Usefulness of a national hip fracture registry to evaluate the profile of patients in whom antiosteoporotic treatment is prescribed following hospital discharge.

This study was carried out to describe the profile of prescription of antiosteoporotic treatment at discharge after a hip fracture in the Spanish National Hip Fracture Registry. Prescription rates among hospitals ranged from 0 to 94% of patients discharged. The prescription rate was higher among patients with better cognitive and functional baseline status. PURPOSE: National hip fracture registries are useful for assessing current care processes. The goals of this study were as follows: first, to know the rate of antiosteoporotic prescription at discharge among hip fracture patients in hospitals participating in the Spanish National Hip Fracture Registry (RNFC); second, to compare the differences between treated and non-treated patients; third, to analyze patients' characteristics associated with antiosteoporotic prescription at discharge; and fourth, to evaluate whether there were differences in the profile of patients discharged from hospitals with high and low prescription rates. METHOD: Patients discharged after a fragility hip fracture in 2017 and participating in the RNFC were included. Demographic variables, cognitive and functional status, prefracture osteoporosis treatment, fracture type, anesthetic risk, hospital volume, and antiosteoporotic prescription at discharge were analyzed. Given that patients were clustered within hospitals, intraclass correlation was calculated and generalized estimating equations were fitted. RESULTS: A total of 6701 patients from 54 hospitals were included. Antiosteoporotic prescription at discharge was prescribed to 36.5% (CI95% 35.8-37.2%), with a wide inter-hospital variability (range 0-94%). The intraclass correlation due of clustering of patients within hospitals was 47.9%. Antiosteoporotic prescription was more likely in patients who were younger, lived at home, previously treated for osteoporosis, had better baseline functional and cognitive status, lower anesthetic risk, and were discharged from high-volume hospitals, all with p < 0.001. The general profile of patients discharged from hospitals with high and low rate of prescription was similar. CONCLUSIONS: There is a wide variability between hospitals regarding antiosteoporotic prescription after hip fracture. This is more likely to be initiated in patients with better clinical, functional, and mental status and in those discharged from hospitals with larger volumes of patients. These results offer insights regarding the selection of patients receiving secondary prevention and raises questions on who and how many should be treated.

Baseline and 1-year follow-up differences between hip-fracture patients admitted from nursing homes and the community. A cohort study on 509 consecutive patients (FONDA Cohort) / Diferencias iniciales y a 1 año de seguimiento entre los pacientes con fractura de cadera de residencia de ancianos y de comunidad. Estudio de una cohorte de 509 pacientes (Cohorte FONDA)

Objective: To determine the clinical and functional differences at hospital admission and at 1 year after a hip fracture (HF) in nursing homes (NH) and community-dwelling (CD) patients. Methods: All patients with HF admitted to the orthogeriatric unit at a university hospital between January 2013 and February 2014 were prospectively included. Clinical and functional variables, and mortality were recorded during the hospital admission. The patients were contacted by telephone at 1 year to determine their vital condition and functional status. Results: A total of 509 patients were included, 116 (22.8%) of whom came from NH. Compared with the CD patients, the NH patients had higher surgical risk (ASA ≥3: 83.6% vs. 66.4%, P<.001), poorer theoretical vital prognosis (Nottingham Profile ≥5: 98.3% vs. 56.6%, P<.001), higher rate of previous functional status (median Barthel index: 55 [IQR, 36-80] vs. 90 [IQR, 75-100], P<.001), poorer mental status (Pfeiffer's SPMSQ>2: 74.1% vs. 40.2%, P<.001), and a higher rate of sarcopenia (24.3% vs. 15.2%, P<.05). There were no differences in in-hospital or at 1-year mortality. At 1 year, NH patients recovered their previous walking capacity at a lower rate (38.5% vs. 56.2%, P<.001). Conclusions: Among the patients with HF treated in an orthogeriatric unit, NH patients had higher, surgical risk, functional and mental impairment, and a higher rate of sarcopenia than CD patients. At 1 year of follow-up, NH patients did not have higher mortality, but they recovered their previous capacity for walking less frequently

Objetivo: Determinar las diferencias clínicas y funcionales, basales y al año de la fractura, en los pacientes hospitalizados por fractura de cadera (FC) que provienen de residencia de ancianos (RA) y de la comunidad. Métodos: Se incluyeron de forma prospectiva todos los pacientes ingresados con el diagnóstico de FC en la unidad de ortogeriatría de un hospital universitario entre enero de 2013 y febrero de 2014. Se recogieron variables clínicas, funcionales, cognitivas y la evolución durante la hospitalización. Se contactó telefónicamente al año para conocer su estado vital y funcional. Resultados: Se incluyeron 509 pacientes, de los que 116 (22,8%) provenían de RA. Comparados con las personas que provenían de comunidad, éstos tenían un mayor riesgo quirúrgico (ASA≥3: 83,6% vs. 66,4%, p<0,001), peor pronóstico vital teórico (Perfil de Nottingham≥5: 98,3% vs. 56,6%, p<0,001), peor estado funcional basal (Índice Barthel medio: 55 [RIC, 36-80] vs. 90 [RIC, 75-100], p<0,001), peor estado mental (Test de Pfeiffer>2: 74,1% vs. 40,2%, p<0,001) y tasas más altas de sarcopenia (24,3% vs. 15,2%, p<0,05). No hubo diferencias en la mortalidad durante la hospitalización ni al año. Al año los pacientes de RA recuperaron su capacidad de ambulación previa con menos frecuencia (38,5% vs. 56,2%, p<0,001). Conclusiones: Los pacientes ingresados por FC provenientes de RA presentan mayor riesgo quirúrgico, mayor deterioro funcional y mental y mayor tasa de sarcopenia que los pacientes de la comunidad. No presentan mayor mortalidad durante el ingreso ni al año de la FC, pero recuperan su capacidad de deambulación previa con menos frecuencia

