Objectives: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice; this disorder is a risk factor for stroke and is associated with substantial morbidity and mortality. Our objective was to develop a cost-utility analysis of the different treatment alternatives in patients aged 40 years old or more with concomitant AF with valve disease in Spain, from the National Health System perspective. Methods: An economic evaluation through a Markov model with four health states (sinus rhythm, AF, dependent stroke, death) was developed to simulate the evolution of a cohort of 1,000 patients receiving each treatment alternative in addition to mitral valve surgery (drug therapy, surgical ablation and catheter ablation). The time horizon was 5 years, with a cycle length of 3 months. Data on costs and effects were obtained from the published literature and expert opinion and were discounted at 3.5%. A sensitivity analysis was developed to determine the robustness of the results. Results: The quality-adjusted life years (QALY) gained were 3.29, 3.89, and 3.83, respectively, for the alternatives of no ablation, surgical ablation and catheter ablation. The costs per patient were 5,770€, 10,034€ and 11,289€, respectively. The surgical ablation cost/QALY rate compared with no ablation was 7,145€. Surgical ablation was dominant versus catheter ablation. The probabilistic sensitivity analysis showed that the results were robust. Conclusions: Surgical ablation is a cost-effective treatment option in patients with concomitant AF, with a cost-effectiveness ratio under the efficiency threshold commonly accepted in Spain.

Lately Spain, the proportion of immigrants has increased in both general and HIV-infected populations. Nevertheles, data on the temporal trends of the epidemic in immigrants and on their sociodemographic, epidemiologic and clinical characteristics are scarce and are scattered in various information sources that cover complementary aspects of this issue. The objectives of the present study were to analyze the available information sources that allow the epidemiology of HIV infection in immigrants in Spain to be studied, and to describe the current situation of HIV infection in immigrants, based on the available information sources.

Objective: To determinate the impact of comorbidity, resource use and cost (healthcare and lost productivity) on maintenance of remission of major depressive disorder in a Spanish population setting. Methods: We performed an observational, prospective, multicenter study using population databases. The inclusion criteria were age >18 years, first depressive episode between January 2003 and March 2007, with antidepressant prescription >60 days after the first prescription and a follow-up of at least 18 months (study: 12 months; continuation: 6 months). Two subgroups were considered: patients with/without remission. Main measures: sociodemographic data, episodes, resource utilization bands, healthcare costs (direct) and lost productivity (indirect). Logistic regression and analysis of covariance (Bonferroni correction) were used for analysis. Results: A total of 4,572 patients were analyzed and 54.6% (95% confidence interval: 53.2-56.0%) were considered in remission. Patients in remission were younger (52.6 vs. 60.7), with a lower proportion of women (71.7% vs. 78.2%), and showed less general morbidity (6.2 vs. 7.7 episodes/year), lower resource utilization bands/year (2.7 vs. 3.0), fewer sick leave days (31.0 vs. 38.5) and shorter treatment duration (146.6 vs. 307.7 days); p<0.01. Lack of remission was associated with fibromyalgia (odds ratio [OR]=2.5), thyroid alterations (OR=1.3) and hypertension (OR=1.2); p<0.001. The annual healthcare cost was €706.0 per patient in remission vs. €1,108.3 without remission (p <0.001) and lost productivity was €1,631.5 vs. €2,024.2, respectively (p <0.001). Conclusions: Patients not achieving remission showed higher morbidity, resources use, healthcare costs and, especially, productivity losses.

Objective: To assess the impact of the distinct diagnostic criteria used in population-based studies on estimation of the prevalence of knee osteoarthritis. Methods: We performed a search for population-based studies of the prevalence of knee osteoarthritis carried out in the general noninstitutionalized population in Europe or the USA. Results: Eight articles were selected, six from Europe and two from the USA. Depending on the study, definition of knee osteoarthritis was based on symptomatic criteria (pain), radiological criteria (the Kellgren and Lawrence scale) or a combination of both symptomatic and radiological criteria. Prevalence estimates ranged from 2.0 to 42.4% with symptomatic criteria, from 16.3 to 33.0% with radiological criteria, and from 1.5 to 15.9% when both criteria were combined. The prevalence was higher for women and increased with age, with the exception of some prevalences estimated through symptoms, which decreased in ages older than 80 years. Conclusions: There is a lack of consensus on the criteria used to diagnose knee osteoarthritis in population-based studies of prevalence. Consequently, prevalence estimates vary widely, depending on the diagnostic criteria used, and not only by age and sex. The prevalence was higher when radiological evidence alone was used, followed by symptomatic criteria and by combinations of both.

