Barreras y facilitadores para el uso de las guías de práctica clínica por residentes de Medicina Familiar y Comunitaria: estudio cualitativo con grupos focales / Barriers and facilitators for the use of clinical practice guidelines by Family and Community Medicine residents: qualitative study with focus groups

Objetivo: identificar barreras y facilitadores para el uso de las guías de práctica clínica (GPC) por residentes de Medicina Familiar y Comunitaria.Métodos: metodología cualitativa. Se formaron tres grupos focales, total 28 residentes de tercer y cuarto año de las siete unidades docentes multiprofesionales de Atención Familiar y Comunitaria de Madrid. Los temas explorados fueron: conocimiento, comprensión, utilidad y uso de GPC. Las categorías elegidas para agrupar el discurso se elaboraron siguiendo el Manual metodológico de GuíaSalud. Análisis sociológico bajo la perspectiva fenomenológica.Resultados: las barreras relacionadas con la formación fueron el modelo de formación recibida para adquirir las habilidades necesarias, la falta de conocimientos para evaluar la calidad de las guías y un limitado conocimiento de los buscadores. Entre las barreras del contexto social y del sistema sanitario, se identificaron el conflicto con las expectativas del paciente, con las recomendaciones de otros especialistas, las características de los pacientes que consultan en Atención Primaria (AP) y la limitación de tiempo en las consultas. Como facilitadores se identificaron la motivación personal, los conocimientos y el modelo de práctica profesional del tutor y que las GPC fueran claras, breves y en diversos formatos.Conclusiones: los residentes dan valor a las GPC como herramientas docentes, de ayuda a la toma de decisiones y para desempeñar un mejor ejercicio profesional, aunque encuentran dificultades y limitaciones en su uso. El papel del tutor se identifica como clave; la formación, motivación y el modelo de práctica del tutor son considerados como los mayores facilitadores.(AU)

Aim: to identify barriers and facilitators for the use of Clinical Practice Guidelines (CPG) by Family and Community Medicine residents.Method: qualitative methodology. Three focus groups were set up, with a total of 28 participants, 3rd and 4th year residents of the 7 Multiprofessional Family and Community Care Teaching Units of Madrid. The topics explored were based on knowledge, understanding, usefulness and use of CPG. The categories chosen for discussion were drawn up according to the GuiaSalud Methodological Manual. Sociological analysis was performed using a phenomenological approach.Results: the barriers related to training were the training model received to acquire the necessary skills, the lack of knowledge to evaluate the quality of guidelines and a limited knowledge of the search engines. Among the barriers related to social context and health system, conflict with the patient's expectations or with the recommendations of other specialists, the characteristics of patients who consult in primary care and the limited time available for consultations were all identified. Personal motivation, the tutor’s knowledge and professional practice model and clear, brief CPGs and in various formats were all identified as facilitators. Conclusions: residents value CPGs as teaching and decision-making tools, as well as a tool to improve their professional practice. However, they detect difficulties and limitations in their use. Training, motivation and the tutor's practice model are considered to be among the greatest facilitators.(AU)

Gender, smoking, and tobacco cessation with pharmacological treatment in a cluster randomized clinical trial.

INTRODUCTION: Whether men find it easier to quit smoking than women is still controversial. Different studies have reported that the efficacy of pharmacological treatments could be different between men and women. This study conducted a secondary analysis of 'Subsidized pharmacological treatment for smoking cessation by the Spanish public health system' (FTFT-AP study) to evaluate the effectiveness of a drug-funded intervention for smoking cessation by gender. METHODS: A pragmatic randomized clinical trial by clusters was used. The population included smokers aged ≥18 years, smoking >10 cigarettes per day, randomly assigned to an intervention group receiving regular practice and financed pharmacological treatment, or to a control group receiving only regular practice. The main outcome was continued abstinence at 12 months, self-reported and validated with CO-oximetry. The percentage, with 95% confidence intervals, of continued abstinence was compared between both groups at 12 months post-intervention, by gender and the pharmacological treatment used. Multilevel logistic regression analysis was performed. RESULTS: A total of 1154 patients from 29 healthcare centers were included. The average age was 46 years (SD=11.78) and 51.7% were men. Overall, the self-reported abstinence at 12 months was 11.1% (62) in women and 15.7% (93) in men (AOR=1.4; 95% CI: 1.0-2.0), and abstinence validated by CO-oximetry was 4.6% (26) and 5.9% (35) in women and men, respectively (OR=1.3; 95% CI: 0.7-2.2). In the group of smokers receiving nicotine replacement treatment, self-reported abstinence was higher in men compared to women (29.5% vs 13.5%, OR=2.7; 95% CI: 1.3-5.8). CONCLUSIONS: The effectiveness of a drug-financed intervention for smoking cessation was greater in men, who also showed better results in self-reported abstinence with nicotine replacement treatment.

