Primary Care Centers In Spain Research Articles

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children

BackgroundAntibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications.MethodsOur trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2–14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost.ResultsDAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD.ConclusionsWhen clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy.Trial registrationThis trial has been registered at www.clinicaltrials.gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Measuring depression in Primary Health Care in Spain: Psychometric properties and diagnostic accuracy of HSCL-5 and HSCL-10.

Depression has a high prevalence among European countries. Several instruments have been designed to assess its symptoms in different populations. The Hopkins Symptom Checklist 25 (HSCL-25) scale has been identified as valid, reproducible, effective, and easy to use. There are short versions of this scale that could be useful in Primary Care (PC) settings, but their psychometric properties are unknown. To assess in PC patients the psychometric properties and diagnostic accuracy of the Spanish version of the HSCL-10 and the HSCL-5 consisting of 10 and 5 items, respectively. A multicenter, cross-sectional study was carried out at six PC centers in Spain. The HSCL-25 was administered to outpatients aged 45-75 who also participated in the structured Composite International Diagnostic Interview (CIDI). HSCL-10 and HSCL-5 were assessed and compared to HSCL-25 regarding total score correlation, internal consistency, and criterion validity against the gold-standard CIDI. This is a methodological study from a secondary data analysis and the primary data has been previously published. Out of 790 patients, 767 completed the HSCL-25 and 736 the CIDI interview (96.0%). Cronbach's Alpha was 0.84 for HSCL-10 and 0.77 for HSCL-5. The known-group method and confirmatory factor analysis were acceptable for the establishment of construct validity. Sensitivity was 79.7% (CI95%, 67.7-88.0%) for HSCL-10, and 78.0% (CI95%, 65.9-86.6%) for HSCL-5, whereas specificity was 83% (CI95%, 80.0-85.7%) for HSCL-10, and 72.8% (CI95%, 69.3-76.0%) for HSCL-5. Area under the curve against CIDI was 0.88 (CI95%, 0.84-0.92%) for HSCL-10, and 0.85 (CI95%, 0.81-0.89%) for HSCL-5. Optimum cutoff point calculated with Youden Index was 1.90 for the HSCL-10 and 1.80 for the HSCL-5. HSCL-10 and HSCL-5 are reliable and valid tools to detect depression symptoms and can be used in PC settings.

Adherence to antidiabetic treatment among patients managed in primary care centres in Spain: the INTENSE study

AimsTo determine the degree and factors related to non-insulin antidiabetic drug (NIAD) adherence in people with type 2 diabetes mellitus (DM2) treated in primary carecentres in Spain. Methods: We did a cross-sectional study. During the study visit, variables related todifferent clinical characteristics, Adherence to Refills and Medications Scale Spanishversion (ARMS-e) and usage of NIAD were collected. We estimated the adherence toNIADs using the proportion of days covered (PDC) equation. Results: In total, 515 participants were included in the study. The mean PDC ratio was70.6 ( ± 28.9), and 50.5% (260) were classified as good adherent (PDC ≥80). Good adherence was highest among users of metformin (67.3%) and lowest among the participants using thiazolidinedione (0.8%). The score for ARMS-e was higher in the poor adherence group. In the multivariable analysis, HbA1c and the use of GLP1-RA or SGLT-2i were negatively associated with good adherence (odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.54, 0.82, OR: 0.20, 95%CI: 0.08, 0.46; OR: 0.56, 95%CI: 0.35, 0.89, respectively). Conclusions: Adherence to NIADs observed in our study is far from optimal. HbA1c and ARMS-e items could be used as adherence indicators to encourage treatment changes to improve T2DM control.

Working Environment, Personal Protective Equipment, Personal Life Changes, and Well-Being Perceived in Spanish Nurses during COVID-19 Pandemic: A Cross-Sectional Study.

During the COVID-19 pandemic, nurses have had to face logistical problems related to critical changes in their work environment, the supply of personal protective equipment (PPE), and hard personal life decisions. This study aimed to investigate the changes in the working environment, PPE use, personal lives, and well-being as perceived by nurses in hospitals and primary care centers in Spain, during the COVID-19 pandemic. A descriptive cross-sectional survey study was conducted in April 2020, including 61 public and private hospitals, and 852 primary care centers. A total of 1296 nurses participated. The redeployment practice for organizational or vulnerability reasons was used by 26.4% of the participants. A total of 61.9% of the nurses doubled the time they used masks, and 8.3% of them could only replace the mask once a week. A total of 11.2% (n = 145) of the nurses left home to avoid infecting their family. Finally, 60.97% of the participants stated that their well-being was reduced compared to the state before the pandemic. Changes in the work environment, the use of PPE, and personal life may be related to the decrease in personal well-being perceived by the nurses.