Objectives: To describe trends in HIV prevalence, in risk
behaviors associated with HIV transmission, and in knowledge and attitudes
related to antiretroviral therapy (ART) among men who have sex with men (MSM)
recruited in Catalonia between 1995 and 2006. Methods: Biannual
cross-sectional surveys were performed. An opportunistic sample of MSM was
recruited in saunas, sex shops, bars and a cruising site in a public park. In
addition, an anonymous self-administered questionnaire was sent by mail to all
members of a gay and lesbian association (Coordinadora Gai-Lesbiana). Oral fluid
samples were collected to determine HIV prevalence. Linear trends in proportions
were assessed by the c² test, stratified by
age. Results: The overall prevalence of HIV infection increased from 8.5%
(1995) to 14.1% (2006) among men aged less than 30 years old (p=0.162)
and from 18.2% (1995) to 21.2% (2006) among those aged 30 years old or more
(p=0.07). Consistent condom use in anal intercourse with occasional
partners decreased from 72.9% to 58.7% in men aged less than 30 years old
(p <0.05) and from 77.2% to 65.6% in those aged 30 years old or more
(p<0.001). The proportion of men who reported they chose riskier
behaviors because of ART increased from 9.2% to 19.4% in men aged less than 30
years old and from 8.3% to 16.7% in those aged 30 years old or more
(p<0.05). Conclusions: An increasing trend in the prevalence of
HIV and associated risk behaviors was found in Catalonia among MSM. Therefore,
preventive programs targeting this population should be intensified and should
include new risk reduction strategies, as well as other educational messages
about ART.

Objective: To analyze how news items about clinical errors
are treated by the press in Spain and their influence on patients.
Methods: We performed a quantitative and qualitative study. Firstly, news
items published between April and November 2007 in six newspapers were analyzed.
Secondly, 829 patients from five hospitals in four autonomous regions were
surveyed. Results: We analyzed 90 cases generating 128 news items,
representing a mean of 16 items per month. In 91 news items (71.1%) the source
was checked. In 78 items (60.9%) the author could be identified. The impact of
these news items was -4.86 points (95% confidence interval [95%CI]: -4.15-5.57).
In 59 cases (57%) the error was attributed to the system, in 27 (21.3%) to
health professionals, and in 41 (32.3%) to both. Neither the number of columns
(p=0.702), nor the inclusion of a sub-header (p=0.195), nor a complementary
image (p=0.9) were found to be related to the effect of the error on safety
perceptions. Of the 829 patients, 515 (62.1%; 95%CI: 58.8-65.4%) claimed to have
recently seen or heard news about clinical errors in the press, on the radio or
on television. The perception of safety decreased when the same person was
worried about being the victim of a clinical error and had seen a recent news
item about such adverse events (c²=15.17;
p=0.001). Conclusions: Every week news items about clinical errors are
published or broadcast. The way in which newspapers report legal claims over
alleged medical errors is similar to the way they report judicial sentences for
negligence causing irreparable damage or harm. News about.

Objectives: To determine the opinions of urban parents on alcohol drinking in teenagers and their positioning regarding the legal restrictive measures. Material and methods: We performed a qualitative study of six focal groups including 42 mothers and fathers of adolescents from six different Spanish regions and from diverse social strata. The quantitative part of the study consisted of a 1-10 scale questionnaire, measuring parents' acceptance and opinion about legal measures restricting underage drinking. Means and standard deviation were calculated. Results: Parents did not consider adolescent alcohol drinking to be a problem so long as it was moderate and leisure time-related. The social and cultural context was permissive with the alcohol consumption. Alcohol intake depended on both external (social pressure) and internal (family) factors. Fathers' preferred to exercise authority, while mothers preferred communication and education skills. Parents approved of teachers' interventions, especially when based on the student's overall education and not restricted to knowledge transmission. Public institutions and authorities were held responsible for adolescents' lack of information, the scarcity of leisure-time alternatives and for not ensuring compliance with current regulations. Parents approved restrictions regarding the sale and advertising of alcohol. Conclusions: Parents recognize adolescent alcohol drinking as a problem and tend to deal with it. Parents use distinct intervention strategies and generally approve legal measures.

