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array:23 [ "pii" => "S2254887416000060" "issn" => "22548874" "doi" => "10.1016/j.rceng.2015.11.004" "estado" => "S300" "fechaPublicacion" => "2016-04-01" "aid" => "1222" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2015" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2016;216:113-20" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4 "PDF" => 4 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0014256515002830" "issn" => "00142565" "doi" => "10.1016/j.rce.2015.11.009" "estado" => "S300" "fechaPublicacion" => "2016-04-01" "aid" => "1222" "copyright" => "Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2016;216:113-20" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 139 "formatos" => array:2 [ "HTML" => 15 "PDF" => 124 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ORIGINAL</span>" "titulo" => "Análisis del proceso asistencial de los pacientes con diabetes mellitus tipo 2 y comorbilidad asociada atendidos en el Sistema Nacional de Salud en España: una perspectiva de los profesionales médicos. 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IMAGINE study" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2635 "Ancho" => 3326 "Tamanyo" => 351794 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Origen y derivación de pacientes con diabetes tipo 2 y comorbilidad.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Gómez-Huelgas, S. Artola-Menéndez, E. Menéndez-Torre" "autores" => array:3 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Gómez-Huelgas" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Artola-Menéndez" ] 2 => array:2 [ "nombre" => "E." 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(B) Sample divided into 2 groups: normal hydration and stages other than normal hydration at discharge (DeH plus HyperH).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Trejo-Velasco, Ó. Fabregat-Andrés, V. Montagud, S. Morell, J. Núñez, L. Fácila" "autores" => array:6 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Trejo-Velasco" ] 1 => array:2 [ "nombre" => "Ó." "apellidos" => "Fabregat-Andrés" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Montagud" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Morell" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Núñez" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Fácila" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256515003045" "doi" => "10.1016/j.rce.2015.12.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256515003045?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887416000084?idApp=WRCEE" "url" => "/22548874/0000021600000003/v1_201604010056/S2254887416000084/v1_201604010056/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Analysis of the healthcare process of patients with type 2 diabetes mellitus and associated comorbidity treated in Spain's National Health System: A perspective of medical professionals. IMAGINE study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "113" "paginaFinal" => "120" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Gómez-Huelgas, S. Artola-Menéndez, E. Menéndez-Torre" "autores" => array:3 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Gómez-Huelgas" "email" => array:1 [ 0 => "ricardogomezhuelgas@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Artola-Menéndez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Menéndez-Torre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, FIMABIS, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Atención Primaria, Centro de Salud José Marvá, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis del proceso asistencial de los pacientes con diabetes mellitus tipo 2 y comorbilidad asociada atendidos en el Sistema Nacional de Salud en España: una perspectiva de los profesionales médicos. Estudio IMAGINE" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1599 "Ancho" => 3297 "Tamanyo" => 217894 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Integrated and multidisciplinary care processes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Type 2 diabetes mellitus (DM2) is a chronic disease with one of the largest impacts on public health worldwide.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> DM2 is a pandemic and affects 366 million individuals. It is predicted that 440 million patients will have DM2 by 2030.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> In Spain, the prevalence of DM2 is 13.8%.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">DM2 is a risk factor for cardiovascular disease, renal failure, leg amputation and blindness and causes the death of 4 million individuals every year, a figure that is estimated to rise by more than 50% over the next 20 years.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">DM2 is often associated with other comorbidities, both concordant (obesity, cardiovascular disease and renal failure) and discordant (respiratory disease, osteoarticular disease, depression and dementia).<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> The presence of comorbidity decreases the cardiovascular benefits of glycemic control,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> limits antidiabetic treatment compliance,<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> affects patients’ quality of life<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> and increases healthcare resource consumption.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> Therefore, the overall approach for patients with diabetes and comorbidity is a considerable healthcare challenge.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Chronicity requires a multidimensional, proactive, ongoing, comprehensive and systemic approach, implemented around an informed and active patient.