After several exploratory and confirmatory clinical trials, the intralesional administration of human recombinant epidermal growth factor (hrEGF) has been approved for the treatment of advanced diabetic foot ulcers (DFU). The aim of this work was to evaluate the effectiveness and safety of this procedure in medical practice.A prospective, post-marketing active pharmacosurveillance was conducted in 41 hospitals and 19 primary care polyclinics. Patients with DFU received hrEGF, 25 or 75 μg, intralesionally 3 times per week until complete granulation of the ulcer or 8 weeks maximum, adjuvant to standard wound care. Outcomes measured were complete granulation, amputations, and adverse events (AE) during treatment; complete lesion re-epithelization and relapses in follow-up .The study included 1788 patients with 1835 DFU  treated from May 2007 to April 2010. Complete granulation was observed in 76% of the ulcers in 5 weeks (median). Ulcer non-ischemic etiology  and age  were the main variables with influence on this outcome. During treatment, 220 (12%) amputations (171 major) were required in 214 patients, mostly in ischemic or Wagner’s grade 3 to 5 ulcers. Re-epithelization was documented in 61% of the 1659 followed-up cases; 5% relapsed per year. AE (4171) were reported in 47% of the subjects. Mild or moderate local pain and burning sensation, shivering and chills, were 87% of the events. Serious events, not related to treatment, occurred in 1.7% of the patients.The favorable benefit/risk balance, confirms the beneficial clinical profile of intralesional hrEGF in the treatment of DFUs. Pharmacovigilance and post-marketing studies are key elements to monitor the safety and effectiveness of approved drugs. They are excellent scenarios to confirm and extend the safety profile and efficacy data acquired in previous clinical trials.Products for the treatment of diabetic foot ulcers (DFU) available in the market have been scarcely effective in advanced and/or ischemic lesions . NecrotiA new procedure has been recently developed for the treatment of these advanced DFU based on the intralesional infiltration of recombinant, human epidermal growth factor (rhEGF) as a lyophilized formulation under the brand name Heberprot-P®. The rationale of this procedure has been published and reviewed recently ,3.Exploratory -6 and coIn April 2007 this treatment was included in the country’s Basic Drugs List and its use was extended to all Angiology services, firstly in the secondary healthcare level  and subsequently in the primary level (polyclinics).At the same time, postmarketing active surveillance was initiated in order to evaluate the effectiveness and safety of the drug in the current medical practice. This article reports the first results of this surveillance.A multicenter, prospective, intensive, post-marketing surveillance was conducted on patients treated from May 2007 to April 2010; follow-up extended to December 2011. The study was coordinated by the Center for the Development of Pharmacoepidemiology (CDF) from the Cuban Ministry of Health and its national network. There were 41 participating hospitals from the 15 Cuban provinces and 19 polyclinics from 7 provinces.2 or larger DFUs were prescribed with rhEGF and included. The indication comprised Wagner’s [Patients, more than 18 years-old, suffering from 1 cmLesion etiology was classified as ischemic or not. When the ankle/brachial index (ABI) was available, patients with values below 0.75 were considered ischemic, following the same criterion used in the clinical trials. Otherwise, clinical signs of ischemia such as absence of pulses , intermittent claudication, pain, local atrophy, coldness, and hair loss were taken into account for this classification.Since it was not feasible to standardize the ulcer size measurement among so many clinical sites, lesion extension-location was considered in three categories: (i) simple, if the ulcer covered only one region of the foot ; (ii) complex, if the extension of the ulcer comprised several regions but not the heel, and (iii) calcaneal if this region was involved.The treatment was as in-patients, although ambulatory care was allowed if the subject could attend the treatment visits. The standard care included the patient’s metabolic control, lesion area sanitation and systematic cures, sharp debridement of the necrotic or infected tissue with minor amputation of the affected zones if necessary, and moist gauze dressing. Wide spectrum antimicrobial drugs were prescribed in patients exhibiting local clinical signs of infection. Pressure off-loading of the affected zones was recommended as well.The product  is lyophilized, containing 75 or 25 μg of rhEGF per vial, to be dissolved with 5 ml of water for injection. In every visit this volume was distributed throughout the lesion in 0.5–1 ml injections. The solution was injected first into the dermo-epidermal junction at equidistant points all over the lesion contours and then downward into the wound bottom to ensure a uniform distribution. The needle was changed for each puncture. The product label indicates injections 3 times per week (tpw) on alternate days. However, in some cases the physicians decided to modify the schedule to daily, twice or once per week. A treatment cycle continued until complete granulation was achieved, lesion closed by autografting or 8 weeks maximum.2 and non-ischemic), but the choice was also determined by each physician’s criteria, his/her experience with this product, and the availability of either drug presentation in the healthcare unit at a certain moment.The rhEGF dose (25 μg or 75 μg) was selected according to the label , relapses, and patient’s survival were evaluated.ad hoc for this purpose. SAE reported were included in the Cuban Pharmacosurveillance System Database, which guarantees the absence of duplicated data when processing reports received from different sources.The variables used to evaluate safety were the adverse events (AE) during the treatment period, considering the type of event, organ and system affected , its serInformation was gathered by the physicians in case report forms (CRF) which covered the in-patient treatment period. Patients’ final outcome was collected in a further follow-up visit, done by the hospital or municipality pharmaco-epidemiology staff, scheduled annually. Emphasis was placed on the training of the personnel in all aspects related to the drug safety evaluation.Deaths during treatment were further investigated by review of the clinical records and, if necropsy was performed, its report. Causes of death were taken from the death certificates, coded according to the International Classification of Disease-10.The occurrence of any type of cancer was actively investigated through: (i) direct interview to the patient in the follow-up visits; (ii) cross-search in the National Cancer Registry (NCR), or (iii) findings in the National Mortality Registry. The latter cross search was also useful for the identification and confirmation of follow-up period deceases.One patient could be treated more than once for the same or a different lesion at different moments. Then the experimental unit considered was the treatment cycle, since each of them generated one CRF. Short term AE were evaluated on this basis. The lesion was the unit taken into account for the analyses of granulation, amputations, healing, and relapses. Survival and long term AE were done on patient basis.The statistical treatment of the data was conducted with the PASW 18.0 software. Measures of central tendency and dispersion such as mean, median, standard deviation (SD), 95% CI, quartile range (QR), minimal and maximal values, were calculated to describe quantitative variables. Graphical normality analysis (QQPlot) and Kolmogorov-Smirnov test for goodness of fit were applied. The chi-square values were calculated to evaluate dependency among qualitative variables. Time variables were estimated using Kaplan-Meier plots and compared with the log-rank test. Logistic or Cox regression models were adjusted to assess the influence of control variables on the outcomes. For the variable-association analyses only the results from the first treatment cycle on each patient were taken into account to avoid considering non-independent observations. Safety related variables were subjected to descriptive statistics. A Bayesian approach was used for the benefit-risk ratio analysis.CRFs were available from 1788 subjects bearing 1835 DFU. This population represents approximately 80% of all the DFU patients treated with rhEGF in the study period, according to weekly reports received at CDF. Of them, 1676 (93.7%), were seen in hospitals and 112 (6.3%) in polyclinics. Most of the patients  received one treatment cycle; 56 (3.1%) were given two cycles; four of them simultaneously on two different lesions and 3 (0.2%) had three cycles. Therefore the whole patient population received 1851 treatment cycles with rhEGF.The main demographic characteristics are shown in Table There were some treatment schedule deviations according to doctors’ decisions: 267 Wagner’s grade 1, 2, or 5 ulcers  were treated as off-label indications; 281 ischemic lesions (36%) were treated with the 25 μg dose; 50 lesions were treated with both doses, considered as 75 μg for the analyses; the three tpw schedule was not followed strictly (see next paragraph); 48 treatment cycles comprised more than 24 injections.The 75 μg dose was given more frequently to Wagner’s grades 3–5 ulcers (61%) than to less severe cases (53%) and to patients with ischemia (64%) than without it (54%). The thrice weekly regime was the most frequently used. However, some cases were treated daily (9%) or less than three tpw (14%). The median number of infiltrations was 10 (range 1–47). The median total exposure to rhEGF was 500 μg (range 25–3825).Interruptions occurred in 462 treatment cycles (25%). The causes were: voluntary abandon in 200 (10.8%) cases; worsening of the lesion in 207 (11.2%); local hypergranulation in 16 (0.9%), and other AE in 39 (2.1%).Complete granulation was achieved in 76% of the ulcers at the end of treatment Table . This faAt the end of treatment 214 patients required 220 amputations (12%)  in 46% (856/1851) of the treatment cycles in 838 subjects (47%). The AE occurring in more than 1% of the patients and the maximal number of repetitions of the event in any subject are summarized in Table The 31 SAE reported are shown in Table The benefit/risk ratio is presented in Figure Post-treatment follow-up information was obtained from 1620 subjects (91%) with 1659 ulcers, at least once during the 4 years after the end of treatment. The follow-up period  comprised 2270.6 years-person. The baseline and demographic characteristics of the followed-up subjects do not differ from the whole patient population (data not shown). Complete ulcer re-epithelization was achieved in 55% of all the lesions , 61% of those evaluated (Table During treatment or follow-up 352 patients (20%) died. Table During the follow-up 42 subjects were identified with neoplasia, not diagnosed before treatment. None of them was on the rhEGF treated region. Locations were: breast (11), colon (5), prostate (4), uterus (4), bladder (2), lung (3), peritoneum (2), and skin basal cell, rectum, endometrium, stomach, fibrosarcoma, pancreas, kidney, pharynx, spinal column, mouth, and not specified, one each. Cancer was not related to the extent of exposure to rhEGF treatment: all these patients had received one treatment cycles; the average exposure was 535 μg of rhEGF (range: 75–2100 μg).The postmarketing surveillance covered all the Angiology wards that manage DFU in Cuba and some primary care units that have incorporated this drug as part of the diabetic patients integral care program. The demographic and baseline characteristics of the subjects parallel those of people with DFU that took part in the clinical trials with this procedure -7: predoSome deviations from the labeled pattern of hrEGF application were seen, which were due to doctors’ preference, according to their judgment of the patient’s evolution. In some cases, ambulatory patients could not attend all the visits. The dose deviations were also determined, eventually, by product availability at a given moment. The off-label use of medicaments, particularly biologics, is not a seldom practice in many settings as part of the common medical practice ,16.Treatment interruptions were mainly due to failure that determined amputation mostly in ischemic, Wagner’s 3–5 lesions. Very few were because of patients’ intolerance (AE or voluntary abandonments). Hypergranulation is noteworthy since it is due to the same mechanism of healing enhancement. It was easily controlled by tissue excess removal and there is no information of related sequels, such as hypertrophic scars or keloids.The results of the previous clinical trials with intralesional hrEGF  were confirmed in this study. The re-epithelization rate found falls within the pooled analysis of the clinical trials too: 59.2%; 95% CI: 53.4– 64.5% . The relThe main variables with influence on the treatment effectiveness, both for granulation and re-epithelization, were ischemia and age, which are well-known adverse prognosis factor for ulcer healing . HoweverAlthough this work did not include a non-treated control group to measure the impact of the treatment on amputation rate, other independent investigations in additional patient series have made such comparisons. González-Acosta et al. found a major amputation rate reduction from 26.7% to 8.3% when intralesional rhEGF was added to conventional standard care . García-The most frequently observed AE such as pain and burning sensation at the injection site, shivering, chills, and local infection coincide with the reported intralesional hrEGF safety profile -7.Local infection is one of the most fearsome AE because it frequently leads to amputation. Approximately 60% of amputations are preceded by infected ulcers . Local iThere is not enough information to relate cardiovascular AE and deaths to the treatment, since the patients have frequent antecedents of cardiovascular diseases. The relationship of diabetes and cardiovascular diseases is well known, moreover if DFU is present ,34. In dA particular concern on the use of growth factors is the possibility of development or stimulation of a pre-existing malignancy. Contrary to PDGF, EGF cannot initiate malignant transformation  and resuIn summary this postmarketing, prospective study is consistent with earlier findings from exploratory and confirmatory clinical trials, while extending the data to a larger clinical setting. The positive findings, related to the clinical evolution of the patients treated at secondary and primary Cuban healthcare levels, suggest a relevant role of this drug in the treatment of DFUs. Further clinical research and post-marketing information from other countries should enrich the evidence shown in this paper.Patient recruitment, treatment and follow-up.Health Unit, Province (number of treatment cycles performed), investigators: “Camilo Cienfuegos” Hospital, Sancti Spíritus (211): Regla Soto-Águila (province coordinator), Pablo Sánchez Pentón, Irelio Borroto Carpio, Reidel Veloso, Yanet Hernández, Ana Tavio Reyes, Mayilé Gómez, Liliam Moreno Perera; “Gustavo Aldereguía Lima” Hospital, Cienfuegos (154): Ivonne Marrero Rodríguez, Belkis Calaña González Posada, Ivette García, Mabel Medina, Nancy Ramírez, Sahily González Acosta, Yadira Alonso, Javier Borrego; “Abel Santamaría” Hospital, Pinar del Río (128): Martha Moreira Martínez, Aida Hernández, Antonio Díaz Díaz, Agustina Gómez García Yanet Crespo, Etty Chirolde, Laureano Peña Bazant Pérez Jose Ortega Baez, Ana Lidia Hernández Méndez; “Arnaldo Milián” Hospital, Villa Clara (101): Teresita Fleito Castex, Felicia García, Seco, Angel Alfaro, Cecilio González Benavidez; “Lucía Iñiguez” Hospital, Holguín (99): Armando González, Eneida Caraballosa, Esther Peña, Isel Sánchez Mirna Enel Pérez Muñoz; “Carlos M. de Céspedes” Hospital, Granma (95): Francisco Vázquez, José Ortega, Juan Planas Brooks, Juan Carrazona, Eberto Caravana; “Antonio Luaces Iraola” Hospital, Ciego de Ávila (87): José Hernández Cañete, Mislene Álvarez Hernández, Xiomara Herrera, Jorge Herrera Zamora; “Manuel Ascunce” Hospital, Camagüey (84): Ariel Hernández Varela, Yanor Agüero, Fidel Rivero Fernández, Raúl Romay Boitrago, Jorge Luis Valdez, Nicolás Socarras, Pedro Vejerano, Ramón Bentrogo, Misleidis González Cedeño, Nelina Morales, Odalis Escalante; “José R. López Tabranes” Hospital, Matanzas (77): Edel Fleitas Pérez, Leydis Hernández Rodríguez, Jaqueline Ramos Serpa, Martha Jiménez, Arístides García Herrera, Elizabeth Cao, Isis de la Caridad Abreu Jiménez, Daymar Bom Pérez, Yadira García; “Agostinho Neto” Hospital, Guantánamo (72): Zulema Mena, Georgina Grave de Peralta, Vladimir Sarrión; “Ernesto Guevara” Hospital, Las Tunas (58): Dianelis González, Zulema Elliot Pérez, José Luis Solis, José Luis Rivero Miranda, José Pablo Ponce; “Ambrosio Grillo” Hospital, Santiago de Cuba (57): Emilio Goulet, Lisandra Betancourt, Alina Echevarría, Jorge Lockhant; “Enrique Cabrera” Hospital, Havana (44): Heriberto Artaza Sans, Sandra González Pelegrí, Angela Blanco Díaz, Natalia Poll Marrón, Evaristo Vargas Machirán, Eduardo Atencio Soriol, Pedro Goicochea Díaz; “Julio Arestegui” Hospital, Matanzas (37): Leitter Pérez, Juan Díaz; “Julio Trigo” Hospital, Havana (36): Reinaldo Martínez Garrido; “Saturnino Lora” Hospital, Santiago de Cuba (36): Natacha Sancho Sueto, Arelis Frómeta, David Díaz, Hever Viguera, Mayelin Sabourit; “Amalia Simoni” Hospital, Camagüey (35): Alberto Álvarez Varona, Jorge Gómez , Gustavo Pérez Hechevarría, Denny González, Victor Alfonso; “Guillermo Domínguez” Hospital, Las Tunas (29): Wilber Velázquez Chacón; “Calixto García” Hospital, Havana (26): Osmel Castillo, Aimeé Rodríguez Hernández, María Campos, Remberto García, Joaquín David Liziaga Vázquez, Julio César Nuñez Vázquez; “Joaquín Castillo” Hospital, Santiago de Cuba (26): Bencay Joa Liranza; Octavio de la Concepción Hospital, Guantánamo (26): Arturo Pons; “Celia Sánchez” Hospital, Granma (24): Odelaisys Hernández Saborit, Sergio Fernández; “Victoria de Girón” Polyclinic, Santiago de Cuba (23): Carlos Calderón, Orlando San Pedro; “Carlos Font” Hospital, Holguín (22): Tamara Pérez; “Roberto Rodríguez” Hospital, Ciego de Ávila (22): Elier del Castillo, Jorge Morales Florat; “Alcides Pino” Polyclinic, Holguín (20): María Antonia Rodríguez, Tania García; “Mártires de Mayarí” Hospital, Holguín (19): Isabel Carrasco, Eneida Caraballosa; Military Hospital, Holguín (18): Pedro Matos García, Olides Cobas Díaz, Daniel Rodríguez Curí; “Diez de Octubre” Hospital, Havana (17): Deysi Acosta Lapera, Héctor Chivas, Manuel Hernández Rivero; National Institute for Angiology and Vascular Surgery, Havana (17): José Fernández Montequín , Calixto Valdez Pérez, José Llanes Barrios, Williams Savingne Gutierrez, Neobalis Franco Pérez, Daniel Reynaldo Concepción; “Comandante Manuel Fajardo” Accommodation, Havana (13): Reyna Lourdes Morejón Vega; “Manuel Fajardo” Hospital, Havana (12): Milagros Romero Gamboa, Máximo Sander López; “Orlando Pantoja” Hospital, Santiago de Cuba (12): Raúl Mesa; “Máximo Gómez” Polyclinic, Granma (12): Rafaela Rondón; “Ciro Redondo” Hospital, Artemisa (11): Odelaysis Hernández Saborí; “Aleida Fernández” Hospital, Mayabeque (11): Pedro González, Vicente Vega Mederos; “Comandante Pinares” Hospital, Artemisa (8): José Ortega Baez; “Martha Abreu” Polyclinic, Villa Clara (8): Juan Miguel García Velázquez; “XXX Anniversary” Polyclinic, Villa Clara (7): Juan Miguel García Velázquez; “Edor Reyes” Polyclinic, Granma (6): Salvador Oliva; “Roberto Fleites” Polyclinic, Villa Clara (6): Juan Miguel García Velázquez; “Miguel Enriquez” Hospital, Havana (5): Luis Olivera Baez, Justa Peñalver; “Santa Cruz del Sur” Hospital, Camagüey (5): Luis Gustavo Cisneros; Banes Hospital, Holguín (4): Antonio Ricardo García; “XXX Aniversario” Hospital, Villa Clara (4): Juan Miguel García Velázquez; Camilo Cienfuegos Polyclinic, Havana (3): Carmen Luisa Ramos; “Manuel A Varona” Polyclinic, Camagüey (3): Esteban Lopez; “Tamara Bunke” Polyclinic, Holguín (3): Luis Aguilar; “Gustavo Aldereguía” Hospital, Holguín (2): Manuel Balán; “Juan Bruno Zayas” Hospital, Santiago de Cuba (2): Rolando Castillo; “San Luis” Polyclinic, Pinar del Río (2): Aida Rosa Hernández; “XX Anniversary” Polyclinic, Villa Clara (2): Juan Miguel García Velázquez; “19 de Abril” Polyclinic, Havana (2): Reyna Lourdes Morejón Vega; “Wajay” Polyclinic, Havana (2): Angela Blanco Díaz; “Colón” Hospital, Matanzas (1): Alejandro Piedra-Fita Tejeda; “Mario Muñoz” Hospital, Matanzas (1): Maylin Torres; “Ramón Pando Ferrer” Polyclinic, Villa Clara (1): Juan Miguel García Velázquez; “Santa Clara” Polyclinic, Villa Clara (1): Juan Miguel García Velázquez; “Isabel Rubio” Polyclinic, Pinar del Río (1): Aida Rosa Hernández; “Raúl Sanchez” Polyclinic, Pinar del Río (1). Aida Rosa Hernández.Monitoring, data management, and analyses.Center for the Development of Pharmacoepidemiology: Isis Belkis Yera Alós, Liuba Carbonell Alonso, Julián Pérez Peña, Francisco Debesa García, Alina Alvarez Crespo, Ismary Alfonso Orta, Giset Jiménez López, Jenny Ávila Pérez, Ana García Milián, Aleida Díaz Hernández; National Pharmacoepidemiology Network: Yumara Díaz Castro (Pinar del Río), Gustavo Rodríguez (Artemisa–Mayabeque), Deborah Rodríguez Piñeiro (Havana), Adis Martín (Havana), Lia Mónica Bravo (Havana), Loida Báez (Havana), Armando Morri (Havana), Leydis Santos Muñoz (Matanzas), Miraida Baute (Cienfuegos), Luis Orlando Rico Martell (Ciego de Ávila), Orlando René Águila González (Villa Clara), Betania Rodríguez (Sancti Spíritus), Natacha Caballero (Camagüey), Soraida García (Las Tunas), Maria Elena Fernández Tablada (Holguín), Gloria Zaldivar (Holguín), Zayda Herrera López (Holguín), Yeraldis Ramírez Calzadilla (Granma), Sheila Tamayo (Santiago de Cuba), Yudeisi Trabanca Beltrán (Guantánamo); Center for Genetic Engineering and Biotechnology: Ernesto López Mola, Angela Tuero Iglesias, Carmen Valenzuela Silva, Jorge Berlanga Acosta, Miriela Gil Mena, Ricardo Silva Rodríguez, Marianela García Siverio, Francisco Hernández Bernal, Elizeth García Iglesias, Leovaldo Álvarez Falcón, María Dolores Castro Santana, Rafael Ibargollín Ulloa, Luis Herrera Martínez, Pedro Antonio López Saura.ABI: Ankle/brachial pressure index; AE: Adverse event; CDF: Center for the development of pharmacoepidemiology; CECMED: State center for the control of medicaments, diagnostics and medical devices; CRF: Case report form; DFU: Diabetic foot ulcer; NCR: National cancer registry; rhEGF: Recombinant human epidermal growth factor; SAE: Serious adverse event; Tpw: Times per week.Authors IBYA, CMVS, ADTI, ELM, and PALS. are employees of the Center for Genetic Engineering and Biotechnology (CIGB), where rhEGF is produced and sponsored the clinical trials and postmarketing study where the data were taken from. The postmarketing study was also financed by the Ministry of Public Health of Cuba. IBYA had no conflict of interest when the study was done. The rest of the authors have no conflict of interests.IBYA wrote the manuscript and participated in the protocol design, interpretation of the results, and final report writing; LAC took part in protocol design, data collection, and monitoring; CMVS made all the statistical analyses of this work, the interpretation of the results, and final report writing; ADTI participated in the statistical analyses; MMM and IMR were the site principal investigators that included more subjects and were part of the work steering committee; ELM took part in study design and organization; PALS collaborated in this manuscript writing and reviewing and contributed in protocol designs, analyses and interpretation of the results, and final report writing.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/2050-6511/14/44/prepub


