Malignant asbestos-related disease in a population exposed to asbestos.

OBJECTIVES: The first asbestos fiber cement plant in Spain operated in Cerdanyola, in the Barcelona metropolitan area, between 1907 and 1997. We describe clinical and epidemiological characteristics of patients diagnosed with the malignant asbestos-related disease (ARD) in the area of the plant between 2007 and 2016. METHODS: A prospective, descriptive study was undertaken in the 12 municipalities of the county of Barcelona most proximate to the plant. We describe malignant ARD cases by time of diagnosis, source of exposure, periods of exposure and latency, and distribution by sex. Cumulative incidence and age-standardized incidence rates (ASIR) are calculated. RESULTS: Of 477 patients diagnosed with ARD between 2007 and 2016, 128 (26%) presented with asbestos-associated malignancy. Pleural mesothelioma was noted in 105 patients (82.0%) with a linear trend Z-score of -0.2 (NS) in men and 2.7 (P < .01) in women. The highest ASIRs for malignant ARD (6.1/100 000 residents/year; 95% confidence interval [CI], 2.2-13.3) and pleural mesothelioma (4.8/100 000 residents/year; 95% CI, 1.5-11.6) occurred in municipalities closest to the focal point of contamination. The origin of malignant ARD was nonoccupational in 32.2% of men and 81.6% of women (P < .001). CONCLUSIONS: More than 20 years after the closure of the fiber cement plant, the grave consequences of exposure to asbestos remain. The detection of cases of pleural mesothelioma in men seems to have plateaued whereas in women an ascending trend continues, which principally has its origin in nonoccupational exposures.

Variability in screening prevention activities in primary care in Spain: a multilevel analysis.

BACKGROUND: Despite evidence of the benefits of prevention activities, studies have reported only partial integration and great variability of screening in daily clinical practice. The study objectives were: 1) To describe Primary Health Care (PHC) screening for arterial hypertension, dyslipidaemia, obesity, tobacco use, and excessive alcohol consumption in 2008 in 2 regions of Spain, based on electronic health records, and 2) To assess and quantify variability in screening, and identify factors (of patient, general practitioners and PHC team) associated with being screened, that are common throughout the PHC population. METHODS: Multicentre, cross-sectional study of individuals aged ≥ 16 years (N = 468,940) who visited the 426 general practitioners (GPs) in 44 PHC teams in Catalonia and Navarre in 2008. OUTCOMES: screening for hypertension, dyslipidaemia, obesity, tobacco use, and excessive alcohol consumption. Other variables were considered at the individual (sociodemographics, visits, health problems), GP and PHC team (region among others). Individual and contextual factors associated with the odds of being screened and the variance attributable to each level were identified using the SAS PROC GLIMMIX macro. RESULTS: The most prevalent screenings were for dyslipidaemia (64.4%) and hypertension (50.8%); the least prevalent was tobacco use (36.6%). Overall, the odds of being screened were higher for women, older patients, those with more comorbidities, more cardiovascular risk factors, and more frequent office visits, and those assigned to a female GP, a GP with a lower patient load, or a PHC team with a lower percentage of patients older than 65 years. On average, individuals in Navarre were less likely to be screened than those in Catalonia. Hypertension and dyslipidaemia screenings had the least unexplained variability between PHC teams and GPs, respectively, after adjusting for individual and contextual factors. CONCLUSIONS: Of the studied screenings, those for obesity, tobacco, and alcohol use were the least prevalent. Attention to screening, especially for tobacco and alcohol, can be greatly improved in the PHC setting.

Intervention to improve social and family support for caregivers of dependent patients: ICIAS study protocol.

