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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Espa&#241;a es el pa&#237;s de Europa que m&#225;s inmigrantes ha recibido en los &#250;ltimos a&#241;os<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; En la Regi&#243;n Sanitaria de Lleida&#44; la poblaci&#243;n inmigrante ha pasado de representar el 2&#44;6&#37; de los residentes en el a&#241;o 2000 al 19&#37; en el a&#241;o 2010<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; El impacto de la poblaci&#243;n inmigrante en el sistema sanitario espa&#241;ol ha sido importante&#44; aunque por ser todav&#237;a un fen&#243;meno reciente se ha evaluado poco&#46; Este cambio de tanta magnitud en la demograf&#237;a puede hacer aumentar las inequidades en salud&#44; definidas como las diferencias que son evitables&#44; injustas e innecesarias&#46; En 2001&#44; el American Institute of Medicine<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> describi&#243; seis dimensiones para la asistencia sanitaria de calidad&#46; Una de ellas es la equidad del sistema&#44; comprendiendo que no debe verse influida por las caracter&#237;sticas personales de sexo&#44; etnia&#44; recursos econ&#243;micos&#44; etc&#46; Sin embargo&#44; hasta la fecha&#44; la existencia de desigualdades en salud ha sido muy bien documentada en todo el mundo&#44; y de igual forma ha sucedido en nuestro pa&#237;s<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; Por ejemplo&#44; en el caso de los inmigrantes se han publicado varios art&#237;culos en Espa&#241;a que muestran claras desigualdades en el uso de los servicios sanitarios<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; de farmacia<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> y bajas laborales<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En lo que respecta al manejo de los factores de riesgo cardiovascular&#44; como ejemplo&#44; en un estudio realizado en Barcelona<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> se ha encontrado que hay un mejor control de la hipertensi&#243;n entre los aut&#243;ctonos&#44; si bien este efecto desaparece cuando se tienen en cuenta otras variables que se distribuyen de forma heterog&#233;nea entre los aut&#243;ctonos y los inmigrantes&#44; en especial la edad y el tabaquismo&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Los estudios que se realizan sobre desigualdades en salud nos indican que la calidad asistencial en ciertos colectivos tiende a ser peor que en la poblaci&#243;n aut&#243;ctona&#46; As&#237;&#44; se ha visto que se les hacen menos mamograf&#237;as&#44; se les prescriben menos betabloqueantes tras un infarto y el grado de control de la hemoglobina glucosilada o del colesterol LDL es peor en algunos pacientes diab&#233;ticos seg&#250;n su etnia<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En el caso de la diabetes&#44; una de las enfermedades cr&#243;nicas m&#225;s comunes y que supone una carga considerable tanto para los pacientes como para los sistemas de salud y la sociedad&#44; hasta la fecha se sabe que hay diferencias entre los grupos de inmigrantes en cuanto a su prevalencia<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; si bien no disponemos de suficiente evidencia para afirmar que&#44; una vez diagnosticada&#44; sea distinto el grado de control<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El objetivo de este estudio es conocer si hay diferencias en la detecci&#243;n y el control de la diabetes entre la poblaci&#243;n aut&#243;ctona y la poblaci&#243;n inmigrante en la Regi&#243;n Sanitaria de Lleida&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">M&#233;todo</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se realiz&#243; un estudio poblacional observacional y transversal entre los 260&#46;843 habitantes de la Regi&#243;n Sanitaria de Lleida que pose&#237;an la tarjeta sanitaria activa a 31 de diciembre de 2010&#44; a partir de la base de datos de la historia cl&#237;nica informatizada&#46; El requisito para pertenecer a dicho registro es hallarse empadronado en un municipio de la regi&#243;n&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Criterios de