AbstractElmidae Curtis, 1830 has cosmopolitan distribution and most species inhabit riffles on streams and rivers, hence the name “riffle beetle”. In recent years, this family has been featured in papers addressing the assessment and environmental monitoring of water quality. In Brazil, studies on the family remain scarce and the present investigation is a pioneering study in the state of São Paulo. This study aims to propose a taxonomic key for the identification of larvae of Elmidae genera known to occur in the State, as well as to report new records and the distribution of these genera. The material analyzed was collected from various locations in each of 15 drainage basins from 2005 to 2010. The identification key includes 12 genera  known in Brazil as well as three morphotypes designated herein as Genus A, Genus M and Genus X. The genus Hexanchorus is recorded for the first time in the state of São Paulo.The family  Elmidae Curtis, 1830, is a truly aquatic beetle family with cosmopolitan distribution. Most species are found mainly in areas of riffles in lotic ecosystems (rivers and streams). The genera of this family are distributed in two subfamilies: Elminae Curtis, 1830 and Larainae LeConte, 1861 . The material is deposited in the collection of the Aquatic Insect Laboratory of the Universidade Federal de São Carlos and the São Paulo Museum of Zoology of the Universidade de São Paulo (Brazil).21°50'S, 48°08'W); Campos do Jordão, Parque Estadual de Campos do Jordão ; Capão Bonito, Parque Estadual de Intervales ; Gália, Estação Ecológica de Caetetus ; Luis Antônio, Estação Ecológica Jataí ; Pedregulho, Parque Estadual das Furnas do Bom Jesus ; Santa Rita do Passa Quatro, Parque Estadual de Vassununga ; São Carlos city region ; São José do Rio Preto ; São Luiz do Paraitinga, Parque Estadual da Serra do Mar – Núcleo Santa Virgínia ; São Paulo city region ; Teodoro Sampaio, Parque Estadual do Morro do Diabo ; Ubatuba, Parque Estadual da Serra do Mar – Núcleo Picinguaba  Jundiaí  Cananéia .The material was collected from 52 aquatic systems in each of 15 drainage basins in the state of São Paulo  in areasOnly mature larvae  were used to build the genus identification key. The traits used to identify the larvae were based on 5 stereomicroscope. The images were treated with Adobe Photoshop CS4 to correct contrast, brightness and imperfections.PageBreakPageBreakThe images used in the identification key were taken with a Leica DFC 280 camera coupled to a Leica MZ9Elmidae at the genus level, encompassing 12 genera previously recorded in South America: Austrolimnius Carter & Zeck, 1929, Heterelmis Sharp, 1882, Hexacylloepus Hinton, 1940, Hexanchorus Sharp, 1882, Huleechius Brown, 1981, Macrelmis Motschulsky, 1859, Microcylloepus Hinton, 1935, Neoelmis Musgrave, 1935, Phanocerus Sharp, 1882, Potamophilops Grouvelle, 1896, Stegoelmis Hinton, 1939 and Xenelmis Hinton, 1936  found in the state of São Paulo, Brazil.Identification key to larvae of


