Impact of hypertension diagnosis on morbidity and mortality: a retrospective cohort study in primary care.

BACKGROUND: Hypertension is responsible for a huge burden of disease. The aim of this study was to evaluate the impact of newly diagnosed hypertension on the occurrence of kidney or cardiovascular events (K/CVEs) and on mortality among community dwellers. METHODS: Retrospective cohort study, conducted from January, 2007, to December, 2018. All patients (age > 18) newly diagnosed with hypertension and no previous K/CVEs in 2007 and 2008, in the primary care centers of Madrid (Spain) (n = 71,770), were enrolled. The control group (n = 72,946) included patients without hypertension, matched by center, sex and age. The occurrence of kidney or CV events, including mortality from these causes and total mortality were evaluated using Cox regression and multistate models. Data were collected from three sources: personal data from administrative records, clinical data from medical records, and mortality data from regional and national databases. RESULTS: The median follow-up was 138.61 months (IQR: 124.68-143.97 months). There were 32,896 K/CVEs (including 3,669 deaths from these causes) and 12,999 deaths from other causes. Adjusted for sex, smoking, diabetes and socioeconomic status, K/CVEs HR was 4.36 (95% CI: 3.80-5.00) for diagnoses before 45 years of age, 2.45(95% CI: 2.28- 2.63) for diagnosis between 45 to 54 years, and HR decreased to 1.86 (95% CI: 1.64-210) for diagnoses over age 85. Total mortality risk was only higher for hypertension diagnosed before 55 years of age (HR: 2.47, 95% CI: 1.90-3.19 for ages 18 to 44; and HR: 1.14, 95% CI: 1.02-1.28 for ages 45 to 54). CONCLUSION: The diagnosis of hypertension in the community environment, in patients without evidence of previous kidney or CV disease, is associated with a large increase in the risk of K/CVEs, but especially in individuals diagnosed before the age of 55. This diagnosis is only associated with an increase in kidney or cardiovascular mortality or overall mortality when it occurs before age 55.

[Chronic diseases and multimorbidiy in patients with toxic oil syndrome: a comparative study with general population.] / Enfermedades crónicas y multimorbilidad en pacientes con síndrome de aceite tóxico: estudio comparativo con población general.

OBJECTIVE: Toxic oil syndrome is a multisystemic disease that arose in 1981 due to the ingestion of contaminated rapeseed oil. Previous studies have found a higher prevalence of cardiovascular risk factors in these patients. The aim of this study was to analyze the differences in the prevalence of chronic diseases among a population affected by Toxic oil syndrome compared with a reference population in the Community of Madrid. METHODS: Cross-sectional observational study of patients with a registry diagnosed with Toxic oil syndrome in the primary care medical record and a reference sample without Toxic oil syndrome matched by age group and sex. Sociodemographic variables, cardiovascular risk factors, cardiovascular and cerebrovascular disease, anxiety, depression, asthma, chronic obstructive pulmonary disease, and low back pain, and multimorbidity (≥2 chronic diseases) were assesed. Descriptive and multivariate analysis was performed to study the association between morbidity and Toxic oil syndrome. RESULTS: 3,527 patients (1,394 Toxic oil syndrome) were included with a mean age of 66 (SD14) years, 71% women. Patients with a diagnosis of SAT were more likely to present multimorbidity (OR 1.36; 95%CI: 1.10-1.45), diabetes (OR 1.55; 95%CI: 1.29-1.86), complicated hypertension (OR 1.77; IC95%: 1.31-2.39), heart attack (OR 2.23; 95%CI: 1.47-3.38), depression (OR 1.39; 95%CI: 1.17-1.66) and asthma (OR 1.56; 95%CI: 1.23-1.97). The prevalence of anxiety was lower in TOS (OR 0.35; 95% CI: 0.18-0.69) as well as low back pain (OR 0.77; 95%CI: 0.65-0.91). CONCLUSIONS: Patients with toxic oil syndrome have a higher frequency of chronic diseases and mutimorbidity compared to the general population of the same sex and age.

OBJETIVO: El síndrome del aceite tóxico es una enfermedad multisistémica que surgió en 1981 debido a la ingesta de aceite de colza contaminado. Estudios previos han encontrado en estos pacientes una mayor prevalencia de factores de riesgo cardiovascular. El objetivo de este estudio fue analizar las posibles diferencias en prevalencia de morbilidad crónica entre una población afectada por síndrome de aceite tóxico comparada con una población de referencia en la Comunidad de Madrid. METODOS: Estudio observacional transversal de pacientes diagnosticados de síndrome del aceite tóxico en la historia clínica de atención primaria y una muestra de referencia sin síndrome del aceite tóxico apareados por grupo de edad y sexo. Se recogieron variables sociodemográficas, factores de riesgo cardiovascular, enfermedad cardiovascular y cerebrovascular, ansiedad, depresión, asma, enfermedad pulmonar obstructiva crónica, lumbalgia y multimorbilidad (≥2 enfermedades crónicas). Se realizó análisis descriptivo y multivariante para estudiar la asociación entre morbilidad y síndrome del aceite tóxico. RESULTADOS: Se incluyeron 3.527 pacientes (1.394 SAT) con una edad media de 66 (14) años, el 71% mujeres. Los pacientes con diagnóstico de síndrome del aceite tóxico tuvieron mayor probabilidad de presentar multimorbilidad (OR 1,36; IC95%: 1,10-1,45), diabetes (OR 1,55; IC95%: 1,29-1,86), hipertensión arterial complicada (OR 1,77; IC95%: 1,31-2,39), infarto (OR 2,23; IC95%: 1,47-3,38), depresión (OR 1,39; IC95%: 1,17-1,66) y asma (OR 1,56; IC95%: 1,23-1,97). La prevalencia de ansiedad fue menor (OR 0,35; IC95%: 0,18-0,69) así como de lumbalgia (OR 0,77; IC95%: 0,65-0,91). CONCLUSIONES: Los pacientes con síndrome de aceite tóxico presentan una mayor frecuencia de enfermedades crónicas y mutimorbilidad comparado con población general del mismo sexo y edad.

