Microalbuminuria y diabetes mellitus tipo 2. Áreas de incertidumbre / Microalbuminuria and type-2 Diabetes Mellitus. Areas of uncertainty

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[Minor surgery in primary care: is continuing education within the team a valid strategy for improving quality?]. / Cirugía menor en atención primaria: es válida la formación continuada intraequipo como estrategia de mejora de calidad?

OBJECTIVE: To evaluate the impact of continuing education within the team (FCI, in Spanish) on the quality of minor surgery. DESIGN: Study of level of quality. SETTING. Primary care. PARTICIPANTS: First evaluation: all the lesions referred for biopsy during 1998 (62 samples). Second evaluation: those referred in 1999-2000 (150). MAIN MEASUREMENTS: Four explicit criteria regulating procedure and result were designed: C1, sufficient information; C2, correct referral; C3, correct extirpation of lesion; C4, clinical-pathological concordance. Request forms and anatomical-pathological reports were assessed. Evaluation was before and after corrective measures (FCI and organisational changes designed to support FCI). The Kappa index of inter-observer concordance, the Compliance Index and Fisher's Z index were analysed. RESULTS: 62 lesions were included in the first evaluation, with high reliability for C1 and C4, good for C2 and moderate for C3. 150 lesions were included in the second evaluation. The compliance indices showed statistically significant increases from the first to the second evaluation for C1 (38.09% and 50.66%, relative improvement of 19%) and C4 (68.85% and 85.2%, relative improvement of 53%). C2 showed an improvement, but without statistical significance (87.30% and 92.66%). The compliance index for C3 dropped (94.73% and 87.50%). 5.33% of cases in the second evaluation (8 biopsies) were malignant or pre-malignant lesions, compared with 20.96% in the first (P<.05). 100% of these latter showed free resection limits. 77.99% of lesions studied through a biopsy in the second evaluation were nevus, seborrhoeic keratosis or dermatofibroma. CONCLUSIONS: FCI is a valid strategy for improving the quality of programmes of minor surgery in primary care. There was significant improvement in the identification of malignant and pre-malignant pathology, in correct referral and in the clinical-pathological concordance of the lesions.

Cirugía menor en atención primaria: ¿es válida la formación continuada intraequipo como estrategia de mejora de calidad? / Minor surgery in primary care: is continuing education within the team a valid strategy for improving quality?

Objetivo. Evaluar el impacto de la formación continuada intraequipo (FCI) en la calidad de la cirugía menor (CM).Diseño. Estudio de nivel de calidad. Emplazamiento. Atención primaria. Participantes. Primera evaluación: todas las lesiones remitidas para biopsia durante 1998 (62 muestras). Segunda evaluación: las remitidas durante 1999-2000 (150).Mediciones principales. Se diseñaron 4 criterios explícitos y normativos de proceso y resultado: C1: información suficiente; C2: remisión adecuada; C3: extirpación lesional correcta, y C4: concordancia clinicopatológica. Se evaluaron hojas de solicitud e informes anatomopatológicos. Evaluación antes y después de medidas correctoras (FCI y cambios organizativos diseñados para potenciarla). Se analizó el índice Kappa de concordancia interobservador, el índice de cumplimiento (IC) y la Z de Fisher. Resultados. En la primera evaluación se incluyeron 62 lesiones, con una fiabilidad alta para C1 y C4, buena para C2 y moderada para C3. En la segunda evaluación se incluyeron 150 lesiones. Entre la primera y la segunda evaluación, los índices de cumplimiento presentaron incrementos estadísticamente significativos para C1 (38,09 per cent y 50,66 per cent; mejora relativa del 19 per cent) y C4 (68,85 per cent y 85,2 per cent; mejora relativa del 53 per cent). C2 presentó mejoría estadísticamente no significativa (87,30 per cent y 92,66 per cent). El índice de cumplimiento de C3 presentó una disminución (94,73 per cent y 87,50 per cent). Un 5,33 per cent de casos en la segunda evaluación (8 biopsias) fueron lesiones malignas y premalignas respecto al 20,96 per cent de la primera (p < 0,05). El 100 per cent de estas últimas presentó límites de resección libres. Un 77,99 per cent de las lesiones biopsiadas en la segunda evaluación fueron nevus, queratosis seborreicas y dermatofibromas. Conclusiones. La FCI es una estrategia válida para mejorar la calidad de programas de CM en atención primaria, observándose mejora significativa en la discriminación de patología maligna y premaligna, en la correcta derivación y en la concordancia clinicopatológica de las lesiones (AU)

[Can we improve the therapeutic management of allergic rhinitis in primary care?]. / ¿Podemos mejorar el manejo terapéutico de la rinitis alérgica en atención primaria?