Management of burnout among the staff of primary care centres in Spain during the pandemic caused by the SARS-CoV-2

BackgroundThe provision of healthcare during the pandemic caused by the SARS-CoV-2 virus represented a challenge for the management of the resources in the primary care centres. We proposed assessing burnout among the staff of those centres and identifying factors that contributed to its appearance and those that limited it.MethodsAn observational study which, by means of anonymous questionnaires, collected information about: (i) demographic variables; (ii) the characteristics of each position; (iii) the measures implemented by the medical decision-makers in order to provide care during the pandemic; and (iv) the Burnout Clinical Subtype Questionnaire (BCSQ-36). We performed a descriptive analysis of the burnout mentioned by the staff, and, by means of a multivariate analysis, we identified the factors which influenced it. Using logit models, we analysed whether receiving specific training in COVID-19, feeling involved in decision-making processes, and/or working within different healthcare systems had effects on the development of burnout.ResultsWe analysed the replies of 252 employees of primary care centres in Spain with an average age of 45 (SD = 15.7) and 22 (SD = 11.4) years of experience. 68% of the participants (n = 173) indicated burnout of the frenetic subtype. 79% (n = 200) of the employees had high scores in at least one burnout subtype, and 62% (n = 156) in at least two. Women older than 45 had a lower probability of suffering burnout. Receiving specific training (OR = 0.28; CI95%: 0.11–0.73) and feeling involved in decision-making (OR = 0.32; CI95%:0.15–0.70) each reduced the probability of developing burnout. Working in a different department increased the likelihood of developing burnout of at least one clinical subtype (OR = 2.85; CI95%: 1.38–5.86).ConclusionsThe staff in primary care centres have developed high levels of burnout. Participation in decision-making and receiving specific training are revealed as factors that protect against the development of burnout. The measures taken to contain the adverse effects of a heavy workload appear to be insufficient. Certain factors that were not observed, but which are related to decisions taken by the healthcare management, appear to have had an effect on the development of some burnout subtypes.

Economic Impact of Low Adherence to COPD Management Guidelines in Spain.

ObjectiveThe objective of this study was to assess the non-adherence level of Spanish clinical practice to guideline recommendations for the treatment of chronic obstructive pulmonary disease (COPD) and to estimate the potential impact on pharmaceutical expenditure resulting from transitioning current treatment patterns according to guidelines.MethodsA model was developed to compare current prescribing patterns with two alternative scenarios: the first aligned with the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2020) recommendations, and the second with the Spanish Guidelines for COPD (GesEPOC 2017). Current treatment practice was obtained from publications that describe treatment patterns by pulmonology departments in Spain. The economic impact between patterns was calculated from the perspective of the Spanish National Health System (NHS), considering the annual pharmacological costs of COPD inhaled maintenance therapy. Two additional analyses were performed: one that included current prescribing patterns of patients managed by pulmonology and primary care centers in Spain (published aggregated data); and another that only considered the appropriate use of inhaled corticosteroids (ICS) treatment according to guidelines.ResultsIt was estimated that 54% and 38% of patients were not treated in line with GOLD and GesEPOC recommendations, respectively, mainly due to a broader use of ICS-based therapies. Adapting treatment to recommendations could provide a potential annual cost-saving of €17,792,022 (according to GOLD) and €5,881,785 (according to GesEPOC). In scenario analysis 1, a 26% of non-adherence to GesEPOC guideline was observed with a potential annual pharmacological cost-saving of €2,707,554. In scenario analysis 2, considering only inappropriate use of ICS treatment, an annual cost-saving of €17,863,750 (according to GOLD) and €9,904,409 (according to GesEPOC) was calculated.ConclusionMore than a third of treatments for COPD patients in Spain are not prescribed in accordance with guideline recommendations. The adaptation of clinical practice to guideline recommendations could provide important cost-savings for the Spanish NHS.

