Variabilidad en la prescripción de la ventilación mecánica a domicilio / Variability in Home Mechanical Ventilation Prescription

Introducción: Hay pocos estudios que hayan analizado la prevalencia y la accesibilidad a la ventilación mecánica a domicilio (VMD). El objetivo del presente estudio es describir la prevalencia de la VMD y estudiar la variabilidad a partir de datos administrativos. Métodos: Se compararon las tasas de VMD en las 37 áreas de salud a partir de los datos de facturación del Servicio Catalán de la Salud, durante el período 2008-2011. Se calcularon las tasas brutas de actividad acumulada (por 100.000 habitantes) utilizando el componente sistemático de variación (CSV) y empírico Bayes (EB). Las razones de actividad estandarizada (REA) se describieron mediante un mapa de sectores de salud. Resultados: La tasa bruta VMD fue de 23 usuarios/100.000 habitantes. Las tasas aumentan con la edad y han crecido un 39%. Los estadísticos que miden la variación no debida al azar muestran una variación elevada en mujeres (CSV = 0,20 y EB = 0,30) y en hombres (CSV = 0,21 y EB = 0,40), y constante a lo largo del tiempo. En un modelo de Poisson multinivel la existencia de un hospital con servicio de neumología se asoció con un mayor número de casos (beta = 0,68; p < 0,0001). Conclusiones: La variabilidad elevada de la VMD puede explicarse, en parte, por la actitud de los profesionales hacia el tratamiento y la accesibilidad a centros que disponen de especialista de neumología. El análisis de los datos administrativos y la confección de mapas de variabilidad permiten identificar variaciones no explicadas y, en ausencia de registros sistemáticos, es una manera factible de realizar el seguimiento de un tratamiento

Introduction: Few studies have analyzed the prevalence and accessibility of home mechanical ventilation (HMV). The aim of this study was to characterize the prevalence of HMV and variability in prescriptions from administrative data. Methods: Prescribing rates of HMV in the 37 healthcare sectors of the Catalan Health Service were compared from billing data from 2008 to 2011. Crude accumulated activity rates (per 100,000 population) were calculated using systematic component of variation (SCV) and empirical Bayes (EB) methods. Standardized activity ratios (SAR) were described using a map of healthcare sectors. Results: A crude rate of 23 HMV prescriptions per 100,000 population was observed. Rates increase with age and have increased by 39%. Statistics measuring variation not due to chance show a high variation in women (CSV= 0.20 and EB = 0.30) and in men (CSV= 0.21 and EB = 0.40), and were constant over time. In a multilevel Poisson model, hospitals with a chest unit were associated with a greater number of cases (beta = 0.68, P < .0001). Conclusions: High variability in prescribing HMV can be explained, in part, by the attitude of professionals towards treatment and accessibility to specialist centers with a chest unit. Analysis of administrative data and variability mapping help identify unexplained variations and, in the absence of systematic records, are a feasible way of tracking treatment

Variability in home mechanical ventilation prescription.

INTRODUCTION: Few studies have analyzed the prevalence and accessibility of home mechanical ventilation (HMV). The aim of this study was to characterize the prevalence of HMV and variability in prescriptions from administrative data. METHODS: Prescribing rates of HMV in the 37 healthcare sectors of the Catalan Health Service were compared from billing data from 2008 to 2011. Crude accumulated activity rates (per 100,000 population) were calculated using systematic component of variation (SCV) and empirical Bayes (EB) methods. Standardized activity ratios (SAR) were described using a map of healthcare sectors. RESULTS: A crude rate of 23 HMV prescriptions per 100,000 population was observed. Rates increase with age and have increased by 39%. Statistics measuring variation not due to chance show a high variation in women (CSV=0.20 and EB=0.30) and in men (CSV=0.21 and EB=0.40), and were constant over time. In a multilevel Poisson model, hospitals with a chest unit were associated with a greater number of cases (beta=0.68, P<.0001). CONCLUSIONS: High variability in prescribing HMV can be explained, in part, by the attitude of professionals towards treatment and accessibility to specialist centers with a chest unit. Analysis of administrative data and variability mapping help identify unexplained variations and, in the absence of systematic records, are a feasible way of tracking treatment.

