Abstract
Background
Caregiver burden is related to personal factors and patient characteristics and is greater when neuropsychiatric symptoms (NPSs) are present. Objective: Estimate the prevalence of ...burden among caregivers of dementia patients and its association with NPSs and identify NPSs causing greater caregiver distress according to dementia stage.
Methods
A cross-sectional observational study in caregivers of noninstitutionalized dementia patients was conducted. Caregiver variables were sociodemographic, time of care, NPS-associated distress based on the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D) and burden based on the Zarit Burden Interview (ZBI). Patient variables were time since disease onset, Global Deterioration Scale (GDS) disease stage, functional assessment and NPS presence and intensity according to the Neuropsychiatric Inventory (NPI). The mean ZBI score, prevalence of burden and NPI-D score with 95% CIs at each dementia stage were estimated. Factors associated with burden were identified by multivariate analysis.
Results
Of the 125 caregivers included, 77.6% were women, with a mean age of 60.7 (± 14.3) years; 78.4% (95%CI: 71.0; 86.0) experienced burden. The mean ZBI score was 12.3 (95%CI: 11.6; 12.9) and increased according to NPS number (p = 0.042). The NPSs causing the most burden were disinhibition (93.5%), irritability (87.3%) and agitation (86.1%). Agitation, apathy, and sleep disorders were the NPSs generating the greatest overall caregiver distress; depression (max NPI-D 1.9), hyperactivity (max NPI-D 2.1), and psychosis symptoms (max NPI-D 1.6) generated the greatest distress at stage GDS 3, stages GDS 4–5, and stages GDS 6–7, respectively. The NPI score (OR = 1.0, 95%CI 1.0; 1.1), intensity of irritability (OR = 1.2, 95%CI 1.0; 1.6), disinhibition (OR = 2.6, 95%CI 1.1; 5.8) and hyperactivity subsyndrome (OR = 1.1, 95%CI 1.0; 1.2) were associated with caregiver burden. Other associated factors were female gender (OR = 6.0, 95%CI 1.6; 22.8), ≥ 8 h daily care (OR = 5.6, 95%CI 1.4; 22.8), working outside the home (OR = 7.6, 95%CI 1.8; 31.8), living with the patient (OR = 4.5, 95%CI 1.1; 19.6), kinship (OR = 5.4, 95%CI 1.0; 28.2) and lower patient education (OR = 8.3, 95%CI 2.3; 30.3).
Conclusions
The burden on caregivers of dementia patients is high and associated with NPS presence and intensity. Disinhibition and irritability caused the highest burden. Depression, hyperactivity and psychosis produce more distress in mild, mild-moderate and severe dementia, respectively.
Osteoarthritis of the lower limb (OALL) worsens health-related quality of life (HRQL), but this impact has not been quantified with standardized measures. We intend to evaluate the impact of OALL on ...HRQL through measures based on individual preferences in comparison to the general population.
A cross-sectional study was designed. A total of 6234 subjects aged 50 years or older without OALL were selected from the Spanish general population (National Health Survey 2011-12). An opportunistic sample of patients aged 50 years or older diagnosed with hip (n = 331) or knee osteoarthritis (n = 393), using the American Rheumatism Association criteria, was recruited from six hospitals and 21 primary care centers in Vizcaya, Madrid and Tenerife between January and December 2015. HRQL was measured with the EQ-5D-5L, and the results were transformed into utility scores. Sociodemographic variables (age, sex, social group, cohabitation), number of chronic diseases, and body mass index were considered. The clinical stage of OALL was collected using the Western Ontario and McMaster Universities Osteoarthritis Index and the Oxford hip score and Oxford knee score. Generalized linear models were constructed using the utility index as the dependent variable.
HRQL expressed by OALL patients was significantly worse than this of the general population. After adjustment for sociodemographic and clinical characteristics, the mean utility loss was -0.347 (95% CI: -0.390, -0.303) for osteoarthritis of the hip and -0.295 (95% CI: -0.336, -0.255) for osteoarthritis of the knee. OALL patients who were treated at a hospital had an additional utility loss of -0.112 (95% CI: -0.158, -0.065).