Use of heuristics during the clinical decision process from family care physicians in real conditions.

The available evidence on the use of heuristics and their relationship with diagnostic error in primary care is very limited. The aim of the study is to identify the use of unknown thought and specifically the possible use of Representativeness, Availability and overconfidence heuristics in the clinical practice of primary care physicians in cases of dyspnoea and to analyse their possible relationship with diagnostic error. A total of 371 patients consulting with new episodes of dyspnoea in Primary Care centres in Spain were registered. Based on specific operational definitions, the use of unconscious thinking and the use of heuristics during the diagnostic process were assessed. Subsequently, the association between their use and diagnostic error was analysed. In 49.6% of cases, the confirmatory diagnosis coincided with the first diagnostic impression, suggesting the use of the representativeness heuristic in the diagnostic decision process. In 82.3% of the cases, the confirmatory diagnosis was among the three diagnostic hypotheses that were first identified by the general physicians, suggesting a possible use of the availability heuristic. In more than 50% of the cases, the physicians were overconfident in the certainty of their own diagnosis. Finally, a diagnostic error was identified in 9.9% of the recorded cases and no statistically significant correlation was found between the use of some unconscious thinking tools (such as the use of heuristics) and the diagnostic error. Unconscious thinking manifested through the acceptance of the first diagnostic impression and the use of heuristics is commonly used by primary care physicians in the clinical decision process in the face of new episodes of dyspnoea; however, its influence on diagnostic error is not significant. The proposed explicit and reproducible methodology may inspire further studies to confirm these results.

Validation and Psychometric Properties of the Spanish Version of the Hopkins Symptom Checklist-25 Scale for Depression Detection in Primary Care.

Depression constitutes a major public health problem due to its high prevalence and difficulty in diagnosis. The Hopkins Symptom Checklist-25 (HSCL-25) scale has been identified as valid, reproducible, effective, and easy to use in primary care (PC). The purpose of the study was to assess the psychometric properties of the HSCL-25 and validate its Spanish version. A multicenter cross-sectional study was carried out at six PC centers in Spain. Validity and reliability were assessed against the structured Composite International Diagnostic Interview (CIDI). Out of the 790 patients, 769 completed the HSCL-25; 738 answered all the items. Global Cronbach’s alpha was 0.92 (0.88 as calculated for the depression dimension and 0.83 for the anxiety one). Confirmatory factor analysis (CFA) showed one global factor and two correlated factors with a correlation of 0.84. Area under the curve (AUC) was 0.89 (CI 95%, 0.86–0.93%). For a 1.75 cutoff point, sensibility was 88.1% (CI 95%, 77.1–95.1%) and specificity was 76.7% (CI 95%, 73.3–79.8%). The Spanish version of the HSCL-25 has a high response percentage, validity, and reliability and is well-accepted by PC patients.

Improving Therapeutic Adherence of Oral Antidiabetics in Insulin-Dependent Patients with Type 2 Diabetes Mellitus: the Combination of a Fixed-Dose

Objective: To assess whether the combination of fixed-dose Oral Antidiabetic drugs (OA) in a single tablet compared to OA separated into 2 or more tablets is an effective strategy to improve adherence in insulin-dependent patients with Type 2 Diabetes Mellitus (DM2). Methods: This was a prospective, longitudinal, multi-center study, carried out in 3 primary care centers in Spain. One hundred and twenty patients treated with OA and insulin prescribed for insulin-dependent DM2 were included. A cluster randomization was performed based on two groups: (1) Control Group (CG): Sixty patients treated with two OA prescribed separately in different tablets, and (2) an Intervention Group (IG): Sixty patients treated with OA were with 2 drugs in combination at a fixed dose, in a single tablet. Three visits took place. AO Adherence was measured by using electronic monitors (MEMS). Average adherence percentage (%; Average AP) and daily compliance (%; Daily AP) was calculated. A patient was considered adherent when AP was 80–100%. Insulin adherence was measured by counting. Results: One hundred and ten patients completed the study (79 in the IG and 31 in the CG). Global adherence was 92,59% and 79,62% in IG and 82,85% and 48,21% in CG at 6 and 12 months, respectively (p<0.05 by groups). Daily adherence was 79,62% and 62,96% in IG and 17,85% and 10,71% in CG at 6 and 12 months, respectively (p<0.05). Global adherence with insulin by count was 77,78% and 70,37% in IG and 57,14% and 60,71% in CG at 6 and 12 months, respectively with significant differences. In the non-adherent group, the number of concomitant medications and glucemia and haemoglobin A glycosylate levels at 6 and 12 months, were significantly higher than in the adherent population. The NNT was 4,42 patients to prevent one non-adherence. Conclusions: The combination of fixed-dose OA in a single tablet compared to OA separated into 2 or more tablets is an effective strategy to improve AO therapeutic adherence in patients with insulin-dependent DM2.