Spanish National Hip Fracture Registry (RNFC): analysis of its first annual report and international comparison with other established registries.

Hip fracture registries have helped improve quality of care and reduce variability, and several audits exist worldwide. The results of the Spanish National Hip Fracture Registry are presented and compared with 13 other national registries, highlighting similarities and differences to define areas of improvement, particularly surgical delay and early mobilization. INTRODUCTION: Hip fracture audits have been useful for monitoring current practice and defining areas in need of improvement. Most established registries are from Northern Europe. We present the results from the first annual report of the Spanish Hip Fracture Registry (RNFC) and compare them with other publically available audit reports. METHOD: Comparison of the results from Spain with the most recent reports from another ten established hip fracture registries highlights the differences in audit characteristics, casemix, management, and outcomes. RESULTS: Of the patients treated in 54 hospitals, 7.208 were included in the registry between January and October 2017. Compared with other registries, the RNFC included patients ≥ 75 years old; in general, they were older, more likely to be female, had a worse prefracture ambulation status, and were more likely to have extracapsular fractures. A larger proportion was treated with intramedullary nails than in other countries, and spinal anesthesia was most commonly used. With a mean of 75.7 h, Spain had by far the longest surgical delay, and the lowest proportion of patients mobilized on the first postoperative day (58.5%). Consequently, development of pressure ulcers was high, but length of stay, mortality, and discharge to home remained in the range of other audits. CONCLUSIONS: National hip fracture registries have proved effective in changing clinical practice and our understanding of patients with this condition. Such registries tend to be based on an internationally recognized common dataset which would make comparisons between national registries possible, but variations such as age inclusion criteria and follow-up are becoming evident across the world. This variation should be avoided if we are to maximize the comparability of registry results and help different countries learn from each other's practice. The results reported in the Spanish RNFC, compared with those of other countries, highlight the differences between countries and detect areas of improvement, particularly surgical delay and early mobilization.

Baseline and 1-year follow-up differences between hip-fracture patients admitted from nursing homes and the community. A cohort study on 509 consecutive patients (FONDA Cohort).

OBJECTIVE: To determine the clinical and functional differences at hospital admission and at 1 year after a hip fracture (HF) in nursing homes (NH) and community-dwelling (CD) patients. METHODS: All patients with HF admitted to the orthogeriatric unit at a university hospital between January 2013 and February 2014 were prospectively included. Clinical and functional variables, and mortality were recorded during the hospital admission. The patients were contacted by telephone at 1 year to determine their vital condition and functional status. RESULTS: A total of 509 patients were included, 116 (22.8%) of whom came from NH. Compared with the CD patients, the NH patients had higher surgical risk (ASA ≥3: 83.6% vs. 66.4%, P<.001), poorer theoretical vital prognosis (Nottingham Profile ≥5: 98.3% vs. 56.6%, P<.001), higher rate of previous functional status (median Barthel index: 55 [IQR, 36-80] vs. 90 [IQR, 75-100], P<.001), poorer mental status (Pfeiffer's SPMSQ>2: 74.1% vs. 40.2%, P<.001), and a higher rate of sarcopenia (24.3% vs. 15.2%, P<.05). There were no differences in in-hospital or at 1-year mortality. At 1 year, NH patients recovered their previous walking capacity at a lower rate (38.5% vs. 56.2%, P<.001). CONCLUSIONS: Among the patients with HF treated in an orthogeriatric unit, NH patients had higher, surgical risk, functional and mental impairment, and a higher rate of sarcopenia than CD patients. At 1 year of follow-up, NH patients did not have higher mortality, but they recovered their previous capacity for walking less frequently.

Effectiveness of an intervention in multicomponent exercise in primary care to improve frailty parameters in patients over 70 years of age (MEFAP-project), a randomised clinical trial: rationale and study design.

