Prognostic factors and predictive model for in-hospital mortality following hip fractures in the elderly.

PURPOSE: The incidence of hip fractures is increasing within the aging population. Our objective was to identify and quantify the risk factors and develop a predictive model for the in-hospital mortality among hip fracture patients older than 65 years. METHODS: This is a prospective study conducted on 331 hip fracture patients older than 65 years admitted to our hospital from 2011 to 2014. Patients' demographics, prehospitalization residential status, prefracture comorbidity data, anti-aggregant and anticoagulant medication, preoperative hemoglobin value, type of fractures, type of treatments, time to surgery, and complications were recorded. RESULTS: The average age was 83 years, 73% female, and 57% of them sustained a femoral neck fracture. In 62.8% of patients, the number of pre-fracture baseline comorbidities was ≥2. The in-hospital mortality rate was 11.4%. In multivariate analysis, age over 90 years, congestive heart failure, asthma, rheumatologic disease, lung cancer, and not taking antiaggregant medication were independently associated with in-hospital mortality. A formula and risk stratification scoring for predicting the risk for in-hospital mortality was developed. Risk-adjustment model based on these variables had acceptable accuracy for predicting in-hospital mortality (c-statistic 0.77). CONCLUSION: Advanced age, and five prefracture comorbidities have a strong association with in-hospital mortality in a hip fracture patient older than 65 years old. Our predictive model was specifically designed for the old hip fracture population. It has an accuracy similar to other risk models. The specificity, positive predictive value, and negative predictive value are high. In addition, it could discriminate a high risk patient from a low risk patient for in-hospital mortality.

Basal insulin initiation in primary vs. specialist care: similar glycaemic control in two different patient populations.

OBJECTIVE: To investigate the effect of healthcare provider (HCP) type (primary vs. specialist) on glycaemic control and other treatment parameters. RESEARCH DESIGN AND METHODS: Study of Once-Daily Levemir (SOLVE(™) ) is an international, 24-week, observational study of insulin initiation in people with type 2 diabetes. RESULTS: A total of 17,374 subjects were included, comprising 4144 (23.9%) primary care subjects. Glycaemic control improved in both HCP groups from baseline to final visit [glycated haemoglobin (HbA1c) -1.2 ± 1.4% (-13.1 ± 15.3 mmol/mol) and -1.3 ± 1.6% (-14.2 ± 17.5 mmol/mol), respectively]. After adjustment for known confounders, there was no statistically significant effect of HCP group on final HbA1c [-0.04%, 95% confidence interval (CI) -0.09 to -0.01 (-0.4 mmol/mol, 95% CI -1.0-0.1 mmol/mol), p = 0.1590]. However, insulin doses at the final visit were higher in primary care patients (+0.06, 95% CI 0.06-0.07 U/kg, p < 0.0001). Logistic regression demonstrated a significant effect of HCP type (primary vs. specialist care) on hypoglycaemia risk [odds ratio (OR) 0.75, 95% CI 0.64-0.87, p = 0.0002]. Primary care physicians took more time to train patients and had more frequent contact with patients than specialists (both p < 0.0001). CONCLUSIONS: Primary care physicians and specialists achieved comparable improvements in glycaemic control following insulin initiation.

Analysing the concept of diagnostic inertia in hypertension: a cross-sectional study.

