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Background Colorectal cancer (CRC) is a major public health problem due to its incidence and mortality. Screening programmes help decrease its impact on the population through early detection. However, the uneven distribution of social determinants of health can cause inequalities. The aim of this study is to identify the social inequalities in the participation in CRC screening programmes. Methods A systematic review of the literature was carried out, searching in both health and social databases for papers published since 2000 in English, Spanish, Portuguese and French. The search strategies combined terms regarding screening, CRC, participation and social inequalities. Included papers were quantitative or qualitative primary studies analyzing gender and socioeconomic inequalities in the participation in CRC screening programmes implemented by public and private health-care providers and addressing 45- to 75-year-old population. Results A total of 96 studies, described in 102 articles, were included. Most were quantitative observational studies and analyzed population-based screening programmes. They were carried out mainly in the UK (n=29) and the USA (n=18). Participation in screening programmes varied from 1.1% to 82.8% using several methods. A total of 87 studies assessed participation by sex and one focussed on men, but only two provided an analysis from a gender perspective. Although men are at a higher risk of developing CRC, they generally were less likely to participate in screening programmes. Screening attendance was higher among the least deprived areas. Conclusions Gender and socioeconomic inequalities in CRC screening participation should be addressed through the design of tailored interventions with a multidimensional focus.

To explore the perceptions and experiences of the general population regarding the impact of the implementation of teleconsultation in primary health care during the pandemic.methodology with a descriptive-interpretative approach, whose fieldwork was carried out between May and November 2020.Study conducted in Navarra and Euskadi. Population groups with different profiles of associated and non-associated citizenship in both Autonomous Communities. A total of 62 primary health care users have participated and 10 focus groups were carried out.The focus groups followed a semi-structured script based on the variables of analysis and dimensions of interest according to the different participant profiles and objectives. The sessions were recorded and transcribed. An inductive content analysis was performed. Data triangulation was realized in order to ensure validity.The perception of teleconsultation by the population has varied throughout the pandemic and has been heterogeneous. The participants consider that the non-face-to-face modality may have repercussions on the quality of care, as well as amplifying inequalities in access to primary health care.It is essential to carry out analyses and evaluations from a health equity perspective in order to make decisions related to the use of technology in general and teleconsultation in particular, in the post-pandemic future of primary health care.

Resumen: Las encuestas de salud son una herramienta clave para la toma de decisiones en políticas de salud y para la planificación de los servicios de salud. El uso de métodos estadísticos para áreas pequeñas que utilizan información de diferentes ámbitos geográficos puede resultar útil para estimar indicadores de salud a una escala geográfica menor que la originalmente considerada en el diseño de una encuesta. Abstract: 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. Palabras clave: Análisis de áreas pequeñas, Encuesta de salud, Estadística espacial, Keywords: Small area analysis, Health survey, Spatial statistics

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.

Resumen: Es imprescindible desarrollar un enfoque integral de las intervenciones institucionales que permita realizar la evaluación del impacto en la salud desde la perspectiva de los determinantes sociales de la salud y la equidad. Para realizar dicha evaluación son necesarias herramientas adaptadas y sencillas. El objetivo de este trabajo es describir la metodología empleada en el diseño y la aplicación de dos herramientas para evaluar el impacto en los determinantes sociales de la salud y la equidad en programas de salud e intervenciones comunitarias. En los programas de salud se aplicó una herramienta adaptada mediante entrevista entre el equipo evaluador y la persona responsable del programa. Las intervenciones comunitarias fueron evaluadas mediante una herramienta on line que además permite obtener un informe con recomendaciones de mejora según los ejes de desigualdad. La aplicación de estos instrumentos puede contribuir a disminuir las desigualdades sociales en salud y a mejorar las intervenciones en salud pública. Abstract: It is essential to develop a comprehensive approach to institutionally promoted interventions to assess their impact on health from the perspective of the social determinants of health and equity. Simple, adapted tools must be developed to carry out these assessments. The aim of this paper is to present two tools to assess the impact of programmes and community-based interventions on the social determinants of health. The first tool is intended to assess health programmes through interviews and analysis of information provided by the assessment team. The second tool, by means of online assessments of community-based interventions, also enables a report on inequality issues that includes recommendations for improvement. In addition to reducing health-related social inequities, the implementation of these tools can also help to improve the efficiency of public health interventions. Palabras clave: Evaluación del impacto en la salud, Determinantes sociales de la salud, Políticas públicas, Equidad, Keywords: Health impact assessment, Social determinants of health, Public policy, Equity

