The Raval Nord Study: Descriptive Analysis of Survival Rates During

Transcripción

The Raval Nord Study: Descriptive
Analysis of Survival Rates During 10 Years
of Home Care
Josep Maria Segura Noguera
Núria Bastida Bastús
Núria Martí Guadaño
Montserrat Riba Romeva
Mireia Marsà Carretero
Santiago Lancho Lancho
A large part of this population presents chronic, incapacitating illnesses that have led to a growing homebased social and health care effort (Freer, 1990; Luker &
Perkins, 1987; Taylor, 1978), which involves allocating
more human and material resources to meet the growing
home care demand. Although the help of other support
professionals may be needed on certain occasions, home
care is provided almost entirely by the primary care
team (PCT; López Pisa, Maymó, & Giró, 1989; Torra,
1989). A biopsychosocial circumstance, such as the
patient’s inability to leave his or her home as a result of
his or her illness, becomes the raison d’être of this care.
Various studies have shown an increase in the
dependent elderly population secondary to progressive
aging. According to the 1992 Enquesta de Salut de
Barcelona (Barcelona Health Care Survey; Barcelona
City Council, Public Health Department, 1992-1993),
20% of patients older than 65 presented some form of
limitation affecting their day-to-day life. This figure
seems to be growing and reached more than 30% in the
2000 Survey (Barcelona City Council, Public Health
Department, 2000). This population is unable to leave
the home without assistance. Home visits to these
housebound patients serve as a support to caregivers
This longitudinal study describes the urban population of chronic patients treated at home and analyzes survival rates of the first 10 years (1992 to
2002) of a primary health care team. Participants
included all of the 1,357 home care chronically ill
patients registered since the beginning of a home
care program (May 1994 to December 2002). The
average age was 82 years, 68% were female, 76%
lacked elevators, 18% cited loneliness, 11% were
totally dependent, and 20% suffered severe cognitive alterations. Cox’s proportional risk method and
survival probability curves by the Kaplan-Meier
method were used. Factors linked to lower survival
(p < .001) included being male (relative risk, RR =
1.67), existence of terminally ill patients because of
neoplastic pathologies (RR = 7.72), living accompanied by other people (RR = 2.39), deteriorated
cognitive function status (slight moderate, RR =
1.74; severe, RR = 2.71), and worsening degree of
autonomy (partially dependent, RR = 1.63; totally
dependent, RR = 3.54).
I
ncreases in life expectancy in recent years have led
to a progressive aging of the population (Gillick,
1989; Spanish Ministry of Social Affairs, 1991).
Key Words: home; care; health; service; primary; survival
Authors’ Note: The authors appreciate the work done by all the members of the Raval Nord primary care team in implementing the
Atencion Domiciliaria program, which has made it possible to draw up this article. We would also like to thank the chronic home care
patients and their families for their willingness to cooperate at all times.
Home Health Care Management & Practice / February 2007 / Volume 19, Number 2, 118-125
DOI: 10.1177/1084822306294479
©2007 Sage Publications
118
Segura Noguera et al. / Home Care Survival Rates
119
FIGURE 1
Study Schematic
1,357 chronic home care patients
treated by the Raval Nord PCT
Monitoring over 104 months
Complete monitoring
952 (70.2%)
Incomplete monitoring
405 (29.8%)
No significant
differences
Survival, continues in program
Survival, discharged from program
No survival due to death
Discharge from program due to change of address
Discharge from program due to institutionalization
Discharge from program due to other causes
Note: PCT = primary care team.
and help the family in the decision as to when hospitalization is appropriate.