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

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

Neighborhood social and economic change and diabetes incidence: The HeartHealthyHoods study.

We studied the association between neighborhood social and economic change and type 2 diabetes incidence in the city of Madrid (Spain). We followed 199,621 individuals living in 393 census tracts for diabetes incidence for 6 years using electronic health records, starting in 2009. We measured neighborhood social and economic change from 2005 to 2009 using a finite mixture model with 16 indicators that resulted in four types of neighborhood change. Adjusted results showed an association between neighborhood change and diabetes incidence: compared to those living in Aging/Stable areas, people living in Declining SES, New Housing and Improving SES areas have an 8% (HR = 0.92, 95% CI 0.87 to 0.99), 9% (HR = 0.91, 95% CI 0.81 to 1.01) and 11% (HR = 0.89, 95% CI 0.81 to 0.98) decrease in diabetes incidence. This evidence can help guide policies for diabetes prevention by focusing efforts on specific urban areas.

Association of neighbourhood socioeconomic status and diabetes burden using electronic health records in Madrid (Spain): the HeartHealthyHoods study.

OBJECTIVE: To study the association between neighbourhood socioeconomic status and diabetes prevalence, incidence, and control in the entire population of northeastern Madrid, Spain. SETTING: Electronic health records of the primary-care system in four districts of Madrid (Spain). PARTICIPANTS: 269 942 people aged 40 or older, followed from 2013 to 2014. EXPOSURE: Neighbourhoodsocioeconomic status (NSES), measured using a composite index of seven indicators from four domains of education, wealth, occupation and living conditions. PRIMARY OUTCOME MEASURES: Diagnosis of diabetes based on ICPC-2 codes and glycated haemoglobin (HbA1c %). RESULTS: In regression analyses adjusted by age and sex and compared with individuals living in low NSES neighbourhoods, men living in medium and high NSES neighbourhoods had 10% (95% CI: 6% to 15%) and 29% (95% CI: 25% to 32%) lower prevalence of diabetes, while women had 27% (95% CI: 23% to 30%) and 50% (95% CI: 47% to 52%) lower prevalence of diabetes. Moreover, the hazard of diabetes in men living in medium and high NSES neighbourhoods was 13% (95% CI: 1% to 23%) and 20% (95% CI: 9% to 29%) lower, while the hazard of diabetes in women living in medium and high NSES neighbourhoods was 17% (95% CI: 3% to 29%) and 31% (95% CI: 20% to 41%) lower. Individuals living in medium and high SES neighbourhoods had 8% (95% CI: 2% to 15%) and 15% (95% CI: 9% to 21%) lower prevalence of lack of diabetes control, and a decrease in average HbA1c % of 0.05 (95% CI: 0.01 to 0.10) and 0.11 (95% CI: 0.06 to 0.15). CONCLUSIONS: Diabetes prevalence, incidence and lack of control increased with decreasing NSES in a southern European city. Future studies should provide mechanistic insights and targets for intervention to address this health inequity.

Effectiveness of a virtual intervention for primary healthcare professionals aimed at improving attitudes towards the empowerment of patients with chronic diseases: study protocol for a cluster randomized controlled trial (e-MPODERA project).

BACKGROUND: Communities of practice are based on the idea that learning involves a group of people exchanging experiences and knowledge. The e-MPODERA project aims to assess the effectiveness of a virtual community of practice aimed at improving primary healthcare professional attitudes to the empowerment of patients with chronic diseases. METHODS: This paper describes the protocol for a cluster randomized controlled trial. We will randomly assign 18 primary-care practices per participating region of Spain (Catalonia, Madrid and Canary Islands) to a virtual community of practice or to usual training. The primary-care practice will be the randomization unit and the primary healthcare professional will be the unit of analysis. We will need a sample of 270 primary healthcare professionals (general practitioners and nurses) and 1382 patients. We will perform randomization after professionals and patients are selected. We will ask the intervention group to participate for 12 months in a virtual community of practice based on a web 2.0 platform. We will measure the primary outcome using the Patient-Provider Orientation Scale questionnaire administered at baseline and after 12 months. Secondary outcomes will be the sociodemographic characteristics of health professionals, sociodemographic and clinical characteristics of patients, the Patient Activation Measure questionnaire for patient activation and outcomes regarding use of the virtual community of practice. We will calculate a linear mixed-effects regression to estimate the effect of participating in the virtual community of practice. DISCUSSION: This cluster randomized controlled trial will show whether a virtual intervention for primary healthcare professionals improves attitudes to the empowerment of patients with chronic diseases. TRIAL REGISTRATION: ClicalTrials.gov, NCT02757781 . Registered on 25 April 2016. Protocol Version. PI15.01 22 January 2016.