Tendencias en la hospitalización por infección del tracto urinario en la población pediátrica de España en el período 2000-2015 / Trends in hospitalization for urinary tract infection in the paediatric age group in the 2000–2015 period in Spain

Objetivo: Analizar las tendencias en la hospitalización por infección del tracto urinario (ITU) en menores de 0-14 años en España en el período 2000-2015. Métodos: Estudio retrospectivo observacional realizado por medio del conjunto mínimo básico de datos hospitalario con códigos de la Clasificación Internacional de Enfermedades (CIE-9). Se incluyeron todos los ingresos por cistitis, pielonefritis e ITU de localización no especificada en niños menores de 15 años. Se recogieron datos sobre el sexo, edad, tipo de alta, diagnóstico principal, comorbilidades, estancia hospitalaria y coste total. Se calcularon tasas crudas de hospitalización por 1000 habitantes menores de 15 años y se llevó a cabo un análisis de regresión segmentada para identificar tendencias temporales. Resultados: En el período 2000-2015, hubo 124.696 ingresos en niños menores de 15 años. De este total, el 72,97% tenían de 0 a 1 año y el 60,12% recibió un diagnóstico de ITU no especificada, el 39,27% de pielonefritis, y el 0,52% de cistitis. La tasa bruta de hospitalización por ITU osciló entre 1,24 en 2000 y 0,98 en 2015. La tasa de hospitalización por ITU fue mayor en niñas que en niños. El análisis de regresión segmentada mostró una tendencia decreciente en la tasa de hospitalización por ITU, con un porcentaje de cambio anual medio (PCAM) del −1,5% (IC 95%: −2,4 a −0,6). Los cambios observados fueron mayores en niñas (PCAM −1,8; IC 95%: −2,5 a −1,0) y en el grupo de 7 a 10 años (PCAM −5,9; IC 95%: −6,7 a −5,2). Conclusiones: La tasa de hospitalización asociada a infección urinaria en pacientes menores de 15 años en España descendió durante el período 2000-2015. Las mayores tasas se dieron en niñas y en menores de 2 años. (AU)

Objective: To analyse the trends in hospital admissions related to urinary tract infection among children aged 0–14 years in Spain in the 2000–2015 period. Methods: We conducted a retrospective observational study using the minimum basic hospital discharge dataset system of Spain, which applies the International Classification of Diseases, version 9 (ICD-9) coding system. We included every hospitalization due to cystitis, pyelonephritis and unspecified UTI among children aged less than 15 years. We collected data on patient sex and age, type of discharge, main diagnosis, comorbidities, length of stay and overall cost. We calculated crude hospitalization rates per 1000 inhabitants aged less than 15 years and performed a joinpoint regression analysis to identify temporal trends. Results: In the 2000–2015 period, there were 124696 hospitalizations in children under 15 years. Of these patients, 72.97% were aged 0–1 year and 60.12% had a diagnosis of unspecified UTI, 39.27% of pyelonephritis, and 0.52% of cystitis. The crude rate of hospitalization due to UTI ranged from 1.24 in year 2000 to 0.98 in 2015. The rate of hospitalization was higher in female versus male patients. The joinpoint analysis found a decreasing trend in the rate of hospitalization due to UTI, with an average annual percent change (AAPC) of −1.5% (95% confidence interval [CI], −2.4 to −0.6). The largest decreases occurred in female patients (AAPC, −1.8; 95% CI, −2.5 to −1.0) and children aged 7–10 years (AAPC −5.9; 95% CI, −6.7 to −5.2). Conclusions: The rate of hospitalization related to UTI in Spain in patients aged up to 14 years decreased during the 2000–2015 period. The highest hospitalization rates occurred in female patients and in the 0-to-1 year age group. (AU)

Psychological impact of the COVID-19 pandemic on primary care workers: a cross-sectional study.

BACKGROUND: The COVID-19 pandemic has had a major impact on the mental health of healthcare workers, yet studies in primary care workers are scarce. AIM: To investigate the prevalence of and associated factors for psychological distress in primary care workers during the first COVID-19 outbreak. DESIGN AND SETTING: This was a multicentre, cross-sectional, web-based survey conducted in primary healthcare workers in Spain, between May and September 2020. METHOD: Healthcare workers were invited to complete a survey to evaluate sociodemographic and work-related characteristics, COVID-19 infection status, exposure to patients with COVID-19, and resilience (using the Connor-Davidson Resilience Scale), in addition to being screened for common mental disorders (depression, anxiety disorders, post-traumatic stress disorder, panic attacks, and substance use disorder). Positive screening for any of these disorders was analysed globally using the term 'any current mental disorder'. RESULTS: A total of 2928 primary care professionals participated in the survey. Of them, 43.7% (95% confidence interval [CI] = 41.9 to 45.4) tested positive for a current mental disorder. Female sex (odds ratio [OR] 1.61, 95% CI = 1.25 to 2.06), having previous mental disorders (OR 2.58, 95% CI = 2.15 to 3.10), greater occupational exposure to patients with COVID-19 (OR 2.63, 95% CI = 1.98 to 3.51), having children or dependents (OR 1.35, 95% CI = 1.04 to 1.76 and OR 1.59, 95% CI = 1.20 to 2.11, respectively), or having an administrative job (OR 2.24, 95% CI = 1.66 to 3.03) were associated with a higher risk of any current mental disorder. Personal resilience was shown to be a protective factor. CONCLUSION: Almost half of primary care workers showed significant psychological distress. Strategies to support the mental health of primary care workers are necessary, including designing psychological support and resilience-building interventions based on risk factors identified.

