A comprehensive analysis of patients' perceptions of continuity of care and their associated factors.

OBJECTIVE: To determine the patients' perceived degree of continuity of care between primary and secondary care and to identify contextual and individual factors that influence patients' perceptions of continuity of care. DESIGN: Cross-sectional study by means of a survey of patients attended to in primary and secondary care. SETTING: Three health-care areas of the Catalonian public health-care system. PARTICIPANTS: A random sample of 1500 patients. MAIN OUTCOME MEASURES: Relational, informational and managerial continuity of care measured by means of Likert scales, using the CCAENA questionnaire. RESULTS: Overall, 93.8 and 83.8% of patients perceived an ongoing relationship with primary and secondary care physicians, respectively (relational continuity), 71.2% perceived high levels of information transfer (informational continuity) and 90.7% perceived high levels of consistency of care (managerial continuity). Patients from health-care areas where primary and secondary care were managed by a single organization and the elderly tended to perceive higher levels of all three types of continuity. Foreign-born patients were less likely to perceive relational continuity with primary care physicians; those with higher educational levels were less likely to perceive high levels of informational continuity and patients with worse health status were less likely to report high levels of managerial and relational continuity with secondary care physicians. CONCLUSIONS: Study results suggest high levels of perceived continuity of care, especially for relational and managerial continuity. The adopted comprehensive approach proves to be useful to properly understand the phenomenon because perceptions and associated factors vary according to the type of continuity.

Blood glucose monitoring during hospitalisation: Advanced practice nurse and semi-automated insulin prescription tools.

INTRODUCTION: Hyperglycemia is very common in hospitalized patients and is associated with worse clinical outcomes. AIMS: We implemented a clinical and educational program to improve the overall glycemic control during hospital admission, and, in patients with HbA1c > 8%, to improve their metabolic control after hospital admission. METHODS: Non-critical patients admitted to cardiovascular areas between October-2017 and February-2019. The program was led by an advanced nurse practitioner (ANP) and included a semiautomated insulin prescription tool. Program in 3 phases: 1) observation of routine practice, 2) implementation, and 3) follow-up after discharge. RESULTS: During the implementation phase the availability of HbA1c increased from 42 to 81%, and the ANP directly intervened in 73/685 patients (11%), facilitating treatment progression at discharge in 48% (de novo insulin in 36%). One-year after discharge, HbA1c in patients who were admitted during the observation phase with HbA1c > 8% (n = 101) was higher than similar patients admitted during implementation phase (8,6 ±â€¯1,5 vs. 7,3 ±â€¯1,2%, respectively, p < 0,001). We evaluated 47710 point of care capillary blood glucose (POC-glucose) in two 9 months periods (one before, one during the program) in cardiology and cardiovascular surgery wards. POC-glucose ≥250 mg/dl (pre vs. during: cardiology 10,7 vs. 8,4%, and surgery 7,4 vs. 4,5%, both p < 0,05) and <70 mg/dl (2,3 vs. 0,8% y 1,5 vs 1%, p < 0,05), respectively, improved during the program. CONCLUSIONS: The program allowed improving inpatient glycemic control, detect patients with poor glycemic control, and optimize metabolic control 1-year after discharge.

[Continuity of care between levels perceived by users of the health system in Catalonia, Spain]. / La continuidad asistencial entre niveles percibida por usuarios del sistema de salud en cataluña.

BACKGROUND: Rapid technological advances, organizational changes in health services and the rise of complex chronic diseases mean that users receive care from a wide variety of providers, threatening continuity of care (CC). The aim is to analyse users' perception of CC, as well as their experienced elements of (dis)continuity in the Catalonian health services. METHODS: Cross-sectional study by means ofa questionnaire survey to a sample of 200 healthcare users attended by more than one level of care for the same condition in the previous 3 months. The survey was conducted in Barcelona and Baix Empordà, between March and June 2009. The applied questionnaire collected first, the users' trajectories within health services and second, their perception of CC using a scale. A descriptive data analysis was conducted. RESULTS: Important elements of relational continuity were identified (86.4 and 83.5% of users were attended in the last year, respectively, by the same physician of primary and secondary care). However, potential elements of discontinuity were identified relating to transfer of clinical information (29.1% and 21.3% of users perceived that secondary care professionals were unaware of their comorbidities and the results of medical tests ordered by physicians of primary care, respectively), coherence of care (levels of referral to primary care of 51.2 %) and accessibility between levels of care (37.8 and 17.6% considered long or excessive waiting time for secondary and primary care, respectively). CONCLUSIONS: The results point to aspects of care, as accessibility and information transfer between professionals that could act as barriers for continuity and would require improvements in the coordination strategies of the health providers.