Interventions Incorporating Interdisciplinary Teaming to Improve Chronic Pain Management in Primary Care: A Systematic Review

Current chronic pain management recommendations emphasize leveraging interdisciplinary care models, which rely on communication, coordination, and collaboration among multiple providers. We aimed to identify key features of interdisciplinary teamwork and teaming processes that facilitate improved pain outcomes for patients experiencing chronic pain in primary care settings. We searched PubMed, EMBASE, CINAHL, and the Cochrane Library for English language, randomized studies published after 2009. Included studies had to report patient-reported pain outcomes (i.e. BPI total pain), include primary care as an intervention setting, and involve interactions between at least two providers and the patient over time. We assessed study quality with the Cochrane Risk of Bias tool. We qualitatively synthesized findings on intervention characteristics related to teamwork and teaming processes and patient pain outcomes. PROSPERO Registration: CRD42020191467. We included 13 randomized studies with 14 total interventions in our review, of which 7 reported one or more significantly improved pain outcome compared to controls over 6 to 12 months of observation. Most studies involved multiple primary care practices in the USA or Canada. Five studies were evaluated either within the Indianapolis Veterans Affairs Medical Center (VAMC) or the Portland VAMC. Other studies took place in primary care centers in Spain, Finland, the UK, and the Netherlands. Interventions with positive pain outcomes often described regularly scheduled patient contact, but there were few identified similarities about the communication, coordination, and collaboration processes among clinical intervention members. Care management and patient follow-up schedules were identified as key characteristics of teamwork or teaming in the interventions associated with improved pain outcomes. Despite widespread emphasis on interdisciplinary teams for pain management, high quality evidence about relevant team structures and teamwork and teaming processes remains limited. Care management and patient follow-up characterized primary care-based interventions involving teaming associated with improved pain outcomes.

Assessing the Impact of Multi-Morbidity and Related Constructs on Patient Reported Safety in Primary Care: Generalized Structural Equation Modelling of Observational Data.

We aimed to examine the complex relationships between patient safety processes and outcomes and multimorbidity using a comprehensive set of constructs: multimorbidity, polypharmacy, discordant comorbidity (diseases not sharing either pathogenesis nor management), morbidity burden and patient complexity. We used cross-sectional data from 4782 patients in 69 primary care centres in Spain. We constructed generalized structural equation models to examine the associations between multimorbidity constructs and patient-reported patient safety (PREOS-PC questionnaire). These associations were modelled through direct and indirect (mediated by increased interactions with healthcare) pathways. For women, a consistent association between higher levels of the multimorbidity constructs and lower levels of patient safety was observed via either pathway. The findings for men replicated these observations for polypharmacy, morbidity burden and patient complexity via indirect pathways. However, direct pathways showed unexpected associations between higher levels of multimorbidity and better safety. The consistent association between multimorbidity constructs and worse patient safety among women makes it advisable to target this group for the development of interventions, with particular attention to the role of comorbidity discordance. Further research, particularly qualitative research, is needed for clarifying the complex associations among men.

Анализ антитромботической терапии у пожилых людей во врачебной клинической практике центров семейной медицины Кыргызской Республики

