Abstract
Objetivo
Determinar el impacto de atención ambulatoria del primer nivel de atención en la hospitalización del diabético tipo 2 en una población con condiciones iguales de aseguramiento.
Diseño
Estudio de casos y controles. Los casos son pacientes diabéticos hospitalizados por enfermedad relacionada con el padecimiento, y los controles son pacientes diabéticos sin antecedente de hospitalización en el último año.
Emplazamiento
Centros de atención primaria urbanos.
Participantes
Los casos fueron seleccionados consecutivamente en 4 de 5 hospitales generales urbanos (n = 123). Los controles fueron elegidos al azar en la unidad de atención primaria de donde provenía el caso (n = 135). Se excluyó a las mujeres con diabetes gestacional y a todos los que no contaban con expediente localizable (aproximadamente un 15%).
Mediciones
Se construyó un índice de atención primaria según las recomendaciones de la Asociación de Médicos Norteamericanos, la Comisión Conjunta de Acreditación de Organizaciones de Salud, el Comité Nacional de Aseguramiento para la Calidad, la Asociación Norteamericana de Diabetes y la Norma Oficial Mexicana. Se consideró que un cumplimiento menor al 60% correspondía a una atención subóptima. Resultados. Los factores de riesgo para la hospitalización fueron los siguientes: menos de 2 vistas al médico de familia en el último año (OR ajustada, 16,2; IC del 95%, 1,5-174,2), valor de glucosa (OR ajustada, 1,006; IC del 95%, 1,002-1,010) y nivel de conocimientos sobre la enfermedad (OR ajustada, 0,98; IC del 95%, 0,96-0,99), además de la práctica de ejercicio y el tiempo de diagnóstico. La atención primaria subóptima se registró en el 65,3% de los casos y el 49,1% de los controles (p = 0,03) e incrementó 2,5 veces el riesgo de hospitalización (IC del 95%, 1,2-5,0; seudo R2 = 0,279; p < 0,001).
Conclusiones
La evidencia disponible indica que la atención primaria puede ser un factor potencial para reducir la tasa de hospitalización por diabetes mellitus tipo 2. Los programas de manejo efectivos contribuirían a evitar hospitalizaciones innecesarias.
Palabras clave: Atención primaria, Primer nivel de atención, Diabetes
Abstract
Objective
To determine the impact of primary care on hospitalization of type 2 diabetics with equal conditions of health insurance.
Design
A case-control study. Case = diabetic hospitalized by a disease related condition. Control = diabetic without hospitalization during the last 12 months.
Setting
Urban primary care centers.
Participants
Cases were consecutively selected from four out of five urban hospitals (n=123). Controls were chosen at random from primary care units matched by primary care source (n=135). Women with gestational diabetes were excluded as well as individuals with missing medical charts (approximately 15%).
Measurements
A primary care index was constructed with process and outcome indicators recommended by the American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, the American Diabetes Association and the Official Mexican Standards. Compliance to less than 60% of recommendations was considered unsatisfactory primary care.
Results
The following were hospitalization risk factors: less than 2 visits to family physician during the last year (OR adjusted, 16,2; 95% CI, 1,5-174,2), glucose level (OR adjusted, 1,006; 95% CI, 1,002-1,010) and cognitive level (OR adjusted, 0,98; 95% CI, 0,96-0,99), in addition to exercising and year of diagnosis. Sixty-five percent of cases observed unsatisfactory primary care compared with 49,1% of controls (P=0,03). Unsatisfactory primary care increased 2,5 times the risk of hospitalization (95% CI, 1,2-5,0) (pseudo R2=0,279; P<0,001).
Conclusions
Primary care is a potential factor for reducing hospitalization of type 2 diabetics. Effective primary care programs would contribute to a better disease control and less unnecessary hospitalizations.
Key words: Primary care, Ambulatory care, Diabetes
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