Effectiveness of a home-based nursing support and cognitive restructuring intervention on the quality of life of family caregivers in primary care: A pragmatic cluster-randomized controlled trial.

BACKGROUND: Caregivers of patients with chronic conditions or disability experience fatigue, burden and poor health-related quality of life. There is evidence of the effectiveness of support interventions for decreasing this impact. However, little is known about the benefits of home-based nursing intervention in primary health care. OBJECTIVES: To evaluate the effectiveness of a home-based, nurse-led-intervention (CuidaCare) on the quality of life of caregivers of individuals with disabilities or chronic conditions living in the community, measured at 12-month follow-up. METHODS: A pragmatic, two-arm, cluster-randomized controlled trial with a 1-year follow-up period was performed between June 2013 and December 2015. Consecutive caregivers aged 65 years or older, all of whom assumed the primary responsibility of caring for people with disabling conditions for at least 6 months a year, were recruited from 22 primary health care centers. Subsequently, 11 centers were randomly assigned to usual care group, and 11 were assigned to the intervention group. The caregivers in the intervention group received the usual care and additional support (cognitive restructuring, health education and emotional support). The primary outcome was quality of life, assessed with the EQ-5D instrument (visual analog scale and utility index score); the secondary outcome variables were perception of burden, anxiety, and depression. Data were collected at baseline, at the end of the intervention, and at the 6- and 12-month follow-up visits. We analyzed the primary outcome as intention-to-treat, and missing data were added using the conditional mean single imputation method. RESULTS: A total of 224 caregivers were included in the study (102 in the intervention group and 122 in the usual care group). Generalized Estimating Equation models showed that the CuidaCare intervention was associated with a 5.46 point (95% CI: 2.57; 8.35) change in the quality of life, as measured with the visual analog scale adjusted for the rest of the variables at 12 months. It also produced an increase of 0.04 point (95% CI: 0.01; 0.07) in the utilities. No statistically significant differences were found between the two groups at 12 months with respect to the secondary outcomes. CONCLUSIONS: The findings suggest that incorporating a home-based, nurse-led-intervention for caregivers into primary care can improve the health-related quality of life of caregivers of patients with chronic or disabling conditions.

Oral versus intramuscular administration of vitamin B12 for vitamin B12 deficiency in primary care: a pragmatic, randomised, non-inferiority clinical trial (OB12).

OBJECTIVES: To compare the effectiveness of oral versus intramuscular (IM) vitamin B12 (VB12) in patients aged ≥65 years with VB12 deficiency. DESIGN: Pragmatic, randomised, non-inferiority, multicentre trial in 22 primary healthcare centres in Madrid (Spain). PARTICIPANTS: 283 patients ≥65 years with VB12 deficiency were randomly assigned to oral (n=140) or IM (n=143) treatment arm. INTERVENTIONS: The IM arm received 1 mg VB12 on alternate days in weeks 1-2, 1 mg/week in weeks 3-8 and 1 mg/month in weeks 9-52. The oral arm received 1 mg/day in weeks 1-8 and 1 mg/week in weeks 9-52. MAIN OUTCOMES: Serum VB12 concentration normalisation (≥211 pg/mL) at 8, 26 and 52 weeks. Non-inferiority would be declared if the difference between arms is 10% or less. Secondary outcomes included symptoms, adverse events, adherence to treatment, quality of life, patient preferences and satisfaction. RESULTS: The follow-up period (52 weeks) was completed by 229 patients (80.9%). At week 8, the percentage of patients in each arm who achieved normal B12 levels was well above 90%; the differences in this percentage between the oral and IM arm were -0.7% (133 out of 135 vs 129 out of 130; 95% CI: -3.2 to 1.8; p>0.999) by per-protocol (PPT) analysis and 4.8% (133 out of 140 vs 129 out of 143; 95% CI: -1.3 to 10.9; p=0.124) by intention-to-treat (ITT) analysis. At week 52, the percentage of patients who achieved normal B12 levels was 73.6% in the oral arm and 80.4% in the IM arm; these differences were -6.3% (103 out of 112 vs 115 out of 117; 95% CI: -11.9 to -0.1; p=0.025) and -6.8% (103 out of 140 vs 115 out of 143; 95% CI: -16.6 to 2.9; p=0.171), respectively. Factors affecting the success rate at week 52 were age, OR=0.95 (95% CI: 0.91 to 0.99) and having reached VB12 levels ≥281 pg/mL at week 8, OR=8.1 (95% CI: 2.4 to 27.3). Under a Bayesian framework, non-inferiority probabilities (Δ>-10%) at week 52 were 0.036 (PPT) and 0.060 (ITT). Quality of life and adverse effects were comparable across groups. 83.4% of patients preferred the oral route. CONCLUSIONS: Oral administration was no less effective than IM administration at 8 weeks. Although differences were found between administration routes at week 52, the probability that the differences were below the non-inferiority threshold was very low. TRIAL REGISTRATION NUMBERS: NCT01476007; EUDRACT (2010-024129-20).

