIONS: Cardiac rehabilitation is poorly implemented in the Spanish National Health Service. The most significant differences between programs were related to the inclusion of high risk patients and with a diagnosis other than myocardial infarction, coordination with out-patient services, and provision of phase III rehabilitation.