Identifying barriers and enablers for benzodiazepine (de)prescription: a qualitative study with patients and healthcare professionals.

BACKGROUND: There has been a steadily growing trend in prescribing benzodiazepines over last decade. Spain is one of the countries where this class of drugs is most extensively prescribed by primary healthcare physicians. The aim of this study is to identify factors that might be acting as barriers and enablers for benzodiazepine (de)prescription from patient and professional perspectives. METHODS: Qualitative study through semi-structured interviews with medical practitioners (n=17) and patients (n=27), and a nominal group with medical practitioners (n=19). Interviews were audio-recorded, transcribed and analyzed using thematic analysis. RESULTS: The analysis revealed key themes and was organized around barriers and enablers connected to three interrelated dimen-sions: the social and community context of prescription; the structure, organization and/or management of the health system, and the doctor-patient relationship. The excessive workload of professionals was widely cited as influencing over-prescription. (De)prescription of benzodiazepine was facilitated by encouraging the social prescription of health assets or developing strategies to therapeutic alliance processes and better doctor-patient communication. CONCLUSION: Our findings suggest that there is a role for the salutogenic approach and the health asset model in the development of a more person-centred clinical care. This study considers the importance of encouraging the use of non-pharmacological methods and techniques in the health system and promoting the creation of multidisciplinary teams, therapeutic alliance processes and better doctor-patient communication by giving professionals training in psychosocial skills.

Safety considerations during prescription of non-steroidal anti-inflammatory drugs (NSAIDs), through a review of systematic reviews.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used drugs worldwide. This makes it necessary to carry out a comprehensive synthesis of the available evidence on the safe and adequate prescription of NSAIDs in patients with cardiovascular disease, chronic kidney disease, hypertension, heart failure or liver cirrhosis and in general population. For this, a review of systematic reviews was carried out. Data extraction and analysis were performed independently by two reviewers and a narrative synthesis of the results was carried out. The use of NSAIDs is associated with a significantly higher probability of hepatotoxicity and kidney damage, as well as increased risk of exacerbation of heart failure. Taking into account the increased cardiovascular, liver and kidney risk, the prescription of NSAIDs should be carried out with caution, considering the treatment duration and the patient's situation. For this reason, patients should be informed about their possible health consequences as well as ensuring adequate monitoring of them.

Night-shift work and breast and prostate cancer risk: updating the evidence from epidemiological studies.

It has been hypothesized that circadian disruption is related to higher cancer risk. Since the International Agency for Research on Cancer classified shift work involving circadian disruption as probably carcinogenic to humans (Group 2A), multiple studies have been conducted to test this hypothesis. The aim of this systematic review was to summarize the findings and evaluate the quality of existing epidemiological studies (case-control and cohort studies) on the relationship between night-shift work and breast and prostate cancer risk. Thirty-three epidemiological studies investigating the relationship between night-shift work and breast (n = 26) or prostate (n = 8) cancer risk were included (one paper included both sites). The Newcastle-Ottawa Scale for the quality of non-randomized studies was used to assess the risk of bias of the publications. The studies included were heterogeneous regarding population (general population, nurses working in rotating shifts, and other) and measurement of exposure to night-shift work (ever vs. never exposure, short vs. long-term, rotating vs. permanent) and, thus, a diversity of outcomes were observed even within the same type of cancer. In summary, 62.5% works found some type of association between night-shift work and increased risk of cancer, for both breast and prostate. The risk of bias scored an average of 7.5 over 9 stars. Due to the limitations inherent in these studies, the evidence of a possible association between night-shift work and breast or prostate cancer risk remains uncertain and more studies providing greater control of exposure and confounding factors are required. Despite the lack of conclusive evidence, application of the precautionary principle seems advisable.

[Identifying indicators of good practice in clinical and healthcare management]. / Identificación de indicadores de buenas prácticas en gestión clínica y sanitaria.

OBJECTIVE: To identify good practices in order to develop and implement indicators of health outcomes for clinical and healthcare management, as well as the characteristics for an indicator to be considered adequate. METHODOLOGY: A scoping review was performed, with the following phases: 1) Search and identification of bibliography. 2) Selection of relevant documents. Including those studies that discussed issues related to good practices for the use of health indicators in the management field. Those published in a language other than English or Spanish or before 2006 were excluded. 3) Analysis and extraction of information. 4) Consultation with stakeholders, using a qualitative methodology through Concept Mapping, with the participation of 40 experts (decision-makers, scientific societies, and health professionals). The data collection process included an inductive and structured procedure, with prioritisation of ideas grouped into clusters, according to feasibility and importance criteria (0-10 scale). RESULTS: Good practices identified 2 levels: 1) macro-management: Define a framework for the evaluation of indicators and establish a benchmark of indicators. 2) meso-management: Establish indicators according to evidence and expert consensus, taking into account priority areas and topics, testing before final use, and communicate results adequately. The characteristics of a suitable indicator are: 1) Approach of an important issue, 2) Scientific validity, 3) Possibility of measurement with reliable data, 4) Meaning of useful and applicable measurement, and 5) Wide scope. CONCLUSIONS: The best practices for the use of indicators in clinical and healthcare management can make it easier to monitor performance and accountability, as well as to support the decision-making addressed at the development of initiatives for quality improvement.

