Differences in Results and Related Factors Between Hospital-at-Home Modalities in Catalonia: A Cross-Sectional Study.

Hospital-at-home (HaH) is a healthcare modality that provides active treatment by healthcare staff in the patient's home for a condition that would otherwise require hospitalization. The aims were to describe the characteristics of different types of hospital-at-home (HaH), assess their results, and examine which factors could be related to these results. A cross-sectional study based on data from all 2014 HaH contacts from Catalonia was designed. The following HaH modalities were considered-admission avoidance (n = 7,214; 75.1%) and early assisted discharge (n = 2,387; 24.9%). The main outcome indicators were readmission, mortality, and length of stay (days). Multivariable models were fitted to assess the association between explanatory factors and outcomes. Hospital admission avoidance is a scheme in which, instead of being admitted to acute care hospitals, patients are directly treated in their own homes. Early assisted discharge is a scheme in which hospital in-care patients continue their treatment at home. In the hospital avoidance modality, there were 8.3% readmissions, 0.9% mortality, and a mean length of stay (SD) of 9.6 (10.6) days. In the early assisted discharge modality, these figures were 7.9%, 0.5%, and 9.8 (11.1), respectively. In both modalities, readmission and mean length of stay were related to comorbidity and type of hospital, and mortality with age. The results of HaH in Catalonia are similar to those observed in other contexts. The factors related to these results identified might help to improve the effectiveness and efficiency of the different HaH modalities.

The validity of recommendations from clinical guidelines: a survival analysis.

BACKGROUND: Clinical guidelines should be updated to maintain their validity. Our aim was to estimate the length of time before recommendations become outdated. METHODS: We used a retrospective cohort design and included recommendations from clinical guidelines developed in the Spanish National Health System clinical guideline program since 2008. We performed a descriptive analysis of references, recommendations and resources used, and a survival analysis of recommendations using the Kaplan-Meier method. RESULTS: We included 113 recommendations from 4 clinical guidelines with a median of 4 years since the most recent search (range 3.9-4.4 yr). We retrieved 39 136 references (range 3343-14 787) using an exhaustive literature search, 668 of which were related to the recommendations in our sample. We identified 69 (10.3%) key references, corresponding to 25 (22.1%) recommendations that required updating. Ninety-two percent (95% confidence interval 86.9-97.0) of the recommendations were valid 1 year after their development. This probability decreased at 2 (85.7%), 3 (81.3%) and 4 years (77.8%). INTERPRETATION: Recommendations quickly become outdated, with 1 out of 5 recommendations being out of date after 3 years. Waiting more than 3 years to review a guideline is potentially too long.

Strategies to assess the validity of recommendations: a study protocol.

BACKGROUND: Clinical practice guidelines (CPGs) become quickly outdated and require a periodic reassessment of evidence research to maintain their validity. However, there is little research about this topic. Our project will provide evidence for some of the most pressing questions in this field: 1) what is the average time for recommendations to become out of date?; 2) what is the comparative performance of two restricted search strategies to evaluate the need to update recommendations?; and 3) what is the feasibility of a more regular monitoring and updating strategy compared to usual practice?. In this protocol we will focus on questions one and two. METHODS: The CPG Development Programme of the Spanish Ministry of Health developed 14 CPGs between 2008 and 2009. We will stratify guidelines by topic and by publication year, and include one CPG by strata.We will develop a strategy to assess the validity of CPG recommendations, which includes a baseline survey of clinical experts, an update of the original exhaustive literature searches, the identification of key references (reference that trigger a potential recommendation update), and the assessment of the potential changes in each recommendation.We will run two alternative search strategies to efficiently identify important new evidence: 1) PLUS search based in McMaster Premium LiteratUre Service (PLUS) database; and 2) a Restrictive Search (ReSe) based on the least number of MeSH terms and free text words needed to locate all the references of each original recommendation.We will perform a survival analysis of recommendations using the Kaplan-Meier method and we will use the log-rank test to analyse differences between survival curves according to the topic, the purpose, the strength of recommendations and the turnover. We will retrieve key references from the exhaustive search and evaluate their presence in the PLUS and ReSe search results. DISCUSSION: Our project, using a highly structured and transparent methodology, will provide guidance of when recommendations are likely to be at risk of being out of date. We will also assess two novel restrictive search strategies which could reduce the workload without compromising rigour when CPGs developers check for the need of updating.

