[Influence of the covid-19 pandemic period of alert on perceived quality of hospital emergencies]. / Influencia del periodo de alarma por la pandemia covid-19 en la calidad percibida de la atención en urgencias hospitalarias.

OBJECTIVE: To assess changes in perceived quality in patients who required A&E hospital care before and during the COVID-19 period of alert. METHODS: Retrospective descriptive observational study using the «Net Promoter Score¼ (NPS), which classifies patients as promoters or detractors. Three perceived quality dimensions (accessibility, professionals, and information) were measured in 160 patients discharged home before alert, and in a further 160 in the first 2 months during alert. A standard of ≥90% promoters and ≤10% detractors was verified by lot acceptance (LQAS) in different access routes and times. Factors related to the probability that a patient was a promoter, or a detractor were analysed using logistic regression. RESULTS: The mean score was lower in accessibility than in the other dimensions (8.6 vs. 9.1 and 9.0, P<.0001). During alert, accessibility obtained better results (NPS 70 vs. 32, P<.001). Per access route, Paediatrics and Ophthalmology improved and Maternity did not experience changes. LQAS showed more lots accepted during alert (85 vs. 72%). The likelihood for a patient to be a promoter was higher during alert (OR 1.85, P<.0001), especially in accessibility (OR 3.08, P<0.0001). The likelihood to be a detractor was reduced (OR .54, P<.05), and also greater in accessibility (OR .39, P<.05). CONCLUSIONS: Perceived quality improved during the period of alert, its declaration being the most influential factor. This improvement is evident in paediatric and ophthalmological patients, but imperceptible in Maternity or Traumatology, perhaps because the pandemic acted as an adequacy corrector.

[Design of a set of indicators for 'Do Not Do' recommendations]. / Diseño de un conjunto de indicadores sobre recomendaciones de «No Hacer¼.

BACKGROUND: There is a growing interest in the optimisation of health care that has fostered and developed initiatives advocating more efficient and safe health care. OBJECTIVE: To determine indicators set for assessing the 'Do Not Do' Recommendations (DNDR) in a Spanish health area, in order to set interventions in motion for improving the quality of care and the patient safety. METHOD: The DNDR published by the health care organisation in 2016 were identified, and those that could be analysed were designed and tested using two assessment methods (if possible, directly from the whole data or, if not, by applying the lot quality assurance sampling - LQAS) and 2016 data from a Spanish health area. Both validity and reliability of these indicators were checked. RESULTS: Of the 271 DNDR identified, 25 (9.3%) were prioritised and their corresponding quality indicator designed. From them, 80% were obtained directly, whereas the rest required LQAS. The interobserver agreement was very high. Efficiency was the quality dimension most frequently involved. CONCLUSIONS: In order to improve the quality of care in terms of adequacy, safety, and sustainability, to assess the DNDR is possible, compulsory, and urgent. Thus, a set of valid, reliable and useful indicators has been designed. This set is focused on identifying improve opportunities and making it possible to approach them.

[Prevention of thromboembolic disease in elderly patients admitted to medical wards]. / Adecuación de la profilaxis tromboembólica en pacientes de edad avanzada hospitalizados en servicios médicos de un hospital de tercer nivel.

OBJECTIVES: To determine the suitability of the prevention of thromboembolic disease in elderly patients admitted to medical departments, as well as some associated factors, such as the measures required in order to improve quality and safety. PATIENTS AND METHODS: A retrospective study in a tertiary level hospital that included elderly patients that were admitted to medical departments. A simple, non-proportional, randomised sample was used, stratified by department. The risk was measured using the Padua prediction model and the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) adjusting depending on the number of discharges. A Lot Quality Assurance Sampling (LQAS) plan was used with three levels, good, (standard 95%, threshold 70%), acceptable (standard 95%, threshold 50%), and not acceptable. RESULTS: A total of 72 cases from 8 departments were evaluated. Just over half (51.4%) of patients had a high risk of thromboembolic disease (Padua≥4), and 23.6% of bleeding (IMPROVE≥7). Besides the advanced age, the adjusted scores were particularly due to cancer (22%) and reduced mobility (19%) for Padua, and male gender (13%) and renal failure (12%) for IMPROVE. The adjusted overall suitability was 57.5% (95%CI: ±19.0%). The OR for suitable conduct on not starting medication, 1.56 (95%CI: 1.07-2.26). The suitability by department was not uniform: all the lots were acceptable, in 3 with level "good" and in 5 with "acceptable". CONCLUSIONS: The suitability of thromboembolic prophylaxis in the study hospital maintains acceptable levels, although not homogeneous. There is an opportunity for improvement that must be taken. The data obtained may help in deciding interventions, with LQAS being useful to optimise the evaluation effort.