inclusi&#243;n</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se incluyeron todos los pacientes diagnosticados de diabetes mellitus de tipo 2 asignados y atendidos en la Regi&#243;n Sanitaria de Lleida&#44; al menos una vez entre el 1 de enero de 2010 y el 31 de diciembre de 2010&#46; Se excluyeron los pacientes que no ten&#237;an registrado el pa&#237;s de origen en la historia cl&#237;nica y los que no acudieron a ninguna visita durante el periodo de estudio&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Los datos considerados fueron&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Variables sociodemogr&#225;ficas&#58; pa&#237;s de origen categorizado en aut&#243;ctonos e inmigrantes &#40;variable independiente principal&#41;&#46; El grupo de inmigrantes fue desagregado en cinco grandes regiones geogr&#225;ficas &#40;Asia&#44; Europa del Este&#44; Magreb&#44; &#193;frica subsahariana y Am&#233;rica del Sur&#41;&#44; y por edad y sexo&#46; Se consideraron inmigrantes los procedentes de pa&#237;ses de renta media o baja seg&#250;n la clasificaci&#243;n del Banco Mundial basada en el producto interior bruto per c&#225;pita<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Factores de riesgo cardiovascular asociados a la diabetes&#58; hipertensi&#243;n&#44; dislipidemia&#44; microalbuminuria&#44; h&#225;bito tab&#225;quico y sobrepeso-obesidad&#44; mediante el &#237;ndice de masa corporal &#40;IMC&#41; categorizado en dos grupos &#40;&#60;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> y &#8805;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; como variables de ajuste se consideraron el riesgo cardiovascular &#40;puntuaci&#243;n de la ecuaci&#243;n de Framingham&#41;&#44; los triglic&#233;ridos &#40;mg&#47;dl&#41;&#44; el colesterol total &#40;mg&#47;dl&#41;&#44; el colesterol LDL &#40;mg&#47;dl&#41;&#44; la presi&#243;n arterial diast&#243;lica y sist&#243;lica &#40;mmHg&#41;&#44; el registro del diagn&#243;stico de hipertensi&#243;n y la dislipidemia&#46; Se consider&#243; paralelamente el diagn&#243;stico de cardiopat&#237;a si se registraba alguno de los diagn&#243;sticos I20-25 de la CIE-10 &#40;angina&#44; infarto agudo de miocardio&#44; complicaciones del infarto agudo de miocardio&#44; isquemia cr&#243;nica&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para las variables de diagn&#243;stico de diabetes se utilizaron las recomendaciones de la American Diabetes Association de 2010<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;HbA1c &#62;6&#44;5&#37;&#44; glucemia en ayunas &#62;126<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; &#62;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl tras una sobrecarga oral de glucosa o con los s&#237;ntomas cl&#225;sicos de hiperglucemia&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Con el fin de evaluar la atenci&#243;n a los pacientes con diabetes y el control de sus posibles complicaciones&#44; se analizaron los siguientes indicadores de calidad&#58; realizaci&#243;n o no de an&#225;lisis de sangre con determinaci&#243;n de la glucosa basal&#44; determinaci&#243;n de HbA1c&#44; fondo de ojo y presi&#243;n arterial&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">La variable principal del estudio fue el buen o mal control de la diabetes seg&#250;n la &#250;ltima hemoglobina glucosilada &#40;&#60;7&#44;5&#37;&#41;&#46; Se consider&#243;&#44; adem&#225;s&#44; un buen control de la presi&#243;n arterial si la sist&#243;lica era &#60;130<span class="elsevierStyleHsp" style=""></span>mmHg y la diast&#243;lica era &#60;85<span class="elsevierStyleHsp" style=""></span>mmHg&#46; En cuanto al colesterol&#44; se valor&#243; el LDL &#60;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Tambi&#233;n se consider&#243; un IMC &#60;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; colesterol total &#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y no tener h&#225;bito tab&#225;quico&#46; Todas las variables hab&#237;an sido registradas en el &#250;ltimo a&#241;o&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Para valorar la frecuentaci&#243;n de los pacientes se agregaron todas las visitas realizadas durante el a&#241;o de estudio&#44; tanto al m&#233;dico