[Ethics of care: Assessment of the ethical issues in the protocols or consensuses on mechanical restraint in force in Spain]

INTRODUCTION

Mechanical restraints are widely used in health care practice, despite the numerous ethical conflicts they raise. The aim of this study is to evaluate the ethical considerations contemplated in the current protocols on mechanical restraint in Spain.

METHOD

Systematic review in PubMed, WOS and Scopus, Google and Google Scholar. An ad hoc list of 30 items was used to evaluate the ethical content of the protocols. The quality of guidelines was assessed with AGREE II.

RESULTS

The need for informed consent (IC) is reflected in 72% of the documents, the IC model sheet is included in only 41% of them, the rest of the analyzed characteristics on IC are fulfilled in percentages between 6% (the document includes the need to reevaluate the indication for IC) and 31% (the document contemplates to whom it should be requested). More than 20 ethical contents are reflected in 31% of them and less than 10 in 19% of the guidelines. The quality of the guides, according to AGREE II, ranged from 27 to 116 points (maximum possible 161), with a mean score of 68.7. Only 9% of the documents were classified as high quality. Finally, the correlation between ethical content and quality measured with AGREE II was 0.75.

CONCLUSIONS

The variability of ethical contents in guidelines on mechanical restraints is very high. The ethical requirements to be included in protocols, consensus or Clinical Practice Guidelines should be defined.

Impact of mediterranean diet promotion on environmental sustainability: a longitudinal analysis

OBJECTIVE

This article aims to estimate the differences in environmental impact (greenhouse gas [GHG] emissions, land use, energy used, acidification and potential eutrophication) after one year of promoting a Mediterranean diet (MD).

METHODS

Baseline and 1-year follow-up data from 5800 participants in the PREDIMED-Plus study were used. Each participant's food intake was estimated using validated semi-quantitative food frequency questionnaires, and the adherence to MD using the Dietary Score. The influence of diet on environmental impact was assessed through the EAT-Lancet Commission tables. The influence of diet on environmental impact was assessed through the EAT-Lancet Commission tables. The association between MD adherence and its environmental impact was calculated using adjusted multivariate linear regression models.

RESULTS

After one year of intervention, the kcal/day consumed was significantly reduced (-125,1 kcal/day), adherence to a MD pattern was improved (+0,9) and the environmental impact due to the diet was significantly reduced (GHG: -361 g/CO2-eq; Acidification:-11,5 g SO2-eq; Eutrophication:-4,7 g PO4-eq; Energy use:-842,7 kJ; and Land use:-2,2 m2). Higher adherence to MD (high vs. low) was significantly associated with lower environmental impact both at baseline and one year follow-up. Meat products had the greatest environmental impact in all the factors analysed, both at baseline and at one-year follow-up, in spite of the reduction observed in their consumption.

CONCLUSIONS

A program promoting a MD, after one year of intervention, significantly reduced the environmental impact in all the factors analysed. Meat products had the greatest environmental impact in all the dimensions analysed.

Quality indicators for the diagnosis and treatment of breast cancer integrated assistance: A critical appraisal

INTRODUCTION

Quality indicators (QIs) are essential for adequate control of the health care management process, recognizing areas of improvement and providing solutions. We aimed to evaluate the Integrated Breast Cancer (BC) Care Process QIs.

METHODS

We studied 487 consecutive BC cases diagnosed from November 1st, 2013, to November 30th, 2019, in a Spanish healthcare area, and we estimated the associated QIs.

RESULTS

Four indicators did not meet the standards and were analysed based on related sociodemographic and clinical variables. The surgical delay after a multidisciplinary team discussion (mean 64%, IQR 59.6-68.5) was lower in elder people (p=0.027), and early histological grades (p=0.019) and stages (p=0.008). The adjuvant treatment delay (mean 55.7%, IQR 51.1-60.3) was lower in advance stages (p=0.002) and when there was no reoperation (p=0.001). The surgical delay after inclusion (mean 83.2%, IQR 79.3-87.2) was lower in early histological grades (p=0.048). The immediate reconstruction (mean 42.3%, IQR 34.0-50.5) reached 72.3% in young women compared to 11.8% in older than 70 years (p=0.001) and it was higher in early stages (45.3% vs 36.2%; p=0.049).

CONCLUSION

The study of QIs evaluated their compliance and analysed the variables influencing them to propose improvement measures. Not all the indicators were equally valuable. Some depended on the available resources, and others on the mix of patients or complementary treatments. It would be essential to identify the specific target populations to estimate the indicators or provide standards stratified by the related variables.

Design of a safety round model for intensive care units

INTRODUCTION

Safety Rounds (SR) are an operational tool that allow knowing adherence to good practices, help identify risks and incidents in patient safety (PS), allowing improvement actions to be implemented. The objective of this work was the design of a procedure to perform SR in an Intensive Care Unit (ICU).

METHODS

Preparation of a checklist for the development of SR in the ICU through the nominal group technique, with the participation of managers, middle managers and professionals from different disciplines and categories. In the first place, a group of experts agreed, based on the recommendations on good practices in PS, the definition of items, their coding, the criteria for compliance and the impact of non-compliance. Subsequently, its viability was determined through a cross-sectional study through the piloting of two SRs to adjust the items in real clinical practice conditions.

RESULTS

A specific SR model for ICUs has been obtained through a checklist. The group of experts prepared a first list made up of 39 items of 6 essential dimensions and defined the method of implementation. Mean time to complete the two SRs was 85 min, including the briefing and subsequent debriefing. After the validation pilot, the dimensions were reduced to 5, 3 items were deleted, 2 items were transferred to another dimension and 3 items related to nosocomial infections and informed consent were modified. In addition, the data sources, the compliance criteria and their relative weight were redefined. The final list was considered useful and relevant to improve practice.

CONCLUSIONS

Through a consensus methodology, a checklist has been built to be used in the RS of an ICU. This model can serve as a basis for its use in healthcare services with similar characteristics.