Введение. Риски тромбоза и кровотечения с возрастом увеличиваются одновременно, при этом пожилой контингент извлекает больше пользы от антитромботической терапии, чем лица молодого возраста. Цель исследования: изучить ситуацию с назначением антикоагулянтной терапии у пациентов пожилого и старческого возраста с фибрилляцией предсердий (ФП) при центрах семейной медицины южных регионов Кыргызской Республики. Материалы и методы. Из 2000 амбулаторных карт медицинского наблюдения отобрано 470 пациентов с неклапанной ФП, которые имели показания для назначения антитромботической терапии: 187 (39,8%) мужчин, 283 (60,2%) женщины, из них 212 (45,1%) городских жителей и 258 (54,9%) сельских жителей. Средний возраст обследованных составил 69,5 ± 10,2 лет. Результаты. Из 377 (80,2%) пациентов должная антикоагулянтная терапия была назначена 162 (42,9%), антиагрегантная терапия — 191 (50,6%), и терапия не была назначена 24 (6,4%) больным при наличии абсолютных показаний. В качестве антикоагулянтной терапии 148 больным был назначен варфарин, адекватная антикоагуляция к концу года составила всего 12,2%. Новый оральный антикоагулянт — ривароксабан был назначен 14 (8,6%) пациентам. Врачами-терапевтами сельской местности 50% больным при необходимости антикоагулянтов была назначена антиагрегантная терапия. Заключение. В южных регионах республики наблюдается неблагоприятная ситуация с назначением антикоагулянтной терапии и ведением пациентов пожилого и старческого возраста. Необходимо продолжить исследования по другим регионам страны для получения полноценной и реальной картины по проблеме и выработки единой и соответствующей рекомендации. Background. The risks of thrombosis and bleeding increase simultaneously with age. At the same time, the elderly population derives more benefit from antithrombotic therapy than young individuals. Objectives: to study the current state of the anticoagulant therapy prescription for elderly and senile patients with atrial fibrillation (AF) at the centers of family medicine in the southern regions of the Kyrgyz Republic. Patients/Methods. From 2000 outpatient medical records, 470 patients with nonvulvar AF were selected who had indications for prescribing antithrombotic therapy: 187 (39.8%) men, 283 (60.2%) women; 212 (45.1%) were urban residents and 258 (54.9%) were village residents. The average age was 69.5 ± 10.2 years. Results. From among 377 (80.2%) patients, needful anticoagulant therapy was prescribed to 162 (42.9%), 191 (50.6%) patients received antiplatelet therapy and therapy was not prescribed to 24 (6.4%) patients in the presence of absolute indications. Warfarin as anticoagulant therapy was prescribed to 148 patients; adequate anticoagulation by the end of the year was only 12.2%. A new oral anticoagulant — rivaroxaban was prescribed to 14 (8.6%) patients. In non-urban area primary care physicians prescribed antiplatelet therapy to 50% of patients who needed anticoagulants. Conclusions. An unfavorable situation is observed with the prescription of anticoagulant therapy and management of elderly and senile patients in the southern regions of the republic. It is necessary to continue study in other regions of the country in order to obtain a complete and real picture of the problem, and to develop a unified and relevant recommendation.

Transdiagnostic group cognitive behavioural therapy for emotional disorders in primary care: the results of the PsicAP randomized controlled trial.

Emotional disorders are highly prevalent in primary care. We aimed to determine whether a transdiagnostic psychological therapy plus treatment-as-usual (TAU) is more efficacious than TAU alone in primary care adult patients. A randomized, two-arm, single-blind clinical trial was conducted in 22 primary care centres in Spain. A total of 1061 adult patients with emotional disorders were enrolled. The transdiagnostic protocol (n = 527) consisted of seven 90-min sessions (8-10 patients) delivered over a 12-14-week period. TAU (n = 534) consisted of regular consultations with a general practitioner. Primary outcome measures were self-reported symptoms of anxiety, depression, and somatizations. Secondary outcome measures were functioning and quality of life. Patients were assessed at baseline, post-treatment, and at 3, 6, and 12 months. Intention-to-treat and per-protocol analyses were performed. Post-treatment primary outcomes were significantly better in the transdiagnostic group compared to TAU (anxiety: p < 0.001; Morris's d = -0.65; depression: p < 0.001; d = -0.58, and somatic symptoms: p < 0.001; d = -0.40). These effects were sustained at the 12-month follow-up (anxiety: p < 0.001; d = -0.44; depression: p < 0.001; d = -0.36 and somatic symptoms: p < 0.001; d = -0.32). The transdiagnostic group also had significantly better outcomes on functioning (d = 0.16-0.33) and quality of life domains (d = 0.24-0.42), with sustained improvement at the 12-month follow-up in functioning (d = 0.25-0.39) and quality of life (d = 0.58-0.72). Reliable recovery rates showed large between-group effect sizes (d > 0.80) in favour of the transdiagnostic group after treatment and at the 12-month follow-up. Adding a brief transdiagnostic psychological intervention to TAU may significantly improve outcomes in emotional disorders treated in primary care. isrctn.org identifier: ISRCTN58437086.