The home care program called the Atencion
Domiciliaria (ATDOM) is the necessary instrument for
the PCT to provide proper, organized home care (Borrell,
1986; López Pisa & Maymó Pijuan, 1991). To this end,
advance planning taking into account the available
resources is required (Pinault & Daveuly, 1989; Segura,
Bastida, Martí, & González, 1994; Segura et al., 1996),
and it is necessary to make regular assessments to ensure
attainment of previously defined objectives. One of the
primary goals of this program, whose coverage has
ranged from 5% to 8% of the elderly population, was to
determine if greater physical and mental deterioration
could be linked to lower survival. It was decided to analyze these aspects of home care. The objective of the present study is to analyze survival rates among this
population of housebound patients who have received
home care during the first 10 years (1992-2002) of operation of a PCT. Figure 1 provides the reader with a visual
of the flow of this study.
MATERIAL AND METHOD
The Dr. Lluís Sayé Primary Care Centre, located in
the Ciutat Vella district of Barcelona, opened its doors
on December 14, 1992. The PCT now has 11 basic
health care units (BHUs) for general medicine. Each
BHU, which comprises a doctor and a nursing graduate, provides care 4 days a week at the center and
spends the other day of the week performing home
care, both spontaneous and scheduled, through an
ATDOM program set up in May 1994. In addition, the
nursing staff spends another weekday working in this
activity on a part-time basis. The Raval Nord borough,
with a population of 17,501 inhabitants according to
the 2000 census, has 4,446 people aged 65 or older
(25.4% of the total). The area is characterized by an
important shortage of lifts (76%) in buildings.
During the past 10 years, the ATDOM program has
included all chronic home care patients requiring care at
home because of mobility problems that prevented them
from going to the primary care center. Thus, one criterion of a housebound patient is the inability to be transported to the PCT as a result of his or her illness. The
maximum monitoring period was 104 months, from
May 1994 to December 2002. The request for home care
was made in most cases by the patient’s family (61%) or
by the PCT itself (26%), whereas social services advised
it in half of the remaining 13% of cases. On some occasions, the aid of the Home Care Support Team (PADES),
including a doctor, nursing staff, and social worker, has
been required, particularly to care for patients classified
as terminal in the target inclusion group.
120
HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2007
The data recorded in the “control and evaluation record”
have been used to analyze several variables referring to the
patients’ characteristics. These characteristics included
•
•
•
•
•
•
•
•
•
•
Age
Gender
Civil status
Origin of the demand
Target inclusion group or category in the program
Prevailing pathology
Degree of autonomy
Mental condition
Loneliness–company
Time included in the program
When the patient was discharged from the program,
the cause for the discharge was analyzed. The following were reasons for discharge:
• Improvement enabling the patient to visit the Public
Health Centre (PHC) by his or her own means
• Death
• Change of address
• Admission to nursing homes outside the borough
• Other causes
Physical capacity was assessed using the Katz index
(Alvarez et al., 1992; Katz, Downs, Cash, & Grotz,
1970; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963),
a scale that uses six basic activities of daily living
(ADLs; bathing, dressing, toileting, transferring, continence, and feeding) to classify the degree of autonomy,
ranging from independent for all functions (A) to
dependent for all functions (G). The H category on the
Katz index includes cases that are not classifiable
according to the remaining categories and in practice
behaves like a category with slight dependence.
Mental capacity was assessed using Pfeiffer’s Short
Portable Mental Status Questionnaire. This is a very
useful test given its speed of application, combined
with acceptable sensitivity and specificity (González
& Salgado, 1992; González Montalvo, Rodríguez
Mañas, & Ruipérez Cantera, 1992; Kane & Kane,
1993; Vinyoles, Recasens, Salvador, & Sáez, 1992),
and it serves to classify patients according to their
cognitive status. These classifications are
•
•
•
•
Intact
Slight deterioration
Moderate deterioration
Severe deterioration
However, the test is impossible to administer to some
patients with severe deterioration.
