Estudio multicéntrico sobre multimorbilidad en internados en áreas clínicas / Multicenter Study on Multimorbidity in Patients in Clinical Areas

Introducción: El estudio de la comorbilidad requiere de un enfoque multilateral con vistas a mejorar la calidad de la atención de los enfermos por el sistema de atención. Objetivos: Explorar la magnitud de la comorbilidad de enfermedades crónicas en adultos internados en los hospitales. Métodos: Se realizó un estudio prospectivo-observacional-longitudinal-analítico. Se incluyeron pacientes internados en las Salas de Clínica Médica o pacientes clínicos en Salas de Internación Indiscriminada. Se realizó un estudio multicéntrico en 42 centros en un período de 2 años, con un muestreo consecutivo. Para el estudio se tuvo en cuenta la estadística descriptiva, inferencial y de regresión. Resultados: El total de pacientes en el estudio fue de 5925, masculinos con el 50,3 por ciento de edad 60,66 ± 0,25 años. Principal procedencia desde la guardia el 73 por ciento. La estadía hospitalaria de 12,61 ± 0,24 días, mayormente en pacientes quirúrgicos (15,45 ± 0,67 vs 11,76 ± 0,23; p < 0,00001). El 23 por ciento recibió tratamiento quirúrgico. El principal nivel educativo: secundario completo 21,6 por ciento. Dificultades económicas: 20 por ciento, mortalidad 9,26 por ciento; prevalencia de dislipemia, diabetes e hipertensión: 22,53 por ciento; 28,82 por ciento y 51,86 por ciento con 473 nuevos diagnósticos, IMC: 27,88 ± 0,65, Charlson global 2,09 ± 0,02 y en óbitos 3,84 ± 0,11. La media de patologías por paciente fue de 2,14 ± 0,01 y aumentó con la edad (p valor regresión lineal < 0,00001). Conclusiones: La hipertensión, la diabetes y la dislipemia representaron las entidades más prevalentes en Salas de Internación Clínica, Las enfermedades cardiovasculares, respiratorias, infectológicas, oncológicas, neurológicas, metabólicas y nefrológicas fueron predictores independientes de mortalidad(AU)

Introduction: The study of comorbidity requires a multilateral approach with a view to improving the quality of care for these patients by the care system. Objectives: To explore the magnitude of the comorbidity of chronic diseases in adults admitted to hospitals. Methods: Prospective-observational-longitudinal-analytical study. Patients hospitalized in a medical clinic room or clinical patients in indiscriminate hospitalization rooms are included, Multicenter study in 42 centers, with 2 years of recruitment. Consecutive sampling. Descriptive, inferential and regression statistics. Results: 5925 recruited, male gender 50,3percent, age 60,66 ± 0,25 years, main origin from the guard 73percent, stay 12,61 ± 0,24 days, longer in surgical (15,45 ± 0,67 vs 11,76 ± 0,23, p < 0,00001), 23percent received surgical treatment. Main educational level: complete secondary school 21,6%. Economic difficulties: 20percent, mortality 9,26percent, prevalence of dyslipidemia, diabetes and hypertension: 22,53percent, 28,82percent and 51,86percent with 473 new diagnoses in said pathologies, BMI: 27,88 ± 0,65, Global Charlson 2,09 ± 0,02 and in deaths 3,84 ± 0,11. The average number of pathologies per patient was 2,14 ± 0,01 and increased with age (p value for linear regression < 0,00001). Conclusions: Hypertension, diabetes and dyslipidemia represented the most prevalent entities in the clinical hospitalization room, cardiovascular, respiratory, infectious, oncological, neurological, metabolic and nephrological diseases were independent predictors of mortality(AU)

Índice PROFUND y mortalidad intrahospitalaria en pacientes pluripatológicos. Análisis post-hoc / PROFUND index and intrahospital mortality in plurypathological patients. A post-hoc analysis

