Derivaciones en los centros de salud de Andalucía según el sexo de profesionales y pacientes: un análisis de género.

BACKGROUND It has been identified differences of medical care practice in primary care related to physician's sex. Simultaneously, there are gender inequalities in the assignment of health resources. Both aspects give rise to an increasing growing interest in the management and provision of health services. OBJECTIVES To examine the differences in the referral practice made by female and male primary care physicians working in health centers in Andalusia, to consider whether there are disparities in referrals received by men and women, and to examine the interaction between patient's sex and physician's sex. METHODS Observational, cross-sectional, and multicenter study. POPULATION 4 health districts in Andalucía and their physicians. SAMPLE 382 physicians. MEASUREMENTS referral rate per visit (RV), referral rate per patient quota (RQ), patient's sex, physician: sex, age, postgraduate family medicine specialty, size of the patient quota by sex, mean number of patients/day by sex, mean age of the patient quota by sex, and proportion of men in the quota. Health center: urban / rural, size of the team, enrolled population, and postgraduate family medicine specialty's accreditation. SOURCES databases of health districts. PERIOD OF STUDY 2010. ANALYSIS Bivariate and multivariate multilevel analysis of the referral rate per visit with mixed Poisson model. RESULTS In 2010 382 physicians made 129,161 referrals to specialized care. The RQ was 23.47 and the RV was 4.92. The RQ in women and men was 27.23 and 19.78 for women physicians, being 27.37 and 19.51 for male physicians. The RV in women and men was 4.92 and 5.48 for women physicians, being 4.54 and 4.93 for male physicians. CONCLUSION There are no differences in referral according to physician's sex. However, there are signs that might indicate the existence of gender inequality, and women patient received less referrals. There are no physician-patient's sex interaction.

Cerebral metabolic effects of exogenous lactate supplementation on the injured human brain.

PURPOSE: Experimental evidence suggests that lactate is neuroprotective after acute brain injury; however, data in humans are lacking. We examined whether exogenous lactate supplementation improves cerebral energy metabolism in humans with traumatic brain injury (TBI). METHODS: We prospectively studied 15 consecutive patients with severe TBI monitored with cerebral microdialysis (CMD), brain tissue PO2 (PbtO2), and intracranial pressure (ICP). Intervention consisted of a 3-h intravenous infusion of hypertonic sodium lactate (aiming to increase systemic lactate to ca. 5 mmol/L), administered in the early phase following TBI. We examined the effect of sodium lactate on neurochemistry (CMD lactate, pyruvate, glucose, and glutamate), PbtO2, and ICP. RESULTS: Treatment was started on average 33 ± 16 h after TBI. A mixed-effects multilevel regression model revealed that sodium lactate therapy was associated with a significant increase in CMD concentrations of lactate [coefficient 0.47 mmol/L, 95% confidence interval (CI) 0.31-0.63 mmol/L], pyruvate [13.1 (8.78-17.4) μmol/L], and glucose [0.1 (0.04-0.16) mmol/L; all p < 0.01]. A concomitant reduction of CMD glutamate [-0.95 (-1.94 to 0.06) mmol/L, p = 0.06] and ICP [-0.86 (-1.47 to -0.24) mmHg, p < 0.01] was also observed. CONCLUSIONS: Exogenous supplemental lactate can be utilized aerobically as a preferential energy substrate by the injured human brain, with sparing of cerebral glucose. Increased availability of cerebral extracellular pyruvate and glucose, coupled with a reduction of brain glutamate and ICP, suggests that hypertonic lactate therapy has beneficial cerebral metabolic and hemodynamic effects after TBI.

Clinical intervals and diagnostic characteristics in a cohort of prostate cancer patients in Spain: a multicentre observational study.

