Use of Health Services in the Months Prior to Suicide in a Country With Low Suicide Rates and Public Universal Access to Healthcare.

AIM: The use of health services prior to suicide has been little studied in countries with low suicide rates and, on the other hand, little is known on the use of concrete medical specialties other than primary care or mental health services. OBJECTIVES: To analyze the use of different types of health services, the psychiatric diagnosis, and treatments received in the year prior to suicide in the region of Gipuzkoa (Spain), a country with low rates of suicide and public universal access to healthcare. METHODS: This is a retrospective descriptive study. We included all suicides registered by the official legal body between 2010 and 2017. RESULTS: 388 suicides were analyzed. 78.9% had some contact with the health service in the last year. Primary care was the most used (60% contacted in the last 12 months and 23.5% in last week) followed by non-psychiatric outpatient specialties, mainly neurology, ophthalmology, and rehabilitation. Hospital discharges in the last month were 3 times higher from non-psychiatric units than from psychiatry (5.9% vs 1.8%). Only 32.5% contacted an outpatient psychiatric service the last year and less than 50% had a prescription of psychotropic drugs. The most frequent psychiatric diagnosis was F40-F49 (29.2%). CONCLUSIONS: Results expand the available knowledge and highlight the role of concrete non-psychiatric specialties (including both outpatient and inpatient services) in suicide prevention. Percentages of healthcare use are in line with other countries including some with different healthcare models and higher suicide rates. HIGHLIGHTSHealthcare use is high but similar to countries with higher suicide ratesThe use of several non-psychiatric specialties (outpatient & inpatient) stands outOnly 1 in 3 saw a psychiatrist and 1 in 2 might have received a psych. diagnosis.

Efecto producido por la población institucionalizada en la estimación del riesgo de mortalidad en áreas pequeñas de Euskadi (España) / Effect of the population in collective dwellings on small-area mortality risk estimation in the Basque Country region (Spain)

OBJETIVO: Cuantificar el efecto que tiene la inclusión de la población institucionalizada en la estimación del riesgo de mortalidad en las secciones censales de Euskadi (España) para las principales causas de mortalidad en el periodo 1996-2003. MÉTODO: Estudio ecológico transversal por áreas pequeñas. Se analizaron las principales causas de mortalidad y por sexo. RESULTADOS: Al analizar el efecto general que tiene en todas las secciones con población institucionalizada se ha visto que no hay apenas ningún efecto reseñable en hombres ni en mujeres. En cambio, cuando se han seleccionado las áreas geográficas donde la población institucionalizada supone un porcentaje importante, más del 10% de la población de esa área, sí se ha observado un efecto incrementando la estimación del riesgo de mortalidad. CONCLUSIONES: El efecto que tiene la inclusión de la población institucionalizada se ve claramente en aquellas causas de mortalidad relacionadas con una mayor dependencia o fragilidad, y por lo tanto con estar en una residencia de personas mayores, como son las demencias y la enfermedad de Alzheimer, y la enfermedad pulmonar obstructiva crónica, sobrestimando el riesgo de mortalidad en torno a un 8% y un 4%, respectivamente, en esas áreas

OBJECTIVE: To quantify the effect of the inclusion of the population in collective dwellings on the estimation of mortality risk in the census areas of the Basque Country (Spain) for the main causes of mortality in the period 1996-2003. METHOD: Small-area ecological cross-sectional study. The main causes of mortality by sex were analyzed. RESULTS: When the general effect on all areas with a a population in collective dwellings was analyzed, hardly any noticeable effect was seen on either men or women. On the other hand, an effect was found when selecting the areas where the population in collective dwellings is more than 10% of the area's population. CONCLUSIONS: The effect of the inclusion of the population in collective dwellings clearly seen in causes of mortality, such as dementia and Alzheimer's disease, and in chronic obstructive pulmonary disease, related to greater dependence or frailty, and therefore related to being in a nursing or elderly persons' home, over-estimating the risk of mortality by approximately 8% and 4%, respectively, in these geographical areas

[Effect of the population in collective dwellings on small-area mortality risk estimation in the Basque Country region (Spain)]. / Efecto producido por la población institucionalizada en la estimación del riesgo de mortalidad en áreas pequeñas de Euskadi (España).

