"Compassionate City" in Patients with Advanced Illnesses and at the End of Life: A Pilot Study.

OBJECTIVES: To evaluate, in a Compassionate City pilot experience (Sevilla), the impact results on health in a population of people with advanced illness and at the end of life. METHODS: The project was undertaken in Sevilla, Spain, between January 2019 and June 2020. A longitudinal, descriptive study was conducted using a longitudinal cohort design with two cross-sectional measurements, pre and post intervention. All patients who entered the program on the start date were included. The networks of care around people with advanced illness and at the end of life, palliative care needs, quality of life, loneliness, anxiety, depression, caregivers' burden and family satisfaction were evaluated. The interventions were conducted by community promoters assigned to the "Sevilla Contigo, Compassionate City" program. RESULTS: A total of 83 people were included in the program. The average number of people involved in care at the beginning of the evaluations was 3.6, increasing to 6.1 at the end of the interventions. The average number of needs detected at the beginning was 15.58, and at the end of interventions, it was 16.56 out of 25. The unmet needs were those related to last wishes (40.7%), emotional relief (18.5%), entertainment (16%), help to walk up and down stairs (8.6%) and help to walk (6.2%). A total of 54.2% showed improved loneliness in the final evaluation. Out of 26 people evaluated for pre and post quality of life, 7 (26.9%) improved their quality of life in the general evaluation and 5 (19.2%) displayed improved anxiety/depression. A total of 6 people (28.6%) improved their quality-of-life thermometer scores. A total of 57.7% of caregivers improved their burden with a mean score of 17.8.

Recomendaciones para el uso racional de la prueba 25-hidroxivitamina D Resumen de política

está disponible en el texto completo

The exponential increase in the request for laboratory tests of 25-Hydroxyvitamin D or [25 (OH) D has ignited the alarms and generated a strong call for attention, since it may reflect deficiencies in the standardization of clinical practice and in the use non-systematic scientific evidence for decision-making in real life, which allows to analyze the indications of the test, its frequency, interpretation and even to assess the impact for health systems, especially when contrasted with the minimum or almost. No effects of the strategy of screening or supplying indiscriminately to the general population, without considering a comprehensive clinical assessment of risks and needs of people. From a purely public health impact point of view, the consequence of massive and unspecified requests is affecting most of the health systems and institutions at the global level. The primary studies that determined average population intake values have been widely used in the formulation of recommendations in Clinical Practice Guidelines, but unfortunately misinterpreted as cut points to diagnose disease and allow the exaggerated prescription of nutritional substitution. The coefficient of variation in routine tests to measure blood levels of 25 (OH) D is high (28%), decreasing the overall accuracy of the test and simultaneously, increasing both the falsely high and falsely low values. The most recent scientific evidence analyzes and seriously questions the usefulness and the real effect of the massive and indiscriminate practice of prescribing vitamin D without an exhaustive risk analysis. The available evidence is insufficient to recommend a general substitution of vitamin D to prevent fractures, falls, changes in bone mineral density, incidence of cardiovascular diseases, cerebrovascular disease, neoplasms and also to modify the growth curve of mothers' children. They received vitamin D as a substitute during pregnancy. The recommendations presented in the document are based on the critical analysis of current evidence and the principles of good clinical practice and invite to consider a rational use of 25 (OH) D tests in the context of a clinical practice focused on people and a comprehensive assessment of needs and risks. The principles of good practice suggest that clinicians may be able to justify that the results of the 25 (OH) D test strongly influence and define clinical practice and modify the outcomes that interest people and impact their health and wellness. Currently there is no clarity on how to interpret the results, and the relationship between symptoms and 25 (OH) D levels, which may not be consistent with the high prevalence of vitamin D deficiency reported. For this reason, it is suggested to review the rationale of the request for tests for systematic monitoring of levels of 25 (OH) D or in all cases where substitution is performed. Consider the use of 25 (OH) D tests within the comprehensive evaluation of people with suspicion or confirmation of the following conditions: rickets, osteomalacia, osteoporosis, hyper or hypoparathyroidism, malabsorption syndromes, sarcopenia, metabolic bone disease.