Evidence-based medicine needs patient and public involvement to remain relevant: A proposal for a new curriculum

INTRODUCTION

Public partnerships, a route to sharing expertise, networks and resources anchored in the United Nations Sustainable Development Goals, has been championed by multiple stakeholders.

OBJECTIVE

To propose a new evidence-based medicine (EBM) curriculum for harnessing patient and public expertise to ensure that EBM teaching and learning can become more relevant and impactful.

METHODS

A curriculum development group comprising of EBM teachers, patient and public involvement representatives, clinicians, clinical epidemiologists, public health experts and educationalists, with experience of delivering and evaluating face-to-face and online EBM courses across many countries and continents, prepared a new EBM course.

RESULTS

A student-centred, problem-based and clinically integrated course for teaching and learning EBM was developed. In the spirit of shared decision-making, practitioners can learn to support patients, articulate their perspectives, recognise the need for their contribution and ensure community involvement when generating and applying evidence. With end users in mind, the application of research findings, delivery of care and EBM effectiveness in the workplace would carry increased priority.

CONCLUSIONS

Embracing patients as EBM collaborators can help deliver cognitive diversity and inspire different ways of thinking and working. Adopting the proposed approach in EBM education lays the foundations for a joint practitioner-patient partnership to ask, acquire, appraise and apply EBM in a more holistic context which will strengthen the EBM proposition.

Intensive Weight-Loss Lifestyle Intervention Using Mediterranean Diet and COVID-19 Risk in Older Adults: Secondary Analysis of PREDIMED-Plus Trial

OBJECTIVES

We tested the effects of a weight-loss intervention encouraging energy-reduced MedDiet and physical activity (PA) in comparison to ad libitum MedDiet on COVID-19 incidence in older adults.

DESIGN

Secondary analysis of PREDIMED-Plus, a prospective, ongoing, multicentre randomized controlled trial.

SETTING

Community-dwelling, free-living participants in PREDIMED-Plus trial.

PARTICIPANTS

6,874 Spanish older adults (55-75 years, 49% women) with overweight/obesity and metabolic syndrome.

INTERVENTION

Participants were randomised to Intervention (IG) or Control (CG) Group. IG received intensive behavioural intervention for weight loss with an energy-reduced MedDiet intervention and PA promotion. CG was encouraged to consume ad libitum MedDiet without PA recommendations.

MEASUREMENTS

COVID-19 was ascertained by an independent Event Committee until December 31, 2021. COX regression models compared the effect of PREDIMED-Plus interventions on COVID-19 risk.

RESULTS

Overall, 653 COVID-19 incident cases were documented (IG:317; CG:336) over a median (IQR) follow-up of 5.8 (1.3) years (inclusive of 4.0 (1.2) years before community transmission of COVID-19) in both groups. A significantly lowered risk of COVID-19 incidence was not evident in IG, compared to CG (fully-adjusted HR (95% CI): 0.96 (0.81,1.12)).

CONCLUSIONS

There was no evidence to show that an intensive weight-loss intervention encouraging energy-reduced MedDiet and PA significantly lowered COVID-19 risk in older adults with overweight/obesity and metabolic syndrome in comparison to ad libitum MedDiet. Recommendations to improve adherence to MedDiet provided with or without lifestyle modification suggestions for weight loss may have similar effects in protecting against COVID-19 risk in older adults with high cardiovascular risks.

Fermented dairy products, diet quality, and cardio-metabolic profile of a Mediterranean cohort at high cardiovascular risk

BACKGROUND AND AIMS

Fermented dairy products have been associated with a better diet quality and cardio-metabolic profile. However, in Mediterranean populations, these associations have not been well characterized. The aim of this study was to assess the diet quality and the associations between the consumption of total fermented dairy products and their subtypes and the prevalence of Metabolic Syndrome (MetS) components in a Mediterranean population at high cardiovascular risk.

METHODS AND RESULTS

Baseline cross-sectional analyses were conducted on 6,572 men and women (mean age: 65 years) with overweight or obesity and MetS recruited into the PREDIMED-Plus cohort. A 143-item Food Frequency Questionnaire (FFQ) was used, and anthropometrical, biochemical, and blood pressure measurements were recorded. Multivariate-adjusted Cox regressions were fitted to analyze the association between quartiles of consumption of fermented dairy products and their subtypes and MetS components to estimate the relative risk (RR) and 95% confidence intervals (95% CIs). Participants who were high consumers of fermented dairy products reported a higher consumption of fruit, vegetables, fish, nuts, and whole bread and a lower consumption of white bread, alcohol, and cookies. Participants in the higher quartile showed a lower prevalence of the low HDL-cholesterol component of the MetS (RR=0.88; 95% CI: 0.78-0.98) than those in the lowest quartile of cheese consumption. Cheese consumption was inversely associated with the prevalence of hypertriglyceridemia. Total fermented dairy products, yogurt, and its types were not associated with any of the MetS components.

CONCLUSIONS

Compared to nonconsumers, participants consuming fermented dairy products reported a better diet quality and, particularly, cheese consumers presented a lower prevalence of hypertriglyceridemia and low HDL-cholesterol plasma levels, which are MetS components.

Factors associated with insomnia in pregnancy: A prospective Cohort Study

OBJECTIVE

To quantify insomnia and their components in a longitudinal cohort of pregnant women and factors associated with insomnia.

STUDY DESIGN

A prospective cohort of 486 healthy singleton pregnancies assembled before the 14th gestational week (February 2013 to March 2016). Insomnia data were collected pre-gestationally, in each trimester and six months post-partum, analysing five different moments. Multiple logistic regression analysis was performed to generate adjusted Odds Ratios (aOR) with 95% confidence intervals (CI) of determinants of insomnia in each trimester, defined using Athens Insomnia Scale (AIS) as score ≥8.