It is essential to develop a comprehensive approach to institutionally promoted interventions to assess their impact on health from the perspective of the social determinants of health and equity. Simple, adapted tools must be developed to carry out these assessments. The aim of this paper is to present two tools to assess the impact of programmes and community-based interventions on the social determinants of health. The first tool is intended to assess health programmes through interviews and analysis of information provided by the assessment team. The second tool, by means of online assessments of community-based interventions, also enables a report on inequality issues that includes recommendations for improvement. In addition to reducing health-related social inequities, the implementation of these tools can also help to improve the efficiency of public health interventions.

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.

ResumenLa evaluación del impacto en la salud es una herramienta de carácter predictivo, de ayuda a la toma de decisiones. La experiencia acumulada muestra que podría desempeñar un papel primordial en el desarrollo de la estrategia de salud en todas las políticas. La evaluación del impacto en la salud ha sido ampliamente utilizada en otros países europeos, en diversos ámbitos sectoriales y administrativos. En la mayoría de los casos se ha introducido de forma no obligatoria e independiente de otros tipos de evaluación del impacto de las políticas sectoriales. Su uso en España es relativamente reciente, escaso, y principalmente limitado a experiencias en el ámbito local y al cribado de actuaciones de una comunidad autónoma. La reforma normativa y organizativa de la salud pública actualmente en curso en España es una gran oportunidad para impulsar el desarrollo de la evaluación del impacto en la salud. Entre las barreras para su desarrollo destacan el predominio de la visión biomédica de la salud entre los profesionales, los responsables políticos y la población general; la desafección política, la escasa cultura de participación ciudadana y de tradición evaluadora en la elaboración de políticas públicas; y el insuficiente desarrollo del trabajo intersectorial. Dado el potencial de la evaluación del impacto en la salud para avanzar en el logro de una mejor salud poblacional y en la reducción de las desigualdades sociales en salud, deberían dedicarse esfuerzos políticos, formativos y de investigación para que esta evaluación se introduzca y desarrolle en los distintos ámbitos administrativos y sectoriales.AbstractHealth impact assessment is a predictive tool to support decisions in policy-making. Current experience shows that health impact assessment could play an important role in the development of the Health in All Policies strategy. This strategy has been extensively used in other European countries and in a wide range of policy and administrative sectors. Health impact assessment is hardly ever mandatory and is frequently carried out separately from other impact assessments. The use of this process in Spain is relatively new, limited and fundamentally based on local level experiences and the screening of regional interventions. The current normative and organizational reform of public health in Spain provides an excellent opportunity to promote the development of health impact assessment.Some of the barriers to the development of this process are related to the biomedical model of health prevailing among health professionals, politicians, and the general population, political disaffection, lack of assessment culture, underdevelopment of community participation processes, and insufficient intersectoral work. Health impact assessment provides an opportunity to move toward improving the population’s health and reducing inequalities in health. Consequently, political commitment, as well as investment in education and research, is needed to introduce and develop health impact assessment in all administrative settings and policy sectors.

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.

Introduccion y objetivos Estimar la supervivencia a los 28 dias y a los 5 anos y los factores pronosticos asociados en personas que han sufrido un primer infarto agudo de miocardio. Metodos Se estudio a 1.677 pacientes con un primer infarto agudo de miocardio que accedieron a un hospital de Guipuzcoa entre 1997 y 2000. Resultados Las mujeres eran unos 10 anos mayores, presentaron mas diabetes mellitus e hipertension y un cuadro clinico mas desfavorable y recibieron menos recursos terapeuticos, aunque eran menos fumadoras que los varones. La supervivencia fue superior entre los varones mayores de 60 anos a los 28 dias y a los 5 anos. En el periodo de 29 dias a 5 anos, los varones de todos los grupos de edad presentaron una supervivencia relativa mas larga. Los factores relacionados con la supervivencia a corto y largo plazo difirieron entre uno y otro sexo. La gravedad de la enfermedad en la fase aguda y la edad en la fase tardia fueron factores relacionados con la supervivencia de varones y mujeres y en el resto de las variables el comportamiento fue distinto entre uno y otro sexo. Conclusiones El infarto es una enfermedad con una elevada mortalidad en la fase aguda. Existe una interaccion entre el sexo y la edad que afecta a la supervivencia tras un infarto agudo de miocardio. Varios factores se asocian a un peor pronostico precoz y tardio en ambos sexos.