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> There are increasingly numerous experiences with implementing interventions that improve the quality of diabetes care.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> However, there are no studies in Spain that analyze, from an interdisciplinary perspective, the views of medical professionals involved in caring for patients with diabetes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study is to analyze the current state of the Spanish public health organization regarding the care of patients with DM2 and comorbidity, with a particular focus on interventions in lifestyle changes, one of the most difficult aspects to implement in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study characteristics</span><p id="par0030" class="elsevierStylePara elsevierViewall">IMAGINE was a cross-sectional study conducted using an online questionnaire.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population (inclusion criterion)</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study population consisted of primary care (PC) physicians, internists and endocrinologists who are members of the participating scientific societies (Study Group Network for Diabetes in Primary Health Care [RedGDPS], Spanish Society of Diabetes [SED] and the Diabetes and Obesity Workgroup of the Spanish Society of Internal Medicine [SEMI]) who regularly treat patients with DM2 (universe of approximately 3600).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Sample size calculation</span><p id="par0040" class="elsevierStylePara elsevierViewall">With a finite population and assuming a maximum error for the total sample of ±5.2% and a 95.5% confidence level (<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2), we calculated a sample size of 302 physicians.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Distribution and selection</span><p id="par0045" class="elsevierStylePara elsevierViewall">The distribution was determined based on the available databases of the participating medical societies. The above-mentioned medical societies invited all of their members to participate and were in charge of disseminating the protocol, the questionnaire and the access instructions. The recruitment was competitive and was closed when the calculated sample of participating physicians was reached.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data collection</span><p id="par0050" class="elsevierStylePara elsevierViewall">An online platform was created specifically for the study, with a data entry period of 2 months.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study variables</span><p id="par0055" class="elsevierStylePara elsevierViewall">The indicators established in the Instrument for Assessing Chronic Care Models (IEMAC)<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> were used as general guidelines. This instrument self-assesses healthcare organizations on the degree to which they implement chronic care management models.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The following sections were assessed: most common healthcare pathways and referrals; criteria for referring patients to other levels; pharmaceutical reconciliation in healthcare transitions; circuit/referrals (excluding emergency departments) in difficult/exacerbation conditions; presence of integrated/multidisciplinary care processes for patients with DM2 and comorbidity; presence of multidisciplinary monitoring and type of specialist who decides on the changes/adjustments in therapy; nursing resources with competency in the management/follow-up of patients with DM2; degree of coordination between hospital and PC specialists; implementation of interconsultations; coordination between nurses and physicians; specialists who conduct smoking cessation interventions; and the importance of multidisciplinary coordination in improving the control/follow-up of DM2.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Frequency and absolute value distribution in a crossed table of all items in the questionnaire, with the classification variables (specialty, sex, professional experience, type of healthcare center and number of patients with DM2 attended regularly). The complete statistical tabulation is available in the scientific societies participating in the study. The statistical analysis was conducted with the tabulation and data analysis program Star for Windows version 2.7.4.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Sample characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">A total of 302 physicians (59.6% men) participated in the study. The mean age was 48.8 (9.3) years, with 22.8 (9.8) years of professional experience. A total of 114 (39%) physicians belonged to PC, 92 (31%) to endocrinology and 74 (25%) to internal medicine; the rest did not specify a specialty. Sixty-eight percent worked in centers with no diabetes reference unit.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Associated comorbidity</span><p id="par0075" class="elsevierStylePara elsevierViewall">The participating physicians treat a monthly average of 32.3 patients with DM2 and associated comorbidity (31.0% PC, 29.1% internal medicine and 36.6% endocrinology); 57% of these patients are older than 65 years.</p><p id="par0080" class="elsevierStylePara elsevierViewall">As with other studies,<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11,15</span></a> arterial hypertension, obesity and hyperlipidemia were the most common comorbidities (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The consulted physicians estimated that 56% of their patients with DM2 have chronic renal failure and that 34% are frail.