A Technological Tool Aimed at Self-Care in Patients With Multimorbidity: Cross-Sectional Usability Study.

BACKGROUND: Information and communication technologies (ICTs) have been positioned as useful tools to facilitate self-care. The interaction between a patient and technology, known as usability, is particularly important for achieving positive health outcomes. Specific characteristics of patients with chronic diseases, including multimorbidity, can affect their interaction with different technologies. Thus, studying the usability of ICTs in the field of multimorbidity has become a key element to ensure their relevant role in promoting self-care. OBJECTIVE: The aim of this study was to analyze the usability of a technological tool dedicated to health and self-care in patients with multimorbidity in primary care. METHODS: A descriptive observational cross-sectional usability study was performed framed in the clinical trial in the primary care health centers of Madrid Health Service of the TeNDER (Affective Based Integrated Care for Better Quality of Life) project. The TeNDER technological tool integrates sensors for monitoring physical and sleep activity along with a mobile app for consulting the data collected and working with self-management tools. This project included patients over 60 years of age who had one or more chronic diseases, at least one of which was mild-moderate cognitive impairment, Parkinson disease, or cardiovascular disease. From the 250 patients included in the project, 38 agreed to participate in the usability study. The usability variables investigated were effectiveness, which was determined by the degree of completion and the total number of errors per task; efficiency, evaluated as the average time to perform each task; and satisfaction, quantified by the System Usability Scale. Five tasks were evaluated based on real case scenarios. Usability variables were analyzed according to the sociodemographic and clinical characteristics of patients. A logistic regression model was constructed to estimate the factors associated with the type of support provided for task completion. RESULTS: The median age of the 38 participants was 75 (IQR 72.0-79.0) years. There was a slight majority of women (20/38, 52.6%) and the participants had a median of 8 (IQR 7.0-11.0) chronic diseases. Thirty patients completed the usability study, with a usability effectiveness result of 89.3% (134/150 tasks completed). Among the 30 patients, 66.7% (n=20) completed all tasks and 56.7% (17/30) required personalized help on at least one task. In the multivariate analysis, educational level emerged as a facilitating factor for independent task completion (odds ratio 1.79, 95% CI 0.47-6.83). The median time to complete the total tasks was 296 seconds (IQR 210.0-397.0) and the median satisfaction score was 55 (IQR 45.0-62.5) out of 100. CONCLUSIONS: Although usability effectiveness was high, the poor efficiency and usability satisfaction scores suggest that there are other factors that may interfere with the results. Multimorbidity was not confirmed to be a key factor affecting the usability of the technological tool. TRIAL REGISTRATION: Clinicaltrials.gov NCT05681065; https://clinicaltrials.gov/study/NCT05681065.

Trends in hospitalisation for urinary tract infection in adults aged 18-65 by sex in Spain: 2000 to 2015.

OBJECTIVE: To analyse trends in urinary tract infection (UTIs) hospitalisation among patients adults 18-65 aged in Spain from 2000-2015. METHODS: Retrospective observational study using the Spanish Hospitalisation Minimum Data Set (CMBD), with codifications by the International Classification of Diseases (ICD-9). Variables: Type of UTIs (pyelonephritis, prostatitis, cystitis and non-specific-UTIs), sex, age (in 5 categories: 18-49 and 50-64 years in men, and 18-44, 45-55 and 56-64 years in women), comorbidity, length of stay, costs and mortality associated with admission. The incidence of hospitalisation was studied according to sex, age group and type of UTIs per 100,000. Trends were identified using Joinpoint regression. RESULTS: From 2000-2015, we found 259,804 hospitalisations for UTIs (51.6% pyelonephritis, 7.5% prostatitis, 0.6% cystitis and 40.3% non-specific UTIs). Pyelonephritis predominated in women and non-specific UTIs in men. The hospital stay and the average cost (2,160 EUR (IQR 1,7872,540 were greater in men. Overall mortality (0.4%) was greater in non-specific UTIs. More women were admitted (rates of 79.4 to 81.7) than in men (30.2 to 41). The greatest increase was found in men aged 50-64 years (from 59.3 to 87). In the Joinpoint analysis, the incidence of pyelonephritis increased in women [AAPC 2.5(CI 95% 1.6;3.4)], and non-specific UTIs decreased [AAPC -2.2(CI 95% -3.3;-1.2)]. Pyelonephritis decreased in men [AAPC -0.5 (CI 95% -1.5;0.5)] and non-specific UTIs increased [AAPC 2.3 (CI 95% 1.9;2.6)] and prostatitis increased [AAPC 2.6 (CI 95% 1.4;3.7)]. CONCLUSIONS: The urinary infection-related hospitalisation rate in adults in Spain increased during the period 2000-2015. Pyelonephritis predominated in women and non-specific UTIs in men. The highest hospitalisation rates occurred in the women but the greatest increase was found in men aged 65-74. The lenght of stay and cost were higher in men.