[Factors related to nutritional status in geriatric patients receiving institutional and home care]. / Factores asociados al estado nutricional de pacientes geriátricos institucionalizados y atendidos en su domicilio.

INTRODUCTION: Malnourishment in the geriatric population is a common and serious situation that is often undiagnosed. This study aimed to compare nutritional status, measured by the Mini Nutritional Assessment (MNA), in the geriatric population institutionalized in residential centres and those included in the In-Home Assistance Program (IHAP) overseen by two urban-rural primary care teams, as well as to identify the factors related to the risk of malnourishment. MATERIAL AND METHODS: We performed a cross-sectional estimation study of the prevalence of malnourishment or risk of malnourishment according to different explanatory variables by means of a logistics model. A total of 102 institutionalized patients and 170 patients included in the IHAP aged more than 65 years old were analyzed. RESULTS: No significant differences were found between institutionalized patients and those included in the IHAP by age, sex or pharmaceutical consumption, but differences were found in typology and the Barthel test. Chronic disease predominated in patients assisted at home (62.4%) and dementia in those who were institutionalized (39.2%). According to the MNA, malnourishment or risk of malnourishment was found in 67.6% of patients in the IHAP and in 93.1% of institutionalized patients. When adjustments were made for age and typology, correct nutritional status was 4.35 times more frequent in IHAP patients than in institutionalized patients. CONCLUSIONS: The profile of patients at greater risk of compromised nutritional status or with established malnourishment includes those that are institutionalized, older than 74 years and/or with dementia. These patients should receive corrective or preventative measures for malnourishment.

Survival, effect measures, and impact numbers after dementia diagnosis: a matched cohort study.

BACKGROUND: Knowledge on survival after diagnosis is important for all stakeholders. We aimed to estimate the survival and life expectancy after a dementia diagnosis, and to quantify the impact of dementia subtypes on mortality. METHODS: Retrospective matched cohort study using a linkage between a dementia-specific registry and two primary care electronic medical records databases. Between 1 January 2007 and 31 December 2015 there were 5,156 subjects aged 60 years and over registered by the Registry of Dementia of Girona and matched to 15,468 age-sex and comorbidity individuals without dementia attended by general practitioners in the province of Girona (Catalonia, Spain). RESULTS: The median survival was 5.2 years (95% CI 5.0 to 5.4), the median life expectancy was 74.7 years (95% CI 71.9 to 76.5), and there were differences by gender. The mortality rate was 127.1 per 1,000 person-years (95% CI 121.6 to 132.7), and the hazard ratio for mortality in persons with dementia ranged between 1.63 (95% CI 1.52 to 1.76) for Alzheimer's disease and 2.52 (95% CI 1.90 to 3.35) for Parkinson-plus syndromes. There was one death per year attributable to dementia for every 18.6 persons with dementia, and for every 2.4 persons with dementia who die, one death was attributable to dementia. CONCLUSION: The prognosis after dementia diagnosis is conditioned by demographic and clinical features. Although survival is larger for women, they also experience a higher number of years of life lost. Parkinson-plus syndromes and dementia due to multiple etiologies are among the most malignant subtypes regarding mortality.

[Hospital emergencies arising from nursing homes in a region: evolution, characteristics and appropriateness]. / Urgencias hospitalarias procedentes de residencias geriátricas de una comarca: evolución, características y adecuación.

