[Differences between institutionalized patients and those included in a home care program in Seville]. / Diferencias entre pacientes institucionalizados y pacientes en atención domiciliaria en la provincia de Sevilla.

OBJECTIVES: To describe the characteristics and clinical differences between institutionalised patients and those included in a home care program. DESIGN: A descriptive, observational, cross-sectional, and multicentre study. Site Seville, 2016. STUDY SUBJECTS: A total 1857 elderly patients of similar characteristics (1441 institutionalised and 416 at home) in Seville in 2016. MEASUREMENTS: The variables studied included gender, age, civil status, family support, pathologies, multiple pathology criteria, and medication prescriptions. Functional and cognitive status was evaluated using the Barthel index, and the Lawton-Brody and Pfeiffer scales. RESULTS: The majority of patients (71.40%) were women. The fact of being institutionalised or being included in a home care program were statistically related to the following pathologies and categories: schizophrenia (p<.001), arterial hypertension (p=.012), diabetes mellitus (p=.001), atrial fibrillation (p<.001), and neoplasia (p=.012), A1 (p=.012), A2 (p<.001), B1 (p<.001), B2 (p=.002), C (p<.001), E1 (p<.001), E3 (p=.01), F2 (p<.01), G2 (p=.024), and H (p=.005). The mean Barthel index of the sample was 49.1±34.45 (95% confidence interval: 47.49-50.7). The mean Lawton-Brody scale in the case of patients included the home care program was 2.33±2.49 and in those institutionalised 1.59±2.12. The mean Pfeiffer scale was 4.93±3.53. CONCLUSIONS: Cognitive impairment was related to institutionalisation, being a result of possible neurological (E3 category) and psychiatric diseases. On the other hand, patient comorbidity was not related to it, because it is very high in patients included in a home care program, in whom functional and cognitive independency status is better.

Communication with patients and the duration of family medicine consultations.

OBJECTIVE: To determine the distribution of consultation times, the factors that determine their length, and their relationship with a more participative, patient-centred consulting style. DESIGN: Cross-sectional multicentre study. LOCATION: Primary Healthcare Centres in Andalusia, Spain. PARTICIPANTS: A total of 119 tutors and family medicine physician residents. PRINCIPAL MEASUREMENTS: Consultation length and communication with the patient were analysed using the CICCAA scale (Connect, Identify, Understand, Consent, Help) during 436 interviews in Primary Care. RESULTS: The mean duration of consultations was 8.8min (sd: 3.6). The consultation tended to be longer when the physician had a patient-centred approach (10.37±4.19min vs 7.54±2.98min; p=0.001), and when there was joint decision-making (9.79±3.96min vs 7.73±3.42min: p=0.001). In the multivariable model, longer consultations were associated with obtaining higher scores on the CICAA scale, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and a smaller number of daily visits (r2=0.32). There was no correlation between physician or patient gender, or problem type. CONCLUSION: A more patient centred medical profile, increased shared decision-making, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and less professional pressure all seem to be associated with a longer consultation.

[Assessment of the use of retinography as a screening method for the early diagnosis of chronic glaucoma in Primary Care: Validation for screening in populations with open-angle glaucoma risk factors]. / Valoración del uso de retinografía como método de diagnóstico precoz de glaucoma crónico en atención primaria: validación para el cribado en población con factores de riesgo para glaucoma de ángulo abierto.