Resumen El índice PROFUND se desarrolló y validó para predecir mortalidad a 12 meses en pacientes pluripatológicos. Sin embargo, su valor potencial para predecir mortalidad intrahospitalaria no ha sido suficientemente estudiado. Se evaluó la capacidad del índice PROFUND en comparación con la proteína C re activa (PCR), la albúmina, y el ancho de distribución eritrocitaria (ADE) para predecir mortalidad intrahospitalaria, mediante el análisis posterior de una cohorte prospectiva de 111 pacientes pluripatológicos internados en clínica médica. La edad promedio fue 75.8 ± 9.3 años. La mortalidad intrahospitalaria fue de 17% (19 pacientes). La mediana (RIQ) del índice PROFUND, albúmina, PCR y ADE en los fallecidos y sobrevivientes fue 12 (4) y 6 (7) p< 0.0001, 2.5 (0.4) y 2.6 (0.8) p 0.295, 58 (64) y 40 (60) p 0.176, 14.5 (2) y 14.6 (3) p 0.523, respectivamente. El análisis logístico multivariado mostró que el índice PROFUND se asocia con mortalidad intrahospitalaria (p 0.0003). El riesgo de fallecer durante la internación es 20% mayor por cada punto que se incrementa el índice PROFUND (OR 1.2, IC95% 1.1-1.4). El área bajo la curva de las características operativas del receptor (AUC-ROC) del índice PROFUND para predecir mortalidad durante la internación (0.760, IC95% 0.628-0.891) fue mayor a la del ADE, PCR y albúmina (0.494 IC95% 0.364-0.624 p 0.012; 0.583 IC95% 0.437-0.728 p 0.028; 0.621 0.494-0.748 p 0.109, respectivamente). El índice PROFUND se asocia a mortalidad intrahospitalaria, con una mayor capacidad predictiva que los biomarcadores estudiados, lo cual se sumaría a su valor pronóstico a largo plazo en pacientes pluripatológicos.

Abstract The PROFUND index was developed and valid to predict mortality at 12 months in polypathological patients (PP). However, its potential value for predicting in-hospital mortality has not been sufficiently studied. The ability of the PROFUND index in comparison with C-reactive protein (CRP), albumin, and red blood cell distribu tion width (RDW) to predict in-hospital mortality was evaluated through the subsequent analysis of a prospective cohort of 111 multiple pathological patients admitted to the clinic medical. The mean age was 75.8 ± 9.3 years. In-hospital mortality was 17% (19 patients). The median (IQR) of the PROFUND index, albumin, CRP and ADE in the deceased and survivors was 12 (4) and 6 (7) p < 0.0001, 2.5 (0.4) and 2.6 (0.8) p 0.295, 58 (64) and 40 (60) p 0.176, 14.5 (2) and 14.6 (3) p 0.523, respectively. The multivariate logistic analysis showed that the PROFUND index is associated with in-hospital mortality (p 0.0003). The risk of dying during hospitalization is 20% higher for each point that the PROFUND index increases (OR 1.2, 95% CI 1.1-1.4). The area under the curve the receiver operating characteristic (AUC-ROC) of the PROFUND index to predict mortality during hospitalization (0.760, 95% CI 0.628-0.891) was higher than that of the RDW, CRP and albumin (0.494 95% CI 0.364-0.624 p 0.012; 0.583 95% CI 0.437-0.728 p 0.028; 0.621 0.494-0.748 p 0.109, respectively). The PROFUND index is associated with in-hospital mortality, with a greater predictive capacity than the biomarkers studied, which would add to its long-term prognostic value in multiple pathological patients.

Índice PROFUND y valoración global subjetiva. Valor pronóstico en pacientes pluripatológicos internados / PROFUND index and global subjective assessment. Prognostic value in hospitalized pluripathological patients

