[Chronic communicable and non-communicable pathology and skin pathology of the migrant patient]

The care of migrant patients includes initial screening and lifelong monitoring, highlighting the importance of preventing and tracking chronic, communicable and non-communicable diseases. The prevalence of hypertension, diabetes mellitus, dyslipidemia, and obesity varies by ethnicity, influenced by genetic factors, lifestyle, and socio-economic status. Preventive measures, health promotion, and risk factor identification are crucial. Chronic communicable diseases may manifest years after transmission, underscoring the necessity of primary care screening, especially for populations from endemic or high-risk areas. Imported skin lesions are a common reason for consultation among migrant and traveller patients. Their ethiology is varied, ranging from common conditions such as scabies, mycoses, and urticaria to tropical dermatoses like filariasis and leprosy.

Consensus document of the Spanish Society of Paediatric Infectious Diseases and the Advisory Committee on Vaccines of the Spanish Association of Pediatrics for vaccination of immunosuppressed individuals

The number of people with immunosuppression is increasing considerably due to their greater survival and the use of new immunosuppressive treatments for various chronic diseases. This is a heterogeneous group of patients in whom vaccination as a preventive measure is one of the basic pillars of their wellbeing, given their increased risk of contracting infections. This consensus, developed jointly by the Sociedad Española de Infectología Pediátrica (Spanish Society of Pediatric Infectious Diseases) and the Advisory Committee on Vaccines of the Asociación Española de Pediatría (Spanish Association of Paediatrics), provides guidelines for the development of a personalised vaccination schedule for patients in special situations, including general recommendations and specific recommendations for vaccination of bone marrow and solid organ transplant recipients, children with inborn errors of immunity, oncologic patients, patients with chronic or systemic diseases and immunosuppressed travellers.

Implementation of programmes for the transition of adolescents to adult care

Up to 15-20% of adolescents have a chronic health problem. Adolescence is a period of particular risk for the development or progression of chronic diseases for both individuals with more prevalent conditions and those affected by rare diseases. The transition from paediatric to adult care begins with preparing and training the paediatric patient, accustomed to supervised care, to assume responsibility for their self-care in an adult care setting. The transition takes place when the young person is transferred to adult care and discharged from paediatric care services. It is only complete when the youth is integrated and functioning competently within the adult care system. Adult care providers play a crucial role in welcoming and integrating young adults. A care transition programme can involve transitions of varying complexity, ranging from those required for common and known diseases such as asthma, whose management is more straightforward, to rare complex disorders requiring highly specialized personnel. The transition requires teamwork with the participation of numerous professionals: paediatricians and adult care physicians, nurses, clinical psychologists, health social workers, the pharmacy team and administrative staff. It is essential to involve adolescents in decision-making and for parents to let them take over gradually. A well-structured transition programme can improve health outcomes, patient experience, the use of health care resources and health care costs.

[Morbidity due to chronic diseases and their health care in Asturias: a gender analysis]

OBJECTIVE

To determine gender differences in the magnitude and complexity of chronic diseases and gender inequalities in health care in the adult population of Asturias in 2022.

METHOD

A cross-sectional population study in people (>14 years) with at least one diagnosis of chronic disease (780,566 inhabitants).

SOURCES OF INFORMATION

computer program for morbidity groups (Ministry of Health), Electronic medical record of primary care and hospital. Comparative analysis by sex and age, the mean values of chronic diseases and complexity index (Student's t test and one-way ANOVA), and probability (odds ratio and 95% CI) of suffering from specific chronic diseases, making one or more visits to the hospital emergency department or one or more admissions to hospital.

RESULTS

89.9% of women and 82.1% of men were registered with at least one chronic disease. The mean was higher in women (4.36) than in men (3.22) (p<0.001). Complexity index: men 4.56 and women 5.85 (p<0.001). Results show that women are more likely to attend the hospital emergency department, with an attendance rate of 50% for the diseases cited, compared with men at 29%. The rate of hospital admission is higher in men in 13 of the 14 diseases studied (85%).

CONCLUSIONS

Gender analysis can also be applied to secondary sources of the National Health System. Despite the greater magnitude and complexity of chronic diseases in women, there is a higher frequency of hospital admissions in men compared to women with the same diseases. This implies an unequal care profile in the field of hospital admissions that the scientific literature associates with gender biases in health care.

Psychometric properties of the Spanish version of the Pediatric Quality of Life Inventory Family Impact Module (PedsQL FIM)

INTRODUCTION

This study analysed the psychometric properties of the Spanish version of the Pediatric Quality of Life Questionnaire Family Impact Module (PedsQL FIM) in the Argentinian population.

PATIENTS AND METHODS

The sample included 232 caregivers, of who 108 were parents of children with chronic diseases (mean, 9.54; standard deviation [SD], 4.43) and 124 parents of children in the general population (mean, 12.37; SD, 4.6).

RESULTS

We assessed the validity of the instrument with the known-groups method, finding significant differences between the case and control groups in the overall and subscale scores (P < .01). We also assessed test validity by means of exploratory factor analysis, which yielded an 8-factor model that explained 74.03% of the variance. We assessed reliability with the Cronbach alpha and found a high internal consistency (α=0.95).

CONCLUSION

The PedsQL module proved to be a valid and reliable tool to assess the impact of a chronic paediatric condition on caregiver quality of life and family functioning.

[Barriers and facilitators of the EfiKroniK exercise program for people with chronic diseases in Primary Care]

OBJECTIVE

Explore patients' perceptions during a supervised exercise program and detect the barriers and facilitators that influence exercise adherence after the supervision period.

DESIGN

A qualitative observational study with three focus groups as the main data collection technique was conducted. SITE: Primary Health centers of Bizkaia.

PARTICIPANTS

Out of the 175 randomized patients in the hybrid effectiveness-implementation trial, a sample of 19 patients from the intervention group were included in the qualitative study (12 advanced-stage onco-haematological patients and seven with severe mental disorders).