There was an error in the Funding statement.The correct statement is: This work was supported by Ministerio de Ciencia e Innovación (SAF/FEDER2010-17907), Red de Trastornos Adictivos  and Fundación Séneca (15405/PI/10), Región de Murcia. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


The Basque Health Service is currently running a series of pilots in healthcare integration with the objective of obtaining better outcomes in the management of chronic patients, through an improvement in the quality of care and in resource use efficiency. Despite evidence that the effectiveness of specific interventions in the management of chronic patients, there is no sound evidence to assess the extent to which models and policies on health integration contribute to improvements in quality of care and cost reduction within health systems. In this context, it is essential to evaluate healthcare integration pilots to determine to what extent expected outcomes are achieved in the medium to long term and, therefore, how integration may contribute to the sustainability of health systems.The objective is to establish an evaluation framework to assess the healthcare integration pilots in the Basque Country that will make it possible to compare results at regional, national and international levels. The evaluation has structure, process and outcome elements see .A series of indicators see  for eachidentifying ad-hoc indicators for each level based on variables related to monitoring of patients, clinical effectiveness and quality of life  or that any single combination of structures and methods will lead to optimal outcomes . Given tHoy en día, el Sistema Sanitario Vasco está desarrollando una serie de experiencias en el ámbito de la integración asistencial con el objetivo de conseguir mejores resultados en la gestión del paciente crónico, a través de la mejora de la calidad de la atención y de un uso más eficiente de los recursos. A pesar de que existe evidencia de la efectividad de intervenciones específicas en la gestión del paciente crónico, no hay estudios sólidos que determinen hasta qué punto los modelos y las políticas de integración asistencial pueden contribuir a la mejora de la calidad y la reducción de costes en el sistema sanitario. En este contexto, la evaluación de las experiencias de integración asistencial es clave de cara a mostrar en qué medida los resultados esperados se consiguen a medio y largo plazo y por tanto, la integración puede contribuir a la sostenibilidad del sistema sanitario.El objetivo es evaluar las experiencias de integración asistencial desarrolladas en el País Vasco a través de un marco evaluativo que permita la comparativa en términos regionales, nacionales e internacionales. Las áreas de evaluación son: estructura, procesos y resultados ver .Se han desarrollado una serie de indicadores ver  para cadidentificándose indicadores ad-hoc para cada estrato en las variables control del paciente, efectividad clínica y calidad de vida  y tampoco existe una combinación única de estructuras y métodos que generen resultados óptimos . Dado qu


The following information was missing from the Funding section: "This work has been supported in part by grants to M. Lathrop from Genome Québec, le Ministère de l'Enseignement supérieur, de la Recherche, de la Science et de la Technologie (MESRST) Québec, and from the ANR in France for the Labex project "Medical Genomics".


We regret any confusion or inconvenience this error may have caused.In the article "Making Room for Mental Health in the Medical Home," the degree for Ilana R. Nossel, MD, was omitted. The correction was made to our website on October 26, 2010, and appears online at http://www.cdc.gov/pcd/issues/2010/nov/09_0198_es.htm. Lamentamos cualquier inconveniente o confusión que este error haya podido causar.En el artículo "Integración de la salud mental en el concepto de "hogar médico", se omitió la mención del título académico de la Dra. Ilana R. Nossel. La corrección se hizo en nuestro sitio web el 26 de octubre del 2010, y se puede encontrar en línea en