AIMS: The aim of this study was to quantify diagnostic inertia (DI) when the physician fails to diagnose hypertension and determine its associated factors. METHODS: This cross-sectional, observational study involved all patients without a diagnosis of hypertension who had their blood pressure (BP) measured at least three times during the second half of 2010 (N = 48,605). Patients with altered mean BP figures (≥ 140/90 mmHg) were considered to experience DI. Secondary variables: gender, atrial fibrillation, diabetes mellitus, dyslipidemia, cardiovascular disease, age and the physician having attended a cardiovascular training course (ESCARVAL). Associated factors were assessed by multivariate logistic regression analysis. RESULTS: Diagnostic inertia was present in 6450 patients (13.3%, 95% CI: 13.0-13.6%). Factors significantly associated with DI were: male gender (OR = 1.46, 95% CI: 1.37-1.55, p < 0.001), atrial fibrillation (OR = 0.73, 95% CI: 0.58-0.92, p = 0.007), the ESCARVAL cardiovascular course (OR = 0.88, 95% CI: 0.81-0.96, p = 0.005), diabetes mellitus (OR = 0.93, 95% CI: 0.87-0.99, p = 0.016), cardiovascular disease (OR = 0.77, 95% CI: 0.67-0.88, p < 0.001) and older age (years) (18-44→OR = 1; 45-59→OR = 12.45, 95% CI: 11.11-13.94; 60-74→OR = 18.11, 95% CI: 16.30-20.12; ≥ 75→OR = 20.43, 95% CI: 18.34-22.75; p < 0.001). The multivariate model had an area under the ROC curve of 0.81 (95% CI: 0.80-0.81, p < 0.001). CONCLUSIONS: This study will help clinical researchers differentiate between the two forms of DI (interpretation of a positive screening test and interpretation of positive diagnostic criteria). The results found here in patients with hypertension suggest that this problem is prevalent, and that a set of associated factors can explain the outcome well (AUC>0.80).

Effect of once-daily insulin detemir on oral antidiabetic drug (OAD) use in patients with type 2 diabetes.

WHAT IS KNOWN AND OBJECTIVE: There are acknowledged benefits to continuing metformin when initiating insulin, but there appears to be growing concern over the role of sulphonylureas and thiazolidinediones when used in combination with insulin. This analysis investigates the effects of continuing or discontinuing oral antidiabetic drugs (OADs) following the initiation of once-daily insulin detemir. METHODS: SOLVE is a 24-week, multinational observational study of insulin detemir initiation in patients with type 2 diabetes mellitus treated with one or more OADs. RESULTS: In the total cohort (n = 17 374), there were significant improvements in HbA1c (-1·3%, 95% CI -1·34; -1·27%) and weight (-0·6 kg, 95% CI -0·65; -0·47 kg), with an increase in the incidence rate of minor hypoglycaemia (+0·256 events ppy, P < 0·001), but not severe hypoglycaemia (-0·038 events ppy, P < 0·001). Study participants had information on OAD use either prior to (n = 17 086) or during insulin initiation (n = 16 346). HbA1c reductions were significantly greater in patients continuing treatment with metformin (-1·3% vs. -1·1%, P < 0·01), thiazolidinediones (-1·3% vs. -1·0%, P < 0·01) and DPP-IV inhibitors (-1·3% vs. -0·9%, P < 0·001). Final insulin doses were significantly greater in patients discontinuing treatment with sulphonylureas (0·29 vs. 0·26 IU/kg, P < 0·001), glinides (0·28 vs. 0·26 IU/kg, P < 0·01), thiazolidinediones (0·31 vs. 0·26 IU/kg, P < 0·001) and DPP-IV inhibitors (0·35 vs. 0·29 IU/kg, P < 0·001) compared with patients continuing these respective agents. All patient subgroups had a mean weight loss irrespective of OAD continuation, apart from those continuing thiazolidinediones (+0·2 kg). The largest improvements in weight were seen following the withdrawal of sulphonylureas and thiazolidinediones (-1·1 and -1·1 kg, respectively). WHAT IS NEW AND CONCLUSION: Discontinuation (or switching) of OADs at the time of insulin initiation appears to be governed principally by concerns about hypoglycaemia and weight. HbA1c improvements were smaller in patients discontinuing OADs at the time of insulin initiation and may be associated with insufficient insulin titration.

Barriers associated with poor control in Spanish diabetic patients. A consensus study.