Census track level socioeconomic inequalities in mortality are described in the Basque Country and its three main cities in the 1996-2003 period. An ecological crosssectional study of small areas was performed. Using principal component analysis a socioeconomic deprivation index was calculated. The mortality risk for each census track and the relation between mortality and socioeconomic deprivation were studied by means of hierarchical Bayesian models. Geographical patterns of the mortality risk and the deprivation index were similar, with higher mortality in more deprived areas. In the Basque Country as a whole the magnitude of the association between mortality and deprivation was higher in men than in women. In the cities, the association was only apparent for men. These results are useful to guide health policies and identify geographical areas with greater needs., Se describen las desigualdades socioeconómicas en la mortalidad por secciones censales en el País Vasco y en sus tres capitales durante el período 1996-2003. Se realizó un estudio ecológico transversal de áreas pequeñas. Mediante el análisis de componentes principales se calculó un índice de privación socioeconómica. El riesgo de mortalidad de cada sección censal, y la relación entre la mortalidad y la privación socioeconómica se estudiaron mediante modelos Bayesianos jerárquicos. Los patrones geográficos del riesgo de mortalidad y del índice de privación fueron similares, con mayor mortalidad en las áreas de mayor privación. En el conjunto del País Vasco la magnitud de la asociación entre la privación y la mortalidad fue mayor en los hombres que en las mujeres. En las capitales esa asociación sólo se evidenció para los hombres. Estos resultados son útiles para orientar las políticas de salud e identificar las áreas geográficas que precisan una mayor atención. [fr] On décrit les inégalités socio-économiques dans la mortalité par sections de recensement au Pays Basque et ses trois capitales pendant la période 1996-2003. Une étude écologique transversale d’aires petites a été accomplie. Au moyen de l’analyse de composantes principales, on a calculé un index de privation socio-économique. Le risque de mortalité de chaque section, et le rapport entre la mortalité et la privation socioéconomique ont été étudiés utilisant des modèles Bayesians hiérarchiques. Les patrons géographiques du risque de mortalité et de l’index de privation étaient semblables, étant la mortalité plus grande dans les aires avec une plus grande privation. Dans l’ensemble du Pays Basque la grandeur de l’association entre la privation et la mortalité était plus grande chez les hommes que chez les femmes. Dans les capitales l’association était evidente seulement chez les hommes. Ces résultats sont utiles pour orienter les politiques de santé et pour identifier les aires géographiques qui ont besoin d’une plus grande attention.

Introduccion: El Conjunto Minimo Basico de Datos (CMBD) es la base de datos hospitalaria mas utilizada en el Sistema Nacional de Salud. El objetivo de este trabajo es evaluar la calidad, en cuanto a errores de codificacion, de las variables administrativas del CMBD de Osakidetza-Servicio Vasco de Salud. Material y metodos: Estudio descriptivo y retrospectivo realizado mediante la revision de 768 historias clinicas de once hospitales. Periodo de estudio: ano 2005. Los datos obtenidos en las historias clinicas se consideraron el patron de comparacion y se establecio el grado de discrepancia con los datos del CMBD. Las variables administrativas medidas fueron: sexo, fechas de nacimiento, de ingreso, de alta y de la primera intervencion, el tipo de ingreso, la circunstancia del alta y el servicio y el medico responsables del alta. Se utilizo el test de la x2 para medir la variabilidad interhospitalaria del porcentaje de discrepancia entre los datos de las historias clinicas y los registros del CMBD. Resultados: Se analizaron 213.091 altas. El porcentaje de errores en el CMBD oscilo entre el 0,7% en la variable sexo y el 24,9% en la de medico responsable. La variabilidad entre los hospitales fue estadisticamente significativa (p < 0,001). Se observo buena calidad en el registro de seis variables: sexo, fecha de nacimiento, fecha de ingreso, fecha de alta, tipo de ingreso y servicio medico responsable. La calidad resulto deficiente en el registro de las variables: fecha de primera intervencion y medico responsable