Objectives: To identify patient expectations of clinical decision-making at consultations with their general practitioners for distinct health problems and to determine the patient and general practitioner characteristics related to these expectations, with special focus on gender. Methods: We performed a multicenter cross-sectional study in 360 patients who were interviewed at home. Data on patients' sociodemographic, clinical characteristics and satisfaction were gathered. General practitioners supplied information on their gender and postgraduate training in family medicine. A questionnaire was used to collect data on patients' expectations that their general practitioner «listen, explain, and take account of their opinion and on expectations of clinical decision making» at consultations with their general practitioner for five problems or hypothetical clinical scenarios (strong chest pain/cold with fever/abnormal discharge/depression or sadness/severe family problem). Patients were asked to indicate their preference that decisions on diagnosis and treatment be taken by: a) the general practitioner alone; b) the general practitioner, taking account of the patient's opinion; c) the patient, taking account of the general practitioner's opinion and d) the patient alone. A logistic regression was performed for clinical decision-making. Results: The response rate was 90%. The mean age was 47.3±16.5 years and 51% were female. Patients' expectations that their general practitioner listen, explain and take account of their opinions were higher than their expectations of participating in decision-making, depending on the problem in question: 32% wished to participate in chest pain and 49% in family problems. Women had lower expectations of participating in depression and family problems. Patients with female general practitioners had higher expectations of participating in family problems and colds. Conclusions: Most patients wished to be listened to, informed and taken into account by their general practitioners and, to a lesser extent, wished to take decisions autonomously, especially for biomedical problems.

An intervention in venues for interaction used by men who have sex with men in Valencia (Spain) was performed to prevent human immunodeficiency virus (HIV) infection or avoid delay in diagnosis and to facilitate contact with the health circuit. Information was provided on prevention and a rapid test for HIV and syphilis was performed. We contacted 500 men and the intervention was performed in 171; 37% of the subjects in saunas and one in four of those in prostitution apartments had never been tested. The prevalence of HIV was 1.6% (n=2) in the saunas, and 11% (n=5) in the apartments (n=5). For syphilis, these percentages were 5% and 2.3% respectively. The intervention revealed the existence of highly exposed population groups with low compliance and facilitated access to the health system in these groups.

Objectives: To describe the actual presence of smoking in restaurant and hospitality premises after the smoking prevention act banning smoking in workplaces came into force in 2006, with wide exemptions in this sector. Methods: We performed an observational, descriptive study in Barcelona (Catalonia, Spain) in 2008 based on cluster sampling, with 1130 premises. The results were stratified by premise type. Results: Up to 85.7% of food shops allowing consumption within their premises (bakeries, pastry shops…) ban smoking, as well as 85% of fast food establishments. Among restaurants, 40% are smoke-free or have separate smoking areas. Bar-cafés and café-restaurants (the most abundant premises) usually allow smoking. There are more smoke-free options in central districts and in shopping malls. Conclusions: Up to 75.4% of all premises allow smoking freely. These results show the limitations of the law.

The upcoming public health law must serve as the basis for public health reform. The text of the law should allow public health structures to be modernized and adapted to the country's new needs. A broader concept of public health and a redefinition of its functions and basic services are required. Some of the main suggestions for the upcoming law are the establishment of a Spanish Agency for Public Health and a Public Health Council, the design of a Spanish Strategy of Public Health, and reform of professional training.

Objective: To analyze the trend in socioeconomic inequalities in all-cause mortality in Barcelona from 1983 to 2004. Methods: We performed an ecological study of trends over 4 cross-sections (1983-1988, 1989-1994, 1995-1999 and 2000-2004), with the basic health area (BHA) as the unit of analysis. The study population consisted of men and women aged 20 years or more living in Barcelona. The information sources were the mortality registry, the municipal census and the census of inhabitants and dwellings. The age- and sex-specific mortality rate (ASMR) for all causes was used as the dependent variable. As the independent variable, a composite index of socioeconomic deprivation of the BHA was calculated; BHAs were grouped in quartiles according to the values on the index. Poisson models were adjusted to estimate the relative risk of mortality from all causes in the 4 groups of BHA, stratified by age groups and sex. Results: In all the study periods, inequalities in mortality were found, depending on the BHA of residence, both for men and for women: the ASMR of the most deprived BHAs were greater than those of less deprived BHA, and were greater among men than among women. Likewise, relative risks in the youngest age groups were higher than in the oldest age groups. However, from the second to fourth study periods, inequalities decreased in absolute and relative terms, especially among men. Conclusions: Inequalities in mortality persist in BHA in Barcelona but have decreased over the last 2 decades. Public policies should take this information into account when tackling inequalities among BHA.