[Why is reperfusion therapy delayed in stroke code patients? A qualitative analysis]. / ¿Por qué se retrasa el tratamiento de reperfusión en pacientes con código ictus? Un análisis cualitativo.

BACKGROUND: Efficacy and safety of reperfusion therapy in acute ischaemic stroke is time-dependent and has a limited therapeutic window, which is, in fact, the main exclusion criterion. Initiatives to evaluate the quality of care are essential to design future interventions and ensure the shortest management times and application of such treatments. OBJECTIVE: The aim of the study is to identify and classify potential causes of delay in the administration of reperfusion therapy in a tertiary hospital, a reference for the comprehensive treatment of acute ischaemic stroke. MATERIAL AND METHODS: The project was developed in Hospital Universitario Virgen de la Arrixaca, Murcia, Spain. A total of 337 patients with acute ischaemic stroke treated with reperfusion therapies were evaluated. For qualitative analysis, 2 working groups were formed: an advocacy group that designed and directed the entire project, and a multidisciplinary one, which served as a source of information and a mechanism for active involvement of all professionals in the stroke-care chain. Information was collected in 3 meetings and then, both the flowcharts and the cause-effect diagram were prepared. RESULTS: Based on the above tools, potential causes of delay were identified and classified according to an operational criterion into unmodified structures, and modifiable ones with known evidence and hypothetical repercussions. Modifiable ones are noted for their importance in the design of future improvement interventions in stroke care. Some of them are: Variability in following established protocols, lack of procedures in some parts of the stroke-care chain, etc. CONCLUSION: Knowledge of the current situation has just been the starting point, but it has been an essential requisite for the design and implementation of a quality improvement program to shorten in-hospital stroke code times.

Estratificación y monitorización de niveles de adecuación de ingresos urgentes en un hospital de tercer nivel / Classification and monitoring of the appropriateness of emergency admissions in a tertiary hospital

Objetivo: Valorar la adecuación del ingreso urgente de adultos en servicios quirúrgicos y no quirúrgicos, estratificar los servicios clínicos por niveles de inadecuación de ingresos urgentes y comprobar la utilidad de la aplicación de técnicas de evaluación rápida en este tipo de mediciones. Material y métodos: Estudio descriptivo retrospectivo en un hospital de tercer nivel, que evalúa las historias clínicas de los ingresos urgentes mediante el protocolo de evaluación de la adecuación (AEP). Se incluyeron los 12 servicios con más volumen de ingresos. Para estratificarlos se construyeron 4 niveles crecientes de inadecuación («A» al «D») fijando valores estándar y umbral de inadecuación en cada uno de ellos y comprobándolos en cada servicio mediante la aceptación de muestras por lotes (LQAS). Se evaluaron aleatoriamente 156 casos (13 por servicio). Se estimó el esfuerzo evaluativo (tiempo invertido). Resultados: El porcentaje de ingresos inadecuados fue del 22,4 ± 6,3%. Nueve servicios (75%) obtuvieron niveles de adecuación buenos o aceptables y uno (8%) inaceptable. El tiempo invertido en la evaluación fue estimado en 17 h. Conclusiones: El AEP resulta útil para evaluar la adecuación de los ingresos y la gestión del proceso «urgencias», aunque su variabilidad impide las comparaciones externas. Su monitorización no implica gran consumo de recursos combinando LQAS con la estimación global de la inadecuación (unificando las muestras) y la estratificación secuencial por niveles. Extender estas técnicas para otros indicadores de calidad que utilicen como fuente de datos la historia clínica o la observación directa puede aumentar la eficiencia de sus planes de monitorización (AU)

Objective: To measure the appropriateness of hospital admissions, to classify its Clinical Services(CS) according to the level of inappropriateness, and to determine the usefulness of applying rapid assessment techniques (lot quality assurance sampling) in these types of measurements. Material and methods: A descriptive, retrospective study was conducted in a tertiary hospital to assess the clinical records of emergency admissions to the 12 CS with a higher volume of admissions, using the Appropriateness Evaluation Protocol (AEP). A four-level («A» to «D») increasingly inadequate admissions scale was constructed setting both standard and threshold values in every stratum. Every CS was classified in one of them using lot quality assurance sampling (LQAS). A total of 156 cases (13 cases from every CS) were assessed. The assessment effort (devoted time) was also estimated. Results: There were 22.4±6.3% of inadequate admissions. In the CS classification, 9 (75%) got a good or acceptable appropriateness level, and only 1 (8%) got an inacceptable level. The time devoted was estimated at 17 hours. Conclusions: AEP is useful to assess the admission appropriateness and may be included in the «Emergencies» process management, although its variability prevents the use for external comparisons. If both LQAS and the appropriateness classification level and the global estimation (by unifying lot samples) are combined, the monitoring is affordable without a great effort. To extend these tools to other quality indicators requiring direct observation or clinical records, manual assessment could improve the monitoring efficiency (AU)

[Classification and monitoring of the appropriateness of emergency admissions in a tertiary hospital]. / Estratificación y monitorización de niveles de adecuación de ingresos urgentes en un hospital de tercer nivel.

