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)

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.

Réplica de los autores a la carta: No hacer: de las recomendaciones a la acción / Reply: Do not do: from recommendations to action

No disponible

Primary prevention of cardiovascular disease: an umbrella review of non-pharmacological interventions / Prevención primaria de enfermedades cardiovasculares: una revisión de revisiones de intervenciones no farmacológicas

Background: The aim of this study is to determine the effectiveness of non-pharmacological interventions for prevention of cardiovascular disease (CVD) events and mortality in healthy adults or those at high risk of CVD. Methods: An umbrella review about primary prevention of non-pharmacological interventions was undertaken in key databases as PubMed Health, Effective Health Care Program AHRQ, McMaster University and the Cochrane Plus until July 2017. The primary outcomes were the relative risk of fatal and non-fatal CVD events, and mortality. Secondary outcomes were adverse events. Results: Twenty-four reviews were included of which thirteen reported outcomes of interest. Four of these found a pooled statistically significant risk reduction: dietary supplements of vitamin D, increased consumption of omega 3 fatty acids, Qigong, and counselling or education to modify more than one cardiovascular risk factor. Seven studies reported adverse events but minor or insignificant with respect to the control group. Conclusions: Four non-pharmacological interventions have been shown to provide a statistically significant reduction in risk of CVD events or overall mortality, with minor adverse events if any. Further research should aim for higher methodological quality and longer follow-up of interventions to establish if these interventions, alone or in combination, translate into definite long-term health benefits

Fundamento: El objetivo de este estudio es determinar la efectividad de intervenciones no farmacológicas para la prevención de eventos relacionados con enfermedad cardiovascular (CVD), y mortalidad en adultos sanos o con alto riesgo de CVD. Método: Revisión de revisiones sobre prevención primaria de intervenciones no farmacológicas en las bases de datos de PubMed Health, Effective Health Care Program AHRQ, McMaster University and the Cochrane Plus hasta Julio de 2017. Los resultados primarios fueron el riesgo relativo de eventos CVD, fatales y no fatales, y de mortalidad; los efectos adversos fueron los eventos secundarios. Resultados: Se incluyeron veinticuatro revisiones, de las cuales trece informan resultados de interés. Cuatro observaron una reducción significativa del riesgo: suplementación de vitamina D, incremento del consumo de ácidos grasos omega 3, Qigong, y educación para la modificación de factores de riesgo cardiovascular. Siete revisiones informaron sobre eventos adversos menores y/o no significativos respecto del grupo control. Conclusiones: Cuatro intervenciones no farmacológicas son las que muestran una reducción estadísticamente significativa en eventos CVD o mortalidad total, con escasos o nulos efectos adversos. Se requiere de una investigación de mayor calidad metodológica y de mayor seguimiento de las intervenciones para establecer si estas, combinadas o por separado, conducen a claros beneficios en salud a largo plazo

Night-shift work and breast and prostate cancer risk: updating the evidence from epidemiological studies.

It has been hypothesized that circadian disruption is related to higher cancer risk. Since the International Agency for Research on Cancer classified shift work involving circadian disruption as probably carcinogenic to humans (Group 2A), multiple studies have been conducted to test this hypothesis. The aim of this systematic review was to summarize the findings and evaluate the quality of existing epidemiological studies (case-control and cohort studies) on the relationship between night-shift work and breast and prostate cancer risk. Thirty-three epidemiological studies investigating the relationship between night-shift work and breast (n = 26) or prostate (n = 8) cancer risk were included (one paper included both sites). The Newcastle-Ottawa Scale for the quality of non-randomized studies was used to assess the risk of bias of the publications. The studies included were heterogeneous regarding population (general population, nurses working in rotating shifts, and other) and measurement of exposure to night-shift work (ever vs. never exposure, short vs. long-term, rotating vs. permanent) and, thus, a diversity of outcomes were observed even within the same type of cancer. In summary, 62.5% works found some type of association between night-shift work and increased risk of cancer, for both breast and prostate. The risk of bias scored an average of 7.5 over 9 stars. Due to the limitations inherent in these studies, the evidence of a possible association between night-shift work and breast or prostate cancer risk remains uncertain and more studies providing greater control of exposure and confounding factors are required. Despite the lack of conclusive evidence, application of the precautionary principle seems advisable.

Night-shift work and breast and prostate cancer risk: updating the evidence from epidemiological studies / Trabajo nocturno por turnos y el riesgo de cáncer de mama y próstata: actualizando la evidencia a partir de estudios epidemiológicos

