Search

The authors acknowledge the support of the research grants PI16/00670, PI16/00755, PI16/01004, PI16/01187, PI16/01273, PI16/01281, and PI18/01313 of Instituto de Salud Carlos III, co-funded with FEDER grants., Martinez-Beneito, M.A., Vergara-Hernández, C., Botella-Rocamora, P., Corpas-Burgos, F., Pérez-Panadés, J., Zurriaga, Ó., Aldasoro, E., Borrell, C., Cabeza, E., Cirera, L., Osinaga, J.D., Fernández-Somoano, A., Gandarillas, A., Lorenzo Ruano, P.L., Marí-Dell’olmo, M., Nolasco, A., Prieto-Salceda, M.D., Ramis, R., Rodríguez-Sanz, M., Sánchez-Villegas, P.

Providing care for people with chronic diseases is a challenge requiring institutional programs and strategies, thus it necessary to evaluate the impact of the same on the social determinants of health (SDH). The aims were: 1) to describe the impact of the structural determinants of the Health Strategy for the Population with Chronic Diseases (EAPEC) in Asturias and 2) to propose actions for improvement regarding social stratification factors.Qualitative study of six strategic programs of the Chronic Disease Strategy: Health Observatory, Social and Healthcare Coordination, School for Patients Program, Caregivers Program, Mental Health Services Continuity, and Quality and Safety in Healthcare. A screening tool was used, validated for evaluation of the health impact on the structural determinants (socioeconomic and political context and social stratification factors) of the SDH. A personal semi-structured interview was carried out with the manager of each program in 2016, and a final report was produced that included the impacts found and proposals for improvement.All programs had a positive impact on social values (social justice, equity) and the state of wellbeing (social and educational policies). In terms of social stratification, the principal positive effects included age and functional diversity. Regarding the factors linked to geographic location, gender, origin/ethnicity, and social class the principal effects were negative.This strategy aimed at people with chronic diseases has positive effects. However, paying attention to social stratification factors during implementation of the same is a priority.La atención a personas con enfermedades crónicas es un reto que precisa de estrategias y programas institucionales, siendo necesario evaluar su impacto en los determinantes sociales de la salud (DSS). Los objetivos de este trabajo fueron tanto describir el impacto en los determinantes estructurales de la Estrategia de Salud y Atención a la Población con Enfermedad Crónica (EAPEC) de Asturias como proponer acciones de mejora en relación con los factores de estratificación social.Se realizó un estudio cualitativo de 6 programas estratégicos de la Estrategia de Cronicidad: Observatorio de Salud, Coordinación Sociosanitaria, Escuela de Pacientes, Atención a Personas Cuidadoras, Continuidad Asistencial en Salud Mental, Calidad y Seguridad en Atención Sanitaria. Se utilizó una herramienta de cribado validada para la evaluación del impacto en la salud sobre los determinantes estructurales (contexto socioeconómico y político, factores de estratificación social) de los DSS. Se realizó una entrevista personal semiestructurada con el responsable de cada programa en 2016, elaborando un informe final con los impactos detectados y propuestas de mejora.Todos los programas tuvieron un impacto positivo sobre los valores sociales (justicia social, equidad) y el estado de bienestar (políticas sociales, educativas). Dentro de la estratificación social, los principales efectos positivos afectaron a la edad y a la diversidad funcional. En los factores vinculados a la localización geográfica, género, origen/etnia y clase social se concentraron los principales efectos negativos.Esta estrategia dirigida a personas con enfermedades crónicas tiene efectos positivos. Sin embargo, es prioritario prestar atención a los factores de estratificación social durante su ejecución.

Health surveys are a key tool for decision-making in health policies and health services planning. The use of small-area statistical methods that use information at different geographic levels may be useful for estimating health indicators at a lower geographical level than originally considered in the survey design.

