[Mortality and use of healthcare resources in elderly patients in Seville: Differences between institutionalised patients and those included in a home care program]. / Mortalidad y uso de recursos sanitarios en pacientes ancianos en la provincia de Sevilla: diferencias entre pacientes institucionalizados y en atención domiciliaria.

OBJECTIVES: Society is ageing, and as a consequence, the population with increased frailty and comorbidity is growing. The aim is to analyse the mortality and its potential factors, as well as the use of healthcare resources in elderly patients, and to study the differences between institutionalised patients and those included in a home care program. MATERIALS AND METHODS: An observational, longitudinal and prospective cohort study was conducted in Seville during 2016. The study subjects consisted of 1314 elderly patients (1061 institutionalised and 253 at home). The variables studied included mortality and its potential factors, and the use of healthcare resources. RESULTS: No differences were found in mortality between institutionalised and home care program patients (RR=1.044; 95% CI; 0.74-1.46; P=.799). The leading cause of death was circulatory diseases followed by respiratory diseases. Among the factors explaining the mortality, it is important to highlight: age, dependency and admissions in the hospital or the emergency department. The patient's functional independence is associated with a higher survival rate. Differences were found between both groups in the number of calls to the Critical Care and Emergency Services (P=.022) or the primary care doctor (P<.001) and in the hospital admissions (P<.001), the first 2differences being higher in home care program patients, and the latter in institutionalised patients. CONCLUSIONS: There are no differences between groups either in the mortality or in the cause of death. Age, functional dependency and admissions in the hospital are factors which explain the mortality. The use of healthcare resources is higher in patients at home.

Tratamiento con estatinas en pacientes dislipidémicos mayores de 75 años, en prevención primaria / Statin treatment as primary prevention in dyslipidaemic patients older than 75 years

OBJETIVOS: Determinar posibles diferencias en la incidencia de eventos cardiovasculares entre pacientes dislipidémicos mayores de 75 años tratados con estatinas respecto a aquellos que no las toman, en prevención primaria. MATERIAL Y MÉTODOS: Se realiza un estudio de cohortes retrospectivo en mayores de 75 años con dislipidemia en un centro de salud, entre los años 2005 y 2015. Se estudiaron 329 pacientes (182 en tratamiento con estatinas y 147 sin tratamiento hipolipidemiante) que cumplían los criterios de inclusión (paciente de 75 años o más, en tratamiento con estatinas durante al menos 3 años o no haber realizado ningún tratamiento hipolipidemiante, y en prevención primaria). Las variables de estudio fueron todas aquellas que las últimas guías de riesgo cardiovascular establecen como factor de riesgo, siendo «evento cardiovascular» la variable dependiente. Se realizó un análisis descriptivo e inferencial para variables cuantitativas y cualitativas, así como un análisis multivariante mediante regresión logística binaria. RESULTADOS: La incidencia de eventos cardiovasculares en pacientes sin tratamiento con estatinas es de un 15,93% (IC 95% 11,15-21,80), y de un 37,42% (IC 95% 29,87-45,45) en aquellos que sí las tomaban (p < 0,001), con un RR de 2,35 (IC 95% 1,58-3,48). CONCLUSIONES: Existen diferencias estadísticamente significativas con un aumento en la incidencia de eventos cardiovasculares en pacientes que toman estatinas, respecto a los que no. Se plantea si actualmente se está dando la importancia real a las cifras de colesterol en este perfil de pacientes, así como si la indicación de prescripción de estatinas en mayores de 75 años es adecuada en prevención primaria