OBJECTIVE: Hospital emergencies (HE) arising from nursing homes (NH) are on the rise. We analyse the evolution, characteristics and appropriateness of HE of NH residents in a region, as well as resulting hospital admissions. METHOD: Retrospective descriptive study between 2010 and 2013 of institutionalised residents of 11 NH located in Baix Empordà (704 beds) and Palamós Hospital. VARIABLES: Gender, age, morbidity and relative weight according to clinical risk groups (CRG), NH, length of stay, diagnosis of the emergency, appropriateness of HE according to Bermejo's criteria and the HE appropriateness protocol (HEAP), and appropriateness of hospitalisations according to the Appropriateness Evaluation Protocol (AEP). Sample to evaluate appropriateness: 159 HE and 91 hospitalisations. STATISTICAL ANALYSIS: frequency, mean, standard deviation, percentiles, Fisher's exact test and ANOVA, with a confidence interval of 95% and using IBM SPSS Statistics 23. RESULTS: 1,474 people were enrolled, of which 73% were women. Group ≥85 years increased to 60.3% and the mean weight of morbidity was 3.2 to 4.0 (p <0.001). 1,805 HE were generated. The annual rate per 1,000 stays arising from NH increased from 1.64 to 2.05, of which 90.6% were appropriate according to Bermejo's criteria and 93.7% according to the HEAP. Of these, 502 involved hospitalisation. The annual rate per 10 emergencies fell from 2.96 to 2.64 and 98.9% were appropriate according to the AEP. CONCLUSIONS: Hospital emergencies and hospitalisations of NH residents are increasing and are appropriate. Increasing age and disease burden could explain this phenomenon. NH and hospitals should react appropriately, considering the specific needs of this population sector.

[Assessment of the effectiveness of a proactive and integrated healthcare programme for chronic complex patients]. / Evaluación de la efectividad de un programa de atención integrada y proactiva a pacientes crónicos complejos.

OBJECTIVE: To assess the effectiveness of a proactive and integrated care programme to adjust the use of health resources by chronic complex patients (CCP) identified as potential high consumers according to a predictive model based on prior use and morbidity. METHODS: Randomized controlled clinical trial with three parallel groups of CCP: a blinded control group (GC), usual care; a partial intervention group (GIP) reported in the EMR; a total intervention group (GIT), also reported to primary care (PC). Conducted in an integrated health care organization (IHCO), N=128,281 individuals in 2011. Dependent variables: PC visits, emergency attention, hospitalizations, pharmaceutical cost and death. INDEPENDENT VARIABLES: intervention group, age, sex, area of residence, morbidity (by clinical risk group) and recurrence as CCP. STATISTICAL ANALYSIS: ANOVA, student's t test; logistic and multiple linear regressions at the 95% confidence level. RESULTS: 4,236 CCP included for the first intervention year and 4,223 for the second; recurrence as CCP 72%. Mean age 73.2 years, 54.2% women and over 70% with 2 or more chronic diseases. The number of PC visits was significantly higher for GIT than for GIP and GC. The hospital stays were significantly lower in GIP. This effect was observed in the first year and in the second year only in the new CCP. The general indicators of the IHCO were good, before and during the intervention. CONCLUSIONS: A high standard of quality, previous and during the study, and the inevitable contamination between groups, hindered the assessment of the marginal effectiveness of the program.

Cystic dystrophy of the duodenal wall: A rare but need-to-know disease.

Cystic dystrophy of the duodenal wall (CDDW) is a serious but uncommon complication of heterotopic pancreatic tissue characterized by increased duodenal wall thickness associated with intraparietal cystic lesions. It is mainly observed in middle-aged male patients with alcoholic chronic pancreatitis. Clinical symptoms are usually nonspecific and it is important to take them into account in patients with the abovementioned history. Imaging techniques have been useful for diagnosis, especially endoscopic ultrasound (EUS), to visualize cystic lesions in the wall. There is some controversy regarding treatment, because although good results have been obtained with surgical techniques, the recent emergence of EUS-guided drainages has also achieved acceptable results and they are suggested as a good alternative to traditional surgery. Following is our experience in the diagnosis and treatment of four patients with CDDWs; all of whom had a history of alcoholism and smoking, and were studied due to clinical signs of abdominal pain and vomiting. EUS was particularly useful in reaching the final diagnosis.

Analysing the Costs of Integrated Care: A Case on Model Selection for Chronic Care Purposes.

