De-imFAR phase II project: a study protocol for a cluster randomised implementation trial to evaluate the effectiveness of de-implementation strategies to reduce low-value statin prescribing in the primary prevention of cardiovascular disease.

INTRODUCTION: This study aims to reduce potentially inappropriate prescribing (PIP) of statins and foster healthy lifestyle promotion in cardiovascular disease (CVD) primary prevention in low-risk patients. To this end, we will compare the effectiveness and feasibility of several de-implementation strategies developed following the structured design process of the Behaviour Change Wheel targeting key determinants of the clinical decision-making process in CVD prevention. METHODS AND ANALYSIS: A cluster randomised implementation trial, with an additional control group, will be launched, involving family physicians (FPs) from 13 Integrated Healthcare Organisations (IHOs) of Osakidetza-Basque Health Service with non-zero incidence rates of PIP of statins in 2021. All FPs will be exposed to a non-reflective decision assistance strategy based on reminders and decision support tools. Additionally, FPs from two of the IHOs will be randomly assigned to one of two increasingly intensive de-implementation strategies: adding a decision information strategy based on knowledge dissemination and a reflective decision structure strategy through audit/feedback. The target population comprises women aged 45-74 years and men aged 40-74 years with moderately elevated cholesterol levels but no diagnosed CVD and low cardiovascular risk (REGICOR<7.5%), who attend at least one appointment with any of the participating FPs (May 2022-May 2023), and will be followed until May 2024. We use the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate outcomes. The main outcome will be the change in the incidence rate of PIP of statins and healthy lifestyle counselling in the study population 12 and 24 months after FPs' exposure to the strategies. Moreover, FPs' perception of their feasibility and acceptability, and patient experience regarding the quality of care received will be evaluated. ETHICS AND DISSEMINATION: The study was approved by the Basque Country Clinical Research Ethics Committee and was registered in ClinicalTrials.gov (NCT04022850). Results will be disseminated in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04022850.

Initial study of anaemia profile for primary care centres with automated laboratory algorithms reduces the demand for ferritin, iron, transferrin, vitamin B12 and folate tests.

AIM: To evaluate the influence of an algorithm designed to incorporate reflex testing according to haemogram results for analytical tests ordered to investigate anaemia. METHODS: In 2020, a new request for 'initial study of anaemia' was created in three primary care pilot centres for suspected anaemia or new anaemias. A haemogram was ordered and the remainder of the tests were created in a reflex manner according to an algorithm integrated in the laboratory information system that also generates a comment that is completed and validated by a haematologist. The demand for tests was evaluated over three time periods. RESULTS: Of 396 requests, anaemia was detected in 80 (20.2%), with 26 microcytic anaemias (6.57%), 20 iron deficiency anaemias, 41 (10.3%) normocytic anaemias and 13 macrocytic anaemias (3.28%); 4 with folate deficiency; and 1 haemolytic anaemia. No haematological diseases were detected. Twenty-four (6.06%) cases exhibited microcytosis/hypochromia without anaemia, 12 of which exhibited iron deficiency. Four young women exhibiting within-limit haemoglobin levels had iron deficiency. There were 56 (14.1%) cases of macrocytosis without anaemia.With the new profile of 'initial study of anaemia', the demand for tests was reduced and was significantly lower than in the remainder of primary centres for iron, transferrin, ferritin, vitamin B12 and folate. CONCLUSIONS: A new profile of 'initial study of anaemia' in the request form with algorithms integrated in the laboratory information system enabled submission of orders and decreased the demand for unnecessary iron, transferrin, ferritin, vitamin B12 and folate tests.

Impacto de la identificación de pacientes en un programa de cuidados paliativos del País Vasco / The impact of patient identification on an integrated program of palliative care in Basque Country