RESULTS

Insomnia prevalence was 6.1% (3.9-8.9) pre-gestational, 44.2% (39.3-49.6) in first trimester (T1), 46.3% (41.9-51.3) in second (T2) and 63.7% (57.7-67.8) in third trimester (T3). Post-gestational insomnia was 33.2% (28.2-37.9) (p < 0.001 pre-gestational vs T1, T2 vs T3 and T3 vs after pregnancy). There was worsening mean AIS score, from: 2.34 before pregnancy to 9.87 in T3 because the deterioration of nighttime sleep, in absolute terms, but daytime impact was higher in T1. Previous trimester insomnia was associated with insomnia in T2 (aOR = 4.21, 95% CI 2.78-6.37) and T3 (aOR = 4.43, 95% CI 2.77-7.08). Pre-gestational insomnia was determinant of insomnia in T1 (aOR 12.50, 95% CI 3.58-43.60) and obesity was associated with insomnia in T3 (aOR = 2.30, 95% CI 0.99-5.32). On the contrary, moderate physical activity reduced the odds of insomnia in T3 (aOR 0.65, 95% CI 0.40-1.03).

CONCLUSIONS

Insomnia prevalence was high from the beginning of pregnancy, associated with pre-gestational insomnia. In late pregnancy, two out of three pregnant women suffering insomnia. Insomnia prevention should be targeted particularly to those with high body mass index and pre-gestational insomnia.

Partner smoking influences whether mothers quit smoking during pregnancy: a prospective cohort study

OBJECTIVE

To analyse the prevalence and intensity of smoking among pregnant women and their partners, and factors associated with quitting smoking among pregnant women.

DESIGN

A prospective cohort study, starting in 2013.

SETTING

Andalusia, the south of Spain.

SAMPLE

A cohort of 486 healthy pregnant women followed-up on three occasions during pregnancy.

METHODS

Estimation of the proportions of women and partners who quit smoking at each trimester.

MAIN OUTCOME MEASURES

To determine factors associated in a multivariable model, considering sociodemographic, obstetric, anthropometric, lifestyle variables, and the smoking habits of their partners.

RESULTS

A high proportion of women quit smoking during pregnancy (61.08%; 95% confidence interval, 95% CI 53.61-68.55%). The smoking rate amongst mothers decreased from 36.06% (n = 167) before pregnancy to 14.08% (n = 65), 12.39% (n = 54), and 11.92% (n = 51) during the three pregnancy trimesters (P < 0.001), and consumption decreased from 8.71 cigarettes/day in the first trimester to 5.51 cigarettes/day in the second trimester (P < 0.001) and 5.96 cigarettes/day in third trimester (P = 0.0002 first versus third trimester). There was only a minimal decrease in the frequency of smoking among the partners, however: 38.44% (n = 178) before pregnancy, and 36.07% (n = 167), 32.72% (n = 143), and 31.85% (n = 136) during the three trimesters of pregnancy. The consumption of cigarettes did not decrease among partners: 11.75, 11.67, and 12.09 cigarettes/day (P = 0.4299 first versus second trimester; P = 0.654 first versus third trimester). Women whose partner smoked were less likely to quit (adjusted odds ratio, aOR 0.26; 95% CI 0.12-0.55).

CONCLUSIONS

About one in ten pregnant women smoked and one in four was a passive smoker. Strategies to reduce tobacco exposure in pregnancy should include a focus on partner smoking.

TWEETABLE ABSTRACT

Pregnant women quit smoking cigarettes in pregnancy. What about their partners?

[Quality of the anesthesiologist written record during the transfer of postoperative patients: Influence of implementing a structured communication tool]

OBJECTIVE

The lack of communication is a major cause of health care errors, especially during patient transfer between practitioners and/or healthcare units, when standardization of communication is a recommended practice. In our study we wanted to assess whether the application of the structured communication SBAR tool could influence the quality of the information written on the progress sheet by the anesthesiologist involved in the transfer of the patient after surgery.

MATERIAL AND METHODS

This is an observational, retrospective, randomized, quality review of the written record made by the anesthesiologist during the transfer of patients from the surgical area to the postoperative recovery unit, by applying a validated list. We evaluated three observation periods: a control period of two months in 2011 (preSBAR) and a second period of two months in 2012 (postSBAR); in the latter two groups of patients were transferred (postSBAR +) or without SBAR (postSBAR-).

RESULTS

The strength of agreement between raters obtained an intraclass correlation coefficient of 0.8459 (p <0.001). There were significant differences in the study group, with highest average score in the group with SBAR (postSBAR + group: mean ± SD 7.56 ± 1.20 versus postSBAR-group: 5.41 ± 2.98, p <0.001) and depending on the anesthesiologist responsible for the intervention participated in the study (mean ± SD: 7.00 ± 1.99, compared to 4.81 ± 3.24 in the non-participants, p <0.001).

CONCLUSIONS

There was an improvement in the quality of written records made in 2012 during the implementation of the SBAR, without the actual application of this instrument appearing to influence it. The anesthesiologists that were involved in new forms of patient safety were also those who made written records of highest quality.

Evolution of HIV incubation times in AIDS patients

Since introduction of highly active antiretroviral therapy (HAART), the incidence of AIDS has gradually declined, although the incidence of HIV infection is largely unknown. We have studied a sample with 10,571 patients whose data were recorded by Spain's public health system, in the Andalusian Register of Cases of AIDS. The diagnoses correspond to the period January 1981 to June 2008. For this period, AIDS incubation times were analyzed by means of the survival and risk functions, using R survival and DTDA libraries. We have studied the evolution of incubation mean times according to specific variables from database. The obtained results show that the mean times of viral incubation presented a growing trend that was greater among women when the study was limited to heterosexual transmission. Stratifying by category of transmission, the longest incubation period was seen for intravenous drug users (IDU). Both gender and IDU transmission were associated with significantly greater survival without AIDS. In contrast, heterosexual transmission or pneumonia diagnosis were associated with lower survival without AIDS.

