Intervention to reduce perceived loneliness in community-dwelling older people.

AIM: We evaluated the reduction in perceived loneliness and depression and the increase in social support and quality of life in community-dwelling lonely people aged >65 years included in a community intervention compared with nonlonely controls from the same urban area. DESIGN: Randomised clinical trial without blind evaluation. LOCATION: Urban area of Barcelona. PARTICIPANTS: Community dwellers aged >65 years with loneliness identified by the primary care team. INTERVENTIONS: The primary care team together with community agents (municipal social services, community civil and religious associations) carried out 18 sessions developing activities including educational workshops, mindfulness, yoga, walking and visits to urban gardens. RESULTS: We included 55 patients (87% female, mean age 80.6 ± 6.86 years) of whom 82% had moderate and 18% severe loneliness. Six months postintervention, 48.3% of the intervention group did not feel lonely compared with 26.9% of controls (p = 0.001). Social support (DUKE-UNC-11) increased from 33.5 ± 9.3 to 41.4 ± 6.6, and mental health (SF-12) from 36 ± 610.4 to 48 ± 11.1 and depressive symptoms (Yesavage test) decreased from 9.2 ± 3.6 to 5.2 ± 5.0 in the intervention but not the control group. CONCLUSIONS: The intervention mainly reached people with moderate loneliness and significantly improved the perception of loneliness, depressive symptoms, social support and the mental health component of the quality of life. The intervention may be more suitable for people with moderate loneliness, but these types of activities may be difficult to accept by people with severe loneliness not related to the barriers to socialisation generated by ageing.

[Profiles of loneliness and social isolation in urban population]. / Perfiles de soledad y aislamiento social en población urbana.

OBJECTIVE: To assess the prevalence of loneliness and social isolation in a population over 65 cared by a urban primary health team and to identify its main characteristics. DESIGN: Cross-sectional descriptive study by a telephone survey. SETTING: Basic health area of Barcelona. PARTICIPANTS: Random sample of assigned population of 65 or more years old. MAIN MEASUREMENTS: UCLA Loneliness Scale and Lubben Social Network Scale. RESULTS: 278 persons were interviewed (61,36% response rate), 172 women and 106 men, with an average age of 76,7 ± 7,9 years. A higher proportion of factors related to loneliness were identified in non-respondents. Loneliness was closely correlated to social r = 0,736. Moderate loneliness, with a prevalence of 16,54%, was associated to walking difficulties (OR 3,09, 95%, IC 1,03-9,29), cognitive impairment (OR 3,97, 95% IC 1,19-13,27) and architectural barriers (OR 5.29, 95% IC 2.12-13,23), although severe loneliness, with a prevalence of 18,71% was only associated to living together with less people (OR 0.61, 95% IC 0.40-0.93). Social isolation, with a prevalence of 38,85% was associated to aging (OR 1,06, 95% IC 1,02-1,10) and to the belief of having health problems (OR 4,35, 95% IC 1,11-16,99). CONCLUSIONS: Loneliness and social isolation are of high prevalence. The telephone survey underestimates its prevalence. There are 2profiles of loneliness, one with moderate associated to the socialisation difficulties related to aging and another severe not related to health or to barriers that only can be identified by surveys or clinical interview. Interventions must be targeted to each of these profiles.

Randomized trial to reduce emergency visits or hospital admissions using telephone coaching to complex patients.

Background: Comorbidity remains a matter of international interest, given growing prevalence of chronic conditions. Objective: To evaluate the impact that adding a telephone coaching intervention by a family physician to usual care has on reducing resource consumption and improving health status, caregiver burden and quality of life among complex chronic patients (CCP) compared with usual care. Methods: A randomized controlled trial was conducted on a random sample of CCP from three primary care teams in Barcelona. Patients were randomly allocated into intervention or control groups. Evaluations were conducted at baseline and after six-month follow-up. Intervention patients were phoned twice a month by a family physician. Both groups received usual care. Primary endpoint was change in total number of urgent visits per patient. Secondary endpoints were changes in health and mental status, quality of life and caregiver burden. Results: Hundred and sixty-one CCP were included. During follow-up, 9 patients died and 2 were lost. At baseline, patients' characteristics and resource consumption were similar for both groups. After six months, urgent visits per patient decreased in intervention (1.27 baseline versus 0.89 follow-up, P = 0.091) and control (1.06 baseline versus 0.86 follow-up, P = 0.422) groups, mean difference 0.18 [confidence interval (CI) 95% -0.48 to 0.84]. Intervention patients improved in the physical component of the SF-12 questionnaire, while worsening in control patients, mean difference 4.71 (CI 95% -9.03 to -0.41). Differences were not found in the rest of the endpoints. Conclusion: The intervention did not reduce urgent visits among CCP neither improved patient's health.