METHODS

Content analysis of the generated transcripts was performed by combining a deductive approach, based on the domains of the PRACTIS theoretical framework, and an inductive one, based on the postulates of the Grounded Theory.

RESULTS

The data analysis showed that participants were satisfied with the EfiKroniK program and that the main identified benefits were discovery of the benefits of physical exercise, the psychological and emotional management of the disease, the benefits from peer communication and emotional support, and the break from routine of their illness. Participants decreased the levels of physical exercise at the end of the supervision6 due to the confluence of several barriers.

CONCLUSION

A supervised exercise program carried out in Primary Care contributed to the improvement of the quality of life as well as the emotional and social well-being of patients with advanced-stage diseases. Our study identified potential barriers and facilitators associated with exercise participation and its continuity, however, it is necessary to encourage inter-sectoral coordination within the socio-health system to promote integrated and continuous care for chronic patients.

[What have we missed because of COVID-19? Missed diagnoses and delayed follow-ups. SESPAS Report 2022]

La pandemia de COVID-19 y la emergencia de salud pública asociada han afectado a los/las pacientes y a los servicios de salud en lo que respecta a las patologías no relacionadas con la COVID-19. Diversos estudios han evidenciado su desvinculación con los servicios sanitarios, con disminución de las consultas a los servicios de urgencias, de los ingresos hospitalarios de patologías no COVID-19, así como de la incidencia semanal notificada de enfermedades agudas y nuevos diagnósticos en atención primaria. Paralelamente, la pandemia ha tenido efectos directos e indirectos en las personas con enfermedades crónicas; las dificultades de acceso a los servicios sanitarios, la interrupción de la atención, la saturación del propio sistema y su reorientación hacia formatos no presenciales ha reducido la capacidad de prevenir o controlar las enfermedades crónicas, impactando además en los diferentes ámbitos de la vida de las personas, creando nuevas dificultades sociales y económicas, o agravando las preexistentes antes de la pandemia. Todas estas circunstancias se han ido modificando con cada una de las olas epidémicas. Se presenta una revisión de los estudios más relevantes que han ido analizando este problema y se incorporan como estudio de caso los resultados de un estudio observacional retrospectivo realizado en atención primaria en Madrid, que da cobertura sanitaria a una población de más de 6 millones de personas, y cuyo objetivo ha sido analizar la pérdida de nuevos diagnósticos en las patologías más prevalentes, como los problemas comunes de salud mental, enfermedades cardiovasculares y cerebrovasculares, diabetes tipo 2, enfermedad pulmonar obstructiva crónica y tumores de mama y de colon, en la primera y la segunda olas. Se calcularon las tasas de incidencia anual con su intervalo de confianza para cada patología y se comparó la frecuencia mensual de los nuevos códigos registrados entre el 1 de enero y el 31 de diciembre de 2020 con la media mensual de los recuentos observados para los mismos meses en 2016-2019. La tasa de incidencia anual para todos los procesos estudiados disminuyó en 2020, excepto para los trastornos de ansiedad. En relación con la recuperación de los diagnósticos perdidos, la insuficiencia cardiaca es el único diagnóstico que presenta una recuperación por encima de la media después de la primera ola. Para volver a los niveles prepandémicos de diagnóstico y seguimiento de la patología no COVID-19, el sistema sanitario debe reorganizarse y contemplar acciones específicas para los grupos de mayor riesgo.

Efficacy of the Mechanistic Score and COVID-19 Mortality Risk scales to assess the risk of mortality in patients hospitalized for COVID-19

INTRODUCTION

Chronic diseases are associated with a higher risk of mortality from COVID-19.

OBJECTIVE

To compare the efficacy of the Mechanistic Score and COVID-19 Mortality Risk scales for assessing the risk of mortality in patients hospitalized for COVID-19.

METHODS

Comparative, observational, retrospective study. The mortality rate of COVID-19-positive patients was assessed by comparing both scales, according to information obtained from the records of patients hospitalized for COVID-19 in a specialty hospital.

RESULTS

Two-hundred and twenty-one patients were evaluated, out of whom 61% were men and 39% were women; 89% had comorbidity: obesity (88%), hypertension (40%), diabetes mellitus (31%) and cancer (6%). At discharge, 65% survived. The COVID-19 Mortality Risk scale showed a sensitivity of 79% and specificity of 88% for predicting mortality risk. In patients with low risk, the Mechanistic Score showed a sensitivity and specificity of 24 and 97%, respectively; in cases with mild risk, 44 and 97%; with moderate risk, 57 and 77%; with high risk, 95 and 91%; and with remarkably high risk, 100 and 100%.

CONCLUSION

The COVID-19 Mortality Risk scale has higher efficacy than the Mechanistic Score for assessing mortality risk in patients with COVID-19.

[Mobile applications to improve drug adherence: Review and quality analysis]

OBJECTIVE

To review the mobile apps in the Spanish market to improve adherence to medications and evaluate their characteristics and quality to identify high-quality applications.

METHOD

A review was carried out following a stepwise procedure similar to a systematic review of the scientific literature. Apple Apps Store and Google Play Store mobile application digital distribution platforms. Applications aimed at supporting self-management of treatment, which generate reminders, in Spanish, updated in the last 2 years and free. We evaluate the applications according to a set of characteristics considered desirable and the quality with the Mobile App Rating Scale tool.

RESULTS

Out of 708 applications, 3 applications were selected. The Medisafe and Mytherapy applications had 89% and 78% of the desirable characteristics, respectively. Sergio Licea's application only had 56%. The highest global quality score was obtained by the MyTherapy application (3.79/5, IQR: 3-4), followed by Medisafe (3.72/5, (IQR: 3-4) and, finally, Sergio Licea (2.87/5, IQR: 2-4). The quality assessment coincides with the user assessment. There are many available applications, however, most did not meet the selection criteria.

CONCLUSIONS

A systematic stepwise process was able to identify the quality application to be tested in a future study that will provide evidence on the use of a multicomponent intervention to improve medication adherence.