Drug-related problems in older people after hospital discharge and interventions to reduce them

Drug-related problems in older people during care transitions have become a major public health problem since they threaten patient safety. The objective of our paper is to investigate the extent and frequency of drug-related problems (discontinuity, adherence, errors, interactions and adverse events) after hospital discharge and the efficacy of interventions intended to reduce them. We included 20 studies in the review. All of them underlined the high frequency and complexity of drug-related problems in older people after hospital discharge. Interventions proposed to improve care transitions led to diverse and sometimes contradictory results, but the findings suggested that combining hospital discharge measures with home follow-up strategies is of value. We conclude that it is not possible to estimate the frequency of drug-related problem through a review of selected articles or to evaluate the efficacy of the proposed interventions. More research is needed in this field to reduce uncertainty and generate evidence-based recommendations for physicians.

Driver dependent factors and the risk of causing a collision for two wheeled motor vehicles

OBJECTIVE

To assess the effect of driver dependent factors on the risk of causing a collision for two wheeled motor vehicles (TWMVs).

DESIGN

Case control study.

SETTING

Spain, from 1993 to 2002.

SUBJECTS

All drivers of TWMVs involved in the 181 551 collisions between two vehicles recorded in the Spanish registry which did not involve pedestrians, and in which at least one of the vehicles was a TWMV and only one driver had committed a driving infraction. The infractor and non-infractor drivers constituted the case and control groups, respectively.

MAIN OUTCOME MEASURES

Logistic regression analyses were used to obtain crude and adjusted odds ratio estimates for each of the driver related factors recorded in the registry (age, sex, nationality, psychophysical factors, and speeding infractions, among others).

RESULTS

Inappropriate speed was the variable with the greatest influence on the risk of causing a collision, followed by excessive speed and driving under the influence of alcohol. Younger and older drivers, foreign drivers, and driving without a valid license were also associated with a higher risk of causing a collision. In contrast, helmet use, female sex, and longer time in possession of a driving license were associated with a lower risk.

CONCLUSIONS

Although the main driver dependent factors related to the risk of causing a collision for a TWMV were similar to those documented for four wheeled vehicles, several differences in the pattern of associations support the need to study moped and motorcycle crashes separately from crashes involving other types of vehicles.

Risk compensation theory and voluntary helmet use by cyclists in Spain

OBJECTIVE

To obtain empirical data that might support or refute the existence of a risk compensation mechanism in connection with voluntary helmet use by Spanish cyclists.

DESIGN

A retrospective case series.

SETTING

Spain, from 1990 to 1999.

SUBJECTS

All 22 814 cyclists involved in traffic crashes with victims, recorded in the Spanish Register of Traffic Crashes with Victims, for whom information regarding helmet use was available.

MAIN OUTCOME MEASURES

Crude and adjusted odds ratios for the relation between committing a traffic violation and using a helmet.

RESULTS

Fifty four percent of the cyclists committed a traffic violation other than a speeding infraction. Committing a traffic violation was associated with a lower frequency of helmet use (adjusted odds ratio (aOR) 0.63, 95% confidence interval (CI) 0.58 to 0.69). Cycling at excessive or dangerous speed, a violation observed in 4.5% of the sample, was not significantly associated with helmet use either alone (aOR 0.95, 95% CI 0.56 to 1.61) or in combination with any other violation (aOR 0.97, 95% CI 0.79 to 1.20).

CONCLUSIONS

The results suggest that the subgroup of cyclists with a higher risk of suffering a traffic crash are also those in which the health consequences of the crash will probably be higher. Although the findings do not support the existence of a strong risk compensation mechanism among helmeted cyclists, this possibility cannot be ruled out.

Proportion of hospital deaths potentially attributable to nosocomial infection

OBJECTIVE

To determine the fraction of hospital deaths potentially associated with nosocomial infection (NI).

DESIGN

A matched (1:1) case-control study.

SETTING

An 800-bed, tertiary-care, teaching hospital.

PATIENTS

All patients older than 14 years who were admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths that occurred in the hospital comprised the case group. For each case, a control patient was matched for primary admission diagnosis and admission date.

OUTCOME MEASURES

The proportion of hospital deaths potentially associated with NI was estimated from the population attributable risk (PAR) adjusted for age, gender, service, severity of illness, length of stay, and quality of the medical record.

RESULTS

For stays longer than 48 hours, the PAR for all NIs was estimated to be 21.3% (95% confidence interval [CI95], 16.8%-30.5%). The greatest proportion of deaths potentially associated with NIs was observed in patients with only one infection (PAR, 15.0%; CI95, 10.9%-22.6%) and bacteremia or sepsis (PAR, 7.7%; CI95, 4.6%-11.6%).

CONCLUSIONS

NIs are associated with a large proportion of intrahospital deaths. This information may help clinicians and healthcare managers to assess the impact of programs for the prevention and control of NIs on intrahospital death.

Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes

The aim of this prospective cohort study was to identify the risk factors involved in falls in 190 elderly residents of two geriatric centres in Granada (Andalusia, Spain). Because different types of falls may be associated with different factors, falls were classified according to the precipitating cause, either extrinsic or intrinsic. The incidence density and the ratios for crude and adjusted density were calculated. Cox proportional risk analysis was used to calculate adjusted incidence density ratios. Of the 121 falls identified, 63 (52.1%) had a extrinsic precipitating cause, 43 (35.5%) had an intrinsic precipitating cause, and no precipitating cause was determined in 15 falls. The rate of falls with an extrinsic precipitating cause was 0.39 per person per year, while falls with an intrinsic precipitating cause showed a frequency of 0.27 per person per year. For falls with an extrinsic precipitating cause, the most significant risk factors were: age, diabetes mellitus, a history of falling, and treatment with neuroleptics or oral bronchodilators. The number of illnesses acted as a protective factor. For falls with an intrinsic precipitating cause, the independent risk factors were: age, diabetes, dementia, alterations of gait and balance, previous falls, and treatment with digitalins, neuroleptics or antidepressants. These results suggest that the susceptibility to a fall with an intrinsic precipitating cause is easier to identify and has a greater potential for being controlled.