como a la enfermera&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lisis estad&#237;stico</span><p id="par0080" class="elsevierStylePara elsevierViewall">Los datos cuantitativos se describieron mediante la media y su intervalo de confianza del 95&#37;&#46; Las variables cualitativas se describieron como frecuencias y porcentajes&#44; y se contrastaron sus diferencias entre aut&#243;ctonos e inmigrantes mediante el estad&#237;stico ji al cuadrado&#46; Se contrastaron las diferencias en el n&#250;mero de visitas entre grupos a partir de los contrastes no param&#233;tricos U de Mann-Whitney o Kruskal-Wallis&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Con el objetivo de estimar la asociaci&#243;n entre el correcto control de los diferentes par&#225;metros y la variable de inter&#233;s&#44; se utilizaron modelos de regresi&#243;n log&#237;stica y los resultados se presentaron como <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; crudas y ajustadas con su intervalo de confianza&#46; El ajuste de dicha asociaci&#243;n se realiz&#243; mediante regresi&#243;n log&#237;stica multivariada ajustando por edad&#44; sexo y n&#250;mero de visitas al m&#233;dico de cada paciente&#46; El m&#233;todo de ajuste fue forzado &#40;ENTER&#41; y se comprob&#243; la no presencia de colinealidad&#44; y posteriormente la validaci&#243;n del modelo mediante la curva ROC y el test de Hosmer &#38; Lemeshow&#46; Se repitieron los c&#225;lculos con la variable independiente de la zona geogr&#225;fica&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En todos los an&#225;lisis se utiliz&#243; el programa SPSS 15&#46;0 para Windows&#46; En todos los c&#225;lculos se consider&#243; un alfa de 0&#44;05&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#201;tica</span><p id="par0095" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el Comit&#233; &#201;tico de la Fundaci&#243;n IDIAP Jordi Gol en Atenci&#243;n Primaria&#46; Los autores certifican que cumplen los principios &#233;ticos de publicaci&#243;n y las responsabilidades &#233;ticas desarrolladas por <span class="elsevierStyleSmallCaps">gaceta sanitaria</span>&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Descripci&#243;n de la muestra</span><p id="par0100" class="elsevierStylePara elsevierViewall">La muestra fue constituida por 108&#46;747 pacientes mayores de 18 a&#241;os&#44; con registro de pa&#237;s&#44; en situaci&#243;n activa y visitados durante 1 a&#241;o &#40;28&#44;3&#37; inmigrantes&#41;&#46; La consulta a la historia cl&#237;nica identific&#243; 77&#46;999 pacientes aut&#243;ctonos &#40;6846 diab&#233;ticos&#41; y 30&#46;748 pacientes inmigrantes &#40;415 diab&#233;ticos&#41;&#46; El 8&#44;78&#37; de los aut&#243;ctonos eran diab&#233;ticos&#44; frente al 1&#44;35&#37; de los inmigrantes &#40;p &#60;0&#44;001&#41;&#46; No obstante&#44; la muestra de inmigrantes fue muy diferente a la aut&#243;ctona&#58; mayor proporci&#243;n de hombres&#44; m&#225;s j&#243;venes&#44; menor IMC&#44; menos hipertensos&#44; menos dislipid&#233;micos y m&#225;s fumadores&#46; Se observ&#243; que los procedentes de los pa&#237;ses de Europa del Este eran los m&#225;s representados &#40;34&#44;79&#37; de los inmigrantes&#41;&#44; seguidos de los del Magreb &#40;24&#44;2&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">El n&#250;mero medio de visitas al a&#241;o para los pacientes aut&#243;ctonos diab&#233;ticos fue de 11 visitas al m&#233;dico y enfermer&#237;a&#44; y en el caso de los inmigrantes diab&#233;ticos fue 10&#44;9 &#40;diferencia estad&#237;sticamente no significativa&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Registro de indicadores de control</span><p id="par0110" class="elsevierStylePara elsevierViewall">Cumpl&#237;an criterios de diabetes mellitus de tipo 2 un total de 6846 aut&#243;ctonos y 415 extranjeros &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Los par&#225;metros que se monitorizan habitualmente en los diab&#233;ticos se registraban con menor frecuencia en la poblaci&#243;n inmigrante que en la aut&#243;ctona&#44; y destacaba que en la poblaci&#243;n aut&#243;ctona diab&#233;tica se hab&#237;a determinado el colesterol total al 70&#44;8&#37; &#40;inmigrantes 