OBJECTIVES: To determine possible differences in the incidence of cardiovascular events between dyslipidaemia patients older than 75 years treated with statins compared to those not treated with them, as primary prevention. MATERIAL AND METHODS: A retrospective cohort study was conducted in patients older than 75 years with dyslipidaemia in a health centre, between 2005 and 2015. The study included 329 patients (182 on treatment with statins and 147 with no lipid-lowering treatment) who met the inclusion criteria (patients older than 75 years, on treatment with statins for at least 3 years, or to have not had any lipid lowering treatment and as primary prevention). The study variables were all those considered as a risk factor in the latest cardiovascular risk guidelines, and the dependent variable was "cardiovascular event". A descriptive and inferential analysis was carried out for quantitative and qualitative variables, as well as a multivariate analysis using binary logistic regression. RESULTS: The incidence of cardiovascular events in patients without treatment with statins was 15.93% (95% CI 11.15-21.80), and 37.42% (95% CI 29.87-45.45) in those that were taking them (P<.001). The RR was 2.35 (95% CI 1.58-3.48). CONCLUSIONS: There are statistically significant differences, with an increase in the incidence of cardiovascular events in patients taking statins, compared to those who do not. It is currently considered whether real importance is being given to cholesterol levels in this patient group, as well as whether the prescription of statins in patients older than 75 years is suitable in primary prevention

[Statin treatment as primary prevention in dyslipidaemic patients older than 75 years]. / Tratamiento con estatinas en pacientes dislipidémicos mayores de 75 años, en prevención primaria.

OBJECTIVES: To determine possible differences in the incidence of cardiovascular events between dyslipidaemia patients older than 75 years treated with statins compared to those not treated with them, as primary prevention. MATERIAL AND METHODS: A retrospective cohort study was conducted in patients older than 75 years with dyslipidaemia in a health centre, between 2005 and 2015. The study included 329 patients (182 on treatment with statins and 147 with no lipid-lowering treatment) who met the inclusion criteria (patients older than 75 years, on treatment with statins for at least 3 years, or to have not had any lipid lowering treatment and as primary prevention). The study variables were all those considered as a risk factor in the latest cardiovascular risk guidelines, and the dependent variable was "cardiovascular event". A descriptive and inferential analysis was carried out for quantitative and qualitative variables, as well as a multivariate analysis using binary logistic regression. RESULTS: The incidence of cardiovascular events in patients without treatment with statins was 15.93% (95% CI 11.15-21.80), and 37.42% (95% CI 29.87-45.45) in those that were taking them (P<.001). The RR was 2.35 (95% CI 1.58-3.48). CONCLUSIONS: There are statistically significant differences, with an increase in the incidence of cardiovascular events in patients taking statins, compared to those who do not. It is currently considered whether real importance is being given to cholesterol levels in this patient group, as well as whether the prescription of statins in patients older than 75 years is suitable in primary prevention.

Prevalencia de enfermedades osteoarticulares y consumo de recursos. Calidad de vida y dependencia en pacientes con artrosis / Joint diseases and use of resources. Quality of life and dependence in patients with arthrosis

Objetivos. Principal: estimar la prevalencia de enfermedades osteoarticulares. Secundarios: describir la utilización de recursos sanitarios y valorar el impacto en la calidad de vida y dependencia en pacientes con artrosis. Material y métodos. Diseño: estudio observacional descriptivo transversal. Emplazamiento: Centro de salud urbano. Participantes: mayores de 40 años con algún tipo de enfermedad osteoarticular. Muestreo aleatorio. Se estimó una prevalencia del 10%, precisión 3%, confianza 95% y añadiendo un 20% (n=464). Mediciones principales: edad, sexo, enfermedad osteoarticular, utilización de recursos (visitas, derivaciones, pruebas complementarias, fármacos e infiltraciones), calidad de vida (WOMAC) y grado de incapacidad (Katz). Resultados. El 56,9% de las personas estudiadas eran mujeres, la media de edad fue de 59,47 años (DE 13,24). La enfermedad osteoarticular más prevalente fue la artrosis, 33,6% (IC 29,43-38,02). En la artrosis, el 62,9% de pacientes no acudieron a consulta, en otras enfermedades osteoarticulares fueron una vez el 36,3%. El 87,3% en artrosis no se derivó, en otras enfermedades el 86,5%. El 84,3% en artrosis no requirió pruebas complementarias, en otras enfermedades el 77,2%. Tomaron AINE con analgésicos el 43,1%, gastroprotección el 52,4% y el 7,5% se infiltró. Dificultad para subir escaleras (WOMAC) el 55,2%. La categoría A de Katz fue la más frecuente, 69,38%. Conclusiones. La enfermedad osteoarticular más frecuente fue la artrosis. La mayoría recibieron analgésicos, AINE y gastroprotectores. La utilización del resto de recursos (visitas, derivaciones y pruebas complementarias) no fue alta. Existe afectación de la calidad de vida aunque la mayoría eran independientes para ABVD (AU)