Objective: To estimate the incidence and 28-day and 5-year survival rates after a first acute myocardial infarction (AMI) in relation to socioeconomic status in the Basque Country (Spain) between 1999 and 2000. Methods: Data from a population-based registry of AMI were used. The study included 3,619 patients to calculate age-standardized incidence by the direct method and 2,003 patients (out-of-hospital deaths were excluded) to calculate observed and relative survival using the Kaplan-Meier and Hakulinen methods, respectively. Socioeconomic status was quantified using a deprivation index ecologically assigned to each patient according to the census tract of residence at diagnosis of AMI and was categorized into quintiles. Results: Among men, the risk of AMI was higher in the lowest socioeconomic group than in the highest socioeconomic group (RR=1.17; 95%CI: 1.02-1.34). In men, a higher risk of death was observed in the middle (Q3; HR=1.60; 95%CI: 1.02-2.51) and low (Q5; HR=1.65; 95%CI: 1.02-2.69) quintiles compared with the least deprived group for age-adjusted survival during the acute phase. In the fully adjusted model, this effect was attenuated and no significant differences were observed in long-term survival. Among women, no significant differences were observed either in incidence or in short- and long-term survival. Conclusions: Socioeconomic inequalities were only observed in men in incidence and in survival during the acute phase after an AMI.

Objectives To study the association between proximity to air polluting industrial facilities and mortality in the Basque Country (Spain) in the 1996e2003 period. Methods A cross-sectional ecological study with 1465 census sections (CS) as units of analysis with a mean population of 1257 inhabitants. Association of CS mortality with proximity of industries of the European Pollutant Emission Register was studied by type of industrial activity and adjusted for social deprivation. Two distance thresholds (1 km and 2 km) were used as proxies for exposure in a ‘near versus far’ analysis. Causes of mortality studied were: all causes; tracheal, bronchial, and lung cancer; haematological tumours; ischaemic heart disease; cerebrovascular diseases; chronic diseases of the lower respiratory tract; and breast cancer (in women). Poisson’s generalised linear mixed models (GLMM) with two random effects (heterogeneity and structured spatial variability) were used in a fully Bayesian environment. Results Men living in sections within 1 km from energy production industries had greater mortality from tracheal, bronchial, and lung cancer [CI90% 6% to 53%] as compared with people living further. Women had greater mortality from ischaemic heart disease [CI90% 1% to 17%] and respiratory illness [CI90% 1% to 24%] within 2 km from metal-processing industries. On the contrary, within the 1 km buffer from mineral industries, mortality was lower for all causes [CI90% � 20% to � 6%] and for ischaemic heart disease [CI90% � 40% to � 10%] in women, and from respiratory diseases in men [CI90% � 39% to � 4%], while it was greater for breast cancer in women [CI90% 2% to 28%] within the 2 km buffer. Conclusions Analysis of mortality by census sections is a helpful exploratory tool for investigating environmental risk factors and directing actions to sites and risk factors with a greater impact on health. Further epidemiological andenvironmentalinvestigationsaroundmetal-processing and energy-producing plants are required.

Background Smoking is a risk factor for coronary heart disease, but it has been associated with better short-term prognosis in hospitalized patients with acute myocardial infarction. The aims of this study were to determine the association between smoking and myocardial infarction 28-day case-fatality in hospitalized patients and at the population level; and, whether smokers presenting with fatal myocardial infarction are more likely to die before reaching a hospital. Design and methods Population-based myocardial infarction registry, carried out in 1997-1998 in seven regions of Spain, used standardized methods to find and analyze suspected myocardial infarction patients (10 654 patients; 7796 hospitalized). Four categories of smoking status were defined: never-smokers, former smokers for more than 1 year, former smokers for less than 1 year, and current smokers. Results The main end-point was 28-day case-fatality, found to be 20.1, 17.1, 15.6, and 8.9%, in the four smoking status categories, respectively, for hospitalized patients; and 37.4, 33.0, 24.5, and 23.2%, respectively, at population level. Hospitalized current smokers had lower age, sex, and comorbidity-adjusted 28-day case-fatality than never-smokers (odds ratio = 0.71; 95% confidence interval: 0.56-0.90). This association held at population level (odds ratio = 0.68; 95% confidence interval: 0.60-0.76), in which former smoking was also associated with lower case-fatality. In fatal cases, recent former smokers presented a lower risk of out-of-hospital death than never-smokers (odds ratio = 0.47; 95% confidence interval: 0.29-0.77), whereas current smoking was marginally associated with out-of-hospital death (odds ratio = 1.22; 95% confidence interval: 0.99-1.50). Conclusions Current smoking is associated with lower 28-day case-fatality in hospitalized myocardial infarction patients. This association held at population level. Among fatal cases, smoking is associated with higher and recent former smoking with lower risk of dying out-of-hospital.