Development and Management of Networks of Care at the End of Life (the REDCUIDA Intervention): Protocol for a Nonrandomized Controlled Trial.

BACKGROUND: End-of-life needs can be only partly met by formalized health and palliative care resources. This creates the opportunity for the social support network of family and community to play a crucial role in this stage of life. Compassionate communities can be the missing piece to a complete care model at the end of life. OBJECTIVE: The main objective of this study is to evaluate the REDCUIDA (Redes de Cuidados or Network of Care) intervention for the development and management of networks of care around people with advanced disease or at the end of life. METHODS: The study is a 2-year nonrandomized controlled trial using 2 parallel groups. For the intervention group, we will combine palliative care treatment with a community promoter intervention, compared with a control group without intervention. Participants will be patients under a community palliative care team's supervision with and without intervention. The community promotor will deliver the intervention in 7 sessions at 2 levels: the patient and family level will identify unmet needs, and the community level will activate resources to develop social networks to satisfy patient and family needs. A sample size of 320 patients per group per 100,000 inhabitants will offer adequate information and will give the study 80% power to detect a 20% increase in unmet needs, decrease families' burden, improve families' satisfaction, and decrease the use of health system resources, the primary end point. Results will be based on patients' baseline and final analysis (after 7 weeks of the intervention). We will carry out descriptive analyses of variables related to patients' needs and of people involved in the social network. We will analyze pre- and postintervention data for each group, including measures of central tendency, confidence intervals for the 95% average, contingency tables, and a linear regression. For continuous variables, we will use Student t test to compare independent samples with normal distribution and Mann-Whitney U test for nonnormal distributions. For discrete variables, we will use Mann-Whitney U test. For dichotomous variables we will use Pearson chi-square test. All tests will be carried out with a significance level alpha=.05. RESULTS: Ethical approval for this study was given by the Clinical Research Committee of Andalusian Health Service, Spain (CI 1020-N-17), in June 2018. The community promoter has been identified, received an expert community-based palliative care course, and will start making contacts in the community and the palliative care teams involved in the research project. CONCLUSIONS: The results of this study will provide evidence of the benefit of the REDCUIDA protocol on the development and assessment of networks of compassionate communities at the end of life. It will provide information about clinical and emotional improvements, satisfaction, proxy burden, and health care resource consumption regarding patients in palliative care. REGISTERED REPORT IDENTIFIER: RR1-10.2196/10515.

All with You: a new method for developing compassionate communities-experiences in Spain and Latin-America.

BACKGROUND: In recent years, compassion has motivated the development of programs oriented to create communities and societies involved in the relief of suffering. The development of compassionate communities and cities begins in each one of us, though it relies on organizations, providers and societies as a whole who need tools and methodologies as a part of a set of actions to help compassionate communities and cities to become a reality rooted widely in social values. In order to describe the "All with You®" methodology and its components: a method designed to develop compassionate communities and cities at the end of life that can be extended to organizations, communities, municipalities, cities or countries. In addition, this article tries to describe several experiences from applying the method in different cities and contexts. METHODS: A search of models for the development of compassionate communities was carried out initially to guide the elements and phases that could help to create a systematized method that will help organizations to create compassionate communities. After analysing the results, alliances were established with some of the main promoters at the time in the development of compassionate communities to validate the designed method. The city of Seville (Spain) was selected to validate the phases of the method and analyse the results based on a series of indicators. Finally, the methodology is being spread throughout cities in various countries, and the experiences are being evaluated with common indicators. RESULTS: The "All with You®" method (Todos Contigo® in Spanish) has been developed as a systematic approach that enables anyone interested in building compassionate communities or cities to include all of the elements outlined in the Compassionate City Charter. All with You® is a method that includes eight phases that allows organizations to be guided in the development of compassionate communities and cities towards a certification process that is evaluated through a series of structures, process and results indicators. The main actions of this method are based on social awareness, training, and the implementation of networks of care using innovative elements like Community Promoters and the RedCuida protocol to provide support, backing and care for those who face advanced chronic disease and end of life situations. Several cities in Spain and Latin America have already joined the movement of compassionate cities using this method, including four in Spain (Seville, Badajoz, Getxo and Pamplona), four in Colombia (Cali, Medellin, Fusagasugá and Bogotá) and one in Argentina (Buenos Aires). CONCLUSIONS: The All with You® method has made the development of compassionate communities and cities possible, aligning organizations and cities to promote compassionate acts, and to start creating networks involved in a global community united by a vocation for caring.

