Identifying barriers and enablers for benzodiazepine (de)prescription: a qualitative study with patients and healthcare professionals.

BACKGROUND: There has been a steadily growing trend in prescribing benzodiazepines over last decade. Spain is one of the countries where this class of drugs is most extensively prescribed by primary healthcare physicians. The aim of this study is to identify factors that might be acting as barriers and enablers for benzodiazepine (de)prescription from patient and professional perspectives. METHODS: Qualitative study through semi-structured interviews with medical practitioners (n=17) and patients (n=27), and a nominal group with medical practitioners (n=19). Interviews were audio-recorded, transcribed and analyzed using thematic analysis. RESULTS: The analysis revealed key themes and was organized around barriers and enablers connected to three interrelated dimen-sions: the social and community context of prescription; the structure, organization and/or management of the health system, and the doctor-patient relationship. The excessive workload of professionals was widely cited as influencing over-prescription. (De)prescription of benzodiazepine was facilitated by encouraging the social prescription of health assets or developing strategies to therapeutic alliance processes and better doctor-patient communication. CONCLUSION: Our findings suggest that there is a role for the salutogenic approach and the health asset model in the development of a more person-centred clinical care. This study considers the importance of encouraging the use of non-pharmacological methods and techniques in the health system and promoting the creation of multidisciplinary teams, therapeutic alliance processes and better doctor-patient communication by giving professionals training in psychosocial skills.

Identificación de barreras y facilitadores para la (des)prescripción de benzodiacepinas: un estudio cualitativo con pacientes y profesionales sanitarios / Identifying barriers and enablers for benzodiazepine (de)prescription: a qualitative study with patients and healthcare professionals

Fundamento: La tendencia en la prescripción de benzodiacepinas ha crecido en la última década. España está entre los países donde este tipo de fármacos es el más prescrito por profesionales en Atención Primaria. El propósito de este estudio es identificar factores que podrían estar actuando como barreras y facilitadores en la (des)prescripción de benzodiacepinas desde la perspectiva de pacientes y profesionales sanitarios. Material y métodos: Estudio cualitativo a través de entrevistas semiestructuradas con profesionales sanitarios (n=17) y pacientes (n=27), y un grupo nominal con profesionales sanitarios (n=19). Las entrevistas fueron transcritas y analizadas utilizando un análisis temático. Resultados: El análisis reveló temas claves organizados como barreras y facilitadores conectados a tres dimensiones interrelacionadas: el contexto comunitario y social de la prescripción; la estructura, organización y/o gestión del sistema sanitaria, y la relación médico-paciente. La excesiva carga laboral de los profesionales fue ampliamente citada como influyente en la prescripción excesiva. Acciones como promover la prescripción social de activos en salud o desarrollar estrategias para facilitar la alianza terapéutica y mejorar la comunicación médico-paciente, fueron vistos como facilitadores. Conclusiones: Los hallazgos sugieren el rol que el enfoque salutogénico y el modelo de activos en salud pueden jugar en el desarrollo de una atención clínica centrada en la persona. El estudio considera la importancia de promover métodos y técnicas de intervenvión no farmacológicos, la promoción de equipos multidisciplinares y la formación en habilidades psicosociales.(AU)

Background: There has been a steadily growing trend in prescribing benzodiazepines over last decade. Spain is one of the countries where this class of drugs is most extensively prescribed by primaryhealthcare physicians. The aim of this study is to identify factors that might be acting as barriers and enablers for benzodiazepine (de)prescription from patient and professional perspectives.Methods: Qualitative study through semi-structured interviews with medical practitioners (n=17) and patients (n=27), and a nominal group with medical practitioners (n=19). Interviews were audio-recorded, transcribed and analyzed using thematic analysis.Results: The analysis revealed key themes and was organizedaround barriers and enablers connected to three interrelated dimensions: the social and community context of prescription; the structure, organization and/or management of the health system, and the doctor-patient relationship. The excessive workload of professionals was widely cited as influencing over-prescription. (De) prescription of benzodiazepine was facilitated by encouraging the social prescription of health assets or developing strategies to therapeutic alliance processes and better doctor-patient communication. Conclusion: Our findings suggest that there is a role for the salutogenic approach and the health asset model in the development of a more person-centred clinical care. This study considers the importance of encouraging the use of non-pharmacological methods and techniques in the health system and promoting the creation ofmultidisciplinary teams, therapeutic alliance processes and betterdoctor-patient communication by giving professionals training inpsychosocial skills.(AU)

Consideraciones de seguridad en la prescripción de medicamentos antiinflamatorios no esteroideos (AINEs), a través de una revisión de revisiones sistemáticas / Safety considerations during prescription of non-steroidal anti-inflammatory drugs (NSAIDs), through a review of systematic reviews

Los medicamentos antiinflamatorios no esteroideos (AI-NEs) se encuentran entre los medicamentos más consu-midos mundialmente. Esto hace necesario realizar unasíntesis amplia de la evidencia disponible sobre la pres-cripción segura y adecuada de AINEs en pacientes conenfermedad cardiovascular, enfermedad renal crónica,hipertensión, insuficiencia cardíaca o cirrosis hepáticay en población general. Para ello se ha realizado unarevisión de revisiones sistemáticas. El uso de AINEs seasoció a una probabilidad significativamente mayor dehepatotoxicidad y daño renal y un mayor riesgo de exa-cerbación de la insuficiencia cardíaca. Teniendo en cuen-ta el aumento del riesgo cardiovascular, hepático y renal,la prescripción de AINEs debe realizarse con cautela,considerando la duración del tratamiento y la situacióndel paciente. Por ello, se debe informar a los pacientessobre sus posibles consecuencias para la salud así comogarantizar un seguimiento adecuado de los mismos.(AU)

