Low-value clinical practices and harm caused by non-adherence to 'do not do' recommendations in primary care in Spain: a Delphi study.

OBJECTIVE: To determine the non-adherence to the primary care 'do not do' recommendations (DNDs) and their likelihood to cause harm. DESIGN: Delphi study. SETTING: Spanish National Health System. PARTICIPANTS: A total of 128 professionals were recruited (50 general practitioners [GPs], 28 pediatricians [PEDs], 31 nurses who care for adult patients [RNs] and 19 pediatric nurses [PNs]). INTERVENTIONS: A selection of 27 DNDs directed at GPs, 8 at PEDs, 9 at RNs and 4 at PNs were included in the Delphi technique. A 10-point scale was used to assess whether a given practice was still present and the likelihood of it causing of an adverse event. MAIN OUTCOME MEASURE: Impact calculated by multiplying an event's frequency and likelihood to cause harm. RESULTS: A total of 100 professionals responded to wave 1 (78% response rate) and 97 of them to wave 2 (97% response rate). In all, 22% (6/27) of the practices for GPs, 12% (1/8) for PEDs, 33% (3/9) for RNs and none for PNs were cataloged as frequent. A total of 37% (10/27) of these practices for GPs, 25% (2/8) for PEDs, 33% (3/9) for RNs and 25% (1/4) for PNs were considered as potential causes of harm. Only 26% (7/27) of the DNDs for GPs showed scores equal to or higher than 36 points. The impact measure was higher for ordering benzodiazepines to treat insomnia, agitation or delirium in elderly patients (mean = 57.8, SD = 25.3). CONCLUSIONS: Low-value and potentially dangerous practices were identified; avoiding these could improve care quality.

Drivers and strategies for avoiding overuse. A cross-sectional study to explore the experience of Spanish primary care providers handling uncertainty and patients' requests.

OBJECTIVES: Identify the sources of overuse from the point of view of the Spanish primary care professionals, and analyse the frequency of overuse due to pressure from patients in addition to the responses when professionals face these demands. DESIGN: A cross-sectional study. SETTING: Primary care in Spain. PARTICIPANTS: A non-randomised sample of 2201 providers (general practitioners, paediatricians and nurses) was recruited during the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: The frequency, causes and responsibility for overuse, the frequency that patients demand unnecessary tests or procedures, the profile of the most demanding patients, and arguments for dissuading the patient. RESULTS: In all, 936 general practitioners, 682 paediatricians and 286 nurses replied (response rate 18.6%). Patient requests (67%) and defensive medicine (40%) were the most cited causes of overuse. Five hundred and twenty-two (27%) received requests from their patients almost every day for unnecessary tests or procedures, and 132 (7%) recognised granting the requests. The lack of time in consultation, and information about new medical advances and treatments that patients could find on printed and digital media, contributed to the professional's inability to adequately counter this pressure by patients. Clinical safety (49.9%) and evidence (39.4%) were the arguments that dissuaded patients from their requests the most. Cost savings was not a convincing argument (6.8%), above all for paediatricians (4.3%). General practitioners resisted more pressure from their patients (x2=88.8, P<0.001, percentage difference (PD)=17.0), while nurses admitted to carrying out more unnecessary procedures (x2=175.7, P<0.001, PD=12.3). CONCLUSION: Satisfying the patient and patient uncertainty about what should be done and defensive medicine practices explains some of the frequent causes of overuse. Safety arguments are useful to dissuade patients from their requests.

Morir con dignidad. Estudio sobre voluntades anticipadas / Dying with dignity. A study of living wills

Objetivo Describir el perfil de quienes han ejercido su derecho a expresar voluntades anticipadas, analizar la actitud y el conocimiento de los médicos ante ellas, y comparar las normas que regulan este derecho entre comunidades autónomas. Método Estudio descriptivo que incluye análisis mediante muestreo sistemático de 931 registros de voluntades anticipadas en la Comunidad Valenciana, encuesta en papel estructurada y autoadministrada a una muestra de 84 médicos de servicios de urgencias y unidades de cuidados intensivos (tasa respuesta del 45%), y comparación de la legislación autonómica que regula las voluntades anticipadas. Resultados Un 1,6‰ mayores de 16 años han inscrito voluntades anticipadas (relación mujer/hombre de 1,8/1), la mayoría (73,8%) utilizando un documento previamente redactado por una determinada confesión religiosa. Limitar el esfuerzo terapéutico (99%) y obtener fármacos para aliviar el dolor (98%) son las razones habituales para inscribir voluntades anticipadas. Pese a que 61 (72,6%) facultativos atendían con frecuencia a pacientes en situación terminal, sólo el 6% consultaron el registro de voluntades anticipadas en estos casos. El 28% no supo cómo consultar este registro. Hay una amplia variabilidad entre comunidades respecto a la edad para otorgar voluntades anticipadas, cómo actuar en caso de embarazo de la solicitante, ante quién otorgar voluntades anticipadas y el número de puntos en que es posible dejar constancia de estas voluntades. Conclusiones La mayoría de los otorgantes de voluntades anticipadas profesan una determinada confesión y rechazan que se les practiquen determinados tratamientos. La mayoría de los profesionales no comprueba si los enfermos en situación crítica han otorgado voluntades anticipadas. La diversidad de criterios entre comunidades complica el ejercicio del derecho a expresar estas voluntades (AU)

