Frequency and estimated costs of ten low-value practices in the Spanish primary care: a retrospective study.

BACKGROUND: The frequency of low-value practices (LVPs) in the healthcare system is a worldwide challenge. This study aimed to evaluate the LVPs trend in Spanish primary care (PC), its frequency in both sexes, and estimate its related extra cost. METHODS: A multicentric, retrospective, and national research project was conducted. Ten LVPs highly frequent and potentially harmful for patients were analyzed (majority of them related to prescription). Algorithms were applied to collect the data from 28,872,851 episodes registered into national databases (2015-2017). RESULTS: LVPs registered a total of 7,160,952 (26.5%) episodes plus a total of 259,326 avoidable PSA screening tests. In adults, a high frequency was found for inadequate prescription of paracetamol antibiotics, and benzodiazepines . Women received more jeopardizing practices (p ≤ 0.001). Pediatrics presented a downward of antibiotic and paracetamol-ibuprofen prescription combination. The estimated extra cost was close to €292 million (2.8% of the total cost in PC). CONCLUSION: LVPs reduction during the analyzed period was moderate compared to studies following 'Choosing Wisely list' of LVPs and must improve to reduce patient risk and the extra related costs.

["Heparjoc-Actúa": educational tool created through a process of participatory action research with vulnerable immigrant groups to improve accessibility to diagnosis of hepatitis B.] / "HEPARJOC-ACTÚA": herramienta educativa creada a través de un proceso de investigación-acción participativa con colectivos inmigrantes vulnerables para mejorar la accesibilidad al diagnóstico de la hepatitis B.

OBJECTIVE: The World Health Organization estimates that 257 million people suffer from chronic infection by the hepatitis B (HB) virus. It is common for diagnosis to be delayed or never given at all. In Spain, immigrants that come from endemic areas present a prevalence of infection of around 8%. In the year 2015, this study was begun with the aiml of improving accessibility to hepatitis B diagnoses in immigrant communities. METHODS: A descriptive qualitative study was carried out, based on participatory action research (IAP). It was divided into two cycles: in the first cycle, after forming a motor group (GIAP), a participatory community assessment (DCP) was performed with the population, through a descriptive-interpretative qualitative study (ECDI) with 3 focal groups (n=17). A narrative analysis was then performed of thematic content. In the second cycle, two collaborative workshops (coworking) were held to create an educational tool (HEPARJOC) and to co-create an action plan (PDA). As a pilot test, the PDA was put into practice through eight workshops (n=56). A knowledge questionnaire was used to compare the median number of correct responses before and after the workshop, using the t of Student for paired data. RESULTS: A GIAP was formed with 8 members of different sectors and community spaces. In the DCP it was observed that there was a lack of knowledge about different aspects of hepatitis B. Visual, interactive materials were proposed as educational tools, and "HEPARJOC" was created as the final product. In the pilot test of the PDA, the median of correct responses to the knowledge questionnaire about HB was 7.7 (DE=3) before the workshop, and 10.6 (DE=0.2) afterward. The improvement of the median was 2.9 points (IC 95% 2.2-3.6), which is statistically significant (p<0.001). 30 people sought screening (53.6% of participants), and 23 of those people were screened (41% of participants). CONCLUSIONS: "HEPARJOC-ACTUA" is a strategy that could contribute to transforming knowledge and improving accessibility to hepatitis B diagnosis in immigrant communities. Key words: Infectious diseases, hepatitis B, community health, community health agents, health education, participatory action research, immigration. Key words: Infectious.

OBJETIVO: La Organización Mundial de la Salud estima que 257 millones de personas padecen infección crónica por el virus de la hepatitis B (HB). Es habitual que el diagnóstico se retrase o que nunca se llegue a realizar. En España, los inmigrantes procedentes de áreas endémicas presentan prevalencias en torno al 8%. En el año 2015, se inició este estudio con el objetivo de mejorar la accesibilidad al diagnóstico de la hepatitis B en colectivos inmigrantes. METODOS: Se realizó un estudio cualitativo descriptivo, basado en la investigación acción participativa (IAP). Se dividió en dos ciclos: en el primer ciclo, después de configurar un grupo motor (GIAP), se realizó un diagnóstico comunitario participativo (DCP) con la población, a través de un estudio cualitativo descriptivo-interpretativo (ECDI) con 3 grupos focales (n=17). Se llevó a cabo un análisis narrativo de contenido temático. En el segundo ciclo, se realizaron 2 talleres de trabajo colaborativo (coworking) para crear una herramienta educativa (HEPAJOC) y coconstruir un plan de acción (PDA). Como prueba piloto se llevó a cabo este PDA a través 8 talleres (n=56). Se utilizó un cuestionario de conocimientos para comparar la media de respuestas correctas pre y post taller utilizando el t de Student para datos apareados. RESULTADOS: Se configuró un GIAP con 8 miembros de diferentes sectores y espacios comunitarios. En el DCP se observó que existía un desconocimiento en diferentes aspectos sobre la hepatitis B. Se propusieron, como herramientas educativas, materiales visuales e interactivos, elaborando como producto final el "HEPARJOC". En la prueba piloto del PDA, la media de las respuestas correctas al cuestionario de conocimientos sobre la HB fue de 7,7 (DE=3) previamente, y de 10,6 (DE=0,2) posteriormente. La mejoría de la media fue de 2,9 puntos (IC 95% 2,2-3,6), siendo estadísticamente significativa (p<0,001). Solicitaron el cribado 30 personas (53,6%), siendo cribadas 23 (41%). CONCLUSIONES: "HEPARJOC-ACTUA" es una estrategia que puede contribuir a transformar conocimientos y a mejorar la accesibilidad al diagnóstico de la hepatitis B en colectivos inmigrantes.