OBJECTIVE: To measure the appropriateness of hospital admissions, to classify its Clinical Services (CS) according to the level of inappropriateness, and to determine the usefulness of applying rapid assessment techniques (lot quality assurance sampling) in these types of measurements. MATERIAL AND METHODS: A descriptive, retrospective study was conducted in a tertiary hospital to assess the clinical records of emergency admissions to the 12 CS with a higher volume of admissions, using the Appropriateness Evaluation Protocol (AEP). A four-level («A¼ to «D¼) increasingly inadequate admissions scale was constructed setting both standard and threshold values in every stratum. Every CS was classified in one of them using lot quality assurance sampling (LQAS). A total of 156 cases (13 cases from every CS) were assessed. The assessment effort (devoted time) was also estimated. RESULTS: There were 22.4±6.3% of inadequate admissions. In the CS classification, 9 (75%) got a good or acceptable appropriateness level, and only 1 (8%) got an inacceptable level. The time devoted was estimated at 17 hours. CONCLUSIONS: AEP is useful to assess the admission appropriateness and may be included in the «Emergencies¼ process management, although its variability prevents the use for external comparisons. If both LQAS and the appropriateness classification level and the global estimation (by unifying lot samples) are combined, the monitoring is affordable without a great effort. To extend these tools to other quality indicators requiring direct observation or clinical records, manual assessment could improve the monitoring efficiency.

Proceso de evaluación y variabilidad en los congresos de la Sociedad Española de Calidad Asistencial / The assessment process and variability in the conferences of Spanish Society of Quality in Healthcare

Objetivo. Describir el proceso de evaluación de comunicaciones al Congreso de la Sociedad Española de Calidad Asistencial 2011, con énfasis en el procedimiento para controlar la variabilidad interevaluador. Material y método. Proceso descrito mediante IDEF0. Estudio de intervención en ciego para conocer y controlar la variabilidad de los evaluadores. Cinco comunicaciones fueron valoradas por los 27 evaluadores del congreso utilizando 4 criterios explícitos. La suma de puntuaciones fue utilizada para calcular la variabilidad. La razón de variabilidad (RV) de cada evaluador, obtenida al dividir la media de puntuaciones por su puntuación, se empleó para controlar la variabilidad ajustando las puntuaciones brutas. Resultados. Misión del proceso: «evaluar de forma ágil, transparente y equitativa las comunicaciones recibidas al congreso de la SECA». Se identificó como clientes y se exploraron necesidades y expectativas de congresistas, autores y SECA. Se desarrolló diagramado IDEF0. Variabilidad: puntuación máxima 170, mínima 37, media 115,4, coeficientes: variación 23%, asimetría −0,7, curtosis 2,1. RV máxima 3,12, mínima: 0,68. Conclusiones. IDEF0 puede servir para avanzar en la mejora del proceso de evaluación y facilitar el trabajo de futuros comités. La variabilidad entre evaluadores es alta. RV es una herramienta fácil de obtener y sencilla de aplicar que produce puntuaciones ajustadas para controlar la variabilidad interevaluador (AU)

Objective. To describe the abstracts assessment process in the 2011 Conference of the Spanish Society for Quality in Health Care, focusing on the procedures adopted to control the interobserver variability. Material and methods. Process described using the IDEF0 model. An interventional blinded study is designed to know and control the interobserver variability of the 27 Conference appraisers, who scored 5 submitted abstracts using 4 explicit criteria. The sum of these scores is used to estimate the variability. The variability ratio (VR) of every appraiser is obtained dividing the average score by his total score, and used to control the variability adjusting the gross score of every abstract. Results. Process mission: “to assess the abstracts submitted to Conference in an easy, open and fair way”. Attendants to the conference, abstract authors and the Society have been identified as clients, their needs and explored expectations. Variability scores: maximum 170, minimum 37, average 115.4. Coefficients: variation 23%, asymmetry −.7, kurtosis 2.1. VR: maximum 3.12, minimum .68. Conclusions. IDEF0 diagrams could be useful to improve the evaluation process and facilitate the work of future scientific committees. The appraisers’ variability was too important to be omitted. VR is an easy to get and simple to use tool that produces adjusted scores to control this (AU)

[The assessment process and variability in the conferences of Spanish Society of Quality in Healthcare]. / Proceso de evaluación y variabilidad en los congresos de la Sociedad Española de Calidad Asistencial.