OALL has a great impact on HRQL. People with OALL perceive a utility loss of approximately 0.3 points compared to the general population without osteoarthritis, which is very high in relation to the utility loss reported for other chronic diseases and for arthritis in general.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The objective was to describe the prevalence and intensity of neuropsychiatric symptoms (NPSs) isolated and grouped into subsyndromes in patients with dementia in primary care (PC) to analyse their ...distribution based on stages of dementia and the relationship between them and the intensity of symptoms.
Design: Cross-sectional study.
Patients with dementia, not institutionalized, in a PC follow-up.
Sociodemographic and clinical variables. Assessment instruments: The frequency and intensity of NPSs were measured with the Neuropsychiatric Inventory (NPI), and the stages of dementia with the Global Deterioration Scale (GDS).
The number of NPSs per patient, the mean NPI value, and the prevalence and intensity of NPSs isolated and grouped into subsyndromes were calculated, as were their 95% confidence intervals (CIs). The analyses were performed on an overall basis and by GDS scores. To analyse the association between the NPI and GDS scores, multivariate analysis was performed with a generalized linear model.
Overall, 98.4% (95% CI 94.5;99.8) of the patients presented some type of NPS, with an average of five symptoms per patient. The most frequent symptoms were apathy 69.8% (95% CI 61.1;77.5), agitation 55.8% (95% CI 46.8;64.5) and irritability 48.8% (95% CI 39.9;57.8). The more intense NPSs were apathy NPI 3.2 (95% CI 2.5;3.8) and agitation NPI 3.2 (95% CI 2.5;4.0). For subsyndromes, hyperactivity predominated 86.0% (95% CI 78.8;91.5), followed by apathy 77.5% (95% CI 69.3;84.4). By phase of dementia, the most common isolated symptom was apathy (60.7-75.0%). Affective symptoms and irritability predominated in the initial stages, and psychotic symptoms predominated in advanced stages. The mean NPI score was 24.9 (95% CI 21.5;28.4) and increased from 15.6 (95% CI 8.2;23.1) for GDS 3 to 28.9 (95% CI 12.6;45.1) for GDS 7. Patients with in the most advanced stages of dementia presented an NPI score 7.6 (95% CI 6.8;8.3) points higher than the score for mild dementia with adjustment for the other variables.
A high prevalence of NPSs was found among patients with dementia treated in PC. Symptoms change and increase in intensity as the disease progresses. Scales such as the NPI allow these symptoms to be identified, which may facilitate more stage-appropriate management.
Abstract Background: The CyberKnife is a new, frameless stereotactic radiosurgery system. This work reviews its safety and efficacy in the treatment of intra- and extracranial lesions. Methods: A ...literature search was made of the Medline, Embase, Pascal Biomed, CINAHL and Cancerlit databases. Health technology assessment reports on stereotactic radiosurgery systems were also consulted. All searches were made in June 2007. Data on efficacy and safety were extracted and then synthesized into the present review. Results: Thirty five clinical studies were identified, the majority of which included no patient comparison group. These studies assessed the use of the CyberKnife mainly in the treatment of primary and metastatic intracranial and spinal tumours. Conclusions: The CyberKnife system allows to carry out standard radiosurgical and fractionated stereotactic radiotherapy procedures. The use of this system offers an alternative for the treatment of inoperable tumours, and of lesions located close to critical structures that cannot be treated using other types of stereotactic radiosurgery system. Unfortunately, the quality of the reviewed papers still does not allow definite conclusions to be drawn regarding the safety and efficacy of these treatments.
Economic theory classifies an intervention as socially beneficial if the total Willingness to Pay (WTP) of those who gain exceeds the total Willingness to accept (WTA) of those who are harmed. This ...paper examines the differences in health system users' valuation of a health care service in primary care setting based on the WTP and WTA perspectives, discussing the impact of personal and service variables, including risk attitudes, on these disparities.
Six hundred and sixty two subjects who asked for care in health centres in the Region of Madrid (Spain) were interviewed, using the contingent valuation method to estimate WTP and WTA. Patient sociodemographic characteristics, health needs, satisfaction with the service and risk attitude and behaviour under risk (measured by self-reported scales and lottery games respectively) were collected. Generalised Linear Models were used to estimate the association between the explanatory variables and the WTA/WTP ratio.