Actividad asistencial y costes en los últimos 3 meses de vida de pacientes fallecidos con cáncer en Euskadi / Care costs and activity in the last three months of life of cancer patients who died in the Basque Country (Spain)

Objetivo: Analizar el consumo de recursos sanitarios y su coste en los últimos meses de vida de la población fallecida por neoplasia maligna en la Comunidad Autónoma del País Vasco. Método: Estudio retrospectivo observacional sobre una población con diagnóstico de neoplasia maligna fallecida en el País Vasco (2010 y 2011). Fuente de datos: Conjunto Mínimo Básico de Datos y Registro de Mortalidad. Variables: sexo, edad, lugar de defunción, localización del tumor, actividad asistencial y costes en los últimos 3 meses de vida. Análisis descriptivo de la actividad asistencial y costes. Regresiones lineales multivariadas para obtener los costes medios ajustados según sexo, edad y lugar de defunción. Resultados: Se identificaron 9333 fallecidos/as por neoplasia maligna durante 2010 y 2011. El 65,4% eran hombres, el 61,5% tenían 70 o más años de edad, la edad media era de 72,9 años y el 71,1% falleció en el hospital. Las personas fallecidas en el hospital tuvieron un coste medio de casi el doble con respecto a las fallecidas en el domicilio (14.794 euros y 7.491 euros, respectivamente; p <0,001), y un 31,3% superior al de la residencia (11.269 euros; p <0,001). Conclusiones: Es necesaria una mayor capacidad de intervención al final de la vida en el nivel comunitario, reforzando la capacidad de atención desde la atención primaria, tanto desde su capacitación como desde el soporte de equipos expertos con el fin de cambiar el perfil actual de atención hacia una mayor atención extrahospitalaria que permita un menor consumo de recursos y una mayor atención en el domicilio (AU)

Objective: To analyse the use of health resources and its budget in the last months of life of the population who died from malignant neoplasm in the Basque Autonomous Country (Spain). Method: Retrospective observational study of a population with a diagnosis of malignancy deceased in the Basque Country (2010 and 2011). Data source: MDS and Mortality Register. Variables: gender, age, place of death, tumour location, clinical activity data and costs in the last three months of life. We performed a descriptive analysis of clinical activity and costs, and lineal multivariate regressions to obtain the adjusted mean costs by gender, age and place of death. Results: 9,333 deaths from malignancy were identified in 2010 and 2011. 65.4% were men, 61.5% aged 70 or over, mean age 72.9 years, 71.1% died in hospital. People who died in the hospital had an average cost of about double that of the people who died at home (euros14,794 and euros7,491, respectively; p <0.001) and 31.3% higher than in the nursing home (euros11,269; p <0.001). Conclusions: Greater interventions at the end of life at the community level are necessary, strengthening the care capacity of primary health care, both from training and support from expert teams in order to change the current care profile to a more outpatient care that allows a lower consumption of resources and greater care at home (AU)

[Care costs and activity in the last three months of life of cancer patients who died in the Basque Country (Spain)]. / Actividad asistencial y costes en los últimos 3 meses de vida de pacientes fallecidos con cáncer en Euskadi.