[Social isolation and loneliness: What can we do as Primary Care teams?] / Aislamiento social y soledad: ¿qué podemos hacer los equipos de atención primaria?

Loneliness and social isolation are emerging health conditions in the elderly population, in particular widows, high frequency users of health services and those with chronic problems and depression. Loneliness is the subjective feeling of having less affection and closeness than that desired in the intimate or relational field. Social isolation is an objective situation of having minimal contact with other people. Its contribution to increased morbidity and mortality is comparable to other well known risk factors that we deal with daily as Primary Care teams. Strategies to identify these problems in our patients and to perform scientific evidence based studies at individual and community level in cooperation with other community resources and interventions are discussed. The Primary Care team must promote the autonomy of these patients, facilitating their sociability, and act on their social maladaptive thoughts that hinder their social integration.

Predictors of mortality among elderly dependent home care patients.

BACKGROUND: The purpose of this study is to identify which variables--among those commonly available and used in the primary care setting--best predict mortality in a cohort of elderly dependent patients living at home (EDPLH) that were included in a home care program provided by Primary Care Teams (PCT). Additionally, we explored the risk of death among a sub-group of these patients that were admitted to hospital the year before they entered the home care program. METHODS: A one-year longitudinal cohort study of a sample of EDPLH patients included in a home care programme provided by 72 PCTs. Variables collected from each individual patient included health and social status, carer's characteristics, carer's burden of care, health and social services received. RESULTS: 1,001 patients completed the study (91.5%), 226 were admitted to hospital the year before inclusion. 290 (28.9%) died during the one-year follow-up period. In the logistic regression analysis women show a lower risk of death [OR= 0.67 (0.50-0.91)]. The risk of death increases with comorbidity [Charlson index OR= 1.14 (1,06-1.23)], the number of previous hospital admissions [OR= 1,16 (1.03-1.33)], and with the degree of pressure ulcers [ulcers degree 1-2 OR = 2.94 (1.92-4.52); ulcers degree 3-4 OR = 4.45 (1.90-10.92)]. The logistic predictive model of mortality for patients previously admitted to hospital identified male sex, comorbidity, degree of pressure ulcers, and having received home care rehabilitation as independent variables that predict death. CONCLUSIONS: Comorbidity, hospital admissions and pressure ulcers predict mortality in the following year in EDPLH patients. The subgroup of patients that entered home care programs with a previous record of hospital admission and a high score in our predictive model might be considered as candidates for palliative care.

Forumclínic: the shaping of virtual communities to assist patients with chronic diseases.

Information and communication technologies (ICTs) provide new opportunities to complement traditional care while enhancing patient autonomy. With the objective to supplement patient care, a group of health professionals at the Hospital Clínic de Barcelona created Forumclínic, an online networking website in Spanish and Catalan. In 2008, seven web- and DVD-based chronic disease portals (Diabetes, Schizophrenia, Cardiac Ischemia, COPD, Depression, Breast Cancer and cardiovascular risk) were created with the following resources: multimedia patient education material; physician-specialist transcribed research (articles) news; an open question forum (for clinician-user and user-to-user interaction); and patient and specialist interview videos on the progress of disease, common diagnosis and treatment procedures; and information on the best or worst prognoses. Using data from Google Analytics, server logs were used to observe online behaviour patterns and user postings. This data combined with a mixed methods approach were used to evaluate the development of a virtual community (VC). A virtual community was developed when the number of forum visits was greater than those in the disease portal (definition). While nearly half of the visitors were from the Americas, the Schizophrenia, Breast Cancer, Depression and COPD forums met the criteria for and developed a virtual community. However, the Diabetes and Cardiac Ischemia forums did not reach VC status. It is also interesting to note that users in their late thirties and early forties were primarily women. The development of four virtual communities in Forumclínic seems to support the self-care needs of virtual patients. Users also reported appreciating the increased interaction with experts online and commonly collaborated with the forum moderator to guide and support other users with similar conditions in managing their health. Thence, we believe that Forumclínic is a good model to complement traditional patient care. A formal evaluation of this adjuvant form of care, from both the users' and moderators' perspective, is currently in its final stages.