Concordancia y utilidad de un sistema de estratificación para la toma de decisiones clínicas / Concordance and usefulness of a stratification system for clinical decision making

OBJETIVOS: 1) Analizar la concordancia entre la clasificación por niveles de riesgo del agrupador grupos de morbilidad ajustados (GMA) y el nivel de intervención asignado por los médicos de familia (MF). 2) Estudiar la utilidad del agrupador como herramienta de ayuda en historia clínica electrónica (HCE) para la toma de decisiones clínicas. DISEÑO: Estudio observacional transversal de concordancia. Emplazamiento: Atención Primaria, Servicio Madrileño de Salud. PARTICIPANTES: Veintiocho MF. Se seleccionó una muestra de 840 pacientes adscritos a cupos de los MF participantes por muestreo aleatorizado estratificado no proporcional (kappa 0,65, precisión 0,125, porcentajes positivos 5%, nivel de confianza 95%). Mediciones principales: Índice kappa de Cohen ponderado para el grado de concordancia entre el nivel (bajo, medio o alto) de riesgo de ingreso hospitalario/consumo de recursos del paciente propuesto por el agrupador GMA y el nivel (bajo, medio o alto) de intervención (autocuidado, gestión de la enfermedad, gestión del caso) asignado por el MF. A través de un cuestionario autoadministrado elaborado ad hoc los MF valoraron la utilidad del agrupador. RESULTADOS: El índice de kappa ponderado obtenido fue de 0,60 (IC 95% 0,55-0,65). En un 3% el grado de desacuerdo fue máximo. El MF consideró en el 76% de los casos que el agrupador había sido útil para la asignación de los niveles de intervención. CONCLUSIÓN: La fuerza de concordancia obtenida fue moderada/buena; la incorporación de un agrupador en la HCE puede servir de ayuda como recordatorio para una toma de decisiones más proactiva/integrada según las necesidades sociosanitarias de las personas con enfermedades crónicas

OBJECTIVES: 1) To analyse concordance between the level of risk classification using the Adjusted Groups Morbidity (GMA) tool and the assigned level of intervention by general practitioners (GP). 2) To study the usefulness of the GMA tool as an aid in electronic medical records (EMR) for decision making. DESIGN: Cross-sectional observational study of concordance. LOCATION: Primary Care. Madrid Health Service. PARTICIPANTS: Twenty eight GPs. A sample of 840 patients assigned to participating GPs was selected by disproportionate stratified random sampling (0.65 kappa, 0.125 precision, 5% positive rate, 95% confidence level). MAIN MEASUREMENTS: Weighted Cohen Kappa index for the degree of concordance between the GMA tool and the GPs. The usefulness of the tool was assessed using an ad hoc developed questionnaire. RESULTS: Kappa weighted index obtained was 0.60 (95% CI: 0.55-0.65). In 3% of cases the disagreement was maximum. The GPs found that the grouping tool had been useful in 76% of cases. CONCLUSION: Moderate strength/good concordance; incorporating a grouping tool in the EMR helps as a reminder for taking more proactive/integrated decisions based on social and health needs of people with chronic diseases

[Concordance and usefulness of a stratification system for clinical decision making]. / Concordancia y utilidad de un sistema de estratificación para la toma de decisiones clínicas.

OBJECTIVES: 1) To analyse concordance between the level of risk classification using the Adjusted Groups Morbidity (GMA) tool and the assigned level of intervention by general practitioners (GP). 2) To study the usefulness of the GMA tool as an aid in electronic medical records (EMR) for decision making. DESIGN: Cross-sectional observational study of concordance. LOCATION: Primary Care. Madrid Health Service. PARTICIPANTS: Twenty eight GPs. A sample of 840 patients assigned to participating GPs was selected by disproportionate stratified random sampling (0.65 kappa, 0.125 precision, 5% positive rate, 95% confidence level). MAIN MEASUREMENTS: Weighted Cohen Kappa index for the degree of concordance between the GMA tool and the GPs. The usefulness of the tool was assessed using an ad hoc developed questionnaire. RESULTS: Kappa weighted index obtained was 0.60 (95%CI: 0.55-0.65). In 3% of cases the disagreement was maximum. The GPs found that the grouping tool had been useful in 76% of cases. CONCLUSION: Moderate strength/good concordance; incorporating a grouping tool in the EMR helps as a reminder for taking more proactive/integrated decisions based on social and health needs of people with chronic diseases.