Objective To describe the profile of persons who exercise their right to draw up a living will, to analyze physicians’ knowledge of living wills and attitudes toward them, and to compare the regulations pertaining to this right in the distinct autonomous regions of Spain. Method A descriptive study that included an analysis of a systematic sample of 931 living wills registered in the autonomous region of Valencia (Spain), a self-administered structured questionnaire administered to a sample of 84 physicians working in emergency departments and intensive care units (45% response rate), and a comparison of the regional legislation covering living wills. Results A total of 1.6% of inhabitants aged 16 or over had registered a living will (female/male ratio: 1.8/1). Most (73.8%) used a standard document drawn up by a particular religious faith. The most common reasons for writing a living will were to limit therapeutic efforts (99%) and obtain pain-relieving drugs (98%). Although 61 physicians (72.6%) frequently attended the terminally ill, only 6% consulted the register of living wills in these situations and 28% did not know how to consult this register. There is wide variation among regions in the minimum age for registering a living will, in the procedure to be followed if the signer is pregnant, in designating a person as having the authority to make a living will, and in the number of registration points available to deposit living wills. Conclusions Most persons registering a living will are healthy individuals with a particular religious faith who reject certain treatments. Most health professionals do not check whether critically ill patients have made a living will. Exercising the rights contained in living wills is complicated by the diversity of criteria among different regions (AU)

[Dying with dignity. A study of living wills]. / Morir con dignidad. Estudio sobre voluntades anticipadas.

OBJECTIVE: To describe the profile of persons who exercise their right to draw up a living will, to analyze physicians' knowledge of living wills and attitudes toward them, and to compare the regulations pertaining to this right in the distinct autonomous regions of Spain. METHOD: A descriptive study that included an analysis of a systematic sample of 931 living wills registered in the autonomous region of Valencia (Spain), a self-administered structured questionnaire administered to a sample of 84 physicians working in emergency departments and intensive care units (45% response rate), and a comparison of the regional legislation covering living wills. RESULTS: A total of 1.6% of inhabitants aged 16 or over had registered a living will (female/male ratio: 1.8/1). Most (73.8%) used a standard document drawn up by a particular religious faith. The most common reasons for writing a living will were to limit therapeutic efforts (99%) and obtain pain-relieving drugs (98%). Although 61 physicians (72.6%) frequently attended the terminally ill, only 6% consulted the register of living wills in these situations and 28% did not know how to consult this register. There is wide variation among regions in the minimum age for registering a living will, in the procedure to be followed if the signer is pregnant, in designating a person as having the authority to make a living will, and in the number of registration points available to deposit living wills. CONCLUSIONS: Most persons registering a living will are healthy individuals with a particular religious faith who reject certain treatments. Most health professionals do not check whether critically ill patients have made a living will. Exercising the rights contained in living wills is complicated by the diversity of criteria among different regions.

Patient report on information given, consultation time and safety in primary care.

OBJECTIVE: To analyse the frequency of adverse events to treatment reported by patients in relation to consultation time, attention from their usual doctor and information provided by their doctor about treatment. DESIGN: Descriptive study. Patients were invited to respond to a telephone survey. SETTING: 21 Primary Care health centres in Spain. PARTICIPANTS: 15,282 patients attended by GPs or paediatricians (error of 1% for p=q=0.50, α 95%) were selected at random from the total consultations recorded in 1 month. For sampling, quotas were assigned for type of attention, age and sex. In the case of children (under 14 years), the survey was answered by their parents. MAIN OUTCOME MEASURES: Patients' report on frequency of unexpected or adverse reaction to a treatment; whether informed or not about possible complications of the treatment and precautions to take; consultation time; and whether or not patient is usually seen by the same doctor. RESULTS: 1557 (17.6%, CI 95% 16.8 to 18.4%) of the adults and 867 (13.7%, 95% CI 12.8 to 14.5%) of the children reported adverse or unexpected reactions to the treatment according to patients' reports. Consultation time (OR 0.5, 95% CI 0.4 to 0.5), doctor rotation at the health centre (OR 2.04, 95% CI 1.85 to 2.25) and information on treatment precautions (OR 0.47, 95% CI 0.43 to 0.53) determine the higher risk of adverse reactions to treatment. CONCLUSIONS: Planning at health centres should involve the monitoring of mean consultation time and doctor rotation as indirect indicators of safety. Furthermore, protocols related to the information provided to patients should be reviewed.