It has been hypothesized that circadian disruption is related to higher cancer risk. Since the International Agency for Research on Cancer classified shift work involving circadian disruption as probably carcinogenic to humans (Group 2A), multiple studies have been conducted to test this hypothesis. The aim of this systematic review was to summarize the findings and evaluate the quality of existing epidemiological studies (case-control and cohort studies) on the relationship between night-shift work and breast and prostate cancer risk. Thirty-three epidemiological studies investigating the relationship between night-shift work and breast (n = 26) or prostate (n = 8) cancer risk were included (one paper included both sites). The Newcastle-Ottawa Scale for the quality of non-randomized studies was used to assess the risk of bias of the publications. The studies included were heterogeneous regarding population (general population, nurses working in rotating shifts, and other) and measurement of exposure to night-shift work (ever vs. never exposure, short vs. long-term, rotating vs. permanent) and, thus, a diversity of outcomes were observed even within the same type of cancer. In summary, 62.5% works found some type of association between night-shift work and increased risk of cancer, for both breast and prostate. The risk of bias scored an average of 7.5 over 9 stars. Due to the limitations inherent in these studies, the evidence of a possible association between night-shift work and breast or prostate cancer risk remains uncertain and more studies providing greater control of exposure and confounding factors are required. Despite the lack of conclusive evidence, application of the precautionary principle seems advisable

Se ha formulado la hipótesis de que la disrupción circadiana está relacionada con un mayor riesgo de cáncer. Desde que la Agencia Internacional de Investigación sobre el Cáncer clasificó la disrupción circadiana asociada al trabajo por turnos como "probablemente carcinógeno para los humanos" (Grupo 2A) se han llevado a cabo numerosos estudios para confirmar o rechazar esta hipótesis. Por esa razón, el objetivo de esta revisión sistemática fue analizar la posible asociación entre el trabajo nocturno por turnos y el riesgo de cáncer de mama o próstata. Se incluyeron treinta y tres estudios epidemiológicos sobre la relación entre el riesgo de padecer cáncer de mama (n = 26) o próstata (n = 8) y el trabajo nocturno; un estudio evaluó ambas localizaciones. El riesgo de sesgo de los artículos se evaluó mediante la escala Newcastle-Ottawa. Los estudios incluidos en esta revisión fueron heterogéneos respecto a población incluida (población general, enfermeras a turnos, y otros), medida de la exposición a trabajo nocturno (siempre vs nunca, a corto vs largo plazo, a turnos o fijo) y, por tanto, los hallazgos fueron variados incluso para el mismo tipo de cáncer. En resumen, un 62,5% de los estudios encontraron asociación entre el trabajo nocturno y el riesgo aumentado de padecer cáncer, tanto de mama como de próstata. El riesgo de sesgo medio fue de 7,5 estrellas sobre 9. Debido a las limitaciones inherentes a estos estudios, la evidencia de una posible asociación entre el trabajo nocturno y el riesgo de cáncer de mama o próstata sigue siendo incierta, por lo que se requieren más estudios epidemiológicos con mayor control de la exposición y de los factores de confusión. No obstante, parece aconsejable la aplicación del principio de precaución

[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)

Do social inequalities exist in terms of the prevention, diagnosis, treatment, control and monitoring of diabetes? A systematic review.

The major increase in the prevalence of diabetes mellitus (DM) has led to the study of social inequalities in health-care. The aim of this study is to establish the possible existence of social inequalities in the prevention, diagnosis, treatment, control and monitoring of diabetes in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems. We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for all relevant articles published up to 15 December 2007. We included observational studies carried out in OECD countries with universal healthcare systems in place that investigate social inequalities in the provision of health-care to diabetes patients. Two independent reviewers carried out the critical assessment using the STROBE tool items considered most adequate for the evaluation of the methodological quality. We selected 41 articles from which we critically assessed 25 (18 cross-sectional, 6 cohorts, 1 case-control). Consistency among the article results was found regarding the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Socioeconomic inequalities were also found in the diagnosis and control of the disease, but no evidence of any gender inequalities was found. In general, the methodological quality of the articles was moderate with insufficient information in the majority of cases to rule out bias. This review shows that even in countries with a significant level of economic development and which have universal healthcare systems in place which endeavour to provide medical care to the entire population, socioeconomic and ethnic inequalities can be identified in the provision of health-care to DM sufferers. However, higher quality and follow-up articles are needed to confirm these results.

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)

[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

Comparación de costes y supervivencia en pacientes intervenidos quirúrgicamente de cáncer colorrectal según diferentes modelos organizativos / A comparison of costs and survival in colorrectal cancer patients undergoing surgery according to different organizational models

Objetivo: determinar la efectividad y los costes de los diferentesmodelos organizativos en la atención a los pacientes con cáncercolorrectal, ya sea a través de las unidades funcionales de gestiónclínica o servicios clínicos tradicionales.Método: se analizó la mortalidad postoperatoria y a largo plazo(30 días y 5 años) en función del número de pacientes sometidosa tratamiento quirúrgico en el hospital para su cáncer colorrectal,ajustado por factores confundentes a nivel de pacientes.Para ello se realizó una revisión exhaustiva de la literatura y con lainformación obtenida se realizó un meta-análisis de efectos aleatorios.En cuanto a los costes se realizó una búsqueda bibliográficapara describir las diferencias entre los hospitales según el númerode pacientes atendidos al año.Resultados: se encontró que aquellas intervenciones realizadasen hospitales de gran volumen mostraban un menor coste porintervención y una menor media en días de estancia hospitalaria.El meta-análisis mostró que el riesgo de morir a los 30 días y5 años en los hospitales de alto volumen es menor que aquelloscon bajo volumen (OR: 1,112; IC95% 0,986-1,255 y OR:1,114; IC95% 1,105-1,183 respectivamente).Conclusiones: la mortalidad postoperatoria a corto y largoplazo es menor en hospitales con alto volumen de casos al año

