The efficacy of a supervised exercise training programme on readmission rates in patients with myocardial ischemia: results from a randomised controlled trial.

BACKGROUND: The results of research into the outcomes of physical rehabilitation and its relationship with post-myocardial ischaemia survival and readmissions are inconclusive. Our primary aim was to evaluate the efficacy of a supervised exercise training programme in terms of decreasing hospital cardiac readmission in patients with myocardial ischaemia. METHODS: We conducted a randomised controlled trial including patients with myocardial ischaemia. Eligible patients were assigned to a control group receiving standard care or to an intervention group that took part in a supervised exercise training programme. The follow-up period was 12 months after hospital discharge. RESULTS: Of 478 patients assessed for eligibility, 86 were randomised to the control group ( n = 44) or the intervention group ( n = 42). Cardiac readmission rates were 14% versus 5% ( p = 0.268) in the control and intervention groups, respectively, and all-cause readmission rates were 23% versus 15% ( p = 0.34). There were no deaths in either group. More control patients were treated in the emergency services (50% vs. 24%; p = 0.015). In terms of health-related quality of life, patients in the intervention group presented with significant increases in functional capacity and mobility. More intervention patients returned to work (77.3% vs. 36.0%; p = 0.005). CONCLUSIONS: The supervised physical exercise programme was effective at reducing the number of emergency room visits and at increasing the percentage of patients who returned to work. It also improved patients' exercise capacity and increased their health-related quality of life. Although the results were promising, the programme was not associated with a significant reduction in cardiac and all-cause readmission rates.

Randomized clinical trial to evaluate the effect of a supervised exercise training program on readmissions in patients with myocardial ischemia: a study protocol.

BACKGROUND: In recent decades, several studies have assessed the value of cardiac rehabilitation as secondary prevention and have reported substantial reductions in readmissions. However, conclusive evidence is scarce. The present study aims to evaluate the efficacy of a supervised exercise training program for improving percentages of hospital readmission for cardiac causes in patients with myocardial ischemia in the first year after a cardiac event. The effect on all-cause readmission, all-cause mortality, functional capacity, quality of life and adherence to regular exercise is also discussed. METHODS/DESIGN: This study will be conducted as a randomized controlled trial. Eligible patients will be randomly assigned to a control group receiving standard care or to an intervention group which, in addition to standard care, will take part in a supervised exercise training program consisting of three hours a week (spread over three alternate days) of supervised exercise training for 10 weeks. Both groups will perform an exercise stress test and a blood test during the first and third month after hospital discharge. The follow-up period will be 12 months after hospital discharge. The primary outcome measures will be the percentage of patients readmitted, total number of readmissions and length of hospitalization for cardiac disease during the first year after hospital discharge, and time to first hospital admission for cardiac disease. DISCUSSION: A representative group of hospitalized patients after myocardial ischemia will be studied in order to provide comprehensive data on the potential impact of a supervised exercise training program on hospital readmission rates. TRIAL REGISTRATION: Current Controlled Trials ISRCTN57634424.

Práctica y productos terapéuticos en medicinas complementarias y alternativas, ¿mercado regulado o mercado libre? / No disponible

No disponible

Comorbilidades de los trastornos relacionados con sustancias y los trastornos mentales en mujeres hospitalizadas / Comorbidity associated with substance use disorder and mental disorders in hospitalized women

Introducción: Las comorbilidades de los trastornos mentales (TM) y los trastornos relacionados con sustancias (TRS) afectan a todo el proceso de atención sanitaria. Esta investigación tiene como objetivo analizar las comorbilidades de los TRS y los TM en mujeres hospitalizadas. Material y método: Fuente de información: altas hospitalarias generadas durante 2003 pertenecientes al Conjunto Mínimo Básico de Datos de Alta Hospitalaria del Servicio Catalán de Salud. Se realizó análisis de la x2 y se evaluó la comorbilidad mediante el índice de Charlson. Resultados: El 43,1% de los pacientes diagnosticados con TM eran mujeres y el 56,9%, varones. Respecto a los TRS, el 14,8% eran mujeres y el 85,2%, varones. Comparando comorbilidades, la prueba de la x2 arroja diferencias significativas (p < 0,0001) entre los grupos de mujeres con TM y con TRS; el 2,9% con TM y el 6% con TRS presentan índice de Charlson > 4. Conclusiones: Las comorbilidades con TM y con TRS son frecuentes en el contexto hospitalario. Los pacientes con TRS presentan comorbilidad más grave que los pacientes con TM. Las mujeres con TRS presentan comorbilidad más grave que las mujeres con TM (AU)