Historia clínica electrónica en los ensayos clínicos de efectividad con medicamentos integrados en la práctica clínica / Electronic medical record in clinical trials of effectiveness of drugs integrated in clinical practice

No disponible

Grado de control del tratamiento anticoagulante oral en los centros de Atención Primaria de la Comunidad de Madrid: estudio CHRONOS-TAO / Quality control of oral anticoagulant therapy in Primary Care in Madrid City, Spain: CHRONOS-TAO study

Objetivos: Conocer el grado de control de los pacientes en tratamiento con anticoagulantes orales atendidos en Atención Primaria (AP) estimando el tiempo en rango terapéutico (TRT) según el método de Rosendaal, y compararlo con el porcentaje de international normalized ratio (INR, «razón normalizada internacional») en rango y el análisis transversal (última INR). Material y método: Estudio observacional retrospectivo con datos de la historia clínica electrónica de todos los centros de AP (n = 262) de la Comunidad de Madrid. Se incluyeron todos los pacientes en tratamiento con acenocumarol con rango terapéutico de INR entre 2 y 3. Se excluyeron los pacientes con valvulopatías y aquellos con seguimiento discontinuo (< 3 determinaciones de INR, período de > 90 días o ≥ 3 períodos de > 60 días entre 2 determinaciones). La población final fue de 49.312. Las variables consideradas fueron todos los valores de INR y sus fechas respectivas. Se calculó el TRT por los 3 métodos referidos, considerando «rango terapéutico» valores de INR entre 2-3, y rango «ajustado» valores de INR entre 1,8-3,2. Consideramos «control óptimo» en cada paciente si el TRT > 60%. Resultados: El TRT por el método de Rosendaal fue del 66,8% (81,7% ajustado), el porcentaje de INR en rango, del 58,8% (66,5% ajustado), y el análisis transversal, del 70,5% (76,8% ajustado). La media (desviación estándar) de los TRT por paciente fue del 65% (20,3), y el porcentaje de pacientes con un TRT > 60% fue del 63,3% (88,1% ajustado). Conclusión: El grado de control de los pacientes anticoagulados en AP es aceptable, similar o superior respecto a otros estudios y a los ensayos pivotales de nuevos anticoagulantes. Comparados con el método de Rosendaal, el porcentaje total de INR infraestima el grado de control, y el análisis transversal lo sobrestima ligeramente (AU)

Objectives: To determine quality control of patients with oral anticoagulant treatment recruited in Primary Care (PC) using the Rosendaal method to estimate time in therapeutic range (TTR) and comparing it with fraction of international normalized ratio (INR) in range and cross-sectional analysis (last INR registred). Material and method: A retrospective observational study based on electronic medical record in routine clinical practice. Setting: PC centers (262) in Madrid. We included all patients with acenocumarol treatment, with an INR therapeutic range established between 2 and 3. We excluded patients with valvular pathology and disrupted clinical follow up in PC (< 3 INR determinations in the studied period, a period of > 90 days or ≥ 3 periods of > 60 days between 2 determinations). The final population was 49,312 patients. The variables considered were all INR values and their respective dates. TTR was calculated by the 3 methods above mentioned. We considered 'therapeutic range' INR between 2-3 and 'adjusted range' INR between 1.8-3.2. Optimal control for each patient was considered TTR > 60%. Results: By using Rosendaal method, TTR was 66.8% (81.7% adjusted), with a percentage of total INR in range was 58.8% (66.5% adjusted), and, with the cross-sectional analysis, it was 70.5% (76.8% adjusted). Mean TTR was 65% (standard deviation 20.3), and the percentage of patients with TTR > 60% was 63.3% (88.1% adjusted). Conclusion: The quality control of patients with oral anticoagulants in PC in Madrid is acceptable, similar or higher to other studies and pivotal trials of new anticoagulants. Compared to the Rosendaal method, total fraction of INR underestimates quality control, and cross-sectional analysis slightly overestimates it (AU)

[Quality control of oral anticoagulant therapy in Primary Care in Madrid City, Spain: CHRONOS-TAO study]. / Grado de control del tratamiento anticoagulante oral en los centros de Atención Primaria de la Comunidad de Madrid: estudio CHRONOS-TAO.

OBJECTIVES: To determine quality control of patients with oral anticoagulant treatment recruited in Primary Care (PC) using the Rosendaal method to estimate time in therapeutic range (TTR) and comparing it with fraction of international normalized ratio (INR) in range and cross-sectional analysis (last INR registred). MATERIAL AND METHOD: A retrospective observational study based on electronic medical record in routine clinical practice. SETTING: PC centers (262) in Madrid. We included all patients with acenocumarol treatment, with an INR therapeutic range established between 2 and 3. We excluded patients with valvular pathology and disrupted clinical follow up in PC (<3 INR determinations in the studied period, a period of>90 days or ≥ 3 periods of>60 days between 2 determinations). The final population was 49,312 patients. The variables considered were all INR values and their respective dates. TTR was calculated by the 3 methods above mentioned. We considered "therapeutic range" INR between 2-3 and "adjusted range" INR between 1.8-3.2. Optimal control for each patient was considered TTR>60%. RESULTS: By using Rosendaal method, TTR was 66.8% (81.7% adjusted), with a percentage of total INR in range was 58.8% (66.5% adjusted), and, with the cross-sectional analysis, it was 70.5% (76.8% adjusted). Mean TTR was 65% (standard deviation 20.3), and the percentage of patients with TTR>60% was 63.3% (88.1% adjusted). CONCLUSION: The quality control of patients with oral anticoagulants in PC in Madrid is acceptable, similar or higher to other studies and pivotal trials of new anticoagulants. Compared to the Rosendaal method, total fraction of INR underestimates quality control, and cross-sectional analysis slightly overestimates it.