OBJECTIVE: To quantify the effect of the inclusion of the population in collective dwellings on the estimation of mortality risk in the census areas of the Basque Country (Spain) for the main causes of mortality in the period 1996-2003. METHOD: Small-area ecological cross-sectional study. The main causes of mortality by sex were analyzed. RESULTS: When the general effect on all areas with a a population in collective dwellings was analyzed, hardly any noticeable effect was seen on either men or women. On the other hand, an effect was found when selecting the areas where the population in collective dwellings is more than 10% of the area's population. CONCLUSIONS: The effect of the inclusion of the population in collective dwellings clearly seen in causes of mortality, such as dementia and Alzheimer's disease, and in chronic obstructive pulmonary disease, related to greater dependence or frailty, and therefore related to being in a nursing or elderly persons' home, over-estimating the risk of mortality by approximately 8% and 4%, respectively, in these geographical areas.

Estimación de indicadores de salud en áreas pequeñas a partir de datos de la Encuesta de Salud de Euskadi / Small area estimation of health indicators based on data from the Basque Country Health Survey

Las encuestas de salud son una herramienta clave para la toma de decisiones en políticas de salud y para la planificación de los servicios de salud. El uso de métodos estadísticos para áreas pequeñas que utilizan información de diferentes ámbitos geográficos puede resultar útil para estimar indicadores de salud a una escala geográfica menor que la originalmente considerada en el diseño de una encuesta

Health surveys are a key tool for decision-making in health policies and health services planning. The use of small-area statistical methods that use information at different geographic levels may be useful for estimating health indicators at a lower geographical level than originally considered in the survey design

[Small area estimation of health indicators based on data from the Basque Country Health Survey]. / Estimación de indicadores de salud en áreas pequeñas a partir de datos de la Encuesta de Salud de Euskadi.

Health surveys are a key tool for decision-making in health policies and health services planning. The use of small-area statistical methods that use information at different geographic levels may be useful for estimating health indicators at a lower geographical level than originally considered in the survey design.

Cardiorespiratory fitness and development of abdominal obesity.

Both, cardiorespiratory fitness and abdominal obesity are independently associated with developing cardiovascular disease and its risk factors. However, the relationship between both attributes is unclear. We examine the relationship between cardiorespiratory fitness and the risk of developing abdominal obesity, and secondarily, other adiposity measures. Retrospective observational study of a cohort of 1284 sedentary patients, who had participated in a clinical trial of physical activity promotion carried out in Spain (2003-2007). At baseline, they were free of cardiovascular disease, hypertension, diabetes, dyslipidemia and/or abdominal obesity, with an indirect VO2max measurement, were 19-80 years old, 62% women, and had completed the two year follow-up. The exposure factor was cardiorespiratory fitness categorized as high, moderate or low, according to tertiles of VO2max values. The main outcome measure was the risk of developing abdominal obesity, as defined by waist circumference >102 (men) and >88 (women) cm. Secondary outcomes were the risk of developing: general obesity, excess body fat, and their combination ("defined" obesity). At two years, 10.5% of the participants had developed abdominal obesity: 6.1% in the high cardiorespiratory fitness tertile, 9.7% in the moderate tertile (adjusted odds ratio, 1.20; 95% confidence interval 0.68-2.10), and 15.7% in the low tertile (adjusted odds ratio, 2.29; 95% confidence interval 1.34-3.91). Moreover, 2.2% of participants in the high cardiorespiratory fitness tertile developed "defined" obesity as did 5.4% in the low tertile (adjusted odds ratio, 2.90; 95% confidence interval 1.15-7.29). Low cardiorespiratory fitness levels are associated with a higher risk of developing abdominal and "defined" obesity.

Predictors of long-term change of a physical activity promotion programme in primary care.

BACKGROUND: Further research is needed to improve the evidence regarding determinants of physical activity (PA) as a crucial step to plan higher effective intervention strategies. The goal of the present study is to identify socio-demographic and clinical characteristics of primary care (PHC) insufficiently active patients that are associated with longitudinal changes in the level of physical activity. METHODS: Longitudinal analysis of baseline socio-demographic and clinical predictors of physical activity change in insufficiently active PHC patients who participated in a PA-promoting multi-centre randomized clinical trial conducted from October 2003 through March 2006. The primary outcome measure was the self-reported physical activity assessed with the 7-day Physical Activity Recall (PAR), at baseline, 6, 12 and 24 months. Baseline covariates included sex, age, social class, anthropometric measures and other cardiovascular risk factors or associated diseases (Diabetes, HTA, tobacco use, etc.), and stage of readiness to change PA. Generalized linear mixed models were used to estimate longitudinal association of studied variables on PA change over the three follow-up measurements. RESULTS: A total of 3691 patients (85% of the 4317 recruited in the trial) with at least one follow-up measurement were included in the longitudinal analysis. At baseline, analysed patients (mean age: 50.6 years; 64.6% women) devoted 34.7 minutes and 2.36 metabolic equivalent hours per week (MET.h/week) to moderate and vigorous physical activity. Older age, male gender, higher social class, lower BMI, diagnosis of diabetes or hypertension, and measurement season were significant predictors of PA longitudinal change. The effect of baseline readiness to change on PA dose was modified by time, showing a positive gradient in favour of those with more readiness to change that increases significantly at 12 and 24 months (p-value interaction < .0001). CONCLUSIONS: Identified baseline characteristics such as readiness to change and risk factors can guide physicians to prioritize time and intervention efforts for maximizing their impact on insufficiently active PHC patients.