54&#44;9&#37;&#41; y se hab&#237;a valorado el fondo de ojo al 27&#44;6&#37; &#40;inmigrantes 15&#44;7&#37;&#41;&#46; Se ajustaron modelos log&#237;sticos por edad y sexo para estimar la asociaci&#243;n entre ser inmigrante y la existencia de registro de cada uno de los par&#225;metros&#46; Observamos que los par&#225;metros se registraban con menor frecuencia en los inmigrantes que en los aut&#243;ctonos&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control de los pacientes diab&#233;ticos</span><p id="par0115" class="elsevierStylePara elsevierViewall">Al comparar los indicadores de calidad de los dos grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#44; observamos que hab&#237;a diferencias estad&#237;sticamente significativas entre ellos a favor de un mayor control en los aut&#243;ctonos&#46; En el caso de la HbA1c &#60;7&#44;5&#37;&#44; era del 68&#44;04&#37; en la poblaci&#243;n aut&#243;ctona y del 54&#44;76&#37; en los inmigrantes&#46; Sin embargo&#44; la presi&#243;n arterial obtuvo mayor tasa de control en los inmigrantes&#44; quienes ten&#237;an menor prevalencia de obesidad &#40;&#62;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; y los resultados fueron muy parecidos en ambos en cuanto a colesterol total &#40;&#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#44; colesterol LDL &#40;&#60;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; y microalbuminuria &#40;&#60;20<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Aun as&#237;&#44; en los inmigrantes se encontr&#243; una mayor proporci&#243;n de fumadores&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control de los indicadores de calidad seg&#250;n grupos</span><p id="par0120" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se presentan las OR ajustadas por edad&#44; sexo y n&#250;mero de visitas estimadas para el control de cada uno de los indicadores de calidad por el hecho de ser inmigrante&#46; Podemos observar que los inmigrantes tienen un riesgo un 27&#37; inferior de alcanzar un control &#243;ptimo de la HbA1c &#40;OR ajustada<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;73&#41;&#46; No se detectaron diferencias significativas en cuanto al control del colesterol LDL&#44; la microalbuminuria y la presi&#243;n arterial diast&#243;lica&#46; En el caso de la presi&#243;n arterial sist&#243;lica&#44; el colesterol total&#44; el IMC y el tabaquismo&#44; se comprob&#243; que los inmigrantes ten&#237;an un mayor control que los aut&#243;ctonos&#44; teniendo en cuenta la edad&#44; el sexo y la frecuentaci&#243;n al centro de atenci&#243;n primaria&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Finalmente&#44; dada la heterogeneidad hallada entre el grupo inmigrante y el aut&#243;ctono&#44; se ajust&#243; un modelo considerando todas las variables analizadas &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Los factores que se asociaron de forma significativa a tener un buen control de la HbA1c &#40;&#60;7&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#41; fueron la edad&#44; el sexo&#44; la hipertensi&#243;n&#44; la dislipidemia&#44; el tabaquismo&#44; la presi&#243;n arterial&#44; los triglic&#233;ridos&#44; el riesgo cardiovascular &#40;Framingham&#41; y la cardiopat&#237;a &#40;ICD-10&#58; I20-I25&#41;&#46; Una vez ajustado por las variables mencionadas&#44; se estim&#243; que el riesgo de tener un buen control de HbA1c era un 30&#37; inferior en el grupo inmigrante que en el aut&#243;ctono&#44; de lo que se desprende que los inmigrantes tienen una menor probabilidad de alcanzar un control &#243;ptimo&#46; El modelo discriminaba moderadamente &#40;curva ROC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;65&#41; y estaba bien calibrado &#40;contraste de Hosmer &#38; Lemeshow&#59; p &#62;0&#44;05&#41;&#46; Teniendo en cuenta la zona geogr&#225;fica de origen&#44; los pacientes latinoamericanos y de Europa del Este se comportaban de forma parecida a los aut&#243;ctonos&#46; En el caso de los inmigrantes de origen asi&#225;tico&#44; magreb&#237; o subsahariano&#44; ten&#237;an un riesgo estad&#237;sticamente inferior de alcanzar el control de la HbA1c&#44; o lo que es lo mismo&#44; presentaban determinaciones