OBJECTIVE: To describe the abstracts assessment process in the 2011 Conference of the Spanish Society for Quality in Health Care, focusing on the procedures adopted to control the interobserver variability. MATERIAL AND METHODS: Process described using the IDEF0 model. An interventional blinded study is designed to know and control the interobserver variability of the 27 Conference appraisers, who scored 5 submitted abstracts using 4 explicit criteria. The sum of these scores is used to estimate the variability. The variability ratio (VR) of every appraiser is obtained dividing the average score by his total score, and used to control the variability adjusting the gross score of every abstract. RESULTS: Process mission: "to assess the abstracts submitted to Conference in an easy, open and fair way". Attendants to the conference, abstract authors and the Society have been identified as clients, their needs and explored expectations. Variability scores: maximum 170, minimum 37, average 115.4. Coefficients: variation 23%, asymmetry -.7, kurtosis 2.1. VR: maximum 3.12, minimum .68. CONCLUSIONS: IDEF0 diagrams could be useful to improve the evaluation process and facilitate the work of future scientific committees. The appraisers' variability was too important to be omitted. VR is an easy to get and simple to use tool that produces adjusted scores to control this.

Calidad del registro en OMI-AP de los pacientes con ictus seguidos en atención primaria / Quality of records in OMI-AP of the patients with stroke followed in primary care

Objetivos. 1) Conocer el grado de registro y control de los factores de riesgo cardiovascular en los pacientes con ictus atendidos en atención primaria en la región de Murcia mediante historia clínica informatizada. 2) Analizar el tratamiento farmacológico registrado en los pacientes con ictus. Material y método. Estudio observacional descriptivo, retrospectivo, valorado a través de los registros en OMI (historia clínica electrónica) en todas las zonas de salud del Servicio Murciano de Salud. Se seleccionó una muestra de 407 pacientes con ictus. Las variables analizadas fueron: tipo de ictus, tiempo de evolución, factores de riesgo cardiovascular registrados, enfermedades cardiovasculares registradas, medicación y grado de control de los factores de riesgo modificables. Resultados. Los factores de riesgo cardiovascular registrados fueron hipertensión arterial (81,1%), dislipemia (72,5%), diabetes (41,3%), obesidad abdominal (22,9%), y tabaquismo (8,8%). Las enfermedades cardiovasculares registradas fueron la cardiopatía isquémica (22,1%), fibrilación auricular (13,8%), nefropatía (11,8%), infarto agudo de miocardio (5,7%) e hipertrofia ventricular izquierda (3,4%). El 2,5% (10) de los pacientes registrados cumplieron con todos los criterios de buen control. El LDL colesterol estaba controlado (<100mg/dl) y registrado en el 24,8% de los pacientes y la presión arterial en el 41,3%. Según OMI-AP recibían tratamiento con antihipertensivos el 78,1% de los pacientes, con hipolipemiantes el 47,4% y con antiagregantes o anticoagulantes el 79,1%. Conclusiones. Los pacientes que han sufrido un ictus y según los datos registrados en OMI-AP presentan un deficiente control de sus factores de riesgo cardiovascular(AU)

Objectives. 1) To determine the level of registration and control of cardiovascular risk factors in stroke patients treated in primary care in Murcia through electronic medical records. 2) To describe the registered drug treatment in patients with stroke. Material and Methods. Observational descriptive, retrospective, evaluated through the records in OMI (electronic medical records) in all areas of Murcia Health Service. Material and Methods. A sample of 407 patients with stroke was analyzed. The analyzed variables were type of stroke, time of evolution, registered cardiovascular risk factors, registered cardiovascular disease, medication and degree of control of modifiable risk factors. Results. Cardiovascular risk factors recorded were hypertension (81.1%), dyslipemia (72.5%), diabetes (41.3%), abdominal obesity (22.9%) and tobacco (8.8%). Registered cardiovascular diseases were ischemic heart disease (22.1%), atrial fibrillation (13.8%), nephropathy (11.8%), myocardial infarction (5.7%) and left ventricular hipertrophy (3.4%). 2.5% (10) of patients met all criteria for good control. The LDL cholesterol was controlled (<100mg/dl) and recorded in 24.8% of patients and blood pressure in 41.3%. 78.1% of patients were being treated with antihypertensive drugs, 47.4% with lipid-lowering drugs, and 79.1% with antiplatelet or anticoagulant. Conclusions. According to data recorded at OMI-AP the patients who have suffered a stroke have poor control of cardiovascular risk factors(AU)

[Quality of records in OMI-AP of the patients with stroke followed in primary care]. / Calidad del registro en OMI-AP de los pacientes con ictus seguidos en atención primaria.