OBJECTIVE: The aim of this study is to determine usefulness, validity of retinographies performed in Primary Care as a tool for early diagnosis of open-angle chronic glaucoma (OAG). DESIGN: An observational, descriptive and cross-sectional study with two blinded parallel observers: 2 general practitioners and 1 ophthalmologist. LOCATION: Urban Primary Care Health Centre, and the Ophthalmology Department outpatient clinic. PARTICIPANTS: A total of 196 patients of both genders, between 40-70years, with diabetes and hypertension, and undiagnosed with glaucoma, were recruited by phone call after checking patient lists. Two patients that did not arrive for their appointments for the ophthalmology tests were considered as losses. MEASUREMENTS: For the quantitative diagnostic variable of glaucoma: Accuracy calculated from the sensitivity and specificity, safety from the positive and negative predictive values and the positive and negative probability ratio; interobserver concordance by Kappa index ratio and the intraclass correlation (IC). RESULTS: The retinography for OAG screening has a sensitivity of 21% (95%CI: 0-43%), a specificity of 93% (95%CI: 89-97%), a negative predictive value of 94% (95%CI: 90-97%), and positive of 20% (95%CI: 0-40%); positive probability ratio of 3.07 (95%CI: 0.98-9.62) and negative 0.84 (95%CI: 0.64-1.11). The IC was 0.653 (95%CI: 0.495-0.769) and kappa index of 0.140 (0.106ET). CONCLUSIONS: According to this proposed model, retinography is not a useful tool for the early diagnosis of OAG in Primary Care, as it is not safe enough. Before it can be used, it would need adjustments for its low sensitivity, and the use other combined tests. The training of general practitioners would also need to be improved.

Communication skills of tutors and family medicine physician residents in Primary Care clinics.

AIM: To determine the communicative profiles of family physicians and the characteristics associated with an improved level of communication with the patient. DESIGN: A descriptive multicentre study. LOCATION: Primary Healthcare Centres in Almeria, Granada, Jaen and Huelva. PARTICIPANTS: 119 family physicians (tutors and 4th year resident physicians) filmed and observed with patients. PRINCIPAL MEASUREMENTS: Demographic and professional characteristics. Analysis of the communication between physicians and patients, using a CICAA (Connect, Identify, Understand, Agree and Assist, in English) scale. A descriptive, bivariate, multiple linear regression analysis was performed. RESULTS: There were 436 valid interviews. Almost 100% of physicians were polite and friendly, facilitating a dialogue with the patient and allowing them to express their doubts. However, few physicians attempted to explore the state of mind of the patient, or enquire about their family situation or any important stressful events, nor did they ask open questions. Furthermore, few physicians summarised the information gathered. The mean score was 21.43±5.91 points (maximum 58). There were no differences in the total score between gender, city, or type of centre. The linear regression verified that the highest scores were obtained from tutors (B: 2.98), from the duration of the consultations (B: 0.63), and from the age of the professionals (B: -0.1). CONCLUSION: Physicians excel in terms of creating a friendly environment, possessing good listening skills, and providing the patient with information. However the ability to empathise, exploring the psychosocial sphere, carrying out shared decision-making, and asking open questions must be improved. Being a tutor, devoting more time to consultations, and being younger, results in a significant improvement in communication with the patient.

Relationship between Diet, Menstrual Pain and other Menstrual Characteristics among Spanish Students.

This study sought to describe and compare adherence to the Mediterranean diet and consumption of local foods from the Huelva region among Spanish university women in relation to menstrual pain and other menstrual characteristics. This cross-sectional study included 311 health science students. The study variables were sociodemographic and gynecologic characteristics, adherence to the Mediterranean diet using the KIDMED questionnaire, alcohol consumption (SDU) and consumption of local food. A descriptive bivariate analysis and multiple binary regression were performed for menstrual pain. Up to 55.3% of participants had moderate adherence to the Mediterranean diet and only 29.6% had high adherence. Women with low adherence had longer menstrual cycles (p < 0.01). Eating less than two pieces of fruit per day (OR = 3.574; 95%CI = 1.474-8.665; p < 0.05) and eating pulses more than one day a week (OR = 2.320; 95%CI = 1.006-5.348) raised the probability of suffering menstrual pain. A positive correlation between SDU and cycle length was identified (r = 0.119, p = 0.038), and menstrual bleeding was lower in women who consumed olive oil daily (p = 0.044). In conclusion, the Mediterranean diet, alcohol consumption and consuming typical foods from southern Spain appear to influence cycle length, menstrual flow and menstrual pain. Further research is necessary to confirm and expand these findings.

Spontaneous Coronary Artery Dissection and Hypothyroidism.

