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a figure that is estimated to rise by more than 50&#37; over the next 20 years&#46;<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&#44; both concordant &#40;obesity&#44; cardiovascular disease and renal failure&#41; and discordant &#40;respiratory disease&#44; osteoarticular disease&#44; depression and dementia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> The presence of comorbidity decreases the cardiovascular benefits of glycemic control&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> limits antidiabetic treatment compliance&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> affects patients&#8217; quality of life<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> and increases healthcare resource consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> Therefore&#44; the overall approach for patients with diabetes and comorbidity is a considerable healthcare challenge&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Chronicity requires a multidimensional&#44; proactive&#44; ongoing&#44; comprehensive and systemic approach&#44; implemented around an informed and active patient&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> However&#44; there are no studies in Spain that analyze&#44; from an interdisciplinary perspective&#44; the views of medical professionals involved in caring for patients with diabetes&#46;</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&#44; with a particular focus on interventions in lifestyle changes&#44; one of the most difficult aspects to implement in clinical practice&#46;<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&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population &#40;inclusion criterion&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study population consisted of primary care &#40;PC&#41; physicians&#44; internists and endocrinologists who are members of the participating scientific societies &#40;Study Group Network for Diabetes in Primary Health Care &#91;RedGDPS&#93;&#44; 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obesity and hyperlipidemia were the most common comorbidities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The consulted physicians estimated that 56&#37; of their patients with DM2 have chronic renal failure and that 34&#37; are frail&#46;</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&#46;8&#37; of all the cases originated in PC&#46; For 59&#37; of the physicians&#44; &#8220;all or almost all cases&#8221; originated at this healthcare level&#46; Only 40&#37; of the patients with DM2 and comorbidity were referred from other healthcare levels&#46; PC physicians indicated higher rates of referral to other levels than did internal medicine physicians or endocrinologists &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</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&#37; of the participants stated that their centers had implemented healthcare pathways between PC and hospital care for referring patients with DM2 and comorbidity&#46; Most of these pathways &#40;51&#37;&#41; were only applied occasionally&#46; The main reasons for referral were the presence of severe renal failure&#44; poor glycemic control and the screening or follow-up of patients with diabetic retinopathy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The participating physicians considered that pharmaceutical reconciliation was only performed in 52&#37; of the transitions between different healthcare levels&#46; Twenty-seven percent of the physicians stated that reconciliation is only performed occasionally&#44; and 14&#37; stated that reconciliation never or almost never occurs&#46;</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&#44; except for telephone access&#44; which was installed in a third of the centers&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Only 10&#37; of the centers had implemented a comprehensive and multidisciplinary care process for patients with DM2 and comorbidity&#44; the majority of which included PC&#44; nursing and endocrinology or internal medicine &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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 &#8220;good&#8221; or &#8220;very good&#8221; in 41&#37; of the cases&#44; &#8220;poor&#8221; or &#8220;very poor&#8221; in 20&#37; and &#8220;regular&#8221; in 35&#37;&#46; Fifty-eight percent of the physicians reported conducting interconsultations&#44; clinical meetings or consultancies to treat specific patients&#46; These interconsultations are mostly conducted by endocrinologists &#40;27&#46;3&#37;&#41;&#46; Nonface-to-face consultation &#40;via the Internet&#41; was less common &#40;32&#37;&#41; and also predominates in endocrinology&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diabetes education</span><p id="par0115" class="elsevierStylePara elsevierViewall">The patients&#8217; diabetes education activities are shared between the physician and nurse&#46; The physician assumes a greater role in antitobacco counseling &#40;44&#46;8&#37;&#41; and glycemic self-analysis reviews &#40;31&#37;&#41;&#44; while the nurse specializes in insulin therapy techniques &#40;65&#46;7&#37;&#41;&#44; diet planning &#40;44&#46;2&#37;&#41;&#44; physical activity &#40;37&#46;9&#37;&#41; and foot examinations &#40;36&#46;9&#37;&#41;&#46; The degree of interdisciplinary work between physicians and nurses is greater in PC than in the hospital setting&#46; For example&#44; antitobacco counseling is coordinated with nursing more often in PC &#40;64&#46;4&#37;&#41; than in internal medicine &#40;21&#46;3&#37;&#41; or endocrinology &#40;32&#46;4&#37;&#41;&#46; Some 63&#46;5&#37; of the physicians verify the achievement of the patient&#39;s nutritional education objectives&#46; Thirty-six percent of the physicians stated that they were &#8220;less than satisfied or not at all satisfied&#8221; with the results&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In 47&#37; of the cases&#44; the nurse was responsible for implementing the dietary treatment&#46; Only 5&#37; of those surveyed had a nutritionist&#46; The mean time invested in providing patients with dietetic information&#44; which in most cases was less than 10<span class="elsevierStyleHsp" style=""></span>min &#40;65&#37;&#41;&#46; Only 58&#37; of the participants conducted a dietary record&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The physician and nurse almost equally divide the responsibility for recommending physical activity&#44; which consists primarily of recommending heart-healthy aerobic exercise&#46; Most of these participants &#40;80&#37;&#41; dedicated less than 5<span class="elsevierStyleHsp" style=""></span>min per patient&#46; Only 10&#37; used a system for screening for sarcopenia&#46; Most of the physicians surveyed &#40;38&#46;9&#37;&#41; were &#8220;less than or not at all&#8221; satisfied with the achievement of physical activity objectives&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">PC physicians&#44; pulmonologists and nurses were the practitioners who led smoking cessation interventions&#46; The main activities are minimal motivational counseling and informational&#47;educational planning&#46; The average cessation rate after a year was estimated at 26&#37;&#46;</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 &#40;80&#46;8&#37;&#41;&#44; the continuing education of health professionals &#40;72&#46;3&#37;&#41; and patient education programs &#40;72&#37;&#41; were the 3 most often cited factors for improving the treatment and control of DM2 with comorbidity&#46; Moreover&#44; the main barriers to improving the quality are the scarcity of time for implementing nondrug treatments &#40;75&#46;6&#37;&#41;&#44; the lack of qualified personnel for lifestyle changes &#40;66&#46;5&#37;&#41;&#44; the limitations in coordinating PC-specialized care &#40;66&#46;5&#37;&#41; and the organizational deficiencies &#40;64&#46;1&#37;&#41;&#46;</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&#44; polypathology and chronicity&#46; A recent consensus among family physicians&#44; internists and nurses in Spain has proposed terminology for unifying the criteria&#46; Comorbidity refers to the various satellite diseases that accompany the primary acute or chronic disease&#46; Polypathology indicates the presence of 2 or more chronic symptomatic diseases that have a similar degree of complexity and management difficulties&#46; The concept of the complex chronic patient includes the presence of limiting and progressive diseases that result in an overuse of health services&#44; polypharmacy and functional impairment and have a negative social and family impact&#46;<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&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;18</span></a> most patients with DM2 in Spain do not achieve the control objectives recommended by current guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> which indicates the need to improve the quality of care for these patients&#46; In this respect&#44; an overall approach to patients with DM2 and associated comorbidity is considered a key element&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;10&#44;21</span></a> The proper assessment of comorbidity in DM2 is essential for determining treatment intensity and therapeutic objectives&#44; given that the presence of multiple severe comorbidities limits the benefits of glycemic control&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;22</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Although the focus has classically been on comorbidity concordant with DM2 &#40;i&#46;e&#46;&#44; that which shares etiopathogenic mechanisms such as obesity&#44; other cardiovascular risk factors&#44; cardiovascular disease and microvascular complications&#41;&#44; there is a growing interest in discordant disease associated with diabetes &#40;lung disease&#44; osteoarticular disease&#44; depression&#44; dementia and malignancies&#41; and its impact on health outcomes&#46; It has been reported that more than 70&#37; of patients with DM2 have at least one discordant comorbidity at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Discordant comorbidity associated with DM2 limits the patients&#8217; ability to self-care&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;23&#8211;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&#46;<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&#44; which should be considered when implementing improvement plans&#46; The presence of specific interlevel healthcare pathways appears to be in the minority according to the surveyed professionals&#44; despite the fact that establishing specific referral circuits has been shown to be useful in improving the results of diabetes treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;13</span></a> The main causes for referral from PC to hospital care are renal failure&#44; poor glycemic control and diabetic retinopathy&#46; A number of multidisciplinary consensus statements have recently been published in Spain&#44; focusing on aspects that attempt to improve on this deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">26&#8211;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&#46;<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&#46;<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&#46; This model includes 6 key components<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a>&#58; &#40;1&#41; the leadership of the healthcare organization to ensure the necessary resources and to break barriers&#44; &#40;2&#41; the promotion of self-care&#44; &#40;3&#41; the support of scientific evidence-based decision-making&#44; &#40;4&#41; design and coordination of services provision and healthcare processes&#44; &#40;5&#41; medical information systems and &#40;6&#41; public health and community policies&#46; The chronic care model has been implemented successfully in the care of patients with diabetes&#46;<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 &#40;SNHS&#41; &#40;ref&#46; 2012&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> in line with other international guidelines &#40;International Diabetes Federation&#44; American Diabetes Association&#41;&#44; emphasizes the importance of interlevel and multidisciplinary work and patient involvement for improving the health outcomes of patients with diabetes&#46; Of special relevance is the role of nursing in diabetes education&#46;<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&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The considerable majority of patients with DM2 in Spain have excess body weight or abdominal obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> Weight