We obtained the WTA/WTP ratio for 570 subjects (mean 1.66 CI 95%: 1.53-1.79; median 1, interquartile range 1-2). People with higher education or in high social groups expressed WTA values closest to WTP. The opposite occurred in patients with the greatest health needs or who were born abroad. Self-reported expression of risk aversion appeared also related to increases in the WTA/WTP ratio. Satisfaction with the service evaluated was the most influential factor in the WTA/WTP ratio.
Health need, difficulty in obtaining substitutes and satisfaction with the service could serve for profiling people averse to loss for health care services in primary care setting. Self-reported expression of risk aversion could also be related to increases in the WTA/WTP ratio. This would mean that these characteristics should be taken into account both in the design and implementation of new healthcare interventions, as in the making decision for disinvestment.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The preferences of citizens are a basic element to incorporate into the decision-making process when planning health policies. Contingent valuation (CV) is a common method for calculating the value ...for citizens that new technologies, interventions, and the provision of services or policies have. However, choosing the correct CV tool may not be a neutral decision. This work aims to assess the substitution of a healthcare service by comparing valuation differences between the willingness to pay (WTP) for the maintenance of the service versus the willingness to accept compensation (WTA) for its substitution, both of which are related to subject characteristics, with a particular focus on trust in institutions and risk aversion.
A CV study was designed to study Dutch population preferences when physician assistants replace anaesthesiologists. Differences between the distributions of WTA and WTP were compared through full decomposition methods, and conditional quantile regression was performed.
Nearly two-thirds of surveyed citizens expressed null values for WTA and WTP. The other third systematically reported a value of WTA higher than that of WTP, which increased further with lower income and the possible presence of a strategic bias. In contrast, being more than 65 years old, having trust in government, and preferring anaesthesiologists decreased the WTA-WTP difference. Risk aversion had no clear association with the WTA-WTP gap.
Known differences between the perceived value of health services from the perspective of gains and losses could be related to people's characteristics. Trust in government but not aversion to risk was related to the WTA-WTP differences. Identifying a profile of citizens who are averse to losing health services should be considered when designing and implementing health services or interventions or making disinvestment decisions.
Clinical practice guidelines (CPGs) have teaching potential for health professionals in training clinical reasoning and decision-making, although their use is limited. The objective was to evaluate ...the effectiveness of a game-based educational strategy e-EDUCAGUIA using simulated clinical scenarios to implement an antimicrobial therapy GPC compared to the usual dissemination strategies to improve the knowledge and skills on decision-making of family medicine residents. Additionally, adherence to e-EDUCAGUIA strategy was assessed.
A multicentre pragmatic cluster-randomized clinical trial was conducted involving seven Teaching Units (TUs) of family medicine in Spain. TUs were randomly allocated to implement an antimicrobial therapy guideline with e-EDUCAGUIA strategy ( intervention) or passive dissemination of the guideline (control). The primary outcome was the differences in means between groups in the score test evaluated knowledge and skills on decision-making at 1 month post intervention. Analysis was made by intention-to-treat and per-protocol analysis. Secondary outcomes were the differences in mean change intrasubject (from the baseline to the 1-month) in the test score, and educational game adherence and usability. Factors associated were analysed using general linear models. Standard errors were constructed using robust methods.
Two hundred two family medicine residents participated (104 intervention group vs 98 control group). 100 medicine residents performed the post-test at 1 month (45 intervention group vs 55 control group), The between-group difference for the mean test score at 1 month was 11 ( 8.67 to 13.32) and between change intrasubject was 11,9 ( 95% CI 5,9 to 17,9). The effect sizes were 0.88 and 0.75 respectively. In multivariate analysis, for each additional evidence-based medicine training hour there was an increase of 0.28 points (95% CI 0.15-0.42) in primary outcome and in the change intrasubject each year of increase in age was associated with an improvement of 0.37 points and being a woman was associated with a 6.10-point reduction. 48 of the 104 subjects in the intervention group (46.2%, 95% CI: 36.5-55.8%) used the games during the month of the study. Only a greater number of evidence-based medicine training hours was associated with greater adherence to the educational game ( OR 1.11; CI 95% 1.02-1.21).
