Do internists know what limitation of therapeutic effort means? / ¿Saben los internistas qué es la limitación del esfuerzo terapéutico?

OBJECTIVES: To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. METHODS: A survey was administered to Spanish internists on their knowledge of LTE and the training in palliative care. RESULTS: A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most often chosen responses were «not starting an active treatment¼(85.0%) and «withdrawing an active treatment¼ (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing the planning for end-of-life care with the patient, and 81.3% stated that they had had some conflict with their LTE decisions. CONCLUSIONS: Only 1 of every 4 internists knew the proper definition for LTE, with no association with the level of training in palliative care.

The natural history of Parkinson's disease in the province of Segovia: mortality in a longitudinal study (20-year follow-up).

OBJECTIVE: We determined mortality rates and predictors of survival in 273 patients with Parkinson's disease based on a 20-year follow-up longitudinal study. MATERIAL AND METHODS: We examined 273 patients with Parkinson's disease during a 20-year follow-up, recruited between 1978 and 1998. All patients were regularly followed at the Department of Neurology until December 31, 1998, or death. RESULTS: By then, 69 patients had died, crude mortality was rate 4.43, and standardized mortality ratio for the total patient group was 1.39 (95% CI, 1.10-1.50). As Parkinson's disease is a chronic progressive disorder in adult life, disease-related mortality would be expected to increase in later stages after 15 or 20 years. Mean age at death in our cohort was 78.27 (95% CI, 76.90-79.20). Median time of death was 11 years (95% CI, 9.50-12.49). Independent predictors of mortality during the follow-up were age at onset (hazard ratio, 1.05; 95% CI, 1.01-1.09; P = 0.01), clinical form - akinesia and rigidity (hazard ratio, 2.20; 95% CI, 1.06-4.88; P = 0.03) - and treatment with dopaminergic agonist (hazard ratio, 0.49; 95% CI, 0.23-1.03; P = 0.06). Cardiovascular disease was the most frequent cause of death in 42%. CONCLUSIONS: This study suggests a link between mortality with age of onset and treatment without dopamine agonists as initial treatment. So, there is an association between decreased mortality and tremor as initial clinical forms at onset.

Latex allergy in primary care providers.

BACKGROUND: Health care workers represent one of the major risk groups for developing latex allergy. Most studies have examined hospital workers. The aims of this study were to analyze the prevalence of latex allergy in primary care providers and to describe the characteristics of health care workers who are allergic to latex. MATERIAL AND METHODS: A self-administered questionnaire on work activity, history of symptoms, and allergic reactions to latex products was completed by a sample of primary care workers. Skin prick tests were performed with a commercial latex extract, and serum specific immunoglobulin (Ig) E to latex and its main allergens was determined. RESULTS: Of the 620 workers contacted, 341 completed the questionnaire and 170 were tested with latex allergens. The prevalence of latex allergy was 5.9% (95% confidence interval 2.4%-9.4%). Most allergic workers with a previous diagnosis of latex allergy showed negative or lowered specific IgE levels and a reduced wheal size to latex in comparison with the previous tests. We found 3 cases with elevated latex-specific IgE due to cross-reactivity with pollen profilin, although the results were not clinically relevant. Allergy to latex was associated with the number of surgical interventions and with allergy to kiwi, banana, chestnuts, and avocado. CONCLUSIONS: The prevalence of latex allergy in this study was 5.9%. The importance of a firm diagnosis at the onset of symptoms should be stressed, since reducing contact with latex can yield negative test results. Assessment of IgE reactivity to the individual latex allergens (component-resolved diagnosis) can detect sensitization to panallergens such as profilin and help to clarify the diagnosis.

Do internists know what limitation of therapeutic effort means?