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Patient origin and referral</span><p id="par0085" class="elsevierStylePara elsevierViewall">Some 71.8% of all the cases originated in PC. For 59% of the physicians, “all or almost all cases” originated at this healthcare level. Only 40% of the patients with DM2 and comorbidity were referred from other healthcare levels. PC physicians indicated higher rates of referral to other levels than did internal medicine physicians or endocrinologists (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Healthcare pathways</span><p id="par0090" class="elsevierStylePara elsevierViewall">Only 37% of the participants stated that their centers had implemented healthcare pathways between PC and hospital care for referring patients with DM2 and comorbidity. Most of these pathways (51%) were only applied occasionally. The main reasons for referral were the presence of severe renal failure, poor glycemic control and the screening or follow-up of patients with diabetic retinopathy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The participating physicians considered that pharmaceutical reconciliation was only performed in 52% of the transitions between different healthcare levels. Twenty-seven percent of the physicians stated that reconciliation is only performed occasionally, and 14% stated that reconciliation never or almost never occurs.</p><p id="par0100" class="elsevierStylePara elsevierViewall">There are few alternatives to the emergency department for patients who are difficult to manage or have exacerbations, except for telephone access, which was installed in a third of the centers.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Only 10% of the centers had implemented a comprehensive and multidisciplinary care process for patients with DM2 and comorbidity, the majority of which included PC, nursing and endocrinology or internal medicine (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Coordination among the different specialists</span><p id="par0110" class="elsevierStylePara elsevierViewall">The degree of coordination among the different specialists who treat patients with DM2 and comorbidity was classified as “good” or “very good” in 41% of the cases, “poor” or “very poor” in 20% and “regular” in 35%. Fifty-eight percent of the physicians reported conducting interconsultations, clinical meetings or consultancies to treat specific patients. These interconsultations are mostly conducted by endocrinologists (27.3%). Nonface-to-face consultation (via the Internet) was less common (32%) and also predominates in endocrinology.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diabetes education</span><p id="par0115" class="elsevierStylePara elsevierViewall">The patients’ diabetes education activities are shared between the physician and nurse. The physician assumes a greater role in antitobacco counseling (44.8%) and glycemic self-analysis reviews (31%), while the nurse specializes in insulin therapy techniques (65.7%), diet planning (44.2%), physical activity (37.9%) and foot examinations (36.9%). The degree of interdisciplinary work between physicians and nurses is greater in PC than in the hospital setting. For example, antitobacco counseling is coordinated with nursing more often in PC (64.4%) than in internal medicine (21.3%) or endocrinology (32.4%). Some 63.5% of the physicians verify the achievement of the patient's nutritional education objectives. Thirty-six percent of the physicians stated that they were “less than satisfied or not at all satisfied” with the results.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In 47% of the cases, the nurse was responsible for implementing the dietary treatment. Only 5% of those surveyed had a nutritionist. The mean time invested in providing patients with dietetic information, which in most cases was less than 10<span class="elsevierStyleHsp" style=""></span>min (65%). Only 58% of the participants conducted a dietary record.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The physician and nurse almost equally divide the responsibility for recommending physical activity, which consists primarily of recommending heart-healthy aerobic exercise. Most of these participants (80%) dedicated less than 5<span class="elsevierStyleHsp" style=""></span>min per patient. Only 10% used a system for screening for sarcopenia. Most of the physicians surveyed (38.9%) were “less than or not at all” satisfied with the achievement of physical activity objectives.</p><p id="par0130" class="elsevierStylePara elsevierViewall">PC physicians, pulmonologists and nurses were the practitioners who led smoking cessation interventions. The main activities are minimal motivational counseling and informational/educational planning. The average cessation rate after a year was estimated at 26%.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Healthcare improvement needs</span><p id="par0135" class="elsevierStylePara elsevierViewall">Multidisciplinary work (80.8%), the continuing education of health professionals (72.3%) and patient education programs (72%) were the 3 most often cited factors for improving the treatment and control of DM2 with comorbidity. Moreover, the main barriers to improving the quality are the scarcity of time for implementing nondrug treatments (75.6%), the lack of qualified personnel for lifestyle changes (66.5%), the limitations in coordinating PC-specialized care (66.5%) and the organizational deficiencies (64.1%).