Predictors of patient satisfaction in surgery.

BACKGROUND: We sought to evaluate the satisfaction of surgical patients in order to identify predictors of patient satisfaction, using a cross-sectional surgery patients' survey in 24 public hospitals in Spain and a total of 15,539 inpatients and 7,899 outpatients. RESULTS: Seventy-seven percent of inpatients and 88.3% of outpatients were satisfied (chi(2) = 509.31; P < .0001). Case-mix and hospital size were associated with satisfaction in inpatients (chi(2) = 19.31; P = .013). Older inpatients tended to be more satisfied (chi(2) = 80.54; P = .001), whereas; younger outpatients showed higher satisfaction levels (chi(2) = 51.73; P = .004). The most influential factors on inpatient satisfaction were information at admission (odds ratio [OR], 4.05; 95% confidence interval [CI], 2.91-5.63), knowing what type of professional one was dealing with at any given time (OR, 4.01; 95% CI, 3.01-5.34), and informed consent (OR, 3.37; 95% CI, 2.41-4.71). For outpatients, the most influential factors were informed consent (OR, 7.62; 95% CI, 3.68-15.80) and information about home care after discharge (OR, 7.010; 95% CI, 3.06-15.96). CONCLUSION: We should consider the importance of patient information before and after treatment in the design of clinical pathways to offer better and more comprehensive care to surgical patients.

Puntos de vista de pacientes, ciudadanos, profesionales y directivos sobre cómo llevar a la práctica una atención sanitaria centrada en el paciente / How to achieve patient-centered healthcare: patients’, citizens’, health professionals’ Asesores. Universidad Miguel Hernández. Elche. Alicante. España

Objetivo: Analizar qué entienden por "humanización" profesionales y directivos sanitarios y líderes de asociaciones ciudadanas y de pacientes. Material y método: Investigación cualitativa. Participaron: 20 representantes de asociaciones de pacientes o ciudadanas, 2 presidentes de colegios profesionales, 18 profesionales de Servicios de Atención e Información al Paciente, 41 directivos de centros sanitarios (hospitales y atención primaria). Los temas abordados fueron: ¿qué es humanizar la atención sanitaria? ¿Cómo hacer para mejorar la calidad de la atención personal a los pacientes (atención más digna y humana)? ¿En qué ha cambiado el perfil de los pacientes? ¿Qué nuevas demandas están planteando los pacientes? ¿Qué derechos y deberes del paciente deben desarrollarse en el futuro? Resultados: Comunicación, empatía, trato personalizado, calidad técnica, comodidad y una buena gestión de los recursos definen el concepto de humanización. Formación, información al paciente, medios y mejoras en infraestructuras constituyen ejes para mejorar la calidad de la atención. Actualmente, el paciente demanda mayor información (que contrasta), nuevas prestaciones y no respeta igual el criterio médico. Se hace necesario insistir en: información, libre elección, trato respetuoso, equidad, segunda opinión, atención urgente, participación en toma de decisiones, deber de respeto hacia los profesionales y colaborar en la sostenibilidad. Conclusiones: Se deben impulsar acciones que favorezcan la autonomía del paciente y una mayor accesibilidad de los recursos sanitarios. El marco para el desarrollo y el cumplimiento de los derechos del paciente y el respeto a sus valores como persona requiere también de su compromiso para hacer un uso responsable de los recursos

Objective: To analyze what health professionals, health managers, and the leaders of patient associations understand by "humanization". Material and method: We performed a qualitative study. Participants consisted of 20 representatives of patient or citizens' associations, two presidents of professional associations, 18 representatives of the patient advice and liaison service, 41 health managers (hospitals and primary care). The following questions were analyzed: What does humanizing health care mean? How can personalized patient care (making healthcare more dignified and human) be improved? How has the patient profile changed? What new demands are patients making? Which rights and responsibilities of the patient should be developed in the future? Results: The concept of humanization was defined as communication, empathy, personalized dealings between patients and staff, technical quality, comfort, and good resource management. The main factors for improving healthcare quality were training, patient information, resources, and improvements in infrastructure. Patients currently demand more information (which they check) and new services, and show less respect for medical criteria. The following factors should be stressed: information, free choice, respect, equity, second opinions, emergency care, and participation in decision making. Patients' duty to respect health professionals and collaborate in the sustainability of the system should also be emphasized. Conclusions: Actions encouraging patient autonomy and greater accessibility to health resources should be encouraged. The development of patients rights and respect for their values, and compliance with these elements, also requires responsible resource use by patients