loss&#44; through changes in diet and physical activity&#44; has been shown to improve glycemic control&#44; cardiovascular risk factors and quality of life for patients with DM2&#44; as well as to reduce the healthcare costs of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> However&#44; to achieve good outcomes&#44; the lifestyle interventions must be intensive&#44; multidisciplinary and structured&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> In Spain&#44; these programs have shown their efficacy&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> In our study&#44; 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&#46; Furthermore&#44; the patients with DM2 expressed their difficulty in adopting the changes in diet and physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> As a whole&#44; these data highlight the need for the NHS to establish structured programs on lifestyle changes for the population with DM2&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study has 2 strong points&#46; The first is that&#44; until now&#44; no analysis had been performed in Spain on the healthcare organization in terms of the care for patients with DM2 and comorbidity&#46; Second&#44; this is an interdisciplinary study at the national level&#44; 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&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">This study&#44; however&#44; has a number of limitations&#46; Firstly&#44; only 10&#37; of the medical specialists who are members of the collaborating societies were interviewed&#46; We cannot therefore rule out a bias of participation by those physicians most interested in diabetes&#46; PC physicians are under-represented in the sample&#44; as they response to the survey to a lesser degree&#46; Second&#44; the study was conducted in a self-assessed manner&#59; however&#44; this is a common practice among epidemiological surveys&#46; The survey also did not include nurses&#44; a group of paramount importance in treating diabetes&#46; Finally&#44; in order to have an overall and objective idea of the problem being addressed&#44; a patient survey should have been included&#44; which would have helped us understand their degree of satisfaction with their treatment&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In conclusion&#44; Spanish physicians propose the improvement of multidisciplinary work&#44; 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&#46; These directives are in line with those published in the Diabetes Strategy of the SNHS &#40;ref&#46; 2012&#41;&#46;<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&#46;</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>&#46;</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&#46;</p></span></span>"
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            0 => "Diabetes mellitus tipo 2"
            1 => "Comorbilidad"
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        "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 &#40;DM2&#41; and comorbidity in Spain&#39;s National Health System&#46;</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&#46; A total of 302 family physicians&#44; internists and endocrinologists participated in the study&#46; The participants were recruited voluntarily by their respective scientific societies and received no remuneration&#46;</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 &#40;71&#46;8&#37;&#41;&#46; Forty percent are referred to hospital care&#44; mainly due to renal failure&#44; poor glycaemic control and for a retinopathy assessment&#46; Only 52&#37; of those surveyed conducted medication reconciliation in the transition between healthcare levels&#46; Fifty-eight percent reported conducting interconsultations&#44; clinical meetings or consultancies between healthcare levels&#46; The 3 main factors identified for improving the follow-up and control of DM2 with comorbidity were the multidisciplinary study &#40;80&#46;8&#37;&#41;&#44; the continuing education of health professionals &#40;72&#46;3&#37;&#41; and therapeutic education programs &#40;72&#37;&#41;&#46; A lack of time&#44; a lack of qualified personnel for lifestyle interventions and organizational shortcomings were mentioned as the main obstacles for improving the care of these patients&#46;</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&#46; Promoting multidisciplinary care and training programs for practitioners and patients can help improve the quality of care&#46; Therapy reconciliation represents a priority area for improvement in this population&#46;</p></span>"
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      "es" => array:3 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar la atenci&#243;n que reciben los pacientes con diabetes mellitus tipo 2 &#40;DM2&#41; y comorbilidad en el Sistema Nacional de Salud espa&#241;ol&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal mediante encuesta <span class="elsevierStyleItalic">online</span>&#46; Participaron 302 m&#233;dicos de familia&#44; internistas y endocrin&#243;logos&#44; reclutados por sus respectivas sociedades cient&#237;ficas&#44; de manera voluntaria y no retribuida&#46;</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 Atenci&#243;n Primaria &#40;71&#44;8&#37;&#41;&#46; Un 40&#37; son derivados a atenci&#243;n hospitalaria&#44; principalmente por insuficiencia renal&#44; mal control gluc&#233;mico y evaluaci&#243;n de retinopat&#237;a&#46; Solo el 52&#37; de los encuestados realizaban conciliaci&#243;n farmacol&#243;gica en la transici&#243;n entre niveles asistenciales&#46; El 58&#37; manifestaron realizar interconsultas&#44; sesiones cl&#237;nicas o consultor&#237;as entre niveles asistenciales&#46; Los 3 principales factores identificados para mejorar el seguimiento y control de la DM2 con comorbilidad fueron el trabajo multidisciplinar &#40;80&#44;8&#37;&#41;&#44; la formaci&#243;n continuada de los profesionales sanitarios &#40;72&#44;3&#37;&#41; y los programas de educaci&#243;n terap&#233;utica &#40;72&#37;&#41;&#46; La falta de tiempo&#44; 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&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los pacientes con DM2 y comorbilidad son atendidos en Atenci&#243;n Primaria&#46; Promover la atenci&#243;n multidisciplinaria y los programas formativos para profesionales y pacientes puede contribuir a mejorar la calidad asistencial&#46; La conciliaci&#243;n terap&#233;utica representa un &#225;rea prioritaria de mejora en esta poblaci&#243;n&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-Huelgas R&#44; Artola-Men&#233;ndez S&#44; Men&#233;ndez-Torre E&#46; An&#225;lisis del proceso asistencial de los pacientes con diabetes mellitus tipo 2 y comorbilidad asociada atendidos en el Sistema Nacional de Salud en Espa&#241;a&#58; una perspectiva de los profesionales m&#233;dicos&#46; Estudio IMAGINE&#46; Rev Clin Esp&#46; 2016&#59;216&#58;113&#8211;120&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diseases associated with type 2 diabetes&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Origin and referral of patients with type 2 diabetes and comorbidity&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Multiple-choice&#59; total greater than 100&#37;&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#46;5&nbsp;\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&#46; Diabetic retinopathy screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;6&nbsp;\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&#46; Diabetic retinopathy follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;8&nbsp;\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&#46; Significant obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;9&nbsp;\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&#46; Poor glycemic control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;7&nbsp;\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&#46; Poor blood pressure control despite taking 3 drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;8&nbsp;\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&#46; Frequent&#44; severe or unintentional hypoglycemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;9&nbsp;\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&#46; Patient with moderate renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;7&nbsp;\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&#46; Diabetes education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;4&nbsp;\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&#46; Patient with macroalbuminuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;8&nbsp;\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&#46; Assessment of diabetic foot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;8&nbsp;\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&#46; Intensification of insulin therapy to more complex regimens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;4&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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            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"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "6th ed&#46;"
                        "fecha" => "2014"
                        "editorial" => "International Diabetes Federation"
                        "editorialLocalizacion" => "Bruselas&#44; B&#233;lgica"
                      ]
                    ]
                  ]
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              ]
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            1 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quality of life and satisfaction with treatment in subjects with type 2 diabetes&#58; results from primary health care in Turkey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Ozder"
                            1 => "M&#46; Sekeroglu"
                            2 => "H&#46;H&#46; Eker"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Clin Exp Med"
                        "fecha" => "2014"
                        "volumen" => "7"
                        "paginaInicial" => "5715"
                        "paginaFinal" => "5722"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25664097"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de la diabetes mellitus y de las alteraciones del metabolismo de los hidratos de carbono en Espa&#241;a&#58; Estudio Di&#64;bet&#46;es"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Soriguer"
                            1 => "A&#46; Goday"
                            2 => "A&#46; Bosch-Comas"
                            3 => "E&#46; Bordi&#250;"
                            4 => "A&#46; Calle-Pascual"
                            5 => "R&#46; Carmena"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00125-011-2336-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetologia"
                        "fecha" => "2012"
                        "volumen" => "55"
                        "paginaInicial" => "88"
                        "paginaFinal" => "93"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21987347"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and incidence density rates of chronic comorbidity in type 2 diabetes patients&#58; an exploratory cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Luijks"
                            1 => "T&#46; Schermer"
                            2 => "H&#46; Bor"
                            3 => "C&#46; van Weel"
                            4 => "T&#46; Lagro-Janssen"
                            5 => "M&#46; Biermans"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1741-7015-10-128"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Med"
                        "fecha" => "2012"
                        "volumen" => "10"
                        "paginaInicial" => "128"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23106808"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes&#58; a cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Greenfield"
                            1 => "J&#46; Billimek"
                            2 => "F&#46; Pellegrini"
                            3 => "M&#46; Franciosi"
                            4 => "G&#46; de Berardis"
                            5 => "A&#46; Nicolucci"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-151-12-200912150-00005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2009"
                        "volumen" => "151"
                        "paginaInicial" => "854"
                        "paginaFinal" => "860"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20008761"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perceived challenges and priorities in co-morbidity management of older patients with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46;A&#46; Beverly"
