La equidad en la consulta clínica. Propuestas a pacientes, profesionales, gestores y políticos para limitar la discriminación / Equality in clinical practice. Proposals for patients, professionals and managers and policies to limit discrimination

Objetivo: Realizar propuestas que mejoren la equidad de la atención clínica. Métodos: Diseño: Grupo de discusión con enfoque cualitativo realizado desde la perspectiva de la equidad en la consulta. Entorno: Debate realizado en 2013 en España, centrado en la equidad en el trabajo clínico. Participantes: 98 profesionales de atención primaria de varios países. Instrumentos: El análisis de las respuestas fue realizado por los firmantes del presente trabajo agrupadas por temas, interpretadas y reestructuradas por los analistas para dar consistencia. Se diseñó un instrumento de recogida de datos con respuestas abiertas, que permitía responder de forma libre a 3 cuestiones generales que abordaban la mejora de la equidad desde la vertiente del propio profesional, del paciente, y del gestor y del político sanitario. No se fijó como horizonte analítico la saturación de los discursos, por entender que desde esta perspectiva subjetiva de priorización no existía posibilidad de que los discursos llegaran a saturarse. Resultados: Se agregaron las respuestas en los 3 ejes principales recomendando a los profesionales que fueran conscientes de su posibilidad discriminatoria. A los pacientes se les propuso confiar en sus profesionales de salud, exigir la asignación de un profesional de referencia, y a los gestores facilitar los sistemas de información, contribuir a disminuir las desigualdades en salud y fomentar la autonomía del trabajador. Conclusiones: El trabajo presenta propuestas concretas para fomentar una mejora en la equidad en la consulta, durante la prestación de servicios (AU)

Objective: To make feasible and practical proposals to improve equality in the course of clinical care during the patient-provider encounter. Methods: Design: A focus group study was conducted with a qualitative approach from the perspective of reducing health inequalities in the clinic. Setting: A classroom discussion focused on equality in clinical work. Subjects: 98 professionals from several countries. Measurement tools: An analysis of the responses was performed, grouped by themes interpreted by analysts, and restructured to provide consistency and uniformity to responses given. Data were collected using a questionnaire with open answers, allowing free-form answers to three general questions that addressed improving equality from the perspective of the professional themselves, patients, and health policy managers. No saturation horizon of analytical discourses was set, to understand that from this subjective prioritization of opinion there is no possibility that discourses reached saturation. Results: Responses were added to the 3 principal axes, recommending that professionals be aware of their discriminatory ability. Patients were asked to trust their health professionals and that they should be assigned to a professional. It was also proposed that managers provide information systems, help reduce health inequalities, and encourage professional freedom. Conclusions: The paper presents concrete measures to promote improved equality in clinics during the delivery of health care (AU)

[Equality in clinical practice. Proposals for patients, professionals and managers and policies to limit discrimination]. / La equidad en la consulta clínica. Propuestas a pacientes, profesionales, gestores y políticos para limitar la discriminación.

OBJECTIVE: To make feasible and practical proposals to improve equality in the course of clinical care during the patient-provider encounter. METHODS: Design: A focus group study was conducted with a qualitative approach from the perspective of reducing health inequalities in the clinic. Setting: A classroom discussion focused on equality in clinical work. Subjects: 98 professionals from several countries. Measurement tools: An analysis of the responses was performed, grouped by themes interpreted by analysts, and restructured to provide consistency and uniformity to responses given. Data were collected using a questionnaire with open answers, allowing free-form answers to three general questions that addressed improving equality from the perspective of the professional themselves, patients, and health policy managers. No saturation horizon of analytical discourses was set, to understand that from this subjective prioritization of opinion there is no possibility that discourses reached saturation. RESULTS: Responses were added to the 3 principal axes, recommending that professionals be aware of their discriminatory ability. Patients were asked to trust their health professionals and that they should be assigned to a professional. It was also proposed that managers provide information systems, help reduce health inequalities, and encourage professional freedom. CONCLUSIONS: The paper presents concrete measures to promote improved equality in clinics during the delivery of health care.

