Jesús Martín-Fernández

Satisfacción del paciente con la relación con su médico de familia: un estudio con el Patient-Doctor Relationship Questionnaire

OBJECTIVEnTo describe patient satisfaction of their relationship with the family physician, using the PDRQ-9 questionnaire and assess its psychometric properties.nnnDESIGNnCross-sectional study.nnnSETTINGnSix Primary Care Health centres in the Community of Madrid, Spain.nnnPARTICIPANTSnFour hundred and fifty one patients randomly selected from those who had just visited their family physician.nnnINTERVENTIONSnInterviews were carried out to collect demographic characteristics, health needs, the accessibility to the service, and the socioeconomic situation of the subjects.nnnMEASUREMENTSnThe PDRQ-9 responses were collected and a synthetic satisfaction index was constructed. A multivariable model was designed to explain differences in satisfaction.nnnRESULTSnThe mean satisfaction index was 4.41 (95% CI: 4.33-4.48) on a scale of 1 (the worst) to 5 (the best satisfaction possible), with a median of 4.78 (interquartile range 4.00-5.00). Four of every 10 subjects expressed the maximum possible satisfaction (ceiling effect). A single factor explained 75.3% of the variance, with a Cronbach alpha value of 0.952. Age (OR 1.03, 95% CI: 1.02-1.05) and living in rural areas (OR 1.44, 95% CI: 0.94-2.20) were associated with above average satisfaction.nnnCONCLUSIONSnPrimary care users feel their relationship with their family physicians are very satisfactory, particularly in those who are older and who live in rural areas. The PDRQ-9 questionnaire shows a high internal consistency, but it is not good enough to discriminate in the upper part of the scale.

Perception of the economic value of primary care services: a willingness to pay study.

OBJECTIVEnIdentify the economic value the user attributes to the visit to the family physician, in a setting of a National Health System, by the Willingness to Pay (WTP) expressed.nnnMETHODSnEconomic evaluation study, by the contingent valuation method. Questions were asked about WTP using a payment card format. Interviews were conducted with 451 subjects, in areas with different socioeconomic characteristics. An ordered probit was used to evaluate models validity.nnnRESULTSnMedian WTP expressed was euro18 (interquartile range euro8-28), not including zero-answers of thirty-four subjects (7.5%). This value represents 2% of average adjusted family incomes. Patients with higher incomes or with chronic illnesses presented a probability of 5-14 percentage points of expressing a high WTP. For every point of increase of patient satisfaction, the probability of presenting a WTP in the lowest range decreases 7.0 percentage points. Subjects with a low education level and those older than 65 expressed a lower WTP. Accessibility, risk perception, nationality and having private insurance were not related to the WTP expressed.nnnCONCLUSIONSnUsers of primary care have a clear perception of the economic value of care received from the family physician, even in a framework of providing services financed by taxes and without cost at the moment of use. This value increases in subjects with higher incomes, with greater need for care, or more satisfied.

Oral versus intramuscular administration of vitamin B12 for the treatment of patients with vitamin B12 deficiency: a pragmatic, randomised, multicentre, non-inferiority clinical trial undertaken in the primary healthcare setting (Project OB12).

BackgroundThe oral administration of vitamin B12 offers a potentially simpler and cheaper alternative to parenteral administration, but its effectiveness has not been definitively demonstrated. The following protocol was designed to compare the effectiveness of orally and intramuscularly administered vitamin B12 in the treatment of patients ≥65u2009years of age with vitamin B12 deficiency.Methods/designThe proposed study involves a controlled, randomised, multicentre, parallel, non-inferiority clinical trial lasting one year, involving 23 primary healthcare centres in the Madrid region (Spain), and patients ≥65 years of age. The minimum number of patients required for the study was calculated as 320 (160 in each arm). Bearing in mind an estimated 8-10% prevalence of vitamin B12 deficiency among the population of this age group, an initial sample of 3556 patients will need to be recruited.Eligible patients will be randomly assigned to one of the two treatment arms. In the intramuscular treatment arm, vitamin B12 will be administered as follows: 1u2009mg on alternate days in weeks 1 and 2, 1u2009mg/week in weeks 3–8,and 1u2009mg/month in weeks 9–52. In the oral arm, the vitamin will be administered as: 1u2009mg/day in weeks 1–8 and 1u2009mg/week in weeks 9–52. The main outcome variable to be monitored in both treatment arms is the normalisation of the serum vitamin B12 concentration at weeks 8, 26 and 52; the secondary outcome variables include the serum concentration of vitamin B12 (in pg/ml), adherence to treatment, quality of life (EuroQoL-5D questionnaire), patient 3satisfaction and patient preferences. All statistical tests will be performed with intention to treat and per protocol. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in analyses.DiscussionThe results of this study should help establish, taking quality of life into account, whether the oral administration of vitamin B12 is an effective alternative to its intramuscular administration. If this administration route is effective, it should provide a cheaper means of treating vitamin B12 deficiency while inducing fewer adverse effects. Having such an alternative would also allow patient preferences to be taken into consideration at the time of prescribing treatment.Trial registrationThis trial has been registered with ClinicalTrials.gov, number NCT 01476007, and under EUDRACT number 2010-024129-20.