                            1 => "L&#46;A&#46; Wray"
                            2 => "C&#46;J&#46; Chiu"
                            3 => "K&#46; Weinger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Diabet Med J Br Diabet Assoc"
                        "fecha" => "2011"
                        "volumen" => "28"
                        "paginaInicial" => "781"
                        "paginaFinal" => "784"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Understanding the determinants of health for people with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;L&#46; Maddigan"
                            1 => "D&#46;H&#46; Feeny"
                            2 => "S&#46;R&#46; Majumdar"
                            3 => "K&#46;B&#46; Farris"
                            4 => "J&#46;A&#46; Johnson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2105/AJPH.2005.067728"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Public Health"
                        "fecha" => "2006"
                        "volumen" => "96"
                        "paginaInicial" => "1649"
                        "paginaFinal" => "1655"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16873750"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comorbidity in patients with diabetes mellitus&#58; impact on medical health care utilization"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;N&#46; Struijs"
                            1 => "C&#46;A&#46; Baan"
                            2 => "F&#46;G&#46; Schellevis"
                            3 => "G&#46;P&#46; Westert"
                            4 => "G&#46;A&#46; van den Bos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1472-6963-6-84"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Health Serv Res"
                        "fecha" => "2006"
                        "volumen" => "6"
                        "paginaInicial" => "84"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16820048"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Review of strategies to enhance outcomes for patients with type 2 diabetes&#58; payers&#8217; perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46; Greenapple"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Health Drug Benefits"
                        "fecha" => "2011"
                        "volumen" => "4"
                        "paginaInicial" => "377"
                        "paginaFinal" => "386"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25126364"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Maastricht Study&#58; an extensive phenotyping study on determinants of type 2 diabetes&#44; its complications and its comorbidities"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;T&#46; Schram"
                            1 => "S&#46;J&#46;S&#46; Sep"
                            2 => "C&#46;J&#46; van der Kallen"
                            3 => "P&#46;C&#46; Dagnelie"
                            4 => "A&#46; Koster"
                            5 => "N&#46; Schaper"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10654-014-9889-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Epidemiol"
                        "fecha" => "2014"
                        "volumen" => "29"
                        "paginaInicial" => "439"
                        "paginaFinal" => "451"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24756374"
                            "web" => "Medline"
                          ]
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              ]
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                    0 => array:2 [
                      "titulo" => "Foundations of care&#58; education&#44; nutrition&#44; physical activity&#44; smoking cessation&#44; psychosocial care&#44; and immunization"
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                          "etal" => false
                          "autores" => array:1 [
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                          ]
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                      ]
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                      "doi" => "10.2337/dc15-S007"
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                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2015"
                        "volumen" => "38"
                        "numero" => "Suppl"
                        "paginaInicial" => "S20"
                        "paginaFinal" => "S30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25537702"
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                          ]
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of quality improvement strategies on the management of diabetes&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;C&#46; Tricco"
                            1 => "N&#46;M&#46; Ivers"
                            2 => "J&#46;M&#46; Grimshaw"
                            3 => "D&#46; Moher"
                            4 => "L&#46; Turner"
                            5 => "J&#46; Galipeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Lancet Lond Engl"
                        "fecha" => "2012"
                        "volumen" => "379"
                        "paginaInicial" => "2252"
                        "paginaFinal" => "2261"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "13"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Calidad de vida y satisfacci&#243;n con el tratamiento de sujetos condiabetes tipo 2&#58; resultados en Espa&#241;a del estudio PANORAMA"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Depablos-Velasco"
                            1 => "E&#46; Salguero-Chaves"
                            2 => "J&#46; Mata-Poyo"
                            3 => "B&#46; Derivas-Otero"
                            4 => "R&#46; Garc&#237;a-S&#225;nchez"
                            5 => "P&#46; Viguera-Ester"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.endonu.2013.05.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endocrinol Nutr"
                        "fecha" => "2014"
                        "volumen" => "61"
                        "paginaInicial" => "18"
                        "paginaFinal" => "26"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24055176"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development of an instrument for the assessment of chronic care models &#91;en espa&#241;ol&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Nu&#241;o-Solin&#237;s"
                            1 => "P&#46; Fern&#225;ndez-Cano"
                            2 => "J&#46;J&#46; Mira-Solves"
                            3 => "N&#46; Toro-Polanco"
                            4 => "J&#46; Carlos Contel"
                            5 => "M&#46; Guilabert Mora"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gac Sanit SESPAS"
                        "fecha" => "2013"
                        "volumen" => "27"
                        "paginaInicial" => "128"
                        "paginaFinal" => "134"
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673605671024"
                          "estado" => "S300"
                          "issn" => "01406736"
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measuring quality of life of old type 2 diabetic patients in primary care in Portugal&#58; a cross-sectional study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F&#46; Prazeres"
                            1 => "D&#46; Figueiredo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/2251-6581-13-68"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Diabetes Metab Disord"
                        "fecha" => "2014"
                        "volumen" => "13"
                        "paginaInicial" => "68"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24963468"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "16"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Desarrollo de gu&#237;as de pr&#225;ctica cl&#237;nica en pacientes con comorbilidad y pluripatolog&#237;a&#46; Documento de trabajo presentado por las sociedades cient&#237;ficas Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;&#44; Sociedad Espa&#241;ola de Medicina de Familia y Comunitaria &#40;semFYC&#41; y Federaci&#243;n de Asociaciones de Enfermer&#237;a Comunitaria y Atenci&#243;n Primaria &#40;FAECAP&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "P&#46; Alonso Coello"
                            1 => "M&#46; Bernabeu Wittel"
                            2 => "E&#46; Casariego Vales"
                            3 => "M&#46; Rico Bl&#225;zquez"
                            4 => "R&#46; Rotaeche del Campo"
                            5 => "S&#46; S&#225;nchez G&#243;mez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2013"
                        "editorial" => "Multim&#233;dica Proyectos&#44; S&#46; L&#46;"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "en representaci&#243;n de la Red de Grupos de Estudio de la Diabetes en Atenci&#243;n Primaria de la Salud&#46; Evoluci&#243;n de los indicadores de calidad asistencial al diab&#233;tico tipo2 en atenci&#243;n primaria &#40;1996&#8211;2007&#41;&#46; Programa de mejora continua de calidad de la Red de Grupos de Estudio de la Diabetes en Atenci&#243;n Primaria de la Salud"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Franch Nadal"
                            1 => "S&#46; Artola Men&#233;ndez"
                            2 => "J&#46; Diez Espino"
                            3 => "M&#46; Mata Cases"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Cl&#237;n &#40;Barc&#41;"
                        "fecha" => "2010"
                        "volumen" => "135"
                        "paginaInicial" => "600"
                        "paginaFinal" => "607"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fifteen years of continuous improvement of quality care of type 2 diabetes mellitus in primary care in Catalonia&#44; Spain"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Mata-Cases"
                            1 => "P&#46; Roura-Olmeda"
                            2 => "M&#46; Berengu&#233;-Iglesias"
                            3 => "M&#46; Birul&#233;s-Pons"
                            4 => "X&#46; Mundet-Tuduri"
                            5 => "J&#46; Franch-Nadal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1742-1241.2011.02872.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Clin Pract"
                        "fecha" => "2012"
                        "volumen" => "66"
                        "paginaInicial" => "289"
                        "paginaFinal" => "298"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22340449"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0285"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Control of glycemia and cardiovascular risk factors in patients with type 2 diabetes in primary care in Catalonia &#40;Spain&#41;"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "M&#46; Mata-Cases"
                            2 => "E&#46; Hermosilla"
                            3 => "R&#46; Morros"
                            4 => "F&#46; Fina"
                            5 => "M&#46; Rosell"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/dc11-1679"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2012"
                        "volumen" => "35"
                        "paginaInicial" => "774"
                        "paginaFinal" => "779"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22344609"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current guidelines have limited applicability to patients with comorbid conditions&#58; a systematic analysis of evidence-based guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Lugtenberg"
                            1 => "J&#46;S&#46; Burgers"
                            2 => "C&#46; Clancy"
                            3 => "G&#46;P&#46; Westert"
                            4 => "E&#46;C&#46; Schneider"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0025987"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS One"
                        "fecha" => "2011"
                        "volumen" => "6"
                        "paginaInicial" => "e25987"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22028802"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preventable hospitalization among elderly Medicare beneficiaries with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;R&#46; Niefeld"
                            1 => "J&#46;B&#46; Braunstein"
                            2 => "A&#46;W&#46; Wu"
                            3 => "C&#46;D&#46; Saudek"
                            4 => "W&#46;E&#46; Weller"