OBJECTIVE: To evaluate improvement in therapeutic management of allergic rhinitis. DESIGN: Study of level of quality (longitudinal, prospective, intervention). SETTING: Primary care. PATIENTS AND OTHERS PARTICIPANTS: First evaluation (second quarter of 1995): 73 out of 305 patients were sampled (confidence 5%, accuracy 10%). Second evaluation (second quarter of 1996). Sample of 51 patients from a total of 210. INTERVENTIONS: Explicit criteria and standard procedure, based on consensus, for rhinitis treatment and an overall indicator of the general quality of rhinitis management were analysed. Criterion 1 (C1): correctly scaled treatment; criterion 2 (C2): initial treatment of choice with inhaled corticoids; criterion 3 (C3): correct use of oral corticoids or immunotherapy; criterion 4 (C4): coadjutant therapy according to predominant symptoms. Corrective measures: ongoing training and routine use of guide to practice. STATISTICS: index of compliance with criteria, Chi squared and Fisher's Z tests of a tail to compare both evaluations. MEASUREMENTS AND MAIN RESULTS: First evaluation: index of compliance with C1 = 59% (CI +/- 11), C2 = 41% (CI +/- 11), C3 = 90% (CI +/- 6) and C4 = 83% (CI +/- 8). Criteria and summary indicator obtained better results in patients attended by allergists. Second evaluation with overall improvement: C1 = 68.6% (CI +/- 13), C2 = 57% (CI +/- 13), C3 = 94% (CI +/- 6), C4 = 98% (CI +/- 3). Significant differences for C4 and C2 (p < 0.05). Overall quality and quality of criteria improved for patients attended in our environment. The summary indicator went up from 35.6% to 57% (p = 0.019), with the quality levels (C1-C4) becoming the same as those of the patients with allergy attended and with significant differences in the first evaluation disappearing. CONCLUSIONS: Ongoing training and routine use of guides to practice enables the therapeutic management of allergic rhinitis in primary care to be improved.

¿podemos mejorar el manejo terapéutico de la rinitis alérgica en atención primaria? / Can we improve therapeutic management of allergic rhinitis in primary care?

Objetivo. Evaluar mejora del manejo terapéutico de la rinitis alérgica. Diseño. Estudio de nivel de calidad (longitudinal, prospectivo, de intervención).Emplazamiento. Atención primaria. Pacientes u otros participantes. Primera evaluación (segundo trimestre de 1995): entre 305 pacientes se muestrearon 73 (confianza, 5 por ciento; precisión, 10 por ciento). Segunda evaluación (segundo trimestre de 1996). Tamaño muestral de 51 pacientes de un total de 210.Intervenciones. Se analizaron criterios explícitos y normativos de proceso basados en consenso de tratamiento de rinitis y un indicador resumen de calidad de manejo global. Criterio 1 (C1): tratamiento correctamente escalonado. Criterio 2 (C2): tratamiento inicial electivo con corticoides inhalados. Criterio 3 (C3): correcta utilización de corticoides orales o inmunoterapia. Criterio 4 (C4): terapia coadyuvante según síntomas predominantes. Medidas correctoras: formación continuada y uso rutinario de guía para la práctica. Estadística: índice cumplimiento criterios, 2 y Z de Fisher con test de una cola para comparar ambas evaluaciones. Mediciones y resultados principales. Primera evaluación: índice cumplimiento C1 = 59 por ciento (IC ñ 11); C2 = 41 por ciento (IC ñ 11); C3 = 90 por ciento (IC ñ 6), y C4 = 83 por ciento (IC ñ 8). Los criterios y el indicador resumen obtuvieron mejores resultados en los pacientes atendidos por alergólogos. Segunda evaluación con mejora global: C1 = 68,6 por ciento (IC ñ 13); C2 = 57 por ciento (IC ñ 13); C3 = 94 por ciento (IC ñ 6), y C4 = 98 por ciento (IC ñ 3). Diferencias significativas para C4 y C2 (p < 0,05). La calidad global y de criterios mejoró entre los pacientes atendidos en nuestro ámbito. El indicador resumen pasó del 35,6 por ciento al 57 por ciento (p = 0,019), igualándose los niveles de calidad (C1-C4) a los de pacientes atendidos en alergia y desapareciendo las diferencias significativas de la primera evaluación. Conclusiones. La formación continuada y la utilización rutinaria de guías para la práctica permite mejorar el manejo terapéutico de la rinitis alérgica en atención primaria. (AU)