The data were entered into a database (DbaseIII
Plus) and then processed using the SPSS10.0 for
Windows package both for descriptive statistics and to
analyze survival. For the latter case, the values of the
most complex variables, such as cognitive status and
Katz index, were grouped together. Also grouped
together were some of the initial categories of the target group variables (chronic pathology, transitory
home care, dementias, terminal patients, and home
care risk groups) and loneliness–company (lives alone,
lives with other people older or younger than 60). For the
target group, cases of home care risk were also categorized as a chronic pathology. For loneliness–company,
people who live with others were classified under a
single category. For cognitive status, slight and moderate deterioration were merged, and cases where the test
could not be administered were included in the severe
category. For the Katz index, the categories were simplified to independent (Katz index A), partially dependent (Katz indexes B, C, D, E, F, H), and totally
dependent (Katz index G). Cox’s proportional risk
method was used to determine the estimated relative
risk (RR) of mortality depending on the different
recoded categories of the studied variables, whereas
the relevant combined survival probability curves were
calculated according to the Kaplan-Meier method. The
statistical significance level used at all times was α =
.05. Finally, an adjusted analysis with all variables
associated with survival was performed to assess
whether all preserved their significance.
RESULTS
A total of 1,357 chronic patients received home care
through the ATDOM program. Notably, 18% of the
patients lived in nursing homes in the borough, whereas
another 18% lived alone. Although the remaining 64%
lived in dwellings with others, 33% of them lived with
people older than 60. There is a clear prevalence of
females (68.3%) beyond age 75 (p < .001), as shown in
Table 1.
As for civil status, widowed topped the list with
50.7%, followed by married (32.1%), single (14.8%),
and other (2.4%), with significant differences according to gender (p < .001). There were more men among
the married (61.0%) and more women among the single (69.4%). In the widowed category, there was a significant prevalence of women (87.1%). The average
TABLE 1
Chronic Home Care Patients According to Age and Gender
Male
Age Group
Younger than 35
35-64
65-74
75-84
85 or older
Overall
Female
n
%
n
%
6
57
102
146
119
430
54.6
69.5
53.4
29.2
20.7
31.7
5
25
89
353
455
927
45.4
30.5
46.6
70.8
79.3
68.3
121
Figures 2 to 6 show the combined Kaplan-Meier
survival probability curve according to the mentioned
predictive factors.
Significant differences (p < .001) were also found in
average age depending on the survival of the patients
(yes = 73, no = 79). Patients without a full follow-up
(29.8%) did not present significant differences in the
studied variables. The analysis adjusted by variables
associated with survival did not experience changes of
interest with respect to the raw analysis (all variables
maintained their significance, except cognitive status).
Discussion
age was 82 (SD = 11), with differences (p < .001)
depending on gender (female = 84, male = 77).
The distribution according to target groups for inclusion in the program included chronic pathology
(78.4%), terminally ill (7.9%), dementias (6.3%), transitory home care (5.7%), and belonging to risk group
(1.7%). As for the 1,091 (80.4%) program discharges,
194 (14.3%) patients were admitted to nursing homes
and social health care centers outside our area, 130
(9.6%) moved away from the borough, 116 (8.5%)
recovered their former autonomy, and 570 (42.0%)
died. In the 81 remaining cases (6.0%), contact with the
patient was lost, and therefore the reason for leaving the
program was unknown.
Of the patients, 10.9% were dependent for all basic
ADLs (Katz index G), whereas 58.9% were partially
dependent (Katz index B 22.6%, C 13.1%, D 6.6%, E
4.1%, F 7.8%, H 4.7%), and 30.2% were independent
with regard to all activities (Katz index A). Of the
patients, 54.1% did not present alterations in the mental status test used, whereas 16.4% showed slight deterioration, 9.7% showed modest deterioration, and
19.8% presented severe deterioration (in 4.1% of cases,
the test was virtually impossible to administer). As
expected, the better degree of autonomy and cognitive
status of patients living alone was significant (p < .001).