BACKGROUND: Despite the existence of formal professional support services, informal support (mainly family members) continues to be the main source of eldercare, especially for those who are dependent or disabled. Professionals on the primary health care are the ideal choice to educate, provide psychological support, and help to mobilize social resources available to the informal caregiver.Controversy remains concerning the efficiency of multiple interventions, taking a holistic approach to both the patient and caregiver, and optimum utilization of the available community resources. .For this reason our goal is to assess whether an intervention designed to improve the social support for caregivers effectively decreases caregivers burden and improves their quality of life. DESIGN: CONTROLled, multicentre, community intervention trial, with patients and their caregivers randomized to the intervention or control group according to their assigned Primary Health Care Team (PHCT). STUDY AREA: Primary Health Care network (9 PHCTs). STUDY PARTICIPANTS: Primary informal caregivers of patients receiving home health care from participating PHCTs. SAMPLE: Required sample size is 282 caregivers (141 from PHCTs randomized to the intervention group and 141 from PHCTs randomized to the control group. INTERVENTION: a) PHCT professionals: standardized training to implement caregivers intervention. b) Caregivers: 1 individualized counselling session, 1 family session, and 4 educational group sessions conducted by participating PHCT professionals; in addition to usual home health care visits, periodic telephone follow-up contact and unlimited telephone support. CONTROL: Caregivers and dependent patients: usual home health care, consisting of bimonthly scheduled visits, follow-up as needed, and additional attention upon request.Data analysisDependent variables: Caregiver burden (short-form Zarit test), caregivers' social support (Medical Outcomes Study), and caregivers' reported quality of life (SF-12)INDEPENDENT VARIABLES: a) Caregiver: sociodemographic data, Goldberg Scale, Apgar family questionnaire, Holmes and Rahe Psychosocial Stress Scale, number of chronic diseases. b) Dependent patient: sociodemographic data, level of dependency (Barthel Index), cognitive impairment (Pfeiffer test). DISCUSSION: If the intervention intended to improve social and family support is effective in reducing the burden on primary informal caregivers of dependent patients, this model can be readily applied throughout usual PHCT clinical practice. TRIAL REGISTRATION: Clinical trials registrar: NCT02065427.

Pleural mesothelioma in relation to meteorological conditions and residential distance from an industrial source of asbestos.

OBJECTIVES: Few studies have focused on pleural mesothelioma and environmental exposure in individuals residing around an industrial source of asbestos. The aim of this study is to determine whether residential distance and wind conditions are related to the risk of developing pleural mesothelioma. METHODS: In this retrospective cohort study carried out in an area of Barcelona province (Catalonia, Spain), 24 environmental pleural mesothelioma cases were diagnosed between 2000 and 2009. We calculated the age-standardised incidence rate ratios of developing this disease in the population studied, taking into account the residential distance from the plant. For cases living within a 500-m radius of the plant, the geographical location in relation to the factory was also assessed. RESULTS: The incidence rate of environmental pleural mesothelioma was higher in the population living within 500 m of the plant than in those living in a radius of 500-2000 m and much higher than those living at 2000-10 000 m. The highest incidence rate ratio for pleural mesothelioma (161.9) was found in the southeast quadrant of the 500-m area, coinciding with the predominant wind direction. CONCLUSIONS: Residential distance from an industrial source of asbestos and local wind conditions have a considerable impact on the risk of developing environmental pleural mesothelioma.

Risk factors associated with asbestos-related diseases: a community-based case-control study.

BACKGROUND: Asbestos is a first level carcinogen. However, few epidemiological studies analyse the risk and protective factors associated with asbestos-related diseases and follow up these conditions in the general population. Pleural mesothelioma, caused by inhalation of asbestos fibres at work, at home or in the environment, is the most representative asbestos-related disease.The objectives of this study are to analyse the risk and protective factors associated with asbestos-related diseases and to investigate the incidence of new clinical manifestations in patients already diagnosed with some form of ARD. METHODS/DESIGN: We have designed a matched case-control study with follow up of both cohorts from a population of a health district of the Barcelona province that has been exposed to asbestos for a period of 90 years. DISCUSSION: A better understanding of asbestos-related diseases should improve i) the clinical and epidemiological follow up of patients with this condition; ii) the design of new treatment strategies; iii) and the development of preventive activities. At the end of the study, the two cohorts created in this study (affected cases and healthy controls) will constitute the basis for future research.

Prospective study of asbestos-related diseases incidence cases in primary health care in an area of Barcelona province.