Introduccion y objetivos La paraoxonasa 1 (PON1) y la paraoxonasa 2 (PON2) son enzimas antioxidantes cuyos polimorfismos PON1-192 y PON2-311 se han relacionado con el riesgo de infarto agudo de miocardio, con resultados discordantes. El objetivo de este estudio es determinar la asociacion con el riesgo de infarto agudo de miocardio (IAM) de los polimorfismos PON1-192 y PON2-311 y su interaccion. Metodos Se realizo un estudio de casos y controles en el que se recluto a 746 pacientes consecutivos con IAM y 1.796 controles libres de enfermedad cardiovascular seleccionados al azar de la misma poblacion de la que provenian los casos, en 4 comunidades autonomas espanolas entre 1999 y 2000. Se determinaron los polimorfismos PON1-192 y PON2-311, ademas de los factores clasicos de riesgo cardiovascular. Se estimaron modelos de regresion logistica para los analisis multivaribles. Resultados Las odds ratio (OR) del genotipo QQ del polimorfismo PON1-192 y el SS del PON2-311 (presen-tes en el 50 y el 66% de la poblacion, respectivamente) de presentar un IAM fueron 1,26 (intervalo de confianza [IC] del 95%, 1,02-1,55) y 1,25 (IC del 95%, 1,04-1,50), respectivamente, en comparacion con los portadores de los alelos R y C. Ademas, para los sujetos que presentan ambos genotipos QQ y SS, la OR ajustada de tener un IAM se incremento hasta 1,41 (IC del 95%, 1,13-1,76). Conclusiones Nuestros resultados indican que los polimorfismos PON1-192 y PON2-311 son factores de riesgo de IAM independientes en nuestra poblacion.

Introduction and objectives 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. Methods 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. Results 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 [Cl], 1.02-1.55) and 1.25 (95% Cl, 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% Cl, 1.13-1.76). Conclusiones Our results indicate that the PON1-192 and PON2-311 polymorphisms were independent risk factors of AMI in our population.

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.

Fundamento y objetivo Diferencias en la presentacion clinica del infarto agudo de miocardio (IAM), como la edad, la comorbilidad y la frecuencia de sintomas atipicos, podrian condicionar un proceso de cuidados hospitalarios distinto segun el sexo. Este estudio analiza la magnitud y los determinantes de las diferencias entre sexos en la revascularizacion precoz en personas ingresadas por IAM. Pacientes y metodo Se estudio a 2.836 pacientes con IAM que accedieron a cuidados hospitalarios (IBERICA-Pais Vasco). Se estimo el riesgo relativo (RR) de revascularizacion precoz en los varones respecto a las mujeres teniendo en cuenta la edad, la presentacion clinica, los antecedentes y la demora extrahospitalaria. Se aplico la metodologia de descomposicion de efectos y el analisis de regresion log-binomial. Resultados El 29% de los pacientes eran mujeres y su edad mediana, de 77 anos. El RR de revascularizacion de los varones respecto a las mujeres fue distinto segun la edad. Tras ajustar por hipertension arterial, diabetes, Killip III-IV al ingreso y sintomas atipicos, no se apreciaban diferencias significativas a los 45 anos (RR = 0,91; intervalo de confianza [IC] del 95%, 0,77-1,07), mientras que para los mayores de 64 anos, el RR de revascularizacion fue de 1,24 (IC del 95%, 1,05-1,47). Al ajustar por la demora extrahospitalaria, las diferencias por sexo y la interaccion del sexo con la edad no eran significativas. Conclusiones El retraso en el acceso a la atencion sanitaria de las mujeres mayores es causa de las diferencias por sexo en la revascularizacion precoz. Es necesario analizar las razones de esta demora.