BACKGROUND: The objective of this study is to investigate whether the algorithm proposed by Manning and Mullahy, a consolidated health economics procedure, can also be used to estimate individual costs for different groups of healthcare services in the context of integrated care. METHODS: A cross-sectional study focused on the population of the Baix Empordà (Catalonia-Spain) for the year 2012 (N = 92,498 individuals). A set of individual cost models as a function of sex, age and morbidity burden were adjusted and individual healthcare costs were calculated using a retrospective full-costing system. The individual morbidity burden was inferred using the Clinical Risk Groups (CRG) patient classification system. RESULTS: Depending on the characteristics of the data, and according to the algorithm criteria, the choice of model was a linear model on the log of costs or a generalized linear model with a log link. We checked for goodness of fit, accuracy, linear structure and heteroscedasticity for the models obtained. CONCLUSION: The proposed algorithm identified a set of suitable cost models for the distinct groups of services integrated care entails. The individual morbidity burden was found to be indispensable when allocating appropriate resources to targeted individuals.

[Predicting individual risk of high healthcare cost to identify complex chronic patients]. / Predicción del riesgo individual de alto coste sanitario para la identificación de pacientes crónicos complejos.

OBJECTIVE: To develop a predictive model for the risk of high consumption of healthcare resources, and assess the ability of the model to identify complex chronic patients. METHODS: A cross-sectional study was performed within a healthcare management organization by using individual data from 2 consecutive years (88,795 people). The dependent variable consisted of healthcare costs above the 95th percentile (P95), including all services provided by the organization and pharmaceutical consumption outside of the institution. The predictive variables were age, sex, morbidity-based on clinical risk groups (CRG)-and selected data from previous utilization (use of hospitalization, use of high-cost drugs in ambulatory care, pharmaceutical expenditure). A univariate descriptive analysis was performed. We constructed a logistic regression model with a 95% confidence level and analyzed sensitivity, specificity, positive predictive values (PPV), and the area under the ROC curve (AUC). RESULTS: Individuals incurring costs >P95 accumulated 44% of total healthcare costs and were concentrated in ACRG3 (aggregated CRG level 3) categories related to multiple chronic diseases. All variables were statistically significant except for sex. The model had a sensitivity of 48.4% (CI: 46.9%-49.8%), specificity of 97.2% (CI: 97.0%-97.3%), PPV of 46.5% (CI: 45.0%-47.9%), and an AUC of 0.897 (CI: 0.892 to 0.902). CONCLUSIONS: High consumption of healthcare resources is associated with complex chronic morbidity. A model based on age, morbidity, and prior utilization is able to predict high-cost risk and identify a target population requiring proactive care.

A cross-sectional study to compare two blood collection methods: direct venous puncture and peripheral venous catheter.

OBJECTIVES: To demonstrate the equivalence between blood collection methods using direct venous puncture (DVP) and a peripheral venous catheter or cannula (PVC). DESIGN AND SETTING: A cross-sectional study of simple crossover design with within-subject measures carried out between October 2011 and May 2012 at a regional hospital in Spain. PARTICIPANTS: 272 patients aged 18 or older hospitalised or admitted to the short-stay unit (SSU) who required laboratory testing and PVC to administer saline solution, intravenous fluid therapy and/or intravenous medication. Excluded were those with PVC collection time exceeding 20 s, difficulty of venoclysis, or who presented with arteriovenous fistula, language difficulties, in critical condition or altered consciousness with no family to consent. PRIMARY AND SECONDARY OUTCOME MEASURES: 18 variables were recorded for DVP and PVC, along with age, sex, diagnosis, vein location for DVP, location of the PVC, PVC calibre, saline syringe, intravenous fluid therapy, medication, haemolysis and clotted blood during DVP or PVC collection. Univariate analysis, Pearson's product-moment correlation coefficient (r), Lin's concordance correlation coefficient (rc) and Bland-Altman's 95% agreement interval were provided. RESULTS: Included in the study were 272 patients, primarily aged 65 or older (80.9%), males (52.6%) and receiving intermittent medication (43.4%). Values obtained with both methods showed a positive linear association, being moderate for pO2 (r=0.405) and very high for all others (r>0.86). Levels were concordant (rc≥0.9), except for calcium (rc=0.860), pH (rc=0.853), pCO2 (rc=0.843) and pO2 (rc=0.336) and equivalent for all determinations except pCO2 and pO2, where clinically significant differences were found in more than 9% of cases (21.2%, 95% CI 16.6% to 26.5% and 73.1%, 95% CI 67.4% to 78.1%). CONCLUSIONS: Blood collection methods using DVP and PVC can be used interchangeably for most routine laboratory tests.