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.

Enfermedades crónicas en población pediátrica: comorbilidades y uso de servicios en atención primaria / Chronic diseases in the paediatric population: Comorbidities and use of primary care services

INTRODUCCIÓN: Los grupos de morbilidad ajustados (GMA) están siendo utilizados en la estratificación de los pacientes crónicos en atención primaria (AP). El objetivo del estudio fue describir las características, prevalencia de comorbilidades y utilización de servicios en AP de los pacientes crónicos pediátricos y analizar factores asociados al peso de complejidad según GMA. PACIENTES Y MÉTODOS: Estudio observacional descriptivo transversal. Se incluyeron los pacientes<18 años de una zona básica de salud clasificados como crónicos según los GMA de la historia clínica electrónica de AP de la Comunidad de Madrid. Se recogieron variables sociodemográficas, clínico-asistenciales y de uso de servicios en AP. Análisis univariado, bivariado y regresión lineal. RESULTADOS: De los 2.961 pacientes<18 años se identificaron como crónicos 423 (15,7%), de los que 408 (96,5%) eran de bajo riesgo. Su edad media fue 9,5 (DE=4,7) años y el 54,1% eran varones. La media de enfermedades crónicas fue 1,1 (DE=0,4) y el 11,3% tenían multimorbilidad. Las enfermedades más prevalentes fueron: asma (6,1%), trastorno por déficit de atención e hiperactividad (TDAH) (1,8%) y obesidad (1,4%). La media de visitas/año al pediatra fue 4,9 (DE=6,3). Se asoció a mayor peso de complejidad la edad<5 años (coeficiente B [CB]=2,6; IC 95%=2,1; 3,1), número de enfermedades crónicas (CB=1,6; IC 95%=1,1; 2,1) y contactos anuales con AP (CB=0,1; IC 95%=0,06;0,11). CONCLUSIONES: En población pediátrica encontramos un número importante de pacientes con enfermedades crónicas, siendo el asma, el TDAH y la obesidad las enfermedades más prevalentes. El uso de servicios de AP fue elevado. La mayor complejidad responde a la edad lactante y la preescolar, a la multimorbilidad y a los mayores contactos con AP

INTRODUCTION: Adjusted morbidity groups (AMG) are being used in the stratification of chronic patients in Primary Care (PC). The aim of this study was to describe the characteristics, prevalence of comorbidities, and use of PC services by chronic paediatric patients as well as to analyse factors associated with the weight of complexity according to AMG. PATIENTS AND METHODS: A cross-sectional study conducted on patients <18 years-old from a basic health area, classified as chronic according to the AMG of the Madrid Primary Care computerised clinical records. Sociodemographic and clinical-care variables were collected, as well as the use of services in PC. Univariate, bivariate and linear regression analysis were performed. RESULTS: A total of 2,961 patients<18 years were included, of whom 423 (15.7%) were identified as chronic, and 408 (96.5%) were low risk patients. Their mean age was 9.5 (SD=4.7) years, and 54.1% were male. The mean of chronic diseases was 1.1 (SD=0.4) and 11.3% had multiple morbidity. The most prevalent diseases were asthma (6.1%), attention deficit hyperactivity disorder (ADHD) (1.8%), and obesity (1.4%). The mean number of visits to the paediatrician was 4.9 (SD=6.3). Age<5 years-old (Coefficient B [CB]=2.6, 95% CI=2.1, 3.1), number of chronic diseases (CB=1.6, 95% CI=1.1; 2.1), and annual contacts with PC (CB=0.1, 95% CI=0.06; 0.11) were associated with greater complexity weight. CONCLUSIONS: A significant number of patients with chronic diseases were found in the paediatric population. The most prevalent diseases were asthma, ADHD, and obesity. The use of PC services was high. The greatest complexity corresponded to nursing and pre-school age, multiple morbidity, and higher number of contacts with PC

Social support, social context and nonadherence to treatment in young senior patients with multimorbidity and polypharmacy followed-up in primary care. MULTIPAP Study.

OBJECTIVE: To estimate the prevalence of nonadherence to treatment and its relationship with social support and social context in patients with multimorbidity and polypharmacy followed-up in primary care. METHODS: This was an observational, descriptive, cross-sectional, multicenter study with an analytical approach. A total of 593 patients between 65-74 years of age with multimorbidity (≥3 diseases) and polypharmacy (≥5 drugs) during the last three months and agreed to participate in the MULTIPAP Study. The main variable was adherence (Morisky-Green). The predictors were social support (structural support and functional support (DUFSS)); sociodemographic variables; indicators of urban objective vulnerability; health-related quality of life (EQ-5D-5L-VAS & QALY); and clinical variables. Descriptive, bivariate and multivariate analyses with logistic regression models and robust estimators were performed. RESULTS: Four out of ten patients were nonadherent, 47% had not completed primary education, 28.7% had an income ≤1050 €/month, 35% reported four or more IUVs, and the average perceived health-related quality of life (HRQOL) EQ-5D-5L-VAS was 65.5. The items that measure functional support, with significantly different means between nonadherent and adherent patients were receiving love and affection (-0.23; 95%CI: -0.40;-0.06), help when ill (-0.25; 95%CI: -0.42;-0.08), useful advice (-0.20; 95%CI: -0.37;-0.02), social invitations (-0.22; 95%CI:-0.44;-0.01), and recognition (-0.29; 95%CI:-0.50;-0.08). Factors associated with nonadherence were belonging to the medium vs. low tertile of functional support (0.62; 95%CI: 0.42;0.94), reporting less than four IUVs (0.69; 95%CI: 0.46;1.02) and higher HRQOL perception (0.98; 95%CI: 0.98;0.99). CONCLUSIONS: Among patients 65-74 years of age with multimorbidity and polypharmacy, lower functional support was related to nonadherence to treatment. The nonadherence decreased in those patients with higher functional support, lower urban vulnerability and higher perceived health status according to the visual analog scale of health-related quality of life.