Differences between willingness to pay and willingness to accept for visits by a family physician: a contingent valuation study.

BackgroundThe economic value attributed by users of health services in public health systems can be useful in planning and evaluation. This value can differ from the perspectives of Willingness to Pay (WTP) and Willingness to Accept [Compensation] (WTA).Our objective was to study the perceptions of the patient about the service provided by the family physician by means of the WTA/WTP ratio.MethodsAn economic evaluation study by the Contingent Valuation Method was designed. Interviews were conducted with 451 subjects at six health centres (four urban and two rural) in areas with different socioeconomic characteristics. A payment card was used to measure the WTP and WTA. Other characteristics of the subject or service that could influence these responses were collected. An explicative model was constructed to study the WTA/WTP relationship.ResultsFour hundred and four subjects (89.6%) expressed a WTP and WTA different from zero. The WTA/WTP quotient showed a median of 1.55 (interquartile range 1-3.08) and a mean of 3.30 (IC 95%: 2.84-3.75). The WTA/WTP ratio increases with age and in low-income areas. It decreases in professional groups with more specialized activities, with growing family income, and in the chronically ill. Other characteristics related to the perception of state of health, accessibility to the service, satisfaction, or perception of risk were not explicative.ConclusionsSubjects who were older and had a less favourable socioeconomic situation expressed a higher WTA/WTP ratio when valuing the visit to the family physician. These characteristics could identify a profile of aversion to loss with respect to this service.

Effectiveness of an intervention for prevention and treatment of burnout in primary health care professionals

BackgroundBurnout syndrome is an important health problem that affects many professionals and must be addressed globally, with both organizational measures and personal interventions. Burnout of health professionals can be prevented in order to avoid personal, familial, and social consequences, as well as repercussions for patients.Methods/designThis work describes a protocol for a controlled, pragmatic, randomized clinical trial in 2 parallel groups: intervention and control. All health professionals from 7 health care centers will form the intervention group, and all health professionals from 7 different health care centers will form the control group. The intervention group will receive 16xa0hours of training at their work place. The Maslachs burnout inventory, the Cuestionario de Desgaste Profesional Médico or the Cuestionario de Desgaste Profesional de Enfermería, and the 28-item Goldbergs General Health Questionnaire, validated for our setting, will be used as measurement tools. Change in the average scores from the Maslachs burnout inventory emotional exhaustion scale will be compared between the intervention and control groups, measured as intention-to-treat, and the intervention will be considered effective if a minimum decrease of 20% is achieved.DiscussionDue to the deleterious consequences of burnout syndrome for people suffering from it and for the organization where they work, it is necessary to evaluate the effectiveness of certain interventions for its prevention. Organizational measures are important for preventing burnout syndrome, but so is providing professionals with coping strategies, as this group intervention intends to do.Trial registrationClinicalTrials.gov processed this record on June 10, 2013. ClinicalTrials.gov Identifier: NCT01870154.