Non-steroidal anti-inflammatory drugs (NSAIDs) areamong the most widely used drugs worldwide. Thismakes it necessary to carry out a comprehensivesynthesis of the available evidence on the safe andadequate prescription of NSAIDs in patients with car-diovascular disease, chronic kidney disease, hyper-tension, heart failure or liver cirrhosis and in generalpopulation. For this, a review of systematic reviewswas carried out. The use of NSAIDs is associated witha significantly higher probability of hepatotoxicity andkidney damage, as well as increased risk of exacerba-tion of heart failure. Taking into account the increasedcardiovascular, liver and kidney risk, the prescription ofNSAIDs should be carried out with caution, consideringthe treatment duration and the patient’s situation. Forthis reason, patients should be informed about theirpossible health consequences as well as ensuring ade-quate monitoring of them.(AU)

Safety considerations during prescription of non-steroidal anti-inflammatory drugs (NSAIDs), through a review of systematic reviews.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used drugs worldwide. This makes it necessary to carry out a comprehensive synthesis of the available evidence on the safe and adequate prescription of NSAIDs in patients with cardiovascular disease, chronic kidney disease, hypertension, heart failure or liver cirrhosis and in general population. For this, a review of systematic reviews was carried out. Data extraction and analysis were performed independently by two reviewers and a narrative synthesis of the results was carried out. The use of NSAIDs is associated with a significantly higher probability of hepatotoxicity and kidney damage, as well as increased risk of exacerbation of heart failure. Taking into account the increased cardiovascular, liver and kidney risk, the prescription of NSAIDs should be carried out with caution, considering the treatment duration and the patient's situation. For this reason, patients should be informed about their possible health consequences as well as ensuring adequate monitoring of them.

[Identifying indicators of good practice in clinical and healthcare management]. / Identificación de indicadores de buenas prácticas en gestión clínica y sanitaria.

OBJECTIVE: To identify good practices in order to develop and implement indicators of health outcomes for clinical and healthcare management, as well as the characteristics for an indicator to be considered adequate. METHODOLOGY: A scoping review was performed, with the following phases: 1) Search and identification of bibliography. 2) Selection of relevant documents. Including those studies that discussed issues related to good practices for the use of health indicators in the management field. Those published in a language other than English or Spanish or before 2006 were excluded. 3) Analysis and extraction of information. 4) Consultation with stakeholders, using a qualitative methodology through Concept Mapping, with the participation of 40 experts (decision-makers, scientific societies, and health professionals). The data collection process included an inductive and structured procedure, with prioritisation of ideas grouped into clusters, according to feasibility and importance criteria (0-10 scale). RESULTS: Good practices identified 2 levels: 1) macro-management: Define a framework for the evaluation of indicators and establish a benchmark of indicators. 2) meso-management: Establish indicators according to evidence and expert consensus, taking into account priority areas and topics, testing before final use, and communicate results adequately. The characteristics of a suitable indicator are: 1) Approach of an important issue, 2) Scientific validity, 3) Possibility of measurement with reliable data, 4) Meaning of useful and applicable measurement, and 5) Wide scope. CONCLUSIONS: The best practices for the use of indicators in clinical and healthcare management can make it easier to monitor performance and accountability, as well as to support the decision-making addressed at the development of initiatives for quality improvement.

[Prioritization of non-recommended clinical activities in Primary Care]. / Priorización de actividades clínicas no recomendadas en Atención Primaria.

OBJECTIVE: To prioritize non-recommended clinical activities in Primary Care (PC), from "Do not do" recommendations listed by the Sociedad Española de Medicina de Familia y Comunitaria (Semfyc), according to expert consensus (physicians, nurses and pharmacists). METHODS: The consensus for the prioritization of non-recommended practices in PC was performed through an online procedure. We used as a base the list of "do not-do" recommendations of the SEMFYC. We asked the experts to prioritize practices that should be de-adopted in PC, based on four prioritization criteria: frequency of occurrence, cost of the activity, ease of disposal and damage caused, which were scored from one to five, according to their recommendation. Scores were summarized in median and quartile values. Two rounds were necessary to obtain a consensus. A modified e-Delphi technique was used. RESULTS: 34 experts (62%) participated in the first consultation round and prioritized 19 recommendations with a score = 3.5. These recommendations were again analyzed in a second round, in which 32 panelists agreed to prioritize 17 practices (13 related to prescription, three diagnostic tests, and one clinical analysis). The high priority list included seven practices with values = 4: 1) Prescription of a new drug in elderly patients without having reviewed the previous treatments; 2) Lipid-lowering drugs without calculating the overall cardiovascular risk; 3) Not systematically prescribing gastric protection with proton pump inhibitors to patients consuming Nonsteroidal anti-inflammatory drugs (NSAIDs); 4) Glucose self-analysis in non-insulinized type 2 diabetics; 5) Benzodiazepines in the long term; 6) Bisphosphonates in patients with low risk of fracture; and 7) Antibiotics in lower respiratory tract infections. CONCLUSION: This study provides information for the prioritization of 17 non-AP activities in which short-term de-adoption would significantly increase the efficiency of the public health system.