OBJECTIVES: 1) To determine the level of registration and control of cardiovascular risk factors in stroke patients treated in primary care in Murcia through electronic medical records. 2) To describe the registered drug treatment in patients with stroke. MATERIAL AND METHODS: Observational descriptive, retrospective, evaluated through the records in OMI (electronic medical records) in all areas of Murcia Health Service. A sample of 407 patients with stroke was analyzed. The analyzed variables were type of stroke, time of evolution, registered cardiovascular risk factors, registered cardiovascular disease, medication and degree of control of modifiable risk factors. RESULTS: Cardiovascular risk factors recorded were hypertension (81.1%), dyslipemia (72.5%), diabetes (41.3%), abdominal obesity (22.9%) and tobacco (8.8%). Registered cardiovascular diseases were ischemic heart disease (22.1%), atrial fibrillation (13.8%), nephropathy (11.8%), myocardial infarction (5.7%) and left ventricular hypertrophy (3.4%). 2.5% (10) of patients met all criteria for good control. The LDL cholesterol was controlled (<100mg/dl) and recorded in 24.8% of patients and blood pressure in 41.3%. 78.1% of patients were being treated with antihypertensive drugs, 47.4% with lipid-lowering drugs, and 79.1% with antiplatelet or anticoagulant. CONCLUSIONS: According to data recorded at OMI-AP the patients who have suffered a stroke have poor control of cardiovascular risk factors.

[Effectiveness of an intervention to improve medical prescription quality in specialized care]. / Efectividad de una intervención en la mejora de la calidad de prescripción con receta médica en atención especializada.

OBJECTIVE: The study was designed to research whether providing doctors with customized reports on prescription indicators,plus a presentation of the project to clinical departments and hospital boards, would improve prescription quality in specialized care. MATERIAL AND METHODS: Quasi experimental intervention study. During three periods of time we observed whether any differences between physicians receiving said reports (intervention group) and physicians not receiving said reports (control group)occurred in three overall quality markers (94 physicians)--generic drugs, low therapeutic value drugs, and irrelevant novel drugs-and two specific indicators--angiotensin converting enzyme inhibitors (109 physicians) and omeprazole (169 physicians). Indicators were assessed using mean values (95% Cl) and differences between groups with the z test. RESULTS: Prior to the intervention, indicators had no significant differences. At 4-6 months after delivering the report, generic drug prescription improved in the intervention group - 3.13%(1.79-4.47) versus 1.81% (1.08-2.54) in the control group,p = 0.041. After 10-12 months the intervention group had significantly improved versus the control group regarding: generic drugs, 4.01% (2.28-5.73) versus 2.22% (1.56-2.87), p = 0.025;ACE inhibitors, 58.89% (47.56-70.21) versus 45.91% (36.03-55.79), p = 0.042; and low therapeutic utility drugs, 8.57%(5.56-11.6) versus 12.35% (8.96-15.74), p = 0.047. Improvement regarding omeprazole did not reach statistical significance,and novel medications remained virtually unchanged. CONCLUSION: The intervention proved effective for the improvement of qualitative prescription indicators in specialized care.

[Prescription of drugs in family medicine: on the trail of efficiency]. / Prescripción de medicamentos en medicina de familia: tras las pistas de la eficiencia.

OBJECTIVE: To analyse the effect of various factors on the efficiency of drug prescription by general practitioners (GPs). DESIGN: Descriptive, cross-sectional study. SETTING: Primary care in Murcia, Cartagena, and Lorca, in which 535 GPs work in the care of 921,281 people. Murcia Region (Spain).Participants. Prescriptions issued by the 288 GPs who were working constantly and continuously in May-June 1998 and who were away from work for no longer than 10% of the time (53.8%). MAIN MEASUREMENTS: We measured their efficiency with two general indicators--potential saving (PS) and prescription of generics (PG)--and 3 specific indicators: efficiency of prescription of omeprazole (EO), enalapril (EE), and ranitidine (ER). We analysed their relationship with structural-organisational factors and with the population attended, the doctor and his/her action. Bivariate and multivariate analyses (logistic regression) were used. RESULTS: There was an association with programmed consultation (PC); a weak inverse relationship with age of doctor, years qualified, pensioners allocated, case load and inter-consultations conducted; and a direct correlation with the length of the consultation. PG was related to rural environment, being non-permanent, specialist in family medicine, belonging to a primary care team. In the multivariate analysis PC was related to all the indicators: PS (OR=1.96), PG (OR=2.10), EO (OR=2.63), ER (OR=2.84), EE (OR=2.06); and the inter-consultations conducted with general efficiency of PS (OR=1.70), PG (OR=1.91). Rural environment was the worst for PS (OR=2.43). CONCLUSIONS: The main factors related to the efficiency of GPs prescription can be changed. The most important is the existence of PC. A lot of inter-consultations and working in a rural environment means worse general efficiency.