Validation of the FRAX predictive model for major osteoporotic fracture in a historical cohort of Spanish women.

FRAX is a fracture risk assessment tool to estimate the 10-yr probability of a major osteoporotic fracture or a hip fracture. The aim of the study was to assess the predictive ability of FRAX for major osteoporotic fracture in a cohort of Spanish women. The study was based on a retrospective cohort of women aged 40-90 yr. Patients were followed from their first bone densitometry to the first major osteoporotic fracture event (forearm, proximal humerus, clinical spine, or hip fracture) or for 10 yr whichever comes first. A total of 1231 women were included. Bone mineral density data and self-reported data on risk factors for fracture were obtained. The predictive ability of FRAX was assessed by analyzing calibration and discrimination, with the calculation of observed-to-expected (O/E) fracture ratios and the receiver operating characteristic (ROC) curve, respectively. A total of 222 women (18.1%) reported at least 1 fracture after the first assessment. The incidence of fracture was 14 (95% confidence interval [CI]: 10-17), 19 (95% CI: 15-23), 28 (95% CI: 21-36), and 67 (95% CI: 8-125) cases per 1000 woman-years in women aged <55, 55-64, 65-74, and ≥75 yr, respectively. The O/E ratio was 3.9 (95% CI: 3.4-4.5; p<0.0001). The area under the ROC curve was 61% (95% CI: 57-65%). FRAX underestimated the risk of major osteoporotic fracture in this cohort of Spanish women, particularly in those with a low risk of fracture according to the clinical factors used in the FRAX tool. Our findings highlight the need for validation studies of FRAX in Spain.

Reliability and validity of the Spanish version of the Child Health and Illness Profile Child-Edition/Child Report Form (CHIP-CE/CRF).

OBJECTIVES: To assess the reliability and validity of the Spanish version of the CHIP-CE/CRF. METHODS: Cross-sectional study was conducted in a representative sample of primary school children in Spain. Children were administered the Spanish version of the CHIP-CE/CRF. The Achenbach Child Behavioral Checklist was given to parents. RESULTS: The overall response rate was 75% (n = 979). Internal consistency was >0.70 for 3 out of 5 domains, and the intraclass correlation coefficient for test-retest stability ranged from 0.69 to 0.80. Confirmatory factor analysis replicated the original model. Younger children scored higher in Satisfaction than older children. Girls scored lower in Comfort but higher in Risk Avoidance than boys. CONCLUSIONS: The Spanish version of the CHIP-CE/CRF has shown acceptable reliability and validity, similar to the properties of the original US version. Future studies should analyze the instrument's sensitivity to change.

Factores de riesgo de fracturas por fragilidad en una cohorte de mujeres españolas / Risk factors for fragility fractures in a cohort of Spanish women

Introducción Las fracturas por fragilidad constituyen un problema de salud pública. El objetivo fue analizar la asociación de los principales factores de riesgo de osteoporosis con la fracturas por fragilidad en una cohorte de mujeres con indicación de densitometría ósea. Métodos Cohorte retrospectiva con seguimiento hasta una fractura por fragilidad, de una población de mujeres de 40 a 90 años de edad con una primera visita para realizarse una densitometría entre enero de 1992 y febrero de 2008. Se calcularon la tasa de incidencia de fracturas por 1000 mujeres-año de seguimiento y la hazard ratio (HR) de fractura mediante un modelo de regresión de Cox. Resultados Se estudiaron 49.735 mujeres con una edad media de 57,8 años (desviación estándar: 8,5). De ellas, 3631 mujeres (7,1%) declararon al menos una fractura por fragilidad en las visitas posteriores a la basal. Los factores de riesgo con una mayor HR ajustada fueron la edad ≥75 años respecto a < 55 años (HR: 3,8; intervalo de confianza del 95% [IC95%]: 3,3-4,4) y tener un resultado de la densitometría valorable como osteoporosis respecto a normal (HR: 2; IC95%: 1,8-2,2). Los antecedentes de fracturas de húmero, cadera o vertebral tuvieron una HR ajustada de 1,2 (IC95%: 1,1-1,3).Conclusiones Los principales factores de riesgo de fracturas por fragilidad fueron la edad avanzada, el resultado de la densitometría y los antecedentes de fractura, aunque un 74% de las fracturas se produjeron con una densidad mineral ósea normal u osteopenia. Otros factores significativos fueron la artritis reumatoide y haber estado en tratamiento prolongado con corticosteroides(AU)