Reliability and validity of the 7-day Physical Activity Recall interview in a Spanish population.

The aim of this study was to assess the reliability and convergent validity of the 7-day Physical Activity Recall (7-day PAR) interview in a sample of the Spanish population. Valid 7-day PAR interviews were conducted and RT3 accelerometer measurements taken for 160 subjects from the primary care population aged 24-83, 75 men and 85 women. Two 7-day PAR interviews were conducted, with a one-week interval, with 147 of these participants. Test-retest reliability was assessed using intraclass correlation coefficients. Convergent validity between the 7-day PAR and the accelerometer data were examined using Spearman's correlation coefficients, and the kappa index of agreement was calculated. The 7-day PAR reliability coefficients were 0.68 (95%CI: 0.58-0.76) for total energy expenditure, 0.65 (95%CI: 0.54-0.73) for the activity dose, and 0.61 (95%CI: 0.50-0.70) and 0.75 (95%CI: 0.67-0.81) for time spent on moderate and vigorous-intensity activity, respectively. These coefficients ranged from 0.91 to 0.96 in participants who reported a typical week in both interviews. Convergent validity ranged from 0.25 for time spent on vigorous activity to 0.52 for the activity dose, and the kappa index was 0.43 (95%CI: 0.30-0.56). Reliability and convergent validity coefficients in the Spanish population were generally moderate and similar to those found in other studies.

Supervised exercise for acute coronary patients in primary care: a randomized clinical trial.

BACKGROUND: Functional capacity is a prognostic factor for coronary patients; accordingly, they are recommended to walk. OBJECTIVE: To assess whether an exercise program supervised in primary care increases their functional capacity more than unsupervised walking. METHODS: A randomized clinical trial was carried out at eight primary care centres of the Spanish Health Service and involving 97 incident cases of low-risk acute coronary patients, <80 years old, randomly assigned to either an unsupervised walking program (UW group; n = 51) or a 6-month cycle ergometer exercise program with gradually increasing frequency and workload intensity supervised by primary care nurses (SE group; n = 46). The two groups received the same common components of secondary prevention care. Changes in functional capacity were assessed in terms of peak oxygen consumption (VO2peak) during exercise testing measured at baseline and at 7 months by cardiologists blinded to group assignment. RESULTS: Overall, 76% of participants completed the study, 30 in the SE and 44 in the UW. Both groups increased baseline-adjusted VO2peak: 5.56ml/kg per minute in the SE (95% confidence interval [CI] 3.38-7.74) and 1.64ml/kg per minute in the UW (95% CI -0.15 to 3.45). The multivariate-adjusted difference between groups was 4.30ml/kg per minute (95% CI 1.82-6.79; P = 0.001) when analyzing completers and 2.83ml/kg per minute (95% CI 0.61-5.05; P = 0.01) in the intention-to-treat analysis, including all participants with baseline values carried forward for those lost to follow-up. CONCLUSIONS: A cycle ergometer exercise program supervised by primary care nurses increased the functional capacity of coronary patients more than unsupervised walking with a clinically relevant difference.

Do socioeconomic inequalities in mortality vary between different Spanish cities? a pooled cross-sectional analysis.