A tool for assessing continuity of care across care levels: an extended psychometric validation of the CCAENA questionnaire.

BACKGROUND: The CCAENA questionnaire was developed to assess care continuity across levels from the patients' perspective. The aim is to provide additional evidence on the psychometric properties of the scales of this questionnaire. METHODS: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care in three health care areas of the Catalan health care system. Data were collected in 2010 using the CCAENA questionnaire. To assess psychometric properties, an exploratory factor analysis was performed (construct validity) and the item-rest correlations and Cronbach's alpha were calculated (internal consistency). Spearman correlation coefficients were calculated (multidimensionality) and the ability to discriminate between groups was tested. RESULTS: The factor analysis resulted in 21 items grouped into three factors: patient-primary care provider relationship, patient-secondary care provider relationship and continuity across care levels. Cronbach's alpha indicated good internal consistency (0.97, 0.93, 0.80) and the correlation coefficients indicated that dimensions can be interpreted as separated scales. Scales discriminated patients according to health care area, age and educational level. CONCLUSION: The CCAENA questionnaire has proved to be a valid and reliable tool for measuring patients' perceptions of continuity. Providers and researchers could apply the questionnaire to identify areas for health care improvement.

Factors associated to experienced continuity of care between primary and outpatient secondary care in the Catalan public healthcare system.

OBJECTIVE: To analyze patient's reported elements of relational, informational and managerial (dis)continuity between primary and outpatient secondary care and to identify associated factors. METHODS: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care for the same condition. The study settings consisted of three health areas of the Catalan health system. Data were collected in 2010 using the CCAENA questionnaire, which identifies patients' experiences of continuity of care. Descriptive analyses and multivariable logistic regression models were carried out. RESULTS: Elements of continuity of care were experienced by most patients. However, elements of discontinuity were also identified: 20% and 15% were seen by more than one primary or secondary care physician, respectively. Their secondary care physician or both professionals were identified as responsible for their care by 40% and 45% of users, respectively. Approximately 20% reported a lack of information transfer. Finally, 72% of secondary care consultations were due to primary care referral, whilst only 36% reported a referral back to primary care. Associated factors were healthcare setting, age, sex, perceived health status and disease duration. CONCLUSION: Users generally reported continuity of care, although elements of discontinuity were also identified, which can be partially explained by the healthcare setting and some individual factors. Elements of discontinuity should be addressed to better adapt care to patients' needs.

[Strategy to increase screening for cardiovascular risk factors among young people]. / Estrategia para aumentar el cribado de los factores de riesgo cardiovascular en la población joven.

OBJECTIVE: To evaluate the effectiveness of an intervention to increase the participation among young people in the Health Prevention and Promotion Activities Programme (PAPPS) and the register of their variables. To evaluate differences in registering based on age and sex. DESIGN: randomized, controlled clinical trial. SETTING: Palamós primary care centre. PARTICIPANTS: A total of 828 people between the ages of 25 and 40 assigned to a nurse with one of the PAPPS variables improperly completed: 415 in control group and 413 in intervention group. INTERVENTION: letter to complete the PAPPS and phone call if the response after three weeks was less than 10%. VARIABLES: age, sex, nationality, clinic attendance, number of variables of PAPPS variables properly completed and the correct registration of each one at the beginning and end of the period. STATISTICAL ANALYSIS: univariate and bivariate analysis, 95% confidence interval, RRR and NNT. RESULTS: Heterogeneous groups as regards clinic attendance: 5 (1.2%) of control and 85 (20.6%) of intervention group, NNT=5 (95% CI, 4-7); and properly completed registration of PAPPS (P<.001): 5 (1.2%) of control and 73 (17.7%) of intervention, NNT=6 (95% CI, 5-8). At the end, there were differences with regard to age and sex in the number of variables completed and in the registration of cholesterol (P<.001), and only in regard to age in body mass index (P=.005). CONCLUSIONS: The strategy significantly increased the number of people who completed the PAPPS and their registration. Sex and age influenced the completion.