BACKGROUND: Physical activity may reverse frailty in the elderly, but we encounter barriers to the implementation of exercise programs in this population. Our main aim is to evaluate the effect of a multicomponent physical activity program, versus regular medical practice, on reverting pre-frailty status among the elderly, 12 months post-intervention. METHODS: Randomized parallel group multicenter clinical trial located in primary care setting, among non-dependent and pre-frail patients > 70 years old, including 190 patients (95 intervention, 95 control group). INTERVENTION: Multicomponent physical activity program (MEFAP, for its acronym in Spanish) with twelve 1.5 h-weekly sessions comprised of: 1. Informative session; 2. Exercises for improving aerobic resistance, muscle strength, propioception-balance and flexibility; and 3. Handing out of at-home exercise chart (twice/week). Main variable: pre-frailty according to the Fried phenotype. Secondary variables: sociodemographic, clinical and functional variables; exercise program adherence, patient satisfaction with the program and quality of life. We will perform an intention-to-treat analysis by comparing the retrogression from pre-frailty (1 or 2 Fried criteria) to robust status (0 Fried criteria) by the end of the intervention, 6 months and 12 months post-intervention. The accumulated incidence in each group will be calculated, as well as the relative risk (RR) and the number needed to treat (NNT) with their corresponding 95% confidence intervals. Protocol was approved by the Ethics Committee Hospital la Paz. DISCUSSION: Within the context of regular clinical practice, our results will provide evidence regarding the effects of exercise interventions on frailty among pre-frail older adults, a key population given their significant potential for functional, physical, and mental health improvement. TRIAL REGISTRATION: NCT03568084 . Registered 26 June 2018. Date of enrollment of the first participant to the trial: July 2nd 2018.

Spanish National Hip Fracture Registry (SNHFR): a description of its objectives, methodology and implementation / Registro Nacional Español de Fracturas de Cadera (RNFC): descripción de sus objetivos, metodología e implementación

Objective: To ascertain the current situation and clinical variability of the provision of care for Hip Fracture (HF) in Spain and the factors related to it by using a National Registry (NHFR) with high patient numbers and territorial representation NHFR, and to compare results on a national and international level and propose standards and criteria to improve healthcare quality. Design: Continuous registry for at least three years of a representative sample of patients admitted to Spanish hospitals due to HF using the Minimum Common Dataset - international Fragility Fracture Network (FFN) MCD, adapted for Spanish. Study scope and subjects: all patients over the age of 74 years who are hospitalized with a diagnosis of a fragility HF at the participating hospitals distributed throughout the Spanish territory. Initially 48 hospitals are included, and we expect to incorporate the highest number of sites possible. Results: It is expected to ascertain the current situation of provision of care for HF in Spain. Each hospital will be offered information regarding their results and their situation compared to the rest. The results from national hospitals will be compared to others included in the registry and to hospitals abroad, which use the same database. Variability will be studied, care standards will be established, and objectives will be proposed for the continuous improvement of the care process of this condition

Objetivo: Conocer la situación actual y la variabilidad clínica del proceso asistencial a la Fractura de Cadera (FC) en España y los factores relacionados con la misma mediante la utilización de un Registro Nacional (RNFC) con elevada casuística y representación territorial RNFC, así como comparar resultados en el ámbito nacional e internacional y proponer estándares y criterios para mejorar la calidad asistencial. Diseño: Registro continuo durante al menos tres años de una muestra representativa de los pacientes ingresados por FC en los hospitales españoles mediante el Minimum Common Dataset - MCD internacional de la Fragility Fracture Network (FFN) adaptado al castellano. Ámbito y sujetos del estudio: se incluirán todos los pacientes mayores de 74 años hospitalizados con el diagnóstico de FC por fragilidad en los hospitales participantes repartidos por el territorio español. Inicialmente están incluidos 48 hospitales, a los que se espera que se vayan incorporando el mayor número posible de centros. Resultados: Se pretende conocer la situación actual de la atención a este proceso en España Se ofrecerá a cada hospital la información de sus resultados y su situación en relación al resto, se compararán los resultados de los hospitales nacionales entre sí y con los hospitales extranjeros incluidos en registros que usan la misma base de datos. Se estudiará la variabilidad, se establecerán estándares asistenciales y se plantearán objetivos para la mejora continua del proceso en la atención a esta patología

Spanish National Hip Fracture Registry (SNHFR): a description of its objectives, methodology and implementation.

OBJECTIVE: To ascertain the current situation and clinical variability of the provision of care for Hip Fracture (HF) in Spain and the factors related to it by using a National Registry (NHFR) with high patient numbers and territorial representation NHFR, and to compare results on a national and international level and propose standards and criteria to improve healthcare quality. DESIGN: Continuous registry for at least three years of a representative sample of patients admitted to Spanish hospitals due to HF using the Minimum Common Dataset - international Fragility Fracture Network (FFN) MCD, adapted for Spanish. STUDY SCOPE AND SUBJECTS: all patients over the age of 74 years who are hospitalized with a diagnosis of a fragility HF at the participating hospitals distributed throughout the Spanish territory. Initially 48 hospitals are included, and we expect to incorporate the highest number of sites possible. RESULTS: It is expected to ascertain the current situation of provision of care for HF in Spain. Each hospital will be offered information regarding their results and their situation compared to the rest. The results from national hospitals will be compared to others included in the registry and to hospitals abroad, which use the same database. Variability will be studied, care standards will be established, and objectives will be proposed for the continuous improvement of the care process of this condition.

Body mass index and all-cause mortality among type 2 diabetes mellitus patients: Findings from the 5-year follow-up of the MADIABETES cohort.