[The validation of a questionnaire for measuring the organizational climate in health centers]. / Validación de un cuestionario para la medición del clima organizacional en centros de salud.

OBJECTIVE: To check the reliability and to analyse the validity of a questionnaire on organisational atmosphere (OA). DESIGN: Crossover and observational. SETTING: Primary care teams (PCTs). PARTICIPANTS: Two questionnaires were offered to all the doctors, nurses and social workers (548 professionals) from the 29 PCTs in an autonomous community. One questionnaire was on the OA and the other was a subjective assessment of satisfaction with the structure and functioning of their own team. MEASUREMENTS AND MAIN RESULTS: When the results were analysed (initial factorial analysis), 3 items with only slight discrimination were eliminated from the OA questionnaire. Construction validity (factorial analysis with varimax method), reliability of the questionnaire (Cronbach's alpha and Spearman-Brown coefficient) and of criterion (correlation between OA and variables in the subjective assessment questionnaire) were calculated. The overall response rate was 77.5% (402 professionals). Three dimensions which explained 57% of total variability and which confirmed adequate construction validity were identified: team-work, cohesion and commitment. "Team-work" comprised 9 items and explained 27.18% of total variability. "Cohesion" had 7 items, which explained 16.55% of variability. Lastly, "Commitment" explained 13.47% of variability, with 5 items. The validity of criterion was adequate (close correlation between OA and subjective assessment of structure and operation). Reliability was high (0.89 alpha and 0.92 Spearman-Brown for the entire questionnaire and > 0.7 for the dimensions). CONCLUSIONS: The reliability and validity of the adapted questionnaire are sufficient and permit its routine primary care use in our health system to be recommended.

[Description of the organizational climate in primary care teams in an autonomous community]. / Descripción del clima organizacional en equipos de atención primaria de una comunidad autónoma.

OBJECTIVE: To describe the organisational atmosphere (OA) in primary care teams (PCTs) in an autonomous community. DESIGN: Crossover and observational. SETTING: PCTs. PARTICIPANTS: A questionnaire on OA was administered after prior validation to all the doctors, nurses and social workers at 29 PCTs. MEASUREMENTS AND MAIN RESULTS: The OA in the different teams was described, comprehensively and by dimensions: team-work, cohesion and commitment. Multiple regression was used to find the relationship between OA (dependent variable) and the independent variables: age of the professionals, years of functioning of the PCT, teaching status, type, location (rural or urban) and profession (coordinators, doctors, nurses, clerical staff). Overall reply rate was 77.5% (402 professionals): it was higher for coordinators. Average score on the questionnaire was 3.53 (SD = 0.56): it was higher for nurses. Results by dimensions were: team-work 3.67 (SD = 0.59), cohesion 3.54 (SD = 0.71) and commitment 3.37 (SD = 0.72). OA was seen as better by teaching teams (p < 0.02), both overall and for the teamwork and cohesion dimensions. Coordinators had better self-perception of the OA, both overall and by dimensions (p < 0.01). Teams who had worked together for a long time thought the atmosphere was worse. The type of job and the number of years doing it did not affect the perception of OA. CONCLUSIONS: 1. The evaluation of OA is generally positive, though it can certainly be improved. 2. Perception is not uniform, as coordinators and teaching teams see the OA as better. 3. Teams working together for many years see the OA as worse.

[Characteristics of the leadership of health center coordinators in the autonomous community of Murcia]. / Características del liderazgo de los coordinadores de centros de salud en la Comunidad Autónoma de Murcia.