Analysis of burden in caregivers of people with Alzheimer's disease using self-report and supervision hours.

OBJECTIVES: This study aimed to describe the baseline characteristics of informal carers of community-living Alzheimer's disease (AD) patients by AD severity group and to identify factors associated with two measures of caregiver burden. DESIGN AND SETTING: GERAS is a prospective observational study in France, Germany, and the UK, designed to assess costs and resource use associated with AD, for patients and their caregivers, stratified by disease severity. PARTICIPANTS: 1497 community-dwelling AD patients and their primary caregivers. MEASUREMENTS: Subjective caregiver burden assessed using the Zarit Burden Interview [ZBI] and time spent supervising patients (an objective measure of burden recorded using the Resource Utilization in Dementia instrument) during the month before the baseline visit were recorded. Separate multiple linear regression analyses using ZBI total score and caregiver supervision time as dependent variables were performed to identify patient and caregiver factors independently associated with caregiver burden. RESULTS: Increasing AD severity was associated with both subjective caregiver burden (ZBI total score) and overall caregiver time, which includes supervision time (both p<0.001, ANOVA). Better patient functioning (on instrumental activities of daily living) was independently associated with both a lower ZBI total score and less supervision time, whereas higher levels of caregiver distress due to patient behavior were associated with greater caregiver burden. Other factors independently associated with an increased ZBI total score included younger caregiver age, caregiver self-reported depression, caring for a male patient, and longer time since AD diagnosis. Caregivers living with the patient, being a male caregiver, patient living in a rural location, higher patient behavioral problem subdomain scores for apathy and psychosis, more patient emergency room visits, not receiving food delivery and receiving financial support for caregiving were all associated with greater caregiver supervision time. CONCLUSION: Our results show that subjective caregiver burden and caregiver time are influenced by different factors, reinforcing the need to consider both aspects of caregiving when trying to minimize the burden of AD. However, interventions that minimize caregiver distress and improve patient functioning may impact on both subjective and objective burden.

Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study.

BACKGROUND: The Cancer Fast-track Programme's aim was to reduce the time that elapsed between well-founded suspicion of breast, colorectal and lung cancer and the start of initial treatment in Catalonia (Spain). We sought to analyse its implementation and overall effectiveness. METHODS: A quantitative analysis of the programme was performed using data generated by the hospitals on the basis of seven fast-track monitoring indicators for the period 2006-2009. In addition, we conducted a qualitative study, based on 83 semistructured interviews with primary and specialised health professionals and health administrators, to obtain their perception of the programme's implementation. RESULTS: About half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track, though the cancer detection rate declined across the period. Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009). Professionals associated with the implementation of the programme showed that general practitioners faced with suspicion of cancer had changed their conduct with the aim of preventing lags. Furthermore, hospitals were found to have pursued three specific implementation strategies (top-down, consensus-based and participatory), which made for the cohesion and sustainability of the circuits. CONCLUSION: The programme has contributed to speeding up diagnostic assessment and treatment of patients with suspicion of cancer, and to clarifying the patient pathway between primary and specialised care.

[Impact of cancer in Catalonia: consequences for priorities in the prevention, diagnosis and treatment of cancer]. / Impacto del cáncer en Cataluña: consecuencias para las prioridades en prevención, diagnóstico y tratamiento.