Resumen El índice PROFUND es una de las puntuaciones pronósticas sugeridas en pacientes pluripatológicos (PP). A pesar del valor pronóstico de la desnutrición y su prevalencia en esta población, el mismo no incluye una variable que estime el estado nutricional. La valoración global subjetiva (VGS) es una herramienta ampliamente validada para tal fin. Se evaluó mediante un estudio prospectivo y observacional, la capacidad pronóstica de mortalidad a 12 meses del índice PROFUND y VGS en PP internados en clínica médica. Ingresaron al estudio 111 pacientes. Edad 75.8 (± 9.3) años. Índice PROFUND 7.6 (± 4.7) puntos. El 60.1% presentaba desnutrición moderada-severa por VGS. Fallecieron 66 dentro del año. En el modelo de Cox, la VGS y el índice PROFUND se asocian con mortalidad a los 12 meses (p < 0.0001 y p 0.0026 respectivamente). En los desnutridos severos, el riesgo es aproximadamente 6 veces mayor en comparación a los normonutridos (HR: 6.514, IC95% 2.826-15.016) y para un mismo nivel de VGS, el riesgo es un 10% mayor por cada punto que aumenta el índice PROFUND (HR: 1.106, IC95% 1.036-1.181). El AUC para predecir mortalidad a 12 meses del índice PROFUND y VGS fue: 0.747 (IC95%: 0.656-0.838); 0.733 (IC95%: 0.651-0.816) y al combinar las dos variables: 0.788 (IC95%: 0.703-0.872, p 0.048). Como conclusión el índice PROFUND y la VGS se asocian con mortalidad y tienen un valor pronóstico similar. La combinación de ambas herramientas permitiría establecer mejor el pronóstico y el manejo en esta compleja población

Abstract The PROFUND index is one of the suggested prognostic scores in pluripathological patients (PP). Despite the prognostic value of malnutrition and its prevalence in this population, it does not include a variable that estimates nutritional status. Subjective global assessment (SGA) is a widely validated tool for this purpose. The prognostic capacity of 12-month mortality of PROFUND index and SGA in PP admitted to a medical clinic was evaluated by a prospective and observational study. 111 patients entered the study. Age 75.8 (± 9.3) years. PROFUND index 7.6 (± 4.7) points. 60.1% had moderate-severe malnutrition due to VGS. 66 died within the year. In the Cox model, SGA and PROFUND index are associated with mortality at 12 months (p <0.0001 and p 0.0026 respectively). In severe malnutrition, the risk is approximately 6 times higher compared to normonutrition (HR: 6.514, 95% CI 2.826-15.016) and for the same level of SGA, the risk is 10% higher for each point that the PROFUND index increases (HR: 1.106, 95% CI 1.036-1.181). The AUC for predicting 12-month mortality from PROFUND index and SGA was: 0.747 (95% CI: 0.656-0.838); 0.733 (95% CI: 0.651-0.816) and when combining the two variables: 0.788 (95% CI: 0.703-0.872, p 0.048). In conclusion, PROFUND index and SGA are associated with mortality and have a similar prognostic value. The combination of both tools would allow better prognosis and management in this complex population.

Simplification of the Barthel scale for screening for frailty and severe dependency in polypathological patients. / Simplificación de la escala de Barthel para el cribado de fragilidad y dependencia severa en pacientes pluripatológicos.

OBJECTIVES: To analyse the sensitivity, specificity and positive predictive (PPV) and negative predictive (NPV) values of each measure of the Barthel index (BI) compared with the full questionnaire for polypathological patients (PPPs). METHODS: Multicentre cross-sectional study. We considered 2 cut-off points for the BI (≥90 points for screening frailty and <60 points for diagnosing severe dependence). For each measure and combination of 2 measures, we calculated the sensitivity, specificity, PPV and NPV with respect to the full BI. RESULTS: The mean BI of the 1,632 included PPPs (mean age, 77.9±9.8years; 53% men) was 69±31 (<90 for 58.7% and <60 for 31.4% of the patients). The "feeding" measure achieved the highest NPV, for a BI ≥60 and ≥90 points (87% and 99.6%, respectively). The "walking" and "going up and down stairs" measures achieved the highest PPV, for a BI ≥60 and ≥90 (99.2%/99.5% and 81%/92%, respectively. The combination of the 2 measures increased the PPV to 95% and 99.6%, respectively. CONCLUSIONS: PPPs in hospital settings have a high rate of functional impairment. The measure for feeding achieved the highest NPV and can therefore be employed for diagnosing severe dependence. The combination of the measures for walking and going up and down stairs achieved the highest PPV and can therefore be employed to propose frailty screening for PPPs.