Introduction Fragility fractures are an important public health issue. The aim of this study was to analyze the association of the main osteoporotic risk factors related to fragility fracture in a cohort of women with an indication of bone densitometry (BD).Methods A retrospective cohort was followed-up until a fragile fracture occurred, in a population of women aged 40 to 90 years with a first visit for BD between January 1992 and February 2008. We calculated the incidence rate of fracture per 1000 women-years of follow-up, and the hazard ratio (HR) of fragile fracture using a Cox regression model. Results A total of 49,735 women were studied. The average age of participants was 57.8 years (SD: 8.5). Of these, 3631 women (7.1%) reported a new fragility fracture in post-baseline visits. Risk factors with higher adjusted HR were age ≥ 75 years compared with age < 55 years (HR: 3.8; 95% CI: 3.3-4.4) and having a BC result evaluated as osteoporosis compared to normal (HR: 2.0; 95% CI: 1.8-2.2). A personal history of humerus, hip or vertebral fractures had an adjusted HR of 1.2 (95% CI: 1.1-1.3).Conclusions The main risk factors for fragility fracture were advanced age, BD result and a personal history of fracture, although 74% of fractures were detected with a bone mineral density classified as normal or osteopenia. Other relevant factors were rheumatoid arthritis or having received prolonged corticosteroid therapy (AU)

[Risk factors for fragility fractures in a cohort of Spanish women]. / Factores de riesgo de fracturas por fragilidad en una cohorte de mujeres españolas.

INTRODUCTION: Fragility fractures are an important public health issue. The aim of this study was to analyze the association of the main osteoporotic risk factors related to fragility fracture in a cohort of women with an indication of bone densitometry (BD). METHODS: A retrospective cohort was followed-up until a fragile fracture occurred, in a population of women aged 40 to 90 years with a first visit for BD between January 1992 and February 2008. We calculated the incidence rate of fracture per 1000 women-years of follow-up, and the hazard ratio (HR) of fragile fracture using a Cox regression model. RESULTS: A total of 49,735 women were studied. The average age of participants was 57.8 years (SD: 8.5). Of these, 3631 women (7.1%) reported a new fragility fracture in post-baseline visits. Risk factors with higher adjusted HR were age ≥ 75 years compared with age < 55 years (HR: 3.8; 95% CI: 3.3-4.4) and having a BC result evaluated as osteoporosis compared to normal (HR: 2.0; 95% CI: 1.8-2.2). A personal history of humerus, hip or vertebral fractures had an adjusted HR of 1.2 (95% CI: 1.1-1.3). CONCLUSIONS: The main risk factors for fragility fracture were advanced age, BD result and a personal history of fracture, although 74% of fractures were detected with a bone mineral density classified as normal or osteopenia. Other relevant factors were rheumatoid arthritis or having received prolonged corticosteroid therapy.

Perceptions and attitudes of clinicians in Spain toward clinical practice guidelines and grading systems: a protocol for a qualitative study and a national survey.