Introduccion y objetivos. Determinar el efecto de un tratamiento en estudios observacionales es problematico por las diferencias existentes entre tratados y no tratados. Un metodo propuesto para controlar estas diferencias es calcular la probabilidad condicionada por covariables de recibir el tratamiento, Propensity Score (PS). Presentamos una aplicacion de este metodo analizando la asociacion entre reperfusion y letalidad a 28 dias en pacientes con infarto agudo de miocardio (IAM). Metodo. Se presenta como calcular la PS de recibir reperfusion y las diferentes estrategias para analizar posteriormente su asociacion con la letalidad mediante modelos de regresion y apareamiento. Utilizamos datos de un registro poblacional de IAM realizado en Espana entre 1997 y 1998 que incluyo 6.307 IAM. Resultados. Se calculo la PS de reperfusion en 5.622 pacientes. En el analisis multivariado la reperfusion se asocio con menor letalidad (odds ratio [OR] = 0,59; intervalo de confianza [IC] del 95%, 0,46-0,77); al ajustar ademas por la PS de reperfusion esta asociacion no fue significativa (OR = 0,76; IC del 95%, 0,57-1,01). En el subgrupo de pacientes apareados, tratados y no tratados con PS de reperfusion similar (n = 3.138), este tratamiento no se asocio con letalidad (OR = 0,95; IC del 95%, 0,72-1,26). Controlando el impacto de los casos con datos insuficientes en la PS de reperfusion, esta se asocio con menor letalidad (OR = 0,66; IC del 95%, 0,55-0,80). Conclusiones. El calculo de la PS es un metodo para controlar las diferencias entre los grupos tratado y no tratado. Tiene limitaciones cuando el apareamiento es incompleto o hay datos insuficientes en la PS calculada. Los resultados del ejemplo presentado indican que la reperfusion reduce la letalidad del IAM.

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.

Objetivo: Conocer los impactos en salud percibidos por vecinos y agentes sociales como consecuencia de dos intervenciones de regeneración urbana (nueva lonja de pescado y reordenación de La Herrera Norte/Oeste) en la bahía de Pasaia (Gipuzkoa, España) que han sido objeto de una evaluación del impacto en salud (EIS). Método: Metodología cualitativa. Muestreo teórico e intencional. Generación de información mediante 18 entrevistas personales y cinco grupos de discusión. Análisis conforme al modelo de análisis sociológico del discurso. Triangulación y contraste de los resultados preliminares entre miembros del equipo y participantes del estudio. Resultados: Se identifican cuatro áreas interrelacionadas de impacto en salud: calidad urbana, conectividad, cohesión social y, en menor grado, empleo. Se se˜nalan los aspectos concretos de mejora a tener en cuenta en cada ámbito, así como la influencia del contexto sociopolítico y las concepciones sobre la salud. Las repercusiones del proceso de ejecución de las obras y las diferentes perspectivas según los roles y perfiles sociales de los participantes constituyen hallazgos asimismo importantes. Conclusiones: El conocimiento de las percepciones y expectativas de los afectados mediante los métodos cualitativos aporta elementos e interrelaciones novedosas y necesarias para la aplicación de la EIS como herramienta de mejora de la salud y de participación ciudadana. Aim: 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). Method: 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. Results: 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. Conclusions: 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. Este proyecto se llevó a cabo gracias a la financiación del Departamento de Salud del Gobierno Vasco (Ref. 20011111051).

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.