In the framework of the plan for improving home care in the region of Valencia [The autonomous region of Valencia has a population of 5.1 million divided into 24 health districts and the governing body of the Valencia Health Service is the Valencia health agency  and the use thereof. Following the recommendations of a group of experts, and on the basis of other pilots carried out in Spain –4 and otNurse community case managers (NCCMs).Hospital liaison nurses (HLNs).The target population of the NCCMs and the HLNs are complex cases, most of which are eligible for home care, that is, individuals at the apex of the Kaiser Permanente pyramid . The terTheir mission is to guarantee integrated and continuous care for complex cases. Their core functions include: active searching, case management, linkage between care sites and support to caregivers. The nurses with these two roles work together and have similar functions but in different spheres: the NCCMs work in the community, while the HLNs work in a hospital environment .The nurses were provided with all suitable ICTs. In particular, the electronic medical records were used as a work tool and for communication between NCCMs and HLNs. Further, we developed a computer program that identifies potential complex patients from hospital databases.In March 2007, we started a pilot in two health districts (Castellón and Alicante) with the involvement of 3 HaH units, 10 PCTs, 3.5 HLNs and 9 NCCMs. The catchment population of the NCCMs in the two districts is 210,689  though not all the PCTs had NCCMs. The data presented here were collected over a period of four years, until March 2011. However, these nurses only became involved in the palliative care pathways in 2009 and, accordingly, the data concerning this group of patients covers only a 2-year period (2009 and 2010).The key results are shown in Significantly increasing the identification of cases by active searching, using both the usual and the new electronic method, and ensuring that the most complex cases are monitored (2052).Promoting home care by PCTs, reaching an average coverage of 58% from 15% at baseline, and reducing the number of “hidden patients” and number of patients on the list for “programmed monitoring”.Improving continuity of information by use of shared electronic medical records.Improving continuity of care, thanks to the large number of bidirectional links between PCTs and HaH units instigated by these nurse.Improving healthcare integration: the close interaction achieved by these links has reinforced the supportive role of HaH units to PCTs and the provision of shared care, increasing the ability to solve problems at home and replacing potential admissions to hospital by transfers of care to HaH units, with the associated benefits for patients and caregivers, as well as in terms of the efficiency of the system.Promoting new services: telephone health services and group activities.Achieving rates of home death of 67%, with the inclusion of palliative care patients on their list of patients.Significantly reducing the use of emergency services (–77%) and hospital admissions (–70%) of patients under their care over a year compared to the year prior to their assessment, the figures being –78% and –64%, respectively, for palliative care patients.Turning caregivers into new “users” of the system.The introduction of two new nursing roles, NCCMs and HLNs, to the home care setting, whose main agents in the AVS are PCTs and HaH units, and the enhanced use of ICTs have contributed to improving care for complex chronic and palliative care patients. In particular, they have proven to be essential roles for identifying such patients and achieving integration and continuity of care.By the end of 2011, the deployment of the AVS model will be extended to 8 districts, with the involvement of 8 HaH units, 26 PCTs, 9 HLNs and 25 NCCMs, reaching a catchment population of 520,000 .La Comunidad Valenciana (CV) tiene 5,1 millones de habitantes y está dividida territorialmente en 24 departamentos de salud. La Agencia Valenciana de Salud (AVS) es el organismo central de gobierno del servicio de salud. En el marco del Plan para la Mejora de la Atención Domiciliaria de la CV [Los resultados ilustraron la fragmentación y la falta de continuidad de la atención entre UHD y PAD para los pacientes crónicos avanzados y paliativos, un grupo de pacientes de alta complejidad y de gran consumo de recursos que puede amenazar la sostenibilidad del sistema.Al alta de las UHD, el escaso desarrollo del PAD generaba dificultades de seguimiento domiciliario. Ante tal situación, la respuesta de las UHD para los pacientes más complejos fue crear una “bolsa de seguimiento programado” totalmente a su cargo y al margen de los EAP.El resto de enfermos al alta de la UHD o del Hospital engrosaba una “bolsa de pacientes ocultos” ya que, al ser desconocida su condición domiciliaria por los EAP, no eran incluidos en el PAD y su atención quedaba fuera de cualquier tipo de programación y control.Los cuidadores no eran considerados objetivo de apoyo por los profesionales sanitarios .Ante la situación descrita, la búsqueda de soluciones se orientó hacia el colectivo de enfermería, profesionales muy relevantes en la atención domiciliaria, y hacia la mejora de las tecnologías de la información y comunicación (TIC). Siguiendo las recomendaciones de un grupo de expertos, y en base a experiencias tanto nacionales –4 como iEnfermeras de Gestión Comunitarias (EGC).Enfermeras de Enlace Hospitalarias (EEH).La población diana de las EGC-EEH son los casos complejos, la mayoría susceptibles de atención domiciliaria y que, conceptualmente, se encontrarían en el vértice de la pirámide de Kaiser . Se defiSu misión es garantizar una atención integrada y continua de los casos complejos.Sus funciones nucleares son: búsqueda activa; gestión de casos; enlace entre ubicaciones asistenciales; y apoyo a cuidadores. Ambos perfiles profesionales trabajan conjuntamente y tienen funciones similares pero desarrolladas en ámbitos distintos: las EGC en el comunitario y las EEH en el hospitalario .Se ha dotado a las enfermeras con todas las TIC disponibles.Se ha utilizado la historia clínica electrónica como instrumento de trabajo y de comunicación entre EEH y EGC.Se ha desarrollado una aplicación informática que, explorando bases de datos hospitalarias, permite identificar pacientes potencialmente complejos.En marzo de 2007 se inició un pilotaje en dos departamentos de salud (Castellón y Alicante). Participaron 3 UHD, 10 EAP, 3,5 EEH y 9 EGC. La cobertura poblacional de las EGC en ambos departamentos fue de 210.689 habitantes (39% de su población). Había EAP con y sin EGC. Los datos presentados abarcan 4 años hasta marzo 2011. En 2009, estas enfermeras se incorporaron a los circuitos de atención paliativa, los datos para este colectivo incluyen 2 años, 2009 y 2010.Los resultados más relevantes se presentan en la Aumentar significativamente la captación de casos mediante la búsqueda activa por medios habituales y/o electrónicos, y el poner bajo control a los casos más complejos (2.052).Dinamizar la atención domiciliaria de los EAP, alcanzando una cobertura media del 58% desde un 15% inicial, reduciendo las bolsas de pacientes ocultos y de seguimiento programado.Mejorar la continuidad informativa mediante la utilización conjunta de la historia clínica electrónica.Mejorar la continuidad asistencial gracias al gran volumen de enlaces bidireccionales entre EAP y UHD gestionados por estas enfermeras.Mejorar la integración asistencial: la fuerte interacción conseguida por los enlaces ha reforzado la función de soporte de las UHD hacia los EAP y la atención compartida, aumentando la capacidad de resolución de problemas en domicilio y sustituyendo probables ingresos hospitalarios por ingresos en UHD, con las consiguientes ventajas tanto para pacientes y cuidadores como para la eficiencia del sistema.Impulsar nuevas prestaciones: la atención telefónica y grupal.Incorporar a los enfermos paliativos en su cartera de pacientes y lograr una mortalidad en domicilio del 67%.Reducir sustancialmente el consumo anual de urgencias (–77%) e ingresos hospitalarios (–70%) de los pacientes bajo su control en relación a los 12 meses previos a su valoración. En paliativos, –78% y –64% respectivamente.Convertir a los cuidadores en nuevos “clientes” del sistema.La incorporación de dos nuevos perfiles enfermería (EGC y EEH) al circuito de atención domiciliaria, cuyos principales agentes en la AVS son los EAP y las UHD, y el desarrollo de las TIC, ha contribuido a mejorar la asistencia a pacientes crónicos complejos y paliativos, convirtiéndose en elementos fundamentales para su captación y para la integración y la continuidad de su atención.Al final de 2011 el despliegue del modelo en la AVS alcanzará a 8 departamentos, con 8 UHD, 26 EAP, 9 EEH y 25 EGC y cubrirá a una población de 520.000 habitantes (10% de la CV).


Intussusceptions in adults is rare. Gastrointestinal lipomas are rare benign tumors and intussusceptions due to a gastrointestinal lipoma constitutes an infrequent clinical entity. Lipoma may develop as a benign tumor in all organs and rarely in large or small intestine. The present report describes a case of jejunojejunal intussusceptions in an adult with a history of colicky upper abdominal pain. Ileo-ileal invagination was diagnosed by computed tomography scan. Exploratory laparotomy revealed jejunojejunal intussusceptions secondary to a lipoma which was successfully treated with segmental intestinal resection. A review of the literature is also performed regarding this rare association revealing the diagnostic and therapeutic debates that exist.L’invagination chez les adultes est rare. Les lipomes gastro-intestinaux sont de rares tumeurs bénignes et l’invagination intestinale due à un lipome gastro-intestinal constitue une entité clinique trés rare. Le lipome peut se développer comme une tumeur bénigne dans tous les organes et rarement dans l’intestin grêle ou le colon. Le présent rapport décrit un cas d’invagination jéjunojéjunale chez un adulte avec une histoire de douleurs abdominales. Iléo-iléale invagination a été diagnostiquée par tomodensitométrie. Une laparotomie exploratrice a révélé l’existence d’une invagination jéjunojéjunale secondaire à un lipome qui a été traitée avec succès par une résection intestinale segmentaire. Une revue de la littérature est également effectuée au sujet de cette association rare révélant les débats diagnostiques et thérapeutiques qui existent. Intussusceptions was reported for the first time in 1674 by Barbette of Amsterdam. In contA 35-year-old man was admitted to the emergency department in a tertiary referral hospital with 4 months history of intermittent upper abdominal pain accompanied with nausea. The patient had no past history of peptic ulcer disease, alteration in bowel habits, melena or weight loss. On examination, he was apyrexial and hemodynamically stable. His abdomen was distended and no palpable abdominal masses; bowel sounds were hyper audible. Initial A rectal examination revealed no masses or blood. Laboratory blood tests were normal. Abdominal radiography revealed prominent dilatation of the small bowel with air fluid levels Figure . AbdominIntussusceptions in adulthood is unusual, with an incidence of approximately 2-3 cases per population of 1 000 000 per year. The mosThe lipoma is a rare benign tumor of the digestive tract. The diagnosis of intussusceptions in adults can be difficult because of atypical and episodic symptoms. A high level of clinical suspicion and an abdominal CT scan are most useful tools for making a timely diagnosis. Surgical resection remains the treatment of choice and produces an excellent prognosis.Written informed consent was obtained from the patient for publication of this case report and accompanying imagesCT: Computed tomography; MRI: Magnetic resonance imaging; CS: Colonoscopy; ECS: Enema contrast study; EGD: Esophagogastroduodenoscopy; US: Ultrasonography; ND: Not described.The authors declare that they have no competing interests.All of the authors were involved in the preparation of this manuscript. OM performed the operation and revised the manuscript. HH was an assistant surgeon and made substantial contributions to conception and design. LC described histological finding and was involved in drafting the manuscript. All authors read and approved the final manuscript.