Functional social support: A systematic review and standardized comparison of different versions of the DUFSS questionnaire using the EMPRO tool.

BACKGROUND: Functional social support is one of the most established predictors of health, and the Duke-UNC Functional Social Support Questionnaire (DUFSS) is one of the most commonly used instruments to measure this parameter. The objective of this study is to systematically review the available evidence on the psychometric and administration characteristics of the different versions of the DUFSS and perform a standardized assessment though to a specifically designed tool. METHODS: A systematic review was performed in the PubMed/MEDLINE, SCOPUS, WOS and SCIELO databases. All articles that contained information on the development process of the instrument, the psychometric properties and aspects related to its administration were included, without restrictions based on publication date, language, or the version of the questionnaire that was studied. The selection and extraction procedure were carried out by two researchers. The articles finally included were peer-reviewed through a standardised assessment using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool. PROSPERO registration number: CRD42022342977. RESULTS: A total of 54 articles were identified. After eliminating duplicates and screening articles based on the selection criteria, 15 studies that examined the DUFSS questionnaire resulting in 4 different versions: 3 articles obtained the 8-item version; 11 the 11-item version; and a single article obtained two versions, the 14-item version and the 5-item version. At least 60% of them did so in a young adult population, predominantly female and with a medium-low socio-economic level or with characteristics of social vulnerability. The EMPRO evaluation showed that the 11-item version (54.01 total score) was the only one that had been studied on all recommended attributes and had higher total scores than the other versions: 8 items (36.31 total score), 14 items (27.48 total score) and 5 items (23.81 total score). This difference appears in all attributes studied, with the highest scores in "reliability (internal consistency)" and "validity". CONCLUSIONS: Of the 4 versions identified in the DUFSS questionnaire, the 11-item version was found to be optimal based on the EMPRO standardized tool. Although, a priori, we could prioritise its use in epidemiological studies over the other versions, it should be noted that this version should also be used with caution because there are attributes that have not been studied.

Traumatic stress symptoms among Spanish healthcare workers during the COVID-19 pandemic: a prospective study.

AIM: To investigate the occurrence of traumatic stress symptoms (TSS) among healthcare workers active during the COVID-19 pandemic and to obtain insight as to which pandemic-related stressful experiences are associated with onset and persistence of traumatic stress. METHODS: This is a multicenter prospective cohort study. Spanish healthcare workers (N = 4,809) participated at an initial assessment (i.e., just after the first wave of the Spain COVID-19 pandemic) and at a 4-month follow-up assessment using web-based surveys. Logistic regression investigated associations of 19 pandemic-related stressful experiences across four domains (infection-related, work-related, health-related and financial) with TSS prevalence, incidence and persistence, including simulations of population attributable risk proportions (PARP). RESULTS: Thirty-day TSS prevalence at T1 was 22.1%. Four-month incidence and persistence were 11.6% and 54.2%, respectively. Auxiliary nurses had highest rates of TSS prevalence (35.1%) and incidence (16.1%). All 19 pandemic-related stressful experiences under study were associated with TSS prevalence or incidence, especially experiences from the domains of health-related (PARP range 88.4-95.6%) and work-related stressful experiences (PARP range 76.8-86.5%). Nine stressful experiences were also associated with TSS persistence, of which having patient(s) in care who died from COVID-19 had the strongest association. This association remained significant after adjusting for co-occurring depression and anxiety. CONCLUSIONS: TSSs among Spanish healthcare workers active during the COVID-19 pandemic are common and associated with various pandemic-related stressful experiences. Future research should investigate if these stressful experiences represent truly traumatic experiences and carry risk for the development of post-traumatic stress disorder.

Burden in caregivers of primary care patients with dementia: influence of neuropsychiatric symptoms according to disease stage (NeDEM project).