Type 2 diabetes prevalence among Andean immigrants and natives in a Southern European City.

AIMS: Inequalities in diabetes prevalence among immigrants from Andean countries remain unknown. Andean populations are one of the largest groups of immigrants in Madrid city. We examined the association between country of birth and type 2 diabetes mellitus (T2DM) prevalence in Andean immigrant population relative to Spanish-natives; and whether this association varied by age, sex and length of residence. METHODS: We analyzed 1,258,931 electronic medical records from Spanish native and Andean immigrant adults aged 40-75 years of Madrid city. We used logistic regression and test interaction terms to address our aims. RESULTS: Andean immigrants showed 1.13 (95% CI 1.10-1.17) greater adjusted odds for T2DM than Spanish natives. This association was positive in Ecuadorians and Bolivians but protective in Peruvians and Colombians. There was heterogeneity of this association according to age and sex. Relative to Spanish natives, odds of T2DM in Andeans of all ages and women were higher but lower in men. CONCLUSION: Andean adults showed greater odds of T2DM compared with Spanish native adults in Madrid, with variation observed by age and sex. These findings emphasize the need for studying immigrant populations in a disaggregated manner to implement specific clinical and preventive approaches.

A primary healthcare information intervention for communicating cardiovascular risk to patients with poorly controlled hypertension: The Education and Coronary Risk Evaluation (Educore) study-A pragmatic, cluster-randomized trial.

PURPOSE: Uncertainty exists regarding the best way to communicate cardiovascular risk (CVR) to patients, and it is unclear whether the comprehension and perception of CVR varies according to the format used. The aim of the present work was to determine whether a strategy designed for communicating CVR information to patients with poorly controlled high blood pressure (HBP), but with no background of cardiovascular disease, was more effective than usual care in the control of blood pressure (BP) over the course of a year. METHODS: A pragmatic, two-arm, cluster-randomized controlled trial was performed. Consecutive patients aged 40-65 years, all diagnosed with HBP in the last 12 months, and all of whom showed poor control of their condition (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg), were recruited at 22 primary healthcare centres. Eleven centres were randomly assigned to the usual care arm, and 11 to the informative intervention arm (Educore arm). At the start of the study, the Educore arm subjects were shown the "low risk SCORE table", along with impacting images and information pamphlets encouraging the maintenance of good cardiovascular health. The main outcome variable measured was the control of HBP; the secondary outcome variables were SCORE table score, total plasma cholesterol concentration, use of tobacco, adherence to prescribed treatment, and quality of life. RESULTS: The study participants were 411 patients (185 in the Educore arm and 226 in the usual care arm). Multilevel logistic regression showed that, at 12 months, the Educore intervention achieved better control of HBP (OR = 1.57; 1.02 to 2.41). No statistically significant differences were seen between the two arms at 12 months with respect to the secondary outcomes. CONCLUSIONS: Compared to usual care, the Educore intervention was associated with better control of HBP after adjusting for age, baseline SBP and plasma cholesterol, at 12 months.