Objectives. Primary objective: to examine the prevalence of osteoarticular (joint) diseases. Secondary: to describe the use of health resources and assess the impact on quality of life and dependency in patients with osteoarthritis. Material and methods. Design: descriptive, cross-sectional and observational study. Location: urban health centre. Participants: a random sample of adults over 40 years-old with any type of joint disease. The study estimated a prevalence of 10%, 3% of precision and 95% of reliability, adding 20% (n=464). Main measurements: age, sex, osteoarticular disease, use of resources (visits, referrals, complementary tests, drugs and infiltrations), life quality (WOMAC) and incapacity level (Katz). Results. Of those surveyed, 56.9% were women, mean age 59.47 years (SD 13.24). The most prevalent osteoarticular disease was osteoarthritis, 33.6% (95% CI 29.43-38.02). A total of 62.9% of patients with osteoarthritis did not visit the doctor, whereas 36.3% of patients with other osteoarticular diseases visited the doctor once. A total of 87.3% of patients with osteoarthritis were not referred, in other diseases 86.5% were. Complementary tests were not required in 84.3% of patients with osteoarthritis, whereas 77.2% of patients with other diseases did. NSAIDs were taken by 43.1% of patients with analgesics; 52.4% took gastroprotection and 7.5% had infiltrates. According to the WOMAC, 55.2% of patients with osteoarthritis had difficulty getting up the stairs. Up to 69.38% of patients were Katz Category A. Conclusions. The most frequent osteoarticular disease was osteoarthritis. Most patients ingested analgesics, NSAIDs and gastroprotection. Use of resources was not high (visits, referrals and complementary tests). The study shows there is an impact on the quality of life, although the majority was independent to BDLA (AU)

[Inter-observer variability in the diagnosis and classification of diabetic retinopathy through biomicroscopy]. / Variabilidad interobservador en el diagnóstico y clasificación de la retinopatía diabética mediante biomicroscopía.

OBJECTIVE: Analysis of the inter-observer variability of biomicroscopy used for the diagnosis of Diabetic Retinopathy. METHODS: This was a descriptive study. Parallel observer-blind evaluations of the degree of retinopathy in type 2 diabetic patients, as defined on biomicroscopic photographs, were performed by two ophthalmologists. The sample size required for the Kappa index among ophthalmologists with a disagreement ratio of 15%, precision ratio of 5% and confidence level of 95% is n=196 (<> being the number of eyes). The only variable measured was the degree of Diabetic Retinopathy, according to the modified Early Treatment Diabetic Research Study (ETDRS) classification. RESULTS: The average age of the 217 patients photographed was of 65.42 years (SE= 9.91). In 191 instances there was total agreement between the 2 ophthalmologists. In 24 instances the discrepancy was only of one degree of the classification of the ETDRS, and in 2 the discrepancy was of two degrees. In no case was it greater than this. (Quadratic weighed Kappa = 0.876, IC95%: 0.655-0.952 and linear weighed Kappa = 0.804, IC95%: 0.729-0.878). CONCLUSIONS: The Weighed Kappa index demonstrated a <> agreement of the degree of diabetic retinopathy. The discrepancies were slight, were of no clinical importance, and would not have affected treatment decisions. The results indicate that this examination, performed by a single ophthalmologist, can be utilised as a reference standard in Diabetic Retinopathy diagnosis.