BACKGROUND: Caregiver burden is related to personal factors and patient characteristics and is greater when neuropsychiatric symptoms (NPSs) are present. OBJECTIVE: Estimate the prevalence of burden among caregivers of dementia patients and its association with NPSs and identify NPSs causing greater caregiver distress according to dementia stage. METHODS: A cross-sectional observational study in caregivers of noninstitutionalized dementia patients was conducted. Caregiver variables were sociodemographic, time of care, NPS-associated distress based on the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D) and burden based on the Zarit Burden Interview (ZBI). Patient variables were time since disease onset, Global Deterioration Scale (GDS) disease stage, functional assessment and NPS presence and intensity according to the Neuropsychiatric Inventory (NPI). The mean ZBI score, prevalence of burden and NPI-D score with 95% CIs at each dementia stage were estimated. Factors associated with burden were identified by multivariate analysis. RESULTS: Of the 125 caregivers included, 77.6% were women, with a mean age of 60.7 (± 14.3) years; 78.4% (95%CI: 71.0; 86.0) experienced burden. The mean ZBI score was 12.3 (95%CI: 11.6; 12.9) and increased according to NPS number (p = 0.042). The NPSs causing the most burden were disinhibition (93.5%), irritability (87.3%) and agitation (86.1%). Agitation, apathy, and sleep disorders were the NPSs generating the greatest overall caregiver distress; depression (max NPI-D 1.9), hyperactivity (max NPI-D 2.1), and psychosis symptoms (max NPI-D 1.6) generated the greatest distress at stage GDS 3, stages GDS 4-5, and stages GDS 6-7, respectively. The NPI score (OR = 1.0, 95%CI 1.0; 1.1), intensity of irritability (OR = 1.2, 95%CI 1.0; 1.6), disinhibition (OR = 2.6, 95%CI 1.1; 5.8) and hyperactivity subsyndrome (OR = 1.1, 95%CI 1.0; 1.2) were associated with caregiver burden. Other associated factors were female gender (OR = 6.0, 95%CI 1.6; 22.8), ≥ 8 h daily care (OR = 5.6, 95%CI 1.4; 22.8), working outside the home (OR = 7.6, 95%CI 1.8; 31.8), living with the patient (OR = 4.5, 95%CI 1.1; 19.6), kinship (OR = 5.4, 95%CI 1.0; 28.2) and lower patient education (OR = 8.3, 95%CI 2.3; 30.3). CONCLUSIONS: The burden on caregivers of dementia patients is high and associated with NPS presence and intensity. Disinhibition and irritability caused the highest burden. Depression, hyperactivity and psychosis produce more distress in mild, mild-moderate and severe dementia, respectively.

Improvement in Quality of Life With the Use of a Technological System Among Patients With Chronic Disease Followed Up in Primary Care (TeNDER Project): Protocol for a Randomized Controlled Trial.

BACKGROUND: Among chronic diseases, cognitive, neurological, and cardiovascular impairments are becoming increasingly prevalent, generating a shift in health and social needs. Technology can create an ecosystem of care integrated with microtools based on biosensors for motion, location, voice, and expression detection that can help people with chronic diseases. A technological system capable of identifying symptoms, signs, or behavioral patterns could provide notification of the development of complications of disease. This would help the self-care of patients with chronic disease and save health care costs, promoting the autonomy and empowerment of patients and their caregivers, improving their quality of life (QoL), and providing health professionals with monitoring tools. OBJECTIVE: The main objective of this study is to evaluate the effectiveness of a technological system (the TeNDER system) to improve quality of life in patients with chronic diseases: Alzheimer disease, Parkinson disease, and cardiovascular disease. METHODS: A multicenter, randomized, parallel-group clinical trial will be conducted with a follow-up of 2 months. The scope of the study will be the primary care health centers of the Community of Madrid belonging to the Spanish public health system. The study population will be patients diagnosed with Parkinson disease, Alzheimer disease, and cardiovascular disease; their caregivers; and health professionals. The sample size will be 534 patients (380 in the intervention group). The intervention will consist of the use of the TeNDER system. The system will monitor the patients by means of biosensors, and their data will be integrated into the TeNDER app. With the information provided, the TeNDER system will generate health reports that can be consulted by patients, caregivers, and health professionals. Sociodemographic variables and technological affinity will be measured, as will views on the usability of and satisfaction with the TeNDER system. The dependent variable will be the mean difference in QoL score between the intervention and control groups at 2 months. To study the effectiveness of the TeNDER system in improving QoL in patients, an explanatory linear regression model will be constructed. All analyses will be performed with the 95% CI and robust estimators. RESULTS: Ethics approval for this project was received on September 11, 2019. The trial was registered on August 14, 2020. Recruitment commenced in April 2021, and the expected results will be available during 2023 or 2024. CONCLUSIONS: This clinical trial among patients with highly prevalent chronic illnesses and the people most involved in their care will provide a more realistic view of the situation experienced by people with long-term illness and their support networks. The TeNDER system is in continuous development based on a study of the needs of the target population and on feedback during its use from the users: patients, caregivers, and primary care health professionals. TRIAL REGISTRATION: ClinicalTrials.gov NCT05681065; https://clinicaltrials.gov/ct2/show/NCT05681065. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47331.

Validation of diagnosis of acute myocardial infarction and stroke in electronic medical records: a primary care cross-sectional study in Madrid, Spain (the e-MADVEVA Study).

