Original article
National survey on the activity of internists in shared care – Interconsultations in Spanish hospitals
Encuesta nacional sobre la actividad de los internistas en asistencia compartida–interconsultas en los hospitales españoles
J. Marco Martíneza,
, E. Montero Ruízb, C. Fernández Pérezc, M. Méndez Bailóna, J.L. García Klepziga, F. Garrachón Vallod
Corresponding author
a Servicio de Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain
b Servicio de Medicina Interna, Hospital Alcalá de Henares, Madrid, Spain
c Unidad de Investigación, Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Madrid, Spain
d Servicio de Medicina Interna, Hospital Virgen de la Macarena, Sevilla, Spain
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Support provided by internists to other healthcare departments is increasing, and new organizational and management methods such as shared care have been developed.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Due to its importance, the specialty of Internal Medicine includes consultative medicine in their teaching program.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Recently, the Spanish Society of Internal Medicine (SEMI) added to their objectives the impetus for this healthcare modality through the creation of the Shared Care and Interconsultations Workgroup (GTACIC).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the initial priorities of the GTACIC has been the implementation of the present study whose main objective is to understand, through a survey sent to the IMDs, the current situation of the work performed by internists outside their department.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0015" class="elsevierStylePara elsevierViewall">A cross-sectional study was conducted by collecting information through a structured survey sent by email to Spanish IMDs and directed to the department heads or those responsible for the activity in each center. GTACIC designed a survey to obtain information on the organization and volume of the departments’ healthcare activity. The form (<a class="elsevierStyleCrossRef" href="#sec0035">Appendix A</a>) was prepared by three physicians with extensive experience in the field of shard care and interconsultations. The survey was sent by email to GTACIC members and was placed on the SEMI website. The open period for responding to the survey lasted from March 17 to May 15, 2015, and the analyzed activity data corresponded to 2014.</p><p id="par0020" class="elsevierStylePara elsevierViewall">According to the hospital registry of the Ministry of Health, Social Services and Equality, there were 895 hospitals registered in Spain in 2014, 595 of which were general or medical-surgical hospitals. The rest were specialized (psychiatric, cancer, ophthalmologic, etc.). Some 253 of the hospitals belonged to the Spanish National Health System.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The interconsultation activity analyzed in this study consisted of the following: (1) on-demand interconsultation: at the request of another department, the IMDs provide care through an internist on a rotating or part-time basis; (2) interconsultation unit: there is a structure within the IMD designed to handle interconsultation activity, with fully dedicated physicians and on-demand delivery; and (3) shared care: the internists have a defined and protocolized activity; the patient's care is jointly led by two specialists, one of whom is the consulting internist, and who do not work on demand but rather in a regulated manner.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">The data were analyzed with the statistical program SPSS (Statistical Package for the Social Sciences, version 15.0, IBM®). The qualitative variables are listed in their frequency distributions; the quantitative variables are presented as means and standard deviation or median, full and interquartile range (IQR). For the qualitative variables, we employed the chi-squared test or Fisher's exact test. For the comparisons among quantitative variables, we employed Student's <span class="elsevierStyleItalic">t</span>-test. For all comparisons, we rejected the null hypothesis, with an alpha error of <.05.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 120 hospitals (108 public and 12 private) responded to the survey, with a representative sample from Spain. Twenty-eight percent of the hospitals were group 1 (<200 beds), 28% were group 2 (200–400 beds), 32% were group 3 (500–1000 beds) and 12% were group 4 (>1000 beds). Compared to the overall composition of IMDs, the median number of physicians was 11 (IQR, 6–17; range, 1–34), with 1 section head (IQR, 0–2; range, 0–12), 1 department head (IQR, 1–1; range, 0–3) and 6 residents (IQR, 0–14; range, 0–40). The median number of hospital beds was 65 (IQR, 48–121; range, 4–667).</p><p id="par0040" class="elsevierStylePara elsevierViewall">All centers had general hospitalization, and 79.2% conducted interconsultation activities. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the responses collected in the survey regarding the remainder of the portfolio of services. Forty-five percent of the centers had a specialized interconsultation unit. The length of time these units have been in operation is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The provinces with departments that had interconsultation units are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In 48% of the IMDs, the interconsultations were distributed on a rotating basis among its physicians. Twenty-eight percent of the IMDs had a specialized interconsultation unit, and 35% had organized shared care. The physicians who worked in interconsultations performed this work on a part-time basis in 61% of the cases and on a full-time basis in 39% of the cases.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The rotation of physicians who conducted interconsultations was daily in 26 (21.7%) departments, weekly in 5 (IQR, 1–3) and monthly in 21 (25%). Other modalities included care provided by the on-call physician (7.5%), according to the requesting specialty, following an alphabetical order, randomized and voluntary. The number of physicians assigned to interconsultations was 1, 2 and 3 in 18%, 17.5% and 10% of the cases, respectively.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Thirty-three percent of the departments had signed shared-care agreements with the other departments to whom they provided care. The department of orthopedic and trauma surgery was the most frequently attended, with 25 cases in which the internist's activity was stable (6 related to the controlling of infections and 16 to the fracture process, generally hip). This department was followed by vascular surgery in seven centers and miscellaneous departments, which included elderly urological patients (three centers), gynecology, otorhinolaryngology and emergency departments (two centers each). For the last case, the consultations were to assess the appropriateness of the hospitalization. Rotations were mandatory for the residents in 30% and voluntary in 14% of the centers that had teaching, regardless of the interconsultation modality they practiced.