BACKGROUND Little is known about the healthcare process for patients with prostate cancer, mainly because hospital-based data are not routinely published. The main objective of this study was to determine the clinical characteristics of prostate cancer patients, the, diagnostic process and the factors that might influence intervals from consultation to diagnosis and from diagnosis to treatment. METHODS We conducted a multicentre, cohort study in seven hospitals in Spain. Patients' characteristics and diagnostic and therapeutic variables were obtained from hospital records and patients' structured interviews from October 2010 to September 2011. We used a multilevel logistic regression model to examine the association between patient care intervals and various variables influencing these intervals (age, BMI, educational level, ECOG, first specialist consultation, tumour stage, PSA, Gleason score, and presence of symptoms) and calculated the odds ratio (OR) and the interquartile range (IQR). To estimate the random inter-hospital variability, we used the median odds ratio (MOR). RESULTS 470 patients with prostate cancer were included. Mean age was 67.8 (SD: 7.6) years and 75.4 % were physically active. Tumour size was classified as T1 in 41.0 % and as T2 in 40 % of patients, their median Gleason score was 6.0 (IQR:1.0), and 36.1 % had low risk cancer according to the D'Amico classification. The median interval between first consultation and diagnosis was 89 days (IQR:123.5) with no statistically significant variability between centres. Presence of symptoms was associated with a significantly longer interval between first consultation and diagnosis than no symptoms (OR:1.93, 95%CI 1.29-2.89). The median time between diagnosis and first treatment (therapeutic interval) was 75.0 days (IQR:78.0) and significant variability between centres was found (MOR:2.16, 95%CI 1.45-4.87). This interval was shorter in patients with a high PSA value (p = 0.012) and a high Gleason score (p = 0.026). CONCLUSIONS Most incident prostate cancer patients in Spain are diagnosed at an early stage of an adenocarcinoma. The period to complete the diagnostic process is approximately three months whereas the therapeutic intervals vary among centres and are shorter for patients with a worse prognosis. The presence of prostatic symptoms, PSA level, and Gleason score influence all the clinical intervals differently.

Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study.

BACKGROUND: Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia. METHODS: Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR). RESULTS: A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant. CONCLUSIONS: Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.

Contextual effects on subjective national identity and nationalist vote in Catalonia

The important inflow of foreign population to western countries has boosted the study of acculturation processes among scholars in the last decades. By using the case of Catalonia, a receiver region of international and national migration since the fifties, this paper seeks to intersect a classic acculturation model and a newly reemerging literature in political science on contextual determinants on individual behavior. Does the context matters for understanding individual’s subjective national identity and, therefore, its voting behavior? Multilevel models show that environment matters. Percentage of Spain-born population in the town is statistically significant to account for variance in the subjective national identity and nationalist vote, even after controlling for age, sex, origin, language and left – right orientation and other contextual factors. This conclusion invites researchers not to underestimate the direct effect of the environment on individual outcomes such as feelings of belonging and vote orientation in contexts of rival identities.

Social Determinants of Child Health in Colombia: Can Community Education Moderate the Effect of Family Characteristics?

Contextual effects on child health have been investigated extensively in previous research. However, few studies have considered the interplay between community characteristics and individual-level variables. This study examines the influence of community education and family socioeconomic characteristics on child health (as measured by height and weight-for-age Z-scores), as well as their interactions. We adapted the Commission on Social Determinants of Health (CSDH) framework to the context of child health. Using data from the 2010 Colombian Demographic and Health Survey (DHS), weighted multilevel models are fitted since the data are not self-weighting. The results show a positive impact of the level of education of other women in the community on child health, even after controlling for individual and family socioeconomic characteristics. Different pathways through which community education can substitute for the effect of family characteristics on child nutrition are found. The interaction terms highlight the importance of community education as a moderator of the impact of the mother’s own education and autonomy, on child health. In addition, the results reveal differences between height and weight-for-age indicators in their responsiveness to individual and contextual factors. Our findings suggest that community intervention programmes may have differential effects on child health. Therefore, their identification can contribute to a better targeting of child care policies.

How Answers on Political Attitudes are Shaped by Interviewers: Evidence from a Panel Survey

We analyze whether the interviewers' political opinions have an influence on those of the respondents. The research uses data from a panel survey in which interviewers are randomly assigned to respondents. The results show that the respondents express significantly similar opinions to those of the interviewers in all questions considered. Multilevel models show that more educated respondents are affected to a slightly higher extent and that the interviewer's experience is also a factor. There is no difference between different respondent subgroups or when both interviewers and respondents share the same socio-demographic characteristics. While there is no evidence for respondents wanting to please the interviewers, the hypothesis of socially desirable behavior can indeed be confirmed.