Introduction: The comorbidity associated with mental disorders (MD) and substance use disorder (SUD) affects the whole process of healthcare. The aim of this study was to analyze the comorbidity associated with SUD and MD in hospitalized women. Material and method: The information sources were the hospital discharges generated in 2003 in the Minimum Data Set of the Catalan health service. The x2 test was performed and comorbidity was evaluated by means of Charlson's index. Results: Women represented 43.1% of patients diagnosed with MD and 14.8% of those diagnosed with SUD, while men represented 56.9% and 85.2%, respectively. In the comparison of comorbidity, the x2 test (p < 0.0001) revealed significant differences between women with TM and those with SUD; Charlson's index > 4 was found in 2.9% of those with MD versus 6% of those with SUD. Conclusions: Comorbidity associated with MD and SUD is frequent in the hospital setting. Patients with SUD show more serious comorbidity than those with MD, while women with SUD show more serious comorbidity than those with MD (AU)

Efecto placebo frente a efecto terapéutico en la práctica clínica y medicinas complementarias y alternativas / Placebo effect versus therapeutic effect in clinical practice and complementary and alternative medicines (CAM)

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Estrategias regulativas para las medicinas complementarias y alternativas: hacia un modelo de entendimiento de prácticas de salud / Regulatory strategies for complementary and alternative medicines: towards a model

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Las medicinas complementarias y alternativas y su contribución al sistema sociosanitario: el qué, el porqué y el cómo / Complementary and alternative medicine and its contribution to the social and health system. What, why, and how

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El reto de evaluar la atención primaria de salud: calidad asistencial y hospitalizaciones evitables / The challenge of evaluating primary care: healthcare quality and avoidable hospitalizations

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[Health system interventions assessment in Spain: an approach through the analysis of the time trends and the geographical variability of avoidable mortality between 1986 -2001]. / Medida del resultado de las intervenciones sanitarias en España: una aproximación mediante el análisis temporal y espacial de la mortalidad evitable entre 1986-2001.

BACKGROUND: Many studies have proposed Avoidable Mortality (ME) to monitor the performance of health services although its usefulness is limited by the multiplicity of the avoidable mortality lists being used. Time trends from 1986-2001 and the geographical distribution of avoidable mortality by provinces, are presented for Spain. METHODS: An Avoidable Mortality consensus list is being used. It includes avoidable mortality through the intervention of health services (ISAS in Spanish) and through health policy interventions (IPSI in Spanish). Time trends are analyzed adjusting Poisson or Joinpoint regression models and the annual percentages of change (APC) are estimated. Changes in geographical distribution between the first half of the analysed period and the second are tested by means of standard mortality ratios (SMR) and comparative mortality rates (CMR) for each province. RESULTS: Between 1986 and 2001 avoidable mortality decreased (APC: -1.68; CI: -1.99 and -1.38) slightly more than non-avoidable mortality (APC: -1.28; CI: -1.40 and -1.17). Higher reduction was observed for ISAS mortality (APC: -2.77; CI: -2.89 and -2.65) and an irregular trend for IPSI (between 1986-1990 increase APC: 4.86; CI: 3.32 and 6.41, between 1990-95 stabilization APC: -0.03; CI: -2.32 and 2.31 and finally 1995-2001 decrease APC: -3.57; CI: -4.72 and -2.40). CONCLUSIONS: Avoidable mortality decreased more than non avoidable mortality and important geographical variability can be observed among provinces which should be monitored in order to identify the health services weaknesses. The higher ISAS mortality was observed in southern provinces and the higher IPSI mortality in some areas on the coast. The pattern is somewhat similar for both analyzed periods.

Medida del resultado de las intervenciones sanitarias en España: una aproximación mediante el análisis temporal y espacial de la mortalidad evitable entre 1986-2001 / Health system interventions assessment in Spain: an approach through the analysis of the time trends and the geographical variability of avoidable mortality between 1986 -2001

Fundamento: Muchos estudios proponen la mortalidad evitable(ME) como indicador para monitorizar los servicios de salud aunquesu generalización está limitada por el gran número de listas de causasutilizadas. El objetivo es analizar la evolución temporal del período1986-2001 y la distribución geográfica de la mortalidad evitable utilizandouna lista de causas consensuada.Métodos: Se analiza la mortalidad evitable global (ME) y agrupadaen causas ISAS (intervenciones de los servicios sanitarios) ycausas IPSI (políticas intersectoriales). Se analiza la evolución temporalajustando una recta de regresión de Poisson o un modelo deregresión de Joinpoint, según el caso, y se estima el porcentaje decambio anual (PCA). Para la distribución geográfica se calculan losíndices de mortalidad estandarizada (IME) por provincia y la razónde mortalidad comparativa (RMC) de cada provincia entre la primeray la segunda parte del periodo temporal.Resultados: Entre 1986-2001 la mortalidad evitable se redujo(PCA -1,68; IC:-1,99 a -1,38) algo más que la no-evitable (PCA -1,28; IC:-1,40 a -1,17). La mayor disminución se observó en la mortalidadpor causas ISAS (PCA del -2,77; IC: -2,89, -2,65) mientrasque la mortalidad por causas IPSI aumentó entre 1986-1990 (PCAdel 4,86; IC: 3,32 y 6,41), se mantiene constante de 1990-1995 (PCAdel -0,03; IC: -2,32 y 2,31) y disminuyó de 1995-2001 (PCA del -3,57; IC: -4,72 y -2,40). Conclusiones: Durante el período estudiado la mortalidad evitableha tenido una reducción mayor que la no evitable y se observandiferencias importantes entre provincias que sería necesario monitorizarpara tratar de identificar posibles disfunciones en los serviciossanitarios. La mortalidad es superior por causas ISAS en la zona surde España y por causas IPSI en algunas provincias costeras y estepatrón no varió mucho en el período analizado