</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">There is significant semantic and conceptual confusion among the terms comorbidity, polypathology and chronicity. A recent consensus among family physicians, internists and nurses in Spain has proposed terminology for unifying the criteria. Comorbidity refers to the various satellite diseases that accompany the primary acute or chronic disease. Polypathology indicates the presence of 2 or more chronic symptomatic diseases that have a similar degree of complexity and management difficulties. The concept of the complex chronic patient includes the presence of limiting and progressive diseases that result in an overuse of health services, polypharmacy and functional impairment and have a negative social and family impact.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Despite the positive trend observed in the past decade,<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17,18</span></a> most patients with DM2 in Spain do not achieve the control objectives recommended by current guidelines,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> which indicates the need to improve the quality of care for these patients. In this respect, an overall approach to patients with DM2 and associated comorbidity is considered a key element.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The high prevalence of comorbidity detected in our study is consistent with that described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4,10,21</span></a> The proper assessment of comorbidity in DM2 is essential for determining treatment intensity and therapeutic objectives, given that the presence of multiple severe comorbidities limits the benefits of glycemic control.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5,22</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Although the focus has classically been on comorbidity concordant with DM2 (i.e., that which shares etiopathogenic mechanisms such as obesity, other cardiovascular risk factors, cardiovascular disease and microvascular complications), there is a growing interest in discordant disease associated with diabetes (lung disease, osteoarticular disease, depression, dementia and malignancies) and its impact on health outcomes. It has been reported that more than 70% of patients with DM2 have at least one discordant comorbidity at the time of diagnosis.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Discordant comorbidity associated with DM2 limits the patients’ ability to self-care,<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6,23–25</span></a> has a significant negative impact on their quality of life<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> and increases the consumption of healthcare resources.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Our results indicate that most patients with DM2 and comorbidity are treated in PC, which should be considered when implementing improvement plans. The presence of specific interlevel healthcare pathways appears to be in the minority according to the surveyed professionals, despite the fact that establishing specific referral circuits has been shown to be useful in improving the results of diabetes treatment.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9,13</span></a> The main causes for referral from PC to hospital care are renal failure, poor glycemic control and diabetic retinopathy. A number of multidisciplinary consensus statements have recently been published in Spain, focusing on aspects that attempt to improve on this deficiency.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">26–29</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The regular presence of polypharmacy in patients with multiple comorbidities justifies the importance of conducting proper therapeutic reconciliation with these patients.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> The low degree of therapeutic reconciliation detected in our study emphasizes the need for addressing this problem with a structured methodology and using an interdisciplinary perspective.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The model of care for chronic patients uses a systematic and comprehensive approach to restructure the medical care and establish alliances between the health systems and the community. This model includes 6 key components<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a>: (1) the leadership of the healthcare organization to ensure the necessary resources and to break barriers, (2) the promotion of self-care, (3) the support of scientific evidence-based decision-making, (4) design and coordination of services provision and healthcare processes, (5) medical information systems and (6) public health and community policies. The chronic care model has been implemented successfully in the care of patients with diabetes.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">The Diabetes Strategy of the Spanish National Health System (SNHS) (ref. 2012),<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> in line with other international guidelines (International Diabetes Federation, American Diabetes Association), emphasizes the importance of interlevel and multidisciplinary work and patient involvement for improving the health outcomes of patients with diabetes. Of special relevance is the role of nursing in diabetes education.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> Our results highlight the need perceived by physicians to improve the specific resources of qualified nursing in this setting.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The considerable majority of patients with DM2 in Spain have excess body weight or abdominal obesity.