MULTIPAP Study: Improving healthcare for patients with multimorbidity.

BACKGROUND: The steady rise in multimorbidity entails serious consequences for our populations, challenges healthcare systems, and calls for specific clinical approaches of proven effectiveness. The MULTIPAP Study comprises three sequential projects (MULTIPAP and MULTIPAP Plus RCTs, and the MULTIPAP Cohort). Results of MULTIPAP RCT are presented. AIM: To evaluate the effectiveness of a complex, patient-centred intervention in young-old patients with multimorbidity and polypharmacy. METHOD: Pragmatic cluster-randomised clinical trial in a primary healthcare setting. GPs were randomly allocated to either conventional care or the MULTIPAP intervention based on the Ariadne Principles with two components: GPs e-training (that is, eMULTIPAP addresses specific, key concepts on multimorbidity, polypharmacy and shared decision-making) and GP-patient-centred interview. Young-old patients aged 65-74 years with multimorbidity and polypharmacy were included. MAIN OUTCOME: difference in the Medication Appropriateness Index (MAI) after 6-month follow-up between groups. SECONDARY OUTCOMES: MAI, quality of life, patient perception, health services use, treatment adherence and cost-effectiveness after 12-month follow-up. RESULTS: 117 GPs from 38 Spanish primary health care recruited 593 patients randomly assigned to the intervention/control groups. Difference in MAI scores between groups in the intention-to-treat analysis after 6 months' follow-up: -2.42 (-4.27 to -0.59), P = 0.009 (adjusted difference in mean MAI score -1.81(-3.35 to -0.27), P = 0.021). SECONDARY OUTCOMES: not significant, including quality of life (adjusted difference in mean EQ-5D-5L (VAS) 2.94 (-1.39 to 7.28), P = 0.183, EQ-5D-5L (index) -0.006(-0.034 to 0.022), P = 0.689). CONCLUSION: The intervention significantly improved medication appropriateness. The observed quality of life improvement was not significant. GPs e-training in multimorbidity has shown to be feasible and well accepted by the professionals. Future studies may test whether this format facilitates implementation.

Efectos del cambio de apariencia de medicamentos en seguridad y adherencia en pacientes crónicos mayores de 65 años en atención primaria. Estudio CAMBIMED / Effects of changing the appearance of medications in safety and adherence in chronic patients over 65 years of age in primary care. CAMBIMED Study

OBJETIVO: Estudiar si en pacientes mayores de 65años con tratamientos antihipertensivos e hipolipemiantes los cambios de fármacos bioequivalentes con diferente apariencia se asocian a un aumento de errores de uso y pérdida de adherencia al tratamiento. DISEÑO: Estudio observacional, longitudinal, prospectivo, de cohorte de 1año de seguimiento entre el 1 de enero de 2013 y el 31 de diciembre de 2014. Emplazamiento: Centros de Salud de la Comunidad de Madrid. PARTICIPANTES: Pacientes ≥ 65 años con diagnóstico de HTA (CIAP K86) y/o dislipidemia (CIAP T93) en tratamiento con enalapril y/o amlodipino y/o simvastatina. Mediciones principales: Se recogieron mediante entrevista en consulta variables sociodemográficas (edad, sexo, nivel de estudios), clínicas, adherencia (test de Morisky-Green y recuento directo), errores de medicación (número y tipo), cambios de fármacos y número, parámetros bioquímicos (colesterol total, colesterol HDL, colesterol LDL, triglicéridos) y variable combinada (error y/o adherencia). Se realizaron 5 visitas: una basal y 4 trimestrales. RESULTADOS: Se incluyeron 274 pacientes, edad media 72 (6,6) años, 47,8% mujeres. Presentaron algún cambio de medicamento 134 pacientes (48,9%), con una mediana de cambios de 3 (RIQ 1-5) y máximo de 11. El riesgo de presentar algún error o disminuir la adherencia estaba aumentado en expuestos a cambios en todas las visitas con RR 1,14 (1,16-1,69) al año de seguimiento. El error más frecuente fue la pérdida de dosis. Por cada cambio la probabilidad de un evento combinado aumenta en un 41%. CONCLUSIONES: Los cambios realizados entre fármacos bioequivalentes con diferente apariencia podrían aumentar el número de errores de medicación y disminuir la adherencia. Habría que realizar más estudios para valorar en qué medida afecta al control de la enfermedad. No se contempla el apartado intervención por tratarse de un estudio observacional