Limitación auditiva y fragilidad social en hombres y mujeres mayores

ObjectiveTo explore the association between hearing loss and social frailty in a sample of Spanish older adults recruited from primary health care network. MethodCross-sectional study on a sample of 445 non-institutionalized adults aged 65 or more years (190 men and 255 women), recruited from primary care centers in Spain. Three self-reported hearing impairment questions were used to assess hearing loss. Social frailty was deemed to exist when the person presented two or more of the following conditions: living alone, absence of a person to provide help, infrequent contact with family, infrequent contact with friends, lack of confident and lack of help for daily activities in the last 3 months. To study the association between hearing loss and social frailty we used logistic regression models adjusted for potential confounders, including physical frailty. ResultsThe mean age of participants was 76.2 years (77.5 years for women). More than half of the participants (54.4%) reported hearing loss and the frequency of social frailty was 23.2%. Hearing loss was associated with social frailty (adjusted odds ratio [aOR]=1.78; 95% confidence interval [95%CI]: 1.04-3.06). However, the association was sex-dependent (p for interaction=0.041). In stratified analysis, the association was only found in women (aOR=3.21; 95%CI: 1.44-7.17). ConclusionsHearing loss was associated with social frailty in women, but not in men. Longitudinal studies are needed to confirm this association and to understand the differential effect of gender.

Association of clinic and ambulatory heart rate parameters with mortality in hypertension.

Resting heart rate (HR) taken in the office has been shown to be associated with cardiovascular outcomes in the general population, hypertension and heart failure. It is unknown whether 24-h oscillographic pulse rate measurement as an approximation of HR derived from ambulatory blood pressure monitoring (ABPM) associates with cardiovascular outcomes in hypertensive patients. We evaluated ABPM recordings from 56 901 patients with complete 3373 421 HR measures entering the final analysis from the Spanish Blood Pressure Monitoring Registry for a median follow-up time of 5.1 years. We explored the association of office HR, mean 24-h HR, mean day HR, mean night HR as well as day-night HR differences, morning mean HR, morning HR surge and night peak HR to all-cause death, cardiovascular death and noncardiovascular death. Data were analyzed by Cox regression analysis, analysis of variance and chi-square test. The Spanish ABPM Registry recorded data in 223 primary care centers in Spain from 2004 until 31 December 2014 at the end of recruitment. Office HR was 3.5 bpm higher than mean 24-h HR, office mean HR versus mean night was 10.4 bpm higher and mean day versus mean night HR 9.3 bpm higher, while there were no relevant difference between office and mean day HR. Office mean, 24-h day and night HR more than 90 bpm were associated with an increased risk for all-cause and noncardiovascular death, whereas for cardiovascular death only mean night HR was predictive. The strongest association to all-cause death was observed with mean night HR [hazard ratio 3.80 (2.87-5.03)], mean 24-h HR [2.85 (2.30-3.54)] and mean day HR [2.22 (1.83-2.70)]. Day-night dipping of more than 8 bpm was associated with a 20% lesser risk on all-cause, cardiovascular and noncardiovascular death. Results were robust after adjusting for relevant risk indicators. HR parameters derived from ABPM provide important information, in particular association with death by mean night HR, mean 24-h HR and reduced day-night HR dipping less than 8 bpm superior to office HR.

Effect of health professional intervention on adherence to statin use according to the cause of patient non-adherence.

Background Non-adherence is a problem that particularly affects those with chronic diseases. Studying causes for not following the treatment is necessary to choose the best intervention to improve non-adherence. Objective Analyze how the intentionality of non-adherence modulates the effects of professional intervention in patients with hypercholesterolemia.Setting: Community pharmacies and primary care centres in Spain. Methods A6-month randomized controlled trial was conducted in 46 community pharmacies and 50 primary care centres in Spain. Adherence to statin therapy was measured with the Morisky-Green-Levine test. Non-adherence was classified based on the intentionality. Results 746 Patientswere recruited for the study (465 non-adherent and 281 adherent). Of those,237 were randomly assigned to the intervention group and 228 to the non-intervention group. The 56.5% of non-adherent patients were classified as unintentional non-adherents and 43.5% as intentional non-adherents. More patients in the intervention group finished being adherent compared with the non-intervention group (+ 17.2% for intentional non-adherents and + 27.4% for unintentional non-adherence). The percentage of patients in the intervention group who completed the study as adherent was higher among those who previously had unintentional non-adherence (66.4%) compared to those with intentional non- adherence (55.3%) (p < 0.001). Conclusion Intervention provided to patients with unintentional non-adherence was more effective than intervention provided to patients with intentional non- adherence.