Vaccination coverage against 2009 seasonal influenza in chronically ill children and adults: analysis of population registries in primary care in Madrid (Spain).

Using electronic clinical records in primary care (ECRPC) of the entire population living in the Autonomous Community of Madrid, Spain (5,102,568 persons) as a data source, this study aimed to ascertain seasonal anti-influenza vaccination coverage in the chronically ill at-risk children (aged 6 months to 14 years) and adults (15-59 years). Of the total population aged 6 months to 59 years with a medical card in the Autonomous Community of Madrid, 10.3% (n=528,095 patients) had a chronic condition for which anti-influenza vaccination was indicated. In children with chronic conditions, coverage was 27.1% and it was particularly high among diabetics (41.1%) and particularly low in children with "other pulmonary conditions" (15.2%). In adults with chronic conditions, coverage was 22.1% and in patients with diagnosed heart failure coverage reached 39.1%; with the lowest coverage was observed in patients suffering neuromuscular diseases (12.8%). The factors associated with vaccination among children and adults suffering a chronic condition included: having been vaccinated during the previous campaign, national origin (lower among immigrants), and having more than one chronic condition. In conclusion, our study shows that vaccination coverage for 2009 seasonal influenza in children and adults with chronic conditions living in Madrid (Spain) was less than acceptable.

Prevalencia de enfermedades crónicas diagnosticadas en población inmigrante y autóctona / Prevalence of diagnosed chronic disorders in the inmigrant and native population

ObjetivoEstimar la prevalencia de problemas de salud crónicos en inmigrantes y compararla con la de la población autóctona, utilizando la historia clínica electrónica (HCE) de atención primaria (AP).MétodosEstudio descriptivo transversal con pacientes de 16 y más años incluidos en el sistema sanitario público de la Comunidad de Madrid. Se estimaron prevalencias ajustadas por edad para cada sexo y nacionalidad (agrupada en regiones) a partir de los episodios de atención registrados en la HCE de AP con alguna anotación en 2005 o 2006.ResultadosEl 36,8% de la población inmigrante presentaba alguna enfermedad crónica (55,3% de autóctonos) tras ajustar por edad, con más frecuencia en mujeres y en población de origen africano y latinoamericano. Las enfermedades más prevalentes en los extranjeros fueron las alergias (tasa cruda: 10,2%), las lumbalgias (9,1%), problemas crónicos de piel (6,8%) y trastornos mentales (6,4%).ConclusionesLa prevalencia de enfermedades crónicas es menor en la población extranjera y varía según el sexo y la procedencia(AU)

ObjectiveTo estimate the prevalence rates of chronic disorders in immigrants and to compare them with those in the native population, based on electronic clinical records in primary care (ECRPC).MethodsWe performed a descriptive cross-sectional study in patients aged 16 and over included in the Madrid Regional Public Health System. Age-adjusted prevalence rates for each sex and region were estimated on the basis of medically examined cases registered in the ECRPC with any new data entry made in 2005 or 2006.ResultsAfter age-adjustment, a total of 36.8% immigrants had some chronic health problem (vs. 55.3% natives). These disorders were more frequent among women and among the population from Africa and Latin America. The highest overall prevalence rates in the foreign population were allergy (10.2% crude rate), low-back pain (9.1%), chronic skin problems (6.8%) and mental disorders (6.4%).ConclusionsThe prevalence rate of chronic disease is lower in the foreign population and differs according to sex and country of origin(AU)

[Prevalence of diagnosed chronic disorders in the immigrant and native population]. / Prevalencia de enfermedades crónicas diagnosticadas en población inmigrante y autóctona.

OBJECTIVE: To estimate the prevalence rates of chronic disorders in immigrants and to compare them with those in the native population, based on electronic clinical records in primary care (ECRPC). METHODS: We performed a descriptive cross-sectional study in patients aged 16 and over included in the Madrid Regional Public Health System. Age-adjusted prevalence rates for each sex and region were estimated on the basis of medically examined cases registered in the ECRPC with any new data entry made in 2005 or 2006. RESULTS: After age-adjustment, a total of 36.8% immigrants had some chronic health problem (vs. 55.3% natives). These disorders were more frequent among women and among the population from Africa and Latin America. The highest overall prevalence rates in the foreign population were allergy (10.2% crude rate), low-back pain (9.1%), chronic skin problems (6.8%) and mental disorders (6.4%). CONCLUSIONS: The prevalence rate of chronic disease is lower in the foreign population and differs according to sex and country of origin.

