[Experience of a single-centre in the preparation of choosing wisely lists in Internal Medicine]. / Experiencia de un centro único en la preparación de listas choosing wisely en Medicina Interna.

OBJECTIVES: To identify areas for improvement, using a local list of interventions with low diagnostic and therapeutic usefulness for the 5 Related Diagnostic Groups, as well as the 5 main diagnoses most frequently seen in the hospital outpatient clinic. METHOD: A literature review method was used, supplemented with a Delphi process with 2 rounds. In the first round, participants in the selection process identified low-value interventions in relation to the most frequently observed diagnoses. In the second round, those interventions with lower usefulness were selected based on their frequency, cost, and risk to the patient. RESULTS: Out of a total of 100 recommendations made by 19 scientific societies, 23 received the highest number of votes in the first round. In the second round, 5 recommendations were selected for inpatients and 5 recommendations for outpatients. CONCLUSIONS: A simple method is described for developing a local guide to reduce the use of unnecessary medical interventions.

[Real clinical medicine and evidence-based medicine: evaluative clinical research]. / Medicina clínica real y medicina basada en la evidencia: una investigación clínica evaluativa.

BACKGROUND: The clinical view is essential in the application of a new paradigm on "evidence based medicine". Also, we hardly haven't studies that had been made with patients in real time and place. We analyzed the rate of evidence that found our clinical praxis. METHODS: A randomized observational epidemiological study was made over 689 clinical decisions in relation with 167 pathological processes, considered in 36 patients. Age (65.9, SD 2.1), sex (23 F, 13 M), comorbidity (4.6, SD 2.1), poly-pharmacy (8.8, SD 3.3). Case-mix of GRDs (infections--even HIV-, chronic respiratory affections, neurologic, cardiovascular diseases, diabetes and its complications ..., in decreased order. We used the D.L. Sackett's criterium (evidence level one "experimental", level two "no experimental but convincing-rational", level three "without any scientific base". A progressive internal control was used in order to adjust the "arbitrariness in the assignation". RESULTS: 60% of the decisions provided elevated care evidence level; 24.5% in level number two, and 15.5% without any foundation. The proceedings reasonably founded were 84.5%. The pharmacological treatment had more evidence. The diagnosticum was more empiric. The primary illness and its treatment concentrated more evidence that the enclosed conditions (65% level one and 50% respectively). The prediction is still unknown (null evidence). CONCLUSIONS: More than a half of the patients were benefited of a clinical praxis, tested in effectiveness and safety. 15.5% of the decisions had an uncertain effect (favourable, newer or damaging). Nowadays, the complex clinical praxis, despite of exceeding the paradigm of "evidence based medicine", should tend toward scientific foundation as much as possible.

Medicina clínica real y medicina basada en la evidencia: una investigación clínica evaluativa / Real clinical medicine and evidence based madicine: an evaluation clinical research

Fundamentos. La perspectiva clínica es esencial en la aplicación del nuevo paradigma de "medicina basada en evidencia". Sin embargo, apenas disponemos de estudios realizados con pacientes en escenario real y en tiempo real. Analizamos qué grado de evidencia fundamenta nuestra práctica clínica. Pacientes y métodos. Estudio epidemiológico observacional aleatorio sobre 689 decisiones clínicas relacionadas con 167 procesos patológicos, tomadas en 36 pacientes. Edad (65,9, DS 2,1), sexo (23 M, 13 H); comorbididad (4,6, DS 2,1); polifarmacia (8,8, DS 3,3). Case-Mix según GRDs (infecciones-incluido HIV-, afecciones respiratorias crónicas; neurología; afecciones cardiovasculares; diabetes y sus complicaciones..., por orden decreciente). Empleamos el criterio de D.L. Sackett (nivel evidencia 1 o "experimental"; nivel 2 "no experimental pero convincente-racional"; nivel 3 o "insustancial". Se empleó un control interno progresivo para el ajuste de "arbitrariedad en la asignación". Resultados. El 60% de las decisiones aportaron cuidados de alto nivel de evidencia. El 24,5 porciento de nivel 2. El 15,5 porciento sin fundamento. Las intervenciones razonablemente fundadas lo fueron en el 84,5 porciento. El tratamiento farmacológico fue "más evidente". El diagnóstico "más empírico". La enfermedad primaria y su tratamiento concentraron más evidencias que las condicciones concurrentes (65% nivel 1 respecto a 50% respectivamente). El pronóstico continúa siendo una incógnita (evidencia nula o marginal). Conclusión. Más de la mitad de los enfermos se beneficiaron de una práctica clínica probada en eficacia y seguridad. Un 15,5% de las decisiones tuvieron un efecto incierto (favorable, neutro o perjudicial). La complejidad clínica diaria, si bien excede actualmente a la simplificación del paradigma "basado en evidencia", debe tender hacia la fundamentación científica tanto como sea posible (AU)

[Elderly, poor, solitary and marginal patients: geriatric vulnerability in emergency services]. / Viejos, pobres, solitarios y marginados: vulnerabilidad geriátrica en un servicio de urgencias.

BACKGROUND: Status is a powerful determinant of health, and it may influence on the demand of Hospital emergency services. The aim of our investigation is to assess whether elderly patients usually wandering emergency services gather more negative socioeconomic conditions. PATIENTS AND METHODS: A cross-sectional study on 800 randomised patients cared in emergency services was carried out. A questionnaire about economic, educational and professional levels, domestic violence, loneliness and life style was applied. A crude analysis was used to assess the age-factor (>/= 65 y.o.) by BMDP (PC 90). The trial was approved by the local Bioethics board. RESULTS: Low incomes, low educational level and loneliness were clinic and statistically related with age (65 and more). Data is offered as n (%), X2 and p < 0.0001 (Fisher exact Test two sided p value). CONCLUSIONS: Elderly patients frequently demanding hospital emergency services gather more vulnerability conditions, not merely medical. Low incomes, low educational level and loneliness are probably working as key factors on the geriatric demand of emergency services.