                            5 => "G&#46;F&#46; Anderson"
                          ]
                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2003"
                        "volumen" => "26"
                        "paginaInicial" => "1344"
                        "paginaFinal" => "1349"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12716786"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0300"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes&#58; a decision analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46;S&#46; Huang"
                            1 => "Q&#46; Zhang"
                            2 => "N&#46; Gandra"
                            3 => "M&#46;H&#46; Chin"
                            4 => "D&#46;O&#46; Meltzer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2008"
                        "volumen" => "149"
                        "paginaInicial" => "11"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18591633"
                            "web" => "Medline"
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                ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Descriptions of barriers to self-care by persons with comorbid chronic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46;A&#46; Bayliss"
                            1 => "J&#46;F&#46; Steiner"
                            2 => "D&#46;H&#46; Fernald"
                            3 => "L&#46;A&#46; Crane"
                            4 => "D&#46;S&#46; Main"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Fam Med"
                        "fecha" => "2003"
                        "volumen" => "1"
                        "paginaInicial" => "15"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15043175"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of chronic pain on diabetes patients&#8217; self-management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;L&#46; Krein"
                            1 => "M&#46; Heisler"
                            2 => "J&#46;D&#46; Piette"
                            3 => "F&#46; Makki"
                            4 => "E&#46;A&#46; Kerr"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
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                        "paginaInicial" => "65"
                        "paginaFinal" => "70"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15616235"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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            24 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Validity of medication adherence self-reports in adults with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;S&#46; Gonzalez"
                            1 => "H&#46;E&#46; Schneider"
                            2 => "D&#46;J&#46; Wexler"
                            3 => "C&#46; Psaros"
                            4 => "L&#46;M&#46; Delahanty"
                            5 => "E&#46; Cagliero"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/dc12-0410"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2013"
                        "volumen" => "36"
                        "paginaInicial" => "831"
                        "paginaFinal" => "837"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23204245"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0320"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of type 2 diabetes in the elderly"
                      "autores" => array:1 [
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                          "autores" => array:6 [
                            0 => "R&#46; G&#243;mez Huelgas"
                            1 => "J&#46; D&#237;ez-Espino"
                            2 => "F&#46; Formiga"
                            3 => "J&#46; Lafita Tejedor"
                            4 => "L&#46; Rodr&#237;guez Ma&#241;as"
                            5 => "E&#46; Gonz&#225;lez-Sarmiento"
                          ]
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                  "host" => array:1 [
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                      "Revista" => array:5 [
                        "tituloSerie" => "Med Cl&#237;nica"
                        "fecha" => "2013"
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                        "itemHostRev" => array:3 [
                          "pii" => "S147444221170045X"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of type 2 diabetes mellitus in patients with chronic kidney disease&#46; Grupo de Trabajo para el Documento de Consenso sobre el tratamiento de la diabetes tipo 2 en el paciente con enfermedad renal cr&#243;nica"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "en nombre del Grupo de Trabajo para el Documento de Consenso sobre el tratamiento de la diabetes tipo 2 en el paciente con enfermedad renal cr&#243;nica"
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46; G&#243;mez-Huelgas"
                            1 => "A&#46; Mart&#237;nez-Castelao"
                            2 => "S&#46; Artola"
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                  "host" => array:1 [
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                        "tituloSerie" => "Med Cl&#237;nica"
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              "identificador" => "bib0330"
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                            2 => "C&#46; Stopka"
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                        "fecha" => "2013"
                        "volumen" => "10"
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                      "titulo" => "Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes"
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                        "paginaInicial" => "145"
                        "paginaFinal" => "154"
                        "link" => array:1 [
                          0 => array:2 [
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        "texto" => "<p id="par0210" class="elsevierStylePara elsevierViewall">The authors would like to thank all physicians who participated in the IMAGINE study&#44; sponsored by the participating scientific societies &#40;<span class="elsevierStyleGrantSponsor" id="gs2">redGDPS</span>&#44; <span class="elsevierStyleGrantSponsor" id="gs3">SED</span> and <span class="elsevierStyleGrantSponsor" id="gs4">SEMI</span>&#41;&#44; as well as Alfredo del Campo Mart&#237;n &#40;Sociolog&#237;a y Comunicaci&#243;n&#44; S&#46;L&#46;&#41; who coordinated the survey&#46;</p> <p id="par0215" class="elsevierStylePara elsevierViewall">The authors would also like to thank <span class="elsevierStyleGrantSponsor" id="gs5">Novartis Pharmaceuticals Corp&#46;</span> for sponsoring this initiative&#46;</p>"
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Original article
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
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
R. Gómez-Huelgasa,
Corresponding author
ricardogomezhuelgas@hotmail.com

Corresponding author.
, S. Artola-Menéndezb, E. Menéndez-Torrec
a Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, FIMABIS, Málaga, Spain
b Atención Primaria, Centro de Salud José Marvá, Madrid, Spain
c Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Spain
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    "titulo" => "Analysis of the healthcare process of patients with type 2 diabetes mellitus and associated comorbidity treated in Spain&#39;s National Health System&#58; A perspective of medical professionals&#46; IMAGINE study"
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        "titulo" => "An&#225;lisis del proceso asistencial de los pacientes con diabetes mellitus tipo 2 y comorbilidad asociada atendidos en el Sistema Nacional de Salud en Espa&#241;a&#58; una perspectiva de los profesionales m&#233;dicos&#46; Estudio IMAGINE"
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    "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 &#40;DM2&#41; is a chronic disease with one of the largest impacts on public health worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> DM2 is a pandemic and affects 366 million individuals&#46; It is predicted that 440 million patients will have DM2 by 2030&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> In Spain&#44; the prevalence of DM2 is 13&#46;8&#37;&#46;<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&#44; renal failure&#44; leg amputation and blindness and causes the death of 4 million individuals every year&#44; a figure that is estimated to rise by more than 50&#37; over the next 20 years&#46;<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&#44; both concordant &#40;obesity&#44; cardiovascular disease and renal failure&#41; and discordant &#40;respiratory disease&#44; osteoarticular disease&#44; depression and dementia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> The presence of comorbidity decreases the cardiovascular benefits of glycemic control&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> limits antidiabetic treatment compliance&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> affects patients&#8217; quality of life<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> and increases healthcare resource consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> Therefore&#44; the overall approach for patients with diabetes and comorbidity is a considerable healthcare challenge&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Chronicity requires a multidimensional&#44; proactive&#44; ongoing&#44; comprehensive and systemic approach&#44; implemented around an informed and active patient&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> However&#44; there are no studies in Spain that analyze&#44; from an interdisciplinary perspective&#44; the views of medical professionals involved in caring for patients with diabetes&#46;</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&#44; with a particular focus on interventions in lifestyle changes&#44; one of the most difficult aspects to implement in clinical practice&#46;<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&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population &#40;inclusion criterion&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study population consisted of primary care &#40;PC&#41; physicians&#44; internists and endocrinologists who are members of the participating scientific societies &#40;Study Group Network for Diabetes in Primary Health Care &#91;RedGDPS&#93;&#44; Spanish Society of Diabetes &#91;SED&#93; and the Diabetes and Obesity Workgroup of the Spanish Society of Internal Medicine &#91;SEMI&#93;&#41; who regularly treat patients with DM2 &#40;universe of approximately 3600&#41;&#46;</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 &#177;5&#46;2&#37; and a 95&#46;5&#37; confidence level &#40;<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; we calculated a sample size of 302 physicians&#46;</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&#46; The above-mentioned medical societies invited all of their members to participate and were in charge of disseminating the protocol&#44; the questionnaire and the access instructions&#46; The recruitment was competitive and was closed when the calculated sample of participating physicians was reached&#46;</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&#44; with a data entry period of 2 months&#46;</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 &#40;IEMAC&#41;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> were used as general guidelines&#46; This instrument self-assesses healthcare organizations on the degree to which they implement chronic care management models&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The following sections were assessed&#58; most common healthcare pathways and referrals&#59; criteria for referring patients to other levels&#59; pharmaceutical reconciliation in healthcare transitions&#59; circuit&#47;referrals &#40;excluding emergency departments&#41; in difficult&#47;exacerbation conditions&#59; presence of integrated&#47;multidisciplinary care processes for patients with DM2 and comorbidity&#59; presence of multidisciplinary monitoring and type of specialist who decides on the changes&#47;adjustments in therapy&#59; nursing resources with competency in the management&#47;follow-up of patients with DM2&#59; degree of coordination between hospital and PC specialists&#59; implementation of interconsultations&#59; coordination between nurses and physicians&#59; specialists who conduct smoking cessation interventions&#59; and the importance of multidisciplinary coordination in improving the