[The pharmaceutical industry and specialised medical training: Residents' perceptions in Madrid, Spain]. / Industria farmacéutica y formación sanitaria especializada: percepciones de los MIR en Madrid.

OBJECTIVE: To assess the frequency of exposure and attitudes to the pharmaceutical industry (PI) of residents in the Region of Madrid (RM), Spain, and to analyse the association with specialty, professional environment and training. METHODS: Cross-sectional electronic survey in May and June 2015 of all medical residents in RM. We collected sociodemographic variables and those of interaction with the PI in four blocks: frequency of interactions, attitudes and perceptions, environment and regulatory framework, and skills; with the first two blocks we created a Synthetic PI Interaction Index (SPIII). Bivariate and multivariate analysis of logistic regression. RESULTS: 350 resident's responses (28% family and community medicine [FCM], 57% hospital, 15% others). Ninety-eight percent reported interacting with the PI. Twenty percent believed their prescribing was influenced by the PI and 48% believed it was influenced by other doctors. Sixty-five precent considered more training necessary. Ninety-six percent had received no information from their college of physicians, 80% did not know the regulations in their medical society and 50% were unaware of those of their institution. Hospital specialty residents showed more likelihood of SPIII ≥ percentile 75 than those of FCM (odds ratio [OR]: 3.96; 95% confidence interval [95%CI]: 1.88-8.35). Training in informal settings was associated with SPIII ≤ percentile 25 (OR: 2.83; 95%CI: 1.32-6.07). CONCLUSIONS: The medical residents in RM had a high level of interaction with the PI and believed its influence low. Hospital specialty residents showed more interaction with the PI. Regulations were not well known by residents and they consideredmore training necessary.

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy: study protocol of a cluster randomized clinical trial (Multi-PAP project).

BACKGROUND: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12 months, as compared with usual care. METHODS/DESIGN: Design: pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. SCOPE: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). POPULATION: patients aged 65-74 years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3 months). SAMPLE SIZE: n = 400 (200 per study arm). INTERVENTION: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. OUTCOMES: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. STATISTICAL ANALYSIS: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. DISCUSSION: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02866799.

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project): a clinical trial by clusters.

BACKGROUND: Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6 months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs. METHODS/DESIGN: We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment. The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6 months post-intervention, using 95 % confidence intervals. A linear multilevel regression will be used to adjust the model. DISCUSSION: The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02210442 .

CuidaCare: effectiveness of a nursing intervention on the quality of life's caregiver: cluster-randomized clinical trial.

BACKGROUND: In Spain, family is the main source of care for dependent people. Numerous studies suggest that providing informal (unpaid) care during a prolonged period of time results in a morbidity-generating burden. Caregivers constitute a high-risk group that experiences elevated stress levels, which reduce their quality of life.Different strategies have been proposed to improve management of this phenomenon in order to minimize its impact, but definitive conclusions regarding their effectiveness are lacking. METHODS/DESIGN: A community clinical trial is proposed, with a 1-year follow-up period, that is multicentric, controlled, parallel, and with randomized allocation of clusters in 20 health care centers within the Community of Madrid. The study's objective is to evaluate the effectiveness of a standard care intervention in primary health care (intervention CuidaCare) to improve the quality of life of the caregivers, measured at 0, 6, and 12 months after the intervention.One hundred and forty two subjects (71 from each group) ≥65 years, identified by the nurse as the main caregivers, and who provide consent to participate in the study will be included.The main outcome variable will be perceived quality of life as measured by the Visual Analogue Scale (VAS) of EuroQol-5D (EQ-5D). The secondary outcome variables will be EQ-5D Dimensions, EQ-5D Index, nursing diagnosis, and Zarit's test. Prognostic variables will be recorded for the dependent patient and the caregiver.The principle analysis will be done by comparing the average change in EQ-5D VAS value before and after intervention between the two groups. All statistical tests will be performed as intention-to-treat. Prognostic factors' estimates will be adjusted by mixed-effects regression models. Possible confounding or effect-modifying factors will be taken into account. DISCUSSION: Assistance for the caregiver should be integrated into primary care services. In order to do so, incorporating standard, effective interventions with relevant outcome variables such as quality of life is necessary. Community care nurses are at a privileged position to develop interventions like the proposed one. TRIAL REGISTRATION: This trial has been registered in ClinicalTrials.gov under code number NCT 01478295.