BACKGROUND: Clinical practice guidelines (CPGs) have become a very popular tool for decision making in healthcare. While there is some evidence that CPGs improve outcomes, there are numerous factors that influence their acceptability and use by healthcare providers. While evidence of clinicians' knowledge, perceptions and attitudes toward CPGs is extensive, results are still disperse and not conclusive. Our study will evaluate these issues in a large and representative sample of clinicians in Spain. METHODS/DESIGN: A mixed-method design combining qualitative and quantitative research techniques will evaluate general practitioners (GPs) and hospital-based specialists in Spain with the objective of exploring attitudes and perceptions about CPGs and evidence grading systems. The project will consist of two phases: during the first phase, group discussions will be carried out to gain insight into perceptions and attitudes of the participants, and during the second phase, this information will be completed by means of a survey, reaching a greater number of clinicians. We will explore these issues in GPs and hospital-based practitioners, with or without previous experience in guideline development. DISCUSSION: Our study will identify and gain insight into the perceived problems and barriers of Spanish practitioners in relation to guideline knowledge and use. The study will also explore beliefs and attitudes of clinicians towards CPGs and evidence grading systems used to rate the quality of the evidence and the strength of recommendations. Our results will provide guidance to healthcare researchers and healthcare decision makers to improve the use of guidelines in Spain and elsewhere.

Reliability and validity of the Spanish version of the Child Health and Illness Profile (CHIP) Child-Edition, Parent Report Form (CHIP-CE/PRF).

BACKGROUND: The objectives of the study were to assess the reliability, and the content, construct, and convergent validity of the Spanish version of the CHIP-CE/PRF, to analyze parent-child agreement, and compare the results with those of the original U.S. version. METHODS: Parents from a representative sample of children aged 6-12 years were selected from 9 primary schools in Barcelona. Test-retest reliability was assessed in a convenience subsample of parents from 2 schools. Parents completed the Spanish version of the CHIP-CE/PRF. The Achenbach Child Behavioural Checklist (CBCL) was administered to a convenience subsample. RESULTS: The overall response rate was 67% (n = 871). There was no floor effect. A ceiling effect was found in 4 subdomains. Reliability was acceptable at the domain level (internal consistency = 0.68-0.86; test-retest intraclass correlation coefficients = 0.69-0.85). Younger girls had better scores on Satisfaction and Achievement than older girls. Comfort domain score was lower (worse) in children with a probable mental health problem, with high effect size (ES = 1.45). The level of parent-child agreement was low (0.22-0.37). CONCLUSIONS: The results of this study suggest that the parent version of the Spanish CHIP-CE has acceptable psychometric properties although further research is needed to check reliability at sub-domain level. The CHIP-CE parent report form provides a comprehensive, psychometrically sound measure of health for Spanish children 6 to 12 years old. It can be a complementary perspective to the self-reported measure or an alternative when the child is unable to complete the questionnaire. In general, the results are similar to the original U.S. version.

Systems to support health technology assessment (HTA) in member states of the European union with limited institutionalization of HTA.

OBJECTIVES: The aim of this study was to support health technology assessment (HTA) capacity building in Member States of the European Union with limited experience or without institutionalized HTA. The main output is a Handbook on HTA Capacity Building. METHODS: The methods used were worldwide surveys of (i) HTA organizations, (ii) information management units, and (iii) HTA educational programs. The results of two surveys (i & ii) were combined with expert opinion to produce the Handbook on HTA Capacity Building. RESULTS: Survey of HTA organizations (n = 41, response rate 35 percent). Most of the organizations were established by the government (61 percent), and all were not-for-profit. Working on HTA (80.5 percent) and doing research (63.4 percent) were the main lines of activity. Survey on information management units (n = 23, response rate 23 percent). Most (74.2 percent) of the responding HTA agencies reported having personnel dedicated to HTA information services. Survey on HTA educational programs (n = 48, response rate 60 percent). In total, nine Master of Science (MSc) programs were identified (three MSc in HTA and six MSc in HTA-related areas). Handbook on HTA Capacity Building. A group of twenty experts from thirteen countries developed the handbook. It consists of nine chapters focusing on HTA institutional development (structural setup, work processes, and visibility). CONCLUSIONS: Setting up organizational structures and establishing effective HTA programs that guide key policy decisions is a challenging task. There are no standard models or pathways. "One size fits all" is not a useful principle because of the wide systemic and cultural differences between countries. The Handbook on HTA Capacity Building includes approaches for overall institutional development, especially in formulating objectives, setting up structures, and defining work processes.

