Margarida Jansà

The burden of chronic disorders on hospital admissions prompts the need for new modalities of care: A cross-sectional analysis in a tertiary hospital

BACKGROUND Chronic disorders constitute a primary concern because of their burden on healthcare systems worldwide. Integrated care strategies enhancing the interface between tertiary care and primary care are pivotal to improve chronic care. AIM To asses the prevalence of chronic disorders on hospital discharges and their impact on unplanned admissions and mortality. DESIGN Cross-sectional analysis of discharge information over 1 year (2004) in one University hospital. METHODS Adoption of an operational definition of chronic disorder based on the WHO. MAIN OUTCOME co-morbid conditions, emergency room and hospital admissions, outpatient consultations and mortality. RESULTS Fifty-eight percent of patients presented at least one chronic condition (19 192 patients, 53% males, 63 +/- 18 years) as primary (12 526 patients, 38%) or secondary diagnosis. The Charlson index was 2 +/- 3. Each chronic condition was associated with a 30% increase of having had an admission in the previous year. Up to 9% (1 656) of chronic patients showed multiple admissions in the previous year: two (917 patients, 55%), three (360, 22%) and four or beyond (379, 23%), being mostly unscheduled hospitalizations. The three most prevalent chronic disorders were cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD). The rate of admissions was associated with co-morbidity (P < 0.001) and mortality (P < 0.001). CONCLUSION The study shows a high impact of cancer on planned hospitalizations whereas cardiovascular diseases and COPD generates a high percentage of unscheduled admissions. We conclude that integrated care services including patient-oriented guidelines are strongly needed to enhance both health and managerial outcomes.

Multidimensional analysis of treatment adherence in patients with multiple chronic conditions. A cross-sectional study in a tertiary hospital.

OBJECTIVE Determine treatment adherence in patients with multiple chronic conditions (MCC). METHODS A random patient sample ≥ 15 years, discharged from hospital with ≥1 chronic conditions (CC) was interviewed after 6-12 months. Analysis included variables in 5 dimensions (WHO): socio-demographics, disease, treatment, patient and health system characteristics. Morisky-Green adherence questionnaire was used. High chronic treatment complexity was defined as: >3 pills/day, >6 inhalations/day, >1 injection/day, pharmacological treatment plus diet or self-monitoring techniques. RESULTS 301 patients were interviewed (62 ± 15 years, 59% males). Despite good treatment information perception (79%), only 3% followed the patient education programme. Poor adherents (82%) were older (64 ± 14 years vs. 55 ± 16 years), had more CC (3.25 ± 2.02 vs. 2.62 ± 2.72), a higher frequency of hypertension (44% vs. 15%), ischaemic heart diseases: (21% vs. 4%), hyperlipidaemia (19% vs. 6%), more pills/day (5.78 ± 4.14 vs. 3.20 ± 4.70) and more complex treatments (95% vs. 70%) (p<0.05). On multivariate analysis number of CC [3.68 (0.75-18.15)], pills/day [2.23 (1.02-4.84)], treatment complexity [4.00 (1.45-11.04)], and hypertension [2.57 (1.06-6.25)] were predictive of poor adherence (OR 95% CI p<0.05). CONCLUSION The WHO conceptual framework allows the construction of poor adherence risk profiles in patients with MCC after hospital discharge. PRACTICE IMPLICATIONS Predictive variables of poor adherence could help clinicians detect patients with MCC most likely to present poor adherence.

Psychometric analysis of the Spanish and Catalan versions of the Diabetes Self-Care inventory- revised version questionnaire

Background The purpose of this study was to validate the Spanish and Catalan versions of the Diabetes Self-Care Inventory-Revised Version (SCI-R) questionnaire to assess the degree of adherence to self-care among adults with diabetes. Methods We validated the Spanish and Catalan translation from, and back translation to, English and cultural adaptation of the SCI-R in type 1 diabetes patients on multiple insulin doses or continuous subcutaneous insulin infusion and in type 2 diabetes patients on oral agents and/or insulin. Internal reliability, structural validity, and external validity (correlation with glycated hemoglobin) were evaluated. Responsiveness to change was assessed in patients 1 year after onset of type 1 diabetes and following a structured education program. Results The SCI-R presented good internal reliability Cronbach’s α: 0.75, test-retest reliability (r = 0.82) and structural validity (r > 0.40). The external validity was also good; the SCI-R correlated with HbA1c in patients with type 1 diabetes on multiple insulin doses (r = −0.50) or continuous subcutaneous insulin infusion (r = −0.66) and in patients with type 2 diabetes on multiple insulin doses (r = −0.62). However, it was not satisfactory in patients on oral agents (r = −0.20) and/or bedtime insulin (r = −0.35). Responsiveness to change was analyzed in 54 patients (age 27.3±7.4 years, 26% men, HbA1c 6.8% ±1.1%); the SCI-R score was 72.3% ±13.7% and correlated negatively with glycated hemoglobin (r = −0.42) and 3 scales of the Diabetes Quality of Life questionnaire (lower score indicating better perception): Impact (r = −0.37), Social Worry (r = −0.36) and Diabetes Worry (r = −0.38), all at P < 0.05. Conclusion The Spanish and Catalan versions of the SCI-R questionnaire show good psychometric properties and both could be considered as useful tools for evaluating self-care behavior in patients with type 1 or type 2 diabetes. However, there are still some subgroups of patients with type 2 diabetes in which the validity of this questionnaire needs further evaluation.

