Sex-dependent effect of socioeconomic status on cardiovascular event risk in a population-based cohort of patients with type 2 diabetes.

BACKGROUND: Socioeconomic status (SES) factors often result in profound health inequalities among populations, and their impact may differ between sexes. The aim of this study was to estimate and compare the effect of socioeconomic status indicators on incident cardiovascular disease (CVD)-related events among males and females with type 2 diabetes (T2D). METHODS: A population-based cohort from a southern European region including 24,650 patients with T2D was followed for five years. The sex-specific associations between SES indicators and the first occurring CVD event were modeled using multivariate Fine-Gray competing risk models. Coronary Heart Disease (CHD) and stroke were considered secondary outcomes. RESULTS: Patients without a formal education had a significantly higher risk of CVD than those with a high school or university education, with adjusted hazard ratios (HRs) equal to 1.24 (95%CI: 1.09-1.41) for males and 1.50 (95%CI: 1.09-2.06) for females. Patients with <18 000€ income had also higher CVD risk than those with ≥18 000€, with HRs equal to 1.44 (95%CI: 1.29-1.59) for males and 1.42 (95%CI: 1.26-1.60) for females. Being immigrant showed a HR equal to 0.81 (95%CI: 0.66-0.99) for males and 1.13 (95%CI: 0.68-1.87) for females. Similar results were observed for stroke, but differed for CHD when income is used, which had higher effect in females. CONCLUSION: Socioeconomic inequalities in CVD outcomes are present among T2D patients, and their magnitude for educational attainment is sex-dependent, being higher in females, suggesting the need to consider them when designing tailored primary prevention and management strategies.

[Emotional overload of health personnel of the Navarra Health Service during the SARS-CoV-2 pandemic]. / Sobrecarga emocional del personal sanitario del Servicio Navarro de Salud durante la pandemia del SARS-CoV-2.

INTRODUCTION: Health care workers faced unprecedented levels of emotional burden related to the COVID-19 pandemic.. This study aims to find out the self-perception of the state of emotional overload of the professionals of the Navarre Osasunbidea Health Service (SNS-O) at two moments during the pandemic and its associated factors. METHOD: Cross-sectional study using a questionnaire that includes the Emotional Overload Self-Assessment Scale sent by email to all SNS-O health professionals at two moments of the pandemic, in October 2020 and October 2021. Results of the global scale and of the subscales '"fear-anxiety"' and ""affective response"' were compared between the two moments of measurement according to position, field, area and service using ANCOVA models. RESULTS: The number of responding participants in the 2020 survey was 1 485 (11,3%) and 950 in the 2021 survey (7,3%). The mean difference for overall score between 2020 and 2021 was -1.87 (95% CI: -2.38, -1.35), indicating less worrying results with the passage of time since the start of the pandemic, with some differences accross occupational categories. CONCLUSIONS: The year 2020 had a great impact on the emotional overload that decreased the following year. One of the greatest fears of health personnel during their occupational exposure to epidemic infectious diseases continues to be the fear of contracting the disease and transmitting it to their family members and social environment. As the proximity to the patient and their environment increases, the probability of psycho-emotional affectation increases.

OBJETIVO: Los trabajadores de la salud se enfrentaron a niveles sin precedentes de carga emocional relacionada con la pandemia de la COVID-19. Este estudio pretende conocer la autopercepción del estado de sobrecarga emocional de los profesionales del Servicio Navarro de Salud-Osasunbidea (SNS-O) en dos momentos durante la pandemia y sus factores asociados. Método: Estudio transversal mediante el uso de un cuestionario que incluye la Escala de Autoevaluación de Sobrecarga Emocional, enviado por correo electrónico a todos los profesionales sanitarios del SNS-O en dos momentos de la pandemia, en octubre de 2020 y octubre de 2021. Los resultados de la escala global y de las subescalas '"miedos-ansiedad"' y '"respuesta afectiva"' se compararon entre los dos momentos de medición según puesto de trabajo, ámbito, área y servicio, mediante modelos ANCOVA?.  Resultados: Participaron en la encuesta de 2020 1.485 (11,3%) sanitarios y 950 (7,3%) en la encuesta de 2021 de. La diferencia media para el score global entre 2020 y 2021 fue -1.87 (95% IC: -2.38, -1.35), indicando una reducción de la sobrecarga emocional con la evolución de la pandemia, con algunas diferencias entre categorías profesionales. CONCLUSIONES: El año 2020 tuvo gran impacto en la sobrecarga emocional que disminuyó al año siguiente. Uno de los mayores temores del personal sanitario durante su exposición laboral a enfermedades infecciosas epidémicas sigue siendo el miedo a contraer la enfermedad y transmitirla a sus familiares y entorno social. Conforme aumenta la proximidad con el paciente y su entorno, incrementa la probabilidad de afectación psicoemocional.

The Answer to "When to Clip" After Colorectal Endoscopic Mucosal Resection Based on a Cost-Effectiveness Analysis.