PURPOSE: To analyse the association between body mass index (BMI) and all-cause mortality in a 5-year follow-up study with Spanish type 2 diabetes mellitus (T2DM) patients, seeking gender differences. METHODS: 3443 T2DM outpatients were studied. At baseline and annually, patients were subjected to anamnesis, a physical examination, and biochemical tests. Data about demographic and clinical characteristics was also recorded, as was the treatment each patient had been prescribed. Mortality records were obtained from the Spanish National Institute of Statistics. Survival curves for BMI categories (Gehan-Wilcoxon test) and a multivariate Cox proportional hazard analysis were performed to identify adjusted Hazard Ratios (HRs) of mortality. RESULTS: Mortality rate was 26.38 cases per 1000patient-years (95% CI, 23.92-29.01), with higher rates in men (28.43 per 1000patient-years; 95% CI, 24.87-32.36) than in women (24.31 per 1000patient-years; 95% CI, 21.02-27.98) (p=0.079). Mortality rates according to BMI categories were: 56.7 (95% CI, 40.8-76.6), 28.4 (95% CI, 22.9-34.9), 24.8 (95% CI, 21.5-28.5), 21 (95% CI, 16.3-26.6) and 23.7 (95% CI, 14.3-37) per 1000person-years for participants with a BMI of <23, 23-26.8, 26.9-33.1, 33.2-39.4, and >39.4kg/m2, respectively. The BMI values associated with the highest all-cause mortality were <23kg/m2, but only in males [HR: 2.78 (95% CI, 1.72-4.49; p<0.001)], since in females this association was not significant [HR: 1.14 (95% CI, 0.64-2.04; p=0.666)] (reference category for BMI: 23.0-26.8kg/m2). Higher BMIs were not associated with higher mortality rates. CONCLUSIONS: In an outpatient T2DM Mediterranean population sample, low BMI predicted all-cause mortality only in males.

Aprendizaje basado en la resolución de problemas: una experiencia práctica / Problem-based-solving learning: a practical experience

El aprendizaje basado en la resolución de problemas incorpora herramientas metodológicas capaces de facilitar la consecución de los objetivos propuestos para la formación de los futuros médicos dentro del marco de la docencia universitaria en el Espacio Europeo de Educación Superior. Promueve una formación más activa, flexible y práctica, que concede mayor protagonismo al trabajo personal tutorizado(aprendizaje autodirigido), en detrimento de las clásicas clases teóricas, eminentemente expositivas, en las que el papel del estudiante es, en general, más pasivo. La Unidad de Medicina de Familia de la Universidad Autónoma de Madrid incorporó el aprendizaje basado en la resolución de problemas en el desarrollo de la asignatura optativa ‘Atención Primaria y Medicina de Familia’, ofertada como optativa a los alumnos de segundo ciclo de licenciatura (cursos 4.º a 6.º)desde el curso 2005-2006. Intentamos con ella promover la formación de médicos capaces de aprender y mantener su competencia durante toda su vida profesional, no sólo en lo referido a la adquisición/integración de conocimientos científicos suficientes, sino también en cuanto al desarrollo de las habilidades necesarias para su adecuada aplicación práctica considerando a cada paciente de modo integral como realidad biopsicosocial, en un contexto sanitario definido, sin olvidar los aspectos bioéticos implícitos al quehacer del médico (respeto hacia el paciente y compromiso social). Revisamos en este artículo el diseño práctico de la asignatura (AU)

Learning based on problem-solving incorporates methodological tools that make it easier to fulfill the aims set for the training of future physicians within the framework of university education in the European Higher Education Area. It encourages a more active, flexible and practical training, which grants a leading role to tutor-guided personal work(self-directed learning) rather than the classical theoretical, eminently expository, classes, in which the student generally played a more passive role. The Family Medicine Unit at the Universidad Autónoma de Madrid has included learning based on problem-solving as part of the elective subject ‘Primary Care and Family Medicine’, which is optional for students in the second cycle of their degree (years 4 to 6),since the academic year 2005-2006. By so doing our aim is to try to promote the training of physicians who are capable of learning and maintaining their competence throughout their entire career. This must not only involve the acquisition/integration of sufficient scientific knowledge but also the development of the skills needed to be able to apply them in a practical sense by considering each patient in a integral manner as a biopsychosocial reality, within a particular health care context. And we must not forget the bioethical aspects that are implicit in the doctor’s work (respect for the patient and social compromise). In this article, we review the practical design of the subject (AU)

¿Cómo conciben la salud y la atención la población inmigrante? El discurso del colectivo ecuatoriano en Madrid / How is the health and care to the immigrant population understood? The speech of the Ecuadorian group in Madrid