The factors that showed a significant link (p < .001)
to lower survival were male gender (RR = 1.67), the
need to be accompanied (RR = 2.39), deteriorated cognitive status (slight-moderate RR = 1.74, severe RR =
2.71), and a lower degree of autonomy (partially
dependent RR = 1.63, totally dependent RR = 3.54)
and the terminal patient target group (mostly because
of neoplastic pathology; RR = 7.72). Table 2 shows
Cox’s proportional risk analysis for the different variable values studied.
The growing importance of home care as part of
primary health care is a phenomenon that will, in the
future, condition the allocation of increasing human
and material resources. The ATDOM program has
proved to be an efficient tool (Contel & González,
1995; Espinosa & Muñoz, 1995; Lindoso, Valencia,
Fernández, Álvarez, & Álvarez, 1994; López Pisa &
Agüera Villar, 1995) that facilitates patient monitoring.
It is important to mention that the implementation of
our program is appropriate even though the patients
were independent for all daily living activities at home
because home visit criteria were that they could not
leave their home to go visit the PHC as a result of their
illnesses. The specific medical cause for the patient
being housebound had little effect on the process of
home visiting.
The basic profile of patients included in the ATDOM
program reveals a strong prevalence of widows, which
is consistent with the majority of studies conducted
(Bilbao et al., 1994; Hernando et al., 1992; Monte,
Alonso, Cabal, & Iglesias, 1995; Sanz, Morente, Calvo,
Gallego, & Carra, 1995) because of the greater life
expectancy of women. The percentage of patients with
a good degree of autonomy is lower than in studies that
analyze the degree of autonomy in the overall elderly
population (Alvarez et al., 1992; Benítez, Hernández,
& Barreto, 1994; Monte et al., 1995). However, if we
compare these data with those of another study
(Hernando et al., 1992) that analyzes this aspect exclusively among the chronic home care patient population,
the figure is higher because in many cases the patients’
inability to go to the PHC by their own means was
because of the absence of lifts and the pluripathology
they presented. We measured their degree of autonomy
according to the Katz index because its usefulness has
been demonstrated in various studies (Alvarez et al.,
122
TABLE 2
Estimated Relative Risks of Mortality of Chronic Home Care Patients According to Studied Variables
Variable
Relative Risk
Gender
Female (reference category)
Male
Target group
Chronic pathology (reference category)
Transitory home care
Dementias
Terminal patient
Loneliness–company
Lives alone (reference category)
Lives with others
Cognitive status
Intact (reference category)
Slight to moderate deterioration
Severe deterioration
Katz index
Independent (reference category)
Partially dependent
Totally dependent
95% Confidence Interval
p
1.67
1.41-1.97
< .001
0.16
1.08
7.72
0.09-0.29
0.80-1.47
6.12-9.74
< .001
.602
< .001
2.39
1.80-3.18
< .001
1.74
2.71
1.13-2.69
1.75-4.19
.012
< .001
1.63
3.54
1.29-2.05
2.63-4.76
< .001
< .001
FIGURE 2
Survival Curve According to Gender
FIGURE 3
Survival Curve According to Loneliness–Company
1.2
1.2
1.0
1.0
.8
.8
.6
1
.6
1
.4
.4
2
.2
0.0
−20
2
0
20
40
60
.2
80
Monitoring time in months
100
120
0.0
−20
0
20
40
60
80
100
Gender
1: female
Loneliness−Company
2: male
1: lives alone
2: lives with others
120
FIGURE 4
Survival Curve According to Target Group
123
FIGURE 5
Survival Curve According to Cognitive Status
1.2
1.0
.8
1
.6
.4
.2
2
3
0.0
0
20
40
60
80
100
120
Mental Test
1: intact
1992; Cruz Jentoft, 1991; González & Salgado, 1992).
The usefulness of this index is confirmed even further
by a previous study that we conducted (Segura,
Bastida, Martí, & Riba, 1997), in which it proved to be
a good predictor both of the patients’ survival and of
visit frequency rates.