Predictive value of a screen for gestational diabetes mellitus: influence of associated risk factors

BACKGROUND

There is a need for solid evidence of the relative advantages of universal vs. selective screening for gestational diabetes mellitus. Our study of a broad obstetric population determines the positive predictive value of the 50-g oral glucose challenge test for screening in the presence and absence of classical gestational diabetes risk factors.

METHODS

A retrospective cohort study was carried out with a total of 2,574 pregnant women. Clinical information was obtained from hospital records and each patient's medical history, and gestational diabetes risk factors were quantified for each pregnant woman. The positive predictive value of a screen was determined with respect to the number of risk factors.

RESULTS

Age 30 or over, family history of diabetes, obesity (BMI > or =27) and previous fetal macrosomia were established as the most frequent risk factors. Just over half (54.2%) of our population presented one or more risk factors. Screening covered 75% of the population, and was positive in 15% of the cases. Diagnosis was confirmed in 64 cases, 57 of them at risk, and seven with no risk factors. We obtained an overall positive predictive value of 21.8% (CI 17.3-27.0). This figure increases with the number of risk factors, from 12% for the women with no risk factors, to 40% for those presenting three or more risk factors.

CONCLUSIONS

A selective screening program that takes into account the clinical background and characteristics of each pregnant woman allows a high yield of true positives while reducing the possible undesirable effects associated with false positives.

Changes in coronary risk profiles in employees after three years of multifactorial intervention

This study was performed with the objective of assessing the effectiveness of the intervention at the work-site on lifestyle-related cardiovascular risk factors in four work-sites in Granada, Spain. Individualized face-to-face counseling was given to 1555 employees (1193 men and 362 women). After 3 years, a blinded assessment of the adequacy of the interventions was carried out. When changes in all employees were analysed together, ('per protocol' analysis) a non-significant reduction (-0.02%; 95% CI: -0.06 to +0.03%) in mean coronary risk was observed. We also distinguished between adequate and inadequate implementation of the intervention protocol. Observed changes in mean coronary risk were compared between both groups (adequate/inadequate implementation). Changes in mean coronary risk were beneficial only in the group that achieved an adequate level of intervention, with an observed significant mean reduction of risk of -0.12% (95% CI: -0.07 to -0.17) whereas changes were in the opposite direction in the other group with a mean change of +0.08% (95% CI: + 0.01 to + 0.16%). Work-site programs of health behaviour modification when appropriately implemented can attain although small, significant changes in cardiovascular risk profiles and thus be especially effective in achieving the population strategy of preventive cardiology.

Risk factors for low birth weight: results from a case-control study in southern Spain

The main objective of this study is to examine the effect of several variables, including altitude of maternal residence, on delivering a low birth weight (LBW) newborn. A case-control study was done. Two hundred forty cases (single newborn weighing less than 2,500 g) and 374 controls (single newborn weighing more than 2,499 g) were included. Information was gathered from the clinical chart of delivering women, through a personal interview and the Spanish Census Bureau (for altitude). Predictors of LBW were assessed through stepwise logistic regression analysis. Several well-known LBW risk factors were identified: hypertension, weight gain during pregnancy, body size (mainly maternal prepregnancy weight), low social class, primiparity, and several conditions (spontaneous delivery, abruptio placentae). Altitude was an independent predictor of LBW at term (more than 37 weeks of gestational age) but not for preterm LBW. Nevertheless, a relationship between altitude and birth weight was not found in controls, although a moderate decreasing gradient with altitude was observed. The limitations of these findings are discussed.

Changes in serum cholesterol in employees after three years of multifactorial intervention

BACKGROUND

To assess long-term effectiveness of a multifactorial intervention at the work-site on serum cholesterol levels.

METHODS

Individualized face-to-face counseling was given to 1,555 employees (76.7% male; mean age = 42.3 years) by occupational physicians at four work-sites. After 3 years, a blinded assessment of the adequacy of the intervention was done. Implementation of the intended intervention by physicians was assessed as adequate in two work-sites (927 employees) and inadequate in the other two (628 employees). Observed changes in serum cholesterol were analyzed in the followed-up individuals. Follow-up rates at each work-site were 78.6% and 44.5% for the adequate intervention, and 85.5% and 60.4% for the inadequate intervention. Changes in serum cholesterol were controlled for potential confounding factors (pre-test levels of risk factors, age, sex, body mass index, educational level, marital status, physical activity and alcohol consumption) by multiple linear regression procedures.

RESULTS

When the intervention was adequately performed, serum cholesterol was significantly lowered with a mean reduction of 14.3 mg/dl (95% C.I.: 11.0 to 17.6) in those employees with baseline levels > or = 200 mg/dl.

CONCLUSIONS

Adequacy of implementation of work-site programs determines their long-term effectiveness in reducing mean serum cholesterol levels.

Proportion of hospital deaths associated with adverse events

OBJECTIVES

To determine the fraction of hospital deaths potentially associated with the occurrence of adverse events (AE).

DESIGN

A paired (1:1) case-control study.

SETTING

An 800-bed, teaching tertiary care hospital.

PATIENTS

All patients older than 14 years admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths (death rate of 3.74%) that occurred in the hospital comprised the case group. For each case, a control patient was matched for both primary diagnosis on admission and admission date.

MEASUREMENTS

The proportion of hospital deaths associated with adverse events (defined as problems of any nature and seriousness faced by the patient during hospitalization, and potentially traceable to clinical or administrative management) was estimated from attributable risks adjusted for age, sex, service, severity of illness, length of stay, and quality of the medical record.

RESULTS

For stays longer than 48 hours, the adjusted attributable risk for all adverse events was estimated to be 0.51 (0.40-0.61). When the data were stratified according to the category of adverse event, the attributable risks remained significant except for administrative problems. The greatest proportion of deaths associated with adverse events was observed for surgical adverse events [0.56 (0.38-0.71)] and nosocomial infection [0.22 (0.14-0.28)].

CONCLUSIONS

A significant proportion of intrahospital deaths were associated with AE. These results suggest the need to consider programs focused on the prevention of mortality from AE.