OBJECTIVE: To study whether the changes in bioequivalent drugs with different appearances are associated with an increase in lack of adherence and medication use errors, in patients > 65 years old treated with antihypertensive and lipid-lowering medications. DESIGN: Observational longitudinal prospective cohort study with a one-year follow-up period between 1 January 2013 and 31 December 2014. LOCATION: Primary Healthcare Centres in the Community of Madrid. PARTICIPANTS: Patients ≥ 65 years-old with a diagnosis of hypertension and/or dyslipidaemia receiving treatment with Enalapril and/or Amlodipine and/or Simvastatin. MAIN MEASUREMENTS: Variables collected during a Primary Care consultation by means of a personal interview were: sociodemographic (age, gender, level of education), clinical variables, adherence (Morisky-Green test and direct counting), medication errors (number and type), medication changes and number, analytical (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides) and combined variable (error and/or adherence). There were 1 baseline and 4 quarterly visits. RESULTS: The study included 274 patients with a mean age 72 (6.6) years, of whom 47.8% were female. Some medication changes were observed in 134 patients (48.9%), with a median of 3 (IQR 1-5) and a maximum of 11 changes. The risk of presenting with a medication use error or decreased adherence was increased in patients exposed to changes in all visits with RR 1.14 (1.16-1.69) at one year of follow-up. The most frequent error was the loss of dose. For each change in medication, the probability of a combined event increases by 41%. CONCLUSIONS: The changes made in bioequivalent drugs with different appearance could increase the number of medication use errors and decrease the adherence. More studies should be carried out to assess how much this affects the control of the disease. The intervention section is not considered because it is an observational study

Grupos de morbilidad ajustados: características y comorbilidades de los pacientes crónicos según nivel de riesgo en Atención Primaria / Adjusted morbidity groups: Characteristics and comorbidities in patients with chronic conditions according to their risk level in Primary Care

OBJETIVOS: Describir las características de los pacientes crónicos según el nivel de riesgo asignado por los grupos de morbilidad ajustados (GMA). Analizar los factores asociados al nivel de riesgo alto y estudiar el efecto de cada uno de ellos. DISEÑO: Estudio observacional descriptivo transversal con enfoque analítico. Emplazamiento: Atención Primaria (AP). Servicio Madrileño de Salud. PARTICIPANTES: Población de 18.107 pacientes estratificados por los GMA integrados en la historia clínica electrónica de AP de la Comunidad de Madrid. Mediciones principales: Variables sociodemográficas, clínico-asistenciales y de uso de servicios. Se realizó análisis univariado, bivariado y multivariante. RESULTADOS: De los 18.107 pacientes se identificaron 9.866 (54,4%) pacientes crónicos, 444 (4,5%) estratificados como de alto riesgo, 1.784 (18,1%) como de medio riesgo y 7.638 (77,4%) como de bajo riesgo. Los de alto riesgo, comparados con medio y bajo riesgo, tenían una edad media mayor (77,8 [12,9]; 72,1 [12,9]; 50,6 [19,4]), menor porcentaje de mujeres (52,3%, 65%, 61,1%), mayor número de enfermedades crónicas (6,7 [2,4]; 4,3 [1,5]; 1,9 [1,1]), polimedicación (79,1%, 43,3%, 6,2%) y contactos con AP (33,9 [28]; 21,4 [17,3]; 7,9 [9,9]) (p < 0,01). En el multivariante el nivel de riesgo alto se relacionó de manera independiente con la edad > 65 (OR = 1,43; IC 95% = 1,03-1,99), sexo masculino (OR = 3,46; IC 95%=2,64-4,52), inmovilidad (OR = 6,33; IC 95% = 4,40-9,11), número de enfermedades crónicas (OR = 2,60; IC 95% = 2,41-2,81) (p < 0,01) y número de contactos con AP > 7 (OR = 1,95; IC 95% = 1,36-2,80). CONCLUSIONES: Más de la mitad de la población fue clasificada por los GMA como crónica, y se estratificó en 3 niveles de riesgo que presentaban diferencias en sexo, edad, deterioro funcional, necesidad de cuidados, morbilidad, complejidad, polifarmacia y contactos con AP. La edad > 65, el sexo masculino, la inmovilidad, el número de enfermedades crónicas y los contactos con AP > 7 fueron los factores asociados al alto riesgo