control&#47;follow-up of DM2&#46;</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&#44; with the classification variables &#40;specialty&#44; sex&#44; professional experience&#44; type of healthcare center and number of patients with DM2 attended regularly&#41;&#46; The complete statistical tabulation is available in the scientific societies participating in the study&#46; The statistical analysis was conducted with the tabulation and data analysis program Star for Windows version 2&#46;7&#46;4&#46;</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 &#40;59&#46;6&#37; men&#41; participated in the study&#46; The mean age was 48&#46;8 &#40;9&#46;3&#41; years&#44; with 22&#46;8 &#40;9&#46;8&#41; years of professional experience&#46; A total of 114 &#40;39&#37;&#41; physicians belonged to PC&#44; 92 &#40;31&#37;&#41; to endocrinology and 74 &#40;25&#37;&#41; to internal medicine&#59; the rest did not specify a specialty&#46; Sixty-eight percent worked in centers with no diabetes reference unit&#46;</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&#46;3 patients with DM2 and associated comorbidity &#40;31&#46;0&#37; PC&#44; 29&#46;1&#37; internal medicine and 36&#46;6&#37; endocrinology&#41;&#59; 57&#37; of these patients are older than 65 years&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As with other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;15</span></a> arterial hypertension&#44; obesity and hyperlipidemia were the most common comorbidities &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The consulted physicians estimated that 56&#37; of their patients with DM2 have chronic renal failure and that 34&#37; are frail&#46;</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&#46;8&#37; of all the cases originated in PC&#46; For 59&#37; of the physicians&#44; &#8220;all or almost all cases&#8221; originated at this healthcare level&#46; Only 40&#37; of the patients with DM2 and comorbidity were referred from other healthcare levels&#46; PC physicians indicated higher rates of referral to other levels than did internal medicine physicians or endocrinologists &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</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&#37; of the participants stated that their centers had implemented healthcare pathways between PC and hospital care for referring patients with DM2 and comorbidity&#46; Most of these pathways &#40;51&#37;&#41; were only applied occasionally&#46; The main reasons for referral were the presence of severe renal failure&#44; poor glycemic control and the screening or follow-up of patients with diabetic retinopathy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The participating physicians considered that pharmaceutical reconciliation was only performed in 52&#37; of the transitions between different healthcare levels&#46; Twenty-seven percent of the physicians stated that reconciliation is only performed occasionally&#44; and 14&#37; stated that reconciliation never or almost never occurs&#46;</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&#44; except for telephone access&#44; which was installed in a third of the centers&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Only 10&#37; of the centers had implemented a comprehensive and multidisciplinary care process for patients with DM2 and comorbidity&#44; the majority of which included PC&#44; nursing and endocrinology or internal medicine &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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 &#8220;good&#8221; or &#8220;very good&#8221; in 41&#37; of the cases&#44; &#8220;poor&#8221; or &#8220;very poor&#8221; in 20&#37; and &#8220;regular&#8221; in 35&#37;&#46; Fifty-eight percent of the physicians reported conducting interconsultations&#44; clinical meetings or consultancies to treat specific patients&#46; These interconsultations are mostly conducted by endocrinologists &#40;27&#46;3&#37;&#41;&#46; Nonface-to-face consultation &#40;via the Internet&#41; was less common &#40;32&#37;&#41; and also predominates in endocrinology&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diabetes education</span><p id="par0115" class="elsevierStylePara elsevierViewall">The patients&#8217; diabetes education activities are shared between the physician and nurse&#46; The physician assumes a greater role in antitobacco counseling &#40;44&#46;8&#37;&#41; and glycemic self-analysis reviews &#40;31&#37;&#41;&#44; while the nurse specializes in insulin therapy techniques &#40;65&#46;7&#37;&#41;&#44; diet planning &#40;44&#46;2&#37;&#41;&#44; physical activity &#40;37&#46;9&#37;&#41; and foot examinations &#40;36&#46;9&#37;&#41;&#46; The degree of interdisciplinary work between physicians and nurses is greater in PC than in the hospital setting&#46; For example&#44; antitobacco counseling is coordinated with nursing more often in PC &#40;64&#46;4&#37;&#41; than in internal medicine &#40;21&#46;3&#37;&#41; or endocrinology &#40;32&#46;4&#37;&#41;&#46; Some 63&#46;5&#37; of the physicians verify the achievement of the patient&#39;s nutritional education objectives&#46; Thirty-six percent of the physicians stated that they were &#8220;less than satisfied or not at all satisfied&#8221; with the results&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In 47&#37; of the cases&#44; the nurse was responsible for implementing the dietary treatment&#46; Only 5&#37; of those surveyed had a nutritionist&#46; The mean time invested in providing patients with dietetic information&#44; which in most cases was less than 10<span class="elsevierStyleHsp" style=""></span>min &#40;65&#37;&#41;&#46; Only 58&#37; of the participants conducted a dietary record&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The physician and nurse almost equally divide the responsibility for recommending physical activity&#44; which consists primarily of recommending heart-healthy aerobic exercise&#46; Most of these participants &#40;80&#37;&#41; dedicated less than 5<span class="elsevierStyleHsp" style=""></span>min per patient&#46; Only 10&#37; used a system for screening for sarcopenia&#46; Most of the physicians surveyed &#40;38&#46;9&#37;&#41; were &#8220;less than or not at all&#8221; satisfied with the achievement of physical activity objectives&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">PC physicians&#44; pulmonologists and nurses were the practitioners who led smoking cessation interventions&#46; The main activities are minimal motivational counseling and informational&#47;educational planning&#46; The average cessation rate after a year was estimated at 26&#37;&#46;</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 &#40;80&#46;8&#37;&#41;&#44; the continuing education of health professionals &#40;72&#46;3&#37;&#41; and patient education programs &#40;72&#37;&#41; were the 3 most often cited factors for improving the treatment and control of DM2 with comorbidity&#46; Moreover&#44; the main barriers to improving the quality are the scarcity of time for implementing nondrug treatments &#40;75&#46;6&#37;&#41;&#44; the lack of qualified personnel for lifestyle changes &#40;66&#46;5&#37;&#41;&#44; the limitations in coordinating PC-specialized care &#40;66&#46;5&#37;&#41; and the organizational deficiencies &#40;64&#46;1&#37;&#41;&#46;</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&#44; polypathology and chronicity&#46; A recent consensus among family physicians&#44; internists and nurses in Spain has proposed terminology for unifying the criteria&#46; Comorbidity refers to the various satellite diseases that accompany the primary acute or chronic disease&#46; Polypathology indicates the presence of 2 or more chronic symptomatic diseases that have a similar degree of complexity and management difficulties&#46; The concept of the complex chronic patient includes the presence of limiting and progressive diseases that result in an overuse of health services&#44; polypharmacy and functional impairment and have a negative social and family impact&#46;<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&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#44;18</span></a> most patients with DM2 in Spain do not achieve the control objectives recommended by current guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> which indicates the need to improve the quality of care for these patients&#46; In this respect&#44; an overall approach to patients with DM2 and associated comorbidity is considered a key element&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;10&#44;21</span></a> The proper assessment of comorbidity in DM2 is essential for determining treatment intensity and therapeutic objectives&#44; given that the presence of multiple severe comorbidities limits the benefits of glycemic control&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;22</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Although the focus has classically been on comorbidity concordant with DM2 &#40;i&#46;e&#46;&#44; that which shares etiopathogenic mechanisms such as obesity&#44; other cardiovascular risk factors&#44; cardiovascular disease and microvascular complications&#41;&#44; there is a growing interest in discordant disease associated with diabetes &#40;lung disease&#44; osteoarticular disease&#44; depression&#44; dementia and malignancies&#41; and its impact on health outcomes&#46; It has been reported that more than 70&#37; of patients with DM2 have at least one discordant comorbidity at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> Discordant comorbidity associated with DM2 limits the patients&#8217; ability to self-care&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;23&#8211;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&#46;<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&#44; which should be considered when implementing improvement plans&#46; The presence of specific interlevel healthcare pathways appears to be in the minority according to the surveyed professionals&#44; despite the fact that establishing specific referral circuits has been shown to be useful in improving the results of diabetes treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;13</span></a> The main causes for referral from PC to hospital care are renal failure&#44; poor glycemic control and diabetic retinopathy&#46; A number of multidisciplinary consensus statements have recently been published in Spain&#44; focusing on aspects that attempt to improve on this deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">26&#8211;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&#46;<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&#46;<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&#46; This model includes 6 key components<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a>&#58; &#40;1&#41; the leadership of the healthcare organization to ensure the necessary resources and to break barriers&#44; &#40;2&#41; the promotion of self-care&#44; &#40;3&#41; the support of scientific evidence-based decision-making&#44; &#40;4&#41; design and coordination of services provision and healthcare processes&#44; &#40;5&#41; medical information systems and &#40;6&#41; public health and community policies&#46; The chronic care model has been implemented successfully in the care of patients with diabetes&#46;<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 &#40;SNHS&#41; &#40;ref&#46; 2012&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> in line with other international guidelines &#40;International Diabetes Federation&#44; American Diabetes Association&#41;&#44; emphasizes the importance of interlevel and multidisciplinary work and patient involvement for improving the health outcomes of patients with diabetes&#46; Of special relevance is the role of nursing in diabetes education&#46;<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&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The considerable majority of patients with DM2 in Spain have excess body weight or abdominal obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> Weight loss&#44; through changes in diet and physical activity&#44; has been shown to improve glycemic control&#44; cardiovascular risk factors and quality of life for patients with DM2&#44; as well as to reduce the healthcare costs of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> However&#44; to achieve good outcomes&#44; the lifestyle interventions must be intensive&#44; multidisciplinary and structured&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> In Spain&#44; these programs have shown their efficacy&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> In our study&#44; 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&#46; Furthermore&#44; the patients