[Evaluation of health center's primary care responsiveness by patients with chronic illnesses]

OBJECTIVE

To evaluate the health systems' response capacity according to the perception of chronic patients, and the factors related to that perception.

METHOD

Source of data: patients diagnosed with at least one chronic disease who visited primary care centers during June and July 2015 in a basic health area of La Rioja.

DESIGN

cross-sectional descriptive study based on interviews to over 18s who visited primary care centers. The dependent variable was the health systems' response capacity and independent variables were sociodemographic and health related. In order to collect data, trained interviewers conducted a short questionnaire in Spanish from the World Health Organization Multi-country Survey Study with 403 subjects. Descriptive statistics, bivariate and multivariate logistic regression were performed.

RESULTS

The overall health systems' response capacity was considered good by 87.10%. The domains that scored highest were: confidentiality (99.3%), dignity (98.3%) and communication (97.3%). Those evaluated worst were: rapid service (38,6%) and quality of basic services (31.8%). Low social class was the most important factor associated with the responsiveness, mainly with autonomy and rapid service. Sex, educational level, and occupation were related to communication domain, and patients with worse perceived health rated the general response worse. The domains considered most important were dignity (33.5%) and rapid service (30.5%).

CONCLUSIONS

The domains best evaluated were those related to respect for people. Rapid service has a low health systems' response capacity, but a high importance, and therefore requires priority action.

[Health care for patients with multimorbidity. The perception of professionals]

Objetivo

Explorar las percepciones de los profesionales sanitarios sobre las características de la atención sanitaria a pacientes con multimorbilidad.

Diseño

Estudio cualitativo de trayectoria fenomenológica realizado entre enero y septiembre de 2015 mediante 3 entrevistas grupales (grupos de discusión) y 15 individuales.

Emplazamiento

Servicio Aragonés de Salud.

Participantes

Profesionales médicos y de enfermería del Servicio Aragonés de Salud pertenecientes a distintos servicios: Medicina Interna, Atención Primaria, Urgencias y Gestión. También se incluyó un farmacéutico.

Métodos

Se realizó un muestreo intencional no probabilístico que permitiese configurar las unidades muestrales buscando criterios de representatividad del discurso, permitiendo conocer e interpretar el fenómeno estudiado en profundidad, en sus diferentes visiones. Se entrevistó a profesionales sanitarios con perfiles diferentes que conociesen en profundidad la atención a pacientes con multimorbilidad. Las entrevistas fueron grabadas, transcritas literalmente e interpretadas, mediante el análisis social del discurso.

Resultados

Se identifica una cultura profesional orientada a la atención de enfermedades individuales, falta de coordinación entre especialidades, pacientes sometidos a numerosas prescripciones, Guías de Práctica Clínica y formación especialmente centradas en enfermedades individuales.

Conclusiones

Tanto la cultura profesional como la organización del sistema sanitario se encuentran orientadas a la atención de enfermedades individuales, lo que redunda en dificultades para ofrecer una atención más integral a los pacientes con multimorbilidad.

[Adjusted morbidity groups: Characteristics and comorbidities in patients with chronic conditions according to their risk level in Primary Care]

Objetivos

Describir las características de los pacientes crónicos según el nivel de riesgo asignado por los grupos de morbilidad ajustados (GMA). Analizar los factores asociados al nivel de riesgo alto y estudiar el efecto de cada uno de ellos.

Diseño

Estudio observacional descriptivo transversal con enfoque analítico.

Emplazamiento

Atención Primaria (AP). Servicio Madrileño de Salud.

Participantes

Población de 18.107 pacientes estratificados por los GMA integrados en la historia clínica electrónica de AP de la Comunidad de Madrid.

Mediciones principales

Variables sociodemográficas, clínico-asistenciales y de uso de servicios. Se realizó análisis univariado, bivariado y multivariante.

Resultados

De los 18.107 pacientes se identificaron 9.866 (54,4%) pacientes crónicos, 444 (4,5%) estratificados como de alto riesgo, 1.784 (18,1%) como de medio riesgo y 7.638 (77,4%) como de bajo riesgo. Los de alto riesgo, comparados con medio y bajo riesgo, tenían una edad media mayor (77,8 [12,9]; 72,1 [12,9]; 50,6 [19,4]), menor porcentaje de mujeres (52,3%, 65%, 61,1%), mayor número de enfermedades crónicas (6,7 [2,4]; 4,3 [1,5]; 1,9 [1,1]), polimedicación (79,1%, 43,3%, 6,2%) y contactos con AP (33,9 [28]; 21,4 [17,3]; 7,9 [9,9]) (p < 0,01). En el multivariante el nivel de riesgo alto se relacionó de manera independiente con la edad > 65 (OR = 1,43; IC 95% = 1,03-1,99), sexo masculino (OR = 3,46; IC 95% = 2,64-4,52), inmovilidad (OR = 6,33; IC 95% = 4,40-9,11), número de enfermedades crónicas (OR = 2,60; IC 95% = 2,41-2,81) (p < 0,01) y número de contactos con AP > 7 (OR = 1,95; IC 95% = 1,36-2,80).

Conclusiones

Más de la mitad de la población fue clasificada por los GMA como crónica, y se estratificó en 3 niveles de riesgo que presentaban diferencias en sexo, edad, deterioro funcional, necesidad de cuidados, morbilidad, complejidad, polifarmacia y contactos con AP. La edad > 65, el sexo masculino, la inmovilidad, el número de enfermedades crónicas y los contactos con AP > 7 fueron los factores asociados al alto riesgo.

Analysis of patients shared in consultations of internal medicine and other medical specialties

BACKGROUND AND OBJECTIVE

The aging population is resulting in an increasing number of patients with multiple diseases that require treatment by various specialties. We examined the evolution of consultations and of the percentage of patients treated by several medical specialties.