Introduction and objectives Analysis of the effect of treatment in observational studies is complex due to differences between treated and nontreated patients. Calculating the probability of receiving treatment conditioned on relevant covariates (propensity score [PS]) has been proposed as a method to control for these differences. We report an application of PS to assess the association between reperfusion treatment and 28-day case fatality in patients with acute myocardial infarction (AMI). Method We describe the procedure used to calculate PS for receiving reperfusion treatment, and different strategies to analyze the association between PS and case fatality with regression modeling and matching. Data were from a population-based registry of 6307 patients with AMI in Spain during 1997–98. Results The PS for reperfusion was calculated in 5622 patients. In the multivariate analysis, reperfusion was associated with lower case fatality (OR=0.59; 95% confidence interval [95% CI], 0.46–0.77). When PS was included as a covariate, this association became non-significant (OR=0.76; 95% CI, 0.57–1.01). In the subgroup of matched patients with a similar PS (n=3138), treatment was not associated with case fatality (OR=0.95; 95% CI, 0.72–1.26). When the influence of cases with missing data on PS was controlled for, reperfusion treatment was associated with lower fatality (OR=0.66; 95% CI, 0.55–0.80). Conclusions Calculating propensity score is a method that controls for differences between treated and nontreated patients. This score has limitations when matching is incomplete and when data are missing. Results of the present example suggest that reperfusion treatment reduces AMI case fatality.

To determine the health impact perceived by residents and social players involved in two urban regeneration interventions (a new fish market and the redevelopment of North/West Herrera) in Pasaia Bay (Gipuzkoa, Spain) that have been the subject of a health impact assessment (HIA).Qualitative methodology was used with theoretical and intentional sampling. Information was obtained through 18 personal interviews and five discussion groups and was analyzed in accordance with the sociological analysis model of discourse. The preliminary results were triangulated and contrasted among the team members and those taking part in the study.Four interrelated areas of health impact were identified: urban quality, connectivity, social cohesion, and-to a lesser extent-employment. Specific aspects for improvement were indicated for each field, as well as the influence of the sociopolitical context and conceptions of health. Other significant findings were the impact of the process of carrying out the building work and the distinct perspectives due to the differing roles and social profiles of participants.Knowledge of the perceptions and expectations of affected individuals through qualitative methods provides novel elements and interrelations that are needed to apply HIA as a tool for improving health and for citizen participation.

Objective The aims of this study were to analyze the dose–response association between leisure time physical activity (PA) practice and myocardial infarction (MI), considering not only the total amount but also the amount of PA at different levels of intensity, and to determine whether these associations were modified by age. Method In a population-based age- and sex-matched case–control study, all first acute MI patients aged 25 to 74 years were prospectively registered in four Spanish hospitals between 2002 and 2004. Controls were randomly selected from population-based samples recruited during the same period of time. The Minnesota PA questionnaire was administered to assess total energy expenditure in PA and in light-, moderate-, and high-intensity PA. Results Finally, 1339 cases and 1339 controls were included. The association between PA and MI likelihood was non-linear, with significantly lower MI odds at low practice levels (≥ 500 MET·min/week), lowest odds around 1500 MET·min/week, and a plateau thereafter. Light- (in subjects older than 64 years), moderate-, and high-intensity PA produced similar benefits. Conclusion Most of the population could reduce their likelihood of MI by engaging in PA at a moderate level of intensity or, in individuals older than 64 years, at a light level of intensity.