Priorización de actividades clínicas no recomendadas en Atención Primaria / Prioritization of non-recommended clinical activities in Primary Care

Fundamento: Priorización de las recomendaciones «no hacer» procedentes de la lista de la Sociedad Española de Medicina de Familia y Comunitaria (Semfyc) de actividades preventivas, diagnósticas, terapéuticas o de cuidados que no es correcto hacer en Atención Primaria (AP), a través de un consenso de profesionales expertos de medicina, farmacia y enfermería. Método: Mediante un procedimiento online se solicitó a los expertos la valoración de cada una de las prácticas «no hacer» con cuatro criterios de priorización: frecuencia de ocurrencia, coste de la actividad, facilidad para la eliminación y daño ocasionado. Cada práctica se puntuó de uno a cinco en función de su recomendación para la eliminación, y las puntuaciones se resumieron en mediana y cuartiles. Fueron necesarias dos rondas para obtener consenso. Se utilizó la técnica e-Delphi modificada. Resultados: En la primera ronda de consulta participaron 34 expertos (62%) que priorizaron 19 recomendaciones (puntuación ≥ 3,5) que fueron analizadas en una segunda ronda en la que consensuaron priorizar 17 prácticas para no hacer en AP (13 de prescripción de medicamentos, tres de pruebas diagnósticas, y una de análisis clínico). La lista de muy alta prioridad incluyó siete prácticas con valores ≥ 4, 1) prescripción de nuevo medicamento en mayores sin haber revisado los tratamientos previos, 2) prescripción de hipolipemiantes sin calcular el riesgo cardiovascular global, 3) prescripción de protección gástrica con inhibidores de la bomba de protones a los pacientes que consumen antiinflamatorios no esteroideos, 4) autoanálisis de la glucosa en diabéticos tipo 2 no insulinizados, 5) prescripción de benzodiacepinas a largo plazo, 6) prescripción de bifosfonatos en pacientes con bajo riesgo de fractura y 7) prescripción de antibióticos en infecciones del tracto respiratorio inferior. Conclusiones. Este estudio ofrece información para la priorización de diecisiete actividades «no hacer» en AP cuya desadopción en el corto plazo aumentaría considerablemente la eficiencia del sistema sanitario público (AU)

Background: To prioritize non-recommended clinical activitiesin Primary Care (PC), from «Do not do» recommendations listed by the Sociedad Española de Medicina de Familia y Comunitaria (Semfyc), according to expert consensus (physicians, nurses and pharmacists). Methods. The consensus for the prioritization of non-recommended practices in PC was performed through an online procedure. We used as a base the list of «do not-do» recommendations of the SEMFYC. We asked the experts to prioritize practices that should be de-adopted in PC, based on four prioritization criteria: frequency of occurrence, cost of the activity, ease of disposal and damage caused, which were scored from one to five, according to their recommendation. Scores were summarized in median and quartile values. Two rounds were necessary to obtain a consensus. A modified e-Delphi technique was used. Results. 34 experts (62%) participated in the first consultation round and prioritized 19 recommendations with a score ≥ 3.5. These recommendations were again analyzed in a second round, in which 32 panelists agreed to prioritize 17 practices (13 related to prescription, three diagnostic tests, and one clinical analysis). The high priority list included seven practices with values ≥ 4.1) Prescription of a new drug in elderly patients without having reviewed the previous treatments; 2) Lipidlowering drugs without calculating the overall cardiovascular risk; 3) Not systematically prescribing gastric protection with proton pump inhibitors to patients consuming Nonsteroidal anti-inflammatory drugs (NSAIDs); 4) Glucose self-analysis in non-insulinized type 2 diabetics; 5) Benzodiazepines in the long term; 6) Bisphosphonates in patients with low risk of fracture; and 7) Antibiotics in lower respiratory tract infections. Conclusion. This study provides information for the prioritization of 17 non-AP activities in which short-term de-adoption would significantly increase the efficiency of the public health system (AU)

[Identification of health outcome indicators in Primary Care. A review of systematic reviews]. / Identificación de indicadores de resultado en salud en atención primaria. Una revisión de revisiones sistemáticas.

INTRODUCTION: Outcome measures are being widely used by health services to assess the quality of health care. It is important to have a battery of useful performance indicators with high validity and feasibility. Thus, the objective of this study is to perform a review of reviews in order to identify outcome indicators for use in Primary Care. METHODOLOGY: A review of systematic reviews (umbrella review) was carried out. The following databases were consulted: MedLine, EMBASE, and CINAHL, using descriptors and free terms, limiting searches to documents published in English or Spanish. In addition, a search was made for free terms in different web pages. Those reviews that offered indicators that could be used in the Primary Care environment were included. RESULTS: This review included a total of 5 reviews on performance indicators in Primary Care, which consisted of indicators in the following areas or clinical care processes: in osteoarthritis, chronicity, childhood asthma, clinical effectiveness, and prescription safety indicators. A total of 69 performance indicators were identified, with the percentage of performance indicators ranging from 0% to 92.8%. None of the reviews identified performed an analysis of the measurement control (feasibility or sensitivity to change of indicators). CONCLUSIONS: This paper offers a set of 69 performance indicators that have been identified and subsequently validated and prioritised by a panel of experts.