BACKGROUND: The relationship between deprivation and mortality in urban settings is well established. This relationship has been found for several causes of death in Spanish cities in independent analyses (the MEDEA project). However, no joint analysis which pools the strength of this relationship across several cities has ever been undertaken. Such an analysis would determine, if appropriate, a joint relationship by linking the associations found. METHODS: A pooled cross-sectional analysis of the data from the MEDEA project has been carried out for each of the causes of death studied. Specifically, a meta-analysis has been carried out to pool the relative risks in eleven Spanish cities. Different deprivation-mortality relationships across the cities are considered in the analysis (fixed and random effects models). The size of the cities is also considered as a possible factor explaining differences between cities. RESULTS: Twenty studies have been carried out for different combinations of sex and causes of death. For nine of them (men: prostate cancer, diabetes, mental illnesses, Alzheimer's disease, cerebrovascular disease; women: diabetes, mental illnesses, respiratory diseases, cirrhosis) no differences were found between cities in the effect of deprivation on mortality; in four cases (men: respiratory diseases, all causes of mortality; women: breast cancer, Alzheimer's disease) differences not associated with the size of the city have been determined; in two cases (men: cirrhosis; women: lung cancer) differences strictly linked to the size of the city have been determined, and in five cases (men: lung cancer, ischaemic heart disease; women: ischaemic heart disease, cerebrovascular diseases, all causes of mortality) both kinds of differences have been found. Except for lung cancer in women, every significant relationship between deprivation and mortality goes in the same direction: deprivation increases mortality. Variability in the relative risks across cities was found for general mortality for both sexes. CONCLUSIONS: This study provides a general overview of the relationship between deprivation and mortality for a sample of large Spanish cities combined. This joint study allows the exploration of and, if appropriate, the quantification of the variability in that relationship for the set of cities considered.

Antenatal education and breastfeeding in a cohort of primiparas.

AIMS: To assess the association between attendance at antenatal education sessions and breastfeeding during the first year of life. BACKGROUND: Although there is evidence that antenatal education encourages breastfeeding, the size and duration of its effect remain unclear. DESIGN: A prospective cohort study. METHODS: The study was conducted in Bizkaia (North of Spain) between May 2005-June 2007 with a consecutive sample of 614 primiparas. Women were classified into three groups according to whether they had received antenatal education and, if so, how many classes (0, 1-4, or 5 or more). Telephone interviews at 1·5, 3, 6 and 12 months were used to estimate the risk of cessation of any breastfeeding and to compare the groups with Cox proportional hazards regression models adjusted for potential confounders. FINDINGS: Initially, 90% of women breastfed their infants, with no differences between the groups. During the first month, the risk of cessation of any breastfeeding was three times as high among non-attendees and twice as high among women who attended 1-4 classes compared with those who attended 5 or more classes. The risk was, however, similar in the three groups from the end of first month onwards. CONCLUSION: The results suggest that though antenatal education may be associated with higher rates of breastfeeding in our setting this is only the case for the first month after the birth. Further research is necessary to optimize this beneficial effect to achieve long-term continuation of breastfeeding.

Two-year longitudinal analysis of a cluster randomized trial of physical activity promotion by general practitioners.

BACKGROUND: We evaluate the effectiveness of a physical activity promotion programme carried out by general practitioners with inactive patients in routine care. METHODS AND FINDINGS: Pragmatic, cluster randomised clinical trial conducted in eleven public primary care centres in Spain. Fifty-six general practitioners (GPs) were randomly assigned to intervention (29) or standard care (27) groups. They assessed the physical activity level of a systematic sample of patients in routine practice and recruited 4317 individuals (2248 intervention and 2069 control) who did not meet minimum physical activity recommendations. Intervention GPs provided advice to all patients and a physical activity prescription to the subgroup attending an additional appointment (30%). A third of these prescriptions were opportunistically repeated. Control GPs provided standard care. Primary outcome measure was the change in self-reported physical activity from baseline to six, 12 and 24 months. Secondary outcomes included cardiorespiratory fitness and health-related quality of life. A total of 3691 patients (85%) were included in the longitudinal analysis and overall trends over the whole 24 month follow-up were significantly better in the intervention group (p<0.01). The greatest differences with the control group were observed at six months (adjusted difference 1.7 MET*hr/wk [95% CI, 0.8 to 2.6], 25 min/wk [95% CI, 11.3 to 38.4], and a 5.3% higher percentage of patients meeting minimum recommendations [95% CI: 2.1% to 8.8%] NNT = 19). These differences were not statistically significant at 12 and 24 months. No differences were found in secondary outcomes. A significant difference was maintained until 24 months in the proportion of patients achieving minimum recommendation in the subgroup that received a repeat prescription (adjusted difference 10.2%, 95% CI 1.5% to 19.4%). CONCLUSIONS: General practitioners are effective at increasing the level of physical activity among their inactive patients during the initial six-months of an intervention but this effect wears off at 12 and 24 months. Only in the subgroup of patients receiving repeat prescriptions of physical activity is the effect maintained in long-term. TRIAL REGISTRATION: clinicaltrials.gov NCT00131079.