OBJECTIVES: To validate the diagnoses of acute myocardial infarction (AMI) and stroke recorded in electronic medical records (EMR) and to estimate the population prevalence of both diseases in people aged ≥18 years. DESIGN: Cross-sectional validation study. SETTING: 45 primary care centres. PARTICIPANTS: Simple random sampling of diagnoses of AMI and stroke (International Classification of Primary Care-2 codes K75 and K90, respectively) registered by 55 physicians and random age-matched and sex-matched sampling of the records that included in primary care EMRs in Madrid (Spain). PRIMARY AND SECONDARY OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values and overall agreement were calculated using the kappa statistic. Applied gold standards were ECGs, brain imaging studies, hospital discharge reports, cardiology reports and neurology reports. In the case of AMI, the ESC/ACCF/AHA/WHF Expert Consensus Document was also used. Secondary outcomes were the estimated prevalence of both diseases considering the sensitivity and specificity obtained (true prevalence). RESULTS: The sensitivity of a diagnosis of AMI was 98.11% (95% CI, 96.29 to 99.03), and the specificity was 97.42% (95% CI, 95.44 to 98.55). The sensitivity of a diagnosis of stroke was 97.56% (95% CI, 95.56 to 98.68), and the specificity was 94.51% (95% CI, 91.96 to 96.28). No differences in the results were found after stratification by age and sex (both diseases). The prevalence of AMI and stroke was 1.38% and 1.27%, respectively. CONCLUSION: The validation results show that diagnoses of AMI and stroke in primary care EMRs constitute a helpful tool in epidemiological studies. The prevalence of AMI and stroke was lower than 2% in the population aged over 18 years.

Adjusted morbidity groups and survival: a retrospective cohort study of primary care patients with chronic conditions.

BACKGROUND: Chronic conditions are one of the main determinants of frailty, functional disability, loss of quality of life and the number one cause of death worldwide. This study aimed to describe the survival of patients with chronic conditions who were followed up in primary care according to the level of risk by adjusted morbidity groups and to analyse the effects of sex, age, clinician and care factors on survival. METHODS: This was a longitudinal observational study of a retrospective cohort of patients with chronic conditions identified by the adjusted morbidity group stratifier of the electronic medical records in a primary health centre of the Region of Madrid, which has an assigned population of 18,107 inhabitants. The follow-up period was from June 2015 to June 2018. A description of survival according to the Kaplan-Meier method and Cox proportional hazards multivariate regression model was used to analyse the effects of sex, age, clinician and care factors. RESULTS: A total of 9,866 patients with chronic conditions were identified; 77.4% (7,638) had a low risk, 18.1% (1,784) had a medium risk, and 4.5% (444) had a high risk according to the adjusted morbidity groups. A total of 477 patients with chronic conditions died (4.8%). The median survival was 36 months. The factors associated with lower survival were age over 65 years (hazard ratio [HR] = 1.3; 95% confidence interval [CI] = 1.1-1.6), receiving palliative care (HR = 3.4; 95% CI = 2.6-4.5), high versus low risk level (HR = 2.4; 95% CI = 1.60-3.7), five chronic conditions or more (HR = 1.5; 95% CI = 1.2-2), complexity index (HR = 1.01; 95% CI = 1.02-1.04) and polymedication (HR = 2.6; 95% CI = 2.0-3.3). CONCLUSIONS: There was a gradual and significant decrease in the survival of patients with chronic conditions according to their level of risk as defined by adjusted morbidity groups. Other factors, such as older age, receiving palliative care, high number of chronic conditions, complexity, and polymedication, had a negative effect on survival. The adjusted morbidity groups are useful in explaining survival outcomes and may be valuable for clinical practice, resource planning and public health research.

Trends in hospitalization for urinary tract infection in the paediatric age group in the 2000-2015 period in Spain.

OBJECTIVE: To analyse the trends in hospital admissions related to urinary tract infection among children aged 0-14 years in Spain in the 2000-2015 period. METHODS: We conducted a retrospective observational study using the minimum basic hospital discharge dataset system of Spain, which applies the International Classification of Diseases, version 9 (ICD-9) coding system. We included every hospitalisation due to cystitis, pyelonephritis and unspecified UTI among children aged less than 15 years. We collected data on patient sex and age, type of discharge, main diagnosis, comorbidities, length of stay and overall cost. We calculated crude hospitalization rates per 1000 inhabitants aged less than 15 years and performed a joinpoint regression analysis to identify temporal trends. RESULTS: In the 2000-2015 period, there were 124 696 hospitalizations in children under 15 years. Of these patients, 72.97% were aged 0-1 year and 60.12% had a diagnosis of unspecified UTI, 39.27% of pyelonephritis, and 0.52% of cystitis. The crude rate of hospitalization due to UTI ranged from 1.24 in year 2000 to 0.98 in 2015. The rate of hospitalization was higher in female versus male patients. The joinpoint analysis found a decreasing trend in the rate of hospitalization due to UTI, with an average annual percent change (AAPC) of -1.5% (95% confidence interval [CI], -2.4 a -0.6). The largest decreases occurred in female patients (AAPC, -1.8; 95% CI, -2.5 a -1.0) and children aged 7-10 years (AAPC - 5.9; 95% CI, -6.7 a -5.2). CONCLUSIONS: The rate of hospitalization related to UTI in Spain in patients aged up to 14 years decreased during the 2000-2015 period. The highest hospitalization rates occurred in female patients and in the 0-to-1 year age group.

Prevalence and comorbidities of Sjogren's syndrome patients in the Community of Madrid: A population-based cross-sectional study.