It is important to note that our results on survival are
consistent with other studies (González Montalvo,
Jaramillo Gómez, Rodríguez Mañas, Guillén Llera, &
Salgado Alba, 1990; Palomo & Gérvas, 2000) in terms
of lower survival rates among males. This last study
(Palomo & Gérvas, 2000) also pointed out, like ours,
the importance of assessing the degree of autonomy and
of the doctor’s initial opinion in relation to possible survival, a variable that we did not study. Some anecdotal
facts gleaned from our study have an explanation. Thus,
the greater survival rate of patients who live alone is
explained by its association with a greater degree of
autonomy and better cognitive status. Patients who we
could not assess using the Short Portable Mental Status
Questionnaire (because of their being very highly
evolved dementias) were considered to be equivalent to
severe dementia. The different, foreseeable evolution in
mortality of the different target inclusion groups was
2: slight-moderate det.
3: severe det.
clear. Although these differences are because of the
characteristics of the patients included in the program,
we believe it is important to describe them. Finally, it is
also important to note that most of the factors associated
with the survival of these patients were already evidenced in the analysis conducted 2 years after the start
of monitoring (Segura et al., 1997), although the existing differences according to the Katz index have lessened slightly over time.
The incomplete monitoring of 29% of the patients
because of changes of address, admission to nursing
homes outside our area, and other unknown causes
does not represent a limitation with regard to the results
because the analysis of these patients did not differ in
terms of predictive survival variables. We must make it
clear that the work done in home care in the Raval
Nord borough during these 10 years was done prior to
the start of the Salut a Casa (“Health at Home”; Catalan
Health Institute, 2001) program recently implemented
in the city of Barcelona and therefore also integrates
the Raval Nord ATDOM program. This made it necessary to adapt our program to the objectives, indicators,
and assessment scales agreed to for the entire city.
Finally, we believe it is important to note that although
there are few primary care studies that analyze patient
124
FIGURE 6
Survival Curve According to Degree of Autonomy
Barcelona City Council, Public Health Department. (2000). Enquesta de
salut de Barcelona 2000 [Barcelona’s health questionnaire 2000].
Barcelona, Spain: Author.
1.2
1.0
Benítez, M. A., Hernández, P., & Barreto, J. (1994). Evaluación geriátrica
exhaustiva en atención primaria: valoración de su utilidad [Exhaustive evaluation of geriatric services in primary care: An assessment of their usefulness]. Atención Primaria, 13(1), 20-26.
.8
.6
Bilbao, I., Gastaminza, A. M., García, J. A., Quindimil, J. A., López, J. L.,
& Huidobro, L. (1994). Los pacientes domiciliarios crónicos y su entorno
en atención primaria de salud [Chronic patients at home and their primary
health environment]. Atención Primaria, 13(4), 188-190.
1
.4
Borrell, F. (1986). Programas de salud en atención primaria. Necesidad de
innovaciones metodológicas [Health programs in primary care. Need of
methodological innovations]. Atención Primaria, 3(2), 91-96.
2
.2
0.0
−20
Barcelona City Council, Public Health Department. (1992-1993). Enquesta
de salut de Barcelona 1992-1993 [Barcelona’s health questionnaire
1992-1993]. Barcelona, Spain: Author.
Catalan Health Institute. (2001). “Salut a casa” program. Implementació
de l’atenció domiciliària a Barcelona [“Salut a Casa” program.
Implementation of the home care in Barcelona]. Barcelona, Spain: Author.
3
0
20
40
60
80
100
120
Katz Index
1: independent
2: partially dependent
3: totally dependent
Contel, J. C., & González, M. (1995). Reflexión sobre la implementación
de programas de atención domiciliaria [Reflection about the implementation of the home care programs]. Enfermería Clínica, 5(5), 205-211.
Cruz Jentoft, A. J. (1991). El índice de Katz [The Katz Index]. Revista
Española de Geriatría y Gerontología, 26, 338-348.