ResumenCon el objetivo de mejorar el conocimiento de la distribución geográfica de los tumores malignos en la Comunidad Autónoma del País Vasco (CAPV), se analizaron las tasas de incidencia estandarizadas por edad de los 13 tipos de cáncer más frecuentes en cada sexo, en relación con las 27 comarcas geográficas en las que se subdividió la Comunidad. Para la realización de este estudio descriptivo de ámbito poblacional se utilizó el Análisis Factorial de Correspondencia (AFC). Reteniendo los dos primeros factores se explicaba en los hombres el 42% de la varianza y en las mujeres el 40%. El principal hallazgo en el sexo masculino fue la gran desigualdad existente entre Álava Rural y la Zona Minera de Bizkaia. Esta última se caracterizaba por las neoplasias de ganglios linfáticos y de laringe, y la primera por tumores pancreáticos, los prostáticos y los de tejido hematopoyético. Se apreció además un patrón geográfico caracterizado por la diferencia entre las comarcas costeras y las de interior. Este mismo patrón fue el resultado más relevante en las mujeres, siendo responsables de la tendencia costa el cáncer de cavidad oral, el melanoma de la piel y las leucemias, y de la tendencia interior el de vesícula biliar, pulmón y estómago.Los hallazgos del estudio confirman el interés del AFC como método exploratorio y pueden motivar a otros investigadores a utilizarlo con más frecuencia.SummaryWith the aim of improving knowledge about the geographical distribution of malignant tumors in the Autonomous Community of the Basque Country, incidence rates standardized by age of the 13 most frequent cancer types in each sex were analyzed, in relation to the 27 geographical regions the Community was divided into.In order to carry out this population based descriptive study correspondence analysis was used. By retaining the first two factors 42% of the variance was explained in the case of men, and 40% in the case of women. The main finding in the male sex was the marked inequality between Rural Alava and the Mining Area of Bizkaia. The latter was characterized by lymphomas and neoplasms of larynx, and the former by neoplasms of pancreas and prostate and leukaemias. It was also found a geographical pattern distinguished by the difference among regions located in the coast and those located in the inner. This last pattern was the most relevant result in the female sex, cancer of oral cavity, malignant melanoma of skin and leukaemias being responsible for the coast pattern, and neoplasms of gallbladder, lung and stomach for the inner pattern.The findings of this study confirm the interest of Correspondence Analysis as an exploratory method and may encourage other investigators to use it much more frequently.

Health not only depends on biologic or lifestyle factors but also on other economic, social, political, and environmental factors that shape the way people live and become ill. Thus, health policies are not the only policies affecting health, and consequently governments are increasingly interested in identifying the effect of other non-health policies on health. Health impact assessment is a prospective methodology that aims to predict the health impacts of policies before their implementation so that modifications can be suggested to maximize positive effects and avoid unexpected negative repercussions on health. The first stage in this process is screening, which can be used to select the interventions that could benefit from complete health impact assessment. Since resources are limited and not all government interventions can be assessed, tools that allow prioritization are essential. As a first stage in the validation of a systematic screening tool for health impact assessment in Spain, this article presents the process of compiling and classifying the non-health public policies of the eighth term of office of the Basque Government. Of the 97 policies analyzed, 76% were related to structural determinants of health inequalities, 79% were tactical or operational, 67% were aimed at specific population groups, and 66% were already implemented. The technical staff of other participating departments perceived the entire process of this initiative and its rationale positively. This initial experience allowed the planning of non-health policies in the Basque Country to be determined in detail as a means to move forward in incorporating impact on health in all policies.

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.

Health impact assessment is a predictive tool to support decisions in policy-making. Current experience shows that health impact assessment could play an important role in the development of the Health in All Policies strategy. This strategy has been extensively used in other European countries and in a wide range of policy and administrative sectors. Health impact assessment is hardly ever mandatory and is frequently carried out separately from other impact assessments. The use of this process in Spain is relatively new, limited and fundamentally based on local level experiences and the screening of regional interventions. The current normative and organizational reform of public health in Spain provides an excellent opportunity to promote the development of health impact assessment. Some of the barriers to the development of this process are related to the biomedical model of health prevailing among health professionals, politicians, and the general population, political disaffection, lack of assessment culture, underdevelopment of community participation processes, and insufficient intersectoral work. Health impact assessment provides an opportunity to move toward improving the population's health and reducing inequalities in health. Consequently, political commitment, as well as investment in education and research, is needed to introduce and develop health impact assessment in all administrative settings and policy sectors.

Background Social values and the political context have an influence on the use and spread of health impact assessment (HIA). In Spain, there is little experience in HIA but some regional governments are already introducing it. The aim of this article is to describe the health impacts of a local regeneration project to improve accessibility in a neighbourhood of Bilbao (Spain), and discuss the main difficulties, opportunities and challenges of the process, considering the specificities of the social and political context. Methods A concurrent and prospective assessment, based on a broad model of health, was carried out following the Merseyside guidelines. A literature review, community profiling and qualitative data collection were undertaken. Profound involvement of members of the community and key informants was judged as essential in the HIA process. Results The overall expected effect of the new lifts, roads, park and the rainwater collection system was positive. Uncertain or negative impacts were identified in some of those areas, and also concerning the burying of four high-voltage power lines. Historical and current characteristics of the community were highly influential on the way local people perceived the project and its impacts. Likewise, the way in which processes of planning and implementation were developing also played an important role. Conclusion The spread of HIA in southern European countries will depend on the progressive introduction of values underlying HIA, as well as on the promotion of intersectoral work, a better knowledge of the social model of health and community9s participation in policy making.