de HbA1c m&#225;s altas&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados relevantes</span><p id="par0130" class="elsevierStylePara elsevierViewall">Hemos observado que a los pacientes diab&#233;ticos de origen inmigrante se les determinan los par&#225;metros de calidad asistencial con menor frecuencia que a los aut&#243;ctonos&#44; ajustando los valores por edad&#44; sexo y frecuentaci&#243;n&#46; Tambi&#233;n hemos comprobado&#44; al comparar ambos colectivos&#44; que los inmigrantes tienen peores valores de HbA1<span class="elsevierStyleHsp" style=""></span>C y&#44; sin embargo&#44; su presi&#243;n arterial est&#225; mejor controlada que la de los aut&#243;ctonos&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La prevalencia de diabetes mellitus de tipo 2 en la poblaci&#243;n inmigrante es del 1&#44;35&#37; y en los aut&#243;ctonos del 8&#44;78&#37;&#46; La menor prevalencia en la poblaci&#243;n inmigrante se justifica por la menor edad de esta poblaci&#243;n&#44; con una media de 35&#44;5 a&#241;os&#44; y es similar a las publicadas en el estudio REGICOR al estudiar una poblaci&#243;n cercana y parecida a la nuestra<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comparaci&#243;n con otros estudios publicados</span><p id="par0140" class="elsevierStylePara elsevierViewall">Hasta la fecha sab&#237;amos que hab&#237;a diferencias en la prevalencia de diabetes entre la poblaci&#243;n extranjera y la aut&#243;ctona<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#44; y son numerosos los factores que pueden contribuir a ello<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; entre los que destacan las caracter&#237;sticas f&#237;sicas&#44; el tipo de dieta y la actividad realizada&#46; Tambi&#233;n se ha detectado que los valores de HbA1c pueden ser distintos entre las diversas etnias&#44; esencialmente por cuestiones biol&#243;gicas<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Por ejemplo&#44; en Londres se ha encontrado que las poblaciones asi&#225;tica<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> y africana<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> tienen m&#225;s riesgo de desarrollar diabetes que la poblaci&#243;n europea&#44; aunque de forma parad&#243;jica pueden tener cifras m&#225;s altas de colesterol HDL y m&#225;s bajas de triglic&#233;ridos<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Conviene recordar que estas diferencias empiezan en la infancia y se mantienen cuando llegan a la vida adulta<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los pacientes inmigrantes tienen un peor control a pesar de acudir a las consultas con igual frecuencia que los aut&#243;ctonos&#46; Estos datos son concordantes con los aportados por otros autores<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#46; Por ejemplo&#44; un trabajo poblacional que analiz&#243; 4309 pacientes diab&#233;ticos de atenci&#243;n primaria en Reino Unido hall&#243;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> como nosotros&#44; diferencias en el seguimiento de la presi&#243;n arterial&#44; el colesterol y la HbA1c&#46; En la poblaci&#243;n negra&#44; los pacientes ten&#237;an menos probabilidad de lograr los objetivos de prevenci&#243;n que la poblaci&#243;n aut&#243;ctona&#44; a pesar de ser atendidos por los mismos profesionales&#46; Tambi&#233;n al analizar el resultado encontrado en poblaci&#243;n asi&#225;tica se observaron diferencias similares&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Wilf-Miron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> evaluaron en Israel las disparidades de salud de 75&#46;000 pacientes diab&#233;ticos y hallaron diferencias en la prevalencia de la diabetes y en su posterior tratamiento&#44; siempre en detrimento de ciertos grupos socioecon&#243;micos y &#233;tnicos&#46; En consecuencia&#44; se evidenciaron una vez m&#225;s las desigualdades en salud que sufren algunos grupos&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Carrasco-Garrido et al<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> atribuyen estas diferencias en el control de la diabetes a la existencia de un concepto de salud y enfermedad por parte del colectivo inmigrante