Effect of a group intervention in the primary healthcare setting on continuing adherence to physical exercise routines in obese women.

AIMS AND OBJECTIVES: To determine the effect of a seven-week-long, group-delivered, nurse-monitored, exercise training programme on the adherence of obese women to physical exercise routines at 12 months. BACKGROUND: The worldwide obesity epidemic is posing huge public health challenges. The main cause of obesity in Europe is very possibly a sedentary lifestyle. Uncertainty exists regarding whether people will continue to exercise once a structured intervention programme of physical activity ends. DESIGN: No-control-group (before-after) intervention study. METHODS: One Hundred Seventy-Four women from the Madrid region (Spain) aged ≥ 45 years with a body mass index of ≥30 undertook a maximum of 21 × 1 hour exercise training programme sessions (three per week) over seven weeks starting in February 2009. The number of women making use of exercise training programme before the intervention, and at 6 and 12 months postintervention, was recorded using the Nursing Outcome Classification. Information was collected by interviewing the study subjects. Bivariate (McNemar and Student's t-tests) and multivariate (binary logistic regression) analyses were then performed. RESULTS: The Nursing Outcome Classification Indicator 'Does the subject follow an exercise training programme?' showed that at the end of one year, the percentage of women who remained adhered to exercise training programme increased in those who completed the study (from 11-41%). As the number of programmed exercise training programme sessions completed increased beyond 14, so too did the likelihood of adhering to an exercise training programme regime at one year. CONCLUSION: The results show that an exercise training programme intervention can encourage obese women to continue exercising after exercise interventions end. RELEVANCE TO CLINICAL PRACTICE: This type of intervention could provide a valuable means of helping women lose weight and improve their health. It may also have important economic benefits for health systems. Clinical trials with longer follow-up times and in other populations are needed to confirm the present results.

Oral versus intramuscular administration of vitamin B12 for the treatment of patients with vitamin B12 deficiency: a pragmatic, randomised, multicentre, non-inferiority clinical trial undertaken in the primary healthcare setting (Project OB12).

BACKGROUND: The oral administration of vitamin B12 offers a potentially simpler and cheaper alternative to parenteral administration, but its effectiveness has not been definitively demonstrated. The following protocol was designed to compare the effectiveness of orally and intramuscularly administered vitamin B12 in the treatment of patients ≥65 years of age with vitamin B12 deficiency. METHODS/DESIGN: The proposed study involves a controlled, randomised, multicentre, parallel, non-inferiority clinical trial lasting one year, involving 23 primary healthcare centres in the Madrid region (Spain), and patients ≥65 years of age. The minimum number of patients required for the study was calculated as 320 (160 in each arm). Bearing in mind an estimated 8-10% prevalence of vitamin B12 deficiency among the population of this age group, an initial sample of 3556 patients will need to be recruited. Eligible patients will be randomly assigned to one of the two treatment arms. In the intramuscular treatment arm, vitamin B12 will be administered as follows: 1 mg on alternate days in weeks 1 and 2, 1 mg/week in weeks 3-8,and 1 mg/month in weeks 9-52. In the oral arm, the vitamin will be administered as: 1 mg/day in weeks 1-8 and 1 mg/week in weeks 9-52. The main outcome variable to be monitored in both treatment arms is the normalisation of the serum vitamin B12 concentration at weeks 8, 26 and 52; the secondary outcome variables include the serum concentration of vitamin B12 (in pg/ml), adherence to treatment, quality of life (EuroQoL-5D questionnaire), patient 3satisfaction and patient preferences. All statistical tests will be performed with intention to treat and per protocol. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in analyses. DISCUSSION: The results of this study should help establish, taking quality of life into account, whether the oral administration of vitamin B12 is an effective alternative to its intramuscular administration. If this administration route is effective, it should provide a cheaper means of treating vitamin B12 deficiency while inducing fewer adverse effects. Having such an alternative would also allow patient preferences to be taken into consideration at the time of prescribing treatment. TRIAL REGISTRATION: This trial has been registered with ClinicalTrials.gov, number NCT 01476007, and under EUDRACT number 2010-024129-20.