Willingness to pay for a quality-adjusted life year: an evaluation of attitudes towards risk and preferences

BackgroundThis paper examines the Willingness to Pay (WTP) for a quality-adjusted life year (QALY) expressed by people who attended the healthcare system as well as the association of attitude towards risk and other personal characteristics with their response.MethodsHealth-state preferences, measured by EuroQol (EQ-5D-3L), were combined with WTP for recovering a perfect health state. WTP was assessed using close-ended, iterative bidding, contingent valuation method. Data on demographic and socioeconomic characteristics, as well as usage of health services by the subjects were collected. The attitude towards risk was evaluated by collecting risky behaviors data, by the subject’s self-evaluation, and through lottery games.ResultsSix hundred and sixty two subjects participated and 449 stated a utility inferior to 1. WTP/QALY ratios varied significantly when payments with personal money (mean €10,119; median €673) or through taxes (mean €28,187; median €915) were suggested. Family income, area income, higher education level, greater use of healthcare services, and the number of co-inhabitants were associated with greater WTP/QALY ratios. Age and female gender were associated with lower WTP/QALY ratios. Risk inclination was independently associated with a greater WTP/QALY when “out of pocket” payments were suggested. Clear discrepancies were demonstrated between linearity and neutrality towards risk assumptions and experimental results.ConclusionsWTP/QALY ratios vary noticeably based on demographic and socioeconomic characteristics of the subject, but also on their attitude towards risk. Knowing the expression of preferences by patients from this outcome measurement can be of interest for health service planning.

Professional quality of life and organizational changes: a five-year observational study in Primary Care

BackgroundThe satisfaction and the quality of life perceived by professionals have implications for the performance of health organizations. We have assessed the variations in professional quality of life (PQL) and their explanatory factors during a services management decentralization process.MethodsIt was designed as a longitudinal analytical observational study in a Health Area in Madrid, Spain. Three surveys were sent out during an ongoing management decentralization process between 2001 and 2005. The professionals surveyed were divided into three groups: Group I (97.3% physicians), group II (92.5% nurses) and group III (auxiliary personnel). Analysis of the tendency and elaboration of an explanatory multivariate model was made. The PQL -35 questionnaire, based on Karaseks demand-control theory, was used to measure PQL. This questionnaire recognizes three PQL dimensions: management support (MS), workload (WL) and intrinsic motivation (IM).Results1444 responses were analyzed. PQL increased 0.16 (CI 95% 0.04 – 0.28) points in each survey. Group II presents over time a higher PQL score than group I of 0.38 (IC 95% 0.18 – 0.59) points. There is no difference between groups I and III.For each point that MS increases, PQL increases between 0.44 and 0.59 points. PQL decreases an average of between 0.35 and 0.49 point, for each point that WL increases.Age appears to have a marginal association with PQL (CI 95% 0.00 – 0.02), as it occurs with being single or not having a stable relationship (CI 95% 0.01 – 0.41). Performing management tasks currently or in the past is related to poorer PQL perception (CI 95% -0.45 – -0.06), and the same occurs with working other than morning shifts (CI 95% -0.03 – -0.40 points).PQL is not related to sex, location of the centre (rural/urban), time spent working in the organization or contractual situation.ConclusionWith the improvement in work control and avoiding increases in workloads, PQL perception can be maintained despite deep organizational changes at the macro-management level. Different professional groups experience different perceptions depending on how the changes impact their position in the organization.

LA CALIDAD DE VIDA RELACIONADA CON LA SALUD COMO FACTOR EXPLICATIVO DE LA UTILIZACIÓN DE LA CONSULTA DE MEDICINA DE FAMILIA: UN ESTUDIO BAJO EL MODELO CONDUCTUAL

Fundamento: La utilizacion de servicios sanitarios se ha estudiado desde varios modelos conceptuales. El objetivo de este trabajo es valorar la influencia de la calidad de vida relacionada con la salud (CVRS) en la variabilidad de la utilizacion de la consulta de atencion primaria bajo el «modelo conductual». Metodos: Estudio transversal analitico. Se entrevisto a 451 sujetos de 6 centros de salud en la Comunidad de Madrid. Se recogieron caracteristicas relacionadas con factores ambientales e individuales (predisponentes, facilitadores y de necesidad) y la CVRS (Euroqol-5D). La utilizacion se recogio de la historia clinica informatizada. Resultados: Hubo una mediana de 13 visitas/ano (rango intercuartil 7-20). La CVRS explicaba un 5,2% de la variabilidad en la utilizacion, vivir en barrios de rentas altas un 2,4%, la edad un 7,4%, la renta individual un 1,0% y los factores relacionados con «necesidad» (enfermedades cronicas e ingresos hospitalarios) explicaban un 4,1% de variabilidad adicional. Cada cambio de tercil de la CVRS se asocio con una disminucion del 13,8% en las consultas/ano. La residencia en zonas de renta alta y cada aumento de 1000€ de renta individual disminuian la utilizacion un 17,5% y un 9,5% respectivamente. La edad se asociaba con un aumento de un 8,0% de visitas/ano por decada. El sufrir enfermedades cronicas o ingresos hospitalarios suponia aumentar un 51,9% y un 26,5% las visitas anuales. Conclusiones: La CVRS se asocia de manera independiente con la variabilidad en la utilizacion de la consulta del medico de familia, una vez ajustado el efecto de la necesidad, como propone el «modelo conductual».

