Loss of socioemotional and occupational roles in individuals with Long COVID according to sociodemographic and clinical factors: Secondary data from a randomized clinical trial.

BACKGROUND: Long COVID syndrome can have a major impact on life organization. Its persistent symptoms may cause a potentially disabling condition that affects the quality of life of those suffering from it. The resulting loss of functional independence hinders the ability to return to normal life. Many research studies carried out on this novel syndrome have focused on describing its extensive symptomatology. Studies on later repercussions, however, such as disability or loss of significant roles, remain scarce. This study examines the loss of socioemotional and occupational roles experienced by individuals suffering from Long COVID, as a result of the disease. A secondary objective is to analyze the sociodemographic and clinical factors associated with this loss of roles. PATIENTS AND METHODS: A cross-sectional study was conducted with the participation of 100 patients diagnosed with Long COVID, over the age of 18, and attended by Primary Health Care in the Autonomous Community of Aragon. The main study variable was the loss of significant socioemotional and occupational roles by the participants. Sociodemographic and clinical data were also collected through a structured interview. Subsequently, a descriptive, correlational, and regression-based statistical analysis was performed using the SPSS Statistics program. RESULTS: Based on the 100 study participants, the median number of roles lost was 3 (IQR 2) and the median number of valuable roles lost was 2 (IQR 2). More cognitive impairment and not having an active work role were predictors of a greater loss of valuables roles. CONCLUSION: Long COVID symptoms hinder the development of socioemotional and occupational roles. Healthcare professionals should consider this when intervening to ensure that their patients may recover their life as it was before the disease.

Approximation to the Consumption of Healthcare Resources and the Economic Cost of SARS-CoV-2 Patient Management: A Retrospective Study.

Spain has become one of the countries most affected by coronavirus disease 2019 (COVID-19), with the highest testing rates, and one of the worst-performing countries in the fight against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. There are no studies related to the consumption of health resources and the economic cost of the SARS-CoV-2 virus. We present a retrospective analysis of 9,811 (Primary Care and Hospital) patients which aimed to estimate public health expenditure by the consumption of health resources due to COVID-19. According to the results, the gender distribution of patients has a similar rate in both groups, with slightly higher rates in women. Similarly, age is the same in both groups, with a median of 62 years in the case of hospitalizations and 61 years in the case of primary care; using a weighted average of these rates and costs, we can estimate that the average cost of care per patient infected with the SARS-CoV-2 virus, regardless of the course is €2373.24. We conclude that a patient with COVID-19 without hospitalization costs €729.79, while the expenses of a hospitalized patient are between €4294.36 and €14440.68, if there is ICU admission.

The impact of the COVID-19 lockdown on depression sufferers: a qualitative study from the province of Zaragoza, Spain.

BACKGROUND AND PURPOSE: The impact of COVID-19 and its control measures have exacerbated existing mental health conditions. Although the deleterious effects of mental health problems are well known, fewer studies have examined the links between the Social Determinants of Health (SDHs) and depression. This study provides insights into the relationship between SDHs and depression during the first strict lockdown in Spain, which lasted for a period of 7 weeks. METHODS: Fifty-two structured interviews were conducted with people diagnosed with depression during June 2020 in the province of Zaragoza (Spain). Interviews were conducted by telephone due to lockdown constraints. Inductive thematic content analysis was used to explore, develop, and define emergent categories of analysis, which were mapped against the SDH framework. RESULTS: Listening to people's experiences of living with depression during lockdown provided insights into their concerns and coping strategies, which are greatly influenced by the conditions in which they live, their job and their age. Examples of these factors include access to and quality of physical spaces, including housing conditions and public spaces for socialising, social support, adverse working conditions which include caring responsibilities, and access to digital technologies and healthcare services. CONCLUSION: SDHs have played a fundamental role in shaping people's health and well-being during the COVID-19 pandemic, and this study has shown that they have a considerable effect on depression outcomes. Governments should consider implementing social welfare programs to tackle both psychosocial problems and material need during crisis situations.

