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

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

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

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

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

CuidaCare: effectiveness of a nursing intervention on the quality of life's caregiver: cluster-randomized clinical trial.

BACKGROUND: In Spain, family is the main source of care for dependent people. Numerous studies suggest that providing informal (unpaid) care during a prolonged period of time results in a morbidity-generating burden. Caregivers constitute a high-risk group that experiences elevated stress levels, which reduce their quality of life.Different strategies have been proposed to improve management of this phenomenon in order to minimize its impact, but definitive conclusions regarding their effectiveness are lacking. METHODS/DESIGN: A community clinical trial is proposed, with a 1-year follow-up period, that is multicentric, controlled, parallel, and with randomized allocation of clusters in 20 health care centers within the Community of Madrid. The study's objective is to evaluate the effectiveness of a standard care intervention in primary health care (intervention CuidaCare) to improve the quality of life of the caregivers, measured at 0, 6, and 12 months after the intervention.One hundred and forty two subjects (71 from each group) ≥65 years, identified by the nurse as the main caregivers, and who provide consent to participate in the study will be included.The main outcome variable will be perceived quality of life as measured by the Visual Analogue Scale (VAS) of EuroQol-5D (EQ-5D). The secondary outcome variables will be EQ-5D Dimensions, EQ-5D Index, nursing diagnosis, and Zarit's test. Prognostic variables will be recorded for the dependent patient and the caregiver.The principle analysis will be done by comparing the average change in EQ-5D VAS value before and after intervention between the two groups. All statistical tests will be performed as intention-to-treat. Prognostic factors' estimates will be adjusted by mixed-effects regression models. Possible confounding or effect-modifying factors will be taken into account. DISCUSSION: Assistance for the caregiver should be integrated into primary care services. In order to do so, incorporating standard, effective interventions with relevant outcome variables such as quality of life is necessary. Community care nurses are at a privileged position to develop interventions like the proposed one. TRIAL REGISTRATION: This trial has been registered in ClinicalTrials.gov under code number NCT 01478295.

[Efficacy of nursing planning after hospital discharge of patients over 65 to reduce their readmission]. / Eficacia de la planificación del alta de enfermería para disminuir los reingresos en mayores de 65 años.

OBJECTIVES: To evaluate the efficacy of nursing care and monitoring of patients over 65 in primary care, to reduce the rate of readmission and to extend time till readmission. DESIGN: Non-randomised clinical trial with control. SETTING: Base Area 8, Madrid, Spain. Primary and specialist care. PARTICIPANTS: Patients over 65 admitted from home with the pathologies under study. There were 97 patients in the study, 49 in the intervention group and 48 in the control group. INTERVENTIONS: In the intervention group, link nursing conducted visits every 48 hours and provided health education to carer and patient. Patients in the control group received conventional care. Patients in both groups were contacted by phone by primary care nurses 2, 6, 12, and 24 weeks after their hospital discharge. MEASUREMENTS: Readmission for the same reason was recorded. As a secondary variable, time till readmission was recorded. RESULTS: Patients in the control group were admitted more often than those in the experimental group (OR, 3.3; 95% CI, 1.13-9.52; adjusted for the admission diagnosis). The result was consistent, on conducting an analysis of the time elapsed before readmission (HR, 2.29; 95% CI, 1.03-5.10; adjusted in the same way). CONCLUSIONS: A planned intervention into discharges with full, individual evaluation reduces readmissions and increases the time till readmission in patients over 65.

Eficacia de la planificación del alta de enfermería para disminuir los reingresos en mayores de 65 años / Efficacy of nursing planning after hospital discharge of patients over 65 to reduce their readmission

Objetivos. Evaluar la eficacia de la planificación del alta y seguimiento en atención primaria de pacientes mayores de 65 años, para disminuir la tasa de reingresos y la reducción del tiempo hasta el reingreso. Diseño. Ensayo clínico controlado, no aleatorizado. Emplazamiento. Área Sanitaria 8 de Madrid. Participantes. Mayores de 65 años que ingresaran procedentes de sus domicilios con las patologías de estudio. Participaron en el estudio 97 pacientes, 49 en el grupo intervención y 48 en el grupo control. Intervenciones. El personal de enfermería de enlace realizaba visitas cada 48 horas y proporcionaba educación sanitaria al cuidador y al paciente. Los pacientes en el grupo control recibieron la atención convencional. El personal de enfermería de atención primaria contactó telefónicamente con los pacientes de ambos grupos a las 2, 6, 12 y 24 semanas después de su alta hospitalaria. Mediciones. Se registró el reingreso por la misma causa y el tiempo hasta el reingreso. Resultados. Los pacientes del grupo control ingresaron con más frecuencia que los del grupo experimental (OR = 3,3; IC del 95%, 1,13-9,52; ajustado por el diagnóstico al ingreso). El resultado concordaba al realizar un análisis considerando el tiempo hasta el reingreso (HR = 2, 29; IC del 95%, 1,03-5,10; ajustando de la misma manera). Conclusiones. Una intervención planificada del alta con una valoración integral individualizada disminuye los reingresos y el tiempo hasta el reingreso en mayores de 65 años

Objectives. To evaluate the efficacy of nursing care and monitoring of patients over 65 in primary care, to reduce the rate of readmission and to extend time till readmission. Design. Non-randomised clinical trial with control. Setting. Base Area 8, Madrid, Spain. Primary and specialist care. Participants. Patients over 65 admitted from home with the pathologies under study. There were 97 patients in the study, 49 in the intervention group and 48 in the control group. Interventions. In the intervention group, link nursing conducted visits every 48 hours and provided health education to carer and patient. Patients in the control group received conventional care. Patients in both groups were contacted by phone by primary care nurses 2, 6, 12, and 24 weeks after their hospital discharge. Measurements. Readmission for the same reason was recorded. As a secondary variable, time till readmission was recorded. Results. Patients in the control group were admitted more often than those in the experimental group (OR, 3.3; 95% CI, 1.13-9.52; adjusted for the admission diagnosis). The result was consistent, on conducting an analysis of the time elapsed before readmission (HR, 2.29; 95% CI, 1.03-5.10; adjusted in the same way). Conclusions. A planned intervention into discharges with full, individual evaluation reduces readmissions and increases the time till readmission in patients over 65