OBJECTIVES: To estimate the prevalence, sociodemographic characteristics and comorbidities of Sjogren's syndrome (SS) patients in the Community of Madrid. METHODS: A population-based cross-sectional cohort of SS patients was derived from the information system for rare diseases in the Community of Madrid (SIERMA) and confirmed by a physician. The prevalence per 10,000 inhabitants among people aged ≥18years in June 2015 was calculated. Sociodemographic data and accompanying disorders were recorded. Univariate and bivariate analyses were performed. RESULTS: A total of 4,778 SS patients were confirmed in SIERMA; 92.8% were female, with a mean age of 64.3 (standard deviation=15.4) years. A total of 3,116 (65.2%) patients were classified as primary SS (pSS), and 1,662 (34.8%) as secondary SS (sSS). The prevalence of SS among people aged ≥18 years was 8.4/10,000 (95%Confidence interval [CI]=8.2-8.7). The prevalence of pSS was 5.5/10,000 (95%CI=5.3-5.7), and that of sSS was 2.8/10,000 (95%CI=2.7-2.9), with rheumatoid arthritis (20.3%) and systemic lupus erythematosus (8.5%) being the most prevalent associated autoimmune diseases. The most common comorbidities were hypertension (40.8%), lipid disorders (32.7%), osteoarthritis (27.7%) and depression (21.1%). The most prescribed medications were nonsteroidal anti-inflammatory drugs (31.9%), topical ophthalmic therapies (31.2%) and corticosteroids (28.0%). CONCLUSION: The prevalence of SS in the Community of Madrid was similar to the overall prevalence worldwide observed in previous studies. SS was more frequent in women in their sixth decade. Two out of every three SS cases were pSS, while one-third were associated predominantly with rheumatoid arthritis and systemic lupus erythematosus.

Sex and income inequalities in preventive services in diabetes.

BACKGROUND: Cancer preventive services (gynaecological cancer screening, colon cancer screening) and cardiometabolic screening are recommended by guidelines to individuals. People with diabetes were less likely to receive them than those without diabetes in some studies. OBJECTIVES: To analyse differences in the coverage of preventive services in people with diabetes compared to non-diabetic individuals and in people with diabetes according to sex and household income. METHODS: We analysed data collected from the European Health Interview Survey 2013-2015, including individuals aged 40-74 (n = 179,318), 15,172 with diabetes from 29 countries. The income of a household (HHI) was described in quintiles. The relationship between the coverage of preventive services (cardiometabolic, vaccination, cancer screening) and sociodemographic characteristics was analysed with multiple logistic regression. RESULTS: Women comprised 53.8% of the total and 40% were 60-74 years. People with diabetes compared to those without diabetes had higher reported coverage of cardiometabolic screening (98.4% vs. 90.0% in cholesterol measurement; 97.0% vs. 93.6% in blood pressure measurement), colorectal cancer screening (27.1% vs. 24.6%) but lower coverage of gynaecological cancer screening (mammography: 29.2% vs. 33.5%, pap smear test: 28.3% vs. 37.9%). Among diabetic patients, women were less likely to receive cholesterol screening (OR = 0.81; 95% CI: 0.72-0.91) and colon cancer screening (OR = 0.79; 95% CI: 0.73-0.86) compared to men. Being affluent was positively associated with receiving cardiometabolic screening and mammography in diabetic patients. CONCLUSION: People with diabetes reported higher coverage of preventive services except gynaecological cancer screening. Disparities were found in diabetes among women and less affluent individuals.

Inequalities in glycemic and multifactorial cardiovascular control of type 2 diabetes: The Heart Healthy Hoods study.

Aim: This study aimed to analyze glycemic control and multifactorial cardiovascular control targets in people with type 2 diabetes (T2DM) in primary care according to sex and socioeconomic status (SES). Materials and methods: This is an observational, cross-sectional, and multicenter study. We analyzed all the patients with T2DMM aged between 40 and 75 years in Madrid city (113,265) through electronic health records from 01 August 2017 to 31 July 2018. SES was defined by an area-level socioeconomic index stratified by quintiles (1st quintile: more affluent). Outcomes: Outcomes included glycemic control (HbA1c ≤ 7%), 3-factor cardiovascular control [HbA1c ≤ 7%, blood pressure (BP), < 140/90 mmHg, LDL < 100 mg/ml] and 4-factor control [HbA1c ≤ 7%, blood pressure (BP) < 140/90 mmHg, LDL < 100 mg/ml, and BMI < 30 kg/m2]. Multilevel logistic regression models analyzed factors associated with suboptimal glycemic control. Results: In total 43.2% were women. Glycemic control was achieved by 63% of patients (women: 64.2% vs. men: 62.4%). Being more deprived was associated with suboptimal glycemic control (OR: 1.20, 95% CI: 1.10-1.32); however, sex was not related (OR: 0.97, 95% CI: 0.94-1.01). The optimal 3-factor control target was reached by 10.3% of patients (women: 9.3% vs. men: 11.2%), especially those in the 5th quintile of SES. The 4-factor control was achieved by 6.6% of the sample. In the 3-factor control target, being women was related to the suboptimal 3-factor control target (OR: 1.26, 95% CI: 1.19- 1.34) but only belonging to SES 4th quintile was related to the unachieved target (OR: 1.47, 95% CI: 1.04-2.07). Conclusion: Suboptimal glycemic control was associated with being less affluent and suboptimal 3-factor control target was associated with being women.