Cancer mortality inequalities in urban areas: a Bayesian small area analysis in Spanish cities.

BACKGROUND: Intra-urban inequalities in mortality have been infrequently analysed in European contexts. The aim of the present study was to analyse patterns of cancer mortality and their relationship with socioeconomic deprivation in small areas in 11 Spanish cities. METHODS: It is a cross-sectional ecological design using mortality data (years 1996-2003). Units of analysis were the census tracts. A deprivation index was calculated for each census tract. In order to control the variability in estimating the risk of dying we used Bayesian models. We present the RR of the census tract with the highest deprivation vs. the census tract with the lowest deprivation. RESULTS: In the case of men, socioeconomic inequalities are observed in total cancer mortality in all cities, except in Castellon, Cordoba and Vigo, while Barcelona (RR = 1.53 95%CI 1.42-1.67), Madrid (RR = 1.57 95%CI 1.49-1.65) and Seville (RR = 1.53 95%CI 1.36-1.74) present the greatest inequalities. In general Barcelona and Madrid, present inequalities for most types of cancer. Among women for total cancer mortality, inequalities have only been found in Barcelona and Zaragoza. The excess number of cancer deaths due to socioeconomic deprivation was 16,413 for men and 1,142 for women. CONCLUSION: This study has analysed inequalities in cancer mortality in small areas of cities in Spain, not only relating this mortality with socioeconomic deprivation, but also calculating the excess mortality which may be attributed to such deprivation. This knowledge is particularly useful to determine which geographical areas in each city need intersectorial policies in order to promote a healthy environment.

Effect on cardiovascular risk of an intervention by family physicians to promote physical exercise among sedentary individuals.

INTRODUCTION AND OBJECTIVES: To evaluate the effect of a program promoting physical activity (PEPAF) implemented by family physicians on cardiovascular risk reduction. METHODS: The cluster randomized clinical trial involved 56 family physicians randomly allocated to an intervention group (n=29) and a control group (n=27). Of the patients recruited, only those aged 30-74 years (1915 PEPAF and 1783 control) were included in the analysis. The intervention involved giving general advice about the benefits of physical activity to all patients and prescribed advice to a subgroup of patients (30%) who agreed to an additional consultation. Outcome measures included risk factors and cardiovascular risk assessed using the Framingham-D'Agostino scale. RESULTS: A significant decrease from baseline in systolic and diastolic blood pressure and pulse pressure was observed after 12 months in both groups (control group: -2.93 mmHg, -1.81 mmHg and -1.15 mmHg, respectively; PEPAF group: -3.35 mmHg, -1.4 mmHg, and -1.94 mmHg, respectively). The high-density lipoprotein cholesterol level increased (control group: +1.73 mg/dl; PEPAF group: +2.67 mg/dl), while the atherogenic index decreased (by 0.12 and 0.16 in the two groups, respectively), all from baseline (P< .05). Cardiovascular risk decreased by 0.68 (95% confidence interval [CI], 0.13-1.25) in the control group and 0.79 (95%CI, 0.22-1.35) in the PEPAF group. There was no significant difference in the improvement at 12 months between the groups. CONCLUSIONS: Patients' participation in the project was effective in improving control of risk factors and decreasing cardiovascular risk. No significant difference in outcome was observed between the control group and the group participating in the program promoting physical activity.

Efecto en el riesgo cardiovascular de una intervención para la promoción del ejercicio físico en sujetos sedentarios por el médico de familia / Effect on cardiovascular risk of an intervention by family physicians to promote physical exercise among sedentary individuals