with DM2 expressed their difficulty in adopting the changes in diet and physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> As a whole&#44; these data highlight the need for the NHS to establish structured programs on lifestyle changes for the population with DM2&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study has 2 strong points&#46; The first is that&#44; until now&#44; no analysis had been performed in Spain on the healthcare organization in terms of the care for patients with DM2 and comorbidity&#46; Second&#44; this is an interdisciplinary study at the national level&#44; 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&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">This study&#44; however&#44; has a number of limitations&#46; Firstly&#44; only 10&#37; of the medical specialists who are members of the collaborating societies were interviewed&#46; We cannot therefore rule out a bias of participation by those physicians most interested in diabetes&#46; PC physicians are under-represented in the sample&#44; as they response to the survey to a lesser degree&#46; Second&#44; the study was conducted in a self-assessed manner&#59; however&#44; this is a common practice among epidemiological surveys&#46; The survey also did not include nurses&#44; a group of paramount importance in treating diabetes&#46; Finally&#44; in order to have an overall and objective idea of the problem being addressed&#44; a patient survey should have been included&#44; which would have helped us understand their degree of satisfaction with their treatment&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In conclusion&#44; Spanish physicians propose the improvement of multidisciplinary work&#44; 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&#46; These directives are in line with those published in the Diabetes Strategy of the SNHS &#40;ref&#46; 2012&#41;&#46;<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&#46;</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>&#46;</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&#46;</p></span></span>"
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              "titulo" => "Coordination among the different specialists"
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    "fechaRecibido" => "2015-08-05"
    "fechaAceptado" => "2015-11-19"
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          "clase" => "keyword"
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            0 => "Type 2 diabetes mellitus"
            1 => "Comorbidity"
            2 => "Healthcare pathways"
            3 => "Multidisciplinary coordination"
            4 => "Health care"
            5 => "Lifestyle"
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            0 => "Diabetes mellitus tipo 2"
            1 => "Comorbilidad"
            2 => "Rutas asistenciales"
            3 => "Coordinaci&#243;n multidisciplinar"
            4 => "Atenci&#243;n sanitaria"
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        "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 &#40;DM2&#41; and comorbidity in Spain&#39;s National Health System&#46;</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&#46; A total of 302 family physicians&#44; internists and endocrinologists participated in the study&#46; The participants were recruited voluntarily by their respective scientific societies and received no remuneration&#46;</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 &#40;71&#46;8&#37;&#41;&#46; Forty percent are referred to hospital care&#44; mainly due to renal failure&#44; poor glycaemic control and for a retinopathy assessment&#46; Only 52&#37; of those surveyed conducted medication reconciliation in the transition between healthcare levels&#46; Fifty-eight percent reported conducting interconsultations&#44; clinical meetings or consultancies between healthcare levels&#46; The 3 main factors identified for improving the follow-up and control of DM2 with comorbidity were the multidisciplinary study &#40;80&#46;8&#37;&#41;&#44; the continuing education of health professionals &#40;72&#46;3&#37;&#41; and therapeutic education programs &#40;72&#37;&#41;&#46; A lack of time&#44; a lack of qualified personnel for lifestyle interventions and organizational shortcomings were mentioned as the main obstacles for improving the care of these patients&#46;</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&#46; Promoting multidisciplinary care and training programs for practitioners and patients can help improve the quality of care&#46; Therapy reconciliation represents a priority area for improvement in this population&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar la atenci&#243;n que reciben los pacientes con diabetes mellitus tipo 2 &#40;DM2&#41; y comorbilidad en el Sistema Nacional de Salud espa&#241;ol&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal mediante encuesta <span class="elsevierStyleItalic">online</span>&#46; Participaron 302 m&#233;dicos de familia&#44; internistas y endocrin&#243;logos&#44; reclutados por sus respectivas sociedades cient&#237;ficas&#44; de manera voluntaria y no retribuida&#46;</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 Atenci&#243;n Primaria &#40;71&#44;8&#37;&#41;&#46; Un 40&#37; son derivados a atenci&#243;n hospitalaria&#44; principalmente por insuficiencia renal&#44; mal control gluc&#233;mico y evaluaci&#243;n de retinopat&#237;a&#46; Solo el 52&#37; de los encuestados realizaban conciliaci&#243;n farmacol&#243;gica en la transici&#243;n entre niveles asistenciales&#46; El 58&#37; manifestaron realizar interconsultas&#44; sesiones cl&#237;nicas o consultor&#237;as entre niveles asistenciales&#46; Los 3 principales factores identificados para mejorar el seguimiento y control de la DM2 con comorbilidad fueron el trabajo multidisciplinar &#40;80&#44;8&#37;&#41;&#44; la formaci&#243;n continuada de los profesionales sanitarios &#40;72&#44;3&#37;&#41; y los programas de educaci&#243;n terap&#233;utica &#40;72&#37;&#41;&#46; La falta de tiempo&#44; 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&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los pacientes con DM2 y comorbilidad son atendidos en Atenci&#243;n Primaria&#46; Promover la atenci&#243;n multidisciplinaria y los programas formativos para profesionales y pacientes puede contribuir a mejorar la calidad asistencial&#46; La conciliaci&#243;n terap&#233;utica representa un &#225;rea prioritaria de mejora en esta poblaci&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-Huelgas R&#44; Artola-Men&#233;ndez S&#44; Men&#233;ndez-Torre E&#46; An&#225;lisis del proceso asistencial de los pacientes con diabetes mellitus tipo 2 y comorbilidad asociada atendidos en el Sistema Nacional de Salud en Espa&#241;a&#58; una perspectiva de los profesionales m&#233;dicos&#46; Estudio IMAGINE&#46; Rev Clin Esp&#46; 2016&#59;216&#58;113&#8211;120&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diseases associated with type 2 diabetes&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Multiple-choice&#59; total greater than 100&#37;&#46;</p>"
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                  <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&#46; Patient with severe renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#46;5&nbsp;\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&#46; Diabetic retinopathy screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;6&nbsp;\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&#46; Diabetic retinopathy follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;8&nbsp;\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&#46; Significant obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;9&nbsp;\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&#46; Poor glycemic control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;7&nbsp;\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&#46; Poor blood pressure control despite taking 3 drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;8&nbsp;\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&#46; Frequent&#44; severe or unintentional hypoglycemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;9&nbsp;\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&#46; Patient with moderate renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;7&nbsp;\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&#46; Diabetes education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;4&nbsp;\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&#46; Patient with macroalbuminuria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;8&nbsp;\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&#46; Assessment of diabetic foot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;8&nbsp;\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&#46; Intensification of insulin therapy to more complex regimens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            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"
                          ]
                        ]
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                      "Libro" => array:4 [
                        "edicion" => "6th ed&#46;"
                        "fecha" => "2014"
                        "editorial" => "International Diabetes Federation"
                        "editorialLocalizacion" => "Bruselas&#44; B&#233;lgica"
                      ]
                    ]
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              ]
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            1 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quality of life and satisfaction with treatment in subjects with type 2 diabetes&#58; results from primary health care in Turkey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Ozder"
                            1 => "M&#46; Sekeroglu"
                            2 => "H&#46;H&#46; Eker"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Clin Exp Med"
                        "fecha" => "2014"
                        "volumen" => "7"
                        "paginaInicial" => "5715"
                        "paginaFinal" => "5722"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25664097"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de la diabetes mellitus y de las alteraciones del metabolismo de los hidratos de carbono en Espa&#241;a&#58; Estudio Di&#64;bet&#46;es"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Soriguer"
                            1 => "A&#46; Goday"
                            2 => "A&#46; Bosch-Comas"
                            3 => "E&#46; Bordi&#250;"
                            4 => "A&#46; Calle-Pascual"
                            5 => "R&#46; Carmena"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00125-011-2336-9"
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                        "tituloSerie" => "Diabetologia"
                        "fecha" => "2012"
                        "volumen" => "55"
                        "paginaInicial" => "88"
                        "paginaFinal" => "93"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21987347"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and incidence density rates of chronic comorbidity in type 2 diabetes patients&#58; an exploratory cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Luijks"
                            1 => "T&#46; Schermer"
                            2 => "H&#46; Bor"
                            3 => "C&#46; van Weel"
                            4 => "T&#46; Lagro-Janssen"
                            5 => "M&#46; Biermans"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1741-7015-10-128"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Med"
                        "fecha" => "2012"
                        "volumen" => "10"
                        "paginaInicial" => "128"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23106808"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes&#58; a cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Greenfield"
                            1 => "J&#46; Billimek"
                            2 => "F&#46; Pellegrini"
                            3 => "M&#46; Franciosi"
                            4 => "G&#46; de Berardis"
                            5 => "A&#46; Nicolucci"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-151-12-200912150-00005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2009"
                        "volumen" => "151"
                        "paginaInicial" => "854"
                        "paginaFinal" => "860"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20008761"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perceived challenges and priorities in co-morbidity management of older patients with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46;A&#46; Beverly"