OBJECTIVE: To analyse the use of health resources and its budget in the last months of life of the population who died from malignant neoplasm in the Basque Autonomous Country (Spain). METHOD: Retrospective observational study of a population with a diagnosis of malignancy deceased in the Basque Country (2010 and 2011). DATA SOURCE: MDS and Mortality Register. VARIABLES: gender, age, place of death, tumour location, clinical activity data and costs in the last three months of life. We performed a descriptive analysis of clinical activity and costs, and lineal multivariate regressions to obtain the adjusted mean costs by gender, age and place of death. RESULTS: 9,333 deaths from malignancy were identified in 2010 and 2011. 65.4% were men, 61.5% aged 70 or over, mean age 72.9 years, 71.1% died in hospital. People who died in the hospital had an average cost of about double that of the people who died at home (€14,794 and €7,491, respectively; p <0.001) and 31.3% higher than in the nursing home (€11,269; p <0.001). CONCLUSIONS: Greater interventions at the end of life at the community level are necessary, strengthening the care capacity of primary health care, both from training and support from expert teams in order to change the current care profile to a more outpatient care that allows a lower consumption of resources and greater care at home.

[Spanish experiences to promote personal autonomy in the elderly]. / Experiencias españolas en la promoción de la autonomía personal en las personas mayores.

OBJECTIVES: To identify studies analyzing the development of initiatives and the requisite characteristics of programs that promote personal autonomy, to identify the initiatives and policies developed in Spain to promote active aging and to determine whether the programs developed are consistent with the evidence in this field. METHOD: We performed a literature review and analyzed the policies developed in each Spanish region. Programs to promote personal autonomy were identified and analyzed through a questionnaire sent to the autonomous regions. RESULTS: Personal autonomy should be promoted through interventions to improve physical, cognitive, social and psycho-affective functions and by eliminating barriers that hamper independent living. Functional capacities are promoted through leisure activities (83%), reading and cognitive rehabilitation. Independent living is encouraged through podiatry services (38.9%) and food services at home (38.9%). Thirteen autonomous communities and the Biscay Regional Council have developed specific policies to promote personal autonomy. Personal autonomy activities are often conducted in senior or day centers. CONCLUSIONS: There are differences in the provision of programs to promote active aging. The development and implementation of these programs depends on the competent authority (Institute for the Elderly and Social Services, town councils, subsidized private entities, etc.). More evidence and a framework that defines common standards and criteria for the development of effective programs are required.

Experiencias españolas en la promoción de la autonomía personal en las personas mayores / Spanish experiences to promote personal autonomy in the elderly

Objetivos: Identificar en la literatura estudios que analicen el desarrollo de iniciativas y expresen las características que deben tener los programas para la promoción de la autonomía personal. Identificar las iniciativas y el desarrollo normativo de la promoción de la autonomía personal en las comunidades autónomas en España y analizar si los programas son consistentes con la evidencia disponible. Método: Revisión de la literatura y análisis de la información normativa e institucional de las comunidades autónomas. Identificación y análisis del desarrollo de programas para la promoción de la autonomía personal mediante cuestionario enviado a las comunidades. Resultados: La promoción de la autonomía personal debe fomentarse con programas que mejoren la capacidad funcional (física, cognitiva, social, psicoafectiva) y con actuaciones que eliminen barreras que dificultan la vida independiente. La capacidad funcional es promovida en las comunidades autónomas con actividades de ocio activo (83%), fomento de la lectura, mantenimiento y rehabilitación cognitiva. La eliminación de barreras personales es promovida en algunas comunidades con servicios de podología (38,9%), y las ambientales con servicios de comida a domicilio (38,9%). Trece comunidades autónomas y la Diputación Foral de Vizcaya han desarrollado normativas para la promoción de la autonomía personal. Las actividades suelen realizarse en centros para mayores o centros de día. Conclusiones: Hay diferencias en la provisión de los programas para la promoción de la autonomía personal. La ejecución y la programación dependen del organismo competente (IMSERSO, ayuntamientos, entidades privadas concertadas, etc.). Se evidencia la necesidad de desarrollar más estudios que generen consenso y establezcan un marco de iniciativas donde se definan estándares y criterios comunes para el desarrollo de programas efectivos (AU)