BACKGROUND: Delphi technique allows developing a multidisciplinary consensus to establish solutions. AIM: To identify barriers and solutions to improve control in patients with Type-2 Diabetes Mellitus (DM2). METHODS: An observational study using the 2-round Delphi technique (June-August 2011). A panel of 108 experts in DM2 from medical and nursing fields (primary care providers and specialists) from different regions completed via email a questionnaire with 41 Likert statements and 9 scores for each one. Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the two groups (Kappa index and McNemar chi-square). RESULTS: Response rate: 65%. Degree of agreement: 63.4% (95% CI 48.7-78.1%) in medicine, and 78.1% (95% CI 65.4-90.8) in nursing (p > 0.05). Overall level of agreement: Kappa = 0.43, (χ(2) = 2.5 p > 0.05). Regarding non-compliance with therapy, it improves with: the information to the partner/family/caregiver, patient education degree in diabetes, patient motivation and ability to share and agree on decisions with the patient. Clinical inertia improves with: motivation degree of healthcare professionals and the calculation of cardiovascular risk; and gets worse with: the shortage of time in consultation, absence of data in medical record, border high limits measurements accepted as normal readings, lack of a treatment goals, lack of teamwork (Physician/Nurse), scarcity of resources and lack of alarm systems in the electronic medical record on goals to achieve. CONCLUSION: The participants achieved an agreement in interventions in non-therapeutic compliance and clinical inertia to improve DM2 control.

[Factors associated with dissatisfaction with pharmacological treatment in patients with type 2 diabetes mellitus: A cross-sectional study]. / Factores asociados a la insatisfacción con el tratamiento farmacológico en pacientes con diabetes mellitus tipo 2: estudio transversal.

BACKGROUND AND OBJECTIVES: Diabetes is a chronic disease with a high impact on both health and Quality of Life Related to Health (QLRH). To evaluate the satisfaction of treatment in patients with type 2 diabetes mellitus through the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and its relationship with sociodemographic variables, with antidiabetic medication and clinical-analytical variables. MATERIALS AND METHODS: This cross-sectional study was conducted in General University Hospital of San Juan de Alicante between September 2016 and December 2017. Two hundred thirty-two patients diagnosed with type 2 diabetes mellitus at least 1 year before inclusion, treated with antidiabetic medication were included. The Spanish version of the DTSQ scale was used to measure satisfaction with treatment. Factors associated with low satisfaction were analyzed by applying the Chi-square test for qualitative variables and Student-T for quantitative variables. To estimate magnitudes of association, logistic models were adjusted. RESULTS: Two hundred thirty-two patients were included in this study. 21.5% of the patients presented low satisfaction with the treatment. Patients who presented low satisfaction with treatment were associated with medications that could cause hypoglycemia (OR: 2.872 [1.195-6.903]), HbA1c levels higher than 7% (OR: 2.260 [1.005-5.083]) and drugs administered by the route oral (OR: 2.749 [1.233-6.131]). CONCLUSIONS: Patients with type 2 diabetes mellitus who had a lower score on the DTSQ questionnaire were associated with medications that produced hypoglycaemia, and with higher levels of HbA1c higher than 7%, and those who took oral medication.

The safety and efficacy of adding once-daily insulin detemir to oral hypoglycaemic agents in patients with type 2 diabetes in a clinical practice setting in 10 countries.