[Design and validation of a questionnaire to measure continuity between care levels from the user's perspective]. / Diseño y validación de un cuestionario para medir la continuidad asistencial entre niveles desde la perspectiva del usuario: CCAENA.

OBJECTIVES: To design and validate an instrument that measures continuity between levels of care from the user's perspective to be applied in any healthcare system providing a continuum of care. METHODS: 1) A questionnaire for the measurement of continuity of care was designed, based on a literature review, and 2) the questionnaire was validated using an expert group, two pretests and a pilot test to a sample of 200 healthcare users. We assessed the questionnaire's comprehensibility, content validity and interviewer burden, as well as the reliability and construct validity of the scale. RESULTS: The instrument encompasses three types of continuity (management, information and relational) and is divided in two complementary parts. The first part addresses the patients' care pathways and the continuity of care for a particular episode that occurred in the last 3 months. The second part measures patients' perception of the continuity between levels of care. The experts agreed that all dimensions of continuity were represented and the interviewees found the questionnaire easy to understand. The mean time required to apply the instrument was 33.9 min. Cronbach's alpha was acceptable (>0.7) in all subscales except one, which was then removed. The multiple correspondence analyses showed associations among theoretically related items. CONCLUSIONS: The questionnaire (CCAENA) seems to be an useful, valid and reliable instrument to assess comprehensively continuity between levels of care from the user's perspective. Further information about the questionnaire's psychometric properties will be obtained by applying it to a larger population.

[The concept of "patient type": utility for the care of surgical patients]. / Concepto <>: utilidad para el cuidado de los pacientes quirúrgicos.

OBJECTIVE: To describe a model of surgical "patient type" by identifying the needs and characteristics of surgical patients. METHOD: We performed a cross-sectional study of surgical patients with one or more diseases and similar needs and/or characteristics admitted to the surgical wards of a general hospital over a 10-month period. The variables analyzed were sociodemographic and clinical data, degree of autonomy, and Virginia Henderson's needs, which were identified through an interview performed in the postoperative period. Univariate analysis, stratified descriptive statistics and multiple correspondence analysis were performed. RESULTS: A total of 270 medium- or low-complexity patients from different surgical specialties took part in the analysis. During the surgical process (pre- and post-operative), almost a half of the patients suffered from hypotension, heart rate showed no significant changes and the risk of developing a pressure ulcer was unmodified according to Norton's scale. The first statistical analysis classified the surgical patients into five groups and showed the relationship between the degree of autonomy (measured through Barthel's index) and the number of personal problems (assessed according to the Henderson model). A subsequent statistical analysis classified the patients into four groups or types, explaining 70% of the total variance. CONCLUSIONS: Through the use of Virginia Henderson's model, a surgical patient type composed of four different groups was identified. The results of this study may be useful in the care of low- and medium-complexity patients in distinct surgical specialties.

Cellular proliferation in the urorectal septation complex of the human embryo at Carnegie stages 13-18: a nuclear area-based morphometric analysis.

In order to analyse the patterns of cellular proliferation both in the mesenchyme of the urorectal septum (URS) and in the adjacent territories (posterior urogenital mesenchyme, anterior intestinal mesenchyme and cloacal folds mesenchyme), as well as their contribution to the process of cloacal division, a computer-assisted method was used to obtain the nuclear area of 3874 mesenchymal cells from camera lucida drawings of nuclear contours of selected sections of human embryos [Carnegie stages (CSs) 13-18]. Based on changes in the size of the nucleus during the cellular cycle, we considered proliferating cells in each territory to be those with a nuclear area over the 75th percentile. The URS showed increasing cell proliferation, with proliferation patterns that coincided closely with cloacal folds mesenchyme, and with less overall proliferation than urogenital and intestinal mesenchymes. Furthermore, at CS 18, we observed the beginning of the rupture in the cloacal membrane; however, no fusion has been demonstrated either between the URS and the cloacal membrane or between the cloacal folds. The results suggest that cloacal division depends on a morphogenetic complex where the URS adjacent territories could determine septal displacement at the time that their mesenchymes could be partially incorporated within the proliferating URS.