INTRODUCTION AND OBJECTIVES: Thyroid hormone affects the metabolism of all tissues in the body. The aim of this study was to analyze the prevalence and implications of thyroid disorders in a cohort of consecutive patients with spontaneous coronary artery dissection (SCAD). METHODS: A total of 73 patients with SCAD were analyzed. Baseline characteristics and clinical outcomes were compared between euthyroid and hypothyroid patients. Subsequently, the prevalence of thyroid function abnormalities and the clinical characteristics of SCAD patients were compared with those in 73 patients with acute coronary syndrome but without SCAD, matched by age, sex, and presentation. RESULTS: Mean age was 55 ± 12 years and 26% had hypothyroidism. Compared with patients with normal thyroid function, patients with SCAD and hypothyroidism were all women (100% vs 69%, P = .01), more frequently had dissection in distal (74% vs 41%, P = .03) and tortuous coronary segments (68% vs 41%, p = .03), and more frequently received conservative medical management (79% vs 41%, P = .007). During a mean clinical follow-up of 4.1 ± 3.8 years, 23% of the patients had adverse cardiac events irrespective of thyroid function status. The prevalence of hypothyroidism was higher in patients with SCAD than in matched patients with acute coronary syndrome without SCAD (26% vs 8%, P = .004). CONCLUSIONS: There is a high prevalence of hypothyroidism in patients with SCAD. Patients with SCAD and hypothyroidism are more frequently women, more frequently have distal dissections in tortuous vessels, and are more frequently managed with a conservative medical strategy.

Antibiotic prescribing patterns and hospital admissions with respiratory and urinary tract infections.

OBJECTIVE: To explore the relationship between antibiotic prescribing indicators for assessing the prescribing quality of general practitioners (GPs) and populations' health outcome indicators. DESIGN: Descriptive cross-sectional study. SETTING: Aljarafe Primary Health Care Area (population 321,034) under the administrative jurisdiction of the Andalusian Public Health Care Service, Spain. In total, 162 GPs, representing 95.29% of the total number of GPs in the study area, were included in the analysis. METHODS: Antibiotic prescribing indicators based on clinical evidence and recommendations from local resistance patterns were chosen by the consensus group technique. Hospital admissions due to respiratory tract and urinary infections in the three hospitals of the study area were recorded. Multiple regression analysis was carried out to determine the relationship between community prescribing of antibiotics and hospital admissions due to serious complications from respiratory and urinary infections. RESULTS: The higher prescribing of antibiotics adjusted for patients and working days was associated with a significantly higher number of adjusted hospital admissions due complications arising from respiratory and urinary infections (p < 0.001) (R (2) = 0.142). This relationship was not found for indicators based on the relative prescribing of recommended first-line versus second and third-line antibiotics. There were fewer patients of women GPs admitted to hospitals (p = 0.021). CONCLUSIONS: Our findings show a statistically significant relationship-at the GPs level-between the quantitative antibiotic prescribing rate and standardized hospital admissions due to complications arising from respiratory and urinary infections of the assisted patients. Strategies should be addressed to reduce unnecessary antibiotic prescribing in primary care.

Development of NSAIDs prescription indicators based on health outcomes.

OBJECTIVE: To explore the relationship between prescribing indicators aimed at assessing the prescribing quality of general practitioners (GPs) and indicators of health outcomes at the population level. DESIGN: Ecological study. SETTING: Aljarafe Primary Health Care Area (population 321,034), part of the Andalusian Public Health Care Service, Spain. A total of 162 GPs, representing 95.29% of the total GPs in the study area, participated in the analysis. METHODS: The prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) was determined using evidence-based indicators chosen by the consensus group technique. Admissions to hospitals in the study area due to digestive ulcer, bleeding or perforation were recorded. Multivariate regression analysis was then carried out to determine both the amount of variation in hospital admissions that can be explained by a combination of prescribing indicators and the strength and direction of independent associations with individual indicators. RESULTS: The higher prescription of NSAIDs adjusted for patients and working days (p = 0.002) and the higher relative prescription of gastroprotective agents versus NSAIDs (p < 0.001) were associated with a higher number of adjusted hospital admissions due to gastrointestinal adverse events (coefficient of correlation R = 0.378). In addition, the higher number of prescriptions for analgesics than for NSAIDs was related to fewer admissions (p = 0.028). There were fewer patients of GPs with postgraduate training admitted to hospital for these complaints (p = 0.049). CONCLUSIONS: The risk of hospitalization for serious gastrointestinal adverse events can be partially linked to the prescribing of NSAIDs based on an analysis of the prescribing indicators. A higher prescribing of NSAIDs was associated with significantly higher admissions. This relationship was not found for indicators based on the relative use of some NSAIDs versus total NSAIDs or on the use of gastroprotective drugs.