AIMS: Evaluate the safety and efficacy of once-daily insulin detemir initiated in routine clinical practice in patients with type 2 diabetes mellitus inadequately controlled with oral hypoglycaemic agents (OHAs). METHODS: This large observational study was conducted in 10 countries. Adverse event data (including hypoglycaemia) and glycaemic control were recorded before and 24 weeks following insulin initiation while patients continued routine clinical management. RESULTS: In this study, 17 374 patients (53% male) were included. Mean pre-insulin values (±s.d.) were: age 62 ± 12 years; body mass index (BMI) 29.3 ± 5.4 kg/m(2); diabetes duration 10 ± 7 years; haemoglobin A1c (HbA1c) 8.9 ± 1.6%. During the study, 27 patients experienced serious adverse drug reaction, severe hypoglycaemic events or both; and there were 31 episodes of severe hypoglycaemia in 21 patients. After 24 weeks, HbA1c was 7.5 ± 1.2% (change of -1.3%; p < 0.001) and mean weight change was -0.6 kg (confidence interval -0.7, -0.5 kg, p < 0.001). Daily insulin dose increased from 13 ± 6 U (0.16 ± 0.09 U/kg) to 22 ± 16 U (0.27 ± 0.17U/kg) by 24 weeks. Multivariate regression analysis identified several independent demographic and treatment predictors of end of study HbA1c. CONCLUSIONS: Addition of once-daily insulin detemir to patients with type 2 diabetes mellitus on OHA therapy resulted in few adverse events, significant improvements in glycaemic control, small reductions in weight and low rates of hypoglycaemia. On the basis of this study, concerns about hypoglycaemia or weight gain should not preclude initiation of basal insulin analogues in patients with poor glycaemic control on OHAs.

[Bibliometric analysis of International Scientific production on primary care]. / Análisis Bibliométrico de la producción Científica Internacional sobre atención primaria.

OBJECTIVE: To present an international view of the scientific production in the field of primary care in the period 1985-2004. DESIGN: Retrospective, observational study. Bibliometric analysis. LOCATION: Medline database. WebSPIRS access through version 4.3. We analysed two periods: 2000-2004 (cross-sectional) and 1985-2004 (developmental). Search based on "MeSH Major" with descriptors: Primary Care or Primary Health Care, Family Practice, Family Physicians, Nurse Practitioners, and Entry Terms associated with these. KEY MEASURES: We analysed the bibliometric indicators of production, circulation, dispersion, and visibility. RESULTS: In 2000-2004, published 20911 articles were published, 0.73% of total production. There was a growth rate (1985-2004) of 221%, which was 2.4 times more than average. Transience rate was 83.17%. The English language is predominant (88.81%) over 34 languages, with Spanish being the next (2.6%). Sixteen countries produce 95.67% of the articles. Spain occupies the 7th place. Universities (52%) are the most productive institutions. There are 1074 different journals with the 10 most productive being: Br J Gen Pract, Adv Nurse Pract, Aust Fam Physician, Fam Pract, Fam Med, BMJ, Aten Primary Health Serv J, Can Fam Physician, J Fam Pract. The proportion of trials (5.43%) in PC is similar to other disciplines and has increased by 453% (1985-2004). CONCLUSIONS: The production of Primary care is about 1% of the total scientific output, with a noticeable and higher than average growth over 20 years. The proportion of clinical trials is similar to other disciplines. Although Anglo-Saxon countries and journals are the highest producers, Spain and the journal Aten Primaria is among those highlighted.

[Ebrictus study. Functional results, survival, and potential years of life lost after the first stroke]. / Estudio Ebrictus. Resultados funcionales, supervivencia y años potenciales de vida perdidos después del primer episodio de ictus.

AIM: To determine the mortality, degree of dependence, survival, and years of life lost (YLL) after first episode of stroke. DESIGN: Cohort study. LOCATION: Community based register. PARTICIPANTS: A total of 553 subjects between 15-90 years with a first episode of definitive or transitory stroke were recruited between 01/04/2006 and 31/03/2008. MEASUREMENTS: The analyses were performed with the use of time-to-event methods, according to the intention-to-treat principle. The level of dependency was assessed according to the Barthel Scale one year after stroke; YLL (1-70 years) from the mean life expectancies at birth; survival analysis by Kaplan-Meier's curves, bivariate analysis comparing the variables between patients who had survived and those who died, and Cox's multivariate. RESULTS: The mean age was 73.3 (±11.6 years. The mean time of follow-up was 29.7 ± 13,4 months, during which 26.6% of the patients died. The mean Barthel score fell by >20%, particularly among women. There was moderate or greater dependence in 41.5% (95%CI 30.6-52.8%) of the subjects. The overall accumulative probability of survival was 0.96 (95% CI 0.94-0.97) in the first month and 0.69 (95% CI 0.65-0.72) in the fourth year. The thrombolytic treatment showed a protective effect on mortality, particularly among the women. The main predictive variables were, history of recurrent cardiovascular event (RR 6.7, 95% CI 2.2-21.7) and aging (RR 1.08, 95% CI 1.01-1.2). The average YLL was 11.5/10000/year SD7.2, and higher among men. CONCLUSION: There are differences in functional outcome, mortality, and potential years of life lost by gender. A new cardiovascular event is an independent prognostic factor of survival.