Variabilidad interobservador en el diagnóstico y clasificación de la retinopatía diabética mediante biomicroscopía / Inter-observer variability in the diagnosis and classification of diabetic retinopathy through biomicroscopy

Objetivo: Análisis de la variabilidad interobservador de la biomicroscopía utilizada para el diagnóstico de retinopatía diabética. Métodos: Diseño: Observacional descriptivo. Valoración en paralelo, de forma ciega para los observadores, del grado de retinopatía diabética mediante biomicroscopía en pacientes diabéticos tipo 2. Muestra: Para la evaluación del índice Kappa, con una estimación de una proporción de desacuerdo del 15%, (precisión del 5% intervalo de confianza del 95%) muestra n=196, (siendo «n» el número de ojos). Variables a medir: grado de retinopatía diabética, según la clasificación del ETDRS modificada. Resultados: La edad media de los pacientes fotografiados fue de 65,42 años (DE= 9,91). De las 217 biomicroscopías realizadas, en 191 se encontró concordancia total. En 24 la discordancia fue tan sólo en un grado de la clasificación del ETDRS y en 2 la discordancia fue en dos grados. En ningún caso fue mayor. Kappa ponderado cuadrático = 0,876, IC95%: 0,655-0,952 y Kappa ponderado lineal =0,804, IC95%: 0,729-0,878. Conclusiones: El índice Kappa ponderado demuestra un grado de acuerdo «muy bueno». Las discrepancias producidas además de escasas no tienen trascendencia clínica, ya que no afectan a la decisión de tratamiento. La biomicroscopía leída por un solo oftalmólogo es un instrumento fiable como patrón de referencia para el diagnóstico de la retinopatía diabética

Objective: Analysis of the inter-observer variability of biomicroscopy used for the diagnosis of Diabetic Retinopathy. Methods: This was a descriptive study. Parallel observer-blind evaluations of the degree of retinopathy in type 2 diabetic patients, as defined on biomicroscopic photographs, were performed by two ophthalmologists. The sample size required for the Kappa index among ophthalmologists with a disagreement ratio of 15%, precision ratio of 5% and confidence level of 95% is n=196 («n» being the number of eyes). The only variable measured was the degree of Diabetic Retinopathy, according to the modified Early Treatment Diabetic Research Study (ETDRS) classification. Results: The average age of the 217 patients photographed was of 65.42 years (SE= 9.91). In 191 instances there was total agreement between the 2 ophthalmologists. In 24 instances the discrepancy was only of one degree of the classification of the ETDRS, and in 2 the discrepancy was of two degrees. In no case was it greater than this. (Quadratic weighed Kappa = 0.876, IC95%: 0.655-0.952 and linear weighed Kappa = 0.804, IC95%: 0.729-0.878). Conclusions: The Weighed Kappa index demonstrated a «very good» agreement of the degree of diabetic retinopathy. The discrepancies were slight, were of no clinical importance, and would not have affected treatment decisions. The results indicate that this examination, performed by a single ophthalmologist, can be utilised as a reference standard in Diabetic Retinopathy diagnosis

[Definition and validation of quality indicators of prescription in primary care]. / Definición y validación de indicadores de calidad de la prescripción en atención primaria.

OBJECTIVE: To define and validate a battery of prescription indicators on the use of anti-hypertensives, lipid-lowerers, diabetes drugs, and insulin, as measurements of family doctors' quality of prescription in primary health care. DESIGN: Transversal, descriptive study. SETTING: Two primary care health districts, Camas and Sierra Norte, Spain. PARTICIPANTS: Eighty three family doctors, 94.32% of the doctors in the study area. DEFINITION AND VALIDATION OF INDICATORS: To construct the prescription indicators, we used evidence found in the scientific bibliography available. To validate it, we analysed its statistical relationship with a series of selected clinical tests, collected from the clinical records. RESULTS: For each doctor, there was a statistically significant relationship between the index of quality of prescription and the clinical quality seen in the records (P=.004). The variables of age, sex, and training fine-tuned the model. CONCLUSIONS: There is a statistically significant relationship between a good prescription indicator and proper control of intermediate health variables.