Analysis of patients shared in consultations of internal medicine and other medical specialties. / Análisis de pacientes compartidos en consultas de medicina interna y otras especialidades médicas.

BACKGROUND AND OBJECTIVE: The aging population is resulting in an increasing number of patients with multiple diseases that require treatment by various specialties. We examined the evolution of consultations and of the percentage of patients treated by several medical specialties. METHODS: We analysed internal medicine (IM) consultations and those of other medical specialties in a hospital during 1997, 2007 and 2017 for the general population and for those older than 65 years. RESULTS: Over the course of 20 years, the rate of first IM consultations per 1000 inhabitants increased 44%, and that of other medical specialties increased 137%. The percentage of patients seen by more than one specialty went from 13.8% in 1997 to 32.6% in 2017 and reached 45.5% for those older than 65 years. CONCLUSIONS: The care for populations with growing comorbidity has a major impact on health systems and requires organisational changes for their care.

Abordaje de los mecanismos de comorbilidad en Diabetes Mellitus Tipo 2 / Approach to mechanisms of comorbidity in Type 2 Diabetes Mellitus

Introducción:A nivel mundial se estima que para 2030 existirá una prevalencia de 366 millones de personas con diabetes. En Cuba, la prevalencia de diabéticos es de 56.7 x 1 000 habitantes. El análisis de las implicaciones reales de la diabetes no se limita a su presencia aislada pues se trata de una entidad con frecuente asociación a otros problemas de salud. Objetivo: Abordar los mecanismos que subyacen en la comorbilidad del paciente con Diabetes Mellitus Tipo 2. Material y Métodos: Se realizó una revisión de fuentes bibliográficas que fueron localizadas mediante el motor de búsqueda Google Académico, biblioteca de los autores y la base de datos Scielo de la Biblioteca Virtual de Salud. Desarrollo: La comorbilidad y la Diabetes mellitus 2 se incrementan con la edad. Los mecanismos subyacentes pueden tener base patogénica o no. Su estudio es importante por los efectos en el proceso diagnóstico, el autocuidado y el éxito del tratamiento. De ahí que los documentos normativos deben tener en cuenta este fenómeno. Para su investigación se cuentan con instrumentos que pueden ser específicos o generales. Conclusiones: La comorbilidad es un fenómeno clínico frecuente en el paciente diabético y debe considerarse al ser esta una enfermedad sistémica(AU)

Introduction: It is estimated that there will be a prevalence of 366 million people suffering from diabetes worldwide by the year 2030. In Cuba, the prevalence of diabetic population is 56.7 per 1 000 inhabitants. The analysis of the real implications of diabetes is not limited to its existence alone, since it is an entity which is frequently associated with other health problems. Objective:To approach the mechanisms that underlie the comorbidity of a patient with Type 2 Diabetes Mellitus. Material and methods: A bibliographic review was carried out using Google Scholar search engine, authors´ libraries, and Scielo database from the Virtual Health Library. Development:Comorbidity, and Type 2 Diabetes mellitus increase with age. The underlying mechanisms may have either a pathogenic basis or not. Their study is important because of the effects in the diagnostic process, the self-care, and the success of the treatment. Hence, the normative documents should consider this phenomenon. The instruments to do research on this topic can be both specific or general. Conclusions:Comorbidity is a frequent clinical phenomenon to be considered in the diabetic patient because diabetes is a systemic disease(AU)

Diagnostic value of a simplified Pfeiffer questionnaire for polypathological patients. / Valor diagnóstico de un cuestionario de Pfeiffer simplificado en pacientes pluripatológicos.