[Influence of the patient's companion on the discussion and length of the clinical interview in primary health care]. / Influencia del acompañante en la negociación y la duración de la consulta en atención primaria.

OBJECTIVE: To find out the percentage of patients who come accompanied to their medical appointments, their companion's profile and his/her influence on the discussion and the length of the clinical interview in Primary Health Care. DESIGN: Descriptive observational study. SETTING: Adoratrices and La Orden Healthcare Centers. Health District: Huelva-Coast. PARTICIPANTS: Non-probabilistic randomized sample of 390 interviews in November 2007. MAIN MEASUREMENTS: Data was collected by 4 external observers on: the companion and his/her characteristics, length of clinical interview, the interview strategies employed, success and differences when with a companion. RESULTS: The companion was present in 30.5% of the clinical interviews (95% CI, 25.9%-35.3%). The typical companion is female (61.3%), 52 years old, wife and co-worker. Strategies were used in 6.7% of interviews (95% CI, 2.8%-15.6%), the most frequent being signalling. The difference as regards initial exposure without interruption was 2s without and with a companion (p=0.276). The interview finished with a difference of 46 s without companion and with companion (p=0.098). As regards the length of the clinical interview, without discussion it was 7 min long and with discussion 8 min and 38 s (p=0.034). There was discussion in 16.4% of the interviews (95% CI, 12.9%-20.5%) and there was agreement in 88.9% (95% CI, 78.4%-95.4%). The most frequent strategy was that of redirecting objectives. CONCLUSIONS: Approximately one third of the patients came accompanied. The most frequent profile was the co-worker. The companion does not have an effect on the length of the interview. Length increases when there is discussion.

[Validation of the electronic mailing of retinographs of diabetic patients in order to detect retinopathy in primary care]. / Validación de la transmisión por correo electrónico de la retinografía de pacientes diabéticos para detectar retinopatía en atención primaria.

OBJECTIVE: Evaluate concordance in biomicroscopy evaluation of diabetic retinopathy degree among ophthalmologists. Validation of e-mail transmission of digital fundus photographs of type 2 diabetes patients as a method of diabetic retinopathy detection. DESIGN: Descriptive study. SETTING: Urban, primary health centre, and hospital. PARTICIPANTS: Type 2 diabetic patients selected of consecutive form when going to the primary health center (n=352). MAIN MEASUREMENTS: Parallel observer-blind evaluation of degree of retinopathy through biomicroscopy performed by ophthalmologists, against digital photographic images sent by e-mail taken by the family doctors. Concordance in the biomicroscopy among ophthalmologists was previously tested. RESULTS: Retinopathy was revealed in 25.70% of the retinographs; 10.44% was mild, 12.05% moderate, and 3.21% severe. Weighted kappa was 0.876 for biomicroscopy concordance. Sensitivity in detecting retinopathy is 76.6% and specificity 95.2%; 92.7% and 99.5% for ophthalmologist-derivable retinopathy. Sensitivity was 66.7% for non-mydriatic retinograph without dilation, 76.9% with elective dilation, and 85% with the mydriatic. CONCLUSIONS: Concordance in evaluation of retinopathy degree through biomicroscopy was "very good." This allows using a single ophthalmologist's exploration as a reference model. E-mail transmission of the photograph of the back of the eye in type 2 diabetic patients as a retinopathy detection method is feasible. Regardless of the type of retinograph used, the photographs should be taken on the dilated eye, as this significantly improves sensitivity.