Introduction and objectives To determine 28-day and 5-year survival rates in patients who have experienced a first acute myocardial infarction and to identify prognostic factors for survival. Methods This study involved 1,677 patients with a first acute myocardial infarction who were treated at a hospital in Guipuzcoa, Spain between 1997 and 2000. Results Women were approximately 10 years older than men, presented more often with diabetes and hypertension, were in a less favorable clinical condition, and consumed fewer medical resources, but were less likely to smoke. Survival rates at 28 days and 5 years were higher in men over 60 years of age. In the period from 29 days to 5 years, the relative survival rate was higher in men from all age groups. Factors associated with short- and long-term survival varied between the sexes. Disease severity in the acute phase and, later on, age were associated with survival in both men and women, whereas the effect of other variables differed between the sexes. Conclusions Myocardial infarction is a condition associated with high mortality in the acute phase. There is an interaction between sex and age that affects survival after an acute myocardial infarction. A number of factors are associated with poor short- and long-term prognoses in both sexes.

Two particular polymorphisms, namely PON1-192 and PON2-311, in the genes encoding the antioxidant enzymes paraoxonase-1 (PON1) and paraoxonase-2 (PON2) have been associated with an increased risk of acute myocardial infarction (AMI). However, previous findings have been contradictory. The aim of this study was to investigate the association between the PON1-192 and PON2-311 polymorphisms and their interaction on AMI risk.This case-control study involved 746 consecutive AMI patients and 1796 control subjects without cardiovascular disease, who were randomly selected from the same population from which the patients came. All participants were recruited between 1999 and 2000 from four Spanish autonomous regions. All were assessed for the presence of PON1-192 and PON2-311 and for classical cardiovascular risk factors. Multivariate analysis was carried out using logistic regression modeling.The odds ratios (OR) of AMI for patients with the PON1-192 QQ and PON2-311 SS genotypes (who comprised 50% and 66% of the population, respectively) were 1.26 (95% confidence interval [CI], 1.02-1.55) and 1.25 (95% CI, 1.04-1.50), respectively, compared with R and C allele carriers. Moreover, in patients with both QQ and SS genotypes, the adjusted OR of AMI increased to 1.41 (95% CI, 1.13-1.76).Our results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

Clinical variability in myocardial infarction (MI) regarding age, comorbidities and atypical symptoms could determine gender differences in inhospital care. This study analyzes the magnitude and determinants of differences between men and women in early reperfusion therapy in people hospitalized after MI.2,836 patients who arrived to hospital with MI were studied (IBERICA-Basque Country study). The relative risk (RR) of receiving early reperfusion for men versus women, adjusted by age, clinical characteristics, risk factors, and pre-hospital delay was estimated. The effect decomposition methodology and the log binomial regression were applied.29% of patients were women with a median age of 77 years. The RR of revascularization in men compared to women was different according to age. When factors such as hypertension diabetes, Killip III-IV at admission and atypical symptoms were taken into account, statistically significant differences between sexes were not detected at 45 years old (RR=0.91; 95% CI=0.77-1.07). However, for 64 years old and over, the RR of reperfusion was 1.24 (95% CI=1.05-1.47). Both the differences by sex and the sex-age interaction were no longer statistically significant after adjusting by pre-hospital delay.The delay to receive medical care in elderly women is responsible of gender differences in early reperfusion. It is necessary to analyze the reasons for treatment-seeking delay.

