[Statistics and causes of mortality in type-2 diabetes]. / Estadísticas y causas de mortalidad en la diabetes tipo 2.

OBJECTIVE: To establish the causes of mortality in people with type-2 diabetes and check the reliability of official records. DESIGN: Cross-sectional, descriptive study. SETTING: Urban health centre with a population which has aged and is depressed socially and economically. PATIENTS: Randomised sample of 120 deceased patients with type-2 diabetes, extracted from the total number of deceased patients with type-2 diabetes on the centre's lists over the last five years. INTERVENTIONS: Personal details, clinical data and clinical cause of death were gathered from the history. Then the clinical cause of death recorded in the Civil Registry was obtained. MEASUREMENTS AND MAIN RESULTS: The main cause of death is neoplasm (25.8%), but if we group the cardiovascular causes they add up to 47.4% of the total. According to official statistics, cardiovascular disease only occasioned death in 35% of cases. There was 61.7% overall concordance between the clinical cause and the official cause in the Civil Registry. There was close concordance only in the case of neoplasms (kappa = 0.84). CONCLUSIONS: We found in our study that the main cause of death in type-2 diabetics was cardiovascular disease (47.7%), while in the Civil Registry mortality for this reason is clearly lower, which leads us to question the validity of the official statistics. This suggests we should insist even more on the importance of monitoring cardiovascular risk factors.

Estadísticas y causas de mortalidad en la diabetes tipo 2 / Statistics and causes of mortality in type-2 diabetes

Objetivo. Establecer las causas de mortalidad en los diabéticos tipo 2 y comprobar la fiabilidad de los registros oficiales. Diseño. Estudio descriptivo, transversal. Emplazamiento. Centro de salud urbano con una población envejecida y socioeconómicamente deprimida. Pacientes. Muestra aleatoria de 120 casos de diabéticos tipo 2 muertos, extraídos del total de diabéticos tipo 2 fallecidos del centro en los últimos 5 años. Intervenciones. A partir de la historia se recogen datos de filiación, datos clínicos y la causa clínica de muerte. Posteriormente se obtiene la causa oficial de fallecimiento que consta en el Registro Civil. Mediciones y resultados principales. La principal causa de muerte son las neoplasias (25,8 por ciento), pero si agrupamos las causas cardiovasculares representan un 47,4 por ciento del total. Según las estadísticas oficiales, la enfermedad cardiovascular ha ocasionado sólo la muerte en un 35 por ciento de los casos. Globalmente coincidían la causa clínica con la causa oficial del Registro Civil en un 61,7 por ciento, encontrando una buena concordancia sólo en el caso de las neoplasias (kappa, 0,84). Conclusiones. En nuestro estudio encontramos que la principal causa de muerte en el diabético tipo 2 es la enfermedad cardiovascular (47,7 por ciento), mientras en el Registro Civil la mortalidad por esta causa es claramente inferior, hecho que nos obliga a cuestionar la validez de las estadísticas oficiales. Por ello, es importante incidir todavía más en la importancia del control de los factores de riesgo cardiovascular (AU)

[Externally induced prescriptions, degree of agreement and ... possibility of change in primary care?]. / Prescripción inducida, grado de conformidad y ... posibilidad de cambio en atención primaria?

OBJECTIVE: To find whether externally induced prescriptions (EIP) condition attendance through their prevalence, quality, the degree of agreement of the PC doctor and his/her capacity to alter them. DESIGN: Cross-sectional study of use of indication-prescription type medicines. SETTING: Health district. PARTICIPANTS: 2656 prescriptions for 678 patients interviewed. MEASUREMENTS: Each interview recorded: type of visit, age, sex, work situation, existence or otherwise of social problems and/or psychiatric pathology; doctor-patient relationship, pharmaceutical preparations (PP) prescribed and those which the patient remembers he/she is taking, indication, origin, duration, speciality of the prescribing person, agreement of the PC doctor issuing the prescription and the possibility of his/her changing it. For each prescription the following was analysed: therapeutic group, intrinsic value, time it lasts, cost and whether it is a recently marketed PP. MAIN RESULTS: 90% of visits to the doctor end in prescription. 58% of patients remember taking one or more EIP. 72% of the prescriptions analysed were externally caused. They came mostly from the public health system (66%), private medicine (20%) and self-medication (11%). There was no PC agreement with almost half these EIPs, but only 13% could be changed. The EIPs without agreement and without possibility of change were greater in: women, the elderly, people on a pension, psychiatric pathologies and in cases of bad doctor-patient relationship. The EIPs originated in health insurance companies, pharmacies, self-medication, former GPs and private doctors. They were associated with ill-defined signs and symptoms, circulatory diseases and locomotive disease. We found no significant differences in expenditure or use of PP recently put onto the market between self-medication and EIP, though there were in quality. CONCLUSIONS: The current model of prescribing medication causes consultations to be greatly "medicinised" at the expense of EIP. Doctors only alter a small part of the EIPs they don't agree with. Longitudinal studies are needed to monitor patients to find the evolution of EIPs (withdrawal, replacement, dragging on or new external prescription).

Prescripción inducida, grado de conformidad y... ¿posibilidad de cambio en atención primaria? / Externally induced prescriptions, degree of agreement in primary care and... the possibility of change in primary care?