BACKGROUND: The results of analysis of incidence, survival and mortality should be applied to set the priorities in cancer prevention and screening and improvement of cancer care in Catalonia. POPULATION AND METHODS: A review of the impact of cancer in Catalonia and its foreseeable tendencies, as well as the recent proposals made across Europe regarding cancer prevention and care, was carried out. RESULTS: The main priority in prevention continues to be smoking prevention in all age groups but especially among young women and people with a low socioeconomic position, together with overweight and obesity reduction, dietary improvements, and avoidance of excessive sun exposure. Colorectal cancer screening should cover all people aged 50 to 69 years old. Cancer care should be based on a multidisciplinary approach, with clinical practice guidelines, and should take into account the psychosocial and rehabilitation aspects of care. Areas that deserve greater efforts to improve oncology care are outcomes assessment among hospitals and improvements in coordination among centers and health professionals. CONCLUSIONS: The main priority should be to apply current knowledge to clinical practice, both in diagnosis and in treatment, within a multidisciplinary framework to improve outcomes. Other priorities aimed at reducing the impact of cancer in Catalonia are reducing the prevalence of smoking and obesity and extending the coverage of colorectal cancer screening to the target population.

Sobrecarga y calidad de vida de los cuidadores informales de pacientes discapacitados / Burden of care and quality of life in informal caregivers for disabled patients

No disponible

Cuida'l: un ensayo clínico que evaluará la eficacia de una intervención en cuidadores de pacientes demenciados / CUIDA'L: a clinical trial to evaluate the efficacy of an intervention among carers of demented patients

No disponible

Influence of serum amyloid A on the decrease of high density lipoprotein-cholesterol in active sarcoidosis.

OBJECTIVE: We have previously observed low levels of high density lipoprotein (HDL) cholesterol in active sarcoidosis. The aim of this study was to analyze the role of serum amyloid A (SAA) on this lipid disorder. METHODS: Eighty five untreated sarcoid patients, 40 with active disease and 45 with inactive disease, were recruited. Sarcoidosis activity was evaluated by means of clinical, chest X-ray, gallium-67 scan, serum angiotensin converting enzyme (peptidyl-dipeptidase A) values, and pulmonary function tests. Analysis of lipoprotein metabolism included: serum cholesterol, low density lipoprotein (LDL)-cholesterol, HDL-cholesterol, HDL(2)-cholesterol, HDL(3)-cholesterol, apolipoprotein A-I (apo A-I), apolipoprotein B (apo B), and triglyceride concentrations. Serum amyloid A protein and lecithin-cholesterol acyltransferase (LCAT) activity were measured. RESULTS: In active sarcoidosis we found significantly reduced levels of HDL-cholesterol (1.17+/-0.36 vs. 1. 44+/-0.39 mmol/l, P=0.002), HDL(3)-cholesterol (0.78+/-0.23 vs. 1. 02+/-0.21 mmol/l, P<0.0001), and apo A-I (1.36+/-0.29 vs. 1.61+/-0. 27 g/l, P<0.0001) and significantly increased levels of triglyceride (1.51+/-0.64 vs. 1.03+/-0.46 mmol/l, P<0.0001), and apo B (1.14+/-0. 25 vs. 0.99+/-0.27 g/l, P=0.012) versus inactive sarcoidosis. Serum amyloid A concentrations were significantly increased in the patients with active disease (155.45+/-154.01 mg/ml) compared to the inactive sarcoid patients (89.70+/-65.36 mg/ml) (P=0.011). There were no significant differences in cholesterol, LDL-cholesterol, HDL(2)-cholesterol or LCAT values between groups. Multivariate logistic regression analysis showed that HDL-cholesterol (regression coefficient b=-1.96; S.E.=0.87; P=0.02) and SAA (regression coefficient b=0.01; S.E.=0.004; P=0.01) were the two variables independently associated with disease activity. Moreover, a significant negative correlation was observed between SAA levels and both HDL-cholesterol (r=-0.39; P=0.01) and apo A-I (r=-0.35; P=0.03) levels, in the active sarcoid group. Conversely, no correlation was found in the inactive sarcoid group. CONCLUSION: The low HDL-cholesterol and apo A-I concentrations seen in active sarcoid patients are associated with a significant increase of SAA levels. We suggest that the displacement of apo A-I by SAA on HDL accounts for the lower level of HDL-cholesterol seen in active sarcoidosis.