AIMS: To describe the characteristics of patients with chronic conditions according to their risk levels assigned by the adjusted morbidity groups (AMG). To analyse the factors associated with a high risk level and to study their effect. DESIGN: Observational cross-sectional study with an analytical focus. LOCATION: Primary care (PC), Madrid Health Service. PARTICIPANTS: Population of 18,107 patients stratified by their risk levels with the AMG in the computerised clinical records of Madrid PC. MAIN MEASUREMENTS: The variables studied were: socio-demographic, clinical-nursing care and use of services. Univariate, bivariate, and multivariate analysis were performed. RESULTS: Of the 18,107 patients, 9,866(54.4%) were identified as chronic patients, with 444 (4.5%) stratified as high risk, 1784 (18,1%) as medium risk, and 7,638 (77.4%) as low risk. The high risk patients, compared with medium and low risk, had an older mean age [77.8 (SD = 12.9), 72.1 (SD = 12.9), 50.6 (SD = 19.4)], lower percentage of women (52.3%, 65%, 61.1%), a higher number of chronic diseases [6.7 (SD = 2.4), 4.3 (SD = 1.5), 1.9 (SD = 1.1)], polymedication (79.1%, 43.3%, 6.2%), and contact with PC [33.9 (28), 21.4 (17.3), 7.9 (9.9)] (P < .01). In the multivariate analysis, the high risk level was independently related to age>65 [1.43 (1.03-1.99), male gender (OR = 3.46, 95% CI = 2.64-4.52), immobility (OR = 6.33, 95% CI = 4.40-9.11), number of chronic conditions (OR = 2.60, 95% CI = 2.41-2.81), and PC contact > 7 times (OR=1.95, 95% CI=1.36-2.80)] (P < .01). CONCLUSIONS: More than half of the population is classified by the AMG as a chronic, and it is stratified into 3 risk levels that show differences in gender, age, functional impairment, need for care, morbidity, complexity, and use of Primary Care services. Age > 65, male gender, immobility, number of chronic conditions, and contact with PC > 7 times were the factors associated with high risk

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

Objetivos: Los objetivos de este estudio son describir la frecuencia de exposición y la actitud de los médicos internos residentes (MIR) de la Comunidad de Madrid (CM) con la industria farmacéutica (IF), y analizar la asociación con la especialidad, el entorno profesional y la formación recibida. Métodos: Estudio descriptivo mediante encuesta electrónica durante mayo y junio de 2015 a los MIR de la CM. Se recogieron variables sociodemográficas y de relación con la IF en cuatro bloques: frecuencia de interacción, actitudes y percepciones, entorno y marco regulatorio, y habilidades adquiridas; con los dos primeros se elaboró un índice sintético de relación con la IF (ISIF). Análisis bivariado y multivariado de regresión logística. Resultados: Respondieron 350 residentes (28% de medicina familiar y comunitaria [MFyC]), 57% de especialidades hospitalarias y 15% de otras). El 98% refirió haber tenido relación con la IF. El 20% creía que influye en su prescripción y el 48% en los demás médicos. El 96% no había recibido información de su colegio profesional, el 80% desconocía si había normas en su sociedad científica y el 50% no sabía si las había en su institución. El 65% consideró necesaria más formación. Los residentes de especialidades hospitalarias presentaron más probabilidad de presentar un ISIF igual o superior al percentil 75 que los de MFyC (odds ratio [OR]: 3,96; intervalo de confianza del 95% [IC95%]: 1,88-8,35). Formarse en entornos informales se asoció a un ISIF menor o igual al percentil 25 (OR: 2,83; IC95%: 1,32-6,07). Conclusiones: Los MIR de la CM tienen un alto nivel de contacto con la IF y creen que su influencia es limitada. Los residentes de especialidades hospitalarias presentan mayor contacto. Las regulaciones son poco conocidas por los residentes, que consideran que es necesaria más formación

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

MULTICAGE CAD-4: Psychometric characteristics for the screening of addictive behaviors / MULTICAGE CAD-4 para la detección de adicciones conductuales: validez estructural después de la inclusión de una escala en el abuso de teléfonos inteligentes

Addictive behaviors are not limited to drugs use, but also include certain daily behaviors that can cause gratification. Their progression to more severe pathological patterns entails grave consequences for the individual, including multiple psychopathological manifestations. The early detection of this type of behavior is of concern to primary health care. Therefore, in order to detect risk at early stages, reliable and valid tools for daily practice are essential. The MULTICAGE CAD-4 questionnaire is a screening tool for simultaneously detecting addictive behaviors. This study includes a new scale for the detection of smartphone abuse. The objective is to evaluate the adequacy of its psychometric properties. A sample of 2,074 subjects that were recruited from primary care centers ofMadrid(Spain) completed the MULTICAGE CAD-4 questionnaire. A confirmatory factor analysis, using unweighted least squares method, was performed. The test showed good internal consistency both at item and scale levels. The questionnaire structure was consistent with theoretical expectations. The MULTICAGE CAD-4, including the new smartphone scale, is a robust, reliable tool with a valid structure for assessing the presence of dysfunctional or potentially addictive behaviors, and especially useful in primary health care services

Los comportamientos adictivos no se limitan al uso de drogas, sino que también incluyen ciertos comportamientos diarios que pueden causar gratificación. Su progresión a patrones patológicos más severos conlleva graves consecuencias para el individuo, incluidas múltiples manifestaciones psicopatológicas. La detección temprana de este tipo de comportamiento es de interés para la atención primaria de salud. Por lo tanto, para detectar riesgos en etapas tempranas, las herramientas confiables y válidas para la práctica diaria son esenciales. El cuestionario MULTICAGE CAD-4 es una herramienta de detección para detectar simultáneamente conductas adictivas. Este estudio incluye una nueva escala para la detección del abuso de teléfonos inteligentes. El objetivo es evaluar la adecuación de sus propiedades psicométricas. Una muestra de 2.074 sujetos reclutados en centros de atención primaria de Madrid (España) completó el cuestionario MULTICAGE CAD-4. Se realizó un análisis factorial confirmatorio, utilizando el método de mínimos cuadrados no ponderados. La prueba mostró una buena consistencia interna tanto a nivel del ítem como de las escalas. La estructura del cuestionario fue consistente con las expectativas teóricas. El MULTICAGE CAD-4, incluida la nueva escala para teléfonos inteligentes, es una herramienta robusta y confiable con una estructura válida para evaluar la presencia de comportamientos disfuncionales o potencialmente adictivos, y especialmente útil en servicios de atención primaria de salud