[Classification of medication interactions in family medicine and effectiveness of an intervention to improve them]. / Tipificación de interacciones medicamentosas en medicina de familia y efectividad de una intervención para su mejora.

OBJECTIVE: a) To build a detection and evaluation tool of drug interactions (DI) in family practice prescribing; b) to elaborate and to offer a DI report, including appearance mechanism, clinical consequences and appropriate alternatives; c) to evaluate their effectiveness to diminish the DI incidence, and d) to check effectiveness of different diffusion methods. DESIGN: Previous phase: we will build the tool and will elaborate the report. Intervention phase: longitudinal, interventional, multicenter. SETTING: Primary care, Murcia Region. PARTICIPANTS: Family doctors (FD) with computerized clinical history frequently used to prescribe, with indefinite contract and who don't reject to participate. INTERVENTIONS: Randomly we will form 4 FD groups to carry out monthly (6 months): a) Minimal intervention: we mail DI reports; b) generic intervention: DI report is delivered in collective session managed by a trained doctor; c) personalized intervention: discussion peer-to-peer between FD and the trained doctor; d) control group: they won't receive DI information. MAIN MEASUREMENTS: We will measure the evolution of DI incidence and their classification according to relevance and repercussions. Different aspects related with FD and patient characteristics and with organizational environment are measured for subject's describing, inclusion-exclusion criteria assurance and conditioning and confusion factors analysis. DISCUSSION: Limitations. Using a new DI classification make difficult external comparisons, although it is useful because we use generalised and prestigious data sources. Applicability. The project produces a tool to avoid prescription errors. Checking the effectiveness in different corrective measures allows to take reasoned decisions for future interventions in quality care.

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Utilización de antihipertensivosen Atención Primaria / Antihypertensive drug use in Primary Health Care

Objetivo. Analizar el uso de antihipertensivos en Atención Primaria en el período comprendido entre 1999 y 2001 y valorar la introducción de los antagonistas de los receptores de la angiotensina II (ARA-II).Métodos. Estudio observacional retrospectivo. Se seleccionaron todas las prescripciones de antihipertensivos mediante recetas de la Seguridad Social en la gerencia de Atención Primaria de Murcia. Las fuentes de datos fueron las cintas de facturación mensual de recetas de la Seguridad Social, nomenclator digitalis de noviembre de 2001, bases de datos de médicos y población con tarjeta sanitaria. Los resultados se expresan en dosis diaria definida (DDD) por 1.000 habitantes y día (DHD).Resultados. El consumo de antihipertensivos se incrementó de 161,7 DHD en 1999 a 183,22 en 2001 (13,3 por ciento).Las prescripciones de antihipertensivos supusieron el 11,67 por ciento del total de recetas. Los fármacos más utilizados fueron los inhibidores de la enzima de conversión de la angiotensina (IECA) (28 por ciento de las DHD totales) y los de mayor crecimiento los ARA-II (incremento del 108 por ciento).Aunque en 2001 los IECA duplicaron a los ARA-II en DHD, el consumo por precio de venta al público (PVP) fue prácticamente el mismo. El uso de diuréticos y betabloqueantes fue del 12,3 por ciento y 8,8 por ciento, respectivamente, en DHD. El fármaco más consumido en todo el período fue enalapril, seguido a distancia por amlodipino, captopril, atenolol y valsartán en 2001.Conclusiones. Los antihipertensivos mantienen una tendencia ascendente de consumo determinada por el incremento de ARA-II. Los IECA continúan siendo los más prescritos y los diuréticos y betabloqueantes probablemente estén infrautilizados. El incremento de ARA-II ha originado un cambio cualitativo en la terapéutica antihipertensiva: se ha detenido la tendencia ascendente de los IECA y se ha incrementado el coste del tratamiento. (AU)

[Clinical data that are essential for the primary care clinical records: an experience of evaluation and improvement]. / Datos clínicos esenciales de la historia clínica de atención primaria: una experiencia de evaluación y mejora.