To describe socioeconomic inequalities in mortality in the Basque Country, using mortality and socioeconomic data by census sections.Mortality and population data were obtained from the Basque Institute of Statistics. Socioeconomic characteristics of the census sections were assigned to each death and a deprivation index combining information from four socioeconomic indicators was computed. Age-adjusted mortality rates by sex, age group (0-64or = 65) and cause of death were calculated for each quintile of the deprivation index. Poisson regression models were fitted to estimate age-adjusted rate ratios and excess mortality attributable to inequalities.Mortality showed a gradient according to the deprivation index in men and women. Mortality was greater in the most deprived sections. Mortality inequalities were observed in men younger than 65 years. A total of 9.3% of deaths in men and 4.9% of those in women were attributable to socioeconomic inequalities. The relative importance of the cause of death differed according to the inequality measure used. Lifestyle-related causes of death were notable.This study illustrates the potential utility of census section socioeconomic indicators both to describe socioeconomic inequalities in mortality and to identify priorities for interventions.

Objectives:During the final period of life, patients with cancer in the Basque Country are given treatment in different types of hospital care. This study compared the quality of care according to the type of care in one of the autonomous communities in Spain.Methods:A retrospective study was carried out of cancer patients who died in conventional hospital services, home hospitalization services, and palliative care units. In addition to hospital stay and readmission number, variables based on the recommendations of Spanish Society for Palliative Care were studied.Results:End-of-life was diagnosed in 57 percent of a sample of 486 patients, 3 days before death (median). The use of symptom control scales was only documented in the clinical records of eight patients. Sociofamily evaluation was not found. Patients in conventional hospital services were less frequently diagnosed with end-of-life and agony and were significantly different from the rest in the reasons for admission, symptoms assessed, drugs used, administration routes, and dosage forms. Pain was evaluated in 50 percent of the patients and was better controlled in palliative care units. Patients not diagnosed with agony (52 percent) were more frequently not given specific treatment.Conclusions:End-of-life in cancer patients was diagnosed too late. The quality of care in palliative care units and by home hospitalization service was better than that in conventional hospitalization. Nevertheless, there were areas for improvement in the three modalities of care.

The type of acute coronary syndrome may account for different prognoses between men and women after myocardial infarction. This study assessed gender differences in 28-day mortality rates for first or recurrent Q-wave and non–Q-wave myocardial infarctions and unstable angina by using data from 5 registries that included 20,836 patients (24.8% women). Mortality rates were higher in women with first Q-wave myocardial infarction but not in the other patients after adjusting for confounding variables.

[Abstract] Background: Myocardial infarction (MI) incidence and mortality display a high geographic variation. Aims: The objective of the present study was to analyze MI mortality, cumulative incidence rate variability in seven regions of Spain from 1997 to 1998. Methods and Results: Standardized methods were used to identify, find, register, and classify MI cases that were classified as definite, possible, insufficient-dataMI, and non-MI. The total population of the seven monitored regions was 7,364,682 inhabitants. Of the 11,256 cases fulfilling eligibility criteria to investigate, 10,660 were selected to calculate MI rates: 6554 (61.5%)non-fatal definite MI, 1179 (11.1%)fatal definite MI, 1859 (17.4%)fatal possible MI, 1068 (10.0%)fatal cases with insufficient data. The IBERICA 25–74 years age-standardized cumulative incidence rates for men and women, were 207 (range: 175–252) and 45 (range: 36–65) per 100,000, respectively. The age-standardized mortality rates for men and women, were 73 (range: 62–94) and 20 (range: 13–29) per 100,000, respectively. Age-standardized case-fatality was 31.4 and 24.2% in men aged 25–74 and 35–64 years, respectively, and 32.7 and 27.0%, respectively, in women. Conclusions: MI cumulative incidence and mortality rates are low compared with other industrialized countries but, vary considerably among regions in a Mediterranean country like Spain. Cataluña. Comissió Interdepartamental de Recerca i Innovació Tecnològica; CIRIT/2001 SGR 00408 Instituto de Salud Carlos III; FIS 96/0026-01 to 05 Instituto de Salud Carlos III; FIS 97/1270 Instituto de Salud Carlos III; FIS 98/1535