Low levels of high density lipoprotein cholesterol in patients with active sarcoidosis.

OBJECTIVE: To determine lipoprotein abnormalities in patients diagnosed with sarcoidosis and their relation to disease activity. METHODS: We studied 90 patients with biopsy-proven sarcoidosis who had not been treated with corticosteroids (44 with active disease and 46 with inactive disease) and 147 control subjects. Sarcoidosis activity was evaluated by means of clinical, chest X-ray, gallium-67 scan, serum angiotensin converting enzyme (peptidyl-dipeptidase A) values, and pulmonary function tests. Analysis of lipoprotein metabolism included: serum cholesterol, low density lipoprotein (LDL)-cholesterol, high density lipoprotein (HDL)-cholesterol, HDL2-cholesterol, HDL3-cholesterol, apolipoprotein A-I, apolipoprotein B, and triglyceride concentrations. RESULTS: Patients with active sarcoidosis had significantly low HDL-cholesterol concentrations (1.15 +/- 0.27 mmol/l) as compared with inactive sarcoid patients (1.40 +/- 0.34 mmol/l) and with the healthy control subjects (1.49 +/- 0.34 mmol/l) (p = 0.00001). The decrease in the HDL-cholesterol concentrations seen in patients with active disease was due mainly to the cholesterol bound to HDL2 subfraction. Apolipoprotein A-I concentrations were significantly reduced in the patients with active disease (1.18 +/- 0.32 g/l) compared to the healthy controls (1.38 +/- 0.27 g/l) (p = 0.003). There were no significant differences in cholesterol, triglyceride, LDL-cholesterol or apolipoprotein B values among the three groups. Multivariate logistic regression analysis showed that HDL-cholesterol was the only variable independently associated with disease activity (Regression Coefficient b = -0.03; S.E. = 0.008; p = 0.0005). CONCLUSION: The decrease in HDL-cholesterol that is observed in patients with sarcoidosis is limited to those with active disease.

[Risk factors of arteriopathy of the lower extremities: lipid and not lipid factors]. / Factores de riesgo de la arteriopatía de las extremidades inferiores: factores lipídicos y no lipídicos.

BACKGROUND: The role of lipoproteins as markers of peripheral arterial disease (PAD) is not well defined. METHODS: We measured both lipid and non-lipid risk factors in 51 male patients with angiographically proven PAD and in 56 control subjects. The independent association of risk factors with PAD was evaluated by means of a multiple logistic regression analysis. RESULTS: The levels of cholesterol bound to high density lipoprotein (HDLc) and to its subfraction HDL2 were lower and triglycerides were higher in patients than in control subjects (1.0 +/- 0.3 vs 1.2 +/- 0.3, p < 0.003; 0.4 +/- 0.2 vs 0.5 +/- 0.3, p < 0.03; and 1.8 +/- 1.2 vs 1.3 +/- 0.7, p < 0.02, respectively). Total cholesterol and LDLc levels were similar in both groups. In the multiple logistic regression analysis that was done with lipid parameters, a statistically significant association of triglycerides (OR = 1.73; CI95% = 1.06-2.80) and HDLc (OR = 0.15; CI95% = 0.05-0.50) with PAD was observed, while HDL subfractions and apolipoproteins were not significantly associated. In the multiple logistic regression analysis that was done with non-lipid parameters, hypertension (OR = 5.35; CI95% = 1.86-15.4) and smoking (packs-year) (OR = 1.04; CI95% = 1.10-1.06) were the only significantly associated with PAD. When lipid and non-lipid parameters were included in the regression analysis, a statistically significant association between hypertension, smoking and HDLc with PAD was observed. CONCLUSIONS: Among lipid risk factors, a low HDLc and high triglycerides, and among non-lipid risk factors hypertension and smoking, are significantly and independently associated with lower limb arteriopathy.