METHODS

We analysed internal medicine (IM) consultations and those of other medical specialties in a hospital during 1997, 2007 and 2017 for the general population and for those older than 65 years.

RESULTS

Over the course of 20 years, the rate of first IM consultations per 1000 inhabitants increased 44%, and that of other medical specialties increased 137%. The percentage of patients seen by more than one specialty went from 13.8% in 1997 to 32.6% in 2017 and reached 45.5% for those older than 65 years.

CONCLUSIONS

The care for populations with growing comorbidity has a major impact on health systems and requires organisational changes for their care.

Adherence to treatment of hypertension, hypercholesterolaemia and diabetes in an elderly population of a Spanish cohort

BACKGROUND AND OBJECTIVE

Sub-optimal adherence to treatment in the general population has been highlighted in several studies, especially in the elderly and/or chronic patients. This study aims to describe the adherence to treatment of diabetes mellitus, dyslipidaemia and hypertension, and to identify the factors that influence adherence.

MATERIAL AND METHOD

Retrospective, cross-sectional observational study on 16,208 patients aged ≥65 years from the EpiChron Cohort who initiated monotherapy treatment of an antidiabetic, a lipid-lowering or an antihypertensive medication in 2010. Adherence was measured by calculating the medication possession ratio during one year, considering those cases with medication possession ratio ≥80% to be adherent. We performed a descriptive study, and a logistic regression model was used to identify the predictors of low adherence.

RESULTS

Adherence to antidiabetics, antihypertensive and lipid-lowering drugs was 72.4%, 50.7% and 44.3%, respectively. An increase in adherence of 3-8% was observed for each additional chronic disease suffered by the patient. The presence of mental illness did not affect adherence, and sex, age and number of prescribed drugs did not present consistent effects.

CONCLUSION

The results obtained show a sub-optimal adherence to treatment for the 3chronic diseases studied. Adherence increased with the number of chronic diseases, while sex, age and number of drugs did not show a consistent effect. It is necessary to investigate if there are other factors that may influence therapeutic adherence, since improving adherence may have a greater impact on health than any progress in therapies.

The elderly traveller

Improved living conditions and advances in medicine have extended life expectancy and quality of life, resulting in an increasing number of elderly travellers. Pathophysiological changes and treatments can reduce the efficacy of vaccines and facilitate drug interactions. Elderly travellers have various characteristics that should be considered when offering pre-trip counselling, which should include proper management of chronic diseases that are susceptible to worsening during the trip, as well as an appropriate study and follow-up after the trip. We performed a narrative review of the main problems of elderly travellers.

[Self-perception of disease in patients with chronic diseases]

OBJECTIVE

The aim of this study is to assess the self-perception of disease by patients with chronic diseases and determine factors related to their perception of disease.

MATERIAL AND METHODS

Cross-sectional descriptive study performed between September 2014 and April 2015 in nine (6 urban and 3 rural) Health Centres of Navarra, Spain. The participants were recruited by convenience sampling of 196 patients aged over 65 years with at least one chronic disease. The outcome variable was: Perception of disease evaluated through The Brief Illness Perception Questionnaire (9 items. Assessment of the cognitive and emotional representation of the disease. A higher total score indicates a greater threat of disease to the patient). Explanatory variables: Evaluation of the care received through the Patient Assessment of Chronic Illness Care, Katz index, Gijon's socio-family evaluation scale and quality of life using the EQ5D questionnaire. Other variables studied were: gender, age, education, Charlson index, and number of chronic diseases. The association between the total The Brief Illness Perception Questionnaire value and the rest of the variables was calculated.

RESULTS

The self-perception of disease is more negative for a larger number of diseases (rho: 0.242; p=.001), greater patient dependence (rho: -0.193; P=.007), and a poorer self-perceived quality of life (EQ VAS rho: -0.484; P<.001. EQ5D5L Index value rho: -0.507; P<.001).

CONCLUSIONS

The perception that chronic patients have about their disease worsens as their diseases and their dependence increase, and also worsens their quality of life.

[Patients' assessment of their chronic illness care]

Objetivo

Valoración de los cuidados recibidos por pacientes crónicos y objetivar factores relacionados con una mejor percepción de estos.

Diseño

Estudio descriptivo transversal, septiembre 2014-abril 2015.

Emplazamiento

Nueve centros de salud de Navarra (6 urbanos, 3 rurales), España.

Participantes

Muestreo de oportunidad; 196 pacientes mayores de 65 años con al menos una enfermedad crónica.

Mediciones principales

Variable resultado: Evaluación de cuidados recibidos mediante el test Patient Assessment of Chronic Illness Care (PACIC) (puntuación de 1 a 5; valores más altos indican mejor percepción sobre la calidad de los cuidados). Variables explicativas: calidad de vida mediante el EQ5D, índice de Katz y escala de valoración sociofamiliar de Gijón. Otras variables: sexo, edad, educación, índice de Charlson y número de enfermedades crónicas. Se valoró la asociación entre el valor numérico del PACIC con el resto de variables.

Resultados

La valoración de los cuidados recibidos según el PACIC fue más alta a mayor número de enfermedades crónicas (rho: 0,196; p = 0,006), a menor autonomía del paciente (incapacidad leve: media 2,9; DE: 0,6 vs. incapacidad moderada/severa: media 3,3; DE: 0,2; p = 0,003), al empeorar la calidad de vida (EQ5D5L Index value rho: −0,227; p = 0,001. EQ VAS rho: −0,145; p = 0,043) y con un mejor entorno sociofamiliar (rho: −0,167; p = 0,022).

Conclusiones

La percepción que los pacientes crónicos tienen sobre los cuidados recibidos es mejor conforme aumenta el número de enfermedades, disminuye su autonomía y empora su calidad de vida. El ámbito social del paciente influye en su percepción de cuidados, siendo esta percepción peor en ámbitos de mayor riesgo social.