Clinical care and health disparities.

Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.

Changes in the atherogenic profile of patients with type 1 Gaucher disease after miglustat therapy.

OBJECTIVE: Type 1 Gaucher disease (GD1) is an autosomal recessive lysosomal storage disorder associated with abnormal accumulation of glucocerebrosides. Plasma total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), and high-density lipoprotein cholesterol (HDL-c) are decreased in GD1 patients. The effects of substrate reduction therapy (SRT) with miglustat on plasma lipids and atherogenic factors have not yet been examined. Here, we report plasma atherogenic profile data from GD1 patients undergoing long-term SRT. METHODS: Plasma was analysed in 26 GD1 patients treated with miglustat for up to 36 months. Ten patients were therapy-naïve and 16 had switched from enzyme replacement therapy (ERT); the interval between stopping ERT and starting SRT was 2-6 weeks. Plasma TC, triglycerides (TG), LDL-c, HDL-c, apolipoproteins (apoA-I, apoB, and Lp[a]), C-reactive protein (CRP) concentrations, and chitotriosidase activity were measured before SRT (baseline) and at 12, 24, and 36 months follow up. RESULTS: In therapy-naïve patients, miglustat significantly increased plasma HDL-c and apoA-I, and slightly increased TC; while TG, CRP concentrations, and TC/HDL-c ratios decreased significantly after 24 months. In contrast, there were no changes in HDL-c and apoA-I, or in the TC/HDL-c ratio in switch patients. However, a decrease in CRP was observed after 12 months. LDL-c and apoB were not significantly altered in either patient group. CONCLUSIONS: Miglustat appears to have beneficial effects on plasma lipid, lipoprotein, and CRP concentrations in therapy-naïve GD1 patients, resulting in an improved atherogenic lipid profile. Further studies are required to determine the effect of miglustat on coronary heart disease risk.

The concept of prevention: a good idea gone astray?

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of "diseases" for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.

La función genuina de filtro del médico de atención primaria / The real filtering role played by the primary care physician

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Médicos rurales, médicos generales / Rural physicians, general practitioners

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Los programas de prevención secundaria del cáncer de mama mediante mamografía: el punto de vista del médico general / Secondary prevention programs of breast cancer by mammography: general practitioner’s point of view

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Respuesta de los autores. Aguja de marear para técnicos de salud / Response from the authors. Compass for health technicians

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Aventuras y desventuras de los navegantes solitarios en el mar de la incertidumbre / Adventures and misadventures of solitary sailors on the sea of uncertainty

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Impacto de los estudios de evaluación económica en la toma de decisiones sanitarias en Atención Primaria

Existe un gran interés en relación con el proceso de toma de decisiones siguiendo criterios de eficiencia en el ámbito de la salud y acerca del creciente papel que está cobrando la evaluación económica en dicho ámbito. En este trabajo intentamos medir el uso de técnicas y resultados de evaluación económica por parte de decisores del ámbito primario. Dicha medición fue llevada a cabo a través de varias herramientas: cuestionarios postales, entrevistas personales y otro tipo de entrevistas semiestructuradas, y fueron realizadas a diferentes grupos de decisores de atención primaria. A través de dichas herramientas identificamos una serie de barreras o factores que tienden a dificultar la utilización de la evaluación económica por parte de los diferentes agentes entrevistados. Podemos clasificarlas en tres grupos: barreras administrativas, barreras de método y barreras de aplicación y práctica. Nuestra conclusión es que el futuro desarrollo de la evaluación económica requerirá varias medidas que permitan la superación de dichas barreras y sugerimos algunas recomendaciones que pueden llevarse fácilmente a la práctica. Por último, dada la propia naturaleza de la evaluación económica, su futuro desarrollo dependerá tanto de la calidad de su contenido como de su credibilidad (AU)

Problemas acuciantes en atención primaria / Pressing problems in Primary Care

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Behavior of phalangeal bone ultrasound in normal women with relation to gonadal status and body mass index.