Lipid metabolism and apolipoprotein E phenotypes in patients with xanthelasma.

PURPOSE: To know the prevalence and types of dyslipidemia associated with xanthelasma. PATIENTS AND METHODS: One hundred fifteen patients with xanthelasma and 105 age-matched control subjects without xanthelasma were evaluated in a cross-sectional study. Univariate and multivariate comparisons of lipid variables (including total cholesterol; triglycerides; very-low-, low-, and high-density lipoprotein cholesterol [VLDL-C, LDL-C, and HDL-C, respectively]; cholesterol of high density lipoprotein [HDL] subfractions 2 and 3 [HDL2-C and HDL3-C]; apolipoprotein (apo) A-I and B; and apo E phenotypes) and nonlipid coronary risk factors were made between patients with and without xanthelasma. RESULTS: Patients with xanthelasma had higher levels of cholesterol, LDL-C, and apo B, and lower levels of HDL2-C than control subjects. The prevalence of the apo E4/E3 phenotype was higher in cases than in controls (P < 0.05). Patients with xanthelasma had a higher prevalence of personal and familiar history of cardiovascular disease and were more overweight than control subjects. A stepwise discriminant analysis disclosed an independent association of xanthelasma with lower HDL-C, HDL2-C, and HDL3-C levels in men, and with higher total cholesterol and lower HDL2-C levels in women. CONCLUSIONS: Xanthelasma appears to be associated with qualitative and quantitative abnormalities of lipid metabolism that may favor lipid deposition in the skin and arterial wall. The findings support the notion that xanthelasma is a marker of dyslipidemia, and underline the need to determine a full lipid profile in these patients to detect those potentially at increased risk of cardiovascular disease.

[Fibrinogen and factor VII in women with dyslipidemia. The preliminary results of the Bellvitge-Costa de Ponent Study. The Bellvitge Study Group]. / Fibrinógeno y factor VII en mujeres con dislipemia. Resultados preliminares del Estudio Bellvitge-Costa de Ponent. Grupo de Estudio Bellvitge.

BACKGROUND: The distribution of serum fibrinogen levels and factor VII in a population of dyslipemic women and their association with other cardiovascular risk factors are herein described. METHODS: Dyslipemic women between 40-70-years of age without cardiovascular disease and with no hypolipemic treatment who attended 21 primary health care consultations were studied. The following data were collected in a questionnaire: smoking habit, high blood pressure, alcohol consumption and menopause. The analytical parameters determined were: total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, fibrinogen and factor VII. The Pearson correlation coefficient was determined to evaluate the association of fibrinogen and factor VII with other cardiovascular risk factors. RESULTS: Serum fibrinogen levels correlated positively with LDL-cholesterol and with the body mass index and negatively with HDL-cholesterol. Factor VII correlated positively with the triglycerides and total cholesterol. No significant differences were observed in the hematic factors among the hypertensive women and those who were not hypertensive. The same was observed in diabetic and in the pre- and postmenopausal women. CONCLUSIONS: In this transversal study a relationship was found between serum fibrinogen level and factor VII activity and other known cardiovascular risk factors.

An enzyme-linked immunosorbent assay method to measure human apolipoprotein E levels using commercially available reagents: effect of apolipoprotein E polymorphism on serum apolipoprotein E concentration.