Development and Validation of a Mobile Application as an Adjuvant Treatment for People Diagnosed with Long COVID-19: Protocol for a Co-Creation Study of a Health Asset and an Analysis of Its Effectiveness and Cost-Effectiveness.

OBJECTIVE: To analyse the overall effectiveness and cost-efficiency of a mobile application (APP) as a community health asset (HA) with recommendations and recovery exercises created bearing in mind the main symptoms presented by patients in order to improve their quality of life, as well as other secondary variables, such as the number and severity of ongoing symptoms, physical and cognitive functions, affective state, and sleep quality. METHODS: The first step was to design and develop the technologic community resource, the APP, following the steps involved in the process of recommending health assets (RHA). After this, a protocol of a randomised clinical trial for analysing its effectiveness and cost-efficiency as a HA was developed. The participants will be assigned to: (1st) usual treatment by the primary care practitioner (TAU), as a control group; and (2nd) TAU + use of the APP as a HA and adjuvant treatment in their recovery + three motivational interviews (MI), as an interventional group. An evaluation will be carried out at baseline with further assessments three and six months following the end of the intervention. DISCUSSION: Although research and care for these patients are still in their initial stages, it is necessary to equip patients and health care practitioners with tools to assist in their recovery. Furthermore, enhanced motivation can be achieved through telerehabilitation (TR).

Cost-effectiveness analysis of a multiple health behaviour change intervention in people aged between 45 and 75 years: a cluster randomized controlled trial in primary care (EIRA study).

BACKGROUND: Multiple health behaviour change (MHBC) interventions that promote healthy lifestyles may be an efficient approach in the prevention or treatment of chronic diseases in primary care. This study aims to evaluate the cost-utility and cost-effectiveness of the health promotion EIRA intervention in terms of MHBC and cardiovascular reduction. METHODS: An economic evaluation alongside a 12-month cluster-randomised (1:1) controlled trial conducted between 2017 and 2018 in 25 primary healthcare centres from seven Spanish regions. The study took societal and healthcare provider perspectives. Patients included were between 45 and 75 years old and had any two of these three behaviours: smoking, insufficient physical activity or low adherence to Mediterranean dietary pattern. Intervention duration was 12 months and combined three action levels (individual, group and community). MHBC, defined as a change in at least two health risk behaviours, and cardiovascular risk (expressed in % points) were the outcomes used to calculate incremental cost-effectiveness ratios (ICER). Quality-adjusted life-years (QALYs) were estimated and used to calculate incremental cost-utility ratios (ICUR). Missing data was imputed and bootstrapping with 1000 replications was used to handle uncertainty in the modelling results. RESULTS: The study included 3062 participants. Intervention costs were €295 higher than usual care costs. Five per-cent additional patients in the intervention group did a MHBC compared to usual care patients. Differences in QALYS or cardiovascular risk between-group were close to 0 (- 0.01 and 0.04 respectively). The ICER was €5598 per extra health behaviour change in one patient and €6926 per one-point reduction in cardiovascular risk from a societal perspective. The cost-utility analysis showed that the intervention increased costs and has no effect, in terms of QALYs, compared to usual care from a societal perspective. Cost-utility planes showed high uncertainty surrounding the ICUR. Sensitivity analysis showed results in line with the main analysis. CONCLUSION: The efficiency of EIRA intervention cannot be fully established and its recommendation should be conditioned by results on medium-long term effects. TRIAL REGISTRATION: Clinicaltrials.gov NCT03136211 . Registered 02 May 2017 - Retrospectively registered.

COVID-19 Inequalities: Individual and Area Socioeconomic Factors (Aragón, Spain).