Identificación de indicadores de resultado en salud en atención primaria. Una revisión de revisiones sistemáticas / Identification of health outcome indicators in Primary Care. A review of systematic reviews

Introducción. Las medidas de resultados están siendo ampliamente utilizadas por los servicios sanitarios para evaluar la calidad de la atención sanitaria. Disponer de una batería de indicadores de resultados de alta validez y factibilidad y que además sean de utilidad resulta de gran importancia. Así, el objetivo de este trabajo es realizar una revisión de revisiones para identificar indicadores de resultado susceptibles del ámbito de atención primaria. Metodología. Se realizó una revisión de revisiones sistemáticas (umbrella review) en la que se consultaron las siguientes bases de datos: MedLine, EMBASE y CINAHL, mediante descriptores y términos libres, limitando las búsquedas a documentos publicados en inglés o castellano. Además, se realizaron búsquedas mediante términos libres en diferentes páginas web. Se incluyeron aquellas revisiones que ofreciesen indicadores susceptibles de ser utilizados en el ámbito de la atención primaria. Resultados. Se incluyeron 5 revisiones sobre indicadores en atención primaria, que recopilaban indicadores sobre los siguientes ámbitos o procesos clínicos: atención en osteoartrosis, atención a la cronicidad, asma infantil, efectividad clínica e indicadores sobre seguridad de prescripción. Se identificaron un total de 69 indicadores de resultados, oscilando el porcentaje de indicadores de resultados sobre el total entre el 0 y el 92,8%, según la revisión analizada. Ninguna de las revisiones identificadas realizó un análisis del control de medición (factibilidad o sensibilidad al cambio de los indicadores). Conclusiones. Este trabajo ofrece un conjunto de 69 indicadores de resultados que han sido identificados y posteriormente validados y priorizados mediante un panel de expertos (AU)

Introduction. Outcome measures are being widely used by health services to assess the quality of health care. It is important to have a battery of useful performance indicators with high validity and feasibility. Thus, the objective of this study is to perform a review of reviews in order to identify outcome indicators for use in Primary Care. Methodology. A review of systematic reviews (umbrella review) was carried out. The following databases were consulted: MedLine, EMBASE, and CINAHL, using descriptors and free terms, limiting searches to documents published in English or Spanish. In addition, a search was made for free terms in different web pages. Those reviews that offered indicators that could be used in the Primary Care environment were included. Results. This review included a total of 5 reviews on performance indicators in Primary Care, which consisted of indicators in the following areas or clinical care processes: in osteoarthritis, chronicity, childhood asthma, clinical effectiveness, and prescription safety indicators. A total of 69 performance indicators were identified, with the percentage of performance indicators ranging from 0% to 92.8%. None of the reviews identified performed an analysis of the measurement control (feasibility or sensitivity to change of indicators). Conclusions. This paper offers a set of 69 performance indicators that have been identified and subsequently validated and prioritised by a panel of experts (AU)

An economic evaluation of two interventions for the prevention of post-surgical infections in cardiac surgery / Evaluación económica de dos intervenciones de prevención de infecciones posquirúrgicas en cirugía cardíaca

OBJECTIVE: To conduct a cost-effectiveness analysis that compares two prophylactic protocols for treating post-surgical infections in cardiac surgery. METHODS: A cost effectiveness analysis was done by using a decision tree to compare two protocols for prophylaxis of post-surgical infections (Protocol A: Those patient with positive test to methicillin-resistant Staphylococcus aureus (MRSA) colonization received muripocin (twice a day during a two-week period), with no follow-up verification. Those who tested negative did not receive the prophylaxis treatment; Protocol B: all patients received the mupirocin treatment). The number of post-surgical infections averted was the measure of effectiveness from the health system's perspective, 30 days following the surgery. The incidence of infections and complications was obtained from two cohorts of patients who underwent cardiac surgery Hospital. The times for applying the two protocols were validated by experts. They cost were calculated from the hospital's analytical accounting management system and Pharmaceutical Service. Only direct costs were taken into account, no discount rates were applied. Incremental cost-effectiveness ratio (ICER) was calculated. A probabilistic sensitivity analysis was performed. RESULTS: A total of 1118 patients were included (721 in Protocol A and 397 in Protocol B). No statistically significant differences were found in age, sex, diabetes, exitus or length of hospital stay between the two protocols. In the control group the rate of infection was 15.3%, compared with 11.3% in the intervention group. Protocol B proves to be more effective and at a lower cost, yielding an ICER of €32,506. CONCLUSION: Universal mupirocin prophylaxis against surgical site infections (SSI) in cardiac surgery as a dominant strategy, because it shows a lower incidence of infections and cost savings, versus the strategy to treat selectively patients according to their test results prior screening