There is a spelling error in affiliation 1. The correct affiliation 1 is: Dipartimento di Fisica e Istituto Nazionale di Fisica Nucleare (INFN), Università di Parma, Parma, Italy


Continuity of care (CC) is based on patient and family care as the main element, with a bidirectional relationship between healthcare and social care services; the main aim being to avoid a lack of coordination between levels of care which could be detrimental to users .CC is associated with patients perceiving a level of consistency and connectedness in their care experience over time. Three inter-related types of CC have been identified , 3: a) rIt has been reported that CC is associated with higher levels of user satisfaction –8, betteIn relation to this working model, the objectives of our case management service are:To optimise and rationalise the use of services and of resources to prevent admissions due to clinical worsening of people with chronic diseases, that is, avoiding unnecessary transfers to hospitalTo decrease visits to the emergency department by people with complex conditions, as well as their number of admissions and, if admitted, the length of their hospital stayTo empower family members by providing them with the necessary tools to avoid clinical worsening and manage risky situations.This intervention was based on the work carried out by a case management unit composed of nurses. Case Management is the process of systematic and dynamic collaboration to provide and coordinate health services for a given population. That is, it is a participative process to enable access to a range of options and services that cover patient needs, as well as reducing fragmentation of care and duplicity of services, while improving the quality of care and cost-effectiveness in the achievement of clinical targets .Patients included on the list of the case management unit under study had complex conditions and had been referred from Primary Care  or Specialised Care . A patient was considered to be complex on the basis of meeting 5 of the following 10 criteria, agreed by the case management unit:≥65 years oldComorbidity according to the Charlson index Five or more drugs (including psychiatric drugs) taken continuouslyTerminal stage of a diseaseBarthel index  of ≤55, Dementia or cognitive deterioration   A descriptive study was carried out comparing a period of one year (from January to December 2010) before and after the management unit was established. For this, data were collected on the basis of the 10 aforementioned criteria, agreed in the case management unit, indicating the level of complexity of the patients.The geographical area, on the outskirts of the city of Barcelona, is the district of Baix Llobregat Litoral which, including the towns of Gavà and Viladecans among others, can be defined as urban and has a population of 120,000. The different levels of care are offered by the same health service provider. On the other hand, they do have different IT systems, but health professionals can access patient data through shared medical records (SMRs).The study population was composed of 78 patients with complex chronic conditions. The inclusion criteria were: patients being registered in the unit and having a level of complexity ≥5 at baseline. After the overall assessment of the patients, the intervention carried out by the nurses was to agree treatment with the patient, producing a personalised care plan with the collaboration of informal caregivers and of the professionals involved in the patient’s care at the various levels of care.Data were retrieved from the primary care and the shared medical records. They was then analysed using the most suitable statistical tests for each of the variables.The level of complexity decreased in 55.76% of patients (n=44) .We also observed a decrease in the number of visits to the emergency department and in the length of hospital stay, both results being statistically significant .The case management model facilitates the three main types of continuity of care: relational, informational and management. The observed reduction in the complexity of the patients indicates that patient health problems were being more effectively monitored by nurses, which enabled worsening in their chronic conditions to be avoided, and in turn a more rational use of health service resources. This indicator is related to activities affecting the three aforementioned types of continuity of care with an associated improvement in patient perceived quality of life and level of satisfaction.Further, our data demonstrate that the intervention significantly reduced Emergency Department attendances and hospital admissions, while inpatient stays tended to be shorter.La continuidad asistencial (CA) está basada en la atención al paciente y núcleo familiar como eje principal, a través de una interrelación bidireccional entre servicios sanitarios y socio-sanitarios con un objetivo asistencial principal, evitar descoordinaciones entre niveles asistenciales que perjudican directamente al usuario .La continuidad asistencial (CA) es el grado de coherencia y unión de las experiencias en la atención que percibe el paciente a lo largo del tiempo. Se distinguen tres tipos de CA , 3 interLa CA se asocia a una mayor satisfacción de los usuarios –8, mejorEn consonancia con este modelo de trabajo, los objetivos de nuestro servicio de gestión de casos son:Optimizar y racionalizar el consumo de servicios y la utilización de recursos para prevenir los ingresos por agudizaciones de las personas con patologías crónicas, evitando traslados innecesarios a los servicios hospitalarios.Disminuir el número de ingresos, tiempo de hospitalización y visitas a urgencias en personas en situación de complejidad.Capacitar a los componentes del núcleo familiar facilitando las herramientas necesarias para resolver situaciones de riesgo y evitar descompensaciones.La experiencia parte del trabajo realizado en una unidad de gestión de casos formada por enfermeras. Se entiende por gestión de casos el proceso de colaboración sistemático y dinámico para proveer y coordinar servicios sanitarios en una población determinada; es decir, un proceso participativo para facilitar opciones y servicios que cubran las necesidades del paciente, a la vez que reduce la fragmentación y duplicación de servicios y mejora la calidad y la relación coste-efectividad de los resultados clínicos .La cartera de pacientes de la unidad de gestión de casos estaba compuesta por pacientes complejos derivados de Centros de Atención Primaria  y Atención Especializada . El perfil de paciente complejo se definió en base al cumplimiento de 5 de los 10 criterios consensuados por la unidad de gestión de casos y descritos a continuación:≥65 años.Comorbilidad en base al índice de Charlson 5 o más fármacos o psicofármacos de forma continua.Proceso terminalValoración de las actividades básicas de la vida diaria (ABVD) a partir de un índice de Barthel ≤55 o menos Demencia o deterioro cognitivo (Test Cognitivo de Pfeiffer >5) 2 o más ingresos no planificados en el hospital por exacerbación en los últimos 12 meses.3 o más visitas a urgencias hospitalarias en los últimos 12 meses.más de dos caídas en los últimos dos mesesVivir solo o con cuidadores con capacidad limitada de soporte. Indicador de riesgo social (TIRS≥1) Se realizó un estudio descriptivo, comparativo de antes y después, durante el periodo de enero a diciembre de 2010, mediante la recogida de datos, en base a los criterios de complejidad consensuados en la unidad de gestión de casos (10 criterios descritos anteriormente) que nos informaban del grado de complejidad de los pacientes.El área geográfica, de 120.000 habitantes, está situada en el Baix Llobregat Litoral, extrarradio de Barcelona, con población urbana, que abarca los municipios de Gavà y Viladecans. Los diferentes niveles de atención asistencial están gestionados por el mismo proveedor de servicios sanitarios. Cuentan con sistemas de información distintos, pero se puede acceder a los datos de los pacientes desde la Historia Clínica Compartida (HCC).La población de estudio estuvo constituida por 78 pacientes en situación de patología crónica y compleja. Los criterios de inclusión fueron: pacientes incluidos en la unidad, con grado de complejidad inicial de ≥5. La intervención de las enfermeras tras valoración integral del paciente fue realizar un pacto terapéutico con el paciente elaborando un plan de cuidados individualizado en el que intervenían los profesionales implicados en la atención del paciente de los diferentes niveles asistenciales y los cuidadores informales.La recogida de la información se hizo a través de la explotación de datos de la historia clínica de Atención Primaria e HCC. El análisis de datos se realizó con las pruebas estadísticas más adecuadas para cada tipo de variable.El grado de complejidad mejoró en un 55,76% (n=44) de los pacientes .Se observó una disminución de las visitas a urgencias y del número de ingresos hospitalarios, siendo estos resultados estadísticamente significativos .El modelo de gestión de casos facilita la continuidad asistencial en los tres ámbitos de actuación: relación, información y gestión. La mejora del grado de complejidad de los pacientes indica que el nivel de vigilancia de las enfermeras respecto a los problemas de salud de los pacientes es mayor, evitando así reagudizaciones de sus procesos crónicos, con lo que se racionaliza el consumo de servicios sanitarios. Este indicador se desprende de los tres ámbitos de actuación mencionados anteriormente donde hay una mejora en la percepción de calidad de vida y el grado de satisfacción por parte de los pacientes. Los resultados obtenidos demuestran una disminución en el número de ingresos hospitalarios significativo, de las visitas a urgencias, y en el tiempo de estancia hospitalaria.