Espinosa, J. M., & Muñoz, F. (1995). Evaluación de los programas de atención domiciliaria en atención primaria de salud [An evaluation of primary
home health care programs]. Cuadernos de Gestión, 1(1), 24-32.
Freer, C. B. (1990). Screening the elderly. British Medical Journal, 300,
1.447-1.448.
survival, the ATDOM program does provide proper
recording means for studying this aspect. Thus, an
appropriate integral assessment of home care makes it
possible to detect problems requiring new objectives to
be defined.
The following key points highlight the findings of
this study:
• Increased life expectancy has led to a progressive
aging of the population and growing home-based
social and health care.
• The housebound population is characterized by being
of a very advanced age, with high mortality, requiring
continued home care.
• Predictive variables of patient survival include gender, the target inclusion group, loneliness–company,
cognitive function, and degree of autonomy.
REFERENCES
Alvarez, M., Alaiz, A., Brun, E., Cabañeros, J., Calzón, M., Cosío, I., et al.
(1992). Capacidad funcional de pacientes mayores de 65 años, según el
índice de Katz. Fiabilidad del método [The functional capacity of patients
over 65 according to the Katz Index. How reliable is this method?].
Atención Primaria, 10, 812-816.
Gillick, M. R. (1989). Long-term care options for the frail elderly. Journal
of American Geriatric Society, 37, 1198-1203.
González, J. I., & Salgado, A. (1992). Manejo del paciente anciano en atención primaria. Líneas guía [Guidelines for the management of the elderly
patient in primary care. Guidelines]. Atención Primaria, 9(4), 219-226.
González Montalvo, J. I., Jaramillo Gómez, E., Rodríguez Mañas, L.,
Guillén Llera, F., & Salgado Alba, A. (1990). Estudio evolutivo de los
pacientes en asistencia geriátrica domiciliaria a los 18 meses [Evaluative
study of the patients in home geriatric assistance at the 18 months]. Revista
Clínica Española, 187, 165-169.
González Montalvo, J. I., Rodríguez Mañas, L., & Ruipérez Cantera, I.
(1992). Validación del cuestionario de Pfeiffer y la escala de incapacidad
mental de la Cruz Roja en la detección del deterioro mental en los pacientes
externos en un servicio de geriatría [Validation of the questionnaire from
Pfeiffer and the mental incapacity scale from Cruz Roja in the detection of
the mental decline of the external patients from a geriatric department].
Revista Española de Geriatría y Gerontología, 27, 129-133.
Hernando, J., Iturioz, P., Torán, P., Arratibel, I., Arregui, A., & Merino, M.
(1992). Problemas y necesidades de salud de los pacientes crónicos domiciliarios [Problems and health care needs of chronic homebound patients].
Atención Primaria, 9(3), 133-136.
Kane, R. A., & Kane, R. L. (1993). Evaluación de las necesidades en los
ancianos. Guía práctica sobre los instrumentos de medición [Evaluation
about necessity of the ancient patients. Practice guideline about the medication instrument]. Barcelona, Spain: SG Editores.
Katz, S., Downs, T. D., Cash, H., & Grotz, R. C. (1970). Progress in development of the index of ADL. The Gerontologist, 10, 20-30.
Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W.
(1963). Studies of illness in the aged: The index of ADL, a standardized
measure of biological and psychosocial function. Journal of American
Medical Association, 85, 914.
Lindoso, T., Valencia, S., Fernández, A., Álvarez, S., & Álvarez, J. A.
(1994). Monitorizar un programa de atención domiciliaria [Monitor a
home care program]. Revista Rol de Enfermería, 188, 13-16.
López Pisa, R. M., & Agüera Villar, B. (1995). Atenció domiciliària:
Avaluació de 5 anys de funcionament del programa. Salut Catalunya, 9(5),
203-207.
López Pisa, R. M., Maymó, N., & Giró, E. (1989). Atención domiciliaria
[Home care]. In A. Martín Zurro & J. F. Cano Pérez (Eds.), Manual de atención primaria (2nd ed., p. 234). Barcelona, Spain: Doyma.
