[Primary care evaluation of the hypertensive patient management in specialized care after derivation (DERIVA-2 Study)]. / Valoración desde atención primaria del manejo del hipertenso en atención especializada (estudio DERIVA-DOS).

INTRODUCTION: To know the opinion/evaluation of the primary care physicians (PCPH) of the received information about patients that were attended in specialized care (SC). DESIGN: Cross-sectional study. LOCATION: Performed nationwide in primary care centers. PARTICIPANTS: Researchers from the primary care network. METHODS: We used the SEH-LELHA derivation criteria guidelines, plus an ad hoc survey that included demographic and anthropometric data, blood pressure levels, and the main reason for derivation to SC at the baseline and final (post-derivation) visit. In addition, time deployed for the study of every patient, changes in diagnosis and treatment, type of follow-up, issues throughout the derivation process and assessment of the medical referred to the PCPH were evaluated. RESULTS: With participation of 578 researchers from primary, the study included 1715 patients aged 60.7±13.3years, 62.7% male. Patients were taking 2.3±1.2 (range 0-10) antihypertensive drugs pre-referral and 2.5±1.2 (0-9) after derivation. Blood pressure levels changed from 166±21.6 /97.7±12.6mmHg to 143±14.4 /85.5±10.5mmHg. The number of controlled patients (BP<140 and <90mmHg) increased from 5.8% to 32.2%. Time between pre- and post-derivation visit was 72±64days (median 57days, IQ26-99). The PCPH received a medical report in 80.3% of cases, 76.9% with an explanation of the results of the complementary tests, 75.8% with additional information or a reasoning of treatment and in 71% of cases information about the patient future management. 63% of PCPH were fully agreed with the management of the specialist, 29% agree and 2% strongly disagree. The derivation was evaluated as effective or very effective in 86% of patients and no effective in 9%. CONCLUSIONS: Communication between AE and SC in HTA is valued satisfactorily by MAP. However there is still room for improvement in the process.

Practical application of brief cognitive tests.

INTRODUCTION: Brief cognitive tests (BCT) may help detect cognitive impairment (CI) in the clinical setting. Several BCT have been developed and/or validated in our country, but we lack specific recommendations for use. DEVELOPMENT: Review of studies on the diagnostic accuracy of BCT for CI, using studies conducted in Spain with BCT which take less than 20 min. We provide recommendations of use based on expert consensus and established on the basis of BCT characteristics and study results. CONCLUSION: The Fototest, the Memory Impairment Screen (MIS) and the Mini-Mental State Examination (MMSE) are the preferred options in primary care; other BCT (Clock Drawing Test [CDT], test of verbal fluency [TVF]) may also be administered in cases of negative results with persistent suspected CI or concern (stepwise approach). In the specialised care setting, a systematic assessment of the different cognitive domains should be conducted using the Montreal Cognitive Assessment, the MMSE, the Rowland Universal Dementia Assessment, the Addenbrooke's Cognitive Examination, or by means of a stepwise or combined approach involving more simple tests (CDT, TVF, Fototest, MIS, Memory Alteration Test, Eurotest). Associating an informant questionnaire (IQ) with the BCT is superior to the BCT alone for the detection of CI. The choice of instruments will depend on the patient's characteristics, the clinician's experience, and available time. The BCT and IQ must reinforce - but never substitute - clinical judgment, patient-doctor communication, and inter-professional dialogue.

[The management of atrial fibrillation and characteristics of its current care in outpatients. AFABE observational study]. / El circuito asistencial de la fibrilación auricular en pacientes ambulatorios: estudio observacional Audit fibrilación auricular en el Baix Ebre.