A sensitive and specific enzyme-linked immunosorbent assay (ELISA) for human apolipoprotein E (apo E) quantification using commercially available reagents is described. The assay is a noncompetitive, sandwich ELISA in which the wells were coated with a monoclonal EO1 antibody anti-human apo E and detected with a polyclonal antibody-peroxidase conjugate anti-apo E. The mean apo E concentration in 168 middle-aged subjects randomly selected from general population was 51.7 +/- 12.4 mg/liter. Apo E levels were highly correlated with apo E phenotypes. Apo E polymorphism, which shows a modulating effect in the catabolism of apo E containing lipoproteins, may explain a large fraction, 18.5%, of the variability of serum apo E levels in middle-aged population. Isoforms apo E2 and apo E4 have an opposite effect on the regulation of serum apo E concentrations. Individuals that express apo E2 isoform present higher apo E levels (65.5 mg/liter for apo E2/E3), whereas the average of individuals with apo E4 is lower (42.8 mg/liter for apo E4/E3) than general population.

[Effectiveness of hypercholesterolemia detection in high risk individuals compared to opportunistic detection]. / Eficacia de la detección de la hipercolesterolemia en los individuos de más alto riesgo frente a la búsqueda oportunista.

BACKGROUND: The aims of this study were to estimate the number of people who should receive some intervention (pharmacologic and/or dietetic) to reduce cholesterol concentrations and to evaluate selective case finding in comparison to opportunistic detection. METHODS: Six hundred twenty-five individuals participating in a study of cardiovascular risk factors were included in the study. Those with total cholesterol concentrations (TC) greater than 6.2 mmol/l and those with CT concentrations greater than 5.2 mmol/l observed upon lipid profile analysis and history of cardiovascular disease and/or risk factors were considered as candidates. Out of these individuals, those with cholesterol concentrations linked to low density lipoproteins greater than 4.14 mmol/l or greater than 3.37 mmol/l and previous history of cardiovascular disease or two risk factors were considered candidates to undergo intervention to reduce cholesterol concentrations. Moreover, the number of individuals with CT concentrations greater than 6.2 mmol/l which would not be detected if CT was only determined in those who already had another cardiovascular risk factor was estimated. RESULTS: 37.5% (CI 95%; 33.8%-41.5%) of the individuals required lipid profile and out of these 88.8% (CI 95%; 3.8%-92.4%) were candidates to receive intervention. Upon evaluating the efficacy of the strategy of selective case finding it was observed that the sensitivities of the risk factors were low, ranging from 22.6% in those with family history of cardiovascular disease to 34.8% in cases with personal history of high blood pressure. CONCLUSIONS: If selective case finding of high risk subjects was the only strategy applied, many individuals with hypercholesterolemia would remain undetected, therefore the strategy of opportunistic detection is preferable whenever possible.

[Early detection of dyslipidemias. Is the isolated determination of total cholesterol efficient?]. / Detección inicial de las dislipemias. Es eficaz la determinación aislada del colesterol total?

BACKGROUND: The aim of this study was to analyze the percentage of individuals with hypoalphalipoproteinemia and isolated hypertriglyceridemia which would not be detected if only total cholesterol were included in the initial detection of dyslipemia. METHODS: Five hundred forty-one individuals participating in a study concerning factors of cardiovascular risk were included in the present study which consisted in a survey on risk factors and a medical examination. The population studied was divided according to the concentration of total cholesterol (TC) in desirable concentrations (5.2 mmol/l), intermediate (5.2-6.2 mmol/l) and elevated (6.2 mmol/l). The concentrations of cholesterol bound to high density lipoproteins (cHDL) less than 0.9 mmol/l and of triglycerides (TG) greater than 2.3 mmol/l were considered as high risk. RESULTS: Hypoalphalipoproteinemia would not be detected in 2.9% of the population studied (IC 95%: 1.5%-4.3%) and isolated triglyceridemia in 2.4% (IC 95%: 1.1%-3.7%) if the cHDL and the TG were only determined in the individuals who had high or elevated CT concentrations and two or more cardiovascular risk factors. CONCLUSIONS: These data support the efficacy of CT as the only test for initial detection of dyslipemia and question the convenience of initial quantification of cHDL and triglycerides in all cases as some authors request.