OBJECTIVES: To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding. METHODS: A survey was administered to Spanish internists on their knowledge of LTE and training in palliative care. RESULTS: A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most frequently selected responses were "not starting an active treatment" (85.0%) and "withdrawing an active treatment" (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing planning for end-of-life care with a patient, and 81.3% stated that they had experienced some conflict with their LTE decisions. CONCLUSIONS: Only 1 of every 4 internists knew the proper definition of LTE, with no association with the level of training in palliative care.

Limitation of therapeutic effort in patients hospitalised in departments of internal medicine. / Limitación del esfuerzo terapéutico en pacientes hospitalizados en servicios de medicina interna.

INTRODUCTION: There is little information on the limitation of therapeutic effort (LTE) in patients admitted to hospital internal medicine units. OBJECTIVES: To describe the indicated LTE regimens in the departments of internal medicine and the characteristics of the patients who undergo them. PATIENTS AND METHODS: An observational, descriptive retrospective study was conducted on 4 hospitals of the Community of Madrid. The study collected demographic and comorbidity data and the LTE orders prescribed for all patients who died during a period of 6 months. RESULTS: The study included 382 patients with a mean age of 85±10 years; 204 were women (53.4%) and 222 (58.1%) came from their homes. Some 51.1% of the patients were terminal, 43.2% had moderate to severe dementia, and 95.5% presented at least moderate comorbidity. Some type of LTE was performed in 318 patients (83.7%); the most common orders were "No cardiopulmonary resuscitation" (292 patients, 76.4%; 95% CI 72.1-80.8), "Do not use aggressive measures" (113 patients, 16.4%; 95% CI 13.7-19.4) and "Do not transfer to an intensive care unit" (102 cases, 14.8%, 95% CI 12.3-17.7). Some type of LTE was performed in 318 patients (83.7%); the most common orders were "No cardiopulmonary resuscitation" (292 patients, 76.4%; 95% CI 72.1-80.8), "Do not use aggressive measures" (113 patients, 16.4%; 95% CI 13.7-19.4) and "Do not transfer to an intensive care unit" (102 cases, 14.8%, 95% CI 12.3-17.7). CONCLUSIONS: LTE is common among patients who die in Internal Medicine. The most widely used regimens were "No CPR" and the unspecific statement "Do not use aggressive measures". The patients were elderly and had significant comorbidity, terminal illness and advanced dementia.

[Morbidity in primary health care: patients versus visits]. / Estudios de morbilidad atendida en atención primaria: pacientes versus visitas.

The introduction of the Family and Community Medicine specialist in Spain implied the beginning of an epidemiological approach in the activities of primary care, and the publication of the first studies on cared morbidity. Variations in tolerance threshold to illness by patients, differences in perception of health problems by physicians, the lack of a consensus on the definition of events that should be registered, together with the lack of a census of the eligible population are important problems for the development of such studies. The majority of studies published in our country have not overcome all these problems in an acceptable way.

[The demand stemming from general medicine consultations of primary care teams managed by INSALUD. Instituto Nacional de la Salud]. / Demanda derivada en las consultas de medicina general de los equipos de atención primaria gestionados por el INSALUD.

We report the results of the study of the referrals to specialized care during the second quarter of 1989 in the primary health care teams run by the National Institute of Health (INSALUD). The average rate was 6.9 referrals/100 medical visits with an important degree of variability among the teams. The teams with the highest referral rates showed valves three times higher than those with lowest rates (11.8/100 vs. 3.5/100). There was also variability among regions (Autonomous Communities). The teams that referred more frequently also used diagnostic procedures more often. The number of patients visited did not play a relevant role in the referral pattern.

[Applicability of the ICF in measuring functioning and disability in unipolar depression in Primary Care settings]. / Aplicación de la CIF para el estudio y evaluación del funcionamiento y la diacapacidad en depresión unipolar en el ámbito de atención primaria.

