[Variability of medical practice in sinusitis as a function of resource utilization]. / Variabilidad de la práctica médica ante una sinusitis en función del consumo de recursos.

OBJECTIVE: To find what factors linked to the doctor affect the variability of clinical practice. DESIGN: Cross-sectional descriptive study through a clinical interview with a fictitious complaint (sinusitis). SETTING: Asturias health centres. PARTICIPANTS: 132 doctors chosen through conglomerate sampling. MEASUREMENTS AND MAIN-RESULTS: Social and professional variables of the doctor (sex, age, years in practice, postgraduate training, courses, recycling courses and distance to the referral centre) were gathered. After the case was presented, the doctor's actions were noted and the cost in pesetas of each action was noted. Cost and the consumption of resources were related to the personal variables of the doctors through multivariate analysis. Mean total expenditure was 76,592 pesetas (minimum: 8958; maximum: 244,220), of which 55,550 were for short-term time off work (average of ten days off) and 15,261 for the consultations made. Average cost of treatment was 3762 pesetas. Through multiple linear regression, the only variable that showed significant effect on expenditure was distance to the referral centre (the greater the distance, the less expenditure). On transforming the total expenditure variable into a dichotomous variable (above and below the mean), the variables with significant effect on less expenditure were courses done, greater distance from the referral centre and being a woman. CONCLUSIONS: There is a very broad variability in decision-taking before the same clinical problem. The only variables that explain (and only partially) an expenditure trend are sex, distance to the referral centre and doing courses.

Variabilidad de la práctica médica ante una sinusitis en función del consumo de recursos / Variability of medical practice in sinusitis as a function of consumption of resources

Objetivo. Conocer qué factores ligados al profesional influyen en la variabilidad de la práctica clínica. Diseño. Descriptivo transversal, mediante entrevista clínica con caso ficticio (sinusitis). Emplazamiento. Centros de salud de Asturias. Participantes. Ciento treinta y dos médicos seleccionados mediante muestreo por conglomerados. Mediciones y resultados principales. Se recogieron variables socioprofesionales del médico (sexo, edad, años de ejercicio, formación posgrado, cursos, reciclajes y distancia al centro de referencia). Tras presentar el caso, se anotaron las acciones que realizó el facultativo, y se calculó el gasto en pesetas de cada acción realizada. Se relacionó el gasto y el consumo de recursos con las variables personales de los médicos mediante análisis multivariante. El gasto total medio fue de 76.592 pts. (mínimo, 8.958; máximo, 244.220), de las que 55.550 corresponden a incapacidad temporal (media de 10 días de baja) y 15.261 a las consultas realizadas. El coste medio del tratamiento fue de 3.762 pts. Mediante regresión lineal múltiple, la única variable que mostró influencia significativa sobre el gasto fue la distancia al centro de referencia (a mayor distancia, menor gasto). Al transformar la variable gasto total en dicotómica (por encima y por debajo de la media), las variables que influían significativamente para un menor gasto eran haber realizado cursos, mayor distancia al centro de referencia y ser mujer. Conclusiones. Existe una amplísima variabilidad en la toma de decisiones ante un mismo problema clínico. Las únicas variables que explican (sólo parcialmente) una tendencia en el gasto son el sexo, la distancia al centro de referencia y la realización de cursos (AU)

[Factors associated with arterial distensibility in hypertension]. / Factores relacionados con la distensibilidad arterial en la hipertensión.