Introducción y objetivos. Evaluar el efecto de un programa de promoción de la actividad física (PEPAF) realizado por médicos de familia en la disminución del riesgo cardiovascular. Métodos. Ensayo clínico por conglomerados en el que se asignó aleatoriamente a 56 médicos de familia a un grupo de intervención (n = 29) y un grupo de control (n = 27). Entre los pacientes reclutados, se analizó a los que estaban entre 30 y 74 años (1.915 PEPAF y 1.783 controles). Intervención: consejo sobre los beneficios de la actividad física a todos los pacientes y prescripción a un subgrupo que aceptó una consulta adicional (30%). Medidas: factores de riesgo y riesgo cardiovascular con la escala Framingham-D’Agostino. Resultados. A los 12 meses se observó un descenso significativo de las presiones arteriales sistólica y diastólica y la presión de pulso en los dos grupos (controles, 2,93, 1,81 y 1,15 mmHg; PEPAF, 3,35, 1,4 y 1,94 mmHg) respecto a la evaluación basal. Hubo incremento del colesterol de las lipoproteínas de alta densidad (controles, 1,73 mg/dl; PEPAF, 2,67 mg/dl) y descenso del índice aterogénico (controles, 0,12; PEPAF, 0,16) respecto al basal (p < 0,05). El riesgo cardiovascular disminuyó en el grupo control 0,68 (intervalo de confianza [IC] del 95%, 0,13-1,25) y en el PEPAF, 0,79 (IC del 95%, 0,22-1,35). No se observaron diferencias significativas en la mejoría a los 12 meses entre el grupo PEPAF y el de controles. Conclusiones. La inclusión de pacientes en el proyecto fue eficaz para mejorar el control de los factores de riesgo y reducir el riesgo cardiovascular; no se observaron diferencias entre el grupo de control y el que recibió promoción de la actividad física (AU)

Introduction and objectives. To evaluate the effect of a program promoting physical activity (PEPAF) implemented by family physicians on cardiovascular risk reduction. Methods. The cluster randomized clinical trial involved 56 family physicians randomly allocated to an intervention group (n=29) and a control group (n=27). Of the patients recruited, only those aged 30-74 years (1915 PEPAF and 1783 control) were included in the analysis. The intervention involved giving general advice about the benefits of physical activity to all patients and prescribed advice to a subgroup of patients (30%) who agreed to an additional consultation. Outcome measures included risk factors and cardiovascular risk assessed using the Framingham-D’Agostino scale. Results. A significant decrease from baseline in systolic and diastolic blood pressure and pulse pressure was observed after 12 months in both groups (control group: –2.93 mmHg, –1.81 mmHg and –1.15 mmHg, respectively; PEPAF group: –3.35 mmHg, –1.4 mmHg, and –1.94 mmHg, respectively). The high-density lipoprotein cholesterol level increased (control group: +1.73 mg/dl; PEPAF group: +2.67 mg/dl), while the atherogenic index decreased (by 0.12 and 0.16 in the two groups, respectively), all from baseline (P<.05). Cardiovascular risk decreased by 0.68 (95% confidence interval [CI], 0.13-1.25) in the control group and 0.79 (95%CI, 0.22-1.35) in the PEPAF group. There was no significant difference in the improvement at 12 months between the groups. Conclusions. Patients’ participation in the project was effective in improving control of risk factors and decreasing cardiovascular risk. No significant difference in outcome was observed between the control group and the group participating in the program promoting physical activity (AU)

Rationale and design of a randomised controlled trial evaluating the effectiveness of an exercise program to improve the quality of life of patients with heart failure in primary care: The EFICAR study protocol.

BACKGROUND: Quality of life (QoL) decreases as heart failure worsens, which is one of the greatest worries of these patients. Physical exercise has been shown to be safe for people with heart failure. Previous studies have tested heterogeneous exercise programs using different QoL instruments and reported inconsistent effects on QoL. The aim of this study is to evaluate the effectiveness of a new exercise program for people with heart failure (EFICAR), additional to the recommended optimal treatment in primary care, to improve QoL, functional capacity and control of cardiovascular risk factors. METHODS/DESIGN: Multicenter clinical trial in which 600 patients with heart failure in NYHA class II-IV will be randomized to two parallel groups: EFICAR and control. After being recruited, through the reference cardiology services, in six health centres from the Spanish Primary Care Prevention and Health Promotion Research Network (redIAPP), patients are followed for 1 year after the beginning of the intervention. Both groups receive the optimized treatment according to the European Society of Cardiology guidelines. In addition, the EFICAR group performs a 3 month supervised progressive exercise program with an aerobic (high-intensity intervals) and a strength component; and the programme continues linked with community resources for 9 months. The main outcome measure is the change in health-related QoL measured by the SF-36 and the Minnesota Living with Heart Failure Questionnaires at baseline, 3, 6 and 12 months. Secondary outcomes considered are changes in functional capacity measured by the 6-Minute Walking Test, cardiac structure (B-type natriuretic peptides), muscle strength and body composition. Both groups will be compared on an intention to treat basis, using multi-level longitudinal mixed models. Sex, age, social class, co-morbidity and cardiovascular risk factors will be considered as potential confounding and predictor variables. DISCUSSION: A key challenges of this study is to guarantee the safety of the patients; however, the current scientific evidence supports the notion of there being no increase in the risk of decompensation, cardiac events, hospitalizations and deaths associated with exercise, but rather the opposite. Safety assurance will be based on an optimized standardised pharmacological therapy and health education for all the participants. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT01033591.

Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial.

BACKGROUND: Physical activity promotion is a priority, but contribution of physicians' interventions is unclear. The effectiveness of the PEPAF ("Experimental Program for Physical Activity Promotion"), which was implemented exclusively by physicians in routine primary care from October 2003 to December 2004, was assessed. METHODS: Fifty-six Spanish family physicians were randomized to either the intervention (n = 29) or standard care (n = 27) arm of the trial. The physicians recruited 4317 physically inactive patients (2248 for intervention and 2069 for control protocols) from a systematic sample after assessing their physical activity in routine practice. Intervention physicians provided advice to all patients and a physical activity prescription to the subgroup attending an additional appointment (30%). The main outcome measure was the change in physical activity measured by blinded nurses using the 7-Day Physical Activity Recall. Secondary outcomes included cardiorespiratory fitness and health-related quality of life. RESULTS: At 6 months, intervention patients increased physical activity more than controls (adjusted difference, 18 min/wk [95% confidence interval, 6-31 min/wk]; metabolic equivalent tasks x hours per week, 1.3 [95% CI, 0.4-2.2]). The proportion of the population achieving minimal physical activity recommendations was 3.9% higher in the intervention group (1.2%-6.9%; number needed to treat, 26). No differences were found in secondary outcomes. The effect of intervention was positively modified in subjects older than 50 years (P < or = .01) and in the prescription subgroup (P < .001). CONCLUSIONS: Family physicians were effective for increasing physical activity of primary care patients. Overall clinical effect was small but relevant for population public health. Within the intervention program, clinically relevant effects were seen in patients receiving a physical activity prescription. Trial Registration clinicaltrials.gov Identifier: NCT00131079.

Agreement between the SCORE and D'Agostino Scales for the classification of high cardiovascular risk in sedentary spanish patients.

BACKGROUND: To evaluate agreement between cardiovascular risk in sedentary patients as estimated by the new Framingham-D'Agostino scale and by the SCORE chart, and to describe the patient characteristics associated with the observed disagreement between the scales. DESIGN: A cross-sectional study was undertaken involving a systematic sample of 2,295 sedentary individuals between 40-65 years of age seen for any reason in 56 primary care offices. An estimation was made of the Pearson correlation coefficient and kappa statistic for the classification of high risk subjects (> or =20% according to the Framingham-D'Agostino scale, and > or =5% according to SCORE). Polytomous logistic regression models were fitted to identify the variables associated with the discordance between the two scales. RESULTS: The mean risk in males (35%) was 19.5% +/- 13% with D'Agostino scale, and 3.2% +/- 3.3% with SCORE. Among females, they were 8.1% +/- 6.8% and 1.2% +/- 2.2%, respectively. The correlation between the two scales was 0.874 in males (95% CI: 0.857-0.889) and 0.818 in females (95% CI: 0.800-0.834), while the kappa index was 0.50 in males (95% CI: 0.44%-0.56%) and 0.61 in females (95% CI: 0.52%-0.71%). The most frequent disagreement, characterized by high risk according to D'Agostino scale but not according to SCORE, was much more prevalent among males and proved more probable with increasing age and increased LDL-cholesterol, triglyceride and systolic blood pressure values, as well as among those who used antihypertensive drugs and smokers. CONCLUSIONS: The quantitative correlation between the two scales is very high. Patient categorization as corresponding to high risk generates disagreements, mainly among males, where agreement between the two classifications is only moderate.

[Methods to smooth mortality indicators: application to analysis of inequalities in mortality in Spanish cities [the MEDEA Project]]. / Métodos para la suavización de indicadores de mortalidad: aplicación al análisis de desigualdades en mortalidad en ciudades del Estado español (Proyecto MEDEA).