Relationship between patients' month of birth and the prevalence of chronic diseases

BACKGROUND AND OBJECTIVES

Patients' month of birth can reflect exposure to certain factors during pregnancy and the first few months of life, which could influence the onset of chronic diseases during adulthood. The aim of this study is to evaluate the association between a patient's month of birth and the presence of chronic diseases in the Spanish population, by analysing the National Health Survey for the year 2006.

PATIENTS AND METHODS

We measured the association between 27 common chronic diseases and the month of birth, estimating the odds ratios and confidence intervals at 95%, using multivariate logistical models and adjusting the results for month of birth and potentially confounding variables.

RESULTS

The sample population was made up of a total of 29,478 individuals, representing approximately 44.7 million Spanish residents on 1 January 2007. Significant associations were found between the month of birth and several chronic diseases. There is a gender-differentiated risk pattern of developing chronic diseases according to the month of birth, with more significant associations and of greater magnitude being detected among men compared to women.

CONCLUSIONS

The associations detected might reflect early exposure to environmental factors in the uterus and during the first few months of life. More specific studies are required to gain a more in-depth understanding of these associations.

[Multimorbidity in general practice and the Ariadne principles. A person-centred approach]

La multimorbilidad, definida como la presencia de dos o más enfermedades crónicas en un mismo individuo, conlleva consecuencias negativas para la persona e importantes retos para los sistemas sanitarios. En atención primaria, donde recae esencialmente la atención de este grupo de pacientes, la consulta es más compleja que la de un paciente con una única enfermedad debido, entre otros, al hecho de tener que manejar mayor cantidad de información clínica, disponer de poca evidencia científica para abordar la multimorbilidad, y tener que coordinar la labor de múltiples profesionales para garantizar la continuidad asistencial. Además, para poder implementar correctamente los planes de tratamiento en estos pacientes es necesario un proceso de toma de decisiones compartida médico-paciente. Entre las distintas herramientas disponibles para apoyar dicho proceso, recientemente se ha desarrollado una dirigida específicamente a pacientes con multimorbilidad en atención primaria y que se describe en el presente artículo: los principios Ariadne.

[Evaluation of satisfaction with telemedicine devices and with the results of the care received among chronic patients. The ValCrònic program]

Objetivo

Evaluar la satisfacción de los pacientes con el programa ValCrònic, los dispositivos de telemedicina y con el resultado de la atención recibida tras 2 años de seguimiento.

Diseño

Estudio observacional descriptivo basado en encuestas telefónicas.

Emplazamiento

Comunidad Valenciana.

Participantes

En total participaron 410 pacientes que presentaban una o varias de las siguientes patologías: hipertensión, insuficiencia cardíaca, diabetes o enfermedad pulmonar obstructiva crónica. Se incluyó a 585 pacientes, de los cuales 104 abandonaron el programa (18 por fallecimiento) y 71 rehusaron participar.

Métodos

Se diseñó y validó una escala específica. Se consideraron los efectos techo y suelo. Se analizó la consistencia interna mediante alfa de Cronbach. Para comprobar la validez de constructo se empleó un análisis exploratorio de componentes principales con criterio de autovaloración igual a 1. Se aplicó el procedimiento de rotación Varimax. Se consideraron como pérdidas aceptables de información cargas factoriales ≥ 0,55. La escala se conformó con 7 preguntas cerradas y 1 abierta.

Resultados

Respondieron un total de 322 pacientes (tasa de respuesta del 78,5%). 118 (36.6%) fueron mujeres. En 48 (14,9%) casos respondió un cuidador. El valor del alfa de Cronbach fue de 0,7. ValCrònic supuso para 278 (86,3%) pacientes una ayuda para conocer mejor su enfermedad, 270 (83,9%) afirmaron hacer un uso más seguro de la medicación gracias a ValCrònic y 283 (87,9%) dijeron conocer ahora mejor su enfermedad. Para 288 (89,4%) los dispositivos fueron fáciles de manejar en casa. Solo en 12 (3,7%) casos el paciente consideró que los dispositivos de telemedicina suponían una carga de trabajo difícil de conciliar en su día a día.

Conclusiones

ValCrònic ha contribuido a la activación de los pacientes para autocuidado.

[Psychosocial strategies to strengthen the coping with Parkinson's disease: Perspectives from patients, family carers and healthcare professionals]

Objetivo

Explorar los principales aspectos psicosociales que influyen en el afrontamiento de la enfermedad de los pacientes con enfermedad de Parkinson (EP) y sus familiares cuidadores.

Diseño

Estudio cualitativo exploratorio que constituye la segunda fase de un proyecto de metodología combinada.

Emplazamiento

Estudio multicéntrico realizado en la Comunidad Autónoma de Navarra en 2014 con la colaboración de Atención Primaria del Servicio Navarro de Salud-Osasunbidea, la Clínica Universidad de Navarra y la Asociación Navarra de Parkinson.

Participantes

Un total de 21 participantes: 9 personas con EP, 7 familiares cuidadores y 5 profesionales sociosanitarios.

Método

Los participantes fueron seleccionados mediante muestreo opinático. Se realizaron grupos focales hasta que se consideró adecuada la saturación de los datos. Las transcripciones fueron analizadas por 2 investigadores a través de un análisis de contenido.

Resultados

Se identificaron 3 aspectos que influían en cómo pacientes y familiares afrontaban la EP: funcionalidad de la atención sanitaria; entorno familiar, y aceptación de la enfermedad. Considerando estos resultados, se proponen estrategias que podrían promover estos aspectos desde atención primaria, para así mejorar la adaptación a esta enfermedad en pacientes y en sus familiares cuidadores.

Conclusiones

La atención sociosanitaria de las personas con EP debería adoptar un enfoque integral que aborde el control de los síntomas del paciente y que responda también a los aspectos psicosociales que influyen en el afrontamiento de la enfermedad, tanto en los pacientes como en sus familiares cuidadores.

[Cross-sectional study of informal caregiver burden and the determinants related to the care of dependent persons]

OBJECTIVE

To describe the burden of informal carers of dependent people and to identify related variables.