[Prioritization of non-recommended clinical activities in Primary Care]. / Priorización de actividades clínicas no recomendadas en Atención Primaria.

OBJECTIVE: To prioritize non-recommended clinical activities in Primary Care (PC), from "Do not do" recommendations listed by the Sociedad Española de Medicina de Familia y Comunitaria (Semfyc), according to expert consensus (physicians, nurses and pharmacists). METHODS: The consensus for the prioritization of non-recommended practices in PC was performed through an online procedure. We used as a base the list of "do not-do" recommendations of the SEMFYC. We asked the experts to prioritize practices that should be de-adopted in PC, based on four prioritization criteria: frequency of occurrence, cost of the activity, ease of disposal and damage caused, which were scored from one to five, according to their recommendation. Scores were summarized in median and quartile values. Two rounds were necessary to obtain a consensus. A modified e-Delphi technique was used. RESULTS: 34 experts (62%) participated in the first consultation round and prioritized 19 recommendations with a score = 3.5. These recommendations were again analyzed in a second round, in which 32 panelists agreed to prioritize 17 practices (13 related to prescription, three diagnostic tests, and one clinical analysis). The high priority list included seven practices with values = 4: 1) Prescription of a new drug in elderly patients without having reviewed the previous treatments; 2) Lipid-lowering drugs without calculating the overall cardiovascular risk; 3) Not systematically prescribing gastric protection with proton pump inhibitors to patients consuming Nonsteroidal anti-inflammatory drugs (NSAIDs); 4) Glucose self-analysis in non-insulinized type 2 diabetics; 5) Benzodiazepines in the long term; 6) Bisphosphonates in patients with low risk of fracture; and 7) Antibiotics in lower respiratory tract infections. CONCLUSION: This study provides information for the prioritization of 17 non-AP activities in which short-term de-adoption would significantly increase the efficiency of the public health system.

[Identification of health outcome indicators in Primary Care. A review of systematic reviews]. / Identificación de indicadores de resultado en salud en atención primaria. Una revisión de revisiones sistemáticas.

INTRODUCTION: Outcome measures are being widely used by health services to assess the quality of health care. It is important to have a battery of useful performance indicators with high validity and feasibility. Thus, the objective of this study is to perform a review of reviews in order to identify outcome indicators for use in Primary Care. METHODOLOGY: A review of systematic reviews (umbrella review) was carried out. The following databases were consulted: MedLine, EMBASE, and CINAHL, using descriptors and free terms, limiting searches to documents published in English or Spanish. In addition, a search was made for free terms in different web pages. Those reviews that offered indicators that could be used in the Primary Care environment were included. RESULTS: This review included a total of 5 reviews on performance indicators in Primary Care, which consisted of indicators in the following areas or clinical care processes: in osteoarthritis, chronicity, childhood asthma, clinical effectiveness, and prescription safety indicators. A total of 69 performance indicators were identified, with the percentage of performance indicators ranging from 0% to 92.8%. None of the reviews identified performed an analysis of the measurement control (feasibility or sensitivity to change of indicators). CONCLUSIONS: This paper offers a set of 69 performance indicators that have been identified and subsequently validated and prioritised by a panel of experts.

Do social inequalities exist in terms of the prevention, diagnosis, treatment, control and monitoring of diabetes? A systematic review.

The major increase in the prevalence of diabetes mellitus (DM) has led to the study of social inequalities in health-care. The aim of this study is to establish the possible existence of social inequalities in the prevention, diagnosis, treatment, control and monitoring of diabetes in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems. We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for all relevant articles published up to 15 December 2007. We included observational studies carried out in OECD countries with universal healthcare systems in place that investigate social inequalities in the provision of health-care to diabetes patients. Two independent reviewers carried out the critical assessment using the STROBE tool items considered most adequate for the evaluation of the methodological quality. We selected 41 articles from which we critically assessed 25 (18 cross-sectional, 6 cohorts, 1 case-control). Consistency among the article results was found regarding the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Socioeconomic inequalities were also found in the diagnosis and control of the disease, but no evidence of any gender inequalities was found. In general, the methodological quality of the articles was moderate with insufficient information in the majority of cases to rule out bias. This review shows that even in countries with a significant level of economic development and which have universal healthcare systems in place which endeavour to provide medical care to the entire population, socioeconomic and ethnic inequalities can be identified in the provision of health-care to DM sufferers. However, higher quality and follow-up articles are needed to confirm these results.