The Department of Cardiology of our hospital has a catchment population of 135,000 people. Until 2005, the relationship between the various levels of care  was incidental. Patients were seen at different levels of care and complementary tests were duplicated due to the lack of connections between these levels, with all the implications this has for patients, quite apart from the associated costs for the health service.In 2005, the CSI HGH took charge of cardiology care in the catchment area, integrating the outpatient cardiology care of five primary care (PC) health districts . In the first year, 12,000 appointments were carried out. The first intervention put into place was to transfer the care of all the monitored patients with no identified heart disease or with only minor conditions to PC. With this step, we managed to reduce the number of visits to specialists of the Department of Cardiology by 30% in two years. Another intervention was introduced in 2007: the establishment of clinical sessions bringing together professionals of the Department of Cardiology and PC. A cardiologist was appointed for referral of non-complex chronic heart patients and for advising primary care colleagues. Despite all this, the response was not consistent across PC, so we proposed to segment the cardiology care offer, according to the needs of our internal client, that is, primary care. Establishment of a single appointment for diagnosis of heart failure (HF), including tests and preparation of the care planStandardise response times for carrying out complementary testsIntroduce congestive heart failure (CHF) nurse case managersEstablish mechanisms for communication with PC that compensate for the lack of shared medical recordsAgree with PC the criteria for patient referral, as well which area of the hospital patients should be sent toAgree on the essential data required across the various levels of careEstablish a set of indicators for monitoring the criteria for referral, the volume of activity in the various areas, and the time patients take to progress along the care pathwayEstablishment of an integrated care plan (ICP) to guide the approach to patients with heart failure:Agree with PC on the types of cases that could benefit from a visit to this unit Setting up of a high-resolution cardiac imaging unit (CIU), establishing an agreed number of processes and standard time (1 week) for performing of tests at the hospital level.Setting up of a service of virtual consultations for minor conditions and queries from PC professionals, for cases in which a visit to the cardiologist is not required.Define the activities and duties of the professionals of each level of care in relation to each care process.The objective was to redefine cardiac care processes towards patient-based care through a model of care that provides specialised care tailored to the needs of the ‘client’ within the care system as well as of patients. The intervention involved: 1. The various interventions in place up to 2010 led to a 50% reduction in annual outpatient consultations  and increased the capacity of PC to deal with cardiac conditions, achieving a follow-up to first appointment ratio of 1.92 in cardiology and waiting times for specialists of less than a week.2. Outcomes of the ICP and referrals for rapid diagnosis of CHF from March 2010 to July 2011: Overall, 112 patients ranging from 43 to 90 years of age have been assessed .Of the patients examined, HF was confirmed in 36 cases and the underlying causes are detailed in 3. Outcomes of the high-resolution CIU from June to July 2011: A total of 20 patients were assessed. Patient age ranged from 25 to 88 years old, with 9 patients being octogenarians. The reasons for the referral are listed in The outcomes with respect to the achievement of diagnosis for the processes that had been the reason for the consultation are reported in 4. Outcomes of the virtual consultations: Over a period of three months, 34 consultations were carried out and, of these, 32 have were resolved virtually. It was only considered necessary for two patients to attend appointments in person to be assessed .Until 2005, the relationship between levels of care was incidental. Despite the fact that there were significant initiatives between primary and specialised care, well received by the latter, a direct connection had not developed between levels of care. Since the time cardiology care came under the responsibility of our hospital, a series of interventions have been put in place in order to agree with primary care, as well as within tertiary care, pathways and criteria for action in line with clinical practice guidelines to provide continuity of care to patients regardless of the level of care where they are treated.Consensus among the various different levels of care involved in the process, from a client-provider  perspective, is essential to determine, on the basis of care needs and the principle of subsidiarity, who does what and where.With the establishment of new practices in integrated patient care, we aim to respond to the care processes that are the reason for consultations quickly and efficiently.Our vision is to develop a cardiology unit capable of adapting its responses to care process requirements as requested by its internal client.El servicio de cardiología de nuestro hospital da cobertura a una población total de 135.000 habitantes. Hasta el año 2005 la relación entre los diferentes niveles asistenciales  eran circunstanciales. El paciente acudía a los diferentes niveles y se producía una duplicidad de exploraciones complementarias, como consecuencia de la falta de conexión, con las implicaciones que conlleva para el paciente y el gasto sanitario.En el año 2005 el C.S.I-HGH se hace cargo de la Atención Cardiológica (AC) del área de referencia, integrando la AC ambulatoria de cinco áreas básicas de Atención Primaria (AP) . En el primer año se realizaron 12.000 visitas. La primera intervención que se realizó fue remitir a AP el 100% de los pacientes controlados que no tenían patología cardiaca o con patología banal. Con esta intervención se consigue en 2 años, reducir un 30% las visitas de cardiología. A partir del 2007 se realiza una segunda intervención, que es la creación de sesiones conjuntas entre el servicio de cardiología y la AP. Se crea el cardiólogo referente para poder derivar a los pacientes cardiópatas crónicos no complejos y la orientación al cliente interno. A pesar de todo, la respuesta por parte de la AP no es homogénea, por lo que nos planteamos segmentar adecuadamente nuestra oferta asistencial cardiológica a las necesidades de nuestro cliente interno Atención Primaria.El objetivo de la intervención es redefinir los procesos asistenciales cardiológicos, poniendo en el eje central al paciente a través de un modelo asistencial que dé respuesta especializada a la necesidad del nivel asistencial ‘cliente’ y del paciente.Estandarizar tiempos de respuesta para la realización de pruebas complementariasImplementar enfermera gestora de la insuficiencia cardiaca congestiva (ICC)Instaurar sistemas de comunicación con la AP, que compensen la falta de una historia clínica unificada.Acordar con la AP criterios de derivación de pacientes y el dispositivo hospitalario al cual remitir al paciente.Acordar la información imprescindible entre los diferentes niveles asistenciales.Implantar un sistema de indicadores para el seguimiento de los criterios de derivación, el volumen de actividades de las diferentes áreas, y el tiempo de ciclo del procesoPuesta en marcha de un Plan Asistencial Integrado (PAI) para el abordaje de los pacientes con Insuficiencia Cardiaca: Creación de un dispositivo de visita única para el diagnóstico de Insuficiencia Cardiaca (IC)Definir de forma consensuada con AP los procesos que se pueden beneficiar de una visita de alta resolución Puesta en marcha de una Unidad de Alta Resolución (UAR) para patología cardíaca, establecimiento de un número de procesos acordados y estandarización de los tiempos (1 semana) para las exploraciones a nivel hospitalario.Puesta en marcha de un servicio de consultaría no presencial para patología banal y dudas por parte de la AP que no requiera visita presencial por parte del cardiólogo.Definir las actividades y responsabilidades de cada nivel asistencial en base a cada proceso.La intervención supuso (2010):1. Las diferentes intervenciones hasta el 2010, han permitido disminuir la actividad ambulatoria anual inicial en un 50% , incrementar la capacidad resolutiva de la AP en patología cardíaca, conseguir una tasa de reiteración en las consultas de cardiología de 1,92, y ser accesibles en <1 semana.2. Resultados PAI + derivaciones a diagnóstico rápido ICC en el periodo comprendido entre marzo 2010 y julio 2011: Se han valorado un total de 112 pacientes, con un intervalo de edad de 43–90 años (Tabla 3).De los pacientes remitidos se ha confirmado el diagnostico de Insuficiencia cardiaca en 36 pacientes y las causas quedan reflejadas en la Figura 3.3. Resultados UAR en el periodo de junio y julio 2011: Se han valorado un total de 20 pacientes, con un intervalo de edad de 25 a 88 años, de los cuales 9 pacientes tenían más 80 años. El motivo de la derivación se describe en la Tabla 4.Los resultados de la resolución del proceso que ha motivado la consulta y el tipo de derivación se muestran en la Figura 4.4. Resultados de la consultoría no presencial: Se han valorado en un periodo de 3 meses un total de 34 consultas que se han solucionado en 32 casos. Sólo en dos de las consultas ha sido necesaria la valoración presencial (por la UAR o en consulta ordinaria).Hasta el año 2005 en nuestro entorno asistencial la relación entre los diferentes niveles era testimonial. A pesar de que ha habido iniciativas importantes desde la AP- Atención Especializada, con buena acogida por ésta última, no ha llegado a cristalizar una relación directa interniveles. A partir de que la AC es asumida por nuestro hospital, se ponen en marcha toda una serie de intervenciones, con la finalidad de consensuar con la primaria, así como con el tercer nivel asistencial, las rutas y los criterios de actuación según las guías de práctica clínica, para dar continuidad asistencial al paciente independientemente del nivel asistencial donde sea tratado.El consenso entre los diferentes niveles asistenciales implicados en el proceso, desde una visión de cliente proveedor , es imprescindible para determinar en base a la necesidad asistencial y el principio de subsidiaridad quien hace que y donde se realiza.Con la puesta en marcha de las nuevas medidas en la atención integral del paciente, se espera dar respuesta al proceso que motiva la consulta en la mayor parte de los casos de forma breve y eficaz. Nuestra visión es disponer de un servicio de cardiología capaz de adecuar sus respuestas asistenciales a la necesidad asistencial del proceso solicitado desde el nivel asistencial cliente.


Affiliation number 7 for the fifth author, Rodolphe Rougerie, is incorrect. The correct affiliation is: INRA, UR633 Unité de Recherche en Zoologie Forestière, Orléans, France.


Hip fracture (HF) is a serious health problem, the prevalence of which is increasing with population ageing , 2. It cHF patients often require long stays on trauma wards due to their age , other cThe objectives were to:Enable the return to the greatest possible level of independence among all patients with potential to make a good recoveryProvide care that meets the specific needs of elderly patients with HFEnsure that the hospital stay at different levels of care is appropriateTailor the social and healthcare provided on discharge and avoid delays in care between levels.In May 2010, a comprehensive and interdisciplinary, coordinated care project was launched for patients with HF, with a protocol for referral from the Department of Traumatology of Donostia Hospital (tertiary care) to the Orthogeriatric Unit (OGU) of Ricardo Berminghan Hospital (sub-acute care), this being extended to include Bidasoa Hospital  in September 2010. All patients admitted through the Emergency Department with HF have been included in this project according to the following protocol:Day 1 of stay – patient assessment and recommendations for social support.Day 5 of stay – after the surgical intervention, a thorough assessment of the patient is carried out, considering their functional status before the fall and at this stage, as well as their mental status, to identify patients who could potentially benefit from care in the Orthogeriatric Unit: those with considerable functional deterioration at the time of assessment [Barthel Index (BI) <60] but who also meet criteria for potentially making a good recovery .For those transferred to the Orthogeriatric Unit (OGU), during the first 24 hours in the unit therapies for relearning to walk and recovering independence in activities of daily living are initiated and measures taken to stabilise concomitant processes and to prevent common geriatric problems  following a geriatric model of comprehensive and interdisciplinary assessment and care .There is planning for discharge from the moment of admission, adapting care provided to the clinical, functional and cognitive status of each patient in coordination with social services. If the patient is considered a candidate for outpatient rehabilitation, access to the gym should be arranged for them before they are discharged to ensure that their physiotherapy is not interrupted.In the first year, 390 patients were included in the project, 297 (76%) women and 93 (24%) men. Of these, 238 (61%) were transferred to the OGU, the mean age of this subset being 82.1 years. The mean length of stay of these HF patients in the acute tertiary care hospital fell from 19.7 days in 2009 to 10.6 days in 2010 after the launch of the project.The functional improvement measured in the OGU was 37.8 points on the BI, the mean BI score on discharge being 72. The mean length of stay in this unit was 21.4 days vs. 34.3 days for HF patients cared for the previous year, with an efficiency score of 1.7 and a Montebello Rehabilitation Factor score of 0.69.On discharge, 7.3% of patients were institutionalised while for 54 patients (23.1%) their general practitioner was contacted for joint management of their case. Candidates for rehabilitation as outpatients continued their therapy without any interruption on discharge.This project with the establishment of a new protocol has enabled the early transfer to an Orthogeriatric Unit of all patients who it was judged could potentially benefit from the type of care it offers. This group included individuals with mild-to-moderate cognitive impairment, in whom it has previously been shown that satisfactory recovery of walking ability can be achieved with tailored rehabilitation , 7, therThe use of the different levels of care has improved, with a notable reduction in the length of stay in the acute hospital and also a decrease in the time spent in sub-acute care. This can be attributed to patients being transferred earlier to a care environment focused on the prevention of geriatric problems and recovery of independence, leading to a fall in the number of complications and a lower level of care being required on discharge .This represents considerable cost savings on hospitalisation, as has previously been demonstrated in relation to Orthogeriatric Units of other acute care hospitals . The funWe found that:A comprehensive assessment of all geriatric patients with hip fracture allowed those individuals who could potentially make a good recovery to be identified.Coordination between levels of care following a protocol enabled a rapid transfer of patients to appropriate types of care avoiding unnecessary delays and hospital stays.The application of a model of geriatric care suited to the needs of these patients led to good functional recovery and a low rate of institutionalisation.The tailoring of the length of stay and type of care provided to such patients had a positive impact on both the direct costs of hospitalisation and those due to the need for care on discharge associated with dependency.La fractura de cadera (FC) constituye un importante problema de salud cuya prevalencia va en aumento con el envejecimiento poblacional , 2, sienLos pacientes con FC generan con frecuencia estancias prolongadas en los Servicios de Traumatología debido a su edad  y caractCon el objetivo de:Restablecer la máxima autonomía de todos los pacientes potencialmente recuperables.Proporcionar asistencia acorde a las necesidades específicas de los ancianos con FC.Adecuar la estancia hospitalaria en los diferentes niveles asistenciales.Adaptar los cuidados sociosanitarios al alta y evitar demoras asistenciales interniveles.En mayo de 2010 se puso en marcha un proyecto de atención coordinada, integral e interdisciplinar a los pacientes afectos de FC, con un protocolo de derivación desde el Servicio de Traumatología del Hospital Donostia  a la Unidad de Ortogeriatría (UOG) del Hospital Ricardo Berminghan , proyecto al que en septiembre de 2010 se sumó el Hospital del Bidasoa .En el proyecto se han incluido todos los pacientes ingresados de Urgencia con (FC), a los que se aplica el siguiente protocolo:Primer día de ingreso, se realiza una valoración y orientación social.Al quinto día tras la intervención quirúrgica se realiza una valoración integral del paciente en la que se analiza su situación funcional previa a la caída y en el momento de la valoración y la situación mental, detectando los pacientes que previsiblemente se van a beneficiar de atención en la Unidad de Ortogeriatría: pacientes con deterioro funcional importante en el momento de la valoración: índice de Barthel <de 60 y que cumplan criterios de potencial recuperabilidad: índice de Barthel previo a la fractura >30 y Mini Examen Cognoscitivo MEC>10En las primeras 24 horas del ingreso en la Unidad de Ortogeriatría se inician las terapias de reentrenamiento de la marcha y recuperación de autonomía para actividades de la vida diaria, además de estabilización clínica de los procesos coadyuvantes y prevención de síndromes geriátricos , síndrome confusional, yatrogenia, etc) siguiendo el modelo geriátrico de valoración/atención integral e interdisciplinar .El alta se trabaja desde el ingreso adaptando los cuidados necesarios a su situación clínica/funcional y cognitiva en coordinación con trabajo social de base. Si el paciente se considera candidato a proseguir rehabilitación ambulatoria se tramita su entrada en gimnasio previa al alta para no interrumpir el tratamiento fisioterápico.En el primer año se han incluido en el proyecto 390 pacientes, con una distribución por sexos, 390 (76%) mujeres y 93 (24%) hombres, habiéndose trasladado a la UOG 238 (61%), siendo la edad media de los trasladados de 82,1 años. La estancia media de los pacientes con FC en el Hospital de agudos ha pasado de 19,7 días en 2009 a 10,6 tras inclusión en el proyecto.La ganancia funcional en la UOG ha sido de 37,8 puntos en el Índice de Barthel (IB), siendo el IB medio al alta de 72 puntos. La estancia media en esta Unidad ha sido de 21,4 días frente a los 34,3 de los pacientes con FC atendidos el año previo, con un índice de eficiencia 1,7 y una eficacia rehabilitadora (Índice de Montebello) de 0,69.Al alta han sido institucionalizados un 7,3% de los pacientes. En 54 pacientes  se contactó con su médico de atención primaria para gestión conjunta del caso. Los candidatos a continuar rehabilitación ambulatoria lo hicieron de forma ininterrumpida tras el alta hospitalaria.Este proyecto ha posibilitado el paso precoz y protocolizado a la UOG de todos los pacientes que potencialmente se iban a beneficiar de este modelo asistencial, incluyendo aquellos con deterioro cognitivo leve-moderado, en los que ya está demostrada una satisfactoria recuperación de la marcha con programas de rehabilitación adaptados , 7 combaLa estancia en los diferentes niveles se ha adecuado con disminución importante en el Hospital de agudos, pero también ha supuesto un descenso en el Hospital de subagudos al ingresar estos pacientes de forma precoz en un entorno de atención orientado a prevención de síndromes geriátricos y recuperación de la autonomía con la consiguiente disminución de complicaciones y necesidad de cuidados al alta que este modelo asistencial conlleva . Esto haLa ganancia funcional ha sido buena al igual que en otras unidades de similares características , 10, resLa valoración geriátrica integral de todos los pacientes con fractura de cadera ha permitido seleccionar los potencialmente rehabilitables.La coordinación interniveles ha permitido el paso adecuado, rápido y protocolizado evitando estancias y demoras innecesarias.La aplicación de un modelo de atención geriátrica adecuado a las necesidades de estos pacientes ha posibilitado una buena recuperación funcional y una baja institucionalización.La adecuación de estancia y de cuidados ha supuesto un impacto económico positivo tanto en los costes directos de hospitalización como en los resultantes de la necesidad de cuidados al alta que la dependencia genera.