ResumenLas intervenciones que se realizan desde las administraciones públicas, muy a menudo tienen que ver con los determinantes de la salud. La evaluación del impacto en la salud (EIS) se utiliza como una herramienta predictiva para incorporar la salud en las políticas públicas no sanitarias. En este trabajo se definen la EIS y sus métodos, procedimientos y aplicaciones, y se discuten las oportunidades y los retos que plantea. La realización de una EIS implica estudiar la intervención, caracterizar la población objeto de la intervención y, mediante la combinación de evidencias cuantitativas y cualitativas, estimar sus impactos potenciales sobre la salud. La EIS se ha ido extendiendo a múltiples sectores (transportes, regeneración urbana, cultura, desarrollo energético, etc.), en ámbitos diversos (local, nacional, europeo) y en numerosos países. A pesar de su escaso uso en España, la EIS permite incorporar la salud en la toma de decisiones de las políticas sectoriales, teniendo en cuenta las desigualdades sociales en salud, y desarrollar así políticas públicas más saludables y equitativas. Por otra parte, se trata de una herramienta en pleno desarrollo metodológico, cuya aplicación se ve dificultada por el predominio de la visión biomédica reduccionista de los determinantes de la salud, y por la dificultad de trabajar con enfoques multisectoriales y participativos en las actuaciones del ámbito público.AbstractInterventions implemented by governments are very frequently related to the determinants of health. Health impact assessment (HIA) is used as a predictive tool to include health in nonhealth policymaking. This paper defines HIA, describes its methods, procedures and applications, and discusses opportunities and challenges associated with HIA. Doing a HIA implies studying the intervention, profiling the target population, and estimating its impacts on health by means of combining quantitative and qualitative evidence. HIA has been used in different kinds of policies (transports, urban regeneration, culture, energy development etc.), at different levels (local, national, European) and in many countries. Despite its scarce use in Spain, HIA allows to consider health in sectorial policymaking, taking into account social inequalities in health, so that healthier public policies can be designed. On the other hand, HIA is a tool under methodological development which use is hindered due to the existing narrow biomedical perspective on the determinants of health, and to the difficulties in working in public policy-making with multisectorial and participative perspectives.

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.

The Minimum Basic Data Set (MBDS) is the most used database in the National Health System. The objective of this study is to evaluate the quality, in terms of coding errors of the administrative variables of the MBDS in the Basque Country Health Service.A retrospective, descriptive study by means of reviewing 768 clinical histories from 11 hospitals.the year 2005. The data obtained in the clinical histories were considered comparison standard and the level of discrepancy with the MBDS was established. The administrative variable measured were: sex, dates of birth, admission, discharge and of the first intervention, admission type and circumstances at discharge, department and physician responsible at discharge. The χ(2) was used to measure the between-hospital variability of the percentage discrepancy between the clinical histories and the MBDS records.There were 213,091 discharge reports analysed. The percentage errors in the MBDS varied between 0.7% in the sex variable and 24.9% in the physician responsible variable. The variability between hospitals was statistically significant (p=0.001). Good quality was observed in the records of the six variables: sex, date of birth, admission date, discharge date, admission type and medical department responsible. The records were lacking in the date of first intervention and the physician responsible variables.

Interventions implemented by governments are very frequently related to the determinants of health. Health impact assessment (HIA) is used as a predictive tool to include health in nonhealth policymaking. This paper defines HIA, describes its methods, procedures and applications, and discusses opportunities and challenges associated with HIA. Doing a HIA implies studying the intervention, profiling the target population, and estimating its impacts on health by means of combining quantitative and qualitative evidence. HIA has been used in different kinds of policies (transports, urban regeneration, culture, energy development etc.), at different levels (local, national, European) and in many countries. Despite its scarce use in Spain, HIA allows to consider health in sectorial policymaking, taking into account social inequalities in health, so that healthier public policies can be designed. On the other hand, HIA is a tool under methodological development which use is hindered due to the existing narrow biomedical perspective on the determinants of health, and to the difficulties in working in public policy-making with multisectorial and participative perspectives.

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.