Objetivos. Conocer si la medicación inducida (MI) condiciona la asistencia a través de su prevalencia, su calidad, el grado de conformidad del médico y su capacidad de modificarla. Diseño. Estudio transversal de utilización de medicamentos del tipo prescripción-indicación. Emplazamiento. Área básica de salud. Participantes. Dos mil seiscientas cincuenta y seis prescripciones correspondientes a 678 pacientes entrevistados. Mediciones. En cada entrevista se recogen: tipo de visita, edad, sexo, situación laboral, existencia o no de problemática social y/o de patología psíquica; relación médico-paciente, presentaciones farmacéuticas (PF) recetadas y las que recuerda estar tomando, indicación, origen, duración, especialidad del inductor, conformidad del transcriptor y posibilidad de cambio. En cada prescripción se analizan: grupo terapéutico, valor intrínseco, cronicidad, coste y si se trata de una PF de reciente comercialización. Resultados principales. Un 90 por ciento de las visitas acaba con prescripción. Un 58 por ciento de los pacientes recuerda tomar una o más MI. Fueron inducidas un 72 por ciento de las prescripciones analizadas, que provenían en su mayoría de la asistencia pública (66 por ciento), de la medicina privada (20 por ciento) y de automedicaciones (11 por ciento). No existe conformidad en casi la mitad de la MI, pudiéndose modificar, tan sólo, un 13 por ciento. La MI sin conformidad y sin posibilidad de cambio es superior en: mujeres, tercera edad, pensionistas, patologías psíquicas y mala relación médico-paciente. Procede principalmente de mutuas, farmacias, automedicaciones, antiguos cabeceras y privados. Se asocia a signos y síntomas mal definidos, enfermedades circulatorias y locomotoras. No encontramos diferencias significativas ni en el gasto, ni en la utilización de PF de reciente comercialización entre la medicación propia y la MI; sí las hay en lo que atañe a la calidad. Conclusiones. El actual modelo de prescripción de envases origina una gran medicalización de las consultas a expensas de la MI. El médico sólo modifica una pequeña parte de la MI sin su conformidad. Son precisos estudios longitudinales de monitorización de pacientes para conocer la evolución (retirada, sustitución, arrastre o nueva inducción) de la MI (AU)

[The evolution of the quality and price of the pharmaceutical supply financed by the public health system]. / Evolución de la calidad y del precio de la oferta farmacéutica financiada por el sistema público de salud.

OBJECTIVES: To find the evolution of quality and price in the supply of medicines financed over the last 28 years. DESIGN: A descriptive, crossover study of the catalogue of products. SAMPLE: Analysis of 11,482 drugs packages financed by the public health system. MEASUREMENTS AND MAIN RESULTS: The intrinsic value of each package, its potential use and its indicator of chronicity were analysed. Me-agains were identified in 3,285 products and me-toos among 879 different active principles. The medicines no longer financed after Act 83/1993 were compared with those still being financed. CONCLUSIONS: The supply of medicines financed has tended towards increases in intrinsic value, single-component products and price. Most of the drugs affected by the act are: older, cheaper, poorer quality and with more active principles. 31% of the supply has still not shown any clinical efficacy.

[Indicators for evaluating social problems in daily health care practice]. / Indicadores para valorar la problemática social en la práctica diaria asistencial.

OBJECTIVES: To define some social indicators which allow the social problems of primary care patients to be studied. DESIGN: A descriptive, crossover study. SETTING: A health district with a socially depressed urban population. PATIENTS: Consecutive sampling of 403 patients. MEASUREMENTS AND MAIN RESULTS: Social risk factors were standardised in function of these criteria: economic, cultural, family, housing, old age and social margination. From these some social indicators were identified, with which a questionnaire with a person-to-person interview was filled in and then the clinical records reviewed. 35% of patients had social problems. We found no connection with gender or age. Pathologies related to the existence of social problems were: mental disorders, infectious diseases, liver and digestive diseases and ill-defined symptoms and signs. There were also more out-patient visits and hospital stays by patients with social problems. CONCLUSIONS: An active search for social problems reveals a much higher occurrence than expected. The finding of a connection between the existence of social problems and determined psychological and organic pathologies could assist the patient's diagnosis and treatment.

[Proposal for a new classification of long-term treatment in primary health care]. / Propuesta de una nueva categorización para tratamientos prolongados en atención primaria.

OBJECTIVE: To evaluate the suitability of medication for an automatised dispensing system (ADS) for prescriptions by means of an indicator specially designed for this study. DESIGN: A descriptive, crossover study of the medicines contained in our ADS. SETTING: Raval-Sud Basic Health District, Barcelona. MEASUREMENTS AND MAIN RESULTS: The indicator was designed and its categories determined through the interaction of the following variables for each medicine: its most usual indication, length of treatment, intrinsic value and the theoretical source of prescription. Then all the medicines included in the ADS were codified and analysed with a computer program. The 728 analysed were classified in 8 different categories: those for acute pathology (32%), for subacute or acute pathology requiring long-term treatment (potentially chronic indication) (9%), for chronic pathology controlled at the primary care level (22%), for chronic pathology controlled in the hospital context (12%), for mental pathology (8%), for chronic pathology well controlled but with a low intrinsic value (3%), medicines of low intrinsic value for chronic pathology (degenerative pathology) without recognised pharmacological alternatives which the family doctor or specialist can prescribe (14%). CONCLUSIONS: If medicines were better defined and codified, the proposed indicator would facilitate rapid discrimination of different groups of drugs' suitability or otherwise for ADS.