OBJETIVO: Realizar un análisis de coste-efectividad que compare dos protocolos profilácticos para el tratamiento de infecciones posquirúrgicas en cirugía cardíaca. MÉTODOS: El análisis de coste-efectividad se llevó a cabo mediante un árbol de decisiones para comparar dos protocolos sobre profilaxis de infecciones posquirúrgicas (en el protocolo A, los pacientes con resultado positivo por colonización de Staphylococcus aureus resistente a la meticilina (SARM) recibieron mupirocina (dos veces al día durante 2 semanas) sin verificación de seguimiento. Aquéllos con resultado negativo no recibieron profilaxis. En el protocolo B, todos los pacientes recibieron el tratamiento con mupirocina). La medida de la efectividad fue el número de infecciones posquirúrgicas que se habían evitado a los 30 días desde la perspectiva del sistema de salud. La incidencia de infecciones y complicaciones se obtuvo a partir de dos cohortes de pacientes a quienes se practicó cirugía cardíaca. Algunos expertos validaron los tiempos de aplicación de los dos protocolos. Los costes se calcularon a partir del sistema de contabilidad analítica del hospital y el Servicio de Farmacia. Sólo se tuvieron en cuenta los costes directos y no se aplicaron tasas de descuento. Se calculó la relación de coste-efectividad incremental (ICER) y se realizó un análisis de sensibilidad probabilístico. RESULTADOS: se incluyó a 1.118 pacientes (721 en el protocolo A y 397 en el protocolo B). No hubo diferencias estadísticamente significativas en cuanto a edad, sexo, diabetes, muerte o duración de la estancia hospitalaria entre los dos protocolos. En el grupo control, la tasa de infección alcanzó el 15,3% y el 11,3% en el grupo de intervención. El protocolo B ha demostrado ser más eficaz y con menor coste, pues se ha obtenido un ICER de 32.506€.CONCLUSIÓN: la profilaxis universal con mupirocina frente a infecciones en el sitio quirúrgico (SSI) en cirugía cardíaca se muestra como una estrategia dominante ya que muestra menor incidencia de infecciones y un ahorro de costes que la estrategia para tratar selectivamente a los pacientes de acuerdo con los resultados obtenidos en la prueba de cribado previa

An economic evaluation of two interventions for the prevention of post-surgical infections in cardiac surgery.

OBJECTIVE: To conduct a cost-effectiveness analysis that compares two prophylactic protocols for treating post-surgical infections in cardiac surgery. METHODS: A cost effectiveness analysis was done by using a decision tree to compare two protocols for prophylaxis of post-surgical infections (Protocol A: Those patient with positive test to methicillin-resistant Staphylococcus aureus (MRSA) colonization received muripocin (twice a day during a two-week period), with no follow-up verification. Those who tested negative did not receive the prophylaxis treatment; Protocol B: all patients received the mupirocin treatment). The number of post-surgical infections averted was the measure of effectiveness from the health system's perspective, 30 days following the surgery. The incidence of infections and complications was obtained from two cohorts of patients who underwent cardiac surgery Hospital. The times for applying the two protocols were validated by experts. They cost were calculated from the hospital's analytical accounting management system and Pharmaceutical Service. Only direct costs were taken into account, no discount rates were applied. Incremental cost-effectiveness ratio (ICER) was calculated. A probabilistic sensitivity analysis was performed. RESULTS: A total of 1118 patients were included (721 in Protocol A and 397 in Protocol B). No statistically significant differences were found in age, sex, diabetes, exitus or length of hospital stay between the two protocols. In the control group the rate of infection was 15.3%, compared with 11.3% in the intervention group. Protocol B proves to be more effective and at a lower cost, yielding an ICER of €32,506. CONCLUSION: Universal mupirocin prophylaxis against surgical site infections (SSI) in cardiac surgery as a dominant strategy, because it shows a lower incidence of infections and cost savings, versus the strategy to treat selectively patients according to their test results prior screening.

Webliografía sobre salud para adolescentes y jóvenes / Webliography of health for adolescents and young people

Objetivos Identificar sitios web con información en castellano sobre salud de adolescentes y jóvenes, y evaluar su adecuación a códigos de conducta. Material y métodos Estudio transversal de adecuación a códigos de conducta de Web sobre salud de adolescentes y jóvenes, identificados de la misma manera como suelen buscar en Internet (buscadores). Tres evaluadores determinaron los sitios web independientemente a través de un cuestionario. Dimensiones: 1) cumplimiento global; 2) responsabilidad; 3) política editorial; 4) protección de datos; 5) autoría; 6) actualización; 7) accesibilidad, y 8) contenido. Se realizó un análisis descriptivo y se estimó el coeficiente κ para valorar la concordancia entre evaluadores. Resultados El 66,7% de los sitios web tenían proveedores españoles. Destacan con cumplimiento global alto 13 sitios web (30,9%): información para adolescentes de la Asociación Española de Pediatría (España), Centro de Salud Manuel Merino Alcalá de Henares (España), Federación de Planificación Familiar Estatal (España), Web de adolescentes de la Generalitat Cataluña (España), información para jóvenes de institutos de salud (Estados Unidos), información sobre mujeres adolescentes (Estados Unidos), información sobre diabetes tipo i de médicos y educadores (España), Portal sobre asma para profesionales (10 países), información para adolescentes del Grupo Puleva (España), información sobre bulimia y anorexia de la Comunidad de Madrid (España), salud y adolescencia de PulsoMed S. A. (España), Asociación Americana de Médicos de Familia (Estados Unidos) e información para jóvenes de la Caja de Salud de Mapfre (España). La dimensión más deficiente fue la de actualización de la información (el 57,1% con cumplimiento bajo) y la protección de datos personales (el 21% de los sitios web con cumplimiento bajo). Se observó un nivel de concordancia entre evaluadores “considerable”. Conclusiones e obtuvo un listado de sitios web con información sobre salud de adolescentes y jóvenes con variabilidad en la adecuación en códigos de conducta(AU)