The game-based educational strategy e-EDUCAGUIA shows positive effects on the knowledge and skills on decision making about antimicrobial therapy for clinical decision-making in family medicin residents in the short term, but the dropout was high and results should be interpreted with caution. Adherence to educational games in the absence of specific incentives is moderate.
ClinicalTrials.gov Identifier: NCT02210442 . Registered 6 August 2014.
To assess the burden of several determinants on health-related quality of life (HRQOL) and to study its heterogeneity among the different Spanish regions.
Cross-sectional study. Data were obtained ...from the Spanish National Health Survey (2012), and HRQOL was measured using the EQ-5D-5L questionnaire (utility and visual analogue scale –VAS– scores). Demographic variables, physical health condition, social variables, mental health status, and lifestyle were also analysed. Tobit regression models were employed to study the relationships between expressed HRQOL and personal characteristics.
A total of 20,979 surveys were obtained. Of them, 62.4% expressed a utility score of 1, corresponding to perfect health (95%CI: 61.8%–63.2%), and 54.2% showed VAS scores ≥80 (95%CI: 53.5%–54.9%). HRQOL was mainly described as a function of age, chronic limitation in daily activities, and mental health status. Belonging to a higher-class strata and physical activity were related to better self-perceived HRQOL. Ageing worsened perceived HRQOL, but did not influence its determinants, and differences in HRQOL by regions were also not significant after model adjustment.
HRQOL perception in the Spanish population varied slightly depending on the measure used (utilities index or VAS). Age, chronic limitations in daily life, and mental health status best explained the variability in perception, and no meaningful differences in HRQOL perception among regions were found after adjustment.
Evaluar la carga de ciertos determinantes de la calidad de vida relacionada con la salud (CVRS) y su heterogeneidad entre diferentes regiones españolas.
Estudio transversal. Utilizando datos de la Encuesta Nacional de Salud (2012), se midió la CVRS con el cuestionario EQ5D-5L (utilidad y escala visual analógica EVA). Se analizaron variables demográficas, estado de salud, variables sociales, salud mental y estilos de vida, utilizando modelos Tobit.
Se incluyeron 20.979 encuestas. El 62,4% de los sujetos expresó una utilidad de 1, perfecta salud (intervalo de confianza del 95% IC95%: 61,8% -63,2%), y el 54,2% mostró puntuaciones en la EVA ≥80 (IC95%: 53,5%-54,9%). La CVRS se vio modificada fundamentalmente por la edad, la limitación crónica en las actividades diarias y el estado de salud mental. La clase social alta y la actividad física aparecían relacionadas con una mejor CVRS. La edad empeoró la percepción de la CVRS, pero no se asoció con un cambio en la influencia de sus determinantes. Después de ajustar los modelos, no había diferencias en la CVRS en las diferentes regiones.
La percepción de la CVRS en la población española varió dependiendo de la medida utilizada (utilidades o EVA). La edad, las limitaciones crónicas en la vida diaria y el estado de salud mental explicaban fundamentalmente las diferencias en la CVRS, y las diferencias entre regiones se explicaron principalmente por diferentes características poblacionales.
Hypertension is responsible for a huge burden of disease. The aim of this study was to evaluate the impact of newly diagnosed hypertension on the occurrence of kidney or cardiovascular events ...(K/CVEs) and on mortality among community dwellers.
Retrospective cohort study, conducted from January, 2007, to December, 2018. All patients (age > 18) newly diagnosed with hypertension and no previous K/CVEs in 2007 and 2008, in the primary care centers of Madrid (Spain) (n = 71,770), were enrolled. The control group (n = 72,946) included patients without hypertension, matched by center, sex and age. The occurrence of kidney or CV events, including mortality from these causes and total mortality were evaluated using Cox regression and multistate models. Data were collected from three sources: personal data from administrative records, clinical data from medical records, and mortality data from regional and national databases.