Unplanned pregnancy as a major determinant in inadequate use of prenatal care

BACKGROUND

Previous reports have stressed the importance of social class and education in prenatal care use. Unplanned pregnancy as a determinant of prenatal care use has been insufficiently studied. The objective of this report was to assess whether unplanned pregnancy is an independent predictor of inadequate use of prenatal care.

METHODS

A 5% sample of women delivering at a hospital (409 women in the study population) was selected. Data on pregnancy were obtained by personal interview and from clinical charts. Prenatal care was considered inadequate according to the Kessner index. Relative risk (RR) and 95% confidence intervals (CI) were estimated. Stepwise logistic regression analysis was applied to select the independent predictors of inadequate prenatal care use.

RESULTS

Prenatal care use was inadequate among 16.4% of the women. Pregnancy was unplanned among 42.8% of the women. Twenty-two percent of women with an unplanned pregnancy used prenatal care inadequately, while 12% of those with planned pregnancies used prenatal care inadequately (RR = 1.9, 95% CI = 1.2-2.9). In crude analysis, inadequate prenatal care use was also related to lower social class, lower education level, no employment outside the home, and multiparity. After adjustment was made for other predictors that were included in a stepwise logistic regression model (maternal education, social class, maternal occupation, parity, and pregnancy-induced hypertension), unplanned pregnancy was a significant risk factor for inadequate use of prenatal care (odds ratio = 2.1, 95% CI = 1.2-3.7) and it was an independent predictor for a delayed first prenatal care visit and for a reduced number of visits.

CONCLUSIONS

The results suggest that unplanned pregnancy is a major determinant for inadequate use of prenatal care.

Comparison of two procedures to estimate the hospital stay attributable to nosocomial infection: matched cohort study versus analysis of covariance of the total unmatched cohort

We compare the results of a matched cohort study with those yielded by analysis of covariance (ANCOVA) in the cohort where the matched study was nested to assess whether the matching design underestimates (as it has been assumed) the extra length of hospitalization due to nosocomial infection. A total of 218 patients developed hospital infection in a cohort of 1483 general surgery patients; 161 were successfully matched 1:1 for surgical procedure, ASA score, age (+/-10 years), emergency-scheduled surgery, preoperative stay, and, whenever possible, number of diagnoses and sex. Unmatched infected patients (57, 23.1%) were different from matched ones. There were no differences for the variables between matched infected patients and their pairs. The matched cohort study overestimates the extra LOH due to hospital infection. The use of ANCOVA in the total cohort obviates the selection bias of the matched cohort design.

[Surveillance of hospital infections: validity of a selective system based on risk markers]

BACKGROUND

In order to achieve simultaneously a higher quality of hospital care and cost-containment, an objective assessment of alternative systems for surveillance of hospital infections is needed in our country. This assessment will allow to make a rational choice of the system to be used at each hospital.

METHODS

719 patients admitted to a Vascular Surgery ward were studied. Sensitivity, specificity, and predictive values for a selective system of surveillance of nosocomial infection (NI) were assessed. This selective system attempted to contain costs by means of limiting the revision of records to those patients who presented fever, prescription of antibiotics after admission or who required laboratory cultures. In this selective method charts revision was retrospectively performed by nurses.

RESULTS

A low sensitivity (50.9%) and acceptable values for specificity and predictive values were found.

CONCLUSIONS

Although this selective method requires only 20% of the reference method's time, its association with an important reduction in sensitivity precludes its systematic use and confines it eventually to low risk wards.

A comparison of two indices of adequacy of prenatal care utilization

In a case-control study, we compared the ability of two indices of antenatal care use, the new Adequacy of Prenatal Care Utilization (APNCU) index and the Kessner index, to predict low birthweight. In crude analyses, both indices showed a linear trend with low birthweight. After controlling for confounding, however, the APNCU index was unrelated to low birthweight. To learn whether the Kessner index added explanatory information to the APNCU index (or vice versa), we regressed the APNCU index on the Kessner index (and vice versa) and computed residuals for both indices. In logistic regression analyses, the residuals of the Kessner index added meaningful information to the APNCU index, whereas the opposite did not occur.

Prenatal care and prevention of preterm birth. A case-control study in southern Spain

The value of prenatal care is controversial and difficult to establish. A national policy for improving perinatal outcomes was proposed and applied throughout Andalusia (Southern Spain) in 1984. Here we report the results of an evaluation of this health care program as regards the prevention of preterm delivery. Effectiveness of prenatal care was assessed on the basis of two case-control studies in a hospital setting: one performed before the program was implemented (1981-1982) and the second one six years after the program began (1990-1993). A total of 229 cases and 395 controls for the period 1981-1982, and 207 cases and 381 controls for 1990-1993 were selected. Prenatal care was assessed based on the number of prenatal care visits, the date of the first visit, and an American composite index adjusting for gestational age. Multiple-factor adjusted odds ratios and their 95% confidence intervals (CI) were estimated using unconditional logistic regression analysis. The use of prenatal care significantly improved across time: the proportion of women receiving no prenatal care decreased from over 30% to less than 5%, and the proportion of women starting prenatal care in the first trimester for 1990-1993 was three times greater than the figure for 1981-1982. In the 1981-1982 case-control study, the date of first visit and the composite index were shown to be unrelated to preterm birth risk; and the number of visits yielded a significant association, although no definite trend could be established. In the 1990-1993 case-control study, a clear and significant relationship was observed between the number of prenatal care visits, the trimester of the first visit, and the adequacy of care according to the composite index. This latter variable, reflecting a more stringent standard of prenatal care, was selected by a stepwise logistic regression analysis as the best predictor for preterm birth risk. The results suggest that the present Andalusian program helps prevent preterm delivery. Nonetheless, its minimum standards should be raised to further decrease preterm birth risk.