[Implementation and improvement in a care program for the elderly on multiple medications in a primary care area]. / Implantación y mejora de un programa de atención al mayor polimedicado en un área de atención primaria.

BACKGROUND: The purpose is to describe the introduction of a Care Program for the Elderly on Multiple Medication in a Primary Care area and the complete improvement cycle after evaluating the initial results The Program was instigated by the Community of Madrid Pharmacy Directorate. METHODS: The Program was aimed at patients over 75 years who took 6 or more active ingredients (9721 patients in the area at the start of the program) and began in September 2006. It is based on coordinating with pharmacists, systematic review of treatment, health education, and the providing of personal dose dispensing systems for the correct use of the medication. Before its introduction, all the health professionals and pharmacists were jointly trained, a person was assigned as being responsible for the primary care teams (EAP) and support material was handed out. An initial evaluation was performed using computerised sentences from the Program data model in the electronic clinical notes, which showed much improvable results. Using quality tools, the causes of low coverage and insufficient results in the rest of the quality indicators were identified and corrective actions were introduced to subsequently monitor and re-assess the program. RESULTS: Evaluation of the indicators included in the program. Initial data analysis (February 2007): cover, 3.5% (361 users included); treatment review (RT), 2.1%; review of medication use (RU), 51.2%; assessment of knowledge of the medication (CM), 84.8%; Morisky test (TM), 57.6%; offer of personal dispensing system (SPD), 57.1%; treatment evaluation (VT), 50.1%; care plans (PC), 19.2%; beers criteria (CB), 14.9%. After introducing the improvement actions, the following results were obtained in December 2007: cover, 131.8% (12,650 users); RT, 80.6%; RU, 62.7%; CM, 92.4%; TM, 9.3; SPD, 67.3%; VT, 61.6%; PC, 27.59%, and CB, 13.6%. CONCLUSIONS: The introduction of an institutional program, the involvement of the management of Area 4, the application of appropriate quality tools, the continuous monitoring of quality indicators and giving this information back to the professionals has enabled, ten months after the corrective measures were introduced, the institutional objectives of coverage to be achieved. It has also significantly improved quality care activities and their recording, achieving the best results for coverage and quality health care in the Community of Madrid program.

Implantación y mejora de un programa de atención al mayor polimedicado en un área de atención primaria / Introduction and improvement of a care program for the elderly on multiple medication in a primary care area

Introducción: El propósito de este estudio es describir la implantación del Programa de Atención al Mayor Polimedicado, impulsado por la Dirección General de Farmacia de la Comunidad de Madrid, en un área de atención primaria y el ciclo completo de mejora con sus resultados tras la evaluación inicial. Métodos: El programa, dirigido a mayores de 75 años que consumen 6 o más principios activos (9.721 personas en el área al inicio del programa), comienza en septiembre de 2006. Se basa en la coordinación con las oficinas de farmacia, la revisión sistemática del tratamiento, la educación sanitaria y la entrega de sistemas personales de dosificación para el correcto uso de la medicación. Para su implantación en el área se formó a todos los profesionales y a los farmacéuticos de las oficinas de farmacia conjuntamente, se nombró responsables en los equipos de atención primaria (EAP) y se repartió material de ayuda. Se realizó una evaluación inicial mediante sentencias informatizadas del modelo de datos del programa en la historia clínica electrónica, que mostraba resultados muy mejorables. Mediante herramientas de calidad se identificaron las causas de la escasa cobertura y los resultados insuficientes en el resto de los indicadores de calidad en la atención y se procedió a implementar las acciones correctivas para, posteriormente, monitorizar y reevaluar el programa. Resultados: Evaluación de los indicadores incluidos en el programa. Primer análisis de datos (febrero de 2007): cobertura del 3,5% (361 usuarios incluidos); revisión del tratamiento (RT), 2,1%; revisión del uso de fármacos (RU), 51,2%; valoración del conocimiento sobre medicación (CM), 84,8%; test de Morisky (TM), 57,6%; propuesta de sistema personal dosificación (SPD), 57,1%; valoración del tratamiento (VT), 50,1%; planes de cuidados (PC), 19,2%; criterios de Beers (CB), 14,9%. En diciembre de 2007, tras la implantación de las acciones de mejora, se obtienen los siguientes resultados: cobertura, 131,8% (12.650 usuarios); RT, 80,6%; RU, 62,7%; CM, 92,4%; TM, 9,3; SPD, 67,3%; VT, 61,6%; PC, 27,59%; CB, 13,6%. Conclusiones: La implantación de un programa institucional, la implicación de la Dirección Gerencial del Área 4, la aplicación de las herramientas de calidad adecuadas, la monitorización continua de los indicadores y la devolución de la información a los profesionales han permitido que, 10 meses después de implantar las medidas correctoras, se superen los objetivos institucionales de cobertura y mejoren significativamente las actividades de buena atención y su registro, con lo que se obtienen los mejores resultados de captación y de calidad asistencial del programa de la Comunidad de Madrid

