La contribución de la nefrología extrahospitalaria al control de la demanda: análisis del Área Integral de Salud Barcelona Esquerra (AISBE) / The contribution of outpatient nephrology to the control of demand: Analysis of the comprehensive Health Area of Barcelona Esquerra (AISBE)

La coordinación entre nefrología y atención primaria se recoge bien en documentos sobre el manejo de la enfermedad renal crónica (ERC), pero se conoce menos el impacto real. Objetivo: Evaluar la eficiencia de un programa de nefrología extrahospitalaria (PNE) implantado progresivamente en 10 años respecto la demanda de atención a la ERC en el Área Integral de Salud Barcelona Esquerra, 524.395 habitantes, más de un tercio de la población barcelonesa. Material y métodos: Se ha recogido el n.° y la edad de las 1.as visitas en nefrología entre 2004 y 2014 y establecido un índice de derivación (ID) entre el n. de 1.as visitas y la ERC estimada en población atendida según la implantación del PNE. Resultados: La población adulta descendió entre 2006 y 2014, pero el n.° de habitantes ≥ 65 años aumentó de 107.025 a 113.461, así la ERC estimada. Insuficiencia renal fue el motivo de > 70% de las 1.as visitas de nefrología. La media de edad fue 74 años en 2004-2009 y 70 años en 2010-2014. El ID mostró dos tendencias en el periodo analizado según el PNE incluyera consultoría presencial o no. Conclusiones: El descenso del ID sugiere mejor resolución de la atención primaria. La mejora mayor en las Áreas Básicas de Salud de referencia (con ID reducido hasta > 44%) coincide con la implantación del PNE. Precocidad y contención del PNE superan la brecha entre la atención primaria y la hospitalaria a fin de dar respuesta a la cronicidad, el envejecimiento y la dependencia

The coordination between nephrology and primary care is well documented in the management of chronic kidney disease (CKD), but the real impact is uncertain Objective: To evaluate the efficiency of an outpatient nephrology program (ONP) implanted progressively over the course of 10 years regarding the demand for CKD care in the Integral Health Area of Barcelona Esquerra, accounting for 524,395 inhabitants, which is more than a third of the population of Barcelona. Material and methods: The number and age of the new referrals to nephrology between 2004 and 2014 were identified and a referral index (RI) was established between the number of new referrals and the estimated prevalence of CKD in the population treated, based on the implementation of the ONP. Results: The adult population decreased between 2006 and 2014, but the number of inhabitants aged 65 years or above increased from 107,025 to 113,461 and so did the estimated CKD. Renal insufficiency was the reason for more than 70% of the referrals made to nephrology. The average age was 74 years old between 2004-2009 and 70 between 2010-2014. The RI showed two trends in the analysed period, depending on whether or not the ONP included the face-to-face consultancy. Conclusions: The decrease in RI suggests a better resolution at primary care. The major improvement in the Basic Health Areas of reference (with RI reduced by more than 44%) coincides with the implementation of the ONP. The implantation of ONP overcome the gap between primary and hospital care in order to respond to chronicity, aging and dependence

Indicator condition-guided HIV testing with an electronic prompt in primary healthcare: a before and after evaluation of an intervention.

OBJECTIVE: Indicator condition (IC)-guided HIV testing is a strategy for the diagnosis of patients with HIV. The aim of this study was to assess the impact on the proportion of HIV tests requested after the introduction of an electronic prompt instructing primary healthcare (PHC) physicians to request an HIV test when diagnosing predefined IC. METHODS: A prospective interventional study was conducted in 2015 in three PHC centres in Barcelona to assess the number of HIV test requests made during the implementation of an electronic prompt. Patients aged 18-65 years without HIV infection and with a new diagnosis of predefined IC were included. The results were compared with preprompt (2013) and postprompt data (2016). RESULTS: During the prompt period, 832 patients presented an IC (median age 41.6 years [IQR 30-54], 48.2% female). HIV tests were requested in 296 individuals (35, 6%) and blood tests made in 238. Four HIV infections were diagnosed (positivity rate 1.7%, 95% CI 0.5% to 4.4%). The number of HIV tests requested based on IC increased from 12.6% in 2013 to 35.6% in 2015 (p<0.001) and fell to 17.9% after removal of the prompt in 2016 (p<0.001). Younger patient age (OR 0.97, 95% CI 0.96 to 0.98), birth outside Spain (OR 1.53, 95% CI 1.06 to 2.21) and younger physician age (OR 0.97, 95% CI 0.96 to 0.99) were independent predictive factors for an HIV test request during the prompt period. The electronic prompt (OR 3.36, 95% CI 2.70 to 4.18) was the factor most closely associated with HIV test requests. It was estimated that 10 (95% CI 3.0 to 26.2) additional new cases would have been diagnosed if an HIV test had been performed in all patients presenting an IC. CONCLUSIONS: A significant increase in HIV test requests was observed during the implementation of the electronic prompt. The results suggest that this strategy could be useful in increasing IC-guided HIV testing in PHC centres.

The contribution of outpatient nephrology to the control of demand: Analysis of the comprehensive Health Area of Barcelona Esquerra (AISBE). / La contribución de la nefrología extrahospitalaria al control de la demanda: análisis del Área Integral de Salud Barcelona Esquerra (AISBE).