Aims To identify health Websites in Spanish on adolescence and youth and to assess the adequacy of their codes of conduct. Methods Cross sectional study of the adequacy of codes of conduct, identified in the same way as young people tend to look on the Internet (search engines). Websites have been independently assessed using a questionnaire by 3 evaluators. Dimensions: 1) accountability, 2) transparency and honesty, 3) author, 4) editorial policy, 5) protection of personal data, 6) updating of information and accessibility. A descriptive analysis was performed and the kappa coefficient was estimated to assess the correlation between evaluators. Results A total of 66.7% of Websites had Spanish suppliers. There were 13 Websites (30.9%) with high compliance: Information for adolescents from the Spanish Association of Pediatrics (Spain), Health Center Manuel Merino Alcala de Henares (Spain), State Family Planning Federation (Spain), Webteens of the Generalitat Catalonia (Spain), Young Information Institutes Health (USA), Information on Female teenagers (USA), Information doctors and educators on type I diabetes (Spain), occupational asthma Portal (10 countries), teenage Information Puleva Group (Spain), Information bulimia and anorexia of the Community of Madrid (Spain), Health of adolescence PulsoMed, SA (Spain), American Association of Family Physicians (USA) and Information for young people from the Mapfre Health Fund (Spain). The worst dimension was updating of information (57.1% with low fullfilment) and protection of personal data, 21% with low fullfilment. The level of concordance between observers was considerable. Conclusions A list was obtained of websites with health information on adolescence and youth, with variability in adequacy in codes of conduct(AU)

[Webliography of health for adolescents and young people]. / Webliografía sobre salud para adolescentes y jóvenes.

AIMS: To identify health Websites in Spanish on adolescence and youth and to assess the adequacy of their codes of conduct. METHODS: Cross sectional study of the adequacy of codes of conduct, identified in the same way as young people tend to look on the Internet (search engines). Websites have been independently assessed using a questionnaire by 3 evaluators. Dimensions: 1) accountability, 2) transparency and honesty, 3) author, 4) editorial policy, 5) protection of personal data, 6) updating of information and accessibility. A descriptive analysis was performed and the kappa coefficient was estimated to assess the correlation between evaluators. RESULTS: A total of 66.7% of Websites had Spanish suppliers. There were 13 Websites (30.9%) with high compliance: Information for adolescents from the Spanish Association of Pediatrics (Spain), Health Center Manuel Merino Alcala de Henares (Spain), State Family Planning Federation (Spain), Webteens of the Generalitat Catalonia (Spain), Young Information Institutes Health (USA), Information on Female teenagers (USA), Information doctors and educators on type I diabetes (Spain), occupational asthma Portal (10 countries), teenage Information Puleva Group (Spain), Information bulimia and anorexia of the Community of Madrid (Spain), Health of adolescence PulsoMed, SA (Spain), American Association of Family Physicians (USA) and Information for young people from the Mapfre Health Fund (Spain). The worst dimension was updating of information (57.1% with low fullfilment) and protection of personal data, 21% with low fullfilment. The level of concordance between observers was considerable. CONCLUSIONS: A list was obtained of websites with health information on adolescence and youth, with variability in adequacy in codes of conduct.

Años de vida ajustados por discapacidad de las personas con infección por el VIH/sida usuarias de drogas por vía parenteral / Disability adjusted life years among people with HIV/AIDS injecting drug users

Determinar la asociación entre ser usuario de droga por vía parenteral (UDVP) y el nivel de salud de personas con virus de la inmunodeficiencia humana (VIH)/sida (en años de vida ajustados por discapacidad [AVAD]) y por sexo, antes del TARGA (terapias antiretrovirales de gran actividad), en uso limitado de TARGA y TARGA. Material y métodos. Estudio descriptivo, incluyendo a 8.800 personas del registro de sida de Andalucía entre 1983-2004. Variables dependientes: años de vida perdidos (AVP), AVAD y estado vital. Variables independientes: sexo, edad al diagnóstico, edad al morir, categoría de transmisión y período de diagnóstico. Se han considerado 3 períodos según el grado de implementación del TARGA; antes de 1996, uso limitado de TARGA (1997 y 1998) y TARGA (después de 1998). Se efectuó un análisis bivariante para analizar si existían diferencias en la muerte y ser UDVP (prueba de ji cuadrado de Pearson) y en los AVP, AVD y AVAD y ser UDVP (prueba de la «t» de Student y la tabla ANOVA). Resultado. En ningún período, ser UDVP se encontró estadísticamente asociado con la muerte. Se han encontrado mayores AVP y AVAD en los UDVP en los 3 períodos. Para los AVD, se encontraron diferencias en los UDVP con respecto a los no UDVP en el período pre-TARGA, en los demás períodos se mantienen las diferencias pero se pierde significación estadística. Conclusiones. No se han encontrado diferencias entre ser UDVP con la muerte en ningún período (pre-TARGA, uso limitado de TARGA y TARGA). Sí se han encontrado diferencias entre los UDVP y los demás grupos con respecto a los AVP y los AVAD (AU)