INTRODUCTION: We use the biopsychosocial model of the International Classification of Functioning, Disability, and Health (ICF): a) to analyze functioning and disability patterns in unipolar depression cases attended in primary care settings; b) to study predictive and mediator variables related to disability in depression, and c) to determine the impact of traditional interventions in depression cases using functional remission as outcome measure. DESIGN: Naturalistic, prospective, longitudinal. SETTING: Multicenter study in primary care. Health Area 2. Region of Madrid. PARTICIPANTS: Adult patients with a diagnosis of unipolar depression who initiate psychopharmacological treatment with selective serotonin reuptake inhibitor (SSRI) in primary care sites. Patients with history of bipolar disorders, psychotic disorders, dementias, and dependence of toxic substances will be excluded. MAIN MEASUREMENTS: Level of functioning and disability in different domains of well-being assessed through ICF related instruments. Stressful life events, social support and cognitive schemes will be analyzed as mediator variables. Socio-demographic and clinical characteristics, psychopharmacological treatment and treatment compliance are considered independent factors. DISCUSSION AND PRACTICAL USE: Selection bias may affect the generalization of the results. The biopsychosocial model underlying the ICF and its methodology are applied to the study of depression in primary care settings for the first time in Spain. Improving our understanding of disability related factors in depressive patients is expected. This study is one of the main research priorities of the EU (MHADIE project).

[Evaluation of referrals in primary care]. / Evaluación de la demanda derivada en atención primaria.

OBJECTIVE: To study the process of referral from primary care in a health area in Madrid. The second objective was to evaluate the trends in the referral process. DESIGN: Observational, descriptive and cross-sectional study. SETTING: Three urban health centers in the Area 2. PARTICIPANTS: All referrals made by 13 doctors during 3 consecutive weeks. The total number of visits attended were 6012. The study was realized between February 2002 and January 2003. MAIN MEASUREMENTS: Patient, doctor and referral characteristics on every referral. RESULTS: 349 referrals were studied. The rate of referral 5.8% (5.21-6.39). The referred patients, 65.5% women, medium age 50.6+/-21. The specialties that received more referrals are gynecologist, ophthalmology, dermatology, otorhinolaryngology, rehabilitation, orthopedic surgeon and general surgeon. The most common conditions referred, 25.6% of all referrals, are gynecologist check, blindness, other illnesses of subcutaneous cellular tissue, arthrosis, joint pain, diabetes, benign neoplasm of skin, depression and hypoacusis. 92.3% of the referrals were sent to the specialist center. 89.7% were normal (no urgent). The reason for referral was to accede to the patient's request in 18.3% of the referrals. CONCLUSIONS: The process of referral is similar to previous studies. Although people are more participative, have more information and the defensive medicine is increasing, the process of referral have not changed.

[Factors affecting drug expenditure in the primary care centre in a health area]. / Factores condicionantes del gasto en farmacia en los centros de atención primaria de un área de salud.

OBJECTIVE: To identify the factors affecting drug expenditure.Design. Cross-sectional study.Setting. Madrid Primary Care area. PARTICIPANTS: 21 health centres. MEASUREMENTS: Association of the drug expenditure per inhabitant of each health centre during 1999 with the characteristics of its staff and operation of the centre. MAIN RESULTS: Expenditure on drugs per inhabitant, 14360 plus minus 3040 pesetas (86.31 plus minus 18.27; general practitioners, 19.62 plus minus 23.8%; doctors working as locums, 40.48 plus minus 20.72%; women doctors, 59.76 plus minus 13.36%; family doctors, 38.57 plus minus 21.35%; team nurses, 86.6 plus minus 18.27%; population over 65, 18.03 plus minus 7.73%; patients per day attended by each general practitioner, 32.82 plus minus 3.81; number of sessions per year on prescription profiles, 5 plus minus 3.91; prescription avoidable because of health card: 3106 plus minus 808 pesetas (18.67 plus minus 4.86 ); compliance with service offer, 1.7 plus minus 3.78. Drug expenditure per inhabitant dropped when sessions on prescription profiles (p = 0.013), the percentage of women doctors (p = 0.067) and the percentage of family doctors (p = 0.035) increased; and it dropped too when the over-65 population (p = 0.099) and the amount of prescription avoidable through the card (p = 0.034) dropped. In the multivariate analysis, the sessions on prescription profiles (ss = -843), the percentage of nurses in the reformed model (ss = -155), the percentage of family doctors (ss = -142) and the percentage of doctors from the traditional model (ss = -121) explain 71.2% of the variability in drug expenditure per inhabitant (F = 6.909; p = 0.002). CONCLUSIONS: The sessions to discuss prescription profiles, the presence of nurses from the reform model, postgraduate medical training and the employment of doctors under the traditional model are the factors that our study finds are linked to lower drug expenditure per inhabitant.