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> Weight loss, through changes in diet and physical activity, has been shown to improve glycemic control, cardiovascular risk factors and quality of life for patients with DM2, as well as to reduce the healthcare costs of these patients.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> However, to achieve good outcomes, the lifestyle interventions must be intensive, multidisciplinary and structured.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> In Spain, these programs have shown their efficacy.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> In our study, the interviewed physicians noted their dissatisfaction with the outcomes of lifestyle changes in their clinical practice and emphasized the scarce time available for these tasks. Furthermore, the patients with DM2 expressed their difficulty in adopting the changes in diet and physical activity.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> As a whole, these data highlight the need for the NHS to establish structured programs on lifestyle changes for the population with DM2.</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study has 2 strong points. The first is that, until now, no analysis had been performed in Spain on the healthcare organization in terms of the care for patients with DM2 and comorbidity. Second, this is an interdisciplinary study at the national level, whose conclusions concerning the barriers and areas of improvement perceived by healthcare professionals could be useful for developing a chronic care model focused on patients in the SNHS with DM2.</p><p id="par0190" class="elsevierStylePara elsevierViewall">This study, however, has a number of limitations. Firstly, only 10% of the medical specialists who are members of the collaborating societies were interviewed. We cannot therefore rule out a bias of participation by those physicians most interested in diabetes. PC physicians are under-represented in the sample, as they response to the survey to a lesser degree. Second, the study was conducted in a self-assessed manner; however, this is a common practice among epidemiological surveys. The survey also did not include nurses, a group of paramount importance in treating diabetes. Finally, in order to have an overall and objective idea of the problem being addressed, a patient survey should have been included, which would have helped us understand their degree of satisfaction with their treatment.</p><p id="par0195" class="elsevierStylePara elsevierViewall">In conclusion, Spanish physicians propose the improvement of multidisciplinary work, the continuing education programs for professionals and the patient education programs as the 3 cornerstones for improving the treatment and control of DM2 with comorbidity in Spain. These directives are in line with those published in the Diabetes Strategy of the SNHS (ref. 2012).<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> The low declared rate of therapeutic reconciliation is an alarming fact that should be addressed as a priority.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Funding</span><p id="par0200" class="elsevierStylePara elsevierViewall">This study was funded by <span class="elsevierStyleGrantSponsor" id="gs1">Novartis</span>.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interests</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest with this publication.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres624497" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec637901" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres624498" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec637900" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study characteristics" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study population (inclusion criterion)" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Sample size calculation" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Distribution and selection" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Data collection" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Study variables" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "Results" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Sample characteristics" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Associated comorbidity" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Patient origin and referral" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Healthcare pathways" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "Coordination among the different specialists" ] 5 => array:2 [ "identificador" => "sec0080" "titulo" => "Diabetes education" ] 6 => array:2 [ "identificador" => "sec0085" "titulo" => "Healthcare improvement needs" ] ] ] 7 => array:2 [ "identificador" => "sec0090" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Conflict of interests" ] 10 => array:2 [ "identificador" => "xack210491" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-08-05" "fechaAceptado" => "2015-11-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec637901" "palabras" => array:6 [ 0 => "Type 2 diabetes mellitus" 1 => "Comorbidity" 2 => "Healthcare pathways" 3 => "Multidisciplinary coordination" 4 => "Health care" 5 => "Lifestyle" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec637900" "palabras" => array:6 [ 0 => "Diabetes mellitus tipo 2" 1 => "Comorbilidad" 2 => "Rutas asistenciales" 3 => "Coordinación multidisciplinar" 4 => "Atención sanitaria" 5 => "Hábitos de vida" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the care received by patients with type 2 diabetes mellitus (DM2) and comorbidity in Spain's National Health System.