In developed countries, the evolution of medicine, technology and social protection has led to the development of complex health systems with multiple specialised healthcare providers, often working as separate islands. The Spanish health system is no exception.There is a consensus that fragmentation of healthcare services particularly hampers the quality of care provided to chronic patients, who often require care from different types of professionals and specialists, as well as a long-term relationship with the healthcare system. Indeed, it can be argued that integrated care is particularly relevant to chronic patients and those with multiple conditions, who “bear the brunt of access, continuity, fragmentation and quality problems found in all health systems” . With thIn this context, the annual Spanish Conference on Chronic Care grew out of an interest in sharing experiences, knowledge and views on innovative approaches and initiatives in the prevention and management of chronic diseases, among healthcare experts, managers, clinicians and policy makers in the field. As in previous years, during the Third Spanish Conference on Chronic Care, “continuity of care” and “integrated care” were recurring topics, and recognised as key for the improvement of care for chronic patients. On this occasion, the conference, held in San Sebastian in May 2011, was organised by the Basque Institute for Healthcare Innovation (O+Berri) and the Basque Health Service (Osakidetza), with the support of the Department of Health and Consumer Affairs of the Basque Government. The present supplement includes a selection of 19 abstracts chosen from among the oral presentations and posters on interventions, projects and studies on healthcare coordination and integrated care presented at the conference.Fragmentation of healthcare delivery is commonplace in the Spanish health system, despite centralised public ownership of healthcare services in most regions. In Spain, the organisation of the healthcare system is devolved to the autonomous regions, which has led to the development of 17 separate regional health services . FinanceIn addition, the coordination of healthcare and social care, which are often both required for chronic patients, especially among the elderly, is particularly hindered by the diversity of institutions involved. In most Spanish regions, long term and social care for the elderly and disabled falls outside the remit of the health authorities, making its coordination and integration with health care even more difficult.The sample of initiatives covered in this conference supplement illustrates how the concept of “integrated care” is being implemented by practitioners in Spain. It includes examples from different regional health systems: the Basque Country (7 abstracts), Catalonia (6), Valencia (2), Andalusia (1), the Canary Islands (1), and Castile—La Mancha (1), as well as a study with participants from twelve autonomous regions (the Esperanza Project). With this publication, we wish to contribute a Spanish perspective on the development of the multifaceted and dynamic concepts of “integrated care”, “healthcare integration”, and “continuity of care”, among others , as wellDifferent models of integration are emerging across Spain , 11. WitAll the interventions described in the abstracts of this conference supplement take a clinical approach to integration, focussing on one or several care processes, even if some are run within integrated health organisations. On the other hand, some focus on care processes for patients with multiple chronic conditions, while others follow a disease management approach.For this group of patients, which would correspond to those at the top of the Kaiser Permanente pyramid , the benThe interventions presented illustrate the following trends towards integrated care for patients with multiple chronic conditions or complex patients in Spain:Units, teams or specialists with a remit for multimorbid patients at the hospital are being developed, often within units of internal medicine. The assigned internal medicine physician and/or continuity of care unit act as a consultant to the primary care level and also ensure a stable point of contact for the patient at the hospital .Case managers are being used, a role most often given to nurses.The improvement of integrated care for complex patients is, in most cases, carried out within broader initiatives for the management of chronic patients. Consistent with the Chronic Care Model and related frameworks , 19, theInterventions are being evaluated in terms of their impact on the use of healthcare resources, and particularly on: number of hospitalisations, length of hospital stay, readmissions, and number of emergency department attendances.A high proportion of the complex patients targeted have a diagnosis of heart failure and/or chronic obstructive pulmonary disease.These abstracts underline the importance of identifying the group of complex patients to be targeted by a given intervention. A range of different population stratification methods and criteria  concern disease management and related approaches. These include examples of:Virtual consultations between a hospital endocrinology service and primary care doctorsAgreed protocols on the care and referral of patients with hip fracture between an acute and a rehabilitation hospitalA shared disease management programme between primary care and an acute hospital for patients with heart failureDevelopment of shared care pathways between primary care and specialised care for chronic obstructive pulmonary disease, heart failure, diabetes mellitus type 2 and spondyloarthritisAssertive community treatment for patients with severe mental disordersA study of variability in practice for depression by care setting The management of an initiative that combines and coordinates several interventions for clinical integration in a health region.The diversity of initiatives and approaches under way highlights that there are neither magical recipes nor definitive evidence about what works best in integrated care. On the other hand, there are plenty of examples showing that business as usual does not work for chronic patients and that there is huge room for improvement . IntegraThe projects and initiatives included in this conference supplement add to the body of evidence on integration strategies for improving care for chronic patients in different contexts.En los países avanzados, el progreso de la medicina, la tecnología y los sistemas de protección social, ha llevado al desarrollo de complejos sistemas sanitarios en los que intervienen múltiples proveedores de servicios sanitarios, que a menudo funcionan de forma aislada. El caso del sistema nacional de salud español no es una excepción.Existe amplio consenso sobre el efecto perjudicial de la fragmentación de los servicios sanitarios sobre la calidad de la atención, especialmente a los pacientes crónicos, ya que estos habitualmente requieren asistencia por parte de distintos tipos de profesionales, así como una relación a largo plazo con el sistema sanitario. Por ello, puede decirse que una atención integrada es especialmente relevante para los pacientes crónicos y pluripatológicos, que son los que más sufren los problemas de acceso, continuidad, fragmentación y calidad, presentes en todos los sistemas sanitarios . Además,El Congreso Nacional de Atención Sanitaria al Paciente Crónico  surgió del interés de diversos expertos sanitarios, gestores, clínicos y decisores políticos en compartir experiencias, conocimientos y perspectivas, en cuanto a enfoques e iniciativas innovadoras en prevención y gestión de enfermedades crónicas. Como en ediciones anteriores, durante el III Congreso Nacional de Atención Sanitaria al Paciente Crónico, la “atención integrada y continuidad asistencial” ha sido un tema recurrente, considerándose un área clave para la mejora de la atención a las enfermedades crónicas. El citado congreso se celebró en Donostia-San Sebastián en mayo del 2011, y fue organizado por O+berri (Instituto Vasco de Innovación Sanitaria) y Osakidetza , con el apoyo del Departamento de Sanidad y Consumo del Gobierno Vasco. Este suplemento congresual incluye una selección de 19 comunicaciones elegidas entre las ponencias, comunicaciones orales y pósters sobre experiencias, proyectos y estudios en coordinación e integración asistencial presentados durante el congreso.Puede decirse que la fragmentación en la provisión de asistencia sanitaria es algo común en el sistema español de salud, a pesar de que en la mayoría de las Comunidades Autónomas (CCAA), los proveedores de servicios sanitarios sean de titularidad pública. En España, la competencia en cuanto a la organización de la asistencia sanitaria se encuentra a nivel regional, a cargo de las CCAAs, lo que ha conducido al desarrollo de 17 servicios regionales de salud diferenciados . FinanciAsimismo, la coordinación entre la atención sanitaria y la socio-sanitaria, que a menudo también requieren los pacientes crónicos, sobre todo aquellos de edad más avanzada, se ve especialmente obstaculizada por la pluralidad de instituciones proveedoras involucradas. Además, en la mayoría de las CCAAs, la atención sanitaria por una parte y la atención socio-sanitaria y social a mayores y dependientes por otra, son competencia de distintas autoridades públicas, lo que dificulta aún más su coordinación e integración.La muestra de experiencias recogidas en este suplemento pretende ilustrar la manera en la que el concepto de “atención integrada” se está empleando actualmente en España. Así, reúne ejemplos de distintos sistemas regionales de salud: País Vasco 7 casos), Cataluña (6), Valencia (2), Andalucía (1), Islas Canarias (1), y Castilla-La Mancha (1), así como un estudio en el que colaboran participantes de doce CCAAs (el proyecto Esperanza). Con esta publicación se espera contribuir, con una perspectiva española, al desarrollo de los conceptos multifacéticos y dinámicos de “atención integrada”, “integración asistencial”, y “continuidad asistencial”, entre otros  casos, C, así comServeis de Salut Integrats Baix Empordà , y el Consorci Sanitari Integral—Hospital General d’Hospitalet .Así, existen distintos modelos de integración asistencial que están emergiendo en España , 11, entLas iniciativas descritas en este suplemento congresual se refieren a experiencias de integración asistencial a nivel micro, que se centran en uno o varios procesos clínicos, incluso si algunas se desarrollan en el marco de OSIs. Entre ellas, algunas se centran en los procesos de los pacientes con múltiples patologías o complejos, y otras siguen un enfoque de gestión de enfermedades.Para este grupo de pacientes, que correspondería a los que se encuentran en el vértice de la pirámide de Kaiser , los benEn las experiencias dirigidas a la integración asistencial para pacientes pluripatológicos o complejos en España, cabe observar algunas tendencias como son:La creación o identificación de unidades, equipos o especialistas responsables de los pacientes pluripatológicos en el hospital, a menudo dentro de unidades de medicina interna. En estos modelos, el médico de medicina interna de referencia o la unidad de continuidad asistencial, según el caso, actúan como consultores para el nivel de atención primaria, y aseguran un punto de contacto estable para el paciente en el hospital .El uso de gestoras de caso, un rol normalmente desempeñado por profesionales de enfermería.Chronic Care Model y otros modelos relacionados [La mejora de la integración asistencial en pacientes complejos a menudo se desarrolla en el marco de iniciativas de gestión de crónicos más amplias. Así, en línea con el cionados , 19, estSuele medirse el efecto de las intervenciones en el uso de recursos sanitarios, y especialmente en los siguientes indicadores: número de hospitalizaciones, estancia hospitalaria, reingresos y número de visitas a urgencias.Gran parte de los pacientes complejos objeto de estas intervenciones tienen diagnóstico de insuficiencia cardiaca o de enfermedad pulmonar obstructiva crónica (EPOC).Además, estos resúmenes ponen de relieve la importancia de los métodos utilizados para identificar al grupo de pacientes complejos que va a ser objeto de una determinada intervención. Actualmente se están testando y utilizando distintos métodos y criterios de estratificación de la población . Estos incluyen ejemplos de:Consulta virtual entre el servicio de endocrinología de un hospital y médicos de atención primaria.Protocolos compartidos para la atención y derivación de pacientes con fractura de cadera entre un hospital agudo y un hospital de rehabilitación.Un programa de enfermedad compartido entre atención primaria y un hospital de agudos para pacientes con fallo cardiaco.Desarrollo de rutas asistenciales compartidas entre atención primaria y atención especializada para EPOC, fallo cardiaco, diabetes mellitus tipo 2 y espondiloartritis.Tratamiento asertivo comunitario para pacientes con trastorno mental grave.Un estudio sobre la variabilidad de la práctica clínica en depresión según el dispositivo asistencial .La gestión de una iniciativa que combina y coordina varias intervenciones de integración clínica en una comarca sanitaria.Chronic Care Model, modelo que sirve de hoja de ruta hacia una mejor atención a crónicos [La diversidad de las experiencias y enfoques existentes pone de manifiesto el hecho de que no hay recetas mágicas ni evidencia definitiva sobre qué funciona mejor en integración asistencial. Sin embargo, hay numerosos ejemplos de que la manera en la que actualmente se gestiona al paciente crónico no es la adecuada, y de que hay un amplio margen para la mejora en su atención . Asimismcrónicos . De hechcrónicos , 22, 23.crónicos .Esperamos que los distintos proyectos y experiencias incluidos en este suplemento contribuyan a la evidencia sobre estrategias de integración para la mejora de la atención a pacientes crónicos en distintos contextos.


