María José Rabanaque

Efectos de la contaminación atmosférica sobre la mortalidad diaria en la ciudad de Zaragoza, España, 1991-1995

Objetivo. Analizar posibles efectos a corto plazo de la contaminacion atmosferica sobre la mortalidad diaria en la poblacion de Zaragoza (Espana). Material y metodos. Estudio ecologico realizado en Zaragoza, Espana, en los anos 1991 a 1993. Mediante modelos de regresion de Poisson autorregresiva se estudio la asociacion entre exposicion a particulas en suspension y dioxido de azufre (SO2), y defunciones diarias de 1991 a 1995. Se consideraron por separado cuatro variables respuesta: mortalidad total para toda la poblacion (excluidas las causas externas), mortalidad en mayores de 69 anos, mortalidad especifica por enfermedades respiratorias y mortalidad por enfermedades cardiovasculares. Resultados. No se utiliza muestra. Se utilizaron los paquetes estadisticos EGRET y SPSS. Se encontraron asociaciones entre niveles de SO2 y mortalidad por enfermedades cardiovasculares, riesgo relativo (RR=1.018 IC 95%: 1.001-1.036), asi como entre particulas en suspension y mortalidad por enfermedades respiratorias (RR=1.028 IC 95%: 1.006-1.051). Durante epocas calidas, se observo un efecto significativo de las particulas en suspension sobre la mortalidad por enfermedades cardiovasculares (RR=1.020 IC 95%: 1.001-1.040). Conclusiones. A pesar de los bajos niveles de contaminacion existentes, se han detectado efectos significativos de incrementos en la concentracion de contaminantes atmosfericos sobre la mortalidad por enfermedades cardiovasculares y respiratorias, especialmente en los meses calidos. El texto completo en ingles de este articulo esta disponible en: http://www.insp.mx/salud/index.html

High Antibiotic Consumption: A Characterization of Heavy Users in Spain

Heavy antibiotic users are those individuals with the highest exposure to antibiotics. They play an important role as contributors to the increasing risk of antimicrobial resistance. We applied different methods to identify and characterize the group of heavy antibiotic users in Spain as well as their exposure to antibiotics. Data on outpatient prescribing of antimicrobials (ATC J01) in 2010 were obtained from a prescription database covering Aragón (northeastern Spain). The antimicrobial consumption at the individual level was analysed both according to the volume of DDD and the number of packages purchased per year. Heavy antibiotic users were identified according to Lorenz curves and characterized by age, gender, and their antimicrobial prescription profile. Lorenz curves demonstrated substantial differences in the individual use of antimicrobials. Heavy antibiotic users (5% of individuals with highest consumption) were responsible for 21% of the total DDD consumed and received ≥6 packages per year. Elderly adults (≥60 years) and small children (0–9 years) were those exposed to the highest volume of antibiotics and with the most frequent exposure, respectively. Heavy users received a high proportion of antibiotics not recommended as first choice in primary health care. In conclusion, heavy antibiotic users consisted mainly of children and old adults. Inappropriate overuse of antibiotics (high quantity, high frequency, and inappropriate antibiotic choice) leads to a substantial risk of the emergence and spread of resistant bacteria, and interventions to reduce overuse of antibiotics should therefore primarily be targeted children and elderly people.

Es pertinente investigar las relaciones entre médicos e industria farmacéutica

Resumen Fundamento y objetivo Analizar la opinion de los medicos sobre la pertinencia de investigar las relaciones medico-industria farmaceutica, y explorar la utilidad de la encuesta realizada por correo electronico. Material y metodos Encuesta via correo electronico a 373 medicos autores de articulos en revistas medicas espanolas en 2007. El estudio consta de 5 preguntas adaptadas de una encuesta realizada en EE.UU. con el mismo objetivo. Las variables de la encuesta son: tipo de ayudas que los medicos habian recibido de la industria en el ultimo ano, el valor en euros de dichas ayudas, y cuantas visitas recibieron de representantes de la industria. Resultados La tasa de respuesta fue del 28,2%. El 90,5% de los medicos considero pertinente el estudio. El 3,2% rechazo participar por desacuerdo con la metodologia. El 92,8% afirmo haber recibido algo de la industria en el ultimo ano (el 62% inscripcion a congresos o viajes, el 60% material de formacion continuada). Los medicos estimaron en valor medio de lo recibido en 900 € (60-12.000 €). Con la cautela debidas a la tasa de respuesta y la muestra de conveniencia, aparecen algunas diferencias por sexo; las mujeres responden que reciben mas muestras gratuitas, y los varones mas honorarios por trabajo o por incluir pacientes en ensayos. Tambien hay diferencias no significativas por ambito de trabajo: los medicos de hospitales indican que reciben mas ayudas que los de atencion primaria, sobre todo viajes a congresos e invitaciones en restaurantes. El numero de visitas de representantes (5-10 por semana) se asocia con mayor percepcion de ayudas. Conclusiones La gran mayoria de los medicos que responden a la encuesta consideran adecuado investigar las relaciones entre medicos e industria. Los datos sugieren que la relacion entre medicos e industria es intensa, de forma concordante con otros trabajos publicados. La tasa de respuesta es baja, aunque la rapidez y facilidad del estudio son ventajas valorables.