[Catalan Primary Health Care as seen from Brasilian health reform]. / La atención primaria catalana vista desde la reforma brasileña de salud.

Brazil has begun a reform of the Single Health System oriented towards boosting Primary Healthcare (PHC), whilst Catalonia has a consolidated PHC model based on a reform that began in the 1980's. Both PHC models are assessed to mutually understand both experiences. In In Catalonia PHC has universal health cover and PHC is central to the region, compared to the more specialist initial orientation of the Brazilian reform, and the current development of the Family Health Program which has reached a cover of 54%. Brazil is considering including the capacity to personally choose a doctor in its model, team management autonomy, variable salaries linked to quality objectives, and the shared medical records that exist in Catalonia. Whilst Catalonia should benefit from the greater community orientation there is in Brazil.

New patient interaction formulas in Spanish and Catalan: a case for forumclinic.

On February of 2007, forumclinic (www.forumclinic.org) was launched. This free, first of its kind, collection of Evidence-Based Medicine chronic disease monograph resources, is targeted for Spanish and Catalan-speaking patients. Information is available both online (i.e., forums) and offline (i.e., DVDs) and is culturally sensitive to the target population. Forumclinic has cantered on active patient engagement through the use of disease-specialist moderated forms. Both the Health on the Net Foundation and the Medical Doctors College of Barcelona have accredited forumclinic as a quality, unbiased, health site that is based on the WHO premise of Social Determinants of Health - increased health education and interaction leads to better health. This descriptive paper will introduce forumclinic and describe the patient/user response to date.

Population and primary health-care team characteristics explain the quality of the service.

OBJECTIVES: To identify the characteristics of the primary health-care (PHC) team's structure and of the assigned population affecting service quality dimensions, and to check whether the PHC team's performance varies when assessing the service quality using crude values or those adjusted by the structural factors that affect it. RESEARCH DESIGN: Cross-sectional descriptive study. SUBJECTS: 213 Catalan PHC teams. MEASUREMENTS: Service quality indicators measured in three dimensions: (1) access and physician-patient relationship; (2) team coordination and (3) evidence-based practice. The PHC team structural factors studied are: experience, setting (urban or rural), geographical dispersion, teaching activities and managerial structure. The catchment population characteristics analysed are: age, socio-economic level, mortality, and the proportion of the population that are immigrants. RESULTS: Access and physician-patient relationship dimension were not affected by the studied structural factors. Team coordination improved in rural teams and in those providing care for older populations. Evidence-based practice was found to be higher in teaching teams, in more experienced teams and in those attending populations with a lower socio-economic level. Adjusted service quality indicator values substantially modify the PHC team quality ranking carried out on the basis of its crude values, especially in the team coordination and evidence-based practice dimensions. CONCLUSIONS: A fair evaluation of PHC team performance must be based on its health-care service quality indicators adjusted for setting, age and socio-economic level of the catchment population and for the team's experience and teaching activities.

Effects of undocumented immigrants exclusion from health care coverage in Spain.

BACKGROUND: In 2012 the Spanish government passed Royal Decree-Law 16/2012 (RDL) aimed at containing public expenditure in response to the economic crisis. This RDL redefined just who would be entitled to public health care. As a result, a large proportion of undocumented immigrants in Spain were excluded from basic publicly financed health care with access only being granted under particular circumstances (emergency care, maternal care, children under 18, asylum seekers and victims of human trafficking). AIM: The aims of this paper are to identify the specific traits of this policy, review its impact on health and health care access, and to evaluate its economic impact. RESULTS: Most political parties and health professional groups opposed the RDL, and a large number of Spanish regions either declined to apply it or opted to apply it partially. To date, the RDL has had a considerable impact on the access of undocumented immigrants to public health care, with evidence suggesting that approximately 870,000 people have been excluded. A slight increase in infectious diseases has been reported, albeit not as high as originally predicted, and recent evidence points to an increase in mortality among this population subgroup. CONCLUSIONS: Regional legislation favouring the coverage of undocumented immigrants might have acted as a counterweight and thus contained the negative health effects in this population subgroup. But the Constitutional Court invalidated all regional arrangements obliging regions to comply with the RDL.