It is essential to understand the impact of social inequalities on the risk of COVID-19 infection in order to mitigate the social consequences of the pandemic. With this aim, the objective of our study was to analyze the effect of socioeconomic inequalities, both at the individual and area of residence levels, on the probability of COVID-19 confirmed infection, and its variations across three pandemic waves. We conducted a retrospective cohort study and included data from all individuals tested for COVID-19 during the three waves of the pandemic, from March to December 2020 (357,989 individuals) in Aragón (Spain). We studied the effect of inequalities on the risk of having a COVID-19 confirmed diagnosis after being tested using multilevel analyses with two levels of aggregation: individuals and basic healthcare area of residence (deprivation level and type of zone). Inequalities in the risk of COVID-19 confirmed infection were observed at both the individual and area level. There was a predominance of low-paid employees living in deprived areas. Workers with low salaries, unemployed and people on minimum integration income or who no longer receive the unemployment allowance, had a higher probability of COVID-19 infection than workers with salaries ≥ €18,000 per year. Inequalities were greater in women and in the second wave. The deprivation level of areas of residence influenced the risk of COVID-19 infection, especially in the second wave. It is necessary to develop individual and area coordinated measures by areas in the control, diagnosis and treatment of the epidemic, in order to avoid an increase in the already existing inequalities.

Effectiveness and cost-effectiveness of a lifestyle modification programme in the prevention and treatment of subclinical, mild and moderate depression in primary care: a randomised clinical trial protocol.

INTRODUCTION: Major depression is a highly prevalent pathology that is currently the second most common cause of disease-induced disability in our society. The onset and continuation of depression may be related to a wide variety of biological and psychosocial factors, many of which are linked to different lifestyle aspects. Therefore, health systems must design and implement health promotion and lifestyle modification programmes (LMPs), taking into account personal factors and facilitators. The main objective of this protocol is to analyse the clinical effectiveness, cost-effectiveness and cost utility of an LMP and an LMP with information and communication technologies (ICTs) as adjunctive treatment for depression in primary care patients. The secondary objectives are to analyse the clinical effectiveness in the subgroup that presents comorbidity and to analyse the correlation between personal factors on health behaviour and lifestyle patterns. METHODS AND ANALYSIS: A randomised, multicenter pragmatic clinical trial with three parallel groups consisting of primary healthcare patients suffering from subclinical, mild or moderate depression. The following interventions will be used: (1) Usual antidepressant treatment with psychological advice and/or psychotropic drugs prescribed by the general practitioner (treatment as usual (TAU)). (2) TAU+LMP. A programme to be imparted in six weekly 90-minute group sessions, intended to improve the following aspects: behavioural activation+daily physical activity+adherence to the Mediterranean diet pattern+sleep hygiene+careful exposure to sunlight. (3) TAU+LMP+ICTs: healthy lifestyle recommendations (TAU+LMP)+monitoring using ICTs (a wearable smartwatch). The primary outcome will be the depressive symptomatology and the secondary outcomes will be the quality of life, the use of health and social resources, personal factors on health behaviour, social support, lifestyle patterns and chronic comorbid pathology. Data will be collected before and after the intervention, with 6-month and 12-month follow-ups. ETHICS AND DISSEMINATION: This study has been approved by the Clinical Research Ethics Committee of Aragón (approval number: C.P.-C.I. PI18/286) and the Research Ethics Committee of the Balearic Islands (IB3950/19 PI). Data distribution will be anonymous. Results will be disseminated via conferences and papers published in peer-reviewed, open-access journals. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03951350).

Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review.

BACKGROUND: Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool. RESULTS: Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias. CONCLUSIONS: DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.

[Equity and patient autonomy in the care strategies for patients with chronic disease of health services in Spain]. / Equidad y autonomía del paciente en las estrategias de atención a personas con enfermedades crónicas en los servicios de salud de España.

OBJECTIVE: To examine the chronic care models of the different Spanish health services and to discuss the ethical questions derived from implementing some of their components. METHOD: Narrative review of care strategies and programmes for chronic patients in the different Autonomous Communities, searching in official health departments' web pages, using the terms "Programmes", "Strategies", "Chronic patients", and "Chronicity". RESULTS: 15 programmes were found. Most of them include all components of the chronic care model, "decision-making support" being under-represented. The main conflicts in the autonomy of patients arise from the use of big data to stratify the population and from telemonitoring. The stratification of population does not consider the social factors that accompany the disease. CONCLUSIONS: Chronic care strategies should consider the autonomy and privacy of patients in the use of clinical data and telemonitoring. In order to be equitable, they would have to provide an integrated health care system, incorporating measures to reduce the inequalities due to the social determinants that accompany the disease.