OBJECTIVE: To find out what variables affect changes in arterial compliance in subjects with hypertension by measuring their pulse wave velocity (PWV). DESIGN: Cross-sectional, descriptive study. SETTING: Rural health centre. PATIENTS: 156 hypertense patients under 76, chosen by simple random sampling from those on the hypertension register. MEASUREMENTS AND INTERVENTIONS: We determined the degree of hypertension, years of evolution, systolic pressure (SBP), diastolic pressure (DBP), body mass index (BMI), glucaemia, whether lipaemia existed, diabetes or glucose intolerance, tobacco habit, age, sex and PWV (measured automatically by computer). We performed multivariate analysis by means of multiple linear regression, with PWV as the dependent variable, and age, SBP, DBP, BMI, years of evolution of hypertension, cholesterol, triglycerides and glucaemia as independent variables. RESULTS: Mean age 62.5 (SD 8.8). 28.2% male. Mean SBP 153 (SD 18.9). Mean DBP 87 (SD 10.3). Mean years of evolution 10.4 (SD 7.4). Mean BMI 31.2 (SD 4.9). Hyperglucaemia 24.4%. Mean glucaemia 111.3 (SD 29). Mean PWV 11.82 (SD 2.37). PWV was above the theoretically normal figures in 69.2% of cases. Multiple linear regression showed that the variables which affected PWV significantly were age, SBP and hyperglucaemia. CONCLUSIONS: Arterial compliance can be improved by controlling SBP, given that the other related factors cannot be changed.

Factores relacionados con la distensibilidad arterial en la hipertensión / Factors relating to arterial compliance in hypertension

Objetivo. Averiguar qué variables influyen en las alteraciones de la distensibilidad arterial en los sujetos hipertensos mediante medición de la velocidad de onda de pulso (VOP). Diseño. Estudio descriptivo transversal. Ámbito. Centro de salud rural. Sujetos. Ciento cincuenta y seis pacientes hipertensos menores de 76 años, seleccionados por medio de muestreo aleatorio simple entre los incluidos en el registro de hipertensión arterial (HTA). Mediciones e intervenciones. Determinamos grado de HTA, años de evolución, tensión arterial sistólica (TAS) y diastólica (TAD), índice de masa corporal (IMC), glucemia, existencia de dislipemia, diabetes o intolerancia a la glucosa, hábito tabáquico, edad, sexo y VOP (medición automática por ordenador). Realizamos análisis multivariante mediante regresión lineal múltiple, siendo la variable dependiente la VOP y las independientes edad, TAS, TAD, IMC, años de evolución de la HTA, colesterol, triglicéridos y glucemia. Resultados. Edad media 62,5 (DE, 8,8); el 28,2 por ciento varones; TAS media, 153 (DE, 18,9); TAD media, 87 (DE, 10,3); media de años de evolución, 10,4 (DE, 7,4); IMC medio, 31,2 (DE, 4,9); hiperglucemia, 24,4 por ciento; glucemia media, 111,3 (DE, 29); VOP media, 11,82 (DE, 2,37). La VOP era superior a las cifras normales teóricas en un 69,2 por ciento. La regresión lineal múltiple mostró que las variables que influyen significativamente en la VOP son edad, TAS e hiperglucemia. Conclusiones. La mejora de la distensibilidad arterial puede obtenerse controlando la TAS, puesto que los otros factores relacionados son inmodificables (AU)

[The validation of checklists for the inhalation technic for the pressurized cartridge and the Turbuhaler]. / Validación de listas de comprobación de la técnica de inhalación para cartucho presurizado y Turbuhaler.

OBJECTIVE: To determine the intra- and interobserver validity and reliability of two checklists for inhalation technique with a pressurized inhaler (PI) and the Turbuhaler. MATERIAL AND METHODS: Transversal descriptive study performed at an urban health clinic in Gijón (Spain). Thirty-four patients, over 14 years of age but younger than 65, who used a PI and 35 who used a Turbuhaler were chosen randomly from among patients in our health clinic practice. The results obtained with each list by two observers were compared with those obtained by electronic monitors (test pattern). Each patient performed 3 inhalation maneuvers. RESULTS: Comparison with the test pattern showed that, between 35.2% and 47% of patients used the PI technique correctly, whereas 74.2% inhaled correctly using the Turbuhaler. The sensitivity of the PI checklist ranged from 62.5 to 91.6 and specificity ranged from 88.8 to 94.4. The sensitivity of the Turbuhaler checklist ranged from 50 to 76.9 specificity ranged from 66.6 to 88.8. Intra-observer agreement (Kappa index) was 0.62 to 0.74 for the PI checklist and between 0.77 and 0.81 for the Turbuhaler list. Interobserver agreement (Kappa index) was 0.68 to 0.81 for the PI list and 0.53 to 0.60 for the Turbuhaler list. CONCLUSIONS: The two checklists are valid instruments and offer good intra- and interobserver reliability, permitting easy identification of patients who perform the inhalation technique incorrectly.