Background: Many studies have proposed Avoidable Mortality(ME) to monitor the performance of health services although itsusefulness is limited by the multiplicity of the avoidable mortalitylists being used. Time trends from 1986-2001 and the geographicaldistribution of avoidable mortality by provinces, are presented forSpain.Methods: An Avoidable Mortality consensus list is being used.It includes avoidable mortality through the intervention of healthservices (ISAS in Spanish) and through health policy interventions(IPSI in Spanish). Time trends are analyzed adjusting Poisson orJoinpoint regression models and the annual percentages of change(APC) are estimated. Changes in geographical distribution betweenthe first half of the analysed period and the second are tested bymeans of standard mortality ratios (SMR) and comparative mortalityrates (CMR) for each province.Results: Between 1986 and 2001 avoidable mortality decreased(APC: -1.68; CI: -1.99 and -1.38) slightly more than non-avoidablemortality (APC: -1.28; CI: -1.40 and -1.17). Higher reduction wasobserved for ISAS mortality (APC: -2.77; CI: -2.89 and -2.65) andan irregular trend for IPSI (between 1986-1990 increase APC: 4.86;CI: 3.32 and 6.41, between 1990-95 stabilization APC: -0.03; CI: -2.32 and 2.31 and finally 1995-2001 decrease APC: -3.57; CI: -4.72and -2.40). Conclusions: Avoidable mortality decreased more than nonavoidable mortality and important geographical variability can beobserved among provinces which should be monitored in order toidentify the health services weaknesses. The higher ISAS mortalitywas observed in southern provinces and the higher IPSI mortality insome areas on the coast. The pattern is somewhat similar for bothanalyzed periods

Antibiotic prescription in primary health care: clinical and economic perspectives (Catalonia, Spain).

OBJECTIVE: To quantify clinical inappropriateness of antibiotic prescription and its costs in primary health care. METHODS: 2470 cases of infectious disease during 1998 were analysed. RESULTS: Of all cases, 69.9% did not require antibiotic treatment. Global clinical inappropriateness amounted to 43.7%, rising to 56.7% with the introduction of economic criteria. Treatment unnecessary but antibiotic provided (27.9%) represented the most important category. Costs of inappropriateness reached 68.4% of the estimated total cost. CONCLUSION: Appropriate antibiotic use should be focused on reducing antibiotic prescription when not indicated and restraining the use of penicillins maintaining restrictive and adequate health policies, and also achieving co-responsibility from the general population.

The role of primary care in preventing ambulatory care sensitive conditions.

BACKGROUND: To examine the postulated relationship between Ambulatory Care Sensitive Conditions (ACSC) and Primary Health Care (PHC) in the US context for the European context, in order to develop an ACSC list as markers of PHC effectiveness and to specify which PHC activities are primarily responsible for reducing hospitalization rates. METHODS: To apply the criteria proposed by Solberg and Weissman to obtain a list of codes of ACSC and to consider the PHC intervention according to a panel of experts. Five selection criteria: i) existence of prior studies; ii) hospitalization rate at least 1/10,000 or 'risky health problem'; iii) clarity in definition and coding; iv) potentially avoidable hospitalization through PHC; v) hospitalization necessary when health problem occurs. Fulfilment of all criteria was required for developing the final ACSC list. A sample of 248,050 discharges corresponding to 2,248,976 inhabitants of Catalonia in 1996 provided hospitalization rate data. A Delphi survey was performed with a group of 44 experts reviewing 113 ICD diagnostic codes (International Classification of Diseases, 9th Revision, Clinical Modification), previously considered to be ACSC. RESULTS: The five criteria selected 61 ICD as a core list of ACSC codes and 90 ICD for an expanded list. CONCLUSIONS: A core list of ACSC as markers of PHC effectiveness identifies health conditions amenable to specific aspects of PHC and minimizes the limitations attributable to variations in hospital admission policies. An expanded list should be useful to evaluate global PHC performance and to analyse market responsibility for ACSC by PHC and Specialist Care.