[An economic assessment of genetic testing for familial adenomatous polyposis]. / Evaluación económica de la prueba genética de la poliposis adenomatosa familiar.

OBJECTIVE: To analyze the cost-effectiveness of genetic testing for first-degree relatives of patients with colon cancer to identify mutations in the APC gene (Adenomatous Polyposis Coli). METHODOLOGY: Analyses were performed from the perspective of the health system. We used a Markov model. We compared genetic testing for the APC gene, the cause of familial adenomatous polyposis (FAP), which results in colon cancer, versus no genetic testing for said gene. The effectiveness measure used was quality-adjusted life-years (QALYs), and costs were measured in euros for 2005. The costs of interventions were extracted from the costs of health services provided by centers under the Andalusian Public Health System, and other parameters were obtained from the literature. RESULTS: The performance of genetic testing is the dominant strategy when compared to the absence of genetic testing given the latter option has an incremental cost of 7,676.34 euros and is less effective. A sensitivity analysis found that genetic testing remains the dominant strategy for a plausible range of costs of the test itself, and for the probability of developing adenocarcinoma. CONCLUSIONS: Our analysis showed that in this patient group genetic testing to detect APC gene mutations is on average less costly and improves QALYs versus no testing.

[Differences in sociodemographic, clinical, psychosocial and health care characteristics between men and women diagnosed with fibromyalgia]. / Diferencias en características sociodemográficas, clínicas y psicológicas entre hombres y mujeres diagnosticados de fibromialgia.

INTRODUCTION: Health differences between men and women are determined by biological differences although health services often contribute to gender inequalities. Very few studies that analyze gender differences have been made up to date in these patients. This study aims to analyze sociodemographic, clinical and psychosocial differences between men and women diagnosed with FM and to examine the differential impact of their symptoms on their usual activities, including work environment, and the response these patients obtain from the health care system. MATERIAL AND METHODS: A descriptive cross-sectional survey was carried out with all the patients diagnosed with FM in 2003 in three clinics rheumatology units of a university hospital in Spain. RESULTS: The sociodemographic characteristics were very similar in men and women. However, there was a greater proportion of men diagnosed with FM on sick leave, compared to women with the same diagnosis. Men had a worse perception of their health, a higher percentage of psychiatric history and current mental illness and more impact of the disease. DISCUSSION: This is one of the first studies in Spain examining the differences between men and women diagnosed with FM. The results obtained in this study corroborate that, as in other diseases, there are gender differences in the clinical and psychosocial characteristics of men and women diagnosed with FM.

[A comparison of costs and survival in colorectal cancer patients undergoing surgery according to different organizational models]. / Comparación de costes y supervivencia en pacientes intervenidos quirúrgicamente de cáncer colorrectal según diferentes modelos organizativos.

OBJECTIVE: To determine the effectiveness and costs of different organizational models in caring for colorectal cancer patients through either clinical management functional units or traditional clinical services. METHOD: Post-operative and long-term (after 30 days and 5 years) mortality was analyzed according to number of patients undergoing surgery because of colorectal cancer. Mortality was adjusted for patient-related confounding factors. With that purpose a thorough review of the literature was conducted; information obtained was used in a meta-analysis of randomized effects. Concerning costs, a literature search was run to describe differences in number of patients per year between hospitals. RESULTS: Surgery costs were found to be smaller, and mean hospital stay shorter, in big-sized hospitals. The meta-analysis showed that the risk of death at 30 days and 5 years was lower in big hospitals versus smaller ones (OR: 1.112; 95% CI 0.986-1.255, and OR: 1.114; 95% CI 1.105-1.183, respectively). CONCLUSIONS: Short- and long-term postoperative mortality is lower in hospitals with a high number of cases per year.

[Mental morbidity and social support in prisoners in treatment with antiretrovirals]. / Morbilidad psíquica y apoyo social en reclusos en tratamiento con antirretrovirales.

OBJECTIVE: To define the incidence of depressive disorders and anxiety disorders in prisoners of three prisons of CCAA in treatment with antiretrovirals, and moreover the associated variables and the intensity of social support within the prison. METHODS: Through a cross-sectional design 281 prisoners were studied. RESULTS: 42% showed mental morbidity and 53.4% lacked social support. To be imprisoned in the Granada prison, to be a woman, poor health state, to describe difficulties for compliance with antiretrovirals drug, a history greater than 13 years for drugs consumption, and usual residence with the couple of family, all were factors associated with mental morbidity. Factors associated with social support non-existence were history of more than one imprisonment, lack of familiarity with the medical equipment, to be more than 35 years old, and to suffer mental morbidity.