Objectives: To identify studies analyzing the development of initiatives and the requisite characteristics of programs that promote personal autonomy, to identify the initiatives and policies developed in Spain to promote active aging and to determine whether the programs developed are consistent with the evidence in this field. Method: We performed a literature review and analyzed the policies developed in each Spanish region. Programs to promote personal autonomy were identified and analyzed through a questionnaire sent to the autonomous regions. Results: Personal autonomy should be promoted through interventions to improve physical, cognitive, social and psycho-affective functions and by eliminating barriers that hamper independent living. Functional capacities are promoted through leisure activities (83%), reading and cognitive rehabilitation. Independent living is encouraged through podiatry services (38.9%) and food services at home (38.9%). Thirteen autonomous communities and the BiscayRegional Council have developed specific policies to promote personal autonomy. Personal autonomy activities are often conducted in senior or day centers. Conclusions: There are differences in the provision of programs to promote active aging. The development and implementation of these programs depends on the competent authority (Institute for the Elderly and Social Services, town councils, subsidized private entities, etc.). More evidence and a framework that defines common standards and criteria for the development of effective programs are required (AU)

[Palliative care support teams and the commitment of primary care teams to terminally ill patients in their homes]. / Equipos de soporte de cuidados paliativos y dedicación de los equipos de atención primaria a pacientes en situación terminal en sus domicilios.

OBJECTIVE: To find out if the activity of palliative care support teams (PCST) does not negatively influences the performance of the primary care "care of terminally ill patients" service. PARTICIPANTS: Terminally ill patients cared for at home. DESIGN: Multicentre observational study. MAIN MEASUREMENTS: The observed variable is the increase in the number of registered patients in primary care, and the number of patients covered between the years 2002 and 2003 and the 4 intervention variables are: total visits, joint visits, assessments, and teaching sessions. RESULTS: The number of patients covered in 2002 was 41.19%, increasing to 45.44% in 2003. The activity rate of the PCST for each 100 000 inhabitants was 526 home visits in 2003, 86.15 joint visits, 313.68 professional assessments, and 23.14 teaching sessions. The joint visits and the teaching sessions were strongly associated with an improvement in the coverage of primary care (Pearson correlation of 0.784 and 0.759, respectively). The total visits were moderately associated (0.525) and the assessments were weakly associated (0.245). CONCLUSIONS: Joint visits and teaching sessions of a PCST are associated to an increase in the activity of primary care teams. Assessments and total visits did not have a negative influence.

Primer nivel asistencial en cuidados paliativos: evolución del contenido de la cartera de servicios de atención primaria y criterios de derivación al nivel de soporte / Primary palliative care: development of the contents of the primary care services portfolioand criteria for referral according to complexity

Los cuidados paliativos son un derecho de la persona, reconocido internacionalmente, que ha de prestarse en 3 niveles de atención: primario (básico), secundario (consulta de equipos especializados) y terciario (atención a pacientes muy complejos que precisan hospitalización). Es preciso definir las funciones que cada uno de estos 3 niveles debe desempeñar, la capacitación necesaria y los criterios de derivación de casos desde la atención primaria a los equipos de cuidados paliativos. Con el objetivo de concretar el contenido del servicio de cuidados paliativos en el primer nivel y determinar el dintel de complejidad que asegure la correcta derivación, se realizó un cuádruple abordaje: revisión sistemática de la bibliografía, revisión de un documento borrador de cartera de servicios, elaboración de un documento de propuesta y validación por un grupo nominal de profesionales de atención primaria. Se revisó más de 1.200 artículos y se elaboró y validó el documento propuesta, que contenía 12 prestaciones de la atención primaria y 4 criterios de derivación a los equipos específicos de cuidados paliativos, todo ello según los objetivos marcados inicialmente. Se concluyó que la atención primaria es responsable de los cuidados paliativos en el domicilio y debe garantizarlos cuando la complejidad no es elevada. Para ello, sus profesionales precisan una adecuada formación que permita el manejo de síntomas físicos y emocionales, basándose en una evaluación sistemática con escalas validadas, y una mejora en la coordinación, de forma que se derive a los pacientes en función de su complejidad y de la propia capacidad del profesional de atención primaria para resolverla. Finalmente, se detectó la necesidad de mejorar los sistemas de evaluación de resultados obtenidos por los servicios de salud en la atención a los pacientes en fase terminal (AU)