Cross National Contact Strategies

Using paradata gathered from the 11-nation Survey of Health, Ageing and Retirement in Europe (SHARE), this paper examines the impact of the first contact attempt and the first contact properties, respectively, on contact and response efficiency using logistic multilevel models. We find that despite the different sample frames and interviewer compensation structure between countries, there are no considerable country effects with respect to making contact, once interviewer effects are controlled. Moreover, results point to an increased efficiency associated with evenings especially on Sundays, at least on the very first contact attempt. For attempts that result in initial contact, Saturday afternoons are most likely to eventually lead to completed interviews, followed by initial contact on weekdays during the daytime. We hypothesize that this may be due to the SHARE sample being composed of people aged 50 and over.

The Nationalism of stateless nations and Europe. The Catalan case

This paper analyzes how the ideas and concepts of Europe have developed in Catalonia, under the conditions of a decentralizing “nation-state” (Spain) on one hand, and the European integration process on the other. It analyzes the programmes, manifestations of political leaders, and political actions of the Catalan political parties, specially the nationalists, from the setting up of the Spanish state of autonomies (1977-1982) until today. The paper tries to show how, in multilevel governance, holistic and enthusiastic visions of an economically and political integrating Europe as a “natural ally” of a Catalan nationalism were partially replaced by more pragmatic and even more critical assessments.

Asessing public policies. The case of education in Europe and the interaction between personal and institutional factors

The paper deals with the comparative study of European citizens' satisfaction with the state of education in their respective countries. Individual and contextual effects are tested applying multilevel analysis. The results show that educational public policies (level of decentralization, degree of comprehensiveness and public spending) as well as the students' social environment (socioeconomic and cultural status) have a sound impact on the opinions about the state of education.

Drug Utilization Studies and Data Registries in Primary Care.

This article reviews the methodology of the studies on drug utilization with particular emphasis on primary care. Population based studies of drug inappropriateness can be done with microdata from Health Electronic Records and e-prescriptions. Multilevel models estimate the influence of factors affecting the appropriateness of drug prescription at different hierarchical levels: patient, doctor, health care organization and regulatory environment. Work by the GIUMAP suggest that patient characteristics are the most important factor in the appropriateness of prescriptions with significant effects at the general practicioner level.

Relatório dos Progressos Realizados para Atingir os ODM

Com o virar do século a Organização das Nações Unidas (ONU) decidiu que era propício e muito simbólico dar um novo impulso à própria Organização e comprometeu-se a combater a pobreza e as doenças que vitimam milhões de crianças em todo o mundo, a maioria das quais com menos de cinco anos, devido a causas totalmente evitáveis como a malária, a diarreia e a pneumonia. Assim, a 8 de Setembro de 2000, 189 Estados membros das ONU adoptaram os “Objectivos de Desenvolvimento do Milénio” (ODM) surgidos da Declaração do Milénio. Foram definidos oito objectivos — cada um deles, um compromisso específico para inverter a propagação da pobreza e das doenças — que são suportados por um Plano de Acção com 18 metas quantificáveis para combater a pobreza, a fome, a doença, o analfabetismo, a discriminação contra a mulher e a degradação ambiental. Muitas das metas dos ODM reflectem um nível de ambição modesto em termos de desenvolvimento humano que os países da ONU se comprometeram a atingir até 2015. Os Objectivos representam igualmente uma parceria entre países desenvolvidos e em desenvolvimento tendo em vista criar um clima a nível nacional e mundial conducente ao desenvolvimento e à eliminação da pobreza. Essa parceria atribui responsabilidades muito claras aos países ricos em termos de prestação de mais ajuda; estabelecimento de regras comerciais mais justas; e alívio significativo da dívida dos países em desenvolvimento. Por seu turno os países em desenvolvimento comprometem-se a vencer o desafio que os ODM colocam. Cabo Verde aceitou o desafio lançado pela ONU para implementar um conjunto de acções estratégicas para que até o ano 2015 um conjunto de objectivos e metas seja realizado. Essa assumpção impõe a integração das metas e indicadores ODM nas políticas públicas nacionais.