INTRODUCCIÓN. El objetivo del estudio era conocer el proceso asistencial del colectivo ecuatoriano, describir su concepto de salud, los factores que influyen en la utilización de los distintos sistemas de atención y las características de los mismos. MATERIAL Y MÉTODOS. Diseño cualitativo a través de grupos de discusión realizado en los años 2002 y 2003 con inmigrantes ecuatorianos residentes en Madrid. Captación por el sistema de "bola de nieve". Criterios de segmentación: sexo, situación administrativa y laboral. Muestreo intencional y teórico hasta el punto de saturación. Utilización para la interpretación de la Teoría Fundamentada. RESULTADOS. La representación social de salud más frecuente es la visión holística de la salud. Existe una percepción idealizada del sistema sanitario español, valorándose la proximidad, la tecnología y la gratuidad. Existe una idealización de la atención especializada que fomenta la minusvaloración del médico de familia y la Atención Primaria. Las urgencias son el sistema más valorado; acuden a él por su rapidez, su flexibilidad de horarios y la presencia de especialistas. CONCLUSIONES. Los profesionales sanitarios deben conocer las características socioculturales de la población inmigrante para mejorar su atención. Se debe fomentar el conocimiento de las características del sistema sanitario por la población inmigrante para una mejor utilización de los recursos sanitarios (AU)

BACKGROUND. The objective of this study was to discover the health care process of the Ecuadorian group, to describe their concept of health, the factors that influence the use of the different care systems and their characteristics. METHODS. Qualitative research conducted through discussion groups in the years 2002 and 2003 with resident Ecuadorian immigrants living in Madrid. They were selected by snowball sampling. Segmentation criteria were gender, administrative and work situation. Intentional and theoretical sampling until the saturation point. Use for the interpretation of the Grounded Theory. RESULTS. The more frequent social representation of health is the holistic view of the health. There is an ideal perception of the Spanish health care system, evaluating proximity, technology and free of charge. Specialized care is glorified, this leading to the undervaluation of the family doctor and primary health care. The emergency services are the most valued system. They go there due to its rapidity, flexibility of schedules and presence of specialists. CONCLUSIONS. The health care professionals must know the sociocultural characteristics of the immigrants to improve their care. Knowledge of the characteristics of the health care system by the population should be encouraged in order to improve the health care resource usage (AU)

Factors associated with health care utilization by the elderly in a public health care system.

OBJECTIVE: The objective was to determine the factors associated with the use of health care services by the elderly residing in the community. METHODS: A cross-sectional study on 787 elderly people over 64 years of age from Albacete City (Castilla-La Mancha, Spain). The study was carried out by personal home interviews during a 9-month period. The dependent variables were: health care utilization, and characteristics. The independent variables were: self-reported health status, self-reported morbidity, medication use, functional status, mental health, lifestyle habits, social support, and sociodemographic status. RESULTS: The health care services were used by 74.5% in the last 3 months of which 59.4% were general practitioner visits, 18.4% were to nursing staff, and 16.5% were specialist visits. Laboratory tests were performed in 39.2% and radiological examinations in 24.9%. Emergency visits accounted for 2.4%, and hospitalization, 2.9%. Users of health care services among the elderly population were objectively more ill, although there was a group of healthy individuals who also visited the physician and a large group of elderly with considerable health problems who never saw their physician. In the multivariate analysis, general practitioner utilization was independently associated with a perceived unmet need for care (OR = 3.15), a negative self-reported health status (OR = 2.51), and a lower educational level (OR = 2.41). CONCLUSIONS: Subjective factors as perceived need for care, a negative self-reported health status and lower educational level are important factors that influence in the utilization of health care services.

[Evaluation of referrals in primary care]. / Evaluación de la demanda derivada en atención primaria.

OBJECTIVE: To study the process of referral from primary care in a health area in Madrid. The second objective was to evaluate the trends in the referral process. DESIGN: Observational, descriptive and cross-sectional study. SETTING: Three urban health centers in the Area 2. PARTICIPANTS: All referrals made by 13 doctors during 3 consecutive weeks. The total number of visits attended were 6012. The study was realized between February 2002 and January 2003. MAIN MEASUREMENTS: Patient, doctor and referral characteristics on every referral. RESULTS: 349 referrals were studied. The rate of referral 5.8% (5.21-6.39). The referred patients, 65.5% women, medium age 50.6+/-21. The specialties that received more referrals are gynecologist, ophthalmology, dermatology, otorhinolaryngology, rehabilitation, orthopedic surgeon and general surgeon. The most common conditions referred, 25.6% of all referrals, are gynecologist check, blindness, other illnesses of subcutaneous cellular tissue, arthrosis, joint pain, diabetes, benign neoplasm of skin, depression and hypoacusis. 92.3% of the referrals were sent to the specialist center. 89.7% were normal (no urgent). The reason for referral was to accede to the patient's request in 18.3% of the referrals. CONCLUSIONS: The process of referral is similar to previous studies. Although people are more participative, have more information and the defensive medicine is increasing, the process of referral have not changed.