Effectiveness of a decision aid for promoting colorectal cancer screening in Spain: a randomized trial

BackgroundColorectal cancer (CRC) screening has shown to reduce incidence and mortality rates, and therefore is widely recommended for people above 50 years-old. However, despite the implementation of population-based screening programs in several countries, uptake rates are still low. Decision aids (DAs) may help patients to make informed decisions about CRC screening.MethodsWe performed a randomized controlled trial to assess the effectiveness of a DA developed to promote CRC screening, with patients from two primary care centers in Spain who never had underwent CRC screening. Contrary to center B (n = 24), Center A (n = 83) attended patients from an area where the population-based screening program was not implemented at that moment. Outcome measures were decisional conflict, knowledge of the disease and available screening options, intention to uptake the test, and concordance between patients’ goals/concerns and intention.ResultsIn center A, there were significant differences favoring the DA in decisional conflict (p < 0.001) and knowledge (p < 0.001). The absolute differences favoring DA group in intention to undergo fecal occult blood test (10.5%) and colonoscopy (13.7%) were significant only before correction for attenuation. In center B the differences were significant only for knowledge (p < 0.001). Patients’ goals and concerns regarding the screening did not significantly predict their intention, and therefore we could not calculate a measure of concordance between the two constructs.ConclusionsA DA improved the decisional process of participants who had never been invited to participate in the Spanish public CRC screening program, replicating previous results in this field. Future research is needed to identify subgroups that could benefit more from these interventions.Trial registrationInternational Standard Registered Clinical/social Study Number: ISRCTN98108615 (Retrospectively registered on 27 December 2018).

Exploring Efficacy of a Serious Game (TOBBSTOP) for Smoking Cessation in Pregnant Women: Pilot Case-Control Study

Background: Tobacco use entails, during pregnancy, a serious risk to the mother and harmful effects on the development of the child. Europa has the highest tobacco smoking prevalence (19.3%) as compared to a worldwide mean of 6.8%. Twenty to thirty percent of pregnant women used tobacco during pregnancy worldwide. These data emphasize the urgent need for community education and implementation of prevention strategies focused on risks associated to tobacco use during pregnancy. Objective: This study aims to investigate the possibility to address this problem through a serious game (TOBBSTOP), something that has proven efficient as a tool for learning in many situations. By using a game for smoke cessation during pregnancy, we aim to maintain cessation and interest pregnant smokers in learning about health care and effects of tobacco by playing a game that helps them to achieve their challenge. Methods: A pilot case-control study enrolls 44 women who were visited in two primary care centers in Spain between March 2015 and November 2016. All participants were pregnant smokers over the age of 17 years attending consultation to a midwife during the first trimester of pregnancy who expressed their desire to stop smoking. We recruited the intervention group (n=22) among the attended on the centers and instructed them to install the game on their smartphone or tablet and use it for 3 months. Until the delivery, all participants had to respond to a questionnaire, assessing their stage on smoke cessation during their follow-up midwife consultations. The selected control group participants (n=22), matched for age, level of tobacco-dependence and number of smoking attempts. We tested the amount of CO at each visit with a carboxymeter during the entire intervention period to assess the abstinence. Results: Pregnant women from the intervention group, with 80.0% (12/15), had significant higher rates of cessation until delivery than control group (χ2=8.4; P=.004). Logistic regression analyses revealed that game’s use was associated with an increased likelihood to maintain smoking cessation during the intervention period compared with those not using the game (odds ratio 4.0; 95% CI 1.3-12.2). Additionally, a Mantel-Cox means’ analysis revealed that the use of the game was associated with an increased number of days without smoking, with an average of 139.7 days (95% CI 97.1-182.4) in the intervention group (χ2=13.912; P<.001). Conclusions: Pregnancy is an ideal opportunity to intervene and control tobacco use among future mothers. On the other hand, serious games is an emerging technology, growing in importance, which is shown as a good tool to assist in maintaining women without smoking and help behavior change during pregnancy. However, due to study design limitations, these outcomes should be interpreted with caution. More research, using larger samples and longer follow-up periods, is needed to replicate the findings of this study.