Objectives. To determine the association between being injecting drug user (IDU) and the level of health of people living with HIV/AIDS (disability adjusted life years [DALY]), differentiated by gender, in three periods, before HAART (highly active antiretroviral therapies) -before 1996, limited use of HAART -1997 and 1998- and HAART ¿after 1998¿. Material and methods. Descriptive study, including 8,800 people in the AIDS registry of Andalusia between 1983-2004. Dependent variables: years of life lost (YLL), years of living with disabilities (YLD), DALY and vital state. Independent variables: gender, age at diagnosis, age at death, category transmission and diagnosis period (have been considered 3 periods according to the degree of implementation of HAART); before HAART (before 1996), limited use of HAART (1997 and 1998) and HAART (after 1998). Bivariate analysis was conducted to examine whether there were differences in dependent variables being injecting drug user (Pearson chi-square, Student¿s t test and ANOVA table). Results. In different periods (pre-HAART, limited use of HAART and HAART), being IDU was not statistically associated with death. We have found higher YLL and DALY in IDU in the 3 studied periods (pre-HAART, as limited use of HAART and HAART). For the YLD, we found differences in injecting drug users compared with non injecting drug users in the period pre-HAART. In the other periods remain differences but lost statistical significance. Conclusions. We have not found any differences between IDU by death in any of the periods studied (pre-HAART, limited use of HAART and HAART). Differences were found between being IDU and other groups with respect to the YLL and DALYs (AU)

[An economic assessment of genetic testing for familial adenomatous polyposis]. / Evaluación económica de la prueba genética de la poliposis adenomatosa familiar.

OBJECTIVE: To analyze the cost-effectiveness of genetic testing for first-degree relatives of patients with colon cancer to identify mutations in the APC gene (Adenomatous Polyposis Coli). METHODOLOGY: Analyses were performed from the perspective of the health system. We used a Markov model. We compared genetic testing for the APC gene, the cause of familial adenomatous polyposis (FAP), which results in colon cancer, versus no genetic testing for said gene. The effectiveness measure used was quality-adjusted life-years (QALYs), and costs were measured in euros for 2005. The costs of interventions were extracted from the costs of health services provided by centers under the Andalusian Public Health System, and other parameters were obtained from the literature. RESULTS: The performance of genetic testing is the dominant strategy when compared to the absence of genetic testing given the latter option has an incremental cost of 7,676.34 euros and is less effective. A sensitivity analysis found that genetic testing remains the dominant strategy for a plausible range of costs of the test itself, and for the probability of developing adenocarcinoma. CONCLUSIONS: Our analysis showed that in this patient group genetic testing to detect APC gene mutations is on average less costly and improves QALYs versus no testing.

Evaluación económica de la prueba genética de la poliposis adenomatosa familiar / No disponible

Objetivo: analizar el coste-utilidad de la prueba genética a familiaresde primer grado de pacientes con cáncer de colon para determinarmutaciones del gen APC (Adenomatous Polyposis Coli).Metodología: los análisis se realizaron desde el punto de vistadel sistema sanitario. Se utilizó un modelo de Markov. Realizaciónde la prueba genética para el gen APC, causante de la poliposisadenomatosa familiar (PAF), que produce cáncer de colon frentea la no realización de la misma. La medida de efectividad utilizadafueron los años de vida ajustados por calidad (AVAC) y la unidadde coste los euros de 2005. Los costes de las intervenciones fueronextraídos de los precios públicos de los servicios sanitariosprestados por centros dependientes del Sistema Sanitario PúblicoAndaluz y los valores de la efectividad y de utilidad de la literatura.Resultados: la realización de la prueba genética se muestracomo una estrategia dominante a la no realización de la misma,ya que esta última tiene un coste incremental de 7.676,34 €, ademásde una menor efectividad. Los análisis de sensibilidad mostraronque la realización de la prueba genética se mantiene como laestrategia dominante dentro de un amplio rango de coste de laprueba y de probabilidad de desarrollar adenocarcinomas.Conclusiones: los análisis mostraron que, para este grupo depacientes, la realización de la prueba genética para la detecciónde la mutación del gen APC es en promedio menos costosa yademás produce una mejora en AVAC comparado con la no realizaciónde la misma

Objective: to analyze the cost-effectiveness of genetic testingfor first-degree relatives of patients with colon cancer to identifymutations in the APC gene (Adenomatous Polyposis Coli).Methodology: analyses were performed from the perspectiveof the health system. We used a Markov model. We comparedgenetic testing for the APC gene, the cause of familialadenomatous polyposis (FAP), which results in colon cancer,versus no genetic testing for said gene. The effectiveness measureused was quality-adjusted life-years (QALYs), and costswere measured in euros for 2005. The costs of interventionswere extracted from the costs of health services provided bycenters under the Andalusian Public Health System, and otherparameters were obtained from the literature.Results: the performance of genetic testing is the dominantstrategy when compared to the absence of genetic testing giventhe latter option has an incremental cost of € 7,676.34 and is lesseffective. A sensitivity analysis found that genetic testing remainsthe dominant strategy for a plausible range of costs of the test itself,and for the probability of developing adenocarcinoma.Conclusions: our analysis showed that in this patient groupgenetic testing to detect APC gene mutations is on average lesscostly and improves QALYs versus no testing

[Organizational characteristics of primary care and hospitalization for to the main ambulatory care sensitive conditions]. / Características organizativas de la atención primaria y hospitalización por los principales ambulatory care sensitive conditions.