Evolución de los diseños epidemiológicos de la investigación clínica en España (1975-1994)

BACKGROUND: Previous studies have shown a sparing utilization of analytical and experimental designs in Spanish clinical research journals. The study aims are to compare among countries, the use of epidemiologic method in articles published in scientific journals, and to determine the extent to which this research has direct funding. METHODS: Cross-sectional study including all original papers published during 1994 in Medicina Clinica [(Med Clin (Barc)], Revista Clinica Espanola (Rev Clin Esp), The Lancet (Lancet) and New England Journal of Medicine (N Engl J Med). They were classified according to epidemiological design and we verified the financial support mention. RESULTS: 594 papers were included. Epidemiological studies without control group prevailed in Spanish journals. The most common designs were descriptive studies in Med Clin (Barc), with 45.5%, and clinical series in Rev Clin Esp, with 41.7%. The 33.6% of original papers published in Lancet and 28.4% of N England J Med were randomized trials. We found information about financial support in 73.7% of papers published in Lancet, in 77.4 % of N Engl J Med, in 23.1% of Med Clin (Barc) papers and not one in the Rev Clin Esp studies. CONCLUSIONS: In Spanish clinical journals the use of epidemiological methods with control group is limited and direct financial support unusual. Wherefore these studies have a limited applicability.

Improving patient safety by detecting obstetric care-related adverse events: application of a new screening guide

PurposeDetermining the magnitude and importance of patient safety-related incidents and the effectiveness of measures to improve patient safety (PS) are high-priority goals in efforts to improve the quality of obstetric care. The aim of this study was to evaluate the usefulness of the MRF1-OBST screening guide in detecting adverse events in women who received obstetric care.MethodsThis retrospective cohort study included 244 women who were hospitalized for delivery. All medical records were reviewed with the MRF1-OBST screening guide to identify adverse events and incidents. This tool is a modified form of the MRF1 screening guide regularly used in epidemiological studies of PS, to which we added items developed specifically for obstetric care. We calculated the positive predictive value and compared the ability of the MRF1 and MRF1-OBST guides to detect incidents related to PS in Obstetrics.ResultsThe MRF1-OBST guide did not identify any additional complications during hospitalization or incidents related to PS that were not also identified by the MRF1 guide.ConclusionsThe MRF1-OBST guide did not improve the detection of obstetric AE. The modified version of the guide required more work to use as a screening aid than the original MRF1 instrument. Efforts to improve the detection of incidents related to PS in obstetrics require complementary tools to be developed for information analysis.

[Public hospital utilization by the foreign population in Aragon, Spain (2004-2007)].

OBJECTIVES To describe hospitalization rates and hospital morbidity among the foreign population residing in Aragon (Spain) by country of birth, between 2004 and 2007, and to compare these rates with those in the autochthonous population. METHODS A retrospective longitudinal study was carried out of hospital discharges of the foreign population in public hospitals in Aragon. Utilization rates were estimated by sex, age, country of birth and main diagnosis. Poisson regression was used to estimate the utilization rate ratios and their 95% confidence intervals. RESULTS Hospitalization rates were lower in the foreign population (adjusted RR: 0.52; 95% CI: 0.51-0.56), except in women aged between 15 and 24 years (RR: 2.9; 95% CI: 2.8-3.0) and among those born in the Maghreb (RR: 1.8; 95% CI: 1.7; 1.9), sub-Saharan Africa (RR: 2.0; 95% CI: 1.9-2.1) and Asia (RR=1.4; 95% CI: 1.3-1.6). When hospital discharges related to obstetrics and gynecology were excluded, only women born in sub-Saharan Africa continued to have adjusted RR greater than 1. These women had higher hospitalization rates in groups of infectious and parasitic diseases (RR: 2.5) and blood and blood-forming organs (RR: 2.8). CONCLUSIONS In Aragon (Spain), public hospital utilization is lower in foreigners than in the autochthonous population. The diseases treated varied by country of birth. The diseases prevalent in these countries, together with hereditary diseases, can increase hospital utilization rates.