OBJECTIVES: To analyse the correlation, sensitivity, specificity and positive predictive (PPV) and negative predictive (NPV) values of each question on the Pfeiffer questionnaire (SPMSQ) compared with the full questionnaire for polypathological patients (PPPs). METHODS: Multicentre cross-sectional study. An SPMSQ score is considered pathological if 3 or more errors are recorded. For each question and combination of 2 questions, we calculated the correlation (kappa index), sensitivity, specificity and predictive values compared with the full SPMSQ. RESULTS: Of the 1632 PPPs included (mean age, 77.9±9.8 years, 53% men), 1434 performed the SPMSQ (the remaining presented delirium); 39% of the PPPs were pathological. The question "What day is it today?" and the command "Count backwards by 3s from 20" obtained good correlation and NPV (85 and 89%, respectively); the combination of both increased the NPV to 97%. The question "When were you born?' achieved good correlation and greater PPV (93%). CONCLUSIONS: The combination of the question "What day is it today?" and the command "Count backwards by 3s from 20" achieved a high NPV. The question related to the date of birth achieved the highest PPV.

Care models for polypathological patients. / Modelos de atención al paciente pluripatológico.

Polypathological patients have specific clinical, functional, psychoaffective, social, family and spiritual characteristics. These patients are generally elderly and frail and have frequent decompensations. They frequently use healthcare resources, have significant functional impairment and have a high index of dependence. This results in a significant social impact, high mortality and a high consumption of resources. The current healthcare models have not answered these needs, which causes problems with accessibility to healthcare services, a lack of coordination among these services, a higher probability of adverse events related to polypharmacy and a high consumption of resources. In the past decade, the healthcare models have changed and are characterized by work in multidisciplinary and interlevel teams, patient self-care, the availability of tools for decision making, information and communication systems and prevention. The goal is to have prepared and proactive health teams and an informed and active patient population. The assessment of health results, processes and the costs for these programs is still based on moderate to low evidence. It is therefore not an easy task to determine the type and intensity of interventions or to determine the patient groups that could gain more benefits.

Polypathology, an emerging phenomenon and a challenge for healthcare systems. / La pluripatología, un fenómeno emergente y un reto para los sistemas sanitarios.

Improvements in living conditions and scientific advances have led to an unprecedented demographic change. The curing of numerous acute diseases and the growing adoption of unhealthy lifestyles have caused a pandemic of cumulative chronic diseases that constitute the leading cause of death worldwide. Currently, the most common situation is the coexistence of multiple chronic diseases (or polypathology). This situation undermines socio-economic development and increases inequality. This results in an overriding need to change the way in which health and disease are addressed. Healthcare systems are not prepared to meet the needs of complex polypathological patients. In this article, we summarise the challenges facing healthcare systems and states, as well as the main recommendations from the organisations responsible for healthcare.

Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness. / Pluripatología, polifarmacia, complejidad terapéutica y uso adecuado de la medicación.

Polypathological patients are usually elderly and take numerous drugs. Polypharmacy affects 85% of these individuals and is not associated with greater survival. On the contrary, polypharmacy exposes these individuals to more adverse effects, such as weight loss, falls, functional and cognitive impairment and hospitalisations. The complexity of a drug regimen covers more aspects than the simple number of drugs consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions. Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients. To prevent polypharmacy, reduce complexity and improve adherence, the appropriate use of drugs is needed. Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication, which are appropriate for the patient's circumstances, are well tolerated and cost-effective and whose benefits outweigh the risks. To improve the drug prescription, periodic reviews of the drugs need to be conducted, especially when the patient changes doctor and during healthcare transitions. The Beers and STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria are effective tools for this improvement. Deprescription for polymedicated polypathological patients that considers their clinical circumstances, prognosis and preferences can contribute to a more appropriate use of drugs.

La comorbilidad y su valor para el médico generalista en Medicina Interna / Comorbidity and its value for the general doctor in Internal Medicine

Introducción: La comorbilidad es un fenómeno que complejiza el cumplimiento de las funciones del médico generalista en la atención a pacientes en salas de medicina interna. Objetivo: Fundamentar las bases de la comorbilidad como variable, en tanto se define en lo conceptual, lo operacional y relaciones esenciales internas y externas con el enfoque en sistema de las funciones del médico clínico en las salas de Medicina Interna de los hospitales. Material y Métodos: Se realizó una revisión bibliográfica que abordasen la comorbilidad y que facilitaran cumplir el objetivo de la investigación. Desarrollo: En el plano conceptual se define la comorbilidad como la asociación de enfermedades donde una tiene carácter protagonista Se presenta la definición conceptual de la comorbilidad. La relación entre enfermedades comórbidas puede estar explicada por asociaciones de clara dependencia patogénica o por coincidencia en el paciente sin relación patogénica directa. Existen numerosos y diversos instrumentos para operacionalizarla disponibles para su aplicación en investigación y la práctica clínica. Conclusiones: Las relaciones entre las diferentes enfermedades son multilaterales y requieren de una interpretación etiopatogénica y fisiopatológica profunda para ser comprendida y analizada en el cumplimiento de las funciones asistenciales, investigativa, docentes y administrativas del médico en salas de Medicina Interna(AU)