Recall bias in a case-control study of low birth weight

The role of report/recall bias in case-control studies of low birth weight (LBW) was investigated in women who gave birth at a tertiary hospital. Prenatal exposure information reported at the postpartum interview was compared with that documented during pregnancy in obstetric records. 169 cases of LBW and 198 controls were selected. The two sets of information on case mothers and control mothers were compared, using the medical record as a reference. Kappa values were estimated. No trend was observed to increase/decrease the sensitivity and specificity of recall. Agreement on alcohol use was very low (kappa = 0.11 for case mothers and 0.03 for control mothers): on obstetrical records, only 12 mothers of cases reported habitual alcohol intake at the first prenatal care visit, whereas in the interview 69 said yes to the same question; in control mothers, the figures were 4 and 89 respectively. Odds ratios (ORs) of exposure estimated from the two sets of data did not differ importantly in 8 variables. Interview data yielded ORs for hypertension (8.39 versus 4.63), anemia (0.44 versus 0.99) that were farther from the null, and ORs in the opposite direction for alcohol (0.83 versus 1.61) and any drug (0.64 versus 1.42). In conclusion, given that OR figures are similar for most variables and no trend is observed in sensitivity/specificity, mothers of normal births can be an adequate reference group, using personal interviews to obtain information on lifestyle, and medical records for conditions.

Epidemiology, therapy and costs of nosocomial infection

In the current climate of cost containment and quality control, nosocomial infection is a worrisome adverse event in hospital care. Hospitalised patients require care for increasingly severe illnesses, and are therefore more susceptible to infection, especially by opportunistic micro-organisms. It is thus necessary to accurately assess and adjust for the severity of the underlying illness in studies of risk factors involved in nosocomial infections. The appearance of new diagnostic and therapeutic techniques provides novel opportunities for infection control and represents a constant challenge to hospital systems. The continuous selection of resistant flora, together with the identification of new pathogens, calls for a reconsideration of hospital policies regarding the dispensation of antibiotics. Epidemiological surveillance continues to be the most important aspect of attempts to monitor infection control programmes, and to identify changes in risk factors that may increase the infection rate. Among the major challenges now facing the infection control practitioner is the use of nosocomial infection rates as an indicator of quality of care. Awareness of infection statistics would serve as a stimulus to the prevention and control of infection, but would be useless if not accompanied by adequate systems to guarantee the comparability of data from different studies and centres. Suitably sensitive and specific surveillance systems should be developed, and the use of site-specific and procedure-specific infection rates adjusted for the patient's intrinsic risk should be encouraged.

[Evaluation of the cost of an intensive medicine unit. Relationship between the cost and the severity of the disease]

BACKGROUND

The evaluation of the costs of intensive care is a subject of interest at present, due to the high resources required by this area of health care services and the rhythm at which these costs increase. Such an evaluation has rarely been carried out in Spain. The aim of this study was to quantify the cost of medical care to critical patients in an Intensive Care Unit (ICU) in addition to evaluate the relationship between the severity of the disease and the short term result of intensive health care.

METHODS

A prospective study was carried out in 1,184 patients admitted (February 1985-February 1986) to the ICU of the Hospital General de Especialidades Virgen de las Nieves in Granada (Spain). Variables collected were the severity of the patient (APACHE II), therapeutic intensity (TISS) received, diagnosis on admission and state on discharge. A detailed and individualized evaluation was performed concerning the costs of hospital stay and treatment in the ICU.

RESULTS

The cost per patient per day in the ICU was found to 54,438 pesetas in 1988. A significant association was demonstrated with age, severity, therapeutic intensity and the result of the stay in the unit, being much higher in the patients who died in the ICU, particularly in those in whom the prognosis "a priori" was good.

CONCLUSIONS

A significant relation was found between the cost and severity of the disease, with the maximum costs being found in patients in whom survival was expected but who died and vice versa.

Difficulties in assessing community-acquired infection as a risk factor for nosocomial infection at an intensive care unit

OBJECTIVE

To analyze the relationship between presentation with a community-acquired infection (CAI) and the risk of subsequent nosocomial infection, and the assessment of a likely diagnostic bias in this association.

DESIGN

A prospective cohort study. APACHE-II and TISS were used to assess severity and therapeutic intensity, respectively. Nosocomial infection (NI) was diagnosed according to SENIC and CDC diagnostic criteria. The relative risk and its 95% confidence interval were estimated.

SETTING

The intensive care unit (ICU) of the University of Granada Hospital (Spain). It is a ten-bed multidisciplinary unit.

PATIENTS

448 patients admitted to the intensive care unit (ICU) between December-1986 and April-1988 who stayed at the ICU for at least 24 hours were included in the study.

RESULTS

The crude analysis suggests that CAI may prevent NI. When data were stratified by other variables a previous infection acted as a preventive factor in patients admitted to the ICU from emergency room, in patients with lower severity level and in those with shorter stay lengths at ICU. Patients with a CAI showed higher severity; they were treated more aggressively, they had a longer stay at ICU before a NI was diagnosed and they remained at ICU longer. In multivariate analysis the NI risk in patients with a CAI compared with those not infected previously and controlling for other variables was of 0.36.

CONCLUSION

The presence of a CAI may introduce a differential information bias in the study of NI.

Influence of nosocomial infection on mortality rate in an intensive care unit

OBJECTIVE

To assess the impact of nosocomial infection on the mortality rate in an intensive care unit (ICU).

DESIGN

Prospective cohort study.

SETTING

The ICU of the University of Granada Hospital in Spain.

PATIENTS

All patients (n = 279) admitted for > or = 48 hrs at the ICU between December 1986 and April 1988.

MEASUREMENTS

Nosocomial infections were diagnosed according to Study on the Efficacy of Nosocomial Infection Control (SENIC) and Centers for Disease Control criteria. Patient severity on admission (using Acute Physiology and Chronic Health Evaluation (APACHE II) and Therapeutic Intensity Scoring Systems were also used.