Objetivo: Evaluar el proceso y el impacto económico de un programa integrado de cuidados paliativos. Diseño: Estudio transversal comparativo. Emplazamiento: Organizaciones Sanitarias Integradas Alto Deba y Goierri Alto-Urola, País Vasco. Participantes: Pacientes fallecidos (oncológicos y no oncológicos) en 2012 (grupo control) y 2015 (grupo intervención) susceptibles de necesitar cuidados paliativos según la estimación mínima de McNamara. Intervenciones: Identificación de pacientes con el código de cuidados paliativos en atención primaria, uso de rutas asistenciales conjuntas en atención primaria y hospitalaria e impartición de cursos formativos. Mediciones principales: Cambio en el perfil de uso de recursos del paciente durante sus últimos 3 meses de vida. Se utilizó el genetic matching para evitar sesgos. Mediante análisis univariante se compararon los grupos y mediante regresiones logísticas y modelos lineales generalizados se analizaron las relaciones entre variables. Resultados: Se identificaron 1.023 pacientes en 2012 y 1.142 en 2015. En 2015 aumentó al doble la probabilidad de ser identificado como paliativo en pacientes oncológicos (19-33%) y no oncológicos (7-16%). La prescripción de opiáceos subió (25-68%) y el fallecimiento en hospital se mantuvo estable. Los contactos por paciente con atención primaria y hospitalización a domicilio aumentaron, mientras que las hospitalizaciones tradicionales disminuyeron. El coste por paciente aumentó un 26%. Conclusiones: El modelo integrado incrementó la identificación de la población diana. La relación entre variables mostró que la identificación repercutió positivamente en la prescripción de opiáceos, fallecimiento fuera del hospital y extensión a enfermedades no oncológicas. Aunque también disminuyeron los ingresos, el coste aumentó debido al uso de hospitalización a domicilio

Objective: Evaluate the process and the economic impact of an integrated palliative care program. Design: Comparative cross-sectional study. Location: Integrated Healthcare Organizations of Alto Deba and Goierri Alto-Urola, Basque Country. Participants: Patients dead due to oncologic and non-oncologic causes in 2012 (control group) and 2015 (intervention group) liable to need palliative care according to McNamara criteria. Interventions: Identification as palliative patients in primary care, use of common clinical pathways in primary and secondary care and arrange training courses for health professionals. Main measures: Change in the resource use profile of patients in their last 3 months. Propensity score by genetic matching method was used to avoid non-randomization bias. The groups were compared by univariate analysis and the relationships between variables were analysed by logistic regressions and generalized linear models. Results: One thousand and twenty-three patients were identified in 2012 and 1,142 patients in 2015. In 2015 doubled the probability of being identify as palliative patient in deaths due to oncologic (19-33%) and non-oncologic causes (7-16%). Prescriptions of opiates rise (25-68%) and deaths in hospital remained stable. Contacts per patient with primary care and home hospitalization increased, while contacts with hospital admissions decreased. Cost per patient rise 26%. Conclusions: The integrated palliative care model increased the identification of the target population. Relationships between variables showed that the identification had a positive impact on prescription of opiates, death outside the hospital and extension to non-oncologic diseases. Although the identification decreased admissions in hospital, costs per patient had a slight increase due to home hospitalizations

[The impact of patient identification on an integrated program of palliative care in Basque Country]. / Impacto de la identificación de pacientes en un programa de cuidados paliativos del País Vasco.

OBJECTIVE: Evaluate the process and the economic impact of an integrated palliative care program. DESIGN: Comparative cross-sectional study. LOCATION: Integrated Healthcare Organizations of Alto Deba and Goierri Alto-Urola, Basque Country. PARTICIPANTS: Patients dead due to oncologic and non-oncologic causes in 2012 (control group) and 2015 (intervention group) liable to need palliative care according to McNamara criteria. INTERVENTIONS: Identification as palliative patients in primary care, use of common clinical pathways in primary and secondary care and arrange training courses for health professionals. MAIN MEASURES: Change in the resource use profile of patients in their last 3 months. Propensity score by genetic matching method was used to avoid non-randomization bias. The groups were compared by univariate analysis and the relationships between variables were analysed by logistic regressions and generalized linear models. RESULTS: One thousand and twenty-three patients were identified in 2012 and 1,142 patients in 2015. In 2015 doubled the probability of being identify as palliative patient in deaths due to oncologic (19-33%) and non-oncologic causes (7-16%). Prescriptions of opiates rise (25-68%) and deaths in hospital remained stable. Contacts per patient with primary care and home hospitalization increased, while contacts with hospital admissions decreased. Cost per patient rise 26%. CONCLUSIONS: The integrated palliative care model increased the identification of the target population. Relationships between variables showed that the identification had a positive impact on prescription of opiates, death outside the hospital and extension to non-oncologic diseases. Although the identification decreased admissions in hospital, costs per patient had a slight increase due to home hospitalizations.