Introduction: The comorbidity is a phenomenon that complicates general doctor´s fulfillment of their functions regarding the care of patients at Internal Medicine Wards. Objective: To base the bases of comorbidity as a variable, insofar it is defined in the conceptual, the operational and essential internal-external relationships with a systemic approach of the functions of the clinical physician in the hospital´s Internal Medicine wards. Material and Methods: A bibliographic revision that take into account comorbidity and allow to satisfy the objective was performed. Development: Conceptually, comorbidity is defined as the association of diseases in which one has a leading role character. The conceptual definition of comorbidity is presented. The relationship between comorbid diseases can be explained by associations of a clear pathogenic dependence or by coincidence in the patient without direct pathogenic relationship. There are numerous and diverse instruments available to make it operable for its application in research and clinical practice. Conclusions: The relations between different diseases are multilateral and need a deep etiopathogenic and fisiopathological interpretation to be understood and examined in the fulfillment of its asitencials, investigative, teaching and administrative functions of the doctor at Internal Medicine wards(AU)

Prevalence of comorbidities and the prognostic value of the PROFUND index in a hospital cardiology unit. / Prevalencia de pluripatología y valor pronóstico del índice PROFUND en una unidad de hospitalización de Cardiología.

INTRODUCTION: The aim of this study was to understand the prevalence of comorbidities and the usefulness of the PROFUND index for the prognostic stratification of patients with comorbidities in a hospital cardiology unit. PATIENTS AND METHODS: We consecutively analysed all patients hospitalized in 2012 in the department of cardiology. We recorded the comorbidities, length of stay, hospital mortality, Charlson indices and PROFUND indices. In the patients with comorbidities, we also recorded the readmissions and mortality during a 1-year follow-up. RESULTS: The study included 1,033 patients (mean age, 67±13.1 years; 35% women), 381 (36.9%) of whom had comorbidities, with a mean Charlson index of 6.4±1.7 and a mean PROFUND index of 2.5±2.5. Compared with the other patients, the patients with comorbidities were older (72 vs. 64 years, p<.001), had a higher mortality rate (2.9% vs. 1.1%, p=.046) and longer hospital stays (8±5.5 vs. 6±5.7 days, p<.001) and were more often admitted for heart failure (42.3% vs. 15.8%, p<.001). The PROFUND index was independently associated with overall mortality (hazard ratio [HR], 1.13; 95% CI: 1.01-1.27; p=.034) and with the presence of major adverse events during the 12-month follow-up (HR, 1.09; 95% CI: 1.01-1.18; p=.026). CONCLUSIONS: A high percentage of patients hospitalized in the department of cardiology had comorbidities. These patients had a higher prevalence of cardiovascular risk factors, longer stays and greater hospital mortality. The PROFUND index independently predicted mortality and adverse events during the follow-up.

[Concordance between stratification systems and identification of patients with multiple chronic diseases in Primary Care]. / Concordancia entre sistemas de estratificación e identificación de pacientes crónicos complejos en Atención Primaria.