OBJECTIVE: To describe the style and effectiveness (adaptability) of the leadership of coordinators of an autonomous community according to the model of leadership on the ground, analysing its relationship with the work environment. DESIGN: Observational crossover study. SETTING: All the functioning teams in this community. PARTICIPANTS: Medical and nursing coordinators. MEASUREMENTS AND MAIN RESULTS: Hersey and Blanchard's questionnaire on leadership on the ground was employed. This identifies 1) the predominant style (scoring for style 0-12). On the approach of the coordinator to personal relationships and/or task development, it identifies 4 points: direction, persuasion, participation, delegation. 2) Adaptability of the manager (ranging from +24 to -24), based on that the best choice between different options depends on the maturity of the group. To contrast work environment and leadership, a validated questionnaire, adapted to our milieu, was used. Overall reply rate (51 coordinators) was 89.4%. Analysis of styles was: persuasive 5.05 points (SD = 1.25), participatory 4.74 (SD 1.76), directive 1.2 (SD 1.11) and delegating 0.34 (SD 0.68). Adaptability scored 8.38 points (SD = 4.67), and was greater for the nursing coordinators (p < 0.002) without differences for type, place or teaching qualifications. The work environment, both overall and by dimensions, correlated with adaptability, although no relationship was found with leaders' styles. CONCLUSIONS: Leadership adaptability was quite high and greater in nursing. The most prevalent styles were the persuasive and the participatory, more efficacious in teams of average maturity. Theoretical effectiveness was positively related to a better work environment.

[Dietary habits and consumption patterns in a health district]. / Hábitos alimentarios y patrones de consumo en una zona de salud.

OBJECTIVE: To describe nutritional habits in a Health District by defining the patterns of food consumption. DESIGN: A descriptive, crossover study. SETTING: Health District of Molina de Segura, Murcia. METHOD: A community survey by interview of 1,071 people (95% confidence; accuracy to 3%), selected from the Municipal Roll by simple randomised sampling, was performed. The statistical methods were: Chi-squared and Student's tests, ANOVA, Pearson's linear correlation, factorial and discriminatory analysis. MEASUREMENTS AND MAIN RESULTS: 17.3%, especially men, never took milk products (p < 0.0005). 12.5%, mainly young people, consumed more than 3 eggs a week (p < 0.02). 85% ate fruit daily; 70%, green and root vegetables; and 78%, olive oil. 12.6% had pulses more than 3 days a week. Only 6.5% had potatoes or pasta daily. Among men and young people there was a "bar culture", along with a "fast food" pattern. CONCLUSIONS: The abandoned Mediterranean diet must be promoted. Measures should be taken to moderate young people's and men's alcohol consumption. "Fast food" and "bar culture" patterns are the most deeply rooted. The nutritional education of the chronically ill should also be emphasised.

[Diagnosis of mild arterial hypertension: 3 or 5 measurements?]. / Diagnóstico de hipertensión arterial ligera: tres o cinco tomas?

OBJECTIVE: To determine the differences in the diagnosis of light arterial hypertension between using three tension measurements (over 2 or 3 weeks) or five (6 or 7 weeks). DESIGN: A descriptive, longitudinal study. SETTING: Santomera Health Centre, Murcia. PARTICIPANTS: In 245 patients initially diagnosed as suffering from light Hypertension (with three takes of blood pressure), two more tension measurements were taken, over four weeks, to make a definitive diagnosis of light arterial Hypertension. 156 patients completed the series, for whom the differences in diagnosis between three and five takes, and variations in their blood pressure figures on repetition of the measurements, were studied. There were no differences in patients' basic characteristics between those who completed the tests and those who didn't. But there were differences between different professionals regarding their compliance with the procedure. RESULTS: 19.9% of the patients diagnosed initially after three blood pressure measurements did not have the diagnosis confirmed after five. Repetition of the measurements signified decrease in diastolic (p < 0.00005) and systolic (p < 0.00005) pressures. Average age of patients definitely diagnosed as having light hypertension was higher than the age of those not confirmed (p < 0.005). The older the patient, the higher the systolic pressure (p < 0.0001). CONCLUSIONS: The diagnosis of light arterial hypertension differed in 19.9% between three measurements and five.