Evaluación de la demanda derivada en atención primaria / Evaluation of referrals in primary care

Objetivo. Analizar el patrón de derivación en consultas de atención primaria de un área de salud de Madrid. Un segundo objetivo es analizar los cambios que se hayan producido en dicho patrón. Diseño. Estudio observacional, descriptivo y transversal de la demanda derivada. Emplazamiento. Tres centros de salud urbanos del Área 2. Participantes. Se han seleccionado todas las derivaciones realizadas durante 3 semanas consecutivas por 13 médicos que atendieron a un total de 6.012 visitas en ese período. El estudio se realizó entre febrero de 2002 y marzo de 2003. Mediciones principales. En cada derivación se determinaron los datos del paciente, del médico y de la derivación. Resultados. Se estudiaron 349 derivaciones, lo que supone una tasa de derivación del 5,8% (5,21-6,39). De los pacientes derivados, el 65,5% era mujer, con una edad media ± desviación estándar (DE) de 50,6 ± 21 años. Las especialidades que han recibido más derivaciones son ginecología, oftalmología, dermatología, otorrinolaringología, rehabilitación, traumatología y cirugía general. Los diagnósticos más frecuentes derivados, el 25,6% del total, son revisión ginecológica, disminución de la agudeza visual, otras enfermedades de la piel y el tejido celular subcutáneo, artrosis, dolor articular, diabetes, neoplasia benigna de la piel, depresión y sordera. Un 92,3% de las derivaciones fueron dirigidas a un centro de especialidades, el 89,7% de forma normal. En el 18,3%, el médico sintió algún grado de presión por parte del paciente para derivarlo. Conclusiones. El patrón de derivación es similar al de estudios anteriores. El hecho de que la población tenga una actitud más participativa y un mayor acceso a la información, y el aumento de la medicina defensiva no parecen haber modificado el patrón de derivación

Objective. To study the process of referral from primary care in a health area in Madrid. The second objective was to evaluate the trends in the referral process. Design. Observational, descriptive and crosssectional study. Setting. Three urban health centers in the Area 2. Participants. All referrals made by 13 doctors during 3 consecutive weeks. The total number of visits attended were 6012. The study was realized between February 2002 and January 2003. Main measurements. Patient, doctor and referral characteristics on every referral. Results. 349 referrals were studied. The rate of referral 5.8% (5.21-6.39). The referred patients, 65.5% women, medium age 50.6±21. The specialties that received more referrals are gynecologist, ophthalmology, dermatology, otorhinolaringology, rehabilitation, orthopedic surgeon and general surgeon. The most common conditions referred, 25.6% of all referrals, are gynecologist check, blindness, other illnesses of subcutaneous cellular tissue, arthrosis, joint pain, diabetes, benign neoplasm of skin, depression and hypoacusis. 92.3% of the referrals were sent to the specialist center. 89.7% were normal (no urgent). The reason for referral was to accede to the patient’s request in 18.3% of the referrals. Conclusions. The process of referral is similar to previous studies. Although people are more participative, have more information and the defensive medicine is increasing, the process of referral have not changed

[Spanish version of the 7 Minute screening neurocognitive battery. Normative data of an elderly population sample over 70]. / Versión española del Test de los 7 Minutos. Datos normativos de una muestra poblacional de ancianos de más de 70 años.

INTRODUCTION: To standardize the Spanish version of the 7 Minute screening neurocognitive battery (7MS) in a population sample of elderly over 70 years. METHODS: We examined 416 persons, living at home, participating in elderly the longitudinal study "Aging in Leganes", aged 71 to 99 years old (mean age: 79 +- 9.2 years; 51.7 % women; 10.6 illiterate, 25 % without formal education). In order to do so, we used an extensive clinical survey, general and neurological exam and extensive neuropsychological battery with several cognitive scales, attention, language, memory, visuomotor skill and reasoning tests, Jorm's IQCODE questionnaire, CES-D depression questionnaire and the 7MS including the Benton Orientation Test, Clock Drawing Test, Free and Cued Learning Test and Categorial Verbal Fluency. Dementia was diagnosed according to DSM-IV criteria but independently of the 7MS scores. Several methods to obtain the total score of the 7MS were analyzed and the normative parameters of the test were obtained in the subgroup of non-demented subjects. RESULTS: The easiest and most efficient method to obtain the total score of the 7MS was the sum of the z-scores of the four subtests. We present the mean values, -1 and -1.5 standard deviations, range and percentiles of the partial and total scores of the 7MS stratified by age (71-75, 76-80, 81-85 and > or = 86 years) and education (less than primary education and primary education or greater) in the subgroup of non-demented subjects. CONCLUSIONS: The normative data of the 7MS obtained in a representative sample of the general elderly population support its rigorous use in the Spanish clinical setting.

[Impact of cataract surgery upon functional capacity of the elderly]. / Repercusión de la intervención de cataratas en la capacidad funcional del anciano.

PURPOSE: To determine the impact of cataract intervention on visual function of the elderly and on autonomy in daily activities, analyzing the influence of clinical and sociodemographic variables. METHODS: Observational and longitudinal study. 185 elderly patients having undergone cataract surgery were compared with 179 elderly patients on a surgical waiting list. The first group was evaluated prior to surgery and at 4 months post-intervention. Control group patients were evaluated at the same times, without having received surgery. For all subjects, the state of visual function was determined by the Activities of Daily Vision Scale (ADVS). Degree of dependence in carrying out basic daily activities, cognitive state and self-perception of vision were also measured. Other variables were visual acuity, other ocular diseases and sociodemographic characteristics. RESULTS: Amongst the elderly patients having undergone surgery, the proportion of subjects able to carry out basic activities 4 months post-intervention (60.7%) was very similar to the initial pre-intervention figure (62.2%). However, in the control group, the proportion (63.1%) diminished significantly at the 4-month mark (48.8%) (p= 0.0001). Of the intervened subjects, 75.7% demonstrated improved self-perception of vision after 4 months as opposed to 15.4% of the non-intervened patients (p= 0.00001). Post-intervention, the mean score on the ADVS rose from 51.0 S.D. 28.4 to 76.0 S.D. 25.4 (p < 0.001). In contrast, the control group's mean score dropped from 54.8 S.D. 24.8 to 46.5 S.D. 27.1 (p < 0.001). CONCLUSIONS: Cataract surgery in the elderly improves visual function and prevents loss of autonomy, delaying dependency in carrying out basic daily activities.