AIM: To provide insights into the characteristics and management of outpatients when their atrial fibrillation (AF) was first detected: diagnosis, treatment and follow-up in the context of the public health system. DESIGN: AFABE is an observational, multicentre descriptive study with retrospective data collection relating to the practice patterns, management and initial strategies of treatment of patients with diagnosed AF in the context of primary care, emergency and cardiologists of the public health system. SETTING: Primary and Specialist care. Baix Ebre region. Tarragona. Spain. SUBJECTS: A representative sample of 182 subjects > 60-year-old with AF who have been randomized, recruited among the registered patients with AF in 22 primary care centres in the area of the study. MESUREMENTS: Demographic data, comorbidities (AF), CHA2DS2-VASc and HAS_BLED scores, and practice patterns results between Primary Care and referral services. RESULTS: A total of 182 patients were included (mean age 78.5 SD:7.3 years; 50% women). Most patients (68.3% 95%CI; 60.3-76.3) had the first contact in Primary Care, of which 56.3% (95%CI; 45.2-66.0) were sent to Hospital Emergency Department where 72.7% (95%CI: 63.5-79.0) of the oral anticoagulation and 58.4% (95%CI: 49.4-66.9) of antiarrhytmic treatments were started. More than half (55.9%:95%CI; 47.2-64.7, of patients with permanent AF were followed-up by the Cardiology department. CONCLUSIONS: Most patients with newly diagnosed AF made a first contact with Primary Care, but around half were sent to Hospital Emergency departments, where they were treated with an antiarrhythmic and/or oral anticoagulation.

[Clinical stages of patients with Alzheimer disease treated in specialist clinics in Spain. The EACE study]. / Estadio evolutivo de los pacientes con enfermedad de Alzheimer que acuden a la consulta especializada en España. Estudio EACE.

INTRODUCTION: The diagnostic paradigm of Alzheimer disease (AD) is changing; there is a trend toward diagnosing the disease in its early stages, even before the complete syndrome of dementia is apparent. The clinical stage at which AD is usually diagnosed in our area is unknown. Therefore, the purpose of this study is to describe the clinical stages of AD patients at time of diagnosis. METHODS: Multicentre, observational and cross-sectional study. Patients with probable AD according to NINCDS-ARDRA criteria, attended in specialist clinics in Spain, were included in the study. We recorded the symptom onset to evaluation and symptom onset to diagnosis intervals and clinical status of AD (based on MMSE, NPI questionnaire, and CDR scale). RESULTS: Participants in this study included 437 specialists representing all of Spain's autonomous communities and a total of 1,707 patients, of whom 1,694 were included in the analysis. Mean MMSE score was 17.6±4.8 (95% CI:17.4-17.9). Moderate cognitive impairment (MMSE between 10 and 20) was detected in 64% of the patients, and severe cognitive impairment (MMSE<10) in 6%. The mean interval between symptom onset and the initial primary care visit was 10.9±17.2 months (95% CI:9.9-11.8), and the interval between symptom onset and diagnosis with AD was 28.4±21.3 months. CONCLUSIONS: Results from the EACE show that most AD patients in our area have reached a moderate clinical stage by the time they are evaluated in a specialist clinic.

Burnout in Specialized Care Nurses during the First COVID-19 Outbreak in Spain.

Background: One of the most outstanding consequences of the pandemic is the impact it had on the mental health of nurses caring for patients with COVID-19 in specialised services. Aim: The aim was to analyse the burnout levels of nursing professionals during the COVID-19 pandemic in specialised care and their relationship with variables of the socio-occupational context. Method: This was a quantitative, descriptive, observational, cross-sectional study, which included a sample of 355 nursing professionals. The instrument used was a questionnaire (Maslach Burnout Inventory Human Services Survey (MBI-HSS)). Results: A mean score of 27.44 (SD = 12.01) was obtained in the subscale "Emotional exhaustion"; in "Depersonalisation", the mean score was 7.26 (SD = 6.00); and, finally, in "Personal fulfilment", the mean score was 38.27 (SD = 7.04). Statistically significant differences were found in the subscale "Emotional exhaustion", which is higher in women than in men. The subscale "Personal Accomplishment" was higher in the age group 51-65 years. Regarding the "Depersonalisation" subscale, statistically significant differences were found with respect to the years of experience in the current service, which is higher in the group aged 39 years or more. Conclusion: Intervention programmes are required in healthcare systems to improve the emotional well-being of nursing professionals.