Role of Musculoskeletal Disorders as Concurrent Chronic Conditions: Are They Underestimated in the Discharge?

Background: Differences in recording concurrent chronic conditions (CCs) could change the weight of the influence of the different CCs on health status. Objectives: To determine the role of musculoskeletal disorders as concurrent CCs. Methods: Cross-sectional study. Discharged patients with CCs were selected by random stratification. Sociodemographic and clinical variables, health status (SF-36), type and number of self-reported and hospital discharge summary CCs were recorded. Relationships were analyzed using linear regression models. Results: In the 227 patients included, mean self-reported CCs were 6.22 (SD 3.37) and mean hospital discharge CCs were 3.1 (SD 1.95). The most-frequent self-reported CCs were hypertension 48.4%, back pain 40.4%, neck pain 39.6%, and musculoskeletal disorders 38.4%. The most frequent discharge CCs were arterial hypertensive disease 38.3%, all cancers 22.0%, ischemic heart diseases, and angina 15.9%. Musculoskeletal disorders had the greatest negative influence on SF-36 dimensions (p < 0.05). Conclusions: Musculoskeletal disorders were underestimated in the discharge summary in comparison with those reported by patients.

Educación terapéutica en la cronicidad: el modelo de la diabetes

Chronic diseases (CDs) are long-standing, usually slowly progressing diseases which cause high morbidity and mortality. According to the WHO report, Global Status Report on Noncommunicable Diseases 2010, 63% of deaths worldwide were due to CDs, mainly respiratory and cardiovascular diseases, cancer, and diabetes mellitus (DM). It is estimated that CD-associated mortality will increase due to the increased prevalence and aging of the population. Many CDs share risk factors such as smoking, alcohol consumption, inadequate diet, and sedentary lifestyles. This situation demands new care models for CDs that emphasize the role of the patient/family themselves in the self-management of their treatment(s), although in DM the self-management associated with its treatment has been important ever since the discovery of insulin in 1921. Diabetes mellitus is a paradigmatic example of a chronic disease that affects all ages and social conditions. DM requires continued medical care, therapeutic education for the self-management of treatment, prevention, and treatment of associated acute and chronic complications. The most relevant facts in the treatment of diabetes which have improved morbidity and mortality over time have included:

Educación terapéutica en alimentación de la persona con diabetes tipo 1 joven y adulta. Adaptación a la terapia con infusión subcutánea continua de insulina

Resumen La presente revision de la literatura cientifica aporta, en primer lugar y a modo de introduccion, informacion sobre la educacion terapeutica de la persona con diabetes y sus famliares, asi como el concepto de educacion dietetica nutricional. En segundo lugar, revisa el enfoque actual del tratamiento de la diabetes mellitus tipo 1 sea con terapia con multiples dosis de insulina (MDI) o con infusion subcutanea continua de insulina (ISCI), y su relacion con el plan de alimentacion mas liberalizado, ya que permiten un mejor ajuste de la dosis de insulina preprandial segun la ingesta de hidratos de carbono (HC); tambien se aportan aspectos relacionados con la adherencia al seguimiento dietetico. Finalmente, en tercer lugar, se exponen las bases y caracteristicas de la terapia ISCI, el aprendizaje especifico que han de realizar las personas con diabetes y sus familiares, centrado basicamente en los aspectos diferenciales relacionados con el plan de alimentacion respecto a las MDI. La terapia ISCI puede ofrecer mas flexibilidad dietetica que cualquier otra modalidad de tratamiento, aunque para optimizar las prestaciones del infusor, el paciente no solo ha de aprender a estimar el aporte de HC, sino tambien otros nutrientes, como el aporte de grasa o fibra, que pueden interferir en su absorcion.