Objective: to determine the effectiveness and costs of differentorganizational models in caring for colorectal cancer patientsthrough either clinical management functional units or traditionalclinical services.Method: post-operative and long-term (after 30 days and5 years) mortality was analyzed according to number of patientsundergoing surgery because of colorectal cancer. Mortality wasadjusted for patient-related confounding factors. With that purposea thorough review of the literature was conducted; informationobtained was used in a meta-analysis of randomiszd effects. Concerningcosts, a literature search was run to describe differences innumber of patients per year between hospitals.Results: surgery costs were found to be smaller, and meanhospital stay shorter, in big-sized hospitals. The meta-analysisshowed that the risk of death at 30 days and 5 years was lower inbig hospitals versus smaller ones (OR: 1.112; 95% CI 0.986-1.255, and OR: 1.114; 95% CI 1.105-1.183, respectively).Conclusions: short- and long-term postoperative mortality islower in hospitals with a high number of cases per year

[Differences in sociodemographic, clinical, psychosocial and health care characteristics between men and women diagnosed with fibromyalgia]. / Diferencias en características sociodemográficas, clínicas y psicológicas entre hombres y mujeres diagnosticados de fibromialgia.

INTRODUCTION: Health differences between men and women are determined by biological differences although health services often contribute to gender inequalities. Very few studies that analyze gender differences have been made up to date in these patients. This study aims to analyze sociodemographic, clinical and psychosocial differences between men and women diagnosed with FM and to examine the differential impact of their symptoms on their usual activities, including work environment, and the response these patients obtain from the health care system. MATERIAL AND METHODS: A descriptive cross-sectional survey was carried out with all the patients diagnosed with FM in 2003 in three clinics rheumatology units of a university hospital in Spain. RESULTS: The sociodemographic characteristics were very similar in men and women. However, there was a greater proportion of men diagnosed with FM on sick leave, compared to women with the same diagnosis. Men had a worse perception of their health, a higher percentage of psychiatric history and current mental illness and more impact of the disease. DISCUSSION: This is one of the first studies in Spain examining the differences between men and women diagnosed with FM. The results obtained in this study corroborate that, as in other diseases, there are gender differences in the clinical and psychosocial characteristics of men and women diagnosed with FM.

Diferencias en características sociodemográficas, clínicas y psicológicas entre hombres y mujeres diagnosticados de fibromialgia / Differences in sociodemographic, clinical, psychosocial and health care characteristics between men and women diagnosed with fibromyalgia

Introducción. Las diferencias en salud entre hombres y mujeres tienen origen biológico, aunque con frecuencia los sistemas sanitarios contribuyen a ellas. Hasta la fecha son escasos los trabajos que analizan diferencias de género en este síndrome. El objetivo del presente trabajo es analizar las diferencias sociodemográficas clínicas y psicológicas entre hombres y mujeres diagnosticados con fibromialgia (FM), y examinar el impacto diferencial de los síntomas en las actividades habituales, incluyendo el entorno de trabajo, y la respuesta del sistema sanitario en estas situaciones. Material y métodos. Se realizó un estudio descriptivo transversal incluyendo a todos los pacientes diagnosticados de FM en 2003 en el servicio de Reumatología de un hospital universitario. Resultados. Las características sociodemográficas resultaron muy similares en hombres y mujeres. Hay una mayor proporción de hombres diagnosticados de FM en situación de baja laboral en comparación con mujeres con similar diagnóstico. Los hombres tienen peor percepción de su salud, mayor porcentaje de antecedentes psiquiátricos y patología mental actual y mayor impacto de la enfermedad. Discusión. Éste es uno de los primeros trabajos en nuestro país que aborda la FM examinando las diferencias entre hombres y mujeres. Los resultados obtenidos corroboran que, como se ha demostrado previamente para otras patologías, existen diferencias de género en las características clínicas y psicosociales de mujeres y hombres diagnosticados con FM (AU)

Introduction. Health differences between men and women are determined by biological differences although health services often contribute to gender inequalities. Very few studies that analyze gender differences have been made up to date in these patients. This study aims to analyze sociodemographic, clinical and psychosocial differences between men and women diagnosed with FM and to examine the differential impact of their symptoms on their usual activities, including work environment, and the response these patients obtain from the health care system. Material and methods. A descriptive cross-sectional survey was carried out with all the patients diagnosed with FM in 2003 in three clinics rheumatology units of a university hospital in Spain. Results. The sociodemographic characteristics were very similar in men and women. However, there was a greater proportion of men diagnosed with FM on sick leave, compared to women with the same diagnosis. Men had a worse perception of their health, a higher percentage of psychiatric history and current mental illness and more impact of the disease. Discussion. This is one of the first studies in Spain examining the differences between men and women diagnosed with FM. The results obtained in this study corroborate that, as in other diseases, there are gender differences in the clinical and psychosocial characteristics of men and women diagnosed with FM (AU)