                            1 => "L&#46;A&#46; Wray"
                            2 => "C&#46;J&#46; Chiu"
                            3 => "K&#46; Weinger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Diabet Med J Br Diabet Assoc"
                        "fecha" => "2011"
                        "volumen" => "28"
                        "paginaInicial" => "781"
                        "paginaFinal" => "784"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0225"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Understanding the determinants of health for people with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;L&#46; Maddigan"
                            1 => "D&#46;H&#46; Feeny"
                            2 => "S&#46;R&#46; Majumdar"
                            3 => "K&#46;B&#46; Farris"
                            4 => "J&#46;A&#46; Johnson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2105/AJPH.2005.067728"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Public Health"
                        "fecha" => "2006"
                        "volumen" => "96"
                        "paginaInicial" => "1649"
                        "paginaFinal" => "1655"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16873750"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comorbidity in patients with diabetes mellitus&#58; impact on medical health care utilization"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;N&#46; Struijs"
                            1 => "C&#46;A&#46; Baan"
                            2 => "F&#46;G&#46; Schellevis"
                            3 => "G&#46;P&#46; Westert"
                            4 => "G&#46;A&#46; van den Bos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1472-6963-6-84"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Health Serv Res"
                        "fecha" => "2006"
                        "volumen" => "6"
                        "paginaInicial" => "84"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16820048"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Review of strategies to enhance outcomes for patients with type 2 diabetes&#58; payers&#8217; perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46; Greenapple"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Health Drug Benefits"
                        "fecha" => "2011"
                        "volumen" => "4"
                        "paginaInicial" => "377"
                        "paginaFinal" => "386"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25126364"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Maastricht Study&#58; an extensive phenotyping study on determinants of type 2 diabetes&#44; its complications and its comorbidities"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;T&#46; Schram"
                            1 => "S&#46;J&#46;S&#46; Sep"
                            2 => "C&#46;J&#46; van der Kallen"
                            3 => "P&#46;C&#46; Dagnelie"
                            4 => "A&#46; Koster"
                            5 => "N&#46; Schaper"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10654-014-9889-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Epidemiol"
                        "fecha" => "2014"
                        "volumen" => "29"
                        "paginaInicial" => "439"
                        "paginaFinal" => "451"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24756374"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0245"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Foundations of care&#58; education&#44; nutrition&#44; physical activity&#44; smoking cessation&#44; psychosocial care&#44; and immunization"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "American Diabetes Association"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/dc15-S007"
                      "Revista" => array:8 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2015"
                        "volumen" => "38"
                        "numero" => "Suppl"
                        "paginaInicial" => "S20"
                        "paginaFinal" => "S30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25537702"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1474442211700965"
                          "estado" => "S300"
                          "issn" => "14744422"
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                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effectiveness of quality improvement strategies on the management of diabetes&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;C&#46; Tricco"
                            1 => "N&#46;M&#46; Ivers"
                            2 => "J&#46;M&#46; Grimshaw"
                            3 => "D&#46; Moher"
                            4 => "L&#46; Turner"
                            5 => "J&#46; Galipeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Lancet Lond Engl"
                        "fecha" => "2012"
                        "volumen" => "379"
                        "paginaInicial" => "2252"
                        "paginaFinal" => "2261"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Calidad de vida y satisfacci&#243;n con el tratamiento de sujetos condiabetes tipo 2&#58; resultados en Espa&#241;a del estudio PANORAMA"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Depablos-Velasco"
                            1 => "E&#46; Salguero-Chaves"
                            2 => "J&#46; Mata-Poyo"
                            3 => "B&#46; Derivas-Otero"
                            4 => "R&#46; Garc&#237;a-S&#225;nchez"
                            5 => "P&#46; Viguera-Ester"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.endonu.2013.05.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endocrinol Nutr"
                        "fecha" => "2014"
                        "volumen" => "61"
                        "paginaInicial" => "18"
                        "paginaFinal" => "26"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24055176"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development of an instrument for the assessment of chronic care models &#91;en espa&#241;ol&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Nu&#241;o-Solin&#237;s"
                            1 => "P&#46; Fern&#225;ndez-Cano"
                            2 => "J&#46;J&#46; Mira-Solves"
                            3 => "N&#46; Toro-Polanco"
                            4 => "J&#46; Carlos Contel"
                            5 => "M&#46; Guilabert Mora"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gac Sanit SESPAS"
                        "fecha" => "2013"
                        "volumen" => "27"
                        "paginaInicial" => "128"
                        "paginaFinal" => "134"
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673605671024"
                          "estado" => "S300"
                          "issn" => "01406736"
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                  ]
                ]
              ]
            ]
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              "identificador" => "bib0265"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Measuring quality of life of old type 2 diabetic patients in primary care in Portugal&#58; a cross-sectional study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F&#46; Prazeres"
                            1 => "D&#46; Figueiredo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/2251-6581-13-68"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Diabetes Metab Disord"
                        "fecha" => "2014"
                        "volumen" => "13"
                        "paginaInicial" => "68"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24963468"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Desarrollo de gu&#237;as de pr&#225;ctica cl&#237;nica en pacientes con comorbilidad y pluripatolog&#237;a&#46; Documento de trabajo presentado por las sociedades cient&#237;ficas Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;&#44; Sociedad Espa&#241;ola de Medicina de Familia y Comunitaria &#40;semFYC&#41; y Federaci&#243;n de Asociaciones de Enfermer&#237;a Comunitaria y Atenci&#243;n Primaria &#40;FAECAP&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "P&#46; Alonso Coello"
                            1 => "M&#46; Bernabeu Wittel"
                            2 => "E&#46; Casariego Vales"
                            3 => "M&#46; Rico Bl&#225;zquez"
                            4 => "R&#46; Rotaeche del Campo"
                            5 => "S&#46; S&#225;nchez G&#243;mez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2013"
                        "editorial" => "Multim&#233;dica Proyectos&#44; S&#46; L&#46;"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0275"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "en representaci&#243;n de la Red de Grupos de Estudio de la Diabetes en Atenci&#243;n Primaria de la Salud&#46; Evoluci&#243;n de los indicadores de calidad asistencial al diab&#233;tico tipo2 en atenci&#243;n primaria &#40;1996&#8211;2007&#41;&#46; Programa de mejora continua de calidad de la Red de Grupos de Estudio de la Diabetes en Atenci&#243;n Primaria de la Salud"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Franch Nadal"
                            1 => "S&#46; Artola Men&#233;ndez"
                            2 => "J&#46; Diez Espino"
                            3 => "M&#46; Mata Cases"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Cl&#237;n &#40;Barc&#41;"
                        "fecha" => "2010"
                        "volumen" => "135"
                        "paginaInicial" => "600"
                        "paginaFinal" => "607"
                      ]
                    ]
                  ]
                ]
              ]
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            17 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fifteen years of continuous improvement of quality care of type 2 diabetes mellitus in primary care in Catalonia&#44; Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Mata-Cases"
                            1 => "P&#46; Roura-Olmeda"
                            2 => "M&#46; Berengu&#233;-Iglesias"
                            3 => "M&#46; Birul&#233;s-Pons"
                            4 => "X&#46; Mundet-Tuduri"
                            5 => "J&#46; Franch-Nadal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1742-1241.2011.02872.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Clin Pract"
                        "fecha" => "2012"
                        "volumen" => "66"
                        "paginaInicial" => "289"
                        "paginaFinal" => "298"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22340449"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0285"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Control of glycemia and cardiovascular risk factors in patients with type 2 diabetes in primary care in Catalonia &#40;Spain&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46; Vinagre"
                            1 => "M&#46; Mata-Cases"
                            2 => "E&#46; Hermosilla"
                            3 => "R&#46; Morros"
                            4 => "F&#46; Fina"
                            5 => "M&#46; Rosell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/dc11-1679"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2012"
                        "volumen" => "35"
                        "paginaInicial" => "774"
                        "paginaFinal" => "779"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22344609"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current guidelines have limited applicability to patients with comorbid conditions&#58; a systematic analysis of evidence-based guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Lugtenberg"
                            1 => "J&#46;S&#46; Burgers"
                            2 => "C&#46; Clancy"
                            3 => "G&#46;P&#46; Westert"
                            4 => "E&#46;C&#46; Schneider"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0025987"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS One"
                        "fecha" => "2011"
                        "volumen" => "6"
                        "paginaInicial" => "e25987"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22028802"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preventable hospitalization among elderly Medicare beneficiaries with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;R&#46; Niefeld"