The affiliations for Miguel Merchan and Juan Carro are incorrect. They are affiliated with 1, the Instituto de Neurociencias de Castilla y León, Universidad de Salamanca, Salamanca, Spain. Please see the full affiliation below:Verónica Lamas 1, Juan C. Alvarado 2, Juan Carro 1, Miguel A. Merchán 11. Instituto de Neurociencias de Castilla y León, Universidad de Salamanca,Salamanca, Spain2. Instituto de Investigación en Discapacidades Neurológicas (IDINE),Facultad de Medicina de Albacete, Universidad de castilla-La Mancha,Campus in Albacete, SpainThe column headings in Table 1 are not appropriately aligned. Please see the corrected Table 1 here:


Chronic diseases (CDs) are a priority health problem. These are conditions that healthcare is not able to cure, and for patients they mean a progressive deterioration of their health and loss of independence. Their prolonged and unpredictable course leads to a loss in quality of life and high use of healthcare and social resources. Since April 2009, our hospital  and its catchment area  have operated a specific programme to provide integrated and longitudinal care.The objective of our programme is to promote home monitoring of CDs and improve patient quality of life. The programme aims to achieve the aforementioned objectives through the development of three areas: scientific and technical services; social and family care; and the coordination of care and safety. Across these areas, there are six main lines of development: stratification of patient risk; comprehensive assessment of patients ; provision of pharmacological treatment and care based on the best available evidence; self-care education; sustained coordination of care; and development of professional skills. These lines have been translated to 11 operational interventions: patient identification; integrated assessment and care; standardisation of procedures; rational use of medicines; self-care education; sectorisation of the inpatient and outpatient areas; transfer on discharge; linkage to electronic health records; follow-up in primary care; close observation to detect exacerbations; and development of professional skills. Currently, the programme is applied in the case of patients with heart failure, chronic obstructive pulmonary disease, multiple diseases, or cancer requiring palliative care. A multidisciplinary group of health professionals  participated in the establishment and implementation of the programme.A total of 1308 patients have participated in the programme so far. Of these, 36.4% were included because they had multiple conditions, 30.8% for being readmitted, 22.4% for being classed as frail .The programme aims to provide a multidisciplinary approach and integrated healthcare for patients with CDs. It has made it possible to reorganise and rationalise our resources. In addition, it promotes continuity between the different levels of care as well as patient safety. Patients and caregivers have become more involved in their own disease and care. The lessons learnt are that it is worth striving to promote team work as it can improve sometimes complex care by sharing the provision of care and it allows the transfer of this innovative experience to other areas of action, producing favourable health outcomes.Las enfermedades crónicas (EC) constituyen un problema prioritario de salud. Se trata de procesos que los sistemas sanitarios no curan. En el paciente condicionan un progresivo deterioro y una pérdida de autonomía. Su curso prolongado e impredecible condicionará una merma en la calidad de vida y un elevado consumo de recursos sanitarios y sociales. Desde abril de 2009 nuestro centro hospitalario  y su área sanitaria de referencia (Distrito Sanitario Aljarafe) cuentan con un programa de atención específico para dar una respuesta integral y longitudinal a esta problemática.El objetivo de nuestro programa es mejorar el control en domicilio de las EC y potenciar la calidad de vida del paciente. Nuestro programa atiende las necesidades referidas, a través del desarrollo de tres áreas: científico-técnica; socio-familiar y cuidados; y el área de coordinación asistencial y seguridad. Estas áreas, se distribuyen en 6 líneas de desarrollo: estratificación del riesgo de los pacientes, evaluación integral , tratamiento farmacológico y cuidados en base a la mejor evidencia disponible, educación en autocuidados, mantenimiento de coordinación asistencial, y desarrollo de competencias profesionales. Estas líneas asistenciales se han expresado finalmente en 11 intervenciones operativas: identificación de pacientes, evaluación y atención integral, homogeneización de procedimientos, uso racional de medicamentos, educación en autocuidados, sectorización de la planta de hospitalización y consultas, transferencia al alta, vinculación de historia clínica digital, seguimiento en atención primaria, atención a las reagudizaciones, y desarrollo de competencias profesionales. Se actúa sobre las siguientes entidades clínicas: insuficiencia cardíaca, enfermedad pulmonar obstructiva crónica, pacientes con pluripatología y paliativos oncológicos. Han participado en su puesta en marcha y desarrollo un grupo multidisciplinar de profesionales sanitarios .Se han incluido 1308 pacientes. Un 36,4% con criterios de pluripatología, un 30,8% por reingreso, un 22,4% por fragilidad (criterios de la Consejería de Salud de la Junta de Andalucía [El programa apuesta por un abordaje multidisciplinar y una Atención Integral del paciente con EC. Ha permitido reorganizar nuestros recursos y racionalizarlos. Potencia las líneas de continuidad asistencial interniveles y las estrategias de seguridad. Hace partícipe al paciente y a su cuidador de su enfermedad y cuidados. La lección aprendida es una apuesta por el trabajo en equipo que trata de transformar una atención en ocasiones compleja, por una compartida y permite trasladar esta práctica innovadora a otros ámbitos de actuación con resultados en salud favorables.