Guía para la indicación de la densitometría ósea en la valoración del riesgo de fractura y en el control evolutivo de la osteoporosis / Bone densitometry measurement and osteoporosis monitoring guide for the assessment of risk fracture

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[A tool (corrected) for the critical appraisal of epidemiological cross-sectional studies]. / Instrumento para la lectura crítica y la evaluación de estudios epidemiológicos transversales.

The aim was to develop a tool for the critical appraisal of epidemiological cross-sectional studies. Several recommendations or guidelines for assessing the strength of scientific evidence provided by observational studies were reviewed, like those from the Agency for Healthcare Research and Quality, the Scottish Intercollegiate Guidelines Group, the Osteba (Basque Office for Health Technology Assessment), and the STROBE Initiative. The tool has 27 items to assess: study question or objective, participants, comparability between groups, definition and measure of main variables; analysis and confusion, results, conclusions, external validity and applicability, and conflict of interest. This tool can be used to critically appraise research papers or to rate evidence during the elaboration of systematic reviews.

Instrumento para la lectura crítica y la evaluación de estudios epidemiológicos transversales / A tool for the critical appraisal of epidemiological cross-sectional studies

El objetivo de este trabajo fue desarrollar un instrumento parala evaluación de la calidad de los estudios epidemiológicostransversales. Se tuvieron en cuenta diferentes recomendacionese instrumentos de valoración de estudios observacionales,como los de la Agency for Healthcare Research andQuality, el Scottish Intercollegiate Guidelines Group, el Osteba(Servicio de Evaluación de Tecnologías Sanitarias del PaísVasco) y la iniciativa STROBE. El instrumento consta de 27ítems para evaluar: pregunta u objetivo de investigación, participantes,comparabilidad entre los grupos estudiados, definicióny medición de las variables principales, análisis y confusión,resultados, conclusiones, validez externa y aplicabilidadde los resultados, y conflicto de interés. Este instrumento puedeutilizarse para la lectura crítica de artículos originales o en laelaboración de revisiones sistemáticas de la evidencia científica (AU)

The aim was to develop a tool for the critical appraisal of epidemiologicalcross-sectional studies. Several recommendationsor guidelines for assessing the strength of scientific evidenceprovided by observational studies were reviewed, like thosefrom the Agency for Healthcare Research and Quality, the ScottishIntercollegiate Guidelines Group, the Osteba (Basque Officefor Health Technology Assessment), and the STROBE Initiative.The tool has 27 items to assess: study question orobjective, participants, comparability between groups, definitionand measure of main variables; analysis and confusion,results, conclusions, external validity and applicability, and conflictof interest. This tool can be used to critically appraise researchpapers or to rate evidence during the elaboration ofsystematic reviews (AU)

Health-related quality of life measurement in children and adolescents: a systematic review of generic and disease-specific instruments.

OBJECTIVE: To identify currently available generic and disease-specific health-related quality of life (HRQOL) instruments for children and adolescents up to 19 years old, to describe their content, and to review their psychometric properties. STUDY DESIGN: Previous reviews on the subject and a new literature review from 2001 to December 2006 (MEDLINE, the ISI Science Citation Index, HealthSTAR and PsycLit) were used to identify measures of HRQOL for children and adolescents. The characteristics (country of origin, age range, type of respondent, number of dimensions and items, name of the dimensions and condition) and psychometric properties (reliability, validity, and sensitivity to change) of the instruments were assessed following international guidelines published by the Scientific Committee of the Medical Outcomes Trust. RESULTS: In total, 30 generic and 64 disease-specific instruments were identified, 51 of which were published between 2001 and 2005. Many generic measures cover a core set of basic concepts related to physical, mental and social health, although the number and name of dimensions varies substantially. The lower age limit for self-reported instruments was 5-6 years old. Generic measures developed recently focused on both child self-report and parent-proxy report, although 26% of the disease-specific questionnaires were exclusively addressed to proxy-respondents. Most questionnaires had tested internal consistency (67%) and to a lesser extent test-retest stability (44.7%). Most questionnaires reported construct validity, but few instruments analyzed criterion validity (n = 5), structural validity (n = 15) or sensitivity to change (n = 14). CONCLUSIONS: The development of HRQOL instruments for children and adolescents has continued apace in recent years, particularly with regard to disease-specific questionnaires. Many of the instruments meet accepted standards for psychometric properties, although instrument developers should include children from the beginning of the development process and need to pay particular attention to testing sensitivity to change.