[The frequency of illnesses attended and its relationship with the maintenance of the family doctor's skill]. / La frecuencia de las enfermedades atendidas y su relación con el mantenimiento de la destreza del médico de familia.

OBJECTIVE: To describe the incidence of health problems dealt with less often in primary care medical consultations, and to discuss its relationship with the maintenance of professional skill, with in-work training and case-load planning. DESIGN: A prospective observational study based on a year's recording. SETTING: The clinics of 44 primary care doctors from 10 autonomous communities. PATIENTS: 418,98 people were attended. INTERVENTIONS: The unit of analysis was the care episode. The incidence per 1000 people attended, in total and by demographic mean, of the less common health complaints (incidence less than 1/1000) was calculated. RESULTS: Primary care doctors attended at greater frequency than 1/1000 all diseases of eyes, ears, mastoids (except salpingitis) and menstrual disorders codifiable under the classification CIPSAP; almost all the respiratory, skin and locomotive diseases, and more than half of the circulatory, genito-urinary, digestive and endocrine-metabolic diseases. Incidence was less than 1/1000 in all the malignant tumours and contagious diseases, except viral hepatitis and tuberculosis in the urban setting. CONCLUSIONS: Primary care doctors do not often attend certain serious diseases, which are nevertheless present in many differential diagnoses (malignant tumours). This should be borne in mind in the training strategies aimed at maintaining doctor's diagnostic skills.

[The referral system: a study on relations between general practitioners and specialists]. / La demanda derivada: un estudio de la relación entre médicos generales y especialistas.

BACKGROUND: To describe the general practitioners referral patterns. There is special emphasis in the delay between the referral and the first consultation with the specialist. Also we consider other aspects of the coordination between both levels of care. METHODS: Cross-sectional study upon 8.095 referrals from 242 spanish doctors. RESULTS: The referral rate was 6.63%, higher in the 15-44 age group and also for men. We find a huge variability in the referral rates among doctors. The referral rates are higher to surgical specialties. The mean delay between referral and specialist appointment was 11 days. The general practitioners didn't receive communication from the specialists in 23.5 of the referrals. CONCLUSIONS: A considerable range of referral rates has been identified. There is a poor continuity and coordination in the patient care.

[Assessing the functional ability of a group of elderly people using COOP-WONCA charts]. / Medición de la capacidad funcional, con las láminas COOP-WONCA, en una población anciana.

OBJECTIVE: To describe the functional ability of elderly people and analyse its relationship to the use of services. DESIGN: A crossover study. SETTING: An urban population within the metropolitan area of the Community of Madrid. PARTICIPANTS: A random sample of 300 people over 70, taken from the municipal census. MEASUREMENTS AND MAIN RESULTS: Functional ability was measured with COOP-WONCA sheets. 25% of the individuals chosen were excluded due to mistakes in the census. Almost half of the elderly people stated that their health was mediocre or poor; half that their physical ability was limited in some important way; and 37% that their frame of mind caused them some or considerable discomfort. Women perceived their health status as poorer than men did. The number of stated chronic health problems and frame of mind were the most important factors for forecasting use of services. CONCLUSIONS: The prevalence of disturbances in functional ability is high in elderly people. Among the different dimensions of functional ability, frame of mind is that which best forecasts use of primary care clinics.