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The departments were also asked whether they had records of the interconsultation activity in any of its formats. Fifty-five percent of the departments kept records since the start of the activity, but 24% had no record. Forty-six percent of those surveyed were willing to participate in a national registry, but 9% indicated that they were not willing.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The daily number of new interconsultation requests was less than 1 in 6% of the IMDs, between 1 and 3 in 36%, between 3 and 5 in 33% and more than 5 in 20%. The most demanding department was trauma (65%), followed by general surgery (14%). The mean stay, defined as the number of days required to close the episode that motivated the interconsultation, was 3–5 days for 37.5% of those surveyed, between 5 and 7 days for 20% and less than 3 days for 18%. The interconsultations were answered the day they were made (58%) or during the following 24<span class="elsevierStyleHsp" style=""></span>h (35%).</p><p id="par0070" class="elsevierStylePara elsevierViewall">The method for responding to the interconsultations varied significantly. Ninety-two percent of the IMDs lacked a methodology protocol on how to conduct an interconsultation. Eighty-three percent of the IMDs believed that a medical history review needed to be performed, 11% believed it was not necessary, and 24% thought that writing a comment was sufficient. Twenty-three percent of the IMDs did not consider requesting laboratory studies or diagnostic tests necessary nor did they consider it necessary to directly prescribe the treatment. For them, it was sufficient to suggest it in the progress comments.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Ninety-five percent of the IMDs did not feel that a new request for interconsultation was necessary to conduct follow-up. When completing an interconsultation, 67% of the IMDs wrote a report if the outcome was complex or if the patient's treatment required it. Only 19% of the IMDs always wrote a report, and 4% never did. Forty-four percent of the reports were written independently of the report written by the petitioning department, and 28% wrote the report as an appendix to the standard report. Twelve percent used other formats.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Forty percent of the largest IMDs assigned a physician to other departments. Seventy-four percent of those surveyed perform interconsultations on demand. Only 17% had organized some type of preoperative consultation, and 24% had a post-hospitalization consultation. The interconsultation request methods were disparate and included the request form (most common at 35%), search (23%) and telephone (17%).</p><p id="par0085" class="elsevierStylePara elsevierViewall">A greater number of physicians and section heads (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.011, respectively) (but not residents) in the IMDs were significantly associated with the presence of specialized interconsultation units. The same factors were associated with the presence of posthospitalization consultations (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03). Although it did not reach statistical significance, there was a tendency with the presence of a preoperative consultation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.07). The number of daily interconsultations did not affect the presence or not of a specialized unit.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In terms of shared care, we found a significant association with the number of section heads, physicians and residents of the department (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.023, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.015 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.046, respectively). We also found a significant association with the presence of a preoperative and posthospitalization consultation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001), as well as a greater number of new daily interconsultations (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Forty-four percent of the hospitals that responded to the survey had more than 500 beds. The IMDs had a median number of physicians of 11 (IQR, 6–17). We can therefore state that, in general, these are medium-sized departments and in some cases large. The interconsultation is practically generalized (80% of the IMDs), but it is surprising that 45% of these interconsultations are performed in a specialized manner, when there are other shortcomings in the portfolio of services. For example, only 55% of the IMDs had a cardiovascular risk unit, and only 29% had home hospitalization (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). This could suggest a selection bias in the survey in favor of those departments with a greater interest in interconsultations.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Interconsultations are mainly performed on a part-time basis and generally on a rotating basis, especially if there is no specialized interconsultation or shared care unit. Although these last two are organizations that work in a structured manner, this does not mean that they are equipped with fixed staff. Thus, the periodicity of the rotations varied between 1 and 6 months, to provide more stability and facilitate the relationships with the departments.</p><p id="par0105" class="elsevierStylePara elsevierViewall">There were 61 hospitals (51%) that assigned more than three physicians to the interconsultation, despite the fact that 33 (54%) of them had staff with less than 10 physicians, which probably reflects a rotational assignment of this task. Frequently, resident rotations are mandatory. Shared care was in the minority, given that only 33% of the centers had this modality. Shared care prevailed in the departments of orthopedic and trauma surgery, with more or less specific programs. A number of studies have shown that this type of activity is effective in reducing minor postoperative complications.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a> The shared care programs in vascular surgery have shown their efficacy in reducing mortality, reducing pain, increasing safety and promoting patient education.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The departments that recorded their activity in some form were in the majority, although it was neither regulated nor uniform. The presence of management tools for recording the activity data would improve the organization of the interconsultation. It is encouraging that most of the IMDs surveyed were willing to formalize a national registry on the interconsultation activity.