Definición y validación de indicadores de calidad de la prescripción en atención primaria

Objetivo. Definir y validar una batería de indicadores de prescripción sobre el uso de antihipertensivos, hipolipemiantes, antidiabéticos y insulinas, como medidores de la calidad de la prescripción de médicos de familia en el ámbito de la atención primaria de salud (APS). Diseño. Estudio descriptivo, transversal. Emplazamiento. Agrupación de 2 distritos sanitarios de atención primaria, Camas y Sierra Norte. Participantes. Un total de 83 médicos de familia, lo que supone el 94,32 por ciento de los médicos del área de estudio. Defición y validación de indicadores. Para la construción de los indicadores de prescripción nos basamos en las evidencias halladas en la bibliografía científica disponible. Para su validación analizamos su relación estadística con una serie de pruebas clínicas seleccionadas, que se recogieron de las historias clínicas. Resultados. Se observó una relación estadísticamente significativa entre el índice de calidad de prescripción y la calidad clínica observada en las historias, para cada médico (p = 0,004). Las variables edad, sexo y formación ajustan mejor el modelo. Conclusiones. Hay una relación estadísticamente significativa entre un buen indicador de prescripción y el adecuado control de variables intermedias de salud.(AU)

Definición y validación de indicadores de calidad de la prescripción en atención primaria / Definition and validation of quality indicators of prescription in primary care

Objetivo. Definir y validar una batería de indicadores de prescripción sobre el uso de antihipertensivos, hipolipemiantes, antidiabéticos e insulinas, como medidores de la calidad de la prescripción de médicos de familia en el ámbito de la atención primaria de salud (APS). Diseño. Estudio descriptivo, transversal. Emplazamiento. Agrupación de 2 distritos sanitarios de atención primaria, Camas y Sierra Norte. Participantes. Un total de 83 médicos de familia, lo que supone el 94,32% de los médicos del área de estudio. Definición y validación de indicadores. Para la construcción de los indicadores de prescripción nos basamos en las evidencias halladas en la bibliografía científica disponible. Para su validación analizamos su relación estadística con una serie de pruebas clínicas seleccionadas, que se recogieron de las historias clínicas. Resultados. Se observó una relación estadísticamente significativa entre el índice de calidad de prescripción y la calidad clínica observada en las historias, para cada médico (p = 0,004). Las variables edad, sexo y formación ajustan mejor el modelo. Conclusiones. Hay una relación estadísticamente significativa entre un buen indicador de prescripción y el adecuado control de variables intermedias de salud

Objective. To define and validate a battery of prescription indicators on the use of anti-hypertensives, lipid-lowerers, diabetes drugs, and insulin, as measurements of family doctors' quality of prescription in primary health care. Design. Transversal, descriptive study. Setting. Two primary care health districts, Camas and Sierra Norte, Spain. Participants. Eighty three family doctors, 94.32% of the doctors in the study area. Definition and validation of indicators. To construct the prescription indicators, we used evidence found in the scientific bibliography available. To validate it, we analysed its statistical relationship with a series of selected clinical tests, collected from the clinical records. Results. For each doctor, there was a statistically significant relationship between the index of quality of prescription and the clinical quality seen in the records (P=.004). The variables of age, sex, and training fine-tuned the model. Conclusions. There is a statistically significant relationship between a good prescription indicator and proper control of intermediate health variables

[Evaluation of clinical competence of family medicine trainer]. / Evaluación de la competencia clínica de tutores de residentes de medicina familiar y comunitaria.

OBJECTIVES: We show the first experience of the application of an objective and structured clinical evaluation (OSCE) procedure to family medicine trainers, that has been carried out in Andalucia. The objective is to use a competence evaluation instrument that, in the short term, will be used not only for trainer accreditation but also for other public sanitary professionals. PARTICIPANTS: Tutors of family and community medicine residents. DESIGN: Observational descriptive. SETTING: Educational unity of family medicine. PRINCIPAL MEASUREMENTS: The competencial components to be assessed are the following: anamnesis, physical exploration, communication, technical skill, management, family attention y preventive activities. The clinical situations were selected using the following priority criteria: prevalence, clinical gravity, prevention and early diagnosis importance, case complexity, doctor's capacity of evaluation and simplicity. RESULTS: Thirteen family medicine trainers took part in the OSCE. Their average age was 42.8 +/- 3.6 years. The test had an overall reliability coefficient (Cronbach's alpha) of 0.73. The overall mean score of the participants was 73 +/- 6.2. The best results about the competencial components were family attention, communication and technical skill. CONCLUSIONS: The OSCE can be a convenient tool for family medical trainer evaluation, helping to orientate their education in the weak points and, in the near future, it can also be used as an instrument do accredit family medicine trainers.