[Analysis of two health attendance models for the non-hospital emergencies in Gipuzkoa: Retrospective study]. / Análisis de dos modelos asistenciales para la atención de las emergencias extrahospitalarias en Guipúzcoa: Estudio retrospectivo.

BACKGROUND AND OBJECTIVE: Out-of-hospital medical emergency services are defined as a functional organization that performs a set of sequential human and material activities. The objective of this study was to compare the mortality of patients attended by the out-of-hospital medical emergency services in 2 neighboring Spanish regions with different models of healthcare transport assistance for emergency care. MATERIAL AND METHOD: Retrospective observational cohort study, done between June 1, 2007 and December 31, 2008 in 2 regions of Gipuzkoa, Alto Deba (AD) and Bajo Deba (BD). The study variables were age, sex and place of exposure (AD/BD), heart rate, blood pressure, initial reason for the call defined by the European Resuscitation Council, unconsciousness and digestive bleeding. 3452 subjects were analyzed. RESULTS: The risk of in situ mortality in BD was 1.31 times higher than in AD (P=.050), that of hospital mortality in BD was 0.71 times lower than in AD (P=.011) and the risk of mortality at one year between counties and the combined mortality (in situ+hospital) did not contribute significant differences. CONCLUSIONS: Mortality (in situ+in-hospital, and one year aftercare) of patients treated by the out-of-hospital emergency medical services in AD (non-medicalized healthcare transport model) was similar to that of the BD region (mixed healthcare transport model).

HLA-G as a new tumor biomarker: detection of soluble isoforms of HLA-G in the serum and saliva of patients with colorectal cancer.

INTRODUCTION: Recent medical investigations suggest that HLA-G, due to its tolerogenic properties, can be used as a biomarker in the diagnosis, treatment, and prognosis of different neoplasms. This observational prospective pilot study aims at detecting sHLA-G in the serum and saliva of patients diagnosed with colorectal cancer (CRC). For this purpose, we compared the expression of sHLA-G from patients with a control sample from a healthy population. MATERIALS AND METHODS: Using the specific enzyme-linked immunosorbent assay (ELISA) method, the expression of sHLA-G in the serum and saliva samples from patients affected by CRC (n = 20) and in a control sample (n = 10) were analyzed. RESULTS: The data showed that in patients with CRC, salivary sHLA-G values were significantly higher than in the control group (18.84 U/ml versus 6.3 U/ml, p = 0.036). In addition, higher levels of sHLA-G were observed in the saliva of patients with CRC in more advanced stages, compared with patients in early stages (24.2 U/ml vs. 8.1 U/ml, p = 0.019). A significant correlation was observed between the concentration of sHLA-G in the serum and saliva of the analyzed samples (Spearman correlation 0.7, p = 0.004). CONCLUSIONS: This study demonstrates, for the first time, the possibility of detecting sHLA-G in the saliva of patients with CRC, resulting in a less invasive alternative to venipuncture. Likewise, we propose that sHLA-G could be an attractive molecular target based on its significant high levels in advanced stages.

Screening for sight threatening diabetic retinopathy using non-mydriatic retinal camera in a primary care setting: to dilate or not to dilate?