OBJECTIVES: To evaluate and improve the presence of essential clinical data in the clinical records of a primary care management area (PCMA) by means of an intervention programme. DESIGN: Intervention study without a control, using evaluation and improvement-of-quality methods. We chose 4 criteria from the minimum technical standards: personal history (PH), family background (FB), allergies to medicines (AM) and list of problems (LP). We evaluated overall compliance and compliance per primary care team (PCT) through batch quality acceptance of samples (LQAS), designed an intervention to improve the situation, and then re-evaluated. SETTING: PCMA of Murcia (45 PCTs). Participants. 42 PCTs (3 were excluded because they had poor coverage in their records). INTERVENTIONS: These lasted 12 months (October 1999-October 2000) and involved the following: graphic report per PCT; session with the PCT; discussion on results and strategies in the Area Management Council; and inclusion of an explicit objective, with incentives, in the management contracts. MAIN MEASUREMENTS AND RESULTS: Significant improvement of the four criteria of the PCMA (improvements: FB, 48.1%; PH, 51.1%; AM, 55.4%; LP, 50.9%). LQAS analysis: we rejected 24 batches (14.3%) at the 1st evaluation and 15 (9.0%) at the second, with FB being the criterion most rejected in both instances. Defects appeared in 14 PCT (33.3%; 3 PCT accounted for 41.7%) at the 1st evaluation, and 7 PCT at the re-evaluation (16.7%; 2 reaching 46.7%). CONCLUSIONS: The presence of essential clinical data in clinical records has improved. LQAS proved to be a rapid and simple method for evaluating, improving and monitoring quality in primary care.

[Effectiveness of a personalized information system on the quality of family doctors' medical prescription]. / Efectividad de un sistema de información personalizada sobre la calidad de prescripción de medicamentos en médicos de familia.

OBJECTIVES: To evaluate the effectiveness of a system of personalised prescription information (PPI) to improve prescription habits of family doctors (FD); to examine how useful PPI is in maintaining these habits, and to analyse its influence through factors of the doctor and his/her environment. DESIGN: Cross-sectional, descriptive pilot study to analyse conditioning factors and possible confusion; quasi-experimental intervention study to assess the effectiveness of PPI, with two groups (experimental and control) and 4 determinations (before the PPI and after: short, medium and long-term).Setting. Family doctors in the Murcia Region. SUBJECTS OF STUDY: The prescriptions of all family doctors in the Murcia region which started before PPI and which continued until the end of the study and without absences of over 10% at each measurement.Intervention. The family doctors from the Murcia city area formed the experimental group: they received PPI with specific proposals for improvement. The FDs of Cartagena and Lorca, who did not receive PPI, made up the control group. Statistical analysis. Logistical regression to identify conditioning factors. Z comparison of proportions contrasted with one-tail hypothesis to check the effectiveness of PPI. LIMITATIONS OF THE DESIGN: Non-randomised allocation to groups made comparison difficult: conditioning factors for stratification or adjustment were studied. PRACTICAL APPLICATION: Confirmation of PPI s effectiveness justifies its dissemination. If there is no such confirmation, it will have to be perfected. Isolating the factors conditioning prescription that can be modified helps find ways to improve PPI.

Datos clínicos esenciales de la historia clínica de atención primaria: una experiencia de evaluación y mejora / Clinical data that are essential for the primary care clinical records: an experience of evaluation and improvement

Objetivo. Evaluar y mejorar la presencia de datos clínicos esenciales en la historia clínica de una gerencia de atención primaria (GAP), mediante un programa de intervención. Diseño. Estudio de intervención no controlado, siguiendo la metodología de evaluación y mejora de la calidad. Seleccionamos 4 criterios usando las Normas Técnicas Mínimas: antecedentes personales (AP), antecedentes familiares (AF), alergias medicamentosas (AM) y lista de problemas (LP). Evaluamos su cumplimiento global y por equipo de atención primaria (EAP); mediante aceptación de muestras por lotes (LQAS), diseñamos una intervención para mejorar y revaluamos. Emplazamiento. GAP de Murcia (45 EAP).Participantes. Cuarenta y dos EAP (excluidos tres por baja cobertura en historias).Intervenciones. Durante 12 meses (octubre 1999 a octubre 2000): informe gráfico por EAP; sesión en los EAP; debate de resultados y estrategias de mejora en el Consejo de Gestión de Área, e inclusión de un objetivo explícito e incentivado en los contratos de gestión. Mediciones y resultados principales. Mejora significativa de los 4 criterios en la GAP (mejoras relativas: AF, 48,1 per cent; AP, 51,1 per cent; AM, 55,4 per cent; LP, 50,9 per cent). Análisis LQAS: rechazamos 24 lotes (14,3 per cent) en la primera evaluación y 15 (9,0 per cent) en la segunda, siendo en ambas AF el más rechazado. Aparecieron defectos en 14 EAP (33,3 per cent; tres EAP acaparan el 41,7 per cent) en la primera evaluación y en 7 EAP al revaluar (16,7 per cent, reuniendo dos el 46,7 per cent).Conclusión. Ha mejorado la presencia de datos clínicos esenciales en la historia clínica. LQAS demostró ser un método rápido y sencillo para la evaluación, mejora y monitorización de la calidad en atención primaria (AU)