Effectiveness of a game-based educational strategy e-EDUCAGUIA for implementing antimicrobial clinical practice guidelines in family medicine residents in Spain: a randomized clinical trial by cluster.

BACKGROUND: Clinical practice guidelines (CPGs) have teaching potential for health professionals in training clinical reasoning and decision-making, although their use is limited. The objective was to evaluate the effectiveness of a game-based educational strategy e-EDUCAGUIA using simulated clinical scenarios to implement an antimicrobial therapy GPC compared to the usual dissemination strategies to improve the knowledge and skills on decision-making of family medicine residents. Additionally, adherence to e-EDUCAGUIA strategy was assessed. METHODS: A multicentre pragmatic cluster-randomized clinical trial was conducted involving seven Teaching Units (TUs) of family medicine in Spain. TUs were randomly allocated to implement an antimicrobial therapy guideline with e-EDUCAGUIA strategy ( intervention) or passive dissemination of the guideline (control). The primary outcome was the differences in means between groups in the score test evaluated knowledge and skills on decision-making at 1 month post intervention. Analysis was made by intention-to-treat and per-protocol analysis. Secondary outcomes were the differences in mean change intrasubject (from the baseline to the 1-month) in the test score, and educational game adherence and usability. Factors associated were analysed using general linear models. Standard errors were constructed using robust methods. RESULTS: Two hundred two family medicine residents participated (104 intervention group vs 98 control group). 100 medicine residents performed the post-test at 1 month (45 intervention group vs 55 control group), The between-group difference for the mean test score at 1 month was 11 ( 8.67 to 13.32) and between change intrasubject was 11,9 ( 95% CI 5,9 to 17,9). The effect sizes were 0.88 and 0.75 respectively. In multivariate analysis, for each additional evidence-based medicine training hour there was an increase of 0.28 points (95% CI 0.15-0.42) in primary outcome and in the change intrasubject each year of increase in age was associated with an improvement of 0.37 points and being a woman was associated with a 6.10-point reduction. 48 of the 104 subjects in the intervention group (46.2%, 95% CI: 36.5-55.8%) used the games during the month of the study. Only a greater number of evidence-based medicine training hours was associated with greater adherence to the educational game ( OR 1.11; CI 95% 1.02-1.21). CONCLUSIONS: The game-based educational strategy e-EDUCAGUIA shows positive effects on the knowledge and skills on decision making about antimicrobial therapy for clinical decision-making in family medicin residents in the short term, but the dropout was high and results should be interpreted with caution. Adherence to educational games in the absence of specific incentives is moderate. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02210442 . Registered 6 August 2014.

[What have we missed because of COVID-19? Missed diagnoses and delayed follow-ups. SESPAS Report 2022]. / ¿Qué hemos dejado de atender por la COVID-19? Diagnósticos perdidos y seguimientos demorados. Informe SESPAS 2022.

The COVID-19 pandemic and the associated public health emergency have affected patients and health services in non-COVID-19 pathologies. Several studies have shown its dissociation from health services, with a decrease in emergency department visits, in hospital admissions for non-COVID-19 pathologies, as well as in the reported weekly incidence of acute illnesses and new diagnoses in primary care. In parallel, the pandemic has had direct and indirect effects on people with chronic diseases; the difficulties in accessing health services, the interruption of care, the saturation of the system itself and its reorientation towards non-face-to-face formats has reduced the capacity to prevent or control chronic diseases. All this has also had an impact on the different areas of people's lives, creating new social and economic difficulties, or aggravating those that existed before the pandemic. All these circumstances have changed with each epidemic wave. We present a review of the most relevant studies that have been analyzing this problem and incorporate as a case study the results of a retrospective observational study carried out in Primary Care in the Madrid Health Service, which provides health coverage to a population of more than 6 million people, and whose objective was to analyze the loss of new diagnoses in the most prevalent pathologies such as common mental health problems, cardiovascular and cerebrovascular diseases, type 2 diabetes, chronic obstructive pulmonary disease, and breast and colon tumors, in the first and second waves. Annual incidence rates with their confidence interval were calculated for each pathology and the monthly frequency of new codes recorded between 1/01/2020 and 12/31/2020 was compared with the monthly mean of observed counts for the same months between 2016 and 2019. The annual incidence rate for all processes studied decreased in 2020 except for anxiety disorders. Regarding the recovery of lost diagnoses, heart failure is the only diagnosis showing an above-average recovery after the first wave. To return to pre-pandemic levels of diagnosis and follow-up of non-COVID-19 pathology, the healthcare system must reorganize and contemplate specific actions for the groups at highest risk.

Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP study.

The beneficial effects of social support on morbidity, mortality, and quality of life are well known. Using the baseline data of the MULTIPAP study (n = 593), an observational, descriptive, cross-sectional study was carried out that analyzed the sex differences in the social support perceived by polymedicated adults aged 65 to 74 years with multimorbidity. The main outcome variable was social support measured through the Duke-UNC-11 Functional Social Support (DUFSS) questionnaire in its two dimensions (confident support and affective support). For both sexes, the perception of functional social support was correlated with being married or partnered and having a higher health-related quality of life utility index. In women, it was correlated with a higher level of education, living alone, and treatment adherence, and in men with higher monthly income, prescribed drugs and fewer diagnosed diseases.

Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial.

BACKGROUND: The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process. OBJECTIVE: To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care. METHODS/DESIGN: This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient. POPULATION: Patients aged 65-74 years with multimorbidity (≥ 3 chronic diseases) and polypharmacy (≥ 5 drugs) during the previous 3 months were included. SAMPLE SIZE: n = 1148 patients (574 per study arm). INTERVENTION: Complex intervention based on the ARIADNE principles with three components: (1) family physician (FP) training, (2) FP-patient interview, and (3) decision-making support system. OUTCOMES: The primary outcome is a composite endpoint of hospital admission or death during the observation period measured as a binary outcome, and the secondary outcomes are number of hospital admission, all-cause mortality, use of health services, quality of life (EQ-5D-5L), functionality (WHODAS), falls, hip fractures, prescriptions and adherence to treatment. Clinical and sociodemographic factors will be explanatory variables. STATISTICAL ANALYSIS: The main result is the difference in percentages in the final composite endpoint variable at 18 months, with its corresponding 95% CI. Adjustments by the main confounding and prognostic factors will be performed through a multilevel analysis. All analyses will be carried out in accordance to the intention-to-treat principle. DISCUSSION: It is important to prevent the cascade of negative health and health care impacts attributable to the multimorbidity-polypharmacy binomial. ICT-enhanced routine clinical practice could improve the prescription process in patient care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04147130 . Registered on 22 October 2019.

Effectiveness of a Conversational Chatbot (Dejal@bot) for the Adult Population to Quit Smoking: Pragmatic, Multicenter, Controlled, Randomized Clinical Trial in Primary Care.

BACKGROUND: Tobacco addiction is the leading cause of preventable morbidity and mortality worldwide, but only 1 in 20 cessation attempts is supervised by a health professional. The potential advantages of mobile health (mHealth) can circumvent this problem and facilitate tobacco cessation interventions for public health systems. Given its easy scalability to large populations and great potential, chatbots are a potentially useful complement to usual treatment. OBJECTIVE: This study aims to assess the effectiveness of an evidence-based intervention to quit smoking via a chatbot in smartphones compared with usual clinical practice in primary care. METHODS: This is a pragmatic, multicenter, controlled, and randomized clinical trial involving 34 primary health care centers within the Madrid Health Service (Spain). Smokers over the age of 18 years who attended on-site consultation and accepted help to quit tobacco were recruited by their doctor or nurse and randomly allocated to receive usual care (control group [CG]) or an evidence-based chatbot intervention (intervention group [IG]). The interventions in both arms were based on the 5A's (ie, Ask, Advise, Assess, Assist, and Arrange) in the US Clinical Practice Guideline, which combines behavioral and pharmacological treatments and is structured in several follow-up appointments. The primary outcome was continuous abstinence from smoking that was biochemically validated after 6 months by the collaborators. The outcome analysis was blinded to allocation of patients, although participants were unblinded to group assignment. An intention-to-treat analysis, using the baseline-observation-carried-forward approach for missing data, and logistic regression models with robust estimators were employed for assessing the primary outcomes. RESULTS: The trial was conducted between October 1, 2018, and March 31, 2019. The sample included 513 patients (242 in the IG and 271 in the CG), with an average age of 49.8 (SD 10.82) years and gender ratio of 59.3% (304/513) women and 40.7% (209/513) men. Of them, 232 patients (45.2%) completed the follow-up, 104/242 (42.9%) in the IG and 128/271 (47.2%) in the CG. In the intention-to-treat analysis, the biochemically validated abstinence rate at 6 months was higher in the IG (63/242, 26%) compared with that in the CG (51/271, 18.8%; odds ratio 1.52, 95% CI 1.00-2.31; P=.05). After adjusting for basal CO-oximetry and bupropion intake, no substantial changes were observed (odds ratio 1.52, 95% CI 0.99-2.33; P=.05; pseudo-R2=0.045). In the IG, 61.2% (148/242) of users accessed the chatbot, average chatbot-patient interaction time was 121 (95% CI 121.1-140.0) minutes, and average number of contacts was 45.56 (SD 36.32). CONCLUSIONS: A treatment including a chatbot for helping with tobacco cessation was more effective than usual clinical practice in primary care. However, this outcome was at the limit of statistical significance, and therefore these promising results must be interpreted with caution. TRIAL REGISTRATION: Clinicaltrials.gov NCT03445507; https://tinyurl.com/mrnfcmtd. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12911-019-0972-z.