Economic valuation of health care services in public health systems: a study about Willingness to Pay (WTP) for nursing consultations.

Background Identifying the economic value assigned by users to a particular health service is of principal interest in planning the service. The aim of this study was to evaluate the perception of economic value of nursing consultation in primary care (PC) by its users. Methods and Results Economic study using contingent valuation methodology. A total of 662 users of nursing consultation from 23 health centers were included. Data on demographic and socioeconomic characteristics, health needs, pattern of usage, and satisfaction with provided service were compiled. The validity of the response was evaluated by an explanatory mixed-effects multilevel model in order to assess the factors associated with the response according to the welfare theory. Response reliability was also evaluated. Subjects included in the study indicated an average Willingness to Pay (WTP) of €14.4 (CI 95%: €13.2–15.5; median €10) and an average Willingness to Accept [Compensation] (WTA) of €20.9 (CI 95%: €19.6–22.2; median €20). Average area income, personal income, consultation duration, home visit, and education level correlated with greater WTP. Women and older subjects showed lower WTP. Fixed parameters explained 8.41% of the residual variability, and response clustering in different health centers explained 4–6% of the total variability. The influence of income on WTP was different in each center. The responses for WTP and WTA in a subgroup of subjects were consistent when reassessed after 2 weeks (intraclass correlation coefficients 0.952 and 0.893, respectively). Conclusions The economic value of nursing services provided within PC in a public health system is clearly perceived by its user. The perception of this value is influenced by socioeconomic and demographic characteristics of the subjects and their environment, and by the unique characteristics of the evaluated service. The method of contingent valuation is useful for making explicit this perception of value of health services.

Variables que condicionan la utilización de la consulta de enfermería en centros de salud de la Comunidad de Madrid

Fundamentos: Diferentes condiciones de utilizacion 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 enfermeria en atencion primaria. Metodos: Estudio multicentrico transversal en 23 centros de salud de la Comunidad de Madrid. Se incluyo a 662 sujetos. Se recogieron variables relativas al centro de salud, de la consulta de enfermeria, caracteristicas sociodemograficas y de necesidad en salud. Se estudiaron la calidad de vida y la satisfaccion de los sujetos. Las variables se clasificaron, segun 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 decada (IC95%: 6,2-16,2) de las consultas/ano de enfermeria. De los factores facilitadores, cada minuto anadido de duracion de la consulta se asocio con un aumento del 2,0% (IC95%: 1,2-2,9%) en las consultas/ano, cada nueva consulta medica se asociaba con un aumento del 2,7% (IC95%: 2,1-3,2%) y la demora en conseguir cita superior a un dia supuso una disminucion del 32,8% (IC95%: 19,3-44,1%) del numero de consultas. Cada condicion cronica, que expresa necesidad en salud, se asocio con un incremento del numero de consultas del 4,8% (IC 95%: 1,7-8,0%). La mejor percepcion de la calidad de vida se asocio con una reduccion de las consultas de un 5,4% (IC95%: 1,0-8,7%). Conclusion: Las diferencias en el uso de la consulta de enfermeria responde a criterios de necesidad, pero tambien esta influenciada por condiciones de accesibilidad.BACKGROUNDnDifferent conditions in health services utilization may create situations of inequity. The objective was analyze the differences of nurse consultation utilization in primary care.nnnMETHODSnCross-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).nnnRESULTSnThe 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.nnnCONCLUSIONnThe difference of the use of primary care nurse consultations is based on health need criteria, but is also influenced by accessibility conditions.