                            1 => "J&#46;B&#46; Braunstein"
                            2 => "A&#46;W&#46; Wu"
                            3 => "C&#46;D&#46; Saudek"
                            4 => "W&#46;E&#46; Weller"
                            5 => "G&#46;F&#46; Anderson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2003"
                        "volumen" => "26"
                        "paginaInicial" => "1344"
                        "paginaFinal" => "1349"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12716786"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes&#58; a decision analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46;S&#46; Huang"
                            1 => "Q&#46; Zhang"
                            2 => "N&#46; Gandra"
                            3 => "M&#46;H&#46; Chin"
                            4 => "D&#46;O&#46; Meltzer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2008"
                        "volumen" => "149"
                        "paginaInicial" => "11"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18591633"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0305"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Descriptions of barriers to self-care by persons with comorbid chronic diseases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46;A&#46; Bayliss"
                            1 => "J&#46;F&#46; Steiner"
                            2 => "D&#46;H&#46; Fernald"
                            3 => "L&#46;A&#46; Crane"
                            4 => "D&#46;S&#46; Main"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Fam Med"
                        "fecha" => "2003"
                        "volumen" => "1"
                        "paginaInicial" => "15"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15043175"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of chronic pain on diabetes patients&#8217; self-management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;L&#46; Krein"
                            1 => "M&#46; Heisler"
                            2 => "J&#46;D&#46; Piette"
                            3 => "F&#46; Makki"
                            4 => "E&#46;A&#46; Kerr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2005"
                        "volumen" => "28"
                        "paginaInicial" => "65"
                        "paginaFinal" => "70"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15616235"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Validity of medication adherence self-reports in adults with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;S&#46; Gonzalez"
                            1 => "H&#46;E&#46; Schneider"
                            2 => "D&#46;J&#46; Wexler"
                            3 => "C&#46; Psaros"
                            4 => "L&#46;M&#46; Delahanty"
                            5 => "E&#46; Cagliero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/dc12-0410"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2013"
                        "volumen" => "36"
                        "paginaInicial" => "831"
                        "paginaFinal" => "837"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23204245"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of type 2 diabetes in the elderly"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; G&#243;mez Huelgas"
                            1 => "J&#46; D&#237;ez-Espino"
                            2 => "F&#46; Formiga"
                            3 => "J&#46; Lafita Tejedor"
                            4 => "L&#46; Rodr&#237;guez Ma&#241;as"
                            5 => "E&#46; Gonz&#225;lez-Sarmiento"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Cl&#237;nica"
                        "fecha" => "2013"
                        "volumen" => "140"
                        "paginaInicial" => "134"
                        "itemHostRev" => array:3 [
                          "pii" => "S147444221170045X"
                          "estado" => "S300"
                          "issn" => "14744422"
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                  ]
                ]
              ]
            ]
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              "identificador" => "bib0325"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of type 2 diabetes mellitus in patients with chronic kidney disease&#46; Grupo de Trabajo para el Documento de Consenso sobre el tratamiento de la diabetes tipo 2 en el paciente con enfermedad renal cr&#243;nica"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "en nombre del Grupo de Trabajo para el Documento de Consenso sobre el tratamiento de la diabetes tipo 2 en el paciente con enfermedad renal cr&#243;nica"
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46; G&#243;mez-Huelgas"
                            1 => "A&#46; Mart&#237;nez-Castelao"
                            2 => "S&#46; Artola"
                            3 => "J&#46;L&#46; G&#243;rriz"
                            4 => "E&#46; Men&#233;ndez"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Med Cl&#237;nica"
                        "fecha" => "2014"
                        "volumen" => "142"
                        "paginaInicial" => "85"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0330"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Consenso en el cribado de la retinopat&#237;a diab&#233;tica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Barrot de la Puente"
                            1 => "J&#46; Franch"
                            2 => "J&#46;A&#46; Girb&#233;s"
                            3 => "M&#46; L&#243;pez G&#225;lvez"
                            4 => "A&#46; Pareja R&#237;os"
                            5 => "P&#46; Romero Aroca"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Diabetes Pr&#225;ctica"
                        "fecha" => "2014"
                        "volumen" => "05"
                        "paginaInicial" => "97"
                        "paginaFinal" => "144"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0335"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "SENEFRO&#46; Documento de consenso 2012 de 10 sociedades cient&#237;ficas sobre la enfermedad renal cr&#243;nica &#91;accessed 4 April 2015&#93;&#46; Available from&#58; <a id="intr0015" class="elsevierStyleInterRef" href="http://www.senefro.org/modules/news/images/v._5.doc_consenso_final_131212_copy1.pdf">http&#58;&#47;&#47;www&#46;senefro&#46;org&#47;modules&#47;news&#47;images&#47;v&#46;&#95;5&#46;doc&#95;consenso&#95;final&#95;131212&#95;copy1&#46;pdf</a>&#46;"
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pharmacological treatment conciliation methodology in patients with multiple conditions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;R&#46; Alfaro-Lara"
                            1 => "M&#46;D&#46; Vega-Coca"
                            2 => "M&#46; Galv&#225;n-Banqueri"
                            3 => "M&#46;D&#46; Nieto-Mart&#237;n"
                            4 => "C&#46; P&#233;rez-Guerrero"
                            5 => "B&#46; Santos-Ramos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Atencion Primaria Soc Esp Med Fam Comunitaria"
                        "fecha" => "2014"
                        "volumen" => "46"
                        "paginaInicial" => "89"
                        "paginaFinal" => "99"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Grupo de Investigaci&#243;n de la I Beca Joaquim Bonal 2006&#46; &#91;Conciliation in medication&#93; &#91;en espa&#241;ol&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "O&#46; Delgado S&#225;nchez"
                            1 => "L&#46; Anoz Jim&#233;nez"
                            2 => "A&#46; Serrano Fabi&#225;"
                            3 => "J&#46; Nicol&#225;s Pico"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Cl&#237;nica"
                        "fecha" => "2007"
                        "volumen" => "129"
                        "paginaInicial" => "343"
                        "paginaFinal" => "348"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Improving chronic illness care&#58; translating evidence into action"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;H&#46; Wagner"
                            1 => "B&#46;T&#46; Austin"
                            2 => "C&#46; Davis"
                            3 => "M&#46; Hindmarsh"
                            4 => "J&#46; Schaefer"
                            5 => "A&#46; Bonomi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Health Aff Proj Hope"
                        "fecha" => "2001"
                        "volumen" => "20"
                        "paginaInicial" => "64"
                        "paginaFinal" => "78"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The chronic care model and diabetes management in US primary care settings&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Stellefson"
                            1 => "K&#46; Dipnarine"
                            2 => "C&#46; Stopka"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5888/pcd10.120180"
                      "Revista" => array:6 [
                        "tituloSerie" => "Prev Chronic Dis"
                        "fecha" => "2013"
                        "volumen" => "10"
                        "paginaInicial" => "E26"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23428085"
                            "web" => "Medline"
                          ]
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                          "pii" => "S1474442207702168"
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                          "issn" => "14744422"
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                  ]
                ]
              ]
            ]
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              "identificador" => "bib0360"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Actualizaci&#243;n 2012"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Estrategia en Diabetes del Sistema Nacional de Salud"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2012"
                        "editorial" => "Ministerio de Sanidad&#44; Servicios Sociales e Igualdad Centro de Publicaciones"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0365"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "A review of recent literature &#8211; nurse case managers in diabetes care&#58; equivalent or better outcomes compared to primary care providers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;A&#46; Watts"
                            1 => "M&#46; Lucatorto"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11892-014-0504-2"
                      "Revista" => array:5 [
                        "tituloSerie" => "Curr Diab Rep"
                        "fecha" => "2014"
                        "volumen" => "14"
                        "paginaInicial" => "504"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24816751"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Look AHEAD Research Group"
                          "etal" => true
                          "autores" => array:5 [
                            0 => "R&#46;R&#46; Wing"
                            1 => "P&#46; Bolin"
                            2 => "F&#46;L&#46; Brancati"
                            3 => "G&#46;A&#46; Bray"
                            4 => "J&#46;M&#46; Clark"
                          ]
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                      "titulo" => "Diabetes prevention in the real world&#58; effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes and of the impact of adherence to guideline recommendations&#58; a systematic review and meta-analysis"
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0210" class="elsevierStylePara elsevierViewall">The authors would like to thank all physicians who participated in the IMAGINE study&#44; sponsored by the participating scientific societies &#40;<span class="elsevierStyleGrantSponsor" id="gs2">redGDPS</span>&#44; <span class="elsevierStyleGrantSponsor" id="gs3">SED</span> and <span class="elsevierStyleGrantSponsor" id="gs4">SEMI</span>&#41;&#44; as well as Alfredo del Campo Mart&#237;n &#40;Sociolog&#237;a y Comunicaci&#243;n&#44; S&#46;L&#46;&#41; who coordinated the survey&#46;</p> <p id="par0215" class="elsevierStylePara elsevierViewall">The authors would also like to thank <span class="elsevierStyleGrantSponsor" id="gs5">Novartis Pharmaceuticals Corp&#46;</span> for sponsoring this initiative&#46;</p>"
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Article information
ISSN: 22548874
Original language: English
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