DESIGN

Descriptive observational cross-sectional study.

LOCATION

Primary Health Care in the southern area of Pontevedra.

PARTICIPANTS

97 caregivers of dependent persons.

KEY MEASUREMENTS

We collected socioeconomic data and health conditions from caregivers and dependent persons, time spent on the daily care and caregiver burden (Zarit abbreviate) through a personal interview. Besides the description of the sample-including their burden level-, a contrast mean was used to identify characteristics that influenced in punctuation of Zarit scale. A logistic regression was used to analyse characteristics that increase the likelihood to experiment burden.

RESULTS

61.9% of caregivers are subject to intense burden. The item on the scale which contributes most to the caregiver burden is the lack of time for oneself, followed by the negative effects of interpersonal relationships. Contrast means shows that degree of relationship, number of care hours, caregiver health and aggressiveness of dependent persons produce significant differences in Zarit scale. Physic and psychological health of caregivers and aggressiveness of dependent persons is associated with the likelihood of developing caregiver burden.

CONCLUSIONS

Informal caregivers of dependent persons show a high level of burden, both related to their characteristics and those of the dependent persons. Caregiver burden rethinks the need for public policies focused on dependence to adopt an integrative caregiver-dependent vision.

[Models of care and classification of "Children with special health care needs-CSHCN": Recommendations from the CSHCN Committee, Chilean Paediatric Society]

"Children with special health care needs" (CSHCN) is an emerging and heterogeneous group of paediatric patients, with a wide variety of medical conditions and with different uses of health care services. There is consensus on how to classify and assess these patients according to their needs, but not for their specific diagnosis. Needs are classified into 6 areas: a) specialised medical care; b) use or need of prescription medication; c) special nutrition; d) dependence on technology; e) rehabilitation therapy for functional limitation; and f) special education services. From the evaluation of each area, a classification for CSHCN is proposed according to low, medium, or high complexity health needs, to guide and distribute their care at an appropriate level of the health care system. Low complexity CSHCN should be incorporated into Primary Care services, to improve benefits for patients and families at this level. It is critical to train health care professionals in taking care of CSHCN, promoting a coordinated, dynamic and communicated work between different levels of the health care system. Compliance with these guidelines will achieve a high quality and integrated care for this vulnerable group of children.

[The transition process from paediatric to adult services: A perspective from hospitalised adolescent sufferers of chronic diseases]

INTRODUCTION

Chronic illnesses during adolescence are a big challenge for the patient, his or her family, and health care providers. The transition from paediatric health services to adult health services involves a programmed and planned transfer process of adolescent sufferers of chronic illnesses, in order to maintain a high quality of life and bio-psycho-social development. There is currently no transition model. The objective of the study is to understand the transition process from the perspective of hospitalised adolescents to collaborate towards the design of a model that meets the needs studied.

PATIENTS AND METHOD

Semi-structured interviews with 13 adolescent sufferers of chronic illnesses, hospitalised in two healthcare centres in Santiago, Chile, in one analytical-relational study, supported by qualitative methodology.

RESULTS

In the analysis, 5 major themes stand out: experience of living with the illness, the importance of the doctor-patient relationship, the concept of limited autonomy to the pharmacology, the absence of the transition process as such, and the identification of barriers and needs for an adequate transition.

CONCLUSIONS

This study is new in Chile in that it explores the phenomenom of the transition of adolescents with chronic illnesses. It emphasises the need to reinforce the concept of self-care and autonomy from early stages of care, and the importance of early planning of a healthy transition process, in accordance to the detected needs of the adolescents themselves.

[General concepts of epigenetics: Projections in paediatrics]

Current evidence supports the notion that alterations in intrauterine growth and during the first years of life have a substantial effect on the risk for the development of chronic disease, which in some cases is even higher than those due to genetic factors. The persistence and reproducibility of the phenotypes associated with altered early development suggest the participation of mechanisms that would record environmental cues, generating a cellular reprogramming (i.e., epigenetic mechanisms). This review is an introduction to a series of five articles focused on the participation of epigenetic mechanisms in the development of highly prevalent chronic diseases (i.e., cardiovascular, metabolic, asthma/allergies and cancer) and their origins in the foetal and neonatal period. This series of articles aims to show the state of the art in this research area and present the upcoming clues and challenges, in which paediatricians have a prominent role, developing strategies for the prevention, early detection and follow-up.

[The experience of women care cargivers with chronic conditions of dependent relatives]

OBJECTIVE

To describe the experience of women caregivers with chronic conditions who care for a dependent relative.

DESIGN

Qualitative study based on constructivist grounded theory.

LOCATION

Study conducted on two Health Areas urban of the Community of Madrid.

PARTICIPANTS

Thirty nine women with a chronic condition who take care of dependent relatives were selected by means of purposive sampling.

METHOD

Data were collected through 23 semi-structured interviews and 2 focus groups between April 2010 and December 2011. Grounded theory procedures were used in the data analysis.

RESULTS

To feel their life hampered describes the subjective experience of family caregivers with chronic conditions who take care of a dependent relative. When comparing their past life with the current life they become aware of the losses they have suffered over time. They feel less strong, sadder and less free; they worry about how to meet the demands of family care. The life they are leading makes them question the meaning of their own lives.

CONCLUSIONS

This study shows the losses realized day by day by women caregivers with a chronic illness, which lead them to lose the meaning of their own lives. To know the experience of these women caregivers will help develop interventions and specific services that compensate for the losses they feel and help improve their quality of living.

[Chronic diseases as a priority for the public health surveillance system in Spain]

At present, epidemiological surveillance in Spain remains focused on the communicable diseases included in the list of notifiable diseases. However, there has been a change in epidemiological pattern that predominated until the last few decades of the twentieth century. Infectious diseases, which used to be the leading causes of morbidity and mortality, have given way to a predominance of chronic diseases. In this regard, progress has been made in the drafting and adoption of specific legal regulations on public health monitoring. However, Spain has yet to develop this legislation which, among other elements, includes the mandate to organize the surveillance of non-communicable diseases in Spain. This article aims to describe some points that should be considered in the development of a national surveillance system linked to existing strategies for the prevention and control of chronic diseases.