BACKGROUND: Asbestos related diseases include a number of conditions due to inhalation of asbestos fibres at work, at home or in the environment, such as pleural mesothelioma, asbestosis and calcified pleural plaques. Few epidemiological studies have established the incidence of asbestos related diseases in our area. The present proposal is based on a retrospective study externally funded in 2005 that is currently taking place in the same area and largely carried out by the same research team.The aim of the study is to achieve a comprehensive and coordinated detection of all new cases of Asbestos Related Diseases presenting to primary care practitioners. METHODS/DESIGN: This is a multicentre, multidisciplinary and pluri-institutional prospective study.Setting12 municipalities in the Barcelona province within the catchment area of the health facilities that participate in the study.SampleThis is a population based study, of all patients presenting with diseases caused by asbestos in the study area.MeasurementsA clinical and epidemiological questionnaire will be filled in by the trained researchers after interviewing the patients and examining their clinical reports. DISCUSSION: Data on the incidence of the different Asbestos Related Diseases in this area will be obtained and the most plausible exposure source and space-time-patient profile will be described. The study will also improve the standardization of patient management, the coordination between health care institutions and the development of preventive activities related with asbestos exposure and disease.

A quality improvement plan for hypertension control: the INCOTECA Project (INterventions for COntrol of hyperTEnsion in CAtalonia).

BACKGROUND: Different studies have shown insufficient blood pressure (BP) control in hypertensive patients. Multiple factors influence hypertension management, and the quality of primary care is one of them. We decided therefore to evaluate the effectiveness of a quality improvement plan directed at professionals of Primary Health Care Teams (PHCT) with the aim to achieve a better control of hypertension. The hypothesis of the study is that the implementation of a quality improvement plan will improve the control of hypertension. The primary aim of this study will be to evaluate the effectiveness of this plan. DESIGN: multicentric study quasi-experimental before - after with control group. The non-randomised allocation of the intervention will be done at PHCT level. SETTING: 18 PHCT in the Barcelona province (Spain). SAMPLE: all patients with a diagnosis of hypertension (population based study). EXCLUSION CRITERIA: patients with a diagnosis of hypertension made later than 01/01/2006 and patients younger than 18 years. INTERVENTION: a quality improvement plan, which targets primary health care professionals and includes educational sessions, feedback to health professionals, audit and implementation of recommended clinical practice guidelines for the management of hypertensive patients. MEASUREMENTS: age, sex, associated co-morbidity (diabetes mellitus type I and II, heart failure and renal failure). The following variables will be recorded: BP measurement, cardiovascular risk and antihypertensive drugs used. Results will be measured before the start of the intervention and twelve months after the start of the study. Dependent variable: prevalence of hypertensive patients with poor BP control. ANALYSIS: Chi-square test and Student's t-test will be used to measure the association between independent qualitative and quantitative variables, respectively. Non-parametric tests will be used for the analysis of non-normally distributed variables. Significance level (alpha) will be set at < 0.05. Outcomes will be analysed on an intention-to-treat basis. DISCUSSION: The implementation of a quality improvement plan might benefit the coordination of different professionals of PHCTs and may also improve blood pressure control. TRIAL REGISTRATION: This protocol has been registered at clinicaltrials.gov with the ID number MS: 1998275938244441.

Variability in the performance of preventive services and in the degree of control of identified health problems: a primary care study protocol.