RESULTS

Mortality risk was 2.48 times higher in patients with a nosocomial infection than in noninfected patients. Relative risk of mortality in nosocomially infected patients was higher in young and less severely ill patients, in those patients with respiratory diseases, and in those patients with longer ICU stays. Logistic stepwise regression analysis, adjusting for several confounding factors (affected organ system, APACHE II score, and therapeutic intensity), showed that the risk of death in nosocomially infected patients was 2.1 times greater (95% confidence interval = 1.0 to 4.41) than in patients without such infection.

CONCLUSIONS

Nosocomial infection increases the risk of death. The effect is stronger in younger and less severely ill patients.

Nonincreased risk of nosocomial infection during a 22-day housekeeping personnel strike in a tertiary hospital

BACKGROUND

From April 2-23, 1992, the housekeeping staff of the University of Granada Hospital was on strike. Measures were implemented to minimize the effects of the strike on patients' health and especially to diminish the risk of hospital infection.

OBJECTIVE

To assess the risk of nosocomial infection during the housekeeping personnel strike.

SETTING

An 800-bed, tertiary care hospital.

METHODS

A case-cohort approach was used. One hundred forty-eight infected patients (with 184 hospital infections) were detected prospectively from March 1, 1992, to May 31, 1992. A sample of 459 of the base population (patients admitted during the same period) was selected. Information on relevant risk factors for hospital infection was abstracted from patients' clinical charts after hospital discharge. Crude odds ratios and adjusted (by proportional hazards model) relative risks (RRs) for the strike period were estimated.

RESULTS

Risk of nosocomial infection did not increase during the strike period (multiple-risk factor adjusted RR = 0.99, 0.96 to 1.01/day of strike). Similar results were observed for major sites of infection (especially surgical wound) and major areas of the hospital (including gynecology, surgery, and intensive care).

CONCLUSION

We concluded that there was no increase in the risk of nosocomial infection during the housekeeping strike.

Validity of the cross-sectional study for the ascertainment of nosocomial infection risk factors

This study was carried out in order to assess the validity of the pure cross-sectional study in the ascertainment of nosocomial infection risk-factors. The results yielded by two designs (cross-sectional and case-control) are compared. A cross-sectional design was performed in a tertiary hospital. 592 patients were studied, 38 of whom were nosocomially infected. The clinical information on all the patients included in this design was reviewed after hospital discharge. A matched case-control study was nested in the population cross-sectionally surveyed. 66 cases (28 additional patients developed a hospital infection) and 132 controls were selected. Odds ratios (ORs) for the risk factors analyzed by both designs were compared. There were no significant differences between the estimates yielded by both designs; however, a trend of lower OR estimates for the cross-sectional study was seen, which may be important for risk factors not strongly related to (low relative risk) nosocomial infection. Several factors which might account for the results observed (random error, bias introduced by matching) are discussed. It is suggested that pure cross-sectional designs for the study of risk factors of nosocomial infection may introduce a negative (toward-the-null) bias.

Menopausal hormone replacement therapy and breast cancer: a meta-analysis

A meta-analysis was performed to determine whether the scientific literature provides enough evidence that hormone replacement therapy after menopause increases the risk of breast cancer. Studies were located by MEDLINE, supplemented by a hand search of all the references in the articles located. The papers were graded as to quality. Those considered unbiased were combined using Woolf's method. Thirty-seven original studies were found: 23 case-control, 13 cohort, and one clinical trial. Overall, a small but statistically significant relative risk (RR) figure of 1.06 was calculated. Women who experienced natural menopause seemed to be at increased risk (RR = 1.13). A significant weighted RR was observed in current hormone replacement therapy users, especially in those who had natural menopause (RR = 1.63). A nonsignificant increasing trend was found between duration of hormone replacement therapy and breast cancer risk, although the opposite was seen when the association was analyzed by time since last use. These results imply that hormone replacement therapy could promote breast cancer.

Usefulness of severity indices in intensive care medicine as a predictor of nosocomial infection risk

To evaluate the relationship between severity and nosocomial infection in critical patients, we have conducted a prospective study at the Intensive Care Unit of the University of Granada Hospital (Spain). Patients' severity was evaluated by APACHE II and TISS. We found a positive association with nosocomial infection risk for an APACHE II score greater than 12 points (RR = 2.45) and for first-day TISS greater than 20 points (RR = 2.51). With a multivariate analysis we did not find an association between APACHE II and nosocomial infection risk, but each TISS point suggests an infection risk increment of 6%. We concluded TISS may be considered a good infection risk predictor. TISS could also be taken into account when nosocomial infection rates from several ICUs are compared.

Patterns of research. Oral contraceptives and cervical cancer

Original papers on the oral contraceptive use-cervical cancer relationship are analysed. The purpose of this study was to ascertain the biases of the original articles collected in relation to various characteristics of any investigation. Papers were located by using MEDLINE, reviewing the references of each article identified by MEDLINE, and then reviewing the contents of those journals in which an original could be published. Fifty-five publications (from 49 original studies) were graded as to quality and classified as biased or unbiased. Nineteen studies were considered unbiased. The most common biases identified were confounding, detection bias, and misclassification bias. The pattern of research/publication has changed since the association began to be analysed: articles shift from gynecological to cancer and epidemiological journals; the number of studies performed by gynecologists alone and pathologists alone decreases, while studies performed by epidemiologists alone or in collaboration with gynecologists increase. This collaboration produced studies with fewer biases. It is suggested that the above mentioned collaboration should be increased to improve access to, and then the application of the results obtained in the original studies on oral contraceptives and cervical cancer.

Hospital stay length as an effect modifier of other risk factors for nosocomial infection

This paper addresses the problem of hospital stay length as a risk factor for nosocomial infection and as a modifier of the effect of other risk factors for hospital infection. Patients were selected form two cross-sectional studies done in two different seasons of 1986. Risk of infection rose fairly steadily as hospital stay length increased (correlation coefficient: 0.83, p less than 0.01). Several risk factors (operation, underlying disease, and age) were analyzed on the basis of 1) raw data and 2) data stratified by length of stay. The results showed that hospital stay length is a strong modifier of the remaining risk factors, generally reducing, their effect on the development of hospital infection as length of stay increases.