The association between different domains of quality of life and symptoms in primary care patients with emotional disorders

Despite the importance of quality of life (QoL) in primary care patients with emotional disorders, the specific influence of the symptoms of these disorders and the sociodemographic characteristics of patients on the various QoL domains has received scant attention. The aim of the present study of primary care patients with emotional disorders was to analyse the associations between four different QoL domains and the most prevalent clinical symptoms (i.e., depression, anxiety and somatization), while controlling for sociodemographic variables. A total of 1241 participants from 28 primary care centres in Spain were assessed with the following instruments: the Patient Health Questionnaire (PHQ)-9 to evaluate depression; the Generalized Anxiety Disorder Scale (GAD)-7 for anxiety; PHQ-15 for somatization; and the World Health Organization Quality of Life Instrument-Short Form (WHOQOL-Bref) to assess four broad QoL domains: physical health, psychological health, social relationships, and environment. The associations between the symptoms and QoL domains were examined using hierarchical regression analyses. Adjusted QoL mean values as a function of the number of overlapping diagnoses were calculated. The contribution of sociodemographic variables to most QoL domains was modest, explaining anywhere from 2% to 11% of the variance. However, adding the clinical variables increased the variance explained by 12% to 40% depending on the specific QoL domain. Depression was the strongest predictor for all domains. The number of overlapping diagnoses adversely affected all QoL domains, with each additional diagnosis reducing the main QoL subscales by 5 to 10 points. In primary care patients with a diagnostic impression of an emotional disorders as identified by their treating GP, clinical symptoms explained more of the variance in QoL than sociodemographic factors such as age, sex, level of education, marital status, work status, and income. Given the strong relationship between depressive symptoms and QoL, treatment of depression may constitute a key therapeutic target to improve QoL in people with emotional disorders in primary care.

Community Assessment of COPD Health Care (COACH) study: a clinical audit on primary care performance variability in COPD care

BackgroundA thorough evaluation of the adequacy of clinical practice in a designated health care setting and temporal context is key for clinical care improvement. This study aimed to perform a clinical audit of primary care to evaluate clinical care delivered to patients with COPD in routine clinical practice.MethodsThe Community Assessment of COPD Health Care (COACH) study was an observational, multicenter, nationwide, non-interventional, retrospective, clinical audit of randomly selected primary care centers in Spain. Two different databases were built: the resources and organization database and the clinical database. From January 1, 2015 to December 31, 2016 consecutive clinical cases of COPD in each participating primary care center (PCC) were audited. For descriptive purposes, we collected data regarding the age at diagnosis of COPD and the age at audit, gender, the setting of the PCC (rural/urban), and comorbidities for each patient. Two guidelines widely and uniformly used in Spain were carefully reviewed to establish a benchmark of adequacy for the audited cases. Clinical performance was analyzed at the patient, center, and regional levels. The degree of adequacy was categorized as excellent (> 80%), good (60–80%), adequate (40–59%), inadequate (20–39%), and highly inadequate (< 20%).ResultsDuring the study 4307 cases from 63 primary care centers in 6 regions of the country were audited. Most evaluated parameters were judged to fall in the inadequate performance category. A correct diagnosis based on previous exposure plus spirometric obstruction was made in an average of 17.6% of cases, ranging from 9.8 to 23.3% depending on the region. During the audited visit, only 67 (1.6%) patients had current post-bronchodilator obstructive spirometry; 184 (4.3%) patients had current post-bronchodilator obstructive spirometry during either the audited or initial diagnostic visit. Evaluation of dyspnea was performed in 11.1% of cases. Regarding treatment, 33.6% received no maintenance inhaled therapies (ranging from 31.3% in GOLD A to 7.0% in GOLD D). The two most frequently registered items were exacerbations in the previous year (81.4%) and influenza vaccination (87.7%).ConclusionsThe results of this audit revealed a large variability in clinical performance across centers, which was not fully attributable to the severity of the disease.