Objective: The aims of this study were to estimate the rate of hospital emergency services (HES) visits per health area, the associated percentage of admissions and the standardized HES utilization ratio, and to analyze their relationship with hospital resources. Methods: We performed an ecological study that combined information from distinct sources (Survey of Health Care Hospitalization Establishments 2006 and Minimum Data Set 2006) to estimate the rate of HES visits and the percentage of associated emergency admissions in 164 health areas in 14 autonomous communities (AC). Results: Among 35.3 million inhabitants in the 164 areas examined, there were 16.2 million visits to the HES (45.75 per 100 inhabitants); more than 2 million (12.6%) were hospitalized. Excluding 5% of extreme areas, rates oscillated between 31.60 and 78.69 HES visits/100 inhabitants, and the percentage of admissions was between 7.6% and 27.9%. These differences were not attenuated after standardization. The AC factor explained 29% of variance in HES visits and 82% of variance in admissions. The rate of visits was not associated with the number of beds or staff physicians but did correlate with the number HES doctors, and smaller and non-teaching hospitals. Conclusions: There is wide variability in the rates of HES visits and emergency admissions in the different areas of the Spanish National Health System. This variability seems to be associated with a differential use for minor problems.

Objective: To estimate the prevalence of young people's involvement in violence measured as participation in physical fights or being physically, sexually or emotionally abused. We also aimed to understand the role of social, demographic and other behavioural characteristics in violence. Methods: We evaluated 7511 adolescents (4243 girls and 3268 boys) aged 15 to 19 years old, enrolled in public schools. Information was obtained using an anonymous, self-administrated questionnaire. Results: The most frequently reported type of violence was emotional abuse (15.6%). Boys reported greater involvement in fights (3.6 vs. 13.6%, p<0.001) and physical abuse (7.5 vs. 19.5%, p<0.001). The prevalence of emotional abuse (16.2 vs. 14.8%, p=0.082) and sexual abuse (2.0 vs. 1.8%, p=0.435) was similar in girls and boys. After adjustment, increasing age decreased the odds of being involved in fights in both genders but increased the odds of emotional abuse. Living in a rented home was associated with physical abuse in girls (odds ratio [OR]: 1.4; 95% confidence interval [95%CI]: 1.0-1.9) and boys (OR: 1.6; 95%CI: 1.2-2.0). In girls the odds of being emotionally abused increased with greater parental education. Smoking and cannabis use were associated with all types of violence in both genders. Conclusions: The most frequently reported form of violence was emotional abuse. We found differences by gender, with boys reporting more physical abuse and involvement in fights. Adolescents whose parents had a higher educational level reported more physical and emotional abuse, which may be related to differences in the perception of abuse.

The inclusion of the quadrivalent human papilloma virus (HPV)
vaccine in the schedule of the Spanish National Health System sparked the debate
over Gardasil^®, which was presented to the public as a "vaccine
against cervical cancer". In this context, Sanofi Pasteur MSD was sued for
misleading advertising in the campaign "cuentaselo.org". Although the
complaint was not admitted, the lawsuit triggered five changes in the ownership
of the web domain which, although backed by scientific societies, was not
supported by law. Because of the violation of the Law of the Society of
Information Services, and prompted by the suspicion that the pharmaceutical
company was behind these changes (as it could not advertise the product), the
platform for the moratorium on the HPV vaccine filed a complaint against the
Spanish Society of Gynecology and Obstetrics (whose logo appeared on the
webpage) for breaching the code of advertising self-regulation. Sanofi Pasteur
MSD, the advertiser which was not mentioned, "accepted the complaint and removed
the webpage", thus corroborating its involvement.