OBJECTIVE: To determine the prevalence of patients with multiple chronic diseases in Primary Care using the multiple morbidity criteria and Clinical Risk Groups, and the agreement in identifying high-risk patients that require case management with both methods. MATERIAL AND METHOD: A cross-sectional study was conducted on 240 patients, selected by random sampling of 16 care quotas from two Primary Health Care centres of a health area. Informed consent was obtained to access their electronic medical records for the study, and a record was made of age, sex, health status of Clinical Risk Groups, severity, multiple morbidity criteria, and Charlson index by physicians during clinical practice. Three patients were excluded due to incomplete data. RESULTS: The prevalence of patients with multiple chronic diseases following the criteria of the Ministry of Health among users was 4.11 (95% CI; 2.13-7.30). The frequency of patients with high risk Clinical Risk Groups (G3) in the chronicity strategy of Valencian Community was 7.59 (95% CI; 4.70-11.70), which includes patients with health status 6 and complexity level 5-6, and health status 7, 8, and 9. Agreement between the two classifications was low, with a kappa index 0.17 (95% CI; 0-0.5) CONCLUSIONS: The prevalence did not differ significantly from that expected, and the agreement between the two stratifications was very weak, not selecting the same patients for highly complex case management.

[Usefulness of the FEV1/FEV6 ratio to detect the prevalence of lung obstruction in hospitalised patients with multiple morbidities]. / Utilidad del índice FEV1/FEV6 en pacientes pluripatológicos hospitalizados para detectar la prevalencia de obstrucción pulmonar.

BACKGROUND: The prevalence of lung obstruction increases with age and the presence of comorbidities. Although a complete spirometry is necessary to confirm the diagnosis, this may be impractical in elderly patients with cognitive impairment or functional dependence. Recently, the use of portable devices using the FEV1/FEV6 ratio have shown to be useful for assessing the presence of lung obstruction, with greater ease of use, but its usefulness has not been established in the elderly population with multiple morbidities. METHODS: A cross-sectional study was conducted on patients hospitalised in the complex chronic patients Unit of the University Hospital Mútua de Terrassa. All of them completed a questionnaire that included -among other things- measurements of functional dependence and cognitive impairment. Three manoeuvres validated with the Piko-6 device were attempted before discharge, and considering an FEV1/FEV6<0.75 as criteria for obstruction. An analysis was performed on the characteristics of the population that was able to perform the tests, as well as the prevalence of pulmonary obstruction. RESULTS: A total of 54 patients were included in the study, of which 35 (64.81%) performed the manoeuvres correctly. Patients who were unable to complete the manoeuvres of the Piko-6 had more functional dependence (Barthel 19 vs. 72, P<.0001) and cognitive impairment (Pfeiffer 1 vs. 9, P<.0001; MEC 28/35 vs. 3/35, P<.010). The prevalence of obstruction was 71.43%, with an underdiagnosis of 72%. CONCLUSIONS: The FEV1/FEV6 ratio was not determined in 35.18% of the patients due to cognitive impairment or functional dependence. The prevalence of obstruction and underdiagnosis exceeded 70%.

[Characteristics of potentially inappropriate prescribing of drugs in elderly polypathological patients]. / Características del uso inadecuado de medicamentos en pacientes pluripatológicos de edad avanzada.

OBJECTIVE: To analyse potentially inappropriate prescribing (PIP) in elderly polypathological patients (PP). METHOD: Multicentre observational, prospective study of 672 patients aged 75 years and older hospitalised in Internal Medicine between April 2011 and March 2012. The Beers, STOPP-START and ACOVE criteria were used to detect potentially inappropriate prescribing and the results of PP and non-PP patients were compared. RESULTS: Of the 672 patients included, 419 (62%) were polypathological, of which 89.3% met PIP criteria versus 79.4% of non-polypathological patients (p <0.01). 40.3% of polypathological patients met at least one Beers criteria, 62.8% at least one STOPP criteria, 62.3% at least one START criteria and 65.6% at least one ACOVE criteria. The rate of potentially inappropriate prescribing was higher in polypathological patients regardless of the tool used. CONCLUSIONS: Given the high rate of potentially inappropriate prescribing in polypathological patients, strategies to improve prescribing adequacy must be developed.

[Development of clinical practice guidelines for patients with comorbidity and multiple diseases]. / Desarrollo de guías de práctica clínica en pacientes con comorbilidad y pluripatología.