[Prevalence of urinary incontinence and linked factors in men and women over 65]. / Prevalencia de la incontinencia urinaria y factores asociados en varones y mujeres de más de 65 años.

OBJECTIVES: To calculate the prevalence of urinary incontinence and to identify linked factors in a population of elderly people living in their homes. DESIGN: Population survey. SETTING: Leganés (Madrid). PARTICIPANTS: Representative sample of people over 65 registered in Leganés (n=1560). Two interviews at home were conducted. The second interview included a medical examination. The reply rate was 75% (n=1150). MAIN MEASUREMENTS: Frequency of involuntary losses of urine and use of medication and absorbents, health status, use of diuretics and oxybutinin, and demographic and social variables. RESULTS: The prevalence of urinary incontinence was 14% (95% CI, 11%-17%) in men and 30% (95% CI, 26%-34%) in women. Advanced age was associated with greater prevalence in men but not in women. In the multivariate analysis, factors associated with urinary incontinence were comorbidity and cognitive deficit. In addition, in women, high Body Mass Index and seriously limited movement were added factors. 20% of women and 5% of men over 65 used absorbents. The use of diuretics and the low number of patients receiving specific treatment for urinary incontinence suggested that there was low detection of this problem. CONCLUSIONS: Urinary incontinence is common and could be better detected and treated in primary care. Prevention of urinary incontinence in women should begin before old age.

Prevalencia de la incontinencia urinaria y factores asociados en varones y mujeres de más de 65 años / Prevalence of urinary incontinence and linked factors in men and women over 65

Objetivos. Estimar la prevalencia de la incontinencia urinaria e identificar los factores asociados en una población de personas mayores que viven en sus domicilios. Diseño. Encuesta poblacional. Emplazamiento. Leganés (Madrid).Participantes. Muestra representativa de las personas mayores de 65 años empadronadas en Leganés (n = 1.560). Se realizaron dos entrevistas en el domicilio, y durante la segunda se incluyó un examen médico. La tasa de respuesta fue del 75 por ciento (n = 1.150).Mediciones principales. Frecuencia de pérdidas involuntarias de orina y utilización de fármacos y absorbentes, estado de salud, uso de diuréticos y oxibutinina y variables demográficas y sociales. Resultados. La prevalencia de incontinencia urinaria fue del 14 por ciento (intervalo de confianza [IC] del 95 por ciento, 11-17) en varones y 30 por ciento (IC del 95 por ciento, 26-34) en mujeres. La edad avanzada está asociada a una mayor prevalencia en los varones pero no en las mujeres. En el análisis multivariado, los factores asociados a la incontinencia urinaria son la comorbilidad y el déficit cognitivo; en las mujeres se añaden, además, el índice de masa corporal elevado y las limitaciones graves de movilidad. El 20 por ciento de las mujeres y el 5 por ciento de los varones mayores de 65 años utilizan absorbentes. La utilización de diuréticos y el bajo número de pacientes con tratamiento específico en personas con incontinencia urinaria sugieren una baja detección de este problema. Conclusiones. La incontinencia urinaria es frecuente y podría ser mejor detectada y tratada en la atención primaria. La prevención de la incontinencia urinaria en las mujeres debería comenzar antes de la vejez (AU)

[Non-detected dementia and use of the health services: implications for primary care]. / Demencia no detectada y utilización de los servicios sanitarios: implicaciones para la atención primaria.

OBJECTIVES: To calculate the proportion of cases of dementia detected in people over 70 living in their homes and to describe the use made by people with dementia of the health and social services. MATERIAL AND METHODS: Population survey of the survivors of the cohort "Growing old in Leganés", started in 1993. In the third monitoring (1999-2000), the clinical diagnosis of dementia on the basis of a neurological examination and an extensive neuro-psychological battery was included. Their use of health and social services and prior diagnoses were also asked. RESULTS: In the sample of survivors (n=527), there was 12.1% prevalence of dementia. Only 30% of the demented had previously been diagnosed by the health services. The proportion of undetected dementia was significantly associated with its seriousness (light 95%, moderate 69%, severe 36%). Compared with older persons who were not demented, the demented used more often hospital services, medical and nursing consultations at home and consultations through third parties; and less often, preventive and rehabilitation services. This trend was accentuated in patients with grave dementia. The use of community social services was very low (below 8% in the most serious cases). CONCLUSIONS: The detection of dementia in the elderly is very low and efforts to detect it in primary care need to be stepped up. Specific social-health resources for this population also need to be increased and the attendance guide-lines for primary care teams, and for health professionals in general, need to be changed.