[Factors associated with hospital readmissions in the elderly]. / Factores asociados a reingresos hospitalarios en pacientes de edad avanzada.

OBJECTIVE: To identify factors associated with hospital readmissions in the elderly. DESIGN: Observational descriptive study. SETTING: Health area 3 of Madrid. PARTICIPANTS: Patients 74 years-old and over with a hospital admission to Hospital Universitario Príncipe de Asturias in 2006. Those with a hospital admission in the previous 6 months were excluded. A total of 1051 patients were identified. MAIN MEASURES: Hospital Discharge Minimum Basic Data Set and primary care information system were used to develop logistical regression models. The dependent variable was the hospital readmission in a 6 month period. Independent variables were socio-demographics, health status and health care activity. RESULTS: There were 22.6% readmissions in the first 6 months. Variables associated with higher risk of readmission were, hospital stay (hospital stay greater than 15 days had an OR: 1.73 (95% CI:1.17-2.54), the total number of medicines prescribed to the patient (OR: 1.05; 95% CI:1.01-1.09), having hypertension (OR:1.56; 95% CI:1.11-2.18), heart failure (OR: 1.56; 95% CI:1.00-2.44) or ischemic heart disease (OR: 1.51; 95% CI:1.00-2.26), and the primary care nursing mean attendance pressure (OR: 0.93; 95% CI:0.87-0.98). The model that integrates information from both systems explains a higher number of factors associated with readmission. CONCLUSIONS: Hospital readmissions have been associated to patient medical condition and to factors related to the health care received. Integrating information from hospital and primary care administrative data bases improves the capacity to identify factors associated with a higher readmission risk.

EDUCORE project: a clinical trial, randomised by clusters, to assess the effect of a visual learning method on blood pressure control in the primary healthcare setting.

BACKGROUND: High blood pressure (HBP) is a major risk factor for cardiovascular disease (CVD). European hypertension and cardiology societies as well as expert committees on CVD prevention recommend stratifying cardiovascular risk using the SCORE method, the modification of lifestyles to prevent CVD, and achieving good control over risk factors. The EDUCORE (Education and Coronary Risk Evaluation) project aims to determine whether the use of a cardiovascular risk visual learning method--the EDUCORE method--is more effective than normal clinical practice in improving the control of blood pressure within one year in patients with poorly controlled hypertension but no background of CVD; METHODS/DESIGN: This work describes a protocol for a clinical trial, randomised by clusters and involving 22 primary healthcare clinics, to test the effectiveness of the EDUCORE method. The number of patients required was 736, all between 40 and 65 years of age (n = 368 in the EDUCORE and control groups), all of whom had been diagnosed with HBP at least one year ago, and all of whom had poorly controlled hypertension (systolic blood pressure >or= 140 mmHg and/or diastolic >or= 90 mmHg). All personnel taking part were explained the trial and trained in its methodology. The EDUCORE method contemplates the visualisation of low risk SCORE scores using images embodying different stages of a high risk action, plus the receipt of a pamphlet explaining how to better maintain cardiac health. The main outcome variable was the control of blood pressure; secondary outcome variables included the SCORE score, therapeutic compliance, quality of life, and total cholesterol level. All outcome variables were measured at the beginning of the experimental period and again at 6 and 12 months. Information on sex, age, educational level, physical activity, body mass index, consumption of medications, change of treatment and blood analysis results was also recorded; DISCUSSION: The EDUCORE method could provide a simple, inexpensive means of improving blood pressure control, and perhaps other health problems, in the primary healthcare setting; TRIAL REGISTRATION: The trial was registered with ClinicalTrials.gov, number NCT01155973 [http://ClinicalTrials.gov].