The behavior of phalangeal bone ultrasound was studied, measured by amplitude-dependent speed of sound (Ad-SOS) in meters per second, in 324 normal women (mean age 48.9 +/- 13.7 years) classified by gonadal status (premenopausal, perimenopausal and postmenopausal) and body mass index (BMI, thin, normal, overweight and obese). Ad-SOS differed significantly with gonadal status and BMI (p<0.0001 for all). In the overall group of women, Ad-SOS correlated negatively with age (r=-0.84, p<0.0001), weight (r=-0.16, p<0.005), BMI (r=-0.27, p<0.0001), and tartrate-resistant acid phosphatase concentration (TRAP) (r=-0.35, p<0.0001). The negative correlation remained significant in the groups separated by gonadal status, but to a lesser extent. After adjusting for confounding variables such as age and weight, Ad-SOS was dependent on age (but not on weight or BMI) in the overall group of women and in the gonadal status groups. In conclusion, Ad-SOS values differed significantly with gonadal status and BMI, and correlated negatively with TRAP. The plot of Ad-SOS against age differed significantly with gonadal status as well as BMI.

Do ultrasound measurements reflect bone microarchitecture rather than bone mass?: An in vitro study of the rat femur with the use of ultrasound, densitometry, and histomorphometry.

RATIONALE AND OBJECTIVES: In an experimental study in 40 rat femurs, the authors correlated the amplitude-dependent speed of bone ultrasound (Ad-SOS) with the bone mineral content and density and with the bone trabecular connectivity: trabecular bone volume, trabecular number, trabecular thickness, and trabecular separation to evaluate and compare the usefulness of the Ad-SOS to determine bone quantity and/or quality. METHODS: Bone mineral content and density were determined with dual-energy x-ray absorptiometry. Trabecular connectivity was determined with histomorphometric techniques. RESULTS: There was a strong correlation between the Ad-SOS and the other parameters studied, with a particularly high positive correlation with trabecular bone volume and trabecular thickness, and an inverse correlation with trabecular separation. The correlation was weaker with the bone mineral content and bone mineral density and with the trabecular number. For the trabecular separation, the correlation was significant in all cases, but it was negative. CONCLUSIONS: Bone ultrasound, in this case Ad-SOS, defines the quality of the bone in terms of trabecular architecture rather than bone density; however, this conclusion is valid only for the rat femur model that the authors used.

Effects of sodium bicarbonate supplementation on axial and peripheral bone mass in rats on strenuous treadmill training exercise.

We observed the effects of sodium bicarbonate supplement on bone mass in rats on strenuous treadmill training. Sixty female Wistar rats (93-days-old; mean initial weight 261 +/- 16 g) were studied. One group of 15 rats was killed at the beginning of the experiments (basal control group), while another group of 15 rats was not manipulated (Exer-NaB-). Another group of 15 rats was exercised but did not receive sodium bicarbonate (Exer+NaB-), while the final group of 15 rats exercised and received sodium bicarbonate (Exer+NaB+) at a dose of 0.05 mg/kg/day, administered by esophageal catheter on exercise days. These rats were killed at the end of 11 weeks. Femoral and vertebral length, weight, and bone mineral content (BMC) and density (BMD) were measured. According to ANOVA with the Tukey-Kramer test, femur length and weight, vertebral weight, femur BMC and BMD, vertebral BMC and BMD and the ratio between femur and vertebral BMC and final body weight, and plasma bicarbonate were lower in the basal control and Exer+NaB- groups than in the two other groups (P < 0.005-0.0001). Overall, there was a positive correlation between femur and vertebral BMC and femur BMC and length (P < 0.0001 for all). Only in the Exer+NaB- group was there a positive association between plasma bicarbonate levels and femur length (r = 0.78; P < 0.0005). Our study demonstrates the adverse effects of strenuous exercise on bone, and the usefulness of sodium bicarbonate supplements in preventing and minimized these effects.