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The workload is proportional to the size of the centers. Only 20% of the departments treated more than 5 new patients daily, and 6% treated less than 1. The first applicant was trauma in most cases. The mean stay varied significantly but usually did not exceed 7 days or go lower than 2 and was therefore lower than the mean stay in the IMDs. More than 90% of the consultations were responded to within 24<span class="elsevierStyleHsp" style=""></span>h of the consultation, a good quality finding that reflects that this activity is seen by most internists as being as important as conventional hospitalization.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Despite the fact that some units had more than 15 years of history (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), 92% of the departments lacked action protocols on how to respond to an interconsultation. There is a considerable margin for improvement on this issue. Eleven percent of those surveyed believe it was not necessary to write a progress comment when consulted, 24% believed that this comment could substitute writing a case report, and 23% believed that diagnostic tests do not need to be requested and that treatments do not need to be written, only suggested. In terms of the discharge report, the majority was inclined to perform it, especially if the outcome was complex. The most common option was to create a document independent of the discharge report, followed closely by the option to prepare an appendix to the discharge report.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Only a minority of centers had created a perioperative or post-hospitalization consultation, the latter being somewhat more common, despite the fact that these tools have been shown to be economically profitable and effective in care, especially benefitting complex patients in terms of surgical results and the perioperative period.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Finally, the dispersion in the means of communication used by the physicians when performing the interconsultations was to be expected. However, it is surprising that in the era of the electronic revolution, the hardcopy request form is still the predominant method in 35% of the centers.</p><p id="par0135" class="elsevierStylePara elsevierViewall">We observed that the large departments, which have a larger number of physicians, section heads and residents, are the most inclined to develop specialized interconsultation and shared care units. In addition, these departments have more frequently initiated preoperative and posthospitalization consultations and are the ones who logically treat a larger volume of interconsultations.</p><p id="par0140" class="elsevierStylePara elsevierViewall">This study provides a current and up-to-date view of the consulting activity of internists through the information provided by them. This view might be somewhat distorted if there was a tendency to receive more responses from departments who implement this activity more completely and fewer responses from those who do not. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> could support this interpretation, given that, in a number of provinces, we received responses only from those IMDs that already had specialized interconsultation units.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In conclusion, the interconsultation activity is well implemented in the surveyed IMDs. Shared care was less extensive, given that it requires greater staff resources, and is more frequently assigned to the department of orthopedic and trauma surgery. The survey reflects the shortcomings of training, a heterogeneous organization and an irregular recording of the interconsultation activity. Moreover, the aging of the population, improved surgical techniques, pressure for the efficient use of hospital resources and the demand by surgery departments warrant further progress in developing new healthcare models. These models need to be homogeneous and protocolized while respecting the idiosyncrasies and needs of each center. The formal incorporation of the development of competencies in interconsultations and shared care in the internal medicine specialty program can help incorporate an inclusive vision in all complex healthcare processes.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres750229" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec752983" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres750228" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec752984" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and method" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-31" "fechaAceptado" => "2016-04-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec752983" "palabras" => array:7 [ 0 => "Interconsultations" 1 => "Spain" 2 => "Survey" 3 => "Healthcare organisation" 4 => "Shared care" 5 => "Internist" 6 => "Resource organisation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec752984" "palabras" => array:7 [ 0 => "Interconsultas" 1 => "España" 2 => "Encuesta" 3 => "Organización asistencial" 4 => "Asistencia compartida" 5 => "Internista" 6 => "Organización de recursos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyse the activity of interconsultations conducted by the departments of internal medicine, communicating their importance to managers and offering information to these departments to improve their organisation.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional study was conducted using an interconsultation activity survey (on-demand consulting activity for other departments) and shared care (consulting activity provided in a regulated manner to other departments).</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We received 120 surveys that corresponded to 108 public and 12 private hospitals. Forty-five percent of the surveyed hospitals had a specialised interconsultation unit, and 31% had shared care. The department most frequently helped by the presence of a stable consultation unit (65% of the cases) was orthopaedic and trauma surgery. Fifty-five percent of the departments of internal medicine surveyed had an interconsultation activity record since the start of their activity. Ninety-two percent of the departments lacked a protocol that regulated interconsultations, and in 74% of the cases, the interconsultation was on demand.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The interconsultation activity is generalised in the departments of internal medicine, but only 45% of these departments have interconsultation units, and only 33% provide the shared care modality. The survey reflects the shortcomings of training and some confusion in the concept of interconsultations. The considerable majority of departments lack organisational interconsultation protocols.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar la actividad de interconsulta (IC), realizada por los Servicios de Medicina Interna (SMI), transmitir su importancia a los gestores y ofrecer información a los SMI para mejorar la organización de la misma.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal mediante una encuesta de actividad en IC (actividad de consultoría a demanda para otros servicios) y asistencia compartida (actividad de consultoría que se presta de modo reglado en otros servicios).