Perceived health status and use of healthcare services among children and adolescents.

BACKGROUND: The aim of the present study was to analyse the use of healthcare services according to health status in a population of children and adolescents, taking into account family socio-demographic characteristics and characteristics of the proxy respondent. METHODS: A total of 836 interviews of proxy respondents for children aged 5-14 years from the Barcelona Health Interview Survey carried out in 2000 were included. Dependent variables were visits to a healthcare professional, visits to the emergency room, and hospitalization. Independent variables were: report of medical conditions, health status of the child measured by the Child Health and Illness Profile-Child Edition, Parent Report Form (CHIP-CE/PRF), the educational level of the head of household, social class, child's healthcare coverage, and proxy-related variables [mental health status by means of the General Health Questionnaire-12 items version (GHQ-12), and other]. Logistic regression analysis was used to estimate prevalence ratio (PR) to compare the use of healthcare services among different categories of independent variables. RESULTS: Children having worse health status were more likely to have visited a healthcare professional [PR = 1.68; 95% confidence interval (95% CI) = 1.09-3.83], whereas children with a reported medical condition were more likely to have made a visit to the emergency service (PR = 1.47; 95% CI = 1.27-2.55) and were hospitalized more frequently (PR = 2.50; 95% CI = 1.12-5.57). Higher likelihood of visits to the emergency room was associated with children having both public and private coverage and a proxy respondent scoring 3 or higher on the GHQ-12. CONCLUSIONS: Use of healthcare services differed by health needs but not by social class. Double healthcare coverage and mental distress of the proxy respondent influenced the use of emergency services.

[Spanish version of the Child Health and Illness Profile-Child Edition Parent Report Form [CHIP-CE/PRF]]. / Versión española del perfil de salud infantil, cuestionario para padres y madres: Child Health and Illness Profile-Child Edition Parent Report Form (CHIP-CE/PRF).

OBJECTIVES: To analyze the reliability and validity of the domains of the Child Health and Illness Profile-Child Edition Parent Report Form (CHIP-CE/PRF) included in the Barcelona Health Survey conducted in 2000 and to obtain population-based reference values. METHODS: Data were obtained from proxy-respondent interviews of children aged 5-14 years old (n = 836) participating in the Barcelona Health Survey 2000. The 4 subdomains of the parent version of the CHIP-PRF included in the health survey were: satisfaction with health, and physical discomfort, emotional discomfort, and limitation of activities of the discomfort domain. Internal consistency was assessed using Cronbach's alpha coefficients. An exploratory factor analysis was carried out and analysis of covariance was performed to assess the construct validity of the subdomains. RESULTS: In all the subdomains assessed, Cronbach's alpha was above 0.70 (range, 0.76-0.98). In the factorial analysis, almost all the items (31/35) presented the highest load in their corresponding subdomain. Most of the expected mean differences among groups were confirmed. Girls aged 10-14 years old scored the lowest, both in satisfaction with health (48.93; 95% confidence interval [CI 95%], 47.40-50.47) and in discomfort (48.87; CI 95%, 47.51-50.22). No differences were found according to the social class of the head of the family. CONCLUSIONS: The present study provides a useful measure of perceived health status in a child health survey.

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