Utilización de los servicios de salud de Atención Primaria en los pacientes crónicos según nivel de riesgo / Health services utilization in Primary Care in patients with chronic conditions according to risk levels

OBJETIVO: Los pacientes crónicos sufren mayor número de problemas de salud y tienen mayores necesidades de asistencia y cuidados. El objetivo de este estudio fue describir la utilización de servicios de salud de Atención Primaria en los pacientes crónicos según el nivel de riesgo asignado por los grupos de morbilidad ajustados (GMA), así como analizar los factores asociados. MÉTODOS: Se realizó un estudio transversal. Se incluyeron pacientes ≥ 18 años identificados como crónicos por el estratificador GMA en una zona básica de salud de la Comunidad de Madrid, con una población adscrita de 18.107 habitantes. Se recogieron variables sociodemográficas, clínico-asistenciales y de utilización de servicios, y se clasificaron según el modelo "conductual" en "factores predisponentes", "factores de necesidad" o "factores facilitadores". Se empleó un análisis univariado, bivariado y multivariante, ajustando un modelo de regresión lineal múltiple con estimadores robustos. RESULTADOS: Se incluyeron 9.443 pacientes crónicos (el 52,1% de la población de la zona seleccionada), con una edad media de 57,8 años (Desviación estándar [DE]=18,7), siendo mujeres el 62,1%. El 4,7% eran pacientes de alto riesgo, el 18,7% de medio riesgo y el 76,6% presentaba bajo riesgo. La media de contactos/año fue de 14,1 (DE=15,2). 34,4 (DE=27,9) en alto riesgo, 21,8 (DE=17,2) en riesgo medio y 10,1 (DE=10,2) en bajo riesgo. De estos contactos, 7,5 (DE=7,1) fueron con médico y 12,9 (DE=12,9) presenciales. Los factores asociados a mayor utilización fueron el riesgo alto (Coeficiente B [CB]=12,6; IC95%=11,1-14,2), el estar inmovilizado (CB=8,8; IC95%=7,3-10,4), la polimedicación (CB=6; IC95%=5,1-6,9), el ser mujer (CB=1; IC95%=0,4-1,5), el número de enfermedades crónicas (CB=1; IC95%=0,8-1,2) y la edad (CB=0,03; IC95%=0,01-0,05). CONCLUSIONES: La utilización de servicios de Atención Primaria en los pacientes crónicos es elevada y aumenta según el nivel de riesgo asignado por los GMA. El contacto con el médico es superior frente al de la enfermería, y el tipo más frecuente es presencial. La mayor utilización responde a factores predisponentes (ser mujer y la edad) y, sobre todo, de necesidad clínica (alto riesgo, multimorbilidad, polimedicación e inmovilidad)

OBJECTIVE: Chronic patients suffer a greater number of health problems and have greater needs for assistance and care. The objective was to describe the use of health services in Primary Care in patients with chronic conditions according to risk level by adjusted morbidity groups (AMG) and analyze the associated factors. METHODS: Cross-sectional study. We included patients ≥18 years-old identified as chronic by the stratification tool according to AMG in a basic health area in the Community of Madrid with an assigned population of 18,107 inhabitants. Sociodemographic, clinical-care and use of services variables were collected and were classified according to the "behavioral" model in predisposing, need or facilitators factors. Univariate, bivariate and multiple linear regression adjusted with robust estimators was performed. RESULTS: 9,443 chronic patients (52.1% of the population in the selected zone) were identified, mean age of 57.8 (SD=18.7); 62.1% women. According to their risk level 4.7% were high risk, 18.7% medium risk and 76.6% low risk. The mean number of contacts per year was 14.1 (SD=15.2); 34.4 (SD=27.9) in high risk; 21.8 (SD=17.2) in medium risk and 10.1 (SD=10.2) in low risk. 7.5 (SD=7.1) contacts were with the doctor and 12.9 (SD=12.9) were face-to-face. The factors associated with higher use of services were high risk (Coefficient B[CB]=12.6; IC95%=11-14.2), immobilization (CB=8.8; IC95%=7.3-10.4), polypharmacy (CB=6; IC95%=5-8.6), female sex (CB=1; IC95%=0.4-1.5), number of chronic diseases (CB=1; IC95%=0.8-1.2) and age (CB=0.03; IC95%=0.01-0.05). CONCLUSIONS: The health services utilization in Primary Care in chronic patients is high and increased according with the risk level by AMG. The contact with the doctor is superior to nurse and the most frequent type is face-to-face. The greater utilization of services responds to predisposing factors (female sex and age) and above all to need factors (high risk, immobility, multimorbidity and polypharmacy)