Validity of an adaptation of the Framingham cardiovascular risk function: the VERIFICA Study.

BACKGROUND: To assess the reliability and accuracy of the Framingham coronary heart disease (CHD) risk function adapted by the Registre Gironí del Cor (REGICOR) investigators in Spain. METHODS: A 5-year follow-up study was completed in 5732 participants aged 35-74 years. The adaptation consisted of using in the function the average population risk factor prevalence and the cumulative incidence observed in Spain instead of those from Framingham in a Cox proportional hazards model. Reliability and accuracy in estimating the observed cumulative incidence were tested with the area under the curve comparison and goodness-of-fit test, respectively. RESULTS: The Kaplan-Meier CHD cumulative incidence during the follow-up was 4.0% in men and 1.7% in women. The original Framingham function and the REGICOR adapted estimates were 10.4% and 4.8%, and 3.6% and 2.0%, respectively. The REGICOR-adapted function's estimate did not differ from the observed cumulated incidence (goodness of fit in men, p = 0.078, in women, p = 0.256), whereas all the original Framingham function estimates differed significantly (p<0.001). Reliabilities of the original Framingham function and of the best Cox model fit with the study data were similar in men (area under the receiver operator characteristic curve 0.68 and 0.69, respectively, p = 0.273), whereas the best Cox model fitted better in women (0.73 and 0.81, respectively, p<0.001). CONCLUSION: The Framingham function adapted to local population characteristics accurately and reliably predicted the 5-year CHD risk for patients aged 35-74 years, in contrast with the original function, which consistently overestimated the actual risk.

Impact of economic incentives on quality of professional life and on end-user satisfaction in primary care.

BACKGROUND: A new economic incentive scheme based on (i) quality of care objectives for physicians, and (ii) professional development for both physicians and nurses, was introduced in primary care teams. OBJECTIVE: To assess weather the implementation of these economic incentive schemes has had an impact on the quality of professional life (QPL) of both physicians and nurses and on end-user satisfaction. METHODS: Before-after study. Participants are 257 primary care teams in Catalonia, Spain, in the period 2002-2003. QPL and end-user satisfaction were used as outcome measures. RESULTS: QPL was improved in terms of the dimension "perception of support from the management structure" among physicians (4.897 versus 5.220; p<0.001) as well as nurses (5.272 versus 5.638; p<0.001). Further, physicians perceived an increase in the dimension "demands made upon them" (6.124 versus 6.364; p<0.001), differently from the nurses group (5.8191 versus 5.929; p=0.063). Overall, user satisfaction did not vary significantly, although a positive relationship was found between "perception of support from the management structure" and user satisfaction among nurses (beta=0.078, p=0.007), and a negative relationship between "demands made upon them" and user satisfaction in the case of physicians (beta=-0.057, p=0.011). CONCLUSIONS: Incentives related to quality of care annual targets may increase physicians' perception of burden and it may have a negative impact on consumer satisfaction. Incentives on long-term professional development seem to be related to an increase in professionals' perception of support from the management structure. Among nurses, this increase is related to an improvement of user satisfaction.

[Primary health care product defined by health professionals and users]. / El producto de la atención primaria definido por profesionales y usuarios.

OBJECTIVE: To identify the components of the primary health care (PHC) product defined by health professionals and users in order to establish indicators for evaluation. METHODS: Qualitative methodology was used with group techniques: a nominal group (health professionals) and focus groups (users). The study was performed in PHC centers in Catalonia (Spain). There were 7 groups: a) family physicians and pediatricians; b) nurses and social workers; c) staff from admissions units and customer services; d) other medical specialists; e) users; f) managers, pharmacists, pharmacologists, and technicians. Participants responded to the question: "Which features should be evaluated in the services that should be provided by PHC?". A content analysis was performed. Textual data were broken down into units and then grouped into categories, following analogy criteria. The interpretative context of the research team was taken into account. RESULTS: Health professionals and users identified 4 dimensions of the PHC product, coinciding with its basic attributes: a) access to services; b) coordination and continuity of the PHC teams with other levels of healthcare; c) relationship between health professionals and users, and d) scientific-technical quality of the PHC teams and the portfolio of services. Equity, satisfaction and efficiency appeared as keystones in all the components of the product identified. CONCLUSION: There was broad agreement in the product definition among health professionals and users. The relationship between health professionals and patients was a key element in all groups. The four dimensions should be included in the evaluation of PHC teams.