The median follow-up was 138.61 months (IQR: 124.68-143.97 months). There were 32,896 K/CVEs (including 3,669 deaths from these causes) and 12,999 deaths from other causes. Adjusted for sex, smoking, diabetes and socioeconomic status, K/CVEs HR was 4.36 (95% CI: 3.80-5.00) for diagnoses before 45 years of age, 2.45(95% CI: 2.28- 2.63) for diagnosis between 45 to 54 years, and HR decreased to 1.86 (95% CI: 1.64-210) for diagnoses over age 85. Total mortality risk was only higher for hypertension diagnosed before 55 years of age (HR: 2.47, 95% CI: 1.90-3.19 for ages 18 to 44; and HR: 1.14, 95% CI: 1.02-1.28 for ages 45 to 54).
The diagnosis of hypertension in the community environment, in patients without evidence of previous kidney or CV disease, is associated with a large increase in the risk of K/CVEs, but especially in individuals diagnosed before the age of 55. This diagnosis is only associated with an increase in kidney or cardiovascular mortality or overall mortality when it occurs before age 55.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background: Different conditions in health services utilization may create situations of inequity. The objective was analyze the differences of nurse consultation utilization in primary care. ...Methods: Cross-sectional study, in 23 health centres in Madrid. Environmental variables, consultation characteristics, socio-demographic and health need characteristics were collected. The quality of life and satisfaction were also studied. The variables were classified according to the «behavioral model» in predisposing, enabling or need variables. Explanatory multivariate models were constructed (Generalized-Estimating-Equations). Results: The higher income areas and aging, predisposing factors, were associated with increases of 17% (95% CI: 0.4 to 36.9%) and 11.0% per decade (95% CI: 6.2 - 16.2) in nursing consultations per year. Among enabling factors, each additional minute of consultation length was associated with an increase of 2.0% (95% CI :1.2-2, 9%) in number of nurse consultations, each new medical consultation was associated with a increase of 2.7% (95% CI: 2.1-3.2%) and the delay in getting appointment over a day, represented a decrease of 32.8% (95% CI: 19.3 to 44.1%) in the total nursing consultations. Each chronic condition, which expresses the need health, was associated with an increase in the number of visits of 4.8% (95% CI: 1.7 to 8.0%). The improved perception of quality of life was associated with a reduction of 5.4% (95% CI 1.0 to 8.7%) of the consultations. Conclusion: The difference of the use of primary care nurse consultations is based on health need criteria, but is also influenced by accessibility conditions.
Fundamentos: Diferentes condiciones de utilización de servicios sanitarios pueden originar situaciones de falta de equidad. El objetivo del trabajo es conocer si existen diferencias en el uso de la consulta de enfermería en atención primaria. Métodos: Estudio multicéntrico transversal en 23 centros de salud de la Comunidad de Madrid. Se incluyó a 662 sujetos. Se recogieron variables relativas al centro de salud, de la consulta de enfermería, características sociodemograficas y de necesidad en salud. Se estudiaron la calidad de vida y la satisfacción de los sujetos. Las variables se clasificaron, según el modelo «conductual», en predisponentes, facilitadoras o de necesidad. Se construyeron modelos multivariantes explicativos. Resultados: Vivir en zonas de renta alta y la edad se asociaron con aumentos del 17% (IC95%: 0,4-36,9%) y del 11,0% por cada década (IC95%: 6,2-16,2) de las consultas/año de enfermería. De los factores facilitadores, cada minuto añadido de duración de la consulta se asoció con un aumento del 2,0% (IC95%: 1,2-2,9%) en las consultas/año, cada nueva consulta médica se asociaba con un aumento del 2,7% (IC95%: 2,1-3,2%) y la demora en conseguir cita superior a un día supuso una disminución del 32,8% (IC95%: 19,3-44,1%) del número de consultas. Cada condición crónica, que expresa necesidad en salud, se asoció con un incremento del número de consultas del 4,8% (IC 95%: 1,7-8,0%). La mejor percepción de la calidad de vida se asoció con una reducción de las consultas de un 5,4% (IC95%: 1,0-8,7%). Conclusión: Las diferencias en el uso de la consulta de enfermería responde a criterios de necesidad, pero también está influenciada por condiciones de accesibilidad.
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