[What are we doing and what could we do from the health system in community health? SESPAS Report 2018]. / ¿Qué hacemos y qué podríamos hacer desde el sistema sanitario en salud comunitaria? Informe SESPAS 2018.

Health means individual and collective well-being determined by factors that transcend the health services. If the health services want to address the collective dimension of health, a change of approach is required. Community health is theoretically included in legislation, training, coordination and planning with strategic frameworks that involve the coordination and participation of institutions, health services and citizenship. We present a discussion article in which five authors reflect on the situation, barriers, strengths and opportunities for action of the health services in relation to community health. Changes are needed in the actions of the health services in relation to community health and the way they approach it to address the health problems faced by the communities in the current socioeconomic situation. Given that health is an essential right, we will make a shift in action towards participation, equity, social orientation, intersectorality, comprehensive approach, social justice, and health in all policies, so that community health is taken into account in our health system.

Complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in primary health care (EIRA study): study protocol for a hybrid trial.

BACKGROUND: Health promotion is a key process of current health systems. Primary Health Care (PHC) is the ideal setting for health promotion but multifaceted barriers make its integration difficult in the usual care. The majority of the adult population engages two or more risk behaviours, that is why a multiple intervention might be more effective and efficient. The primary objectives are to evaluate the effectiveness, the cost-effectiveness and an implementation strategy of a complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in PHC. METHODS: This study is a cluster randomised controlled hybrid type 2 trial with two parallel groups comparing a complex multiple risk behaviour intervention with usual care. It will be carried out in 26 PHC centres in Spain. The study focuses on people between 45 and 75 years who carry out two or more of the following unhealthy behaviours: tobacco use, low adherence to the Mediterranean dietary pattern or insufficient physical activity level. The intervention is based on the Transtheoretical Model and it will be made by physicians and nurses in the routine care of PHC practices according to the conceptual framework of the "5A's". It will have a maximum duration of 12 months and it will be carried out to three different levels (individual, group and community). Incremental cost per quality-adjusted life year gained measured by the tariffs of the EuroQol-5D questionnaire will be estimated. The implementation strategy is based on the "Consolidated Framework for Implementation Research", a set of discrete implementation strategies and an evaluation framework. DISCUSSION: EIRA study will determine the effectiveness and cost-effectiveness of a complex multiple risk intervention and will provide a better understanding of implementation processes of health promotion interventions in PHC setting. It may contribute to increase knowledge about the individual and structural barriers that affect implementation of these interventions and to quantify the contextual factors that moderate the effectiveness of implementation. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03136211 .Retrospectively registered on May 2, 2017.

Factors related to the development of health-promoting community activities in Spanish primary healthcare: two case-control studies.

OBJECTIVE: Spanish primary healthcare teams have the responsibility of performing health-promoting community activities (CAs), although such activities are not widespread. Our aim was to identify the factors related to participation in those activities. DESIGN: Two case-control studies. SETTING: Performed in primary care of five Spanish regions. SUBJECTS: In the first study, cases were teams that performed health-promoting CAs and controls were those that did not. In the second study (on case teams from the first study), cases were professionals who developed these activities and controls were those who did not. MAIN OUTCOME MEASURES: Team, professional and community characteristics collected through questionnaires (team managers/professionals) and from secondary sources. RESULTS: The first study examined 203 teams (103 cases, 100 controls). Adjusted factors associated with performing CAs were percentage of nurses (OR 1.07, 95% CI 1.01 to 1.14), community socioeconomic status (higher vs lower OR 2.16, 95% CI 1.18 to 3.95) and performing undergraduate training (OR 0.44, 95% CI 0.21 to 0.93). In the second study, 597 professionals responded (254 cases, 343 controls). Adjusted factors were professional classification (physicians do fewer activities than nurses and social workers do more), training in CAs (OR 1.9, 95% CI 1.2 to 3.1), team support (OR 2.9, 95% CI 1.5 to 5.7), seniority (OR 1.06, 95% CI 1.03 to 1.09), nursing tutor (OR 2.0, 95% CI 1.1 to 3.5), motivation (OR 3.7, 95% CI 1.8 to 7.5), collaboration with non-governmental organisations (OR 1.9, 95% CI 1.2 to 3.1) and participation in neighbourhood activities (OR 3.1, 95% CI 1.9 to 5.1). CONCLUSIONS: Professional personal characteristics, such as social sensitivity, profession, to feel team support or motivation, have influence in performing health-promoting CAs. In contrast to the opinion expressed by many professionals, workload is not related to performance of health-promoting CAs.