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention.

(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65-74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was -2.42 (95% CI from -4.27 to -0.59) and, between baseline and a 12-month follow-up was -3.40 (95% CI from -5.45 to -1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.

Health-related quality of life in caregivers of community-dwelling individuals with disabilities or chronic conditions. A gender-differentiated analysis in a cross-sectional study.

BACKGROUND: Most care for people with chronic or disabling conditions living in the community is provided in the family context, and this care is traditionally provided by women. Providing informal care has a negative impact on caregivers' quality of life, which adds to existing health inequalities associated with gender. The aim of this study was to analyze factors associated with the health-related quality of life of caregivers and to determine their differences in a gender-differentiated analysis. METHODS: An observational, cross-sectional, multicenter study was conducted in primary healthcare. A total of 218 caregivers aged 65 years or older were included, all of whom assumed the primary responsibility for caring for people with disabling conditions for at least 6 months per year and agreed to participate in the CuidaCare study. The dependent variable was health-related quality of life, assessed with the EQ-5D. The explanatory variables tested were grouped into sociodemographic variables, subjective burden, caregiving role, social support and variables related to the dependent person. The associations between these variables and health-related quality of life were estimated by fitting robust linear regression models. Separate analyses were conducted for women and men. RESULTS: A total of 72.8% of the sample were women, and 27.2% were men. The mean score on the EQ-5D for female caregivers was 0.64 (0.31); for male caregivers, it was 0.79 (0.23). There were differences by gender in the frequency of reported problems in the dimensions of pain/comfort and anxiety/depression. The variables that were associated with quality of life also differed. Having a positive depression screening was negatively associated with quality of life for both genders: -0.31 points (95% CI: -0.47; -0.15) for female caregivers and -0.48 points (95% CI: -0.92; -0.03) for male caregivers. Perceived burden was associated with quality of life in the adjusted model for women (-0.12 points; 95% CI: -0.19; -0.06), and domestic help was associated in the adjusted model for male caregivers (-0.12 points; 95% CI: -0.19; -0.05). CONCLUSIONS: Gender differences are present in informal caregiving. The impact of providing informal care is different for male and female caregivers, and so are the factors that affect their perceived quality of life. It could be useful it incorporates a gender perspective in the design of nursing support interventions for caregivers to individualize care and improve the quality of life of caregivers. TRIAL REGISTRATION: NCT01478295 [ https://ClinicalTrials.gov ]. 23/11/2011.

Effectiveness of a group educational intervention - prolact - in primary care to promote exclusive breastfeeding: a cluster randomized clinical trial.

BACKGROUND: The rates of exclusive breastfeeding at 6 months in Spain are far from recommended by the World Health Organization, which is 50% by 2025. Evidence of the effectiveness of group interventions in late postpartum is limited. The objective of this study was to evaluate the effectiveness of the PROLACT group educational intervention for increasing the proportion of mother-child dyads with exclusive breastfeeding at 6 months compared to the usual practice in primary care. METHOD: Multicentre cluster randomized clinical trial. A total of 434 mother-child dyads who breastfed exclusively in the first 4 weeks of the children's life and agreed to participate were included. The main outcome was exclusive breastfeeding at 6 months. Secondary variables were type of breastfeeding, reasons for abandonment, degree of adherence and satisfaction with the intervention. To study the effectiveness, the difference in the proportions of dyads with exclusive breastfeeding at 6 months was calculated, and the relative risk (RR) and number needed to treat (NNT) were calculated with their 95% CIs. To study the factors associated with the maintenance of exclusive breastfeeding at 6 months, a multilevel logistic regression model was fitted. All analyses were performed to intention to treat. RESULTS: The percentage of dyads with exclusive breastfeeding at 6 months was 22.4% in the intervention group and 8.8% in the control group. PROLACT intervention obtained an RR =2.53 (95% CI: 1.54-4.15) and an NNT = 7 (95%CI: 5-14). The factors associated with exclusive breastfeeding at 6 months were the PROLACT intervention, OR = 3.51 (95%CI: 1.55-7.93); age > 39 years, OR = 2.79 (95%CI: 1.02-7.6); previous breastfeeding experience, OR = 2.61 (95%CI: 1.29-5.29); income between 500 and 833.33 €, OR = 3.52 (95%CI 1.47-8.47).); planning to start work before the infant was 6 months old, OR = 0.35 (0.19-0.63) . CONCLUSIONS: The PROLACT intervention in primary care is more effective than the usual practice for maintaining exclusive breastfeeding at 6 months, and can therefore be considered evidence-based practice for implementation in standard practice. TRIAL REGISTRATION: The trial was registered with ClinicalTrials.gov under code number NCT01869920 (03/06/2013).