[Carpal tunnel syndrome in primary care. Impact of workplace risks]. / Síndrome del túnel carpiano en atención primaria. Impacto de los riesgos laborales.

OBJECTIVE: To describe a series of cases of carpal tunnel syndrome (CTS) diagnosed at our health centre, with an analysis of the influence of work activity. DESIGN: A retrospective and descriptive study of a series of cases. SETTING: Patients on two medical lists who sought health care. PARTICIPANTS: 27 people diagnosed as having CTS. MEASUREMENTS AND MAIN RESULTS: We selected all the cases of CTS diagnosed according to the NIOSH criteria. We analysed symptoms, signs, additional tests and work risks. 24 out of the 27 cases were women. 100% had suggestive symptoms and 48.15% were affected bilaterally. The Tinell sign was positive in 5 cases, the Phalen in 7 and both in 11. 17.4% tested normal. We could see a diagnostic EMG in 19 cases. 59.2% were aged between 40 and 60. In all the cases we detected workplace risk factors: 18.5% housewives, 14.8% working in canning factories and dressmaking, 11.1% working in canning factories and dressmaking and shops/bars, 7.4% were cleaners, canning and fur operatives and mechanics. 3.7% worked at sewing shoes and in agriculture. As an accompanying pathology we detected 14.8% with obesity, 7.4% tenosynovitis and wrist fractures. For 3.7% CTS was a side-effect of diabetes, cervical arthrosis, ACV and dermatomyositis. 55.5% had non associated pathology. CONCLUSIONS: 1) The population of Molina de Segura can be considered at high risk of developing CTS. 2) In our environment women seek care for CTS much more often. 3) Most of our patients develop the condition in the workplace.

[Tobacco: risk factor in a health district]. / El tabaco: factor de riesgo en una zona de salud.

OBJECTIVE: To find the prevalence of tobacco dependency in our community and to identify tobacco consumption in our chronic patients. DESIGN: A crossover study. A descriptive analysis of the data. SETTING: A Health District. Mixed population, both urban and rural. PARTICIPANTS: A Health Survey which included 1,071 individuals (95% Confidence and 3% precision), selected by means of simple random sampling from the Municipal Census. MEASUREMENTS AND MAIN RESULTS: A 32.3% prevalence of tobacco dependency, greater among men (50.7%) than women (15.7%). Among the young, there is a marked tendency for the number of smokers to level out between the sexes. 15.6% of smokers consume more than 24 cigarettes per day. Between 15 and 20% of patients suffering hypertension, diabetes, hypercholesterolaemia and the effects of ischaemic cardiopathy, along with 25% of those who had suffered a CVA and almost 40% of chronic bronchitics, continue to smoke. CONCLUSIONS: Advice against smoking must be directed towards younger and younger age groups, including both men and women. The high prevalence of people still smoking among the chronically ill should cause us to reflect on our advice against tobacco to such patients.

[Is stated income a valid indicator of the socioeconomic status?]. / Son válidos los ingresos declarados como indicador del nivel socioeconómico de la población?

OBJECTIVE: 1) To analyse the validity of the reply to the question on socio-economic income included in health questionnaires. 2) To identify other valid indicators of socio-economic status. DESIGN: Crossover and retrospective observation study. SETTING: Community (Molina de Segura Health District). PARTICIPANTS: 1,071 people over 18, selected by means of simple random sampling. INTERVENTIONS: Analysis of 16 questions relating to home furnishing, consumer goods and stated income. We used Factorial Analysis and the ji2 test. RESULTS: We identified three levels by means of the factorial analysis: a) basic--consisting of hot water, washing-machine, absence of damp patches in the house, individual heating and television. b) Intermediate--consisting of car, video and telephone. c) High--with dishwasher, domestic help and air-conditioning. On analysing the relationship between stated income and socio-economic status we detected association to p < 0.001. The basic level answered more often than expected that their income was less than 50,000 pesetas; the intermediate, between 50 and 100,000; and the high, over 101,000. CONCLUSIONS: 1) It is possible to identify the socio-economic profile of the general population by the belonging of selected of determined consumer items. 2) Stated income is a reliable indicator of socio-economic status. Despite a tendency to a low reply to the question on income, income is not generally under-declared.

[Social assessment of anxiety in primary health care]. / Valoración social de la ansiedad en atención primaria de salud.