OBJECTIVES: To evaluate three different strategies (without or with mydriasis) for community based screening for sight threatening diabetic retinopathy (STDR). DESIGN: A masked cross-sectional comparative study. SETTING: Primary care centre. PARTICIPANTS: 216 type-1 and type-2 diabetic patients (432 eyes). INTERVENTIONS: Screening for STDR was performed with the Topcon CRW6S non-mydriatic camera (NMC), compared with the grading of the seven-field standard stereoscopic photographs, 30 degrees field photographs with mydriasis as the gold standard method. Three fields were studied: Field 1 centred on the macula; field 2 centred on the disc and the macula and field 3 centred on the disc, on the macula and temporal upper to the macula all without and with mydriasis. MAIN OUTCOME MEASURES: Sensitivity and specificity of screening method and prevalence of STDR. Strategies: field 1 (macular), addition of field 2 (nasal), addition of field 3 (superior temporal) all without and with mydriasis. RESULTS: The prevalence of STDR was 14.3%. When screening without mydriasis is performed, the percentage of referred patients increases from 14% (STDR) to almost 33% because of ungradable photographs. Sensitivity of detection of STDR by NMC using single field with mydriasis was 82% (95% confidence interval 72-92%) and without mydriasis 67% (54-80%). Specificity was 99% (97-100%) for single field with mydriasis and 99% (98-100%) without mydriasis. Sensitivity of detection using two fields with mydriasis was 95% (89-100%); without mydriasis (54-80%), slightly better than single field with mydriasis (72-92%). Specificity was similar. CONCLUSIONS: Screening for STDR with NMC can be performed effectively with one non-stereoscopic retinal photograph per eye with mydriasis using tropicamide 0.5%. Screening without mydriasis increases the number of patients to be referred.

[Tools to improve efficiency in the clinical management of hypertensive patients]. / Herramienta para mejorar la eficiencia en el manejo clínico de pacientes hipertensos.

OBJECTIVE: To create a tool to evaluate the efficiency of the clinical management of hypertensive patients in Primary Care. MATERIAL AND METHODS: A web-based questionnaire was designed for Primary Care centres to self-evaluate the management of hypertension in five specific areas: information systems, diagnostic and analytical tests, organisational aspects, use of resources, and continuous training programmes for patients and healthcare professionals. A committee of experts previously defined these questions and their ideal responses or "control", based on the scientific literature or, if there were no published references, by consensus of the committee. A descriptive analysis was performed on the data, and an adherence score was created that ranged from 0 (no adherence) to 1 (total adherence). RESULTS: A total of 35 Primary Care centres entered their data into the website for the clinical management of hypertensive patients. The highest adherence to the ideal algorithm was observed in the area "Diagnostic and analytical tests" (0.69±0.10), and the lowest in "Continuous training programmes for patients and professionals" (0.42±0.21). CONCLUSIONS: The efficiency of clinical management in hypertensive patients can be analysed using the website tool created for this purpose. Its use allows an internal audit to detect the areas that need improvement, and also serves to make comparative evaluations in the different areas of management over time.

[Perception of Primary Care physicians on the integration with cardiology through continuity of healthcare programs in secondary prevention]. / Percepción de los médicos de atención primaria sobre la integración con cardiología mediante programas de continuidad asistencial en prevención secundaria.

OBJECTIVE: To determine the perception of Primary Care (PC) physicians on the integration with cardiology (CA) through continuity of healthcare programs. MATERIAL AND METHODS: A cross-sectional and multicentre study was conducted, in which a total of 200 PC physicians from all over Spain completed a qualitative survey that evaluated the level of integration with CA in secondary prevention. Physicians were grouped according to the level of PC-CA integration. RESULTS: The integration between CA and PC was good, but it was better in those centres with a higher integration (74.0% vs. 60.0%; p=.02) and in general, physicians considered that integration had improved (92.0% vs. 73.0%; p<.001). Almost all PC physicians received the hospital discharge report. The majority of the hospital discharge reports included recommendations about the CA and PC follow-up, control of risk factors, as well as the duration of secondary prevention treatment, with not significant differences according to the level of integration. In 55.8%, 63.6%, and 51.3% of hospital discharge reports, indications were given on when to perform the follow-up blood analysis, as well as information about returning to working life and sexual activity, respectively. The most common communication method was the paper-based report (75 vs. 84%; p=NS). The communication between healthcare levels was greater in those Primary Care centres with a higher level of integration, as well as periodicity of the communication and the satisfaction of physicians (80.0% vs. 63.0%; p=.005). CONCLUSIONS: The level of integration between PC and CA is, in general, satisfactory, but those centres with a higher level of integration benefit more from a greater communication and satisfaction.