Evaluación de la implementación de un programa integrado de atención a las enfermedades del aparato locomotor / Evaluation of the implementation of an integrated program for musculoskeletal system care

Introducción. El carácter crónico de las enfermedades del aparato locomotor requieren una atención integrada de atención primaria y las especialidades de reumatología, traumatología y rehabilitación. El objetivo del trabajo fue evaluar la implementación de un modelo organizativo integrado de gestión de la osteoporosis, lumbalgia, enfermedades del hombro y enfermedades de la rodilla mediante el proceso de mejora continua de Deming, teniendo en cuenta las derivaciones y el consumo de recursos. Material y métodos. En la fase de planificación se utilizó un modelo de simulación para predecir la evolución del consumo de recursos en cada enfermedad del aparato locomotor y realizar un análisis del impacto presupuestario desde 2012 hasta 2020 en la comarca Goierri-Alto Urola. En la etapa de revisión se evaluó el estado del proceso en 2014 utilizando el análisis estadístico para comprobar el grado de consecución de los objetivos para cada enfermedad. Resultados. Según el modelo de simulación la población de pacientes con enfermedad osteomuscular aumentará en un 4,4% en 2020, con un incremento en costes para un sistema convencional de un 5,9%. Si la intervención integrada alcanzase sus objetivos este presupuesto se reduciría en un 8,5%. El análisis estadístico evidenció un descenso de derivaciones a traumatología y una reducción de consultas sucesivas en todas las especialidades. Discusión. La implementación del modelo integrado en las enfermedades de osteoporosis, lumbalgia, hombro y rodilla está todavía en un estadio inicial. Sin embargo, el empoderamiento de la atención primaria mejoró la derivación de pacientes y redujo ligeramente los costes (AU)

Introduction. The chronic nature of musculoskeletal diseases requires an integrated care which involves the Primary Care and the specialities of Rheumatology, Traumatology and Rehabilitation. The aim of this study was to assess the implementation of an integrated organizational model in osteoporosis, low back pain, shoulder disease and knee disease using Deming's continuous improvement process and considering referrals and resource consumption. Material and methods. A simulation model was used in the planning to predict the evolution of musculoskeletal diseases resource consumption and to carry out a Budget Impact Analysis from 2012 to 2020 in the Goierri-Alto Urola region. In the checking stage the status of the process in 2014 was evaluated using statistical analysis to check the degree of achievement of the objectives for each speciality. Results. Simulation models showed that population with musculoskeletal disease in Goierri-Alto Urola will increase a 4.4% by 2020. Because of that, the expenses for a conventional healthcare system will have increased a 5.9%. However, if the intervention reaches its objectives the budget would decrease an 8.5%. The statistical analysis evidenced a decline in referrals to Traumatology service and a reduction of successive consultations in all specialities. Discussion. The implementation of the integrated organizational model in osteoporosis, low back pain, shoulder disease and knee disease is still at an early stage. However, the empowerment of Primary Care improved patient referrals and reduced the costs (AU)

Evaluation of the implementation of an integrated program for musculoskeletal system care. / Evaluación de la implementación de un programa integrado de atención a las enfermedades del aparato locomotor.

INTRODUCTION: The chronic nature of musculoskeletal diseases requires an integrated care which involves the Primary Care and the specialities of Rheumatology, Traumatology and Rehabilitation. The aim of this study was to assess the implementation of an integrated organizational model in osteoporosis, low back pain, shoulder disease and knee disease using Deming's continuous improvement process and considering referrals and resource consumption. MATERIAL AND METHODS: A simulation model was used in the planning to predict the evolution of musculoskeletal diseases resource consumption and to carry out a Budget Impact Analysis from 2012 to 2020 in the Goierri-Alto Urola region. In the checking stage the status of the process in 2014 was evaluated using statistical analysis to check the degree of achievement of the objectives for each speciality. RESULTS: Simulation models showed that population with musculoskeletal disease in Goierri-Alto Urola will increase a 4.4% by 2020. Because of that, the expenses for a conventional healthcare system will have increased a 5.9%. However, if the intervention reaches its objectives the budget would decrease an 8.5%. The statistical analysis evidenced a decline in referrals to Traumatology service and a reduction of successive consultations in all specialities. DISCUSSION: The implementation of the integrated organizational model in osteoporosis, low back pain, shoulder disease and knee disease is still at an early stage. However, the empowerment of Primary Care improved patient referrals and reduced the costs.