Although there is some experience in the study of mortality inequalities in Spanish cities, there are large urban centers that have not yet been investigated using the census tract as the unit of territorial analysis. The coordinated project <> was designed to fill this gap, with the participation of 10 groups of researchers in Andalusia, Aragon, Catalonia, Galicia, Madrid, Valencia, and the Basque Country. The MEDEA project has four distinguishing features: a) the census tract is used as the basic geographical area; b) statistical methods that include the geographical structure of the region under study are employed for risk estimation; c) data are drawn from three complementary data sources (information on air pollution, information on industrial pollution, and the records of mortality registrars), and d) a coordinated, large-scale analysis, favored by the implantation of coordinated research networks, is carried out. The main objective of the present study was to explain the methods for smoothing mortality indicators in the context of the MEDEA project. This study focusses on the methodology and the results of the Besag, York and Mollié model (BYM) in disease mapping. In the MEDEA project, standardized mortality ratios (SMR), corresponding to 17 large groups of causes of death and 28 specific causes, were smoothed by means of the BYM model; however, in the present study this methodology was applied to mortality due to cancer of the trachea, bronchi and lung in men and women in the city of Barcelona from 1996 to 2003. As a result of smoothing, a different geographical pattern for SMR in both genders was observed. In men, a SMR higher than unity was found in highly deprived areas. In contrast, in women, this pattern was observed in more affluent areas.

Métodos para la suavización de indicadores de mortalidad: aplicación al análisis de desigualdades en mortalidad en ciudades del Estado español (Proyecto MEDEA) / Methods to smooth mortality indicators: application to analysis of inequalities in mortality in Spanish cities [the MEDEA Project]

Aunque la experiencia en el estudio de las desigualdadesen la mortalidad en las ciudades españolas es amplia, quedangrandes núcleos urbanos que no han sido investigadosutilizando la sección censal como unidad de análisis territorial.En este contexto se sitúa el proyecto coordinado ®Desigualdadessocioeconómicas y medioambientales en la mortalidaden ciudades de España. Proyecto MEDEA», en el cualparticipan 10 grupos de investigadores de Andalucía, Aragón,Cataluña, Galicia, Madrid, Comunitat Valenciana y PaísVasco. Cabe señalar cuatro particularidades: a) se utiliza comoárea geográfica básica la sección censal; b) se emplean métodosestadísticos que tienen en cuenta la estructura geográficade la región de estudio para la estimación de riesgos; c) seaprovechan las oportunidades que ofrecen 3 fuentes de datoscomplementarias (información sobre contaminación atmosférica,información sobre contaminación industrial y registrosde mortalidad), y d) se emprende un análisis coordinado degran alcance, favorecido por la implantación de la redes temáticasde investigación. El objetivo de este trabajo es explicarlos métodos para la suavización de indicadores de mortalidaden el proyecto MEDEA. El artículo se centra en lametodología y los resultados del modelo de mapa de enfermedadesde Besag, York y Mollié (BYM). Aunque en el proyectose han suavizado, mediante el modelo BYM, las razonesde mortalidad estandarizadas (RME) correspondientesa 17 grandes grupos de causas de defunción y 28 causasespecíficas, aquí se aplica esta metodología a la mortalidadpor cáncer de tráquea, de bronquios y de pulmón en ambossexos en la ciudad de Barcelona durante el período 1996-2003(AU)

Como resultado se aprecia un diferente patrón geográfico enlas RME suavizadas en ambos sexos. En los hombres se observanunas RME mayores que la unidad en los barrios conmayor privación socioeconómica. En las mujeres este patrónse observa en las zonas con un mayor nivel socioeconómico(AU)

Although there is some experience in the study of mortalityinequalities in Spanish cities, there are large urban centersthat have not yet been investigated using the census tract asthe unit of territorial analysis. The coordinated project ®Socioeconomicand environmental inequalities in mortality in Spanishcities. The MEDEA project» was designed to fill this gap,with the participation of 10 groups of researchers in Andalusia,Aragon, Catalonia, Galicia, Madrid, Valencia, and the BasqueCountry. The MEDEA project has four distinguishing features:a) the census tract is used as the basic geographicalarea; b) statistical methods that include the geographical structureof the region under study are employed for risk estimation;c) data are drawn from three complementary data sources(information on air pollution, information on industrialpollution, and the records of mortality registrars), and d) a coordinated,large-scale analysis, favored by the implantation ofcoordinated research networks, is carried out. The main objective of the present study was to explain the methods for smoothingmortality indicators in the context of the MEDEA project.This study focusses on the methodology and the resultsof the Besag, York and Mollié model (BYM) in disease mapping.In the MEDEA project, standardized mortality ratios(SMR), corresponding to 17 large groups of causes of deathand 28 specific causes, were smoothed by means of the BYMmodel; however, in the present study this methodology wasapplied to mortality due to cancer of the trachea, bronchi andlung in men and women in the city of Barcelona from 1996 to2003. As a result of smoothing, a different geographical patternfor SMR in both genders was observed. In men, a SMRhigher than unity was found in highly deprived areas. In contrast,in women, this pattern was observed in more affluentareas(AU)