[Analysis of complaints in primary care using statistical process control]. / Análisis de las reclamaciones en atención primaria mediante el control estadístico de procesos.

OBJECTIVE: To analyze patient complaints in a Primary Health Care District (PHCD) using statistical process control methods compared to multivariate methods, as regards their results and feasibility of application in this context. MATERIAL AND METHOD: Descriptive study based on an aggregate analysis of administrative complaints. SETTING: Complaints received between January 2005 and August 2008 in the Customer Management Department in the 3rd PHCD Management Office, Madrid Health Services. Complaints are registered through Itrack, a computer software tool used throughout the whole Community of Madrid. MAIN VARIABLES: Total number of complaints, complaints sorted by Reason and Primary Health Care Team (PHCT), total number of patient visits (including visits on demand, appointment visits and home visits) and visits by PHCT and per month and year. STATISTICAL ANALYSIS: Multivariate analysis and control charts were used. RESULTS: 44-month time series with a mean of 76 complaints per month, an increasing trend in the first three years and decreasing during summer months. Poisson regression detected an excess of complaints in 8 out of the 44 months in the series. The control chart detected the same 8 months plus two additional ones. CONCLUSIONS: Statistical process control can be useful for detecting an excess of complaints in a PHCD and enables comparisons to be made between different PHC teams. As it is a simple technique, it can be used for ongoing monitoring of customer perceived quality.

[Diabetic autonomic neuropathy diagnosed in primary care in patients with type 2 diabetes]. / Neuropatía autonómica diabética diagnosticada mediante un test cardiovascular en pacientes con diabetes tipo 2.

OBJECTIVE: To determine the prevalence of diabetic autonomic neuropathy (DAN) in patients with type 2 diabetes using a cardiovascular test. DESIGN: Observational, descriptive, cross-sectional study. SETTING: Primary care clinics in Fronteras de Torrejón de Ardoz Health Centre, Area 3, Madrid, Spain. PARTICIPANTS: Of the 361 diabetics assigned to 3 participating patient quotas, 317 patients had type 2 diabetes. Of those, 104 were excluded due to being immobile, cardiac arrhythmia, and/or on treatment with chronotropic drugs. Of the 213 patients included, 169 had the test and 44 were lost. INTERVENTIONS: Performing of the orthostatic response test. MAIN MEASUREMENTS: Age, sex, years since diagnosed with diabetes (measured by patient anamnesis), treatment (hygiene-diet measures, oral antidiabetics, insulin) were recorded, along with the R-R'30:15 ratio (classified as normal: 31.04, borderline: 1.01 to 1.03, and pathological: pound1.00). RESULTS: The prevalence of DAN using the orthostatic response test was 56.2% (95 patients with a pathological R-R'30:15 index) out of a total of 169 patients with type 2 diabetes. The definitive diagnosis of DAN found in the clinical histories reviewed was 1.8%. CONCLUSIONS: DAN goes unnoticed in our evaluation of the patient with diabetes. The improvement in diagnosing this complication and incorporating cardiovascular autonomic dysfunction tests in primary care follow-up protocols, would enable closer metabolic control and improve the prognosis of the disease.

[Randomized clinical trial for primary care patients with neck pain: manual therapy versus electrical stimulation]. / Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea.