[Concordance between stratification systems and identification of patients with multiple chronic diseases in Primary Care]. / Concordancia entre sistemas de estratificación e identificación de pacientes crónicos complejos en Atención Primaria.

OBJECTIVE: To determine the prevalence of patients with multiple chronic diseases in Primary Care using the multiple morbidity criteria and Clinical Risk Groups, and the agreement in identifying high-risk patients that require case management with both methods. MATERIAL AND METHOD: A cross-sectional study was conducted on 240 patients, selected by random sampling of 16 care quotas from two Primary Health Care centres of a health area. Informed consent was obtained to access their electronic medical records for the study, and a record was made of age, sex, health status of Clinical Risk Groups, severity, multiple morbidity criteria, and Charlson index by physicians during clinical practice. Three patients were excluded due to incomplete data. RESULTS: The prevalence of patients with multiple chronic diseases following the criteria of the Ministry of Health among users was 4.11 (95% CI; 2.13-7.30). The frequency of patients with high risk Clinical Risk Groups (G3) in the chronicity strategy of Valencian Community was 7.59 (95% CI; 4.70-11.70), which includes patients with health status 6 and complexity level 5-6, and health status 7, 8, and 9. Agreement between the two classifications was low, with a kappa index 0.17 (95% CI; 0-0.5) CONCLUSIONS: The prevalence did not differ significantly from that expected, and the agreement between the two stratifications was very weak, not selecting the same patients for highly complex case management.

Risk-factors for surgical delay following hip fracture. / Factores de riesgo para la demora quirúrgica en la fractura de cadera.

OBJECTIVE: To identify pre-operative risk factors for surgical delay of more than 2 days after admission in patients older than 65 years with a hip fracture. MATERIAL AND METHODS: A prospective observational study was conducted on 180 hip fractures in patients older than 65 years of age admitted to our hospital from January 2015 to April 2016. The data recorded included, patient demographics, day of admission, pre-fracture comorbidities, mental state, level of mobility and physical function, type of fracture, antiaggregant and anticoagulant medication, pre-operative haemoglobin value, type of treatment, and surgical delay. RESULTS: The mean age of the patients was 83.7 years. The mean Charlson Index was 2.8. The pre-fracture baseline co-morbidities were equal or greater than 2 in 70% of cases. Mean timing of surgery was 3.1 days. At the time of admission, 122 (67.7%) patients were fit for surgery, of which 80 (44.4%) underwent surgery within 2 days. A Charlson index greater than 2, anticoagulant therapy, and admission on Thursday to Saturday, were independently associated with a surgical delay greater than 2 days. CONCLUSIONS: The rate of hip fracture patients undergoing surgery within 2 days is low. Risk factors associated to surgical delay are non-modifiable. However, their knowledge should allow the development of protocols that can reduce surgical delay in this group of patients.

Risk factors for in-hospital mortality following hip fracture. / Factores de riesgo de mortalidad intrahospitalaria en la fractura proximal de fémur.