Background: The purpose is to describe the introduction of a Care Program for the Elderly on Multiple Medication in a Primary Care area and the complete improvement cycle after evaluating the initial results The Program was instigated by the Community of Madrid Pharmacy Directorate. Methods: The Program was aimed at patients over 75 years who took 6 or more active ingredients (9721 patients in the area at the start of the program) and began in September 2006. It is based on coordinating with pharmacists, systematic review of treatment, health education, and the providing of personal dose dispensing systems for the correct use of the medication. Before its introduction, all the health professionals and pharmacists were jointly trained, a person was assigned as being responsible for the primary care teams (EAP) and support material was handed out. An initial evaluation was performed using computerised sentences from the Program data model in the electronic clinical notes, which showed much improvable results. Using quality tools, the causes of low coverage and insufficient results in the rest of the quality indicators were identified and corrective actions were introduced to subsequently monitor and reassess the program. Results: Evaluation of the indicators included in the program. Initial data analysis (February 2007): cover, 3.5% (361 users included); treatment review (RT), 2.1%; review of medication use (RU), 51.2%; assessment of knowledge of the medication (CM), 84.8%; Morisky test (TM), 57.6%; offer of personal dispensing system (SPD), 57.1%; treatment evaluation (VT), 50.1%; care plans (PC), 19.2%; beers criteria (CB), 14.9%. After introducing the improvement actions, the following results were obtained in December 2007: cover, 131.8% (12,650 users); RT, 80.6%; RU, 62.7%; CM, 92.4%; TM, 9.3; SPD, 67.3%; VT, 61.6%; PC, 27.59%, and CB, 13.6%. Conclusions: The introduction of an institutional program, the involvement of the management of Area 4, the application of appropriate quality tools, the continuous monitoring of quality indicators and giving this information back to the professionals has enabled, ten months after the corrective measures were introduced, the institutional objectives of coverage to be achieved. It has also significantly improved quality care activities and their recording, achieving the best results for coverage and quality health care in the Community of Madrid program

Mejora de la seguridad y evaluación de los resultados del proceso de anticoagulación oral implantado en un área de atención primaria / No disponible

Objetivo: Describir la mejora de la seguridad del proceso de atención a pacientes con tratamiento de anticoagulación oral (TAO), implantadoen el Área 4 de Atención Primaria (AP) de Madrid, y evaluar los resultados sobre el control y el seguimiento de dichos pacientes después de 1 año de su implantación.Material y método: El trabajo se articula como proyecto de mejora en 3 fases: a) análisis de debilidades, amenazas, fortalezas y oportunidades(DAFO) tras 1 año de implantación del proceso; b) aplicación de la metodología análisis modal de fallos y efectos (AMFE), y c) evaluación de la implantación, el control y el seguimiento de los pacientescon TAO. La obtención de los datos de los pacientes se realizó a través de una explotación específica de los protocolos de seguimiento TAO de la historia clínica informatizada (HCI) OMI-AP. Se incluyó a todos los pacientes anticoagulados seguidos en AP en elaño 2006, con registro en el protocolo específico TAO informatizado. Resultados: La aplicación de la metodología AMFE, bastante novedosaen AP, ha supuesto identificar los fallos críticos priorizados por el índice de priorización del riesgo (IPR); la puntuación del IPR oscilóentre 8 y 343. Igualmente el AMFE nos ha servido para la introducción de acciones de mejora y la elaboración de los indicadores que nos sirven para monitorizar todo el proceso. Los resultados de la primera evaluación indican que el programa está implantado en el 100% de los equipos. El número de pacientes incluidos en el servicioen 2006 fue de 3.013, lo que supone una cobertura del 59,8%. En cuanto al sexo, el 54,2% de los pacientes seguidos (1.633) son mujeres, el 43% (1.305) son varones y hay un 2,5% (75) no registrado. La media de edad es de 75 años. En cuanto a las indicaciones, fibrilación auricular/arritmias cardíacas es la primera causa conun 61% del total. El valor medio de INR ha sido 2,5. La media de determinaciones por paciente: 12,8. Los valores de INR en rango terapéutico son 20.581 (53%) y en rango ajustado a + 0,2 (posible error del coagulómetro) los valores aumentan hasta el 66%. El porcentajede días que permanecen los valores en rango ha sido del68%, y si lo ajustamos al + 0,2%, ascienden al 79% de los días. Solamente encontramos a 13 pacientes con efectos adversos. Conclusiones: La aplicación del AMFE ha supuesto una mejora importantede todo el proceso, fundamentalmente desde el punto de vista de la seguridad, así como la elaboración de unos indicadores de seguimiento.Este estudio aporta resultados sobre el seguimiento de todos los pacientes con TAO, sin necesidad de muestreo, después de 1 año de su implantación, que nos revelan en general su buen control clínico y la aceptación de los profesionales en la realización del nuevo servicio