The management of patients with comorbidity and polypathology represents a challenge for all healthcare systems. Clinical practice guidelines (CPGs) have limitations when applied to this population. The aim of this study is to propose the terminology and methodology for optimally approach comorbidity and polypathology in the CPGs. Based on a literature review, we suggest a number of proposals for the approach in different phases of CPG preparation, with special attention to the inclusion of clusters of comorbidity in the initial questions the implementation of indirect evidence, the burden of disease management for patients and their environment, when establishing recommendations, as well as the strategies of dissemination and implementation. These proposals should be developed in greater depth with the implication of more agents in order to have valid and useful tools for this population.

Development of clinical practice guidelines for patients with comorbidity and multiple diseases. / Desarrollo de guías de práctica clínica en pacientes con comorbilidad y pluripatología.

The management of patients with comorbidity and polypathology represents a challenge for all healthcare systems. Clinical practice guidelines (CPGs) have limitations when applied to this population. The aim of this study is to propose the terminology and methodology for optimally approach comorbidity and polypathology in the CPGs. Based on a literature review, we suggest a number of proposals for the approach in different phases of CPG preparation, with special attention to the inclusion of clusters of comorbidity in the initial questions the implementation of indirect evidence, the burden of disease management for patients and their environment, when establishing recommendations, as well as the strategies of dissemination and implementation. These proposals should be developed in greater depth with the implication of more agents in order to have valid and useful tools for this population.

[Provision of continuous health care by a unit connected to primary care centres coordinated by specialist physicians]. / Aportación al continuo asistencial de una consulta de conexión con atención primaria coordinada con internistas.

OBJECTIVE: To evaluate the efficacy and efficiency of a system set up to overcome the current disparity between primary and specialist health care and with the capacity to detect patients with significant diseases. MATERIAL AND METHODS: To describe the activity of the Unit for Connection with Primary Care Centres (UCPCC) in the Alcoy Health Area (Alicante) during its first year. RESULTS: A total of 450 visits were made, with 6.5 (95% CI 5.7-7.3) first visits, and 3.9 (95% CI 3.1-4.8) successive ones per day. There were more than 50 reasons for consultation, and more than 60 final diagnoses (65.6% non-significant, 14% undefined and 12.4% significant). Digestive (31%) and functional (14.4%) diseases were the most frequently defined diagnoses, with neoplasic and autoimmune diseases among those defined as significant ones. The great majority (86.9%) of patients required 1-2 visits, with 40% diagnosed by just reviewing the hospital files. More than 20 different complementary examinations were performed, with 38.8%, 34.4%, 21.6%, and 5.2% of patients requiring 0, 1, 2, or ≥ 3, respectively. Patients with a significant pathology were diagnosed more quickly (12.4 ± 19.4 vs. 45.3 ± 52.8 days; P = .001), with less complementary examinations (0,5 ± 0,7 vs. 0,9 ± 0,9 per patient; P = .032. 58.6% vs. 39.6% patients without complementary examinations; P = .052), and were more frequently referred to specialised medicine (58.6% vs. 18.3%, P < .0001). CONCLUSIONS: The demonstrated differential management of patients with potentially significant pathology using existing resources, make the UCPCC with internists an efficient model for the connection between health care levels.

Pluripatología y comorbilidad en pediatría. El niño pluripatológico / Pluripathology and comorbidity in pediatrics. The pluripathologic child

En este artículo científico se patentiza el método holístico del proceso salud-enfermedad, lo cual permite definir la tipología y naturaleza crónica o aguda de la afección, el estado clínico y el pronóstico médico-social del enfermo, en este caso del niño pluripatológico, así como establecer si su proceso morboso es de origen orgánico o si el trastorno funcional depende de condiciones o factores determinantes dañinos (biológicos, ambientales, socioeconómicos e higienosanitarios) para finalmente asumir adecuadas conductas médicas y sociales integradas.

This scientific article licenses the holistic method of health-disease process, which allows to define the typology and chronic or severe nature of the disease, the clinical status and the social-clinic diagnosis of the patient, in this case of the pluripathologic child, such as to establish if his morbid process originates from organic issues or if the functional disorder depends on the conditions or damaging determinant factors (biological, environmental, socioeconomic, and hygienic factors) to finally assume proper medical socially integrated behaviour.