[Teledermatology in the Health Center West Area of Granada: From primary to specialized care]. / Teledermatología en el Área Sanitaria Centro Oeste de Granada: desde atención primaria a especializada.

INTRODUCTION: Teledermatology (TD) is a health tool based on the application of information and communication technologies (ICT) for the care of skin diseases at a distance, allowing a better connection between primary care professionals (PCP) and specialized care. The objective of this study was to analyze the characteristics of the teleconsultations made to our service in a period of 2years (January 1, 2018 to December 31, 2019). MATERIAL AND METHODS: The data was obtained from a TD system with dermoscopy that allows teleconsultations to be carried out asynchronously. Data were analyzed over 24months. The variables studied were the health centre of origin, the diagnostic suspicion of the PCP, the time and type of response, and the clinical judgment issued by the dermatologist. RESULTS: Between January 1, 2018 and December 31, 2019, a total of 3,294 teleconsultations were received. 24.76% were referred to the dermatology consultation, while 25.63% required subsequent follow-up electronically. The most frequent diagnostic suspicion by the PCP was that of benign pathology (54.71%). The most frequent dermatological clinical judgment was that of seborrheic keratosis (20.19%), followed by actinic keratosis (14.02%), acquired common melanocytic nevi (13.24%) and basal cell carcinoma (8.98%). CONCLUSIONS: The TD system is a useful tool that allowed a quick response to a high percentage of consultations, helping to avoid unnecessary referrals and easy communication between primary and specialized care. It also allows prioritizing those patients with malignant tumour pathology.

Development of the professional role of diabetes nurses in specialised diabetes and primary care in Catalonia.

OBJECTIVES: The aim of this study was to describe therapeutic education programmes in diabetes in Catalonia and the differences according to the healthcare setting in which the patients are attended (primary care [PC] and specialised diabetes care [SDC]). METHOD: We performed a descriptive, cross-sectional, comparative study of diabetes nurses (DN) in SDC and PC in Catalonia. The sample was obtained from all the DN in SDC and a randomised cluster sample of DN in PC. The questionnaire of the Study of European Nurses in Diabetes (SEND) validated in Spanish was used. RESULTS: A total of 287 questionnaires were analysed (24.3% SDC and 75.6% PC). More training in diabetes through masters, postgraduate courses and continuing education was observed in SDC (p<0.001) as well as structured, written, education programmes and the combination of individual and group education strategies (p<0.05). The roles of educator, consultant, researcher, manager, liaison or collaborator and innovator and the telematic follow-up of patients was also more developed in SDC (p<0.05). The grade of work satisfaction was elevated in both groups. CONCLUSIONS: (1) Nursing professionals in SDC assume more roles of specialised clinical nursing and also have more training in diabetes and therapeutic education than PC professionals. (2) Professionals in SDC work with a greater proportion of structured diabetes therapeutic education programmes although this should improve in both settings. According to the results obtained and the scientific evidence currently available, the training of DN working in the care of people with diabetes should be accredited in order to increase the use of structured programmes and investigation by DNs in both healthcare settings.

The use of health care services in the Great Recession: evaluating inequalities in the Spanish context.