[Evaluating, improving and monitoring generic drug prescription]. / Evaluación, mejora y monitorización de la prescripción de medicamentos genéricos.

OBJECTIVE: To evaluate and improve generic drug prescription by family physicians in a regional primary care district with a specially-designed intervention. DESIGN: Uncontrolled study of an intervention, based quality evaluation and improvement methods. We selected an indicator that could be constructed with the available data (monthly reports of prescriptions dispensed through the public national health system) and determined the proportion of prescriptions for generic drugs to the total number of prescriptions dispensed, for those medications that had a generic alternative (percentage of generic prescriptions, PGP). After these data were evaluated, an intervention was implemented to increase generic prescriptions. Prescribing behavior was again evaluated and monitored at the end of the intervention period. Setting. Forty-five primary care teams in the Murcia (Southeast Spain) regional primary care district. PARTICIPANTS: A total of 339 family physicians. Interventions. During 15 months, individual reports of prescribing practices, in which changes over time were graphed, were sent to each participating prescriber. Each semester the physicians received a personal letter and a specially-printed, updated card showing the generic medications available and their pharmaceutical forms. One to three face-to-face clinical outreach sessions were held with each primary care team. Specific prescribing goals for the PGP were set and incentives to attain the goals were included in the terms of the contract for clinical services signed between the regional office of primary care management and each primary care team. MAIN OUTCOME MEASURES: The PGP increased from a pre-intervention rate of 2.7% to a post-intervention rate of 17.63%. Absolute improvement was therefore 14.84%, and relative improvement was 15.27%. Variability was monitored and analyzed with control charts. There was no significant variability within the pre- and post-intervention phases, whereas variability increased significantly (indicating improvement) during the intervention phase. CONCLUSIONS: The increase in PGP showed that prescribing for generic preparations improved. Statistical quality control tests were useful in evaluating and tracking the results of the intervention, and were indispensable for monitoring and promptly detecting opportunities to improve prescribing behavior and take appropriate measures.

Efectividad de un sistema de información personalizada sobre la calidad de prescripción de medicamentos en médicos de familia / Effectiveness of a personalised information system on the quality of family doctors' medical prescription

Objetivo. Evaluar la efectividad de un sistema de información personalizada de prescripción (IPP) en la mejora de los hábitos de prescripción de los médicos de familia (MF); conocer su utilidad para mantener estos hábitos, y analizar su influencia por factores del médico y su entorno. Diseño. Estudio descriptivo, transversal, previo para analizar factores condicionantes y de confusión; estudio de intervención cuasiexperimental para valorar la efectividad del IPP, con 2 grupos (experimental y control) y 4 determinaciones (antes del IPP y después: corto, medio y largo plazo).Emplazamiento. MF de la Región de Murcia. Sujetos de estudio. Prescripciones de todos los MF de la Región de Murcia existentes antes del IPP, que continúan hasta finalizar el estudio y sin ausencias superiores al 10 por ciento en cada medición. Formación de los grupos. Intervención: los MF de la Gerencia de Murcia formarán el grupo experimental; reciben el IPP con propuestas específicas de mejora. Los MF de Cartagena y Lorca no reciben el IPP y constituyen el grupo control. Análisis estadístico. Regresión logística para identificar factores condicionantes. Z de comparación de proporciones con contraste de hipótesis unilateral para comprobar la efectividad del IPP. Limitaciones del diseño. La no asignación aleatoria de los grupos dificulta su comparabilidad: se estudian factores condicionantes para estratificación o ajuste. Aplicabilidad práctica. Confirmar la efectividad del IPP justifica su difusión. No hacerlo obligará a perfeccionarlo. Aislar factores modificables condicionantes de la prescripción ayuda a actuar para mejorar (AU)