López Pisa, R. M., & Maymó Pijuan, N. (1991). Programación de la atención domiciliaria. Monografías clínicas de atención primaria [Home care
program. Primary care clinical monographs]. Barcelona, Spain: Doyma.
Luker, K. A., & Perkins, E. S. (1987). The elderly at home: Service needs
and provision. Journal of the Royal College of General Practitioners, 37,
248-250.
Monte, C., Alonso, J. C., Cabal, A., & Iglesias, A. (1995). Capacidad funcional en mayores de 80 años [Functional capacity in population aged 80
years and older]. Atención Primaria, 15(3), 176-178.
Palomo, L., & Gérvas, J. (2000). Mortalidad a los 2 años en pacientes crónicos confinados en el domicilio [Mortality rate after 2 years of chronic
patients confined at home]. Atención Primaria, 25, 176-180.
Pinault, R., & Daveuly, C. (1989). La planificación sanitaria. Conceptos,
métodos, estrategias [Health planification. Concepts, methods, strategies]
(2nd ed.). Barcelona, Spain: Masson.
125
Segura, J. M., Sanz, F., Bastida, N., Martí, N., González, C., & Guerrero, M.
(1996). Descripción y validación de un modelo predictivo de la distribución
geográfica de los enfermos crónicos domiciliarios [Description and validation of a predictive model of the geographical distribution of the homebound
chronically ill]. Atención Primaria, 17(4), 292-294.
Spanish Ministry of Social Affairs. (1991). La tercera edad en España:
aspectos cuantitativos. Proyecciones de la población española de 60 y más
años para el período 1986-2010 [The third age in Spain: quantitative
aspects. Projections of the Spanish population aged 60 and older for the
period 1986-2010]. Madrid: Author.
Taylor, R. B. (1978). Home care. In R. B. Taylor (Ed.), Family medicine:
Principles and practice (pp. 112-116). New York: Springer Verlag.
Torra, J. E. (1989). Atención domiciliaria y atención primaria de salut
[Home care and primary care]. Revista Rol de Enfermería, 125, 37-43.
Vinyoles, E., Recasens, J. M., Salvador, B., & Sáez, A. (1992). La demencia: Una visión desde la atención primaria. Atención Primaria [Dementia:
A primary care perspective], 10(5),789-793.
Josep Maria Segura Noguera is a family physician and doctor at the
Raval Nord primary care team (PCT) work center in Barcelona, Spain.
Núria Bastida Bastús is a family physician at the Raval Nord PCT
work center in Barcelona, Spain.
Núria Martí Guadaño is a nurse at the Raval Nord PCT work
center in Barcelona, Spain.
Sanz, C., Morente, M., Calvo, C., Gallego, P., & Carra, B. (1995).
Valoración psico-física del anciano [Psychophysical valoration of the
ancient patient]. Revista Rol de Enfermería, 206, 17-20.
Montserrat Riba Romeva is a social worker at the Raval Nord
PCT work center in Barcelona, Spain.
Segura, J. M., Bastida, N., Martí, N., & González, C. (1994). Atención domiciliaria: Estudio previo la implantación de un programa [Care at home: Study
preceding the introduction of a program]. Atención Primaria, 14(6), 852.
Mireia Marsà Carretero is a family physician at the Raval Nord
Segura, J. M., Bastida, N., Martí, N., & Riba, M. (1997). Enfermos crónicos domiciliarios. Análisis descriptivo y de supervivencia a los 2 años de la
implantación de un programa de atención domiciliaria [The chronically ill
at home: A descriptive and survival analysis 2 years after the introduction
of a home care program]. Atención Primaria, 19(7), 351-356.
Santiago Lancho Lancho is a family physician at the Raval Nord

The Raval Nord Study: Descriptive Analysis of Survival Rates During

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