OBJECTIVES: To describe the variability in hospitalisation rates because of the most common ambulatory care sensitive conditions (ACSC), by town and gender; b) to describe the influence on these rates of the characteristics of primary care (reformed or non-reformed model and kind of centre), the health level of the population, geographical accessibility and other factors of a social and economic nature. DESIGN: Observational, cross-sectional study of hospital discharges and ecological study for the analysis of rates between towns. MAIN MEASUREMENTS: The rates of hospitalisation by gender for each ACSC (1997-1999), standardised for age through the indirect method by calculating the standardised rate ratios (SRR). The multivariate analysis used Poisson regression. RESULTS: In the diagnoses studied, 41% of the towns had the same number of cases observed and expected for hospitalisation of men; and 65%, for women. Chronic obstructive pulmonary disease in men and heart failure in women were the illnesses that most varied. Hospitalisation rates for most illnesses were higher in towns without a health centre or with a non-reformed model, with over 3000 inhabitants and closer to hospital, although distance from the hospital was an influential factor only in bigger towns. CONCLUSIONS: There is variability between towns in hospitalisation rates for the most common ACSC; b) the differences in hospitalisation rates for the ACSC studied are linked to organisational features of primary care, the size of the town and the distance from the hospital.

[Factors associated with hospitalization for ambulatory care sensitive conditions in municipalities]. / Factores asociados a la hospitalización por procesos sensibles a cuidados ambulatorios en los municipios.

OBJECTIVES: To describe variability in admission rates for ambulatory care sensitive conditions (ASSC) in municipalities in the catchment area of a tertiary hospital and to determine the influence of primary care characteristics, socioeconomic factors, health of the population, and geographical accessibility to the hospital on this variability. METHODS: An ecological study was carried out in 34 municipalities in the area served by the Hospital Virgen de las Nieves in Granada (Spain) including all admissions for ASSC from 1997 to 1999. The admission rates for men and women were calculated separately and were age-standardized by the indirect method. The following factors were analyzed as independent variables: characteristics of primary care (type of healthcare model and type of center), socioeconomic factors (unemployment rate, income per capita, number of business establishments, size of municipality), health (mortality rate), and accessibility (time in minutes from the municipality to the hospital). A multiple lineal regression model was estimated. RESULTS: A total of 9.8% of all hospital admissions were due to ASSC. The mean annual admission rate was 10 admissions per 1.000 inhabitants. This rate was higher for men and for persons aged more than 74 years. The standardized admission ratios were not statistically different from 1 in 56% of the municipalities and were higher than 1 in 26% and lower than 1 in 18%. Sixty-two percent of the variability in rates for men was associated with time taken to reach the hospital, size of municipality, the interaction between both variables, and mortality. Eighteen percent of the variability in rates for women was associated with time taken to reach the hospital and the unemployment rate. CONCLUSIONS: Variability in admission rates for ASSC was not associated with primary care characteristics in the geographical area analyzed. Accessibility (measured as time to the hospital) was the only variable associated with higher rates in both men and women. Admission rates for ASSC among women were higher when unemployment rates were higher, and rates among men were higher in larger municipalities and in those with higher mortality.

Factores asociados a la hospitalización por procesos sensibles a cuidados ambulatorios en los municipios / Hospitalization for ambulatory care sensitive conditions: analysis of related factors in municipalities

Objetivos: Describir la variabilidad en las tasas de hospitalización por procesos sensibles a cuidados ambulatorios (PSCA) entre municipios del área de referencia de un hospital de tercer nivel, y determinar la influencia de las características de la atención primaria, los factores socioeconómicos, el nivel de salud de la población y la accesibilidad geográfica al hospital. Método: Se realizó un estudio ecológico en 34 municipios del área del Hospital Virgen de las Nieves (Granada), abarcando todas las hospitalizaciones por PSCA de 1997 a 1999.Las tasas de hospitalización se calcularon por separado para varones y mujeres y se estandarizaron por el método indirecto según la edad. Se exploraron como variables independientes las siguientes: características de la atención primaria (tipo de modelo y centro), socioeconómicas (desempleo, renta, comercios, tamaño del municipio), de salud (mortalidad) y accesibilidad (crona: minutos desde el municipio al hospital). Se realizó un análisis de regresión lineal múltiple. Resultados: El 9,8 por ciento de los ingresos ocurridos en el hospital fueron por PSCA. La tasa media anual fue de 10 ingresos por 1.000 habitantes, siendo superior en varones y en los mayores de 74 años. En el 56 por ciento de los municipios las razones de hospitalización estandarizadas no fueron estadísticamente diferentes de 1, en un 26 por ciento fueron menores y en un 18 por ciento, mayores. Un 62 por ciento de la variabilidad en las tasas de los varones se explicó por la crona al hospital, el tamaño del municipio, la interacción entre ambas variables y la mortalidad. Las tasas en mujeres se explicaron en un 18 por ciento por la crona y la tasa de desempleo. Conclusiones: La variabilidad de las tasas de hospitalización por PSCA no se asoció a las características de la atención primaria en el ámbito geográfico estudiado. La mayor accesibilidad en tiempo al hospital fue la única variable asociada a mayores tasas en varones y mujeres. Las tasas en mujeres fueron superiores cuanto mayor era el desempleo, y las tasas en varones fueron más altas en los pueblos grandes y con mayor mortalidad.. (AU)