Demencia no detectada y utilización de los servicios sanitarios: implicaciones para la atención primaria / Non-detected dementia and use of the health services: implications for primary care

Objetivo. Estimar la proporción de casos de demencia detectados en personas mayores de 70 años que residen en sus domicilios y describir la utilización de los servicios sanitarios y sociales que hacen las personas con demencia. Material y métodos. Encuesta poblacional de los supervivientes de la cohorte "Envejecer en Leganés" iniciada en 1993. En el tercer seguimiento de 1999-2000 se incorporó el diagnóstico clínico de la demencia realizado según el examen neurológico y una extensa batería neuropsicológica. Se preguntó también sobre la utilización de servicios sanitarios y sociales y sobre diagnósticos previos. Resultados. En la muestra de supervivientes (n = 527), la prevalencia de demencia fue de 12,1 por ciento. Sólo el 30 por ciento de los dementes había sido previamente diagnosticado por los servicios sanitarios. La proporción de demencia no detectada está significativamente asociada con su gravedad (leve, 95 por ciento; moderada, 69 por ciento; grave, 36 por ciento).Comparados con las personas mayores no dementes, los dementes utilizan con mayor frecuencia los servicios hospitalarios, la consulta médica y de enfermería a domicilio y la consulta por terceros, y con menos frecuencia, los servicios preventivos y de rehabilitación. Esta tendencia se acentúa en los pacientes con demencia grave. La utilización de los servicios sociales comunitarios es muy baja (inferior al 8 por ciento en los casos más graves). Conclusiones. La detección de la demencia en los ancianos es muy baja y deben incrementarse los esfuerzos de detección en la atención primaria. También deben aumentar los recursos sociosanitarios específicos para esta población y cambiar las pautas asistenciales del equipo de atención primaria y de los profesionales sanitarios en general (AU)

Situación funcional de los ancianos con cataratas / Functional condition of the elderly with cataracts

OBJETIVO: Describir el estado de la función visual y la capacidad para realizar actividades básicas de la vida diaria en los ancianos diagnosticados de cataratas, analizando la influencia que ejercen sus características sociosanitarias. DISEÑO: Estudio observacional de carácter transversal realizado mediante entrevista personal. EMPLAZAMIENTO: Centros Hospitalarios del Sistema Público existentes en el Área Sanitaria de Albacete. PACIENTES: 364 sujetos de 65 o más años de edad, diagnosticados de cataratas y en lista de espera para ser sometidos a cirugía, seleccionados consecutivamente. El tamaño muestral corresponde a una precisión de ñ 2,5 puntos en la escala de función visual utilizada, una desviación estándar de 25 puntos y un nivel de confianza del 95 per cent. RESULTADOS: El estado de la función visual se evaluó mediante la Escala de las Actividades Visuales de la Vida Diaria (ADVS) y la capacidad funcional global de los ancianos a través del índice de Katz. El resto de las variables consideradas fueron: estado cognitivo, visión autopercibida, agudeza visual, clasificación de la catarata, tensión ocular, datos de morbilidad y características sociodemográficas. El tiempo medio de evolución de las cataratas fue de cinco años. Considerando exclusivamente el ojo portador de la catarata, el 96,6 per cent presentaba una agudeza visual inferior a 0,5 (20/40), estando comprendida en el 51,1 per cent de los casos entre 0 (amaurosis) y 0,05 (20/400). El tipo de catarata predominante fue la madura o completa (43,5 per cent). La puntuación media de los ancianos en la escala ADVS fue de 52,9 puntos ñ 26,9 DE (IC 95 per cent: 50,09-55,65) (rango 0-100). Dicha puntuación fue significativamente inferior en mujeres, mayores de 74 años, viudos o solteros, analfabetos o con estudios primarios incompletos, ancianos con bajo rendimiento intelectual, con alguna enfermedad visual además de la catarata, con mala o muy mala visión autopercibida y con cifras de agudeza visual inferiores a 0,5. Respecto a la capacidad funcional, los ancianos mostraron una puntuación media en la escala ADVS significativamente inferior cuando eran dependientes de otras personas en actividades como bañarse o vestirse (p< 0,001). Mediante regresión múltiple, las variables que mostraron una asociación estadísticamente significativa con una puntuación superior en la escala de función visual fueron la agudeza visual (tanto en el ojo con mejor visión como en el ojo con catarata), una buena visión autopercibida, la independencia física, menor edad, procedencia urbana y sexo masculino. CONCLUSIONES: La ADVS presenta en nuestro medio unos adecuados índices de fiabilidad, por lo que puede considerarse como un método o instrumento apropiado y útil para valorar la pérdida de función visual percibida por los pacientes con cataratas. Prácticamente todos los ancianos de nuestra muestra presentaron en el ojo con catarata una cifra de agudeza visual inferior a 0,60 (20/30) y más de tres cuartas partes inferior a 0,20 (20/100) indicando un estado muy avanzado de la enfermedad en nuestro medio cuando se accede a la intervención. Los resultados muestran que los pacientes con cataratas presentan dificultades importantes para realizar las actividades dependientes de la visión y que, por lo tanto, son susceptibles de obtener beneficio con la intervención (AU)