OBJECTIVE: To analyse the effect of the Great Recession (2008) on primary care (PC) and secondary care (SC) inequalities in Spain. METHOD: Repeated cross-sectional study using Spanish Health Surveys from 2001 to 2017 (n=139,566). Prevalence of PC and SC utilization were calculated standardized by age. Chi square tests for trend were conducted to explore the evolution. We performed logistic regression analyses adjusted by the Andersen's model of demand for care to explore inequalities prior to, during and following the recession. All the analyses were stratified by sex. RESULTS: Healthcare use trends changed from a rapid increase in the pre-recession period to a plateau during the recession and a decrease in the post-recession period. Healthcare use was higher in women (PC: 15.8% to 32.5%; SC: 8.2% to 16.2%) than in men (PC: 11.3% to 24.1%; SC: 5.4% to 11.6%) and the gender gap increased. During the recession the likelihood of PC use was higher in disadvantaged groups, while SC had greater usage amongst more advantaged social groups. Inequalities in SC use increased during the recession and could not be attributed to factors of need. CONCLUSIONS: Healthcare use trends changed as a result of the recession. There are socioeconomic inequalities in the use of PC and SC in Spain, which increased in secondary care, during the recession and in the post-recession period. It is necessary to take into account socioeconomic determinants in health planning, in order to achieve equity in healthcare services.

[Map of resources and healthcare needs for patients with dyslipidaemia in Spain: The MADI study]. / Mapa de recursos y necesidades asistenciales del paciente dislipidémico en España: estudio MADI.

INTRODUCTION: Dyslipidaemia is a major modifiable determining factor of vascular risk and, despite this, a significant number of patients do not achieve lipid goals. The aim of this study is to describe the resources and current needs in clinical practice in Spain, through an analysis of management, organisation and the patient care circuit of dyslipidaemia patient. METHODS: A descriptive, cross-sectional, multicentre study, using a questionnaire, was conducted on physicians, 266 in primary care (PC) and 258 in specialised care (SC), who attended patients with dyslipidaemia in hospitals and centres within the National Health System. Probabilistic analyses were performed, stratifying by care-level, existence of a lipid unit (LU), and geographic area. RESULTS: Observed differences were mostly due to geographic location, rather than the existence of LU in the referral hospitals. Most system deficiencies were found in the southern provinces of the country. Nearly all primary care physicians declared that they diagnose, manage and control dyslipidaemia patients, but a general agreement was lacking for diagnostic and referral criteria. The scarce use of a shared protocol between PC and SC showed evidence of poor coordination between health care providers. Furthermore, there was a remarkably low proportion of patients receiving health care education for their disease. CONCLUSIONS: This study emphasises the need to identify weaknesses in the dyslipidaemia patient care circuit, and to perform the appropriate remedial actions, in particular, to promote coordination between levels of care and to foster patient education about their disease.

[Determinants of the use of different healthcare levels in the General System of Social Security in Health in Colombia and the Unified Health System in Brazil]. / Determinantes del uso de distintos niveles asistenciales en el Sistema General de Seguridad Social en Salud y Sistema Único de Salud en Colombia y Brasil.

OBJECTIVE: To compare the use of different healthcare levels, and its determinants, in two different health systems, the General System of Social Security in Health (GSSSH) and the Unified Health System (UHS) in municipalities in Colombia and Brazil. METHODS: A cross-sectional study was carried out, based on a population survey in two municipalities in Colombia (n=2163) and two in Brazil (n=2155). Outcome variables consisted of the use of primary care services, outpatient secondary care services, and emergency care in the previous 3 months. Explanatory variables were need and predisposing and enabling factors. Bivariate and multivariate logistic regression analyses were performed by healthcare level and country. RESULTS: The determinants of use differed by healthcare level and country: having a chronic disease was associated with a greater use of primary and outpatient secondary care in Colombia, and was also associated with the use of emergency care in Brazil. In Colombia, persons enrolled in the contributory scheme more frequently used the services of the GSSSH than persons enrolled with subsidized contributions in primary and outpatient secondary care and more than persons without insurance in any healthcare level. In Brazil, the low-income population and those without private insurance more frequently used the UHS at any level. In both countries, the use of primary care was increased when persons knew the healthcare center to which they were assigned and if they had a regular source of care. Knowledge of the referral hospital increased the use of outpatient secondary care and emergency care. CONCLUSIONS: In both countries, the influence of the determinants of use differed according to the level of care used, emphasizing the need to analyze healthcare use by disaggregating it by level of care.