INTRODUCTION: Delayed bleeding (DB) is the most common major complication of endoscopic mucosal resection (EMR). Two randomized clinical trials recently demonstrated that clip closure after EMR of large nonpedunculated colorectal polyps (LNPCPs) reduces the risk of DB. We analyzed the cost-effectiveness of this prophylactic measure. METHODS: EMRs of LNCPCPs were consecutively registered in the ongoing prospective multicenter database of the Spanish EMR Group from May 2013 until July 2017. Patients were classified according to the Spanish Endoscopy Society EMR group (GSEED-RE2) DB risk score. Cost-effectiveness analysis was performed for both Spanish and US economic contexts. The average incremental cost-effectiveness ratio (ICER) thresholds were set at 54,000 € or $100,000 per quality-adjusted life year, respectively. RESULTS: We registered 2,263 EMRs in 2,130 patients. Applying their respective DB relative risk reductions after clip closure (51% and 59%), the DB rate decreased from 4.5% to 2.2% in the total cohort and from 13.7% to 5.7% in the high risk of the DB GSEED-RE2 subgroup. The ICERs for the universal clipping strategy in Spain and the United States, 469,706 € and $1,258,641, respectively, were not cost effective. By contrast, selective clipping in the high-risk of DB GSEED-RE2 subgroup was cost saving, with a negative ICER of -2,194 € in the Spanish context and cost effective with an ICER of $87,796 in the United States. DISCUSSION: Clip closure after EMR of large colorectal lesions is cost effective in patients with a high risk of bleeding. The GSEED-RE2 DB risk score may be a useful tool to identify that high-risk population.

Trends and area variations in Potentially Preventable Admissions for COPD in Spain (2002-2013): a significant decline and convergence between areas.

BACKGROUND: Potentially Preventable Hospitalizations (PPH) are hospital admissions for conditions which are preventable with timely and appropriate outpatient care being Chronic Obstructive Pulmonary Disease (COPD) admissions one of the most relevant PPH. We estimate the population age-sex standardized relative risk of admission for COPD-PPH by year and area of residence in the Spanish National Health System (sNHS) during the period 2002-2013. METHODS: The study was conducted in the 203 Hospital Service Areas of the sNHS, using the 2002 to 2013 hospital admissions for a COPD-PPH condition of patients aged 20 and over. We use conventional small area variation statistics and a Bayesian hierarchical approach to model the different risk structures of dependence in both space and time. RESULTS: COPD-PPH admissions declined from 24.5 to 15.5 per 10,000 persons-year (Men: from 40.6 to 25.1; Women: from 9.1 to 6.4). The relative risk declined from 1.19 (19 % above 2002-2013 average) in 2002 to 0.77 (30 % below average) in 2013. Both the starting point and the slope were different for the different regions. Variation among admission rates between extreme areas dropped from 6.7 times higher in 2002 to 4.6 times higher in 2013. CONCLUSIONS: COPD-PPH conditions in Spain have undergone a strong decline and a reduction in geographical variation in the last 12 years, suggesting a general improvement in health policies and health care over time. Variability among areas still remains, with a substantial room for improvement.

Comorbidity and prognostic indices do not improve the 5-year mortality prediction of components of comprehensive geriatric assessment in hospitalized older patients.

BACKGROUND: Advancing age is associated with increased vulnerability to chronic health problems. Identifying factors that predict oldest-old status is vital for developing effective clinical interventions and public health strategies. METHODS: Observational prospective study of patients aged 75 years and older consecutively admitted to an Acute Geriatric Ward of a tertiary hospital. After a comprehensive geriatric assessment all patients were assessed for five comorbidity indices and two prognostic models. Univariate and multivariate logistic regression models were fitted to assess the association between each score and 5-year mortality. The ability of each score to predict mortality was assessed using the area under the receiver operating characteristic curve. RESULTS: 122 patients were enrolled. All patients were followed up for five years. 90 (74%) of them died during the study period. In the logistic regression analyses, apart from age, cognitive impairment and Barthel Index, three indices were identified as statistically associated with 5-year mortality: the Geriatric Index of Comorbidity and the two prognostic indices. The multivariate model that combined age, sex, cognitive impairment and Barthel showed a good discriminate ability (AUC = 0.79), and it did not improve substantially after adding individually any of the indices. CONCLUSIONS: Some prognostic models and the Geriatric Index of Comorbidity are better than other widely used indices such as the Charlson Index in predicting 5-year mortality in hospitalized older patients, however, none of these indices is superior to some components of comprehensive geriatric assessment.

Shared component modelling as an alternative to assess geographical variations in medical practice: gender inequalities in hospital admissions for chronic diseases.

BACKGROUND: Small area analysis is the most prevalent methodological approach in the study of unwarranted and systematic variation in medical practice at geographical level. Several of its limitations drive researchers to use disease mapping methods -deemed as a valuable alternative. This work aims at exploring these techniques using - as a case of study- the gender differences in rates of hospitalization in elderly patients with chronic diseases. METHODS: Design and study setting: An empirical study of 538,358 hospitalizations affecting individuals aged over 75, who were admitted due to a chronic condition in 2006, were used to compare Small Area Analysis (SAVA), the Besag-York-Mollie (BYM) modelling and the Shared Component Modelling (SCM). Main endpoint: Gender spatial variation was measured, as follows: SAVA estimated gender-specific utilization ratio; BYM estimated the fraction of variance attributable to spatial correlation in each gender; and, SCM estimated the fraction of variance shared by the two genders, and those specific for each one. RESULTS: Hospitalization rates due to chronic diseases in the elderly were higher in men (median per area 21.4 per 100 inhabitants, interquartile range: 17.6 to 25.0) than in women (median per area 13.7 per 100, interquartile range: 10.8 to 16.6). Whereas Utilization Ratios showed a similar geographical pattern of variation in both genders, BYM found a high fraction of variation attributable to spatial correlation in both men (71%, CI95%: 50 to 94) and women (62%, CI95%: 45 to 77). In turn, SCM showed that the geographical admission pattern was mainly shared, with just 6% (CI95%: 4 to 8) of variation specific to the women component. CONCLUSIONS: Whereas SAVA and BYM focused on the magnitude of variation and on allocating where variability cannot be due to chance, SCM signalled discrepant areas where latent factors would differently affect men and women.