Different approaches to the assessment of adherence and persistence with cardiovascular-disease preventive medications

Abstract Objective: To assess suitability and comparability of the most common methods of treatment adherence and persistence assessment, as applied to the same pharmacy dataset. Methods: Data on drugs prescribed for cardiovascular primary prevention to participants in the Aragon Workers’ Health Study (AWHS) were collected from a regional electronic drug prescription database. Several different approaches were used to measure treatment adherence (with the medication possession ratio [MPR]) and proportion of days covered [PDC]) and persistence in new users by therapeutic subgroup. Defined daily dose (DDD) was used as a proxy of the number of days’ supply, or substituted with surrogate daily dose values. Results: Higher mean adherence values and proportions of adherent patients were obtained using MPR versus PDC, with additional differences depending on the approach used. The proportion of adherent patients was lowest for oral antidiabetics (14.4%–30.6%) and highest for antihypertensives (70.2%–82.1%). The use of surrogate daily dose values increased adherence for antidiabetics and statins and decreased adherence for antihypertensives. After a 1 year follow-up, treatment persistence was observed for 21.1%, 58.7%, and 29.5% of antidiabetic, antihypertensive and statin users, respectively. Conclusions: Our findings indicate that use of multiple measures of treatment adherence and persistence provides a more complete overview of medication use patterns, and certain limitations associated with DDD for some drug groups can be overcome with replacement by surrogate doses. The PDC indicator seems to provide a more accurate reflection of patient behavior and treatment continuity than the MPR. Any comparison of adherence/persistence should always consider the method used, variables analyzed, and corresponding data collection process.

Poor congruence with guidelines in the use of antibiotics for acute bronchitis: a descriptive study based on electronic health records

BACKGROUND Although acute bronchitis is frequently viral in nature, antibiotics are usually inappropriately prescribed in Primary Care to treat this condition, with serious public health consequences. OBJECTIVE To determine the prevalence and predictors of appropriate management of antibiotic use in acute bronchitis processes diagnosed in outpatients in the Spanish region of Aragón. METHODS Four different electronic health databases provided demographic and clinical information pertaining to patients diagnosed with acute bronchitis in Primary Care in Aragón during 2011, as well as data for corresponding antibiotic prescriptions dispensed at pharmacies. We evaluated adherence to recommendations for antibiotic use in acute bronchitis episodes in adults collected in both international and national guidelines. Finally, regression analyses were used to identify factors associated with appropriate antibiotic management. RESULTS A total of 54701 episodes of acute bronchitis were registered, 9.5% of which corresponded to patients with an underlying chronic respiratory disease. In adults, antibiotics were prescribed in 64.9% of episodes, 17.9% of which involved prescription of a first-choice agent. Overall, 48.5% of episodes were appropriately managed according to guidelines. The likelihood of appropriate treatment was higher for female patients, and lower for patients who were older, presented chronic co-morbidities or were using corticoids. CONCLUSIONS We observed poor levels of adherence to recommendations for antibiotic prescribing in adults with acute bronchitis, in terms of both the decision to prescribe and the choice of antibiotic agent. Older acute bronchitis patients and those with co-morbidities were at greater risk of being inappropriately treated.

Use of Non-Steroidal Anti-Inflammatory Drugs and Associated Gastroprotection in a Cohort of Workers

Background: This study describes the prevalence of non-steroidal anti-inflammatory drug (NSAID) use, and analyses prescribing patterns of NSAIDs and associated gastroprotection. Methods: The study population consisted of 5650 workers at the General Motors automobile assembly plant in Zaragoza, Spain. NSAID prescription data for 2014 were obtained from the prescription database of Aragon (Spain). NSAID consumption was determined based on the number of defined daily doses purchased per year. Heavy NSAIDs users were identified using Lorenz curves. Results: NSAID use in the cohort was high (40.7% of workers, 95% CI 39.4–41.9). The prescription of proton pump inhibitors increased with age. Gastrointestinal protection was lacking in some participants who were being treated with drugs associated with a high risk of gastrointestinal bleeding. Heavy NSAID users (defined as those above the 95th percentile of consumption), accounted for 26% of total DDDs, and consumed a greater proportion of coxibs than non-heavy users. Conclusions: The rate of NSAID consumption in the cohort was high. To reduce the risk of gastrointestinal complications, monitoring and adequate gastroprotection are essential in patients who are prescribed NSAIDs for long periods of time or who are treated concomitantly with drugs that increase the risk of gastrointestinal bleeding.

Response to 'Antibiotic use and resistance': Children and elderly people in Spain are heavy users of antibiotics.

Dear Editor, Firstly, we thank the author for his interest in our study and his positive and constructive comments to our paper. As mentioned, antibiotic consumption in heavy users, especially in children, is really striking. Certainly, our results revealed an antibiotic use in this age group higher than published in previous studies, and in line with different reports repeatedly presenting the high antibiotic consumption existing in Spain compared with other European countries [1]. Determinants involved in antibiotic prescribing are numerous and varied. It is true that therapeutic failures lead to repeated courses of antibiotic treatment. However, it is probably the only reason. Frequent and high consumption of antibiotics, as observed in heavy users, could also be due to factors related to the GP, patient and parents’ expectations or the influence exerted by the pharmaceutical industry [2]. We would like to indicate that vitamin D supplementation for RTI prevention in healthy populations, as proposed by the author to reduce use of antibiotics, has not been supported by sufficient scientific evidence [3]. But we agree that development and implementation of measures aimed at reducing and improving antibiotic use are needed. These actions should be multidimensional and implicate all the involved, both prescribers and users of antibiotics. Using methodologies as we propose and deepen the knowledge about practices at highest risk of contributing to antimicrobial resistance may add to reduce this global threat.