The coordination between nephrology and primary care is well documented in the management of chronic kidney disease (CKD), but the real impact is uncertain. OBJECTIVE: To evaluate the efficiency of an outpatient nephrology program (ONP) implanted progressively over the course of 10 years regarding the demand for CKD care in the Integral Health Area of Barcelona Esquerra, accounting for 524,395 inhabitants, which is more than a third of the population of Barcelona. MATERIAL AND METHODS: The number and age of the new referrals to nephrology between 2004 and 2014 were identified and a referral index (RI) was established between the number of new referrals and the estimated prevalence of CKD in the population treated, based on the implementation of the ONP. RESULTS: The adult population decreased between 2006 and 2014, but the number of inhabitants aged 65 years or above increased from 107,025 to 113,461 and so did the estimated CKD. Renal insufficiency was the reason for more than 70% of the referrals made to nephrology. The average age was 74 years old between 2004-2009 and 70 between 2010-2014. The RI showed two trends in the analysed period, depending on whether or not the ONP included the face-to-face consultancy. CONCLUSIONS: The decrease in RI suggests a better resolution at primary care. The major improvement in the Basic Health Areas of reference (with RI reduced by more than 44%) coincides with the implementation of the ONP. The implantation of ONP overcome the gap between primary and hospital care in order to respond to chronicity, aging and dependence.

Integración entre cardiología y atención primaria: impacto sobre la práctica clínica / Integration between cardiology and primary care: impact on clinical practice

Introducción y objetivos. Evaluar el impacto de un programa de integración entre cardiología y atención primaria en la práctica clínica, comparado con la atención convencional. La integración consiste en un cardiólogo hospitalario en cada centro de atención primaria, historia clínica común, guías clínicas consensuadas, sesiones de consultoría y otras herramientas de coordinación. Métodos. Estudio observacional de dos muestras transversales sobre prevalencias en periodos antes y después de la intervención: atención convencional y atención integrada. Se analiza: distribución de pacientes atendidos, impacto en indicadores de buena práctica clínica en los pacientes con cardiopatía isquémica, insuficiencia cardiaca y fibrilación auricular, satisfacción de atención primaria y uso de recursos. Resultados. Se incluyó a 3.194 pacientes (1.572 en atención convencional y 1.622 en integrada). La integración redistribuyó a los pacientes y aumentó el control del cardiólogo sobre enfermedades graves y el control desde primaria de los factores de riesgo y pacientes estables. En cardiopatía isquémica, mejoró el control de colesterolemia, presión arterial, optimización del tratamiento y documentación de la función ventricular. En insuficiencia cardiaca, aumentó el tratamiento con bloqueadores beta y la valoración funcional. En fibrilación auricular, mejoró el estudio con ecocardiografía e indicación de anticoagulación. El uso de recursos no aumentó. La satisfacción de los médicos de primaria se incrementó con la integración. Conclusiones. Tras la integración, mejoró el control y el tratamiento crónico de los pacientes con cardiopatía isquémica, insuficiencia cardiaca y fibrilación auricular, se redistribuyó a los pacientes crónicos entre atención primaria y cardiología, y aumentó la satisfacción de los médicos de familia, sin objetivarse incremento en el uso de recursos (AU)

Introduction and objectives. To assess the impact of a program integrating cardiology and primary care in clinical practice, compared with usual care. The integrated care consists of a hospital cardiologist in each primary care clinic, shared clinical history, joint practice guidelines, consultation sessions, and other coordinating tools. Methods. Observational, cross-sectional study of 2 series of chronic outpatients: conventional and integrated care. We analyzed patient distribution and the impact on good clinical practice indicators in patients with ischemic heart disease, heart failure and atrial fibrillation, along with primary care practitioner satisfaction and use of resources. Results. We included 3194 patients (1572 usual care, 1622 integrated care). Integrated care changed the patient distribution, allowing the cardiologist to focus on serious pathologies while cardiovascular risk factors and stable patients were monitored in primary care. In ischemic heart disease, improvement was observed in cholesterol management and blood pressure control; optimal medical treatment was more frequently prescribed and ventricular function evaluated more often. In heart failure, Beta-blockers treatment increased and functional class was assessed more often. In atrial fibrillation, an increase in anticoagulation prescription and echocardiography evaluation was observed. Satisfaction parameters improved with integrated care. The use of resources was not increased. Conclusions. Using our integration model, follow-up and chronic treatment of patients with ischemic heart disease, heart failure, and atrial fibrillation were improved. Monitoring of chronic patients was redistributed between primary care and cardiology, and family physicians¡¯ satisfaction levels improved. There was no increase in use of resources (AU)

[Integration between cardiology and primary care: impact on clinical practice]. / Integración entre cardiología y atención primaria: impacto sobre la práctica clínica.

INTRODUCTION AND OBJECTIVES: To assess the impact of a program integrating cardiology and primary care in clinical practice, compared with usual care. The integrated care consists of a hospital cardiologist in each primary care clinic, shared clinical history, joint practice guidelines, consultation sessions, and other coordinating tools. METHODS: Observational, cross-sectional study of 2 series of chronic outpatients: conventional and integrated care. We analyzed patient distribution and the impact on good clinical practice indicators in patients with ischemic heart disease, heart failure and atrial fibrillation, along with primary care practitioner satisfaction and use of resources. RESULTS: We included 3194 patients (1572 usual care, 1622 integrated care). Integrated care changed the patient distribution, allowing the cardiologist to focus on serious pathologies while cardiovascular risk factors and stable patients were monitored in primary care. In ischemic heart disease, improvement was observed in cholesterol management and blood pressure control; optimal medical treatment was more frequently prescribed and ventricular function evaluated more often. In heart failure, ß-blockers treatment increased and functional class was assessed more often. In atrial fibrillation, an increase in anticoagulation prescription and echocardiography evaluation was observed. Satisfaction parameters improved with integrated care. The use of resources was not increased. CONCLUSIONS: Using our integration model, follow-up and chronic treatment of patients with ischemic heart disease, heart failure, and atrial fibrillation were improved. Monitoring of chronic patients was redistributed between primary care and cardiology, and family physicians' satisfaction levels improved. There was no increase in use of resources. Full English text available from: www.revespcardiol.org.