Cardiovascular risk assessment in hypertensive patients with tests recommended by the European Guidelines on Hypertension.

OBJECTIVE: To evaluate the usefulness of the diagnostic tests recommended by the European Society of Hypertension/Cardiology Guidelines (ESH-ESC 2007) in hypertensive patients classified as being at low or moderate risk, analyzing the change to high risk classification and the characteristics associated with such change. METHODS: A cross-sectional study was made in 391 patients aged between 30 and 80 years recently diagnosed with arterial hypertension in the Primary Care setting. The criteria of the 2007 ESH-ESC Guidelines were followed for the evaluation of risk factors, subclinical organ damage, cardiovascular disease and cardiovascular risk. In addition to the routine tests, echocardiography, carotid ultrasound, albumin/creatinine ratio, estimated glomerular filtration rate, ankle-brachial index, pulse wave velocity and retinography were used. We established four levels of testing performed for risk classification. RESULTS: Using the routine tests to evaluate risk (level 1), 218 (55.8%) patients were classified as being at high risk. Of the 173 patients classified as presenting low or moderate risk, the ankle-brachial index, albumin/creatinine ratio and glomerular filtration rate were determined (level 2), and 18 patients (10.4%) were classified as being at high risk. With echocardiography and carotid ultrasound (level 3), another 16 patients (10%) were raised to high risk. Finally, with pulse wave velocity and retinography (level 4), 10 additional patients (5%) were classified as presenting high risk. Patients with increased blood pressure, advanced age and women showed a 4.28-fold (95%CI: 2.01-9.16), 3.54-fold (95%CI: 1.61-7.77) and 1.36-fold (95%CI: 0.62-3.00) higher probability of being reclassified to high cardiovascular risk, respectively. CONCLUSIONS: With the non-routine tests, 25.4% of the low or moderate risk patients were reclassified as presenting high risk.

Comparative study of paediatric prescription drug utilization between the Spanish and immigrant population.

BACKGROUND: The immigrant population has increased greatly in Spain in recent years to the point where immigrants made up 12% of the infant population in 2008. There is little information available on the profile of this group with regard to prescription drug utilization in universal public health care systems such as that operating in Spain. This work studies the overall and specific differences in prescription drug utilization between the immigrant and Spanish population. METHODS: Use was made of the Aragonese Health Service databases for 2006. The studied population comprises 159,908 children aged 0-14 years, 13.6% of whom are foreign nationals. Different utilization variables were calculated for each group. Prescription-drug consumption is measured in Defined Daily Doses (DDD) and DDD/1000 persons/day/(DID). RESULTS: A total of 833,223 prescriptions were studied. Utilization is lower for immigrant children than in Spanish children for both DID (66.27 v. 113.67) and average annual expense (euro21.55 v. euro41.14). Immigrant children consume fewer prescription drugs than Spanish children in all of the therapy groups, with the most prescribed (in DID) being: respiratory system, anti-infectives for systemic use, nervous system, sensory organs. Significant differences were observed in relation to the type of drugs and the geographical background of immigrants. CONCLUSION: Prescription drug utilization is much greater in Spanish children than in immigrant children, particularly with reference to bronchodilators (montelukast and terbutaline) and attention-disorder hyperactivity drugs such as methylphenidate. There are important differences regarding drug type and depending on immigrants' geographical backgrounds that suggest there are social, cultural and access factors underlying these disparities.