[Trend in potentially avoidable hospitalisations for chronic conditions in Spain]

OBJECTIVE

To analyse the trend in potentially avoidable hospitalisations (PAH) in frail patients or those with chronic conditions in Spain during the period 2002-2013.

METHODS

An observational, ecological study was conducted to analyse the trend in age-sex standardised rates of PAH affecting six clinical conditions, and their variation, in the 203 health care areas composing the publicly-funded health system in Spain.

RESULTS

During the period 2002-2013, overall PAH standardised rates decreased by 35%, but systematic variation remained moderately high, around 13% above that expected by chance. Angina admissions showed the largest reduction, followed by those for asthma and chronic obstructive pulmonary disease. In contrast, the prevalence of admissions for dehydration doubled.

CONCLUSIONS

Despite the decrease in PAH rates, systematic variation among areas remains, indicating differences in chronic care management that lead to distinct healthcare outcomes.

[Low concordance between primary care and hospital clinical information]

Objetivos

Medir la concordancia respecto a las enfermedades crónicas registradas en atención primaria (AP) y hospitalaria, y valorar la utilidad de sus registros asistenciales con fines de investigación.

Emplazamiento

Estudio transversal retrospectivo integrando información diagnóstica de AP y hospitalaria de la población de Aragón ingresada en 2010.

Participantes

Se analizó a 75.176 pacientes

Intervenciones

Se analizaron coincidencias, divergencias e índice kappa de los diagnósticos registrados en AP y hospital, estratificando por grupos de edad y sexo.

Mediciones principales

Enfermedades estudiadas: EPOC, diabetes, hipertensión, enfermedad cerebrovascular, cardiopatía isquémica, asma, epilepsia e insuficiencia cardiaca.

Resultados

La concordancia fue mayor en hombres y entre los 45-64 años. Diabetes fue el diagnóstico más concordante (índice kappa: 0,75) mientras que asma obtuvo los valores más bajos (índice kappa: 0,34).

Conclusiones

La baja concordancia de la información diagnóstica contenida en AP y hospital obliga a adoptar medidas que permitan a los profesionales sanitarios a conocer el conjunto de problemas de salud que presenta un paciente.

[Economic evaluation of a program of coordination between levels for complex chronic patients' management]

OBJECTIVE

The complex chronic patient program (CCP) of the Alt Penedès aims to improve the coordination of care. The objective was to evaluate the relationship between the costs associated with the program, and its results in the form of avoided admissions.

DESIGN

Dost-effectiveness analysis from the perspective of the health System based on a before-after study.

LOCATION

Alt Penedès.

MAIN MEASUREMENTS

Health services utilisation (hospital [admissions, emergency visits, day-care hospital] and primary care visits). CCP Program results were compared with those prior to its implementation. The cost assigned to each resource corresponded to the hospital CatSalut's concert and ICS fees for primary care. A sensitivity analysis using boot strapping was performed. The intervention was considered cost-effective if the incremental cost-effectiveness ratio (ICER) did not exceed the cost of admission (€ 1,742.01).

RESULTS

149 patients were included. Admissions dropped from 212 to 145. The ICER was €1,416.3 (94,892.9€/67). Sensitivity analysis showed that in 95% of cases the cost might vary between €70,847.3 and €121,882.5 and avoided admissions between 30 and 102. In 72.4% of the simulations the program was cost-effective.

CONCLUSIONS

Sensitivity analysis showed that in most situations the PCC Program would be cost-effective, although in a percentage of cases the program could raise overall cost of care, despite always reducing the number of admissions.

[Management of time used to treat the chronic patient: a new approach to improve quality of health care]

OBJECTIVE

Chronic disease is the main epidemic of the 21st century. It takes up a large part of the social-health budgets that are dedicated to its care. The aim of this study is to analyze if the welfare quality in the management of the chronic patients improves by implementing non-contact care time.

MATERIAL AND METHODS

Intervention study conducted in the health care center of Orcasitas (January 2012 - September 2013) in patients with hypertension (357), diabetes (180) and/or ischemic heart disease (60). Health care quality was analyzed through the effectiveness in the program, Tracking Objectives in Primary Care. The intervention group had four physical 10minute consultations/year and three non-physical 10minute consultations/year. The patients in the control group were seen as usual. The data were compared using the McNemar test, chi-square and Cochran's Q test.

RESULTS

In the intervention group, the effectiveness increased in the analyzed period by 46%, 54% and 55.9%, respectively, for processes of hypertension, diabetes and dyslipidemia control in ischemic heart disease, whereas in the control group (community of Madrid) it was 2.54%, 1.78%, and 5.44%, respectively, for these processes (statistically significant differences [χ(2)=24.78; χ(2)=39.9 y χ(2)=67.3, P<.0001]).

CONCLUSIONS

Thirty minutes/year of non-presential care represents a significant change in the level of control of chronic patients. These results should be considered in the approach strategies to chronic diseases.

[Transferable skills of healthcare professionals in providing homecare in chronically ill patients]

Objetivo

Determinar, a partir de los análisis de los profesionales de atención domiciliaria, el grado de relevancia de las competencias no técnicas de esos profesionales dedicados a la atención de pacientes con enfermedades crónicas.

Diseño

Investigación cuanti-cualitativa realizada en 2 fases: la 1.^a entre noviembre de 2010 y marzo de 2011 y la 2.^a entre diciembre de 2012 y agosto de 2013.

Emplazamiento

Región Sanitaria de Barcelona ciudad.

Participantes

En la primera fase, 30 profesionales pertenecientes a 6 equipos de atención domiciliaria (3 del ámbito de la atención primaria y 3 del ámbito hospitalario). En la 2.^a fase, 218 profesionales pertenecientes a 50 equipos de atención primaria (EAP) y a 7 programas de atención domiciliaria y equipos de apoyo sanitario y social (PADES).