OBJECTIVE: Identification of the social profile of our anxious patients, and analysis of the usefulness of Bell's questionnaire for our area of work. DESIGN: A retrospective observation study of a crossover type. SETTING: Primary Care. PARTICIPANTS: 55 patients who consulted their Family Doctor and were diagnosed as suffering from Anxiety. MEASUREMENTS AND MAIN RESULTS: We confirmed the diagnosis with the DSM-III-R and then analysed the level of Anxiety with the Hamilton Scale. The social evaluation was done by means of Bell's profile. As test statistics we used the lineal correlation Coefficient, the Student's t and Xi2 tests and Variance Analysis. 65% of diagnoses were Generalised Anxiety. The Hamilton mean was 20.9 points (S = 9.2). Overall social adaptation was unsatisfactory, with the worst results being for the emotional aspects. We observed a higher level of Anxiety as age increased (p = 0.021), related to a worse adaptation to Health (p = 0.014). Dissatisfaction with work and the working environment took the form of professional adaptation being poorer as their work situation deteriorated (p = 0.006). Anxiety levels were higher among the unemployed. Social adaptation was less among people with higher Anxiety levels (p = 0.04), above all as a consequence of worse adaptation to Health (p = 0.002) and worse emotional (p = 0.00001) adaptation. CONCLUSIONS: 1) We must introduce social aspects into analysis of patients with Anxiety. 2) Bell's profile enables us to identify those social aspects which can be tackled when caring for our patients. Its fundamental use is in individual application.

[Evaluation and improvement of quality during practical training in primary health care at health centers of Murcia]. / Evaluación y mejora de la calidad de las prácticas de Atención Primaria realizadas en Centros de Salud de Murcia.

BACKGROUND: To describe the Public Health in Primary Health Care practice for medical students Program objectives, quality of training evaluation method, and implementation results. METHODS: 6 learning objectives were designed and training implemented in 3 Health Centers in the 90-91 academic course. Evaluation included the objectives level of difficulty, and homogeneity in achievement rates between objectives, within Centres and between Centres. Evaluation results were analyzed and used to design changes to increase homogeneity and achievement rates. Same evaluation was performed in the 91-92 academic course to document improvement. RESULTS: In the first evaluation there were highly significant differences in overall (p. < 0.00005) and by objectives (p. > 0.01) achievement rates between centers. Within centres between objectives difficulty was not homogeneous either (p. > 0.001). After implementing remedial actions, differences in difficulty and achievement rates within and between centres decreased. Increased homogeneity affected mostly to two previously less homogeneous objectives. CONCLUSIONS: Quality assurance methods can be successfully applied to improve training of clearly defined and quantified Primary Health Care learning objectives.

[Undergraduate teaching of primary health care. A Delphi study]. / La docencia de atención primaria de salud en el pregrado. Un estudio Delphi.

OBJECTIVE: Given both the limited experience of Undergraduate Teaching in Primary Health Care (PHC) and the lack of contact between different teaching centres, we sought to identify the minimum contents of a potential Syllabus. We made a distinction between items of knowledge required and skills students would have to develop. DESIGN: We undertook a Delphi study, which was longitudinal, prospective and observational. PARTICIPANTS: We defined three groups of experts among groups with PHC teaching experience. 20 Associate Lecturers at Undergraduate level, attached to Health centres; 20 postgraduate PHC teachers, and 7 University staff members involved with Public Health and Preventive and Community Medicine teaching. MAIN MEASUREMENTS AND RESULTS: The reply rate from the three questionnaires was about 60%. There was a high level of agreement. Of the items of knowledge which scored highest, we noted: the doctor-patients relationship, the Promotion of Health and Health education, Integrated Health Programmes, Prevention of Disease and Care of Risk-Groups. Of the skills, we pointed to the Clinical Interview, the construction of a Clinical History at the PHC level, Detection of Risk factors and Physical Examination. CONCLUSIONS: The most valued items of knowledge are those related to the overall Conception of Health, Promotion and Prevention. The most highly-scored skills are those concerning the Doctor-Patient relationship. Questions relating to the Individual are prioritised over those concerning Family and Community. There is a high level of agreement that the acquisition of the necessary theoretical knowledge must be accompanied by the ability to put them into practice.