[Specialized care and primary care in the treatment of asthma: do differences exist?]. / Atención especializada y atención primaria en el tratamiento del asma: Existen diferencias?

OBJECTIVE: To determine whether differences exist in the monitoring, diagnosis and treatment of asthmatic patients between family doctors (FD) and pneumology specialists (PD). DESIGN: A descriptive crossover study, performed through an interview with the patients and a medical exploration. SETTING: Six health centres. PATIENTS: 195 asthmatic patients between 14 and 65, chosen by simple random sampling from among all those registered by computer in the SICAP. MEASUREMENTS AND MAIN RESULTS: Each patient answered a structured interview and had a spirometry test. Which doctor usually monitored their illness, social and demographic data, morbidity parameters, treatment prescribed and their compliance with it, were all determined. 66% of patients were under their FD. No differences were found in the clinical characteristics of patients treated by their FD against those treated by their PD. CONCLUSIONS: Most adult asthmatics are under the care of FDs; however, these appear to under-treat to a considerable degree, especially respecting the use of inhaled corticosteroids. It must be emphasised strongly that Asthma is an inflammatory disease; and FDs must become better informed of the directives of the international consensus on asthma.

[Factors related with the morbidity of asthma]. / Estudio de factores relacionados con la morbilidad del asma.

To determine the clinical situation, prescribed treatment and compliance in patients with asthma, and to identify the parameters that most influence control of the disease. We studied 335 asthma patients assigned to health centers. All were interviewed and respiratory gases were measured. Disease symptoms were recorded, along with treatment prescribed and inhalation method used. Compliance and inhaler use were assessed on a scale. Treatment appropriateness was evaluated against criteria of international consensus. Multiple regression analysis was used to identify the variables that most influenced control of asthma. Variables considered were age, sex, smoking, treatment appropriateness, inhaler technique, compliance with prescribed treatment and time since diagnosis. Disease was mild in 96 patients (28.7%), moderate in 111 (33.1%) and severe in 128 (38.2%). Treatment was appropriate in 118 (35.2%). Seventy-two (21.5%) used more drugs or higher doses than recommended. Prescribed treatment was inappropriate in 145 (43.3%). The inhalation technique was appropriate in 87 (27.5%) and inappropriate in 229 (72.5%). Ninety-four patients (28.1%) complied well with treatment and 241 (71.9%) were poor compliers. The variables that were significantly related to control of asthma were appropriate treatment and compliance. There is a high rate of morbidity due to asthma in the population studied. The percentage of inappropriate treatment is high, and compliance is low, these factors being the ones that most influence control of the disease.

[The work situation of specialists in family and community medicine educated in Asturias]. / Situación laboral de los especialistas en medicina familiar y comunitaria formados en Asturias.

OBJECTIVE: To find out the employment situation and the career level of family doctors (FD) trained through residency in Asturias. DESIGN: A descriptive crossover study carried out with a self-filled questionnaire returned by mail. SETTING: All of Spain. PARTICIPANTS: FDs trained through residency in Asturias up to 1993. MEASUREMENTS AND MAIN RESULTS: 178 (89%) of the 200 FDs located replied. 8 who had not finished their course were excluded. Between 1979 and 1983 42 people began their training (24.7%); 42(24.7%) between 1984 and 1987; and 86 (50.5%) between 1988 and 1991. 96 worked in health centres (56.4%); 30 in hospital casualty (17.6%); 9 in administration and management (5.2%); 16 were unemployed (9.4%) and 8 in other posts (4.7%). 49 FD had a permanent post (28.8%); 32 of these had started their training before 1984. 63 (37.5%) chose family and community medicine (FCM) as a vocation. Of these, 26 began their training between 1979 and 1983, 17 between 1984 and 1987 and 20 after 1988. A significant relationship was found between starting training in 1984 or before and choosing FCM as a vocation; and also between starting FCM training in 1984 or before and having a stable job. CONCLUSIONS: The more recent FCM students had less vocational motivation for their choice of FCM and greater difficulty in obtaining a stable job, which may lead to progressive disenchantment with FCM.