Objective: To describe improvements in the safety of the management of patients under oral anticoagulation therapy (OAT) implemented in Primary Care Area 4 of Madrid, Spain, and evaluate the results of monitoring of these patients 1-year after implementation.Material and method: The project was developed in three phases: a) Analysis of strengths, weaknesses, opportunities and threats (SWOT) 1 year after implementation of the program; b) Applicationof a failure modes and effects analysis (FMEA), and c) Evaluation of the implementation, monitoring and follow-up of patients receiving OAT. Data were gathered through exportation of the OAT follow-up protocols of the computerized medical records of the computerizedmedical office for primary care (Oficina Médica Informatizada para Atención Primaria [OMI-AP]) program.Results: Application of the FMEA methodology, which is fairly novel in primary care, identified the critical failures prioritized by the Risk Prioritization Number (RPN); the RPN ranged from 8 to 343. FMEA was also useful for the introduction of improvementinterventions and the design of indicators to be used in monitoring the entire process. The results of the first evaluation indicate that the program was implanted in 100% of the teams. The number of patients included in the service in 2006 was 3,013, representing a coverage of 59.8%. A total of 54.2% (1,633) of the patients followed-up were women, 43% (1,305) were menand 2.5% (75) were not registered. The mean age was 75 years. The main indication for OAT was atrial fibrillation/cardiac arrhythmia, accounting for 61% of the total. The mean internationalnormalized ratio (INR) was 2.5. The mean number of determinations per patient was 12.8. There were 20,581 (53%) INR values in the therapeutic range and in the range adjusted to + 0.2 (possible error of the coagulometer), these values increasedto 66%. The percentage of days in which values remained in the range was 68% and when adjusted to + 0.2%, this percentage reached 79% of the days. Only 13 patients experienced adverse effects. Conclusions: Application of FMEA methodology substantially improvedthe entire process, especially safety and the design of follow-up indicators. The present study reports the results on the follow-up of all patients with OAT, without the need for sampling, 1 year after implementation. In general, these results show good clinical management and health professionals’ acceptance of carrying out the new service

Implantación y evaluación informática de un programa de mejora de la calidad asistencial en el Área 4 de Atención Primaria de Madrid / Implementation and computerized evaluation of a healthcare quality program in Primary Care Area 4 in Madrid

Objetivo: Describir el procedimiento automatizado y los resultados de la evaluación de criterios de calidad asistencial basados en la evidencia científica del total de pacientes en el Área 4 de Atención Primaria de Madrid. Métodos: El Programa de Calidad Asistencial del Área recoge 5 criterios priorizados con un total de 22 indicadores: seguimiento y control de la hipertensión arterial; control de hemoglobina glucosilada en diabéticos; prevención secundaria de cardiopatía isquémica; prevención con antiagregantes en patologías de alto riesgo cardiovascular, y tratamiento con inhibidores de la enzima de conversión de la angiotensina en pacientes con insuficiencia cardíaca. Para su evaluación, se ha desarrollado una herramienta basada en sentencias de lenguaje estructurado de consulta (SQL) que permite obtener resultados sobre el total de la población del Área, sin realizar muestreos, a través de los datos recogidos en la historia clínica informatizada (HCI). Resultados: Corresponden a la evaluación de diciembre de 2005. Se evaluaron 89.372 pacientes (69.843 hipertensos, 24.142 diabéticos, 10.086 diagnosticados de cardiopatía isquémica, 30.440 con patologías de alto riesgo cardiovascular y 2.517 presentaban insuficiencia cardíaca). La información completa se distribuyó a todos los profesionales en una hoja de cálculo Excel con los datos de todos sus pacientes. Conclusiones: La implantación de un programa de calidad asistencial permite promover y evaluar intervenciones con impacto reconocido en la salud de la población. La utilización de la HCI permite obtener datos de toda la población de referencia, con un coste mínimo, sin necesidad de muestreo y de forma sencilla y rápida

Objectives: To describe to the automated procedure and the results of an evaluation of evidence-based healthcare quality criteria in the total number of patients in Primary Care Area 4 in Madrid. Methods: The Healthcare Quality Program of Area 4 gathers five prioritized criteria with a total of 22 indicators: follow-up and control of hypertension, control of glycosylated hemoglobin in diabetics, secondary prevention of coronary heart disease, prevention with antiplatelet therapy in diseases with high cardiovascular risk, and angiotensin-converting-enzyme inhibitors in the treatment of patients with heart failure. To evaluate the criteria, we developed a tool based on structured query language (SQL) that allowed us to obtain results on the entire population of the Area (581,000 persons), without the need for sampling, through the data gathered in the computerized clinical histories. Results: The results correspond to the evaluation performed in December 2005. A total of 89,372 patients were evaluated (69,843 with hypertension, 24,142 with diabetes, 10,086 with a diagnosis of coronary heart disease, 30,440 with diseases with high cardiovascular risk, and 2,517 with heart failure). The complete information was distributed to all the health professionals in an Excel spreadsheet with data on all their patients. Conclusions: The implementation of a healthcare quality program allows interventions with an established impact on the health of the population to be promoted and evaluated. The use of the computerized clinical history allows data on the entire population in the catchment area to be obtained rapidly and simply, with minimal cost, and without the need for sampling