</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se recibieron 120 encuestas que correspondían a 108 hospitales públicos y 12 privados. El 45% de los hospitales encuestados disponen de unidad de IC monográfica y en el 31% existe asistencia compartida. El servicio más frecuentemente asistido por una consultoría estable (65% de los casos) fue cirugía ortopédica y traumatología. El 55% de los SMI encuestados lleva un registro de la actividad de IC desde el inicio de su actividad. El 92% de los servicios carece de un protocolo que regule la IC y en el 74% de los casos la IC se responde a demanda.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La actividad de IC está generalizada en los SMI, pero solo el 45% de ellos disponen de unidades de IC y el 33% prestan la modalidad de asistencia compartida. La encuesta refleja carencias de formación y cierta confusión en el concepto de IC. La gran mayoría de los servicios carecen de protocolos organizativos de IC.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Marco Martínez J, Montero Ruíz E, Fernández Pérez C, Méndez Bailón M, García Klepzig JL, Garrachón Vallo F. Encuesta nacional sobre la actividad de los internistas en asistencia compartida–interconsultas en los hospitales españoles. Rev Clin Esp. 2016;216:414–418.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0160" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">n</span>: percentage of <span class="elsevierStyleItalic">internal medicine</span> departments in the sample that offer this activity in their catalog of services.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Activity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes % (<span class="elsevierStyleItalic">n</span>) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">General \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (120) \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">Interconsultation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.2 (95) \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">Specialized interconsultation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (54) \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">Cardiovascular risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.8 (67) \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">Infectious/HIV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.5 (81) \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">Heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.5 (33) \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">Metabolic syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.2 (23) \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">Thromboembolic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.8 (43) \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">Coordination with primary care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (48) \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">Home patient care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.2 (35) \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">Palliative care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.7 (44) \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">Short stay unit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.5 (33) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1239626.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Composition of the portfolio of services of the departments of internal medicine.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inception Date \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1990 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1996 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1998 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1999 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1239625.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Only 51 of the 120 departments surveyed provided the inception date.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Inception date of the specialized interconsultation units.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a></p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Province \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interconsultation yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interconsultation no \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alicante \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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">Asturias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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">Barcelona \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \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">Cádiz \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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">Gerona \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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">Coruña \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Las Palmas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Madrid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Malaga \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Murcia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Pontevedra \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Seville \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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">Tarragona \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Toledo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \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">Valencia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \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">Vizcaya \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \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">Zaragoza \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1239627.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Availability of specialized interconsultation units in the Departments of Internal 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Asch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/jhm.1968" "Revista" => array:7 [ "tituloSerie" => "J Hosp Med" "fecha" => "2012" "volumen" => "7" "paginaInicial" => "697" "paginaFinal" => "701" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22961756" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S073510970401099X" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021600000008/v1_201610290712/S2254887416300315/v1_201610290712/en/main.assets" "Apartado" => array:4 [ "identificador" => "1901" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021600000008/v1_201610290712/S2254887416300315/v1_201610290712/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887416300315?idApp=WRCEE" ]
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| 2023 March | 2 | 3 | 5 |
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| 2016 July | 0 | 1 | 1 |