OBJECTIVE: To identify and quantify the risk factors for in-hospital mortality in patients older than 65 years with a hip fracture. MATERIALS AND METHODS: Retrospective review of prospectively collected data. We studied a cohort of 331 hip fracture patients older than 65 years of age admitted to our hospital from 2011 to 2014. Patients demographics, type of residence, physical function, mobility, prefracture comorbidities data, cognitive status, anti-aggregant and anticoagulant medication, preoperative haemoglobin value, type of fracture, type of treatment, surgical delay, and complications, were recorded. RESULTS: The average age was 83, 73% female, and 57% had sustained a subcapital fracture. In 62.8% pre-fracture baseline co-morbidities were equal or greater than 2. The in-hospital mortality rate was 11.4%. In univariate analysis, age over 90, male gender, haemoglobin ≤ 10g/dl, no antiplatelet agents, orthopaedic treatment, number of co-morbidities≥2, Charlson index≥2, age-adjusted Charlson index≥6, congestive heart failure, asthma, rheumatologic disease, were associated with in-hospital mortality. CONCLUSIONS: Preoperative patient-related factors have a strong relationship with in-hospital mortality in a hip fracture patients aged older than 65 years. These factors are non-modifiable; we recommend the development of protocols to reduce in-hospital mortality in this group of patients.

[Methodological aspects of integrated care pathways]. / Aspectos metodológicos de los procesos asistenciales integrados (PAI).

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies.

Differences in the management of hypertension, diabetes mellitus and dyslipidemia between obesity classes.

We did not find any paper that assessed clinical inertia in obese patients. Therefore, no paper has compared the clinical inertia rates between morbidly and nonmorbidly obese patients. A cross-sectional observational study was carried out. We analysed 8687 obese patients ⩾40 years of age who attended their health-care center for a checkup as part of a preventive program. The outcome was morbid obesity. Secondary variables were as follows: failure in the management of high blood pressure (HBP), high blood cholesterol (HBC) and high fasting blood glucose (HFBG); gender; personal history of hypertension, dyslipidemia, diabetes, smoking and cardiovascular disease; and age (years). We analysed the association between failures and morbid obesity by calculating the adjusted odds ratio (OR). Of 8687 obese patients, 421 had morbid obesity (4.8%, 95% confidence interval (CI): 4.4-5.3%). The prevalence rates for failures were as follows: HBP, 34.7%; HBC, 35.2%; and HFBG, 12.4%. Associated factors with morbid obesity related with failures were as follows: failure in the management of HBP (OR=1.42, 95% CI: 1.15-1.74, P=0.001); failure in the management of HBC (OR=0.73, 95% CI: 0.58-0.91, P=0.004); and failure in the management of HFBG (OR=2.24, 95% CI: 1.66-3.03, P<0.001). Morbidly obese patients faced worse management for HBP and HFBG, and better management for HBC. It would be interesting to integrate alarm systems to avoid this problem.

Suitability of antiplatelet therapy in hypertensive patients.

Antiplatelet therapy (AT) is indicated in hypertensive patients with increased cardiovascular risk. The literature about the adequate or inadequate prescription of AT is scarce. We conducted a prospective descriptive study to quantify therapeutic inertia and non-guideline-recommended prescription (NGRP) of AT (aspirinor clopidogrel or both), and to assess associated factors, calculating the adjusted odds ratios (ORs) from multivariate models. In 2007-2009, 712 primary health-care hypertensive patients in a Spanish region were enrolled. Inertia was defined as the lack of an AT prescription, despite being indicated by guidelines, whereas NGRP was defined as AT prescription when there was no guideline recommendation. We also recorded cardiovascular variables. Inertia and NGRP were quantified for primary and secondary prevention. Of 108 patients in secondary prevention, 53 had inertia (49.1%, 95% confidence interval (CI): 39.6-58.5%). Associated profile: female (OR=0.460, P=0.091), no dyslipidemia (OR=0.393, P=0.048), no coronary heart disease (OR=0.215, P=0.001) and high diastolic blood pressure (OR=1.076, P=0.016). In primary prevention, NGRP was present in 69 of 595 patients (11.6%, 95% CI: 9.0-14.2%). Associated profile: male (OR=1.610, P=0.089), smoking (OR=2.055, P=0.045), dyslipidemia (OR=3.227, P<0.001) and diabetes (OR=2.795, P<0.001). Although certain factors were clearly associated with these phenomena much still remains to be learnt.