diferente al de la poblaci&#243;n aut&#243;ctona<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46; Estos estudios encuentran que la poblaci&#243;n inmigrante tiene una mejor percepci&#243;n de buena salud y presentan mejores estilos de vida&#46; Como explican Gimeno-Feliu et al&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> es posible que la frecuentaci&#243;n del sistema sanitario responda a necesidades de atenci&#243;n por enfermedad aguda&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Deber&#237;amos aceptar que la salud y la enfermedad son conceptos construidos socialmente y&#44; por lo tanto&#44; var&#237;an mucho seg&#250;n el entorno sociocultural&#46; Tal y como nosotros tenemos organizado el sistema sanitario&#44; parece que las actividades preventivas no son prioritarias para los inmigrantes al no reconocerlas como necesidades<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&#46; Tanto la barrera idiom&#225;tica como los factores culturales pueden afectar a la percepci&#243;n de enfermedad y&#44; por consiguiente&#44; a la estrategia de autocontrol de la diabetes<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Tambi&#233;n es cierto que no todas las diferencias observadas son atribuibles a las caracter&#237;sticas individuales de los pacientes extranjeros&#44; puesto que las caracter&#237;sticas de los m&#233;dicos que les atienden influyen notablemente en el &#233;xito o el fracaso de las visitas<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Igualmente&#44; hemos observado que los inmigrantes tienen un mejor control de la presi&#243;n arterial que los diab&#233;ticos aut&#243;ctonos&#44; hallazgo que coincide con otros estudios recientes realizados en Espa&#241;a<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#59; sin embargo&#44; hay autores extranjeros que han aseverado exactamente lo contrario&#44; explicando que las desigualdades del sistema sanitario en el control de la presi&#243;n arterial han mejorado en las &#250;ltimas d&#233;cadas&#44; pero no en todos los grupos por igual<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#44; como en los pacientes de raza negra y en la poblaci&#243;n asi&#225;tica&#44; que presentan cifras m&#225;s altas que la poblaci&#243;n blanca&#46; Una posible explicaci&#243;n ser&#237;a lo que la antropolog&#237;a americana denomin&#243; <span class="elsevierStyleItalic">Hispanic paradox</span><a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;34</span></a>&#44; la situaci&#243;n en la cual ciertos grupos deprimidos socialmente ten&#237;an mucho mejores resultados en salud que lo que era previsible&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Limitaciones</span><p id="par0175" class="elsevierStylePara elsevierViewall">Como limitaciones de nuestro estudio debemos destacar que la selecci&#243;n de la muestra no es representativa de toda la poblaci&#243;n inmigrante de la regi&#243;n&#44; sino de la empadronada&#44; puesto que todos los datos de esta investigaci&#243;n fueron extra&#237;dos de la base de historias cl&#237;nicas&#44; cuyas limitaciones ya fueron estudiadas por Ribera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> En dicho an&#225;lisis&#44; estos autores concluyen que los estudios a partir de bases de datos administrativas infraestiman determinadas prevalencias&#44; si bien sus asociaciones pueden estimarse de manera satisfactoria&#46; Al trabajar con un n&#250;mero de efectivos tan alto&#44; aseguramos una potencia estad&#237;stica dif&#237;cilmente alcanzable en estudios observacionales prospectivos&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Tambi&#233;n nos parece importante destacar que podr&#237;a haber cierto sesgo de selecci&#243;n de la muestra al no incluir aquellos pacientes que no acudieron a ninguna visita&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Por otro lado&#44; no dispusimos de los tratamientos farmacol&#243;gicos que nos permitieran contrastar las variables estudiadas con los tratamientos recibidos&#46; Tampoco incluimos en el estudio el tiempo transcurrido desde el diagn&#243;stico&#44; variable que tiene un gran inter&#233;s en el pron&#243;stico de esta enfermedad&#46; Consideramos que el tