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Available Variables

Characteristics of the patient

CHARACTERISTICS OF THE PATIENT

General data

  • Age
  • Date of birth
  • Gender
  • Nacionality

Data of the health service

  • Primary Health Care Center
  • Date of allocation of the patient to a particular PCT, physician and nurse
  • Allocated physician
  • Allocated nurse
  • Type of health coverage (active/retired)

Dispensing of pharmacological drugs

DISPENSING OF PHARMACOLOGICAL DRUGS

Data of all medicines funded by the National Health System and dispensed in pharmacies with prescriptions from CIH professionals; for each dispensed drug we have:

  • National Code
  • Description of presentation
  • Number of units per package
  • Daily dose
  • Month of drug production
  • ATC
  • Monthly number of packages dispensed
  • Unit where the prescription originates from
  • Professional that signs the prescription

Prescription of Medicines

PRESCRIPTION OF MEDICINES

Data of all medicines prescribed in the electronic medical records ECAP:

  • National Code
  • Description of presentation
  • Date of start of prescription
  • Date of end of prescription
  • Units per day of drug
  • ATC Code
  • Unit where the prescription originates from
  • Professional that signs the prescription

Health Problems

HEALTH PROBLEMS

The data of the diagnostics registered by the professionals in the electronic medical records use the ICD-10 classification with a dictionary of natural language created by the CIH (thesaurus). A link with the code CIAP-2, CCS and in some cases with clusters used in other SIDIAP studies exist.

For each health problem we have

  • Code ICD-10
  • Code ICPC-2
  • Code CCS
  • Clusters SIDIAP
  • Description
  • Date of start of diagnosis
  • Date of end of diagnosis
  • PCT where the diagnosis was made

Clinical Parameters

CLINICAL PARAMETERS

Structured data registered in the electronic medical records by health professionals. There are over 500 parameters available. The most frequent and validated by prior SIDIAP studies are:
  • SBP
  • DBP
  • Weight
  • Height
  • BMI
  • Alcohol consumption
  • Smoking

For each clinical parameter we have:

  • Description
  • Value
  • Date of registration of the value

Diagnostic Procedures

DIAGNOSTIC PROCEDURES

Laboratory

These data collect all laboratory tests structured from the database of each laboratory, which are then integrated automatically into the electronic medical records:

  • Urine biochemistry tests
  • Blood biochemistry tests
  • Biochemical analysis of exudates
  • Stool biochemistry
  • Biochemical analysis of other samples
  • Cultures
  • Medicines in plasma
  • Haematology tests
  • Hormones in plasma
  • Blood Immunology Tests
  • Tumour markers in blood
  • Serology
  • Other microbiological testsBioquĂ­mica en orina

For each measurement we have:

  • Code
  • Description
  • Value
  • Units
  • Data of measurement

Imaging

These data originate from the request forms of the tests. The results are non-structured data that have not been analysed.

  • Ultrasound
  • Contrast imaging
  • X-Ray
  • Magnetic Resonance Imaging (MRI)
  • CT-scan

For each imaging test per patient we have:

  • Type of test
  • Date the test was carried out
  • UP that requested the test

Scales

The data originate from the requests for scales/tests in the electronic medical records.

Cognitive scales

  • LOBO (translated adaptation of MMSE)
  • Mini Mental Status Examination
  • PFEIFER (scale)

Alcohol scales

  • AUDIT (questionnaire)
  • CAGE (escale)
  • CRAFFT (test)
  • MALT (questionnaire)

Scales of evaluation of risk situations

  • BARBER (questionnaire)
  • GIJON (test)
  • NORTON (escale)

Mental Health scales

  • GOLBERG (escale)
  • YESAVAGE (test)

Smoking scales

  • FAGESTROM (test)
  • RICHMOND (test)

Pain sscales

  • EVA (escale)

Scales of evaluation of care

Functional scales

Other scales

For each scale we have the following data:

  • Description of the scale or test
  • Result of the test
  • Date of register of the result

Other Diagnostic procedures

The data originate from the request forms for the tests. The results are non-structured data.

Exemples:

Cardiovascular diagnostic procedures

  • Doppler (ankle-brachial index)
  • Electrocardiogram
  • ABPM (Ambulatory blood pressure monitoring)

Digestive tract diagnostic procedures

  • Colonoscopy
  • Upper gastrointestinal endoscopy

Respiratory diagnostic procedures

  • Spirometry
  • Pulse oximetry

The data available for each test per patient are:

  • Test
  • Date the test is carried out
  • Professional requesting the test
  • UP that request the test
  • In some case structured parameters are available:
    • Spirometry: VEMS1, other spirometry measurements
    • AMBP: values of measurements of BP
    • Echocardiogram: ejection fraction
    • ECO-Doppler: ankle-brachial index

Medical procedures

MEDICAL PROCEDURES 

Available structured data refer to immunizations and advice and health education. Some surgical procedures in primary care and other techniques are not yet sufficiently structured.

Immunizations

  • DT
  • DTP
  • Influenza
  • Haemophilus
  • Hepatitis B
  • HPV
  • Meningitis C
  • Pneumococcal vaccine
  • Polio vaccine
  • Tetanus
  • Measles, mumps, rubella
  • Chickenpox

For each vaccine per patient we have:

  • Code of vaccine
  • Description of vaccine
  • Dose number
  • Date of immunization
  • UP where the immunization is administered

Advice / Health education

For instance:

  • Quitting smoking advice
  • Alcohol advice
  • Education for the optimal use of inhalers

Data available:

  • Description of variable
  • Measurement
  • Date of register of measurement

Referrals to secondary and tertiary level

REFERRALS TO SECONDARY AND TERTIARY LEVEL

The data originate from the requests of referral to other specialists by the PC professionals. The following data are available:

  • Specialty of referral
  • Date of request
  • Cause of referral (ICD-10 code)
  • Health Center
    The result of the request in a non-structured text

Sick Leave

SICK LEAVE

The available data per patient are:
  • Cause (ICD-10 code)
  • Date of start
  • Date of end
  • Professional that signs the sick leave
  • Health Center

Visits in Primary Care

VISITS IN PRIMARY CARE 

Visits per patient carried out by the different professionals of PC (GP/nurse/paediatrician/dentist/social worker). For each visit we have registered:

  • Date of visit
  • Type of professional
  • Health Center

Second Level Variables

SECOND LEVEL VARIABLES

Professional

Different measurements on the quality of services from professionals are available:

  • Gender (we could do an approximation from the name)
  • Results of quality standards
    • Clinical Care (EQA)
    • Prescription (EQPF)
    • Register (EQR, EQD)
Primary Health Care Center
  • Localization (coordinates): to calculate distances
  • Undergraduate teaching
  • Costs generated in:
    • Pharmacy
    • Personnel
    • Other
  • Resultts of quality standards
    • Clinical Care (EQA)
    • Prescription (EQPF)
    • Register (EQR, EQD)

Population

  • Dispersal of population
  • Socioeconomic level according to census: MEDEA index
  • Type of population: rural/urban


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