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study using an online survey. A total of 302 family physicians, internists and endocrinologists participated in the study. The participants were recruited voluntarily by their respective scientific societies and received no remuneration.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients with DM2 and comorbidity are mostly treated in Primary Care (71.8%). Forty percent are referred to hospital care, mainly due to renal failure, poor glycaemic control and for a retinopathy assessment. Only 52% of those surveyed conducted medication reconciliation in the transition between healthcare levels. Fifty-eight percent reported conducting interconsultations, clinical meetings or consultancies between healthcare levels. The 3 main factors identified for improving the follow-up and control of DM2 with comorbidity were the multidisciplinary study (80.8%), the continuing education of health professionals (72.3%) and therapeutic education programs (72%). A lack of time, a lack of qualified personnel for lifestyle interventions and organizational shortcomings were mentioned as the main obstacles for improving the care of these patients.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Most patients with DM2 and comorbidity are treated in Primary Care. Promoting multidisciplinary care and training programs for practitioners and patients can help improve the quality of care. Therapy reconciliation represents a priority area for improvement in this population.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar la atención que reciben los pacientes con diabetes mellitus tipo 2 (DM2) y comorbilidad en el Sistema Nacional de Salud español.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal mediante encuesta <span class="elsevierStyleItalic">online</span>. Participaron 302 médicos de familia, internistas y endocrinólogos, reclutados por sus respectivas sociedades científicas, de manera voluntaria y no retribuida.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes con DM2 y comorbilidad son atendidos mayoritariamente en Atención Primaria (71,8%). Un 40% son derivados a atención hospitalaria, principalmente por insuficiencia renal, mal control glucémico y evaluación de retinopatía. Solo el 52% de los encuestados realizaban conciliación farmacológica en la transición entre niveles asistenciales. El 58% manifestaron realizar interconsultas, sesiones clínicas o consultorías entre niveles asistenciales. Los 3 principales factores identificados para mejorar el seguimiento y control de la DM2 con comorbilidad fueron el trabajo multidisciplinar (80,8%), la formación continuada de los profesionales sanitarios (72,3%) y los programas de educación terapéutica (72%). La falta de tiempo, la carencia de personal cualificado en intervenciones sobre el estilo de vida y las deficiencias organizativas fueron citadas como las principales barreras para la mejora asistencial en estos pacientes.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayoría de los pacientes con DM2 y comorbilidad son atendidos en Atención Primaria. Promover la atención multidisciplinaria y los programas formativos para profesionales y pacientes puede contribuir a mejorar la calidad asistencial. La conciliación terapéutica representa un área prioritaria de mejora en esta población.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gómez-Huelgas R, Artola-Menéndez S, Menéndez-Torre E. Análisis del proceso asistencial de los pacientes con diabetes mellitus tipo 2 y comorbilidad asociada atendidos en el Sistema Nacional de Salud en España: una perspectiva de los profesionales médicos. Estudio IMAGINE. Rev Clin Esp. 2016;216:113–120.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1794 "Ancho" => 2934 "Tamanyo" => 319006 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diseases associated with type 2 diabetes.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2635 "Ancho" => 3326 "Tamanyo" => 318889 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Origin and referral of patients with type 2 diabetes and comorbidity.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1599 "Ancho" => 3297 "Tamanyo" => 217894 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Integrated and multidisciplinary care processes.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Multiple-choice; total greater than 100%.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Patient with severe renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Diabetic retinopathy screening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Diabetic retinopathy follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Significant obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Poor glycemic control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Poor blood pressure control despite taking 3 drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Frequent, severe or unintentional hypoglycemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Patient with moderate renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Diabetes education \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. Patient with macroalbuminuria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11. Assessment of diabetic foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12. Intensification of insulin therapy to more complex regimens \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1024389.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Most often cited criteria for referring patients (percentages).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "IDF Diabetes Atlas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "International Diabetes Federation" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "6th ed." 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