BACKGROUND: Preventive activities carried out in primary care have important variability that makes necessary to know which factors have an impact in order to establish future strategies for improvement. The present study has three objectives: 1) To describe the variability in the implementation of 7 preventive services (screening for smoking status, alcohol abuse, hypertension, hypercholesterolemia, obesity, influenza and tetanus immunization) and to determine their related factors; 2) To describe the degree of control of 5 identified health problems (smoking, alcohol abuse, hypertension, hypercholesterolemia and obesity); 3) To calculate intraclass correlation coefficients. DESIGN: Multi-centered cross-sectional study of a randomised sample of primary health care teams from 3 regions of Spain designed to analyse variability and related factors of 7 selected preventive services in years 2006 and 2007. At the end of 2008, we will perform a cross-sectional study of a cohort of patients attended in 2006 or 2007 to asses the degree of control of 5 identified health problems. All subjects older than 16 years assigned to a randomised sample of 22 computerized primary health care teams and attended during the study period are included in each region providing a sample with more than 850.000 subjects. The main outcome measures will be implementation of 7 preventive services and control of 5 identified health problems. Furthermore, there will be 3 levels of data collection: 1) Patient level (age, gender, morbidity, preventive services, attendance); 2) Health-care professional level (professional characteristics, years working at the team, workload); 3) Team level (characteristics, electronic clinical record system). Data will be transferred from electronic clinical records to a central database with prior encryption and dissociation of subject, professional and team identity. Global and regional analysis will be performed including standard analysis for primary health care teams and health-care professional level. Linear and logistic regression multilevel analysis adjusted for individual and cluster variables will also be performed. Variability in the number of preventive services implemented will be calculated with Poisson multilevel models. Team and health-care professional will be considered random effects. Intraclass correlation coefficients, standard error and variance components for the different outcome measures will be calculated.

Intervention for control of hypertension in Catalonia, Spain (INCOTECA Project): results of a multicentric, non-randomised, quasi-experimental controlled intervention study.

OBJECTIVE: The purpose of this study was to assess the effectiveness of a quality improvement (QI) plan aimed at primary healthcare teams (PHCTs) to optimise hypertension control and to compare it with standard clinical care. METHODS: Design Multicentric, non-randomised, quasi-experimental controlled intervention study. Setting 5 PHCTs in the intervention and 13 in the standard care group in the province of Barcelona, Catalonia, Spain. Participants This is a population-based study in which all patients over 18 years of age with a diagnosis of hypertension before 1 January 2006 were included (n=9877 in the intervention group and n=21 704 in the control group). Intervention A QI plan that targeted primary care professionals. The plan included training sessions, implementation of recommended clinical practice guidelines for the management of hypertensive patients and audit and feedback to health professionals. Main outcome measure Prevalence of hypertensive patients with an adequate blood pressure (BP) control. RESULTS: The adjusted difference between intervention and standard care groups in the odds of BP control was 1.3 (95% CI 1.1 to 1.6, p=0.003). Results of the mixed model on repeated measures showed that, on average, an individual in the intervention group had an increase of 92% in the odds of BP control (OR 1.9, 95% CI 1.7 to 2.1). CONCLUSIONS: The implementation of a QI plan can improve BP control. This strategy is potentially feasible for up-scaling within the existing PHCTs. TRIAL REGISTRATION: ClinicalTrials.gov MS: 1998275938244441.

[Asbestos-related diseases in a population near a fibrous cement factory]. / Enfermedad por amianto en una población próxima a una fábrica de fibrocemento.

BACKGROUND AND OBJECTIVE: The first fibrous cement factory in Spain was set up in Cerdanyola, Barcelona, in 1907 and was a source of pollution there until it was closed in 1997. The aim of this study was to determine the clinical and epidemiologic characteristics of the population with by asbestos-related diseases who had worked in the factory and/or lived in the vicinity. MATERIAL AND METHODS: We retrospectively collected information available on patients with asbestos-related diseases who at the time of diagnosis had resided in the area near the fibrous cement factory. Information was obtained from the medical records of the primary care centers of the 12 surrounding towns and the sole referral hospital in the area for cases diagnosed between January 1, 1970 and December 31, 2006. RESULTS: In the 559 patients diagnosed, 1107 cases of asbestos-related diseases were identified. Between 2000 and 2006, the average annual incidence was 9.5 cases per 100,000 inhabitants for the entire study area and 35.5 cases per 100,000 for the area nearest the factory. The prevalence of asbestos-related diseases as of December 31, 2006 was 91 cases per 100,000 inhabitants in the entire study area and 353.4 cases per 100,000 in the area nearest the factory. Of the 1107 asbestos-related disease cases identified, 86.5% were benign and 8.4% pleural mesothelioma. CONCLUSIONS: The factory introduced an important area-wide risk factor for asbestos-related diseases for both workers and for the nearby population. The number of cases of asbestos-related diseases detected annually showed an upward trend. The incidence was extremely high in the period studied.