Incidencia de diabetes en pacientes tratados con antipsicóticos en atención primaria / Incidence of diabetes in patients treated with antipsychotics in primary care

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Explaining differences in perceived health-related quality of life: a study within the Spanish population / Explicar las diferencias en cuanto a la calidad de vida percibida relacionada con la salud: estudio realizado en la población española

Objective: To assess the burden of several determinants on health-related quality of life (HRQOL) and to study its heterogeneity among the different Spanish regions. Method: Cross-sectional study. Data were obtained from the Spanish National Health Survey (2012), and HRQOL was measured using the EQ-5D-5L questionnaire (utility and visual analogue scale -VAS- scores). Demographic variables, physical health condition, social variables, mental health status, and lifestyle were also analysed. Tobit regression models were employed to study the relationships between expressed HRQOL and personal characteristics. Results: A total of 20,979 surveys were obtained. Of them, 62.4% expressed a utility score of 1, corresponding to perfect health (95%CI: 61.8%-63.2%), and 54.2% showed VAS scores ≥80 (95%CI: 53.5%-54.9%). HRQOL was mainly described as a function of age, chronic limitation in daily activities, and mental health status. Belonging to a higher-class strata and physical activity were related to better self-perceived HRQOL. Ageing worsened perceived HRQOL, but did not influence its determinants, and differences in HRQOL by regions were also not significant after model adjustment. Conclusion: HRQOL perception in the Spanish population varied slightly depending on the measure used (utilities index or VAS). Age, chronic limitations in daily life, and mental health status best explained the variability in perception, and no meaningful differences in HRQOL perception among regions were found after adjustment

Objetivo: Evaluar la carga de ciertos determinantes de la calidad de vida relacionada con la salud (CVRS) y su heterogeneidad entre diferentes regiones españolas. Métodos: Estudio transversal. Utilizando datos de la Encuesta Nacional de Salud (2012), se midió la CVRS con el cuestionario EQ5D-5L (utilidad y escala visual analógica [EVA]). Se analizaron variables demográficas, estado de salud, variables sociales, salud mental y estilos de vida, utilizando modelos Tobit. Resultados: Se incluyeron 20.979 encuestas. El 62,4% de los sujetos expresó una utilidad de 1, perfecta salud (intervalo de confianza del 95% [IC95%]: 61,8% -63,2%), y el 54,2% mostró puntuaciones en la EVA ≥80 (IC95%: 53,5%-54,9%). La CVRS se vio modificada fundamentalmente por la edad, la limitación crónica en las actividades diarias y el estado de salud mental. La clase social alta y la actividad física aparecían relacionadas con una mejor CVRS. La edad empeoró la percepción de la CVRS, pero no se asoció con un cambio en la influencia de sus determinantes. Después de ajustar los modelos, no había diferencias en la CVRS en las diferentes regiones. Conclusión: La percepción de la CVRS en la población española varió dependiendo de la medida utilizada (utilidades o EVA). La edad, las limitaciones crónicas en la vida diaria y el estado de salud mental explicaban fundamentalmente las diferencias en la CVRS, y las diferencias entre regiones se explicaron principalmente por diferentes características poblacionales

Actividades preventivas en la mujer. Actualización PAPPS 2018 / No disponible

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La glucemia mantenida entre 110-125 mg/dl ¿es un factor de riesgo de desarrollo de diabetes? / Is a maintained glycemia between 110/125 mg/dl a risk factor in the development of diabetes?

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Hacia un modelo de atención a la multimorbilidad en atención primaria / Towards a multimorbidity care model in Primary Care

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Multimorbilidad en medicina de familia y los principios Ariadne. Un enfoque centrado en la persona / Multimorbidity in general practice and the Ariadne principles. A person-centred approach

La multimorbilidad, definida como la presencia de dos o más enfermedades crónicas en un mismo individuo, conlleva consecuencias negativas para la persona e importantes retos para los sistemas sanitarios. En atención primaria, donde recae esencialmente la atención de este grupo de pacientes, la consulta es más compleja que la de un paciente con una única enfermedad debido, entre otros, al hecho de tener que manejar mayor cantidad de información clínica, disponer de poca evidencia científica para abordar la multimorbilidad, y tener que coordinar la labor de múltiples profesionales para garantizar la continuidad asistencial. Además, para poder implementar correctamente los planes de tratamiento en estos pacientes es necesario un proceso de toma de decisiones compartida médico-paciente. Entre las distintas herramientas disponibles para apoyar dicho proceso, recientemente se ha desarrollado una dirigida específicamente a pacientes con multimorbilidad en atención primaria y que se describe en el presente artículo: los principios Ariadne

Multimorbidity, defined as the coexistence of two or more chronic conditions in one same individual, has negative consequences for people suffering from it and it poses a real challenge for health systems. In primary care, where most of these patients are attended, the clinical management of multimorbidity can be a complex task due, among others, to the high volume of clinical information that needs to be handled, the scarce scientific evidence available to approach multimorbidity, and the need for coordination among multiple health providers to guarantee continuity of care. Moreover, the adequate implementation of the care plan in these patients requires a process of shared decision making between patient and physician. One of the available tools to support this process, which is specifically directed to patients with multimorbidity in primary care, is described in the present article: the Ariadne principles