[The content of the nursing consultation at a health center]. / Contenido de la consulta de enfermería en un centro de salud.

AIMS: To describe the care process in the Nursing Station. To analyse the length of a consultation and factors which affect the length. DESIGN: Crossover study. Analysis of the length of the Consultation, using a multiple lineal regression model. SITE. Urban Health Centre. PATIENTS AND OTHERS TAKING PART: All the calls and consultations, both in the patient's home and in the Health Centre, undertaken by six nurses over a period of two weeks. MAIN MEASUREMENTS AND RESULTS: There were 879 consultations. 65.41% of them took place in the treatment room. Ten health problems represented 72% of the work-load. Health education took un the greatest proportion of time. The average time of a consultation was of 10.40 +/- 0.3 minutes. The length of the consultation depended on the professional involved, on the place where it took place, on the number of problems which the patient had and on the nature of the main problem: multiple correlation coefficient = 0.74; F = 67.52 (p < 0.00000001). CONCLUSIONS: The nurse faces a very limited number of health problems. Most of her activities are preventive or to do with prevention. The length of the Consultation in greatly conditioned by the amount of morbidity.

Variability in GPs' referral rates in Spain.

The purpose of this study is to explore the causes that may influence the variations on referral rates in a sample of 242 general practitioners (GPs) in Spain. We applied Poisson multivariant regression modeling to analyze the role played by different variables related to doctors, patients and practices. The mean referral rate was 6.92 +/- 0.22 with a variant coefficient of 50.6%. The results of the Poisson model showed a statistically significant variation on the following variables: 1) doctor gender; 2) proportion of consultations to the practice made by male patients; 3) proportion of consultations made by patients over 65 years of age; 4) list size, 5) number of doctors in the PCT; 6) number of practice consultations to each doctor per week; 7) accredited practice for VT; 8) location of practice; 9) proportion of outpatient referrals; 10) proportion of private referrals; 11) proportion of emergency referrals; 12) proportion of referrals in which the patient's attitude did not influence the doctor for the referral; 13) proportion of new referrals. The statistical significance for the final model was very high (P < 0.00001). The study draws attention to the influence of some structural characteristics of health care system on the referral rates that could be modified to reduce the number of referrals from Primary to Secondary Care.

[Effect of the physician's and the patient's sex on the clinical interview]. / Influencia del sexo del médico y del paciente en la entrevista clínica.

OBJECTIVE: To analyse differences attributable to the sex of the doctor and of the patient in the activities and content of the clinic appointment in Primary Attention. DESIGN: Analysis of interaction, in terms of activities and content, in 157 clinic appointments. SITE. General medical consultations in four Primary Attention Public Health Centres. PATIENTS: Those who used the health services on the day of the study. INTERVENTION: Tape recording of the appointments. MAIN MEASUREMENTS AND RESULTS: The interviews were recorded. There were shown to be differences according to the sex of the doctor and of the patient in terms of the development and content of the interviews. The style of the woman doctor involved longer interviews with greater social content; in general sameness of sex (doctor and patient) led to greater mutual complementation in the interviews. CONCLUSIONS: It has been shown that there are differences in the activities and content of the clinic appointments in Primary Attention which depend on the sex of the patient and doctor.

[The most often quoted journals in primary care]. / Las revistas más citadas en atención primaria.

The bibliographical references of original articles published during 1988 in four primary care magazines from diverse cultural backgrounds were analysed: Canadian Family Physician (Canada), Journal of Family Practice (United States), Atención Primaria (Spain), and Journal of the Royal College of General Practitioners (United Kingdom). There are 4,225 bibliographical references used in the 328 original reviewed articles. These references had been published in 725 different magazines, of which the ten most oft-quoted account for 38% of the total references. In addition to the four magazines included in our review, the list includes the following: British Medical Journal, New England Journal of Medicine, Journal of the American Medical Association, Lancet, Canadian Medical Association Journal, Annals of Internal Medicine, and American Journal of Obstetrics and Gynecology.