OBJECTIVE: To compare the effectiveness of manual therapy (MT) versus transcutaneous electrical nervous stimulation (TENS) in reducing the intensity of pain in patients with subacute or chronic neck pain (NP) attended at primary care physiotherapy units (PCPU). DESIGN: Randomised clinical trial. SETTING: Thirteen PCPU in 4 health districts of the Community of Madrid, Spain. PARTICIPANTS: Ninety patients with subacute or chronic NP attended. Lost after intervention: 3. INTERVENTIONS: At random, 47 patients were allocated to MT treatment and 43 to TENS. MAIN MEASUREMENTS: Social and demographic characteristics and prognosis variables in the intervention groups were measured. Intensity of pain before and after intervention was calculated by mean values on the analogue visual scale (present moment, average and worst pain of the last 2 weeks). Side-effects were also measured. RESULTS: Difference between before-and-after pain was 21.83 mm (95% CI, 13.71-29.95) for the group treated with Transcutaneous electrical nervous stimulation and 22.87 mm (95% CI, 17.11-28.64) for manual therapy. The difference in averages on comparing the 2 procedures for improvement was 1.04 (95% CI, -8.66% to 10.75%). CONCLUSIONS: TENS and MT significantly reduce patients' perceived intensity of pain, although there were no differences between the 2 groups.There are no conclusive results for the alternative physiotherapy treatments that determine a clear strategy of intervention.

Information needs and information-seeking behavior of primary care physicians.

PURPOSE: The aim of this study was to determine the information needs of primary care physicians in Spain and to describe their information-seeking patterns. METHODS: This observational study took place in primary care practices located in Madrid, Spain. Participants were a random stratified sample of 112 primary care physicians. Physicians' consultations were video recorded for 4 hours. Clinical questions arising during the patient visit and the sources of information used within the consultation to answer questions were identified. Physicians with unanswered questions were followed up by telephone 2 weeks later to determine whether their questions had since been answered and the sources of information used. Clinical questions were classified by topic and type of information. RESULTS: A total of 3,511 patient consultations (mean length, 7.8 minutes) were recorded, leading to 635 clinical questions (0.18 questions per consultation). The most frequent questions were related to diagnosis (53%) and treatment (26%). The most frequent generic type of questions was "What is the cause of symptom x?" (20.5%). Physicians searched for answers to 22.8% of the questions (9.6% during consultations). The time taken and the success rate in finding an answer during a consultation and afterward were 2 minutes (100%) and 32 minutes (75%), respectively. CONCLUSIONS: Primary care physicians working in settings where consultations are of short duration have time to answer only 1 in 5 of their questions. Better methods are needed to provide answers to questions that arise in office practice in settings where average consultation time is less than 10 minutes.

[Study of the Information requirements generated by primary care doctors (ENIGMA Project)]. / Estudio de las necesidades de información generadas por los médicos de atención primaria (proyecto ENIGMA).

OBJECTIVES: To determine the information needs of primary care physicians by identifying the frequency and type of questions arising during consultation, and by describing the information-search pattern. DESIGN. Observational, descriptive, multi-centre study. SETTING: Primary care practices in Madrid, Spain. PARTICIPANTS: Random sample, proportionally stratified by area (urban/rural) and specialty (general practitioner/paediatrician), of 208 primary care physicians out of a total of 1182 physicians; 112 agreed to take part. INTERVENTIONS: Physicians consultations were video-recorded for four hours. Between patients, they were asked to pose all the clinical questions arising during the patient visit and the sources of information used to answer them. Unresolved questions were followed up by phone 2 weeks later to check if answers had been found and what sources of information had been used. Clinical questions were classified by topic and type. MAIN MEASUREMENTS: Number of questions posed and their answers; topic and type of information; information resources used. RESULTS: A total of 3511 patient consultations, leading to 635 clinical questions, were recorded. The most frequent questions were on pharmacology (10%) for general practitioners, and infectious disease (19%) for paediatricians. The most frequent type of question was on the cause/interpretation of a clinical finding (44% for general practitioners and 48% for paediatricians). Answers to 39% of the questions were not sought. A 86% of the answers sought were solved, mainly using the drug compendium (35%) or a text-book (18%). CONCLUSIONS: Primary care physicians tried to resolve less than two-thirds of the questions asked, and mainly did so through readily available printed material. Better methods are needed to provide answers to questions that arise in clinical practice.