Palliative care is an internationally recognized right that should be provided in three levels of healthcare: primary (basic), secondary (specialized teams) and tertiary (care of highly complex patients requiring hospitalization). The functions that each of these three levels should perform, the required resources, and the criteria for referring patients from primary care to palliative care teams should be defined. To define the contents of primary palliative care provesion and the threshold of complexity required to ensure appropriate referral, a four-step approach was used: systematic review of the literature, review of a draft of the services portfolio, drafting of a proposal, and validation of the proposal by a nominal group composed of primary care health professionals. In accordance with the objectives initially established, more than 1,200 articles were reviewed and a proposal was drafted and validated. This proposal contained 12 primary care services and four criteria for referring patients to specific palliative care teams. It was concluded that primary care is responsible for palliative care in the home and should guarantee to provide this care in patients with low complexity. To do this, primary care staff require adequate training that would allow them to manage physical and emotional symptoms, based on systematic evaluation with validated scales. Primary care staff also require improved coordination, so that patients can be referred according to their degree of complexity and the ability of the primary care health professional to provide the necessary care. Finally, the need to improve systems for evaluating the results obtained by the health services in the care of terminally-ill patients was detected (AU)

Equipos de soporte de cuidados paliativos y dedicación de los equipos de atención primaria a pacientes en situación terminal en sus domicilios / Palliative care support teams and the commitment of primary care teams to terminally ill patients in their homes

Objetivo. Comprobar si la actividad de los equipos de soporte de cuidados paliativos (ECP) influye negativamente en el cumplimiento del servicio de «atención a pacientes terminales» en atención primaria. Participantes. Pacientes en situación terminal atendidos en el domicilio. Diseño. Estudio observacional, multicéntrico. Mediciones principales. La variable observada es el aumento en el número de pacientes registrados en atención primaria, y la cobertura de cartera entre los años 2002 y 2003 y las 4 variables de intervención son: visitas totales, visitas conjuntas, asesorías y sesiones docentes. Resultados. La cobertura de cartera en el año 2002 fue del 41,19%, aumentando al 45,44% en 2003. La tasa de actividad de los ECP por cada 100.000 habitantes en 2003 fue de 526 visitas a domicilio; 86,15 visitas conjuntas; 313,68 asesorías a profesionales y 23,14 sesiones docentes. Las visitas conjuntas y las sesiones docentes se asociaron fuertemente con una mejora de cartera de atención primaria (correlación de Pearson de 0,784 y 0,759, respectivamente). Las visitas totales tuvieron una asociación moderada (0,525) y las asesorías, una asociación débil (0,245). Conclusiones. Las visitas conjuntas y las sesiones docentes de un ECP se asocian con un aumento de la actividad de los equipos de atención primaria. Asesorías y visitas totales no influyen negativamente

Objective. To find out if the activity of palliative care support teams (PCST) does not negatively influences the performance of the primary care "care of terminally ill patients" service. Participants. Terminally ill patients cared for at home. Design. Multicentre observational study. Main measurements. The observed variable is the increase in the number of registered patients in primary care, and the number of patients covered between the years 2002 and 2003 and the 4 intervention variables are: total visits, joint visits, assessments, and teaching sessions. Results. The number of patients covered in 2002 was 41.19%, increasing to 45.44% in 2003. The activity rate of the PCST for each 100 000 inhabitants was 526 home visits in 2003, 86.15 joint visits, 313.68 professional assessments, and 23.14 teaching sessions. The joint visits and the teaching sessions were strongly associated with an improvement in the coverage of primary care (Pearson correlation of 0.784 and 0.759, respectively). The total visits were moderately associated (0.525) and the assessments were weakly associated (0.245). Conclusions. Joint visits and teaching sessions of a PCST are associated to an increase in the activity of primary care teams. Assessments and total visits did not have a negative influence