Método

Muestreo intencional en la 1.^a fase y aleatorio en la 2.^a. Se emplearon escalas tipo Likert y grupos focales.

Resultados

A partir de la identificación de 19 categorías competenciales en la 1.^a fase del estudio, se establecieron, en la 2.^a fase, 3 metacategorías competenciales: atención integral centrada en el paciente, organización interprofesional y entre niveles asistenciales y competencia relacional.

Conclusiones

Es necesario favorecer y garantizar las relaciones profesionales entre niveles asistenciales, la continuidad asistencial, la concepción biopsicosocial y la atención holística al paciente y a su entorno, contemplando emociones, expectativas, sentimientos, creencias y valores de pacientes y familiares.

Es imprescindible el diseño e implementación de formación en competencias transversales en el ámbito de cada centro, a través de metodologías didácticas activas y participativas.

[Increasing participation of primary care in the management of people with human immunodeficiency virus: hospital care professionals express their views]

AIM

To determine the opinions of infectious diseases professionals on the possibilities of monitoring patients with HIV in Primary Care.

DESIGN

Qualitative study using in-depth interviews.

LOCATION

Infectious Diseases Unit in the University Hospital "Virgen de la Victoria" in Málaga.

PARTICIPANTS

Health professionals with more than one year experience working in infectious diseases. A total of 25 respondents: 5 doctors, 15 nurses and 5 nursing assistants.

METHOD

Convenience sample. Semi-structured interviews were used that were later transcribed verbatim. Content analysis was performed according to the Taylor and Bogdan approach with computer support. Validation of information was made through additional analysis, expert participation, and feedback of part of the results to the participants.

RESULTS

Hospital care professionals considered the disease-related complexity of HIV, treatment and social aspects that may have an effect on the organizational level of care. Professionals highlighted the benefits of specialized care, although opinions differed between doctors and nurses as regards follow up in Primary Care. Some concerns emerged about the level of training, confidentiality and workload in Primary Care, although they mentioned potential advantages related to accessibility of patients.

CONCLUSIONS

Physicians perceive difficulties in following up HIV patients in Primary Care, even for those patients with a good control of their disease. Nurses and nursing assistants are more open to this possibility due to the proximity to home and health promotion in Primary Care.

[Challenges and opportunities: contributions of the Advanced Practice Nurse in the chronicity. Learning from experiences]

Undoubtedly, our society is facing new economic, political, demographic, social and cultural challenges that require healthcare services able to meet the growing health needs of the population, especially in dealing with chronic conditions. In this new context, some countries such as the United Kingdom have made a firm commitment to develop new models for chronic patients care based on the introduction of new figures of Advanced Practice Nurses, which includes 4 cornerstones of professional practice: advanced clinical skills, clinical management, teaching and research. The implementation of this new figures implies a redefinition of professional competencies and has its own accreditation system and a specific catalogue of services adapted to the population requirements, in order to provide chronic care support from Primary Care settings. This trajectory allows us analysing the process of design and implementation of these new models and the organizational structure where it is integrated. In Spain, there are already experiences in some regions such as Andalucia and the Basque Country, focused on the creation of new advanced nursing roles. At present, it is necessary to consider suitable strategic proposals for the complete development of these models and to achieve the best results in terms of overall health and quality of life of patients with chronic conditions, improving the quality of services and cost-effectiveness through a greater cohesion and performance of healthcare teams towards the sustainability of healthcare services and patient satisfaction.

[Case management and complex chronic diseases: concepts, models, evidence and uncertainties]

Chronic diseases are the greatest challenge for Health Care, but the conventional health care models have failed noticeably. Nurses are one of the main providers of the services developed to tackle this challenge, with special emphasis on case management, as one of the most common forms. But, one of the key problems is that case management is poorly conceptualized, and with the diversity of experience available, make its development and comparative evaluation difficult. An in-depth review on case management definition and concepts is presented in this article, with a description of the models, ingredients and the effectiveness reported in various studies. The remaining uncertainties in case management, such as the heterogeneity of designs and target populations, the weak description of the components, and the scarce use of research models for complex interventions, are also discussed. Finally, some key factors for a successful implementation of case management are detailed, such as a clear definition of accountability and roles, the existence of support to guarantee the competence of case managers, the use of valid mechanisms for case finding, adjusted caseload, accessible and team-shared record systems, or the integration of health and social services.

[Panorama of self-management initiatives in Spain]

OBJECTIVE

To describe the current situation of self-management initiatives in Spain.

METHODS

We performed a descriptive study of self-management support initiatives in Spain from the perspective of the patient as expert. Three databases were searched in October 2010 (Pubmed, Scientific Electronic Library Online [SCIELO] and Indice Médico Español [IME]), using the following Keywords «paciente experto» (expert patient), «paciente activo» (active patient) and «apoyo al autocuidado» (self-management support). Web sites were also consulted, using the same key words. Of the initiatives found, we selected those with the most advanced development and continuity, using the perspective of the expert patient (in which patients have an active role) and with a systematic format and methodology. A questionnaire was designed and was sent to the heads of the selected initiatives in the last quarter of 2010. To update the information, the questionnaire was sent again between August and September, 2012. Subsequently, the web sites were visited to review their contents and presence in social networks.

RESULTS

Seven initiatives were identified in the autonomous regions of Murcia, Andalusia, Galicia, Castile-La Mancha, Basque Country, and Catalonia. These initiatives used distinct methodologies, formats and assessment systems.

CONCLUSIONS

In Spain, there is increasing interest in the development of self-management support programs, although their scope is limited and their impact is mostly unknown, except for patient satisfaction. There is a need for studies on results assessment to identify the impact of these initiatives in our setting, as well as for studies on their implementation to encourage the introduction of patient activation initiatives in routine clinical practice.