[Abstract] Introduction and objectives. To determine the proportion of patients with myocardial infarction (MI) not admitted to a coronary care unit (CCU), the variables associated with admission into a CCU, and whether admission to a CCU, and the availability of coronary angiography in the same hospital, were associated with 28-day case fatality. Patients and method. Population-based registry of MI in patients 25 to 74 years of age, admitted during 1996-1998. Demographic and clinical characteristics were recorded, as well as management, clinical course and survival after 28 days. Hospitals were classified according to the availability of a CCU and catheterization laboratory (advanced hospital), CCU only (intermediate hospital) or neither (basic hospital). Admission to the CCU was also recorded. Results. In all, 9046 cases of MI were recorded; in 11.3% the patient was not admitted to a CCU. Age, smoking (OR=1.33; 95% CI, 1.08-1.64), non-Q MI (OR=0.62; 95% CI, 0.49-0.78) or undetermined location of MI (OR=0.34; 95% CI, 0.23-0.50), Killip 4 score on admission (OR=0.63; 95% CI, 0.40-1.00) and delay in arrival at the hospital >6 h were associated with CCU admission. Patients admitted to a CCU showed a lower case fatality in the first 24 h (4.2% vs 23.5%), which was independent of comorbidity, severity and treatment. The 24-hour survivors admitted to a basic hospital had higher case fatality (17.3% vs 7.8%) than other groups, which was related to differences in treatment. Conclusions. CCU admission is associated with a lower case fatality in the first 24 h. Admission to a basic hospital is associated with a higher 28-day case fatality even in patients who survive 24 h. [Resumen] Introducción y objetivos. Determinar el porcentaje de pacientes con infarto agudo de miocardio (IAM) que no ingresan en una unidad de cuidados intensivos coronaries (UCIC), las variables asociadas al ingreso en una UCIC y si el ingreso en una UCIC, su disponibilidad y la de hemodinámica en el hospital se asocian a la letalidad a 28 días. Pacientes y método. Registro poblacional (1996-1998) de casos de IAM en pacientes con edades comprendidas entre los 25 y los 74 años. Se recogieron variables demográficas, clínicas, el ingreso en UCIC y la letalidad a los 28 días. Se clasificaron los hospitales según la disponibilidad de UCIC y hemodinámica (hospital avanzado), solamente UCIC (hospital intermedio) o ninguno (hospital básico). Resultados. Se registraron 9.046 casos; el 11,3% no ingresó en una UCIC. La edad, el consumo de tabaco (odds ratio [OR] = 1,33; intervalo de confianza [IC] del 95%, 1,08-1,64), el infarto sin onda Q (OR = 0,62; IC del 95%, 0,49-0,78) o ilocalizable (OR = 0,34; IC del 95%, 0,23-0,50), el grado Killip 4 al ingreso (OR = 0,63; IC del 95%, 0,40-1,00) y el retraso > 6 h en llegar al hospital se asociaron al ingreso en UCIC. Los pacientes ingresados en UCIC presentaban menor letalidad que los ingresados en hospitales básicos en las primeras 24 h (el 4,2 frente al 23,5%), independientemente de la gravedad del IAM y de las variables relacionadas con el tratamiento. Los su-pervivientes a 24 h que ingresaban en un hospital bÁsico presentaban mayor letalidad a los 28 días (el 17,3 frente al 7,8%), relacionada con las variables de tratamiento. Conclusiones. El ingreso en una UCIC se asocia a una menor letalidad de los pacientes con IAM en las primeras 24 h. El ingreso en un hospital bÁsico se asocia a una mayor letalidad a los 28 días. Insituto de Salud Carlos III; FIS96/0026-01 to 05 Insituto de Salud Carlos III; FIS97/1270 Insituto de Salud Carlos III; FIS98/1535