SOBRINA Spanish study-analysing the frequency, cost and adverse events associated with overuse in primary care: protocol for a retrospective cohort study.

INTRODUCTION: Several institutions and quality national agencies have fostered the creation of recommendations on what not to do to reduce overuse in clinical practice. In primary care, their impact has hardly been studied. The frequency of adverse events (AEs) associated with doing what must not be done has not been analysed, either. The aim of this study is to measure the frequency of overuse and AEs associated with doing what must not be done (commission errors) in primary care and their cost. METHODS AND ANALYSIS: A coordinated, multicentric, national project. A retrospective cohort study using computerised databases of primary care medical records from national agencies and regional health services will be conducted to analyse the frequency of the overuse due to ignore the do-not-do recommendations, and immediately afterwards, depending on their frequency, a representative random sample of medical records will be reviewed with algorithms (triggers) that determine the frequency of AEs associated with these recommendations. Cost will determine by summation of the direct costs due to the consultation, pharmacy, laboratory and imaging activities according to the cases. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Committee of Primary Care Research of the Valencian Community. We aim to disseminate the findings through international peer-reviewed journals and on the website (http://www.nohacer.es/). Outcomes will be used to incorporate algorithms into the electronic history to assist in making clinical decisions. TRIAL REGISTRATION NUMBER: NCT03482232; Pre-results.

Low-value clinical practices and harm caused by non-adherence to 'do not do' recommendations in primary care in Spain: a Delphi study.

OBJECTIVE: To determine the non-adherence to the primary care 'do not do' recommendations (DNDs) and their likelihood to cause harm. DESIGN: Delphi study. SETTING: Spanish National Health System. PARTICIPANTS: A total of 128 professionals were recruited (50 general practitioners [GPs], 28 pediatricians [PEDs], 31 nurses who care for adult patients [RNs] and 19 pediatric nurses [PNs]). INTERVENTIONS: A selection of 27 DNDs directed at GPs, 8 at PEDs, 9 at RNs and 4 at PNs were included in the Delphi technique. A 10-point scale was used to assess whether a given practice was still present and the likelihood of it causing of an adverse event. MAIN OUTCOME MEASURE: Impact calculated by multiplying an event's frequency and likelihood to cause harm. RESULTS: A total of 100 professionals responded to wave 1 (78% response rate) and 97 of them to wave 2 (97% response rate). In all, 22% (6/27) of the practices for GPs, 12% (1/8) for PEDs, 33% (3/9) for RNs and none for PNs were cataloged as frequent. A total of 37% (10/27) of these practices for GPs, 25% (2/8) for PEDs, 33% (3/9) for RNs and 25% (1/4) for PNs were considered as potential causes of harm. Only 26% (7/27) of the DNDs for GPs showed scores equal to or higher than 36 points. The impact measure was higher for ordering benzodiazepines to treat insomnia, agitation or delirium in elderly patients (mean = 57.8, SD = 25.3). CONCLUSIONS: Low-value and potentially dangerous practices were identified; avoiding these could improve care quality.

Effectiveness of computerized point-of-care reminders on adherence with multiple clinical recommendations by primary health care providers: protocol for a cluster-randomized controlled trial.

BACKGROUND: To determine the effectiveness of reminders compared to no reminders in improving adherence to multiple clinical recommendations measured as the resolution of the clinical condition that motivated the reminder, in a primary care setting with a well-established feedback system. METHODS/DESIGN: A 12-month, cluster-randomized, controlled clinical trial was designed (randomized by primary care team) to evaluate the impact of computerized reminders. All study participants will continue to receive the usual feedback from the electronic health records system. The control group (well-established feedback) will be compared with reminders and a well-established feedback system. The study will include all general practitioners (3425) and nurses (3262) providing primary care for a population aged 14 years or older in the 282 primary care teams reporting to the Catalan Institute of Health. Up to 10 clinical reminders are offered for each patient, recommending action related to at least one of nine clinical conditions: arterial hypertension, elevated cardiovascular risk, type 2 diabetes mellitus, cerebrovascular accident, ischemic heart disease, heart failure, atrial fibrillation, smoking habit, and hepatitis C. The outcomes are the resolution of the clinical condition that motivated the reminder and the time elapsed between the first reminder message and implementation of the recommended action (months). Due to the obvious correlation between reminders about the same patient, the profile of patients assigned to a particular professional, and the professionals assigned to a particular centre, hierarchical modelling will be used to simultaneously estimate the effect of the study variables at these different levels of analysis. To estimate the impact of the intervention arm, an analysis of adherence to each type of reminder will be carried out, using multi-level logistical regression models at level of the primary care centre. Time to adherence will be estimated by the Kaplan-Meier method and comparisons will be done using the log-rank test. DISCUSSION: The results of this study could provide new evidence on the impact of computerized reminders at the point of care on adherence to clinical guidelines in primary care with an established feedback system. Trial registration ISRCTN42391639. October 8, 2012.