[Longitudinal study of hospital readmission for congestive heart failure in Cataluña. 1996-1999]. / Estudio longitudinal de los reingresos en pacientes con insuficiencia cardiaca en Cataluña, 1996-1999.

BACKGROUND: This study is aimed at describing the readmission phenomenon for heart failure patients and identifying some of their related clinical factors by means of a follow-up study with administrative data. METHODS: Longitudinal study of readmissions due to heart failure (HF) among a population > or = age 65 in Catalonia throughout the 1996-1999 period. Information source: Minimum Basic Set of Data of Hospital Discharges from the Catalan Health Service. Definition of HF, etiological or precipitating cause, and comorbility by means of a ICD-9 discharge release codes combination. Analysis units "patient with HF" and an index population or cohort". STATISTICS: Survival analysis (Kaplan-Meier and Log-rank test) and regression models (Cox). RESULTS: The follow-up populations, comprised of 16,919 patients, generated 44,283 admissions (61.8%). The length of time free of readmissions (Mean "ME" in months) and the comparison of the survival curves is statistically significant with lower values in the following categories: 'age 65-74' (ME = 21.6 months); 'male' (23.3); 'healthcare region 6' (16.3); 'reference hospital' (22.9) and 'pure COPD related to the HF (17.7),. The highest risk of readmission, adjusted by the other variables under study, has been found for 'pure COPD' [RR = 1.03, (95% CI: 1.02-1.04), p < 0.001], and ischaemic heart disease [RR = 1.03, (95% CI: 1.01-1.05), p = 0.003]. CONCLUSIONS: This study reveals the clinical complexity and patterns of utilization of hospitals on the part of patients with heart failure, identifying that those having COPD or ischaemic heart disease being top-priority groups for care intervention and thus revealing the potential which administrative data has for clinical planning and management.

Actividad hospitalaria, pacientes y atención primaria / Hospital activity, patients and primary care

Objetivo: El conjunto mínimo básico de datos de alta hospitalaria (CMBDAH) es un sistema de información sanitaria hospitalario que registra la actividad clínica de forma sistemática y exhaustiva en el tiempo y el territorio, con una capacidad mayor de la prevista. El objetivo es establecer el marco teórico para manejar la información del CMBDAH basándose en el paciente y describir su potencial como soporte informativo para la coordinación entre la atención especializada y la atención primaria. Material y método: Estudio descriptivo de la manipulación de las variables del CMBDAH para obtener información basada en el paciente. Variables creadas: "paciente", "reingreso", "fallecimiento" y "población índice" (para analizar los reingresos por paciente). Se calcula el volumen de pacientes para la insuficiencia cardíaca. El marco teórico se documenta con datos cuantitativos del análisis de altas hospitalarias del CMBDAH de Cataluña. Resultados: El 20 por ciento de la población concentra el 40 por ciento de las altas, y la mortalidad hospitalaria se incrementa del 6,3 al 8,4 por ciento en referencia a altas o a pacientes. Al incluir todas las posiciones diagnósticas se observa un incremento del 24 por ciento en la estimación de pacientes afectados por una determinada enfermedad. La variable "paciente" permite identificar a "pacientes que ingresan una sola vez", "pacientes que reingresan" y "pacientes que fallecen". Conclusiones: El análisis del CMBDAH basado en el paciente, además del alta, gana especificidad y precisión, lo que da como resultado una cuantificación de la actividad asistencial relevante para el hospital y la APS, y se convierte en un instrumento informativo de soporte útil para la coordinación entre ámbitos asistenciales (AU)

[Advances of the investigation of "Ambulatory Care Sensitive Conditions" in primary care in Spain]. / Avances en España en la investigación con el indicador "Hospitalización por Enfermedades Sensibles a Cuidados de atención primaria".

Hospitalization due to ambulatory care sensitive conditions (ACSC) is an indicator of hospital activity that has demonstrated its usefulness as an indirect measurement of primary care effectiveness. Since this indicator was recently introduced in Spain, a collaborative effort between the different research groups could facilitate and promote its development and progress. The objective of this paper is to propose a working agenda that, starting from the most recent information, enhances the advance in this research field. The agenda includes the following sections: 1) To draw up specific ACSC lists for adult and pediatric population, as well as to look in greater depth into the concepts of, and differences in avoidable hospitalization and ACSC. 2) To complete the indicator validation process by assessing the external validity. 3) To propose, for future studies, the municipality as the unit of analysis, as well as to individualize the analysis of health conditions allowing for the differences between acute and chronic ones. 4) To adjust the indicators of hospital activity by hospital use index, when data from some hospitals are lacking and comparisons are wanted 5) To include a new variable, provider of primary health care services, in the Minimum Basic Data Set of Hospital Discharges. 6) To use this indicator as a measure of both the distribution of functions between levels of care and the coordination among them.