Paisagens Naturais” como Recursos Turísticos: o caso do Parque Natural de Serra da Malagueta na Ilha de Santiago, Cabo Verde

Esta dissertação coloca em evidência o valor das “Paisagens Naturais” como recursos turísticos, sendo o estudo de caso é o parque natural de Serra da Malagueta, em Cabo Verde, ilha de Santiago. A consciencialização da necessidade de preservar os valores naturais (assumida na actividade turística a partir de 1993, com elaboração da Agenda 21), necessidades psicológicas de encontrar alternativas para lazer e recreio diferentes das dos centros urbanos, necessidade de contacto com formas simples de viver e a busca de uma maior interacção com a Natureza, são factores que influenciaram o surgimento do turismo sustentável, o que valorizou a “Paisagem Natural” que pode ser encontrado nos parques naturais. Os componentes dos parques naturais constituem ofertas potenciais para actividades alternativas de lazer e recreio, daí utilizadas para diversas actividades turísticas de Natureza. A sua concretização implica a intervenção humana para ordenar os usos relativamente às componentes naturais, o que implica a criação de serviços básicos (informação, alojamento, restauração, animação cultural, ambiental). Tal tem conduzido a que alguns parques naturais tenham evoluído de simples recurso natural para destinos turísticos. A sua gestão como destinos turísticos deve complementar a gestão dos processos naturais que ali têm origem, por isso no seu planeamento devem ser incluídas acções de formação dos intervenientes. Este procedimento aumentará a eficácia das actividades turísticas e minimizar-se-á os aspectos negativos, que poderão advir do uso público dos parques naturais, de modo a serem pólos de desenvolvimento local pela sua diferenciação como produtos turísticos, relativamente aos convencionais. Esta deve ser uma das vias a ser seguida em Cabo Verde, pois predomina o turismo de sol e praia. O turismo cultural e de Natureza aparecem como “produtos secundários”, o que não tem favorecido a integração dos diversos parques naturais. Contudo, é frequente encontrar alguns operadores turísticos nacionais a enviarem os turistas aos parques naturais para visitas, mas alguns são usados só como pontos de passagem. Tal deve-se à inexistência de ofertas de alojamento, restauração e animação, o que não tem trazido nenhum benefício para as comunidades locais, situação verificada no parque natural de Serra da Malagueta, objecto deste estudo. Para inverter esta tendência as intervenções devem passar pela instalação dos serviços em falta, regulamentar as actividades do turismo de Natureza, envolver a população local e promover o conhecimento do parque natural junto dos consumidores turísticos.

Emotion and reason in everyday risk perception

Although research has documented the importance of emotion in risk perception, little is knownabout its prevalence in everyday life. Using the Experience Sampling Method, 94 part-timestudents were prompted at random via cellular telephones to report on mood state and threeemotions and to assess risk on thirty occasions during their working hours. The emotions valence, arousal, and dominance were measured using self-assessment manikins (Bradley &Lang, 1994). Hierarchical linear models (HLM) revealed that mood state and emotions explainedsignificant variance in risk perception. In addition, valence and arousal accounted for varianceover and above reason (measured by severity and possibility of risks). Six risks were reassessedin a post-experimental session and found to be lower than their real-time counterparts.The study demonstrates the feasibility and value of collecting representative samples of data withsimple technology. Evidence for the statistical consistency of the HLM estimates is provided inan Appendix.

Modelos estadísticos y evaluación: tres estudios en educación

The educational system in Spain is undergoing a reorganization. At present, high-school graduates who want to enroll at a public university must take a set of examinations Pruebas de Aptitud para el Acceso a la Universidad (PAAU). A "new formula" (components, weights, type of exam,...) for university admission is been discussed. The present paper summarizes part of the research done by the author in her PhD. The context for this thesis is the evaluation of large-scale and complex systems of assessment. The main objectives were: to achieve a deep knowledge of the entire university admissions process in Spain, to discover the main sources of uncertainty and topromote empirical research in a continual improvement of the entire process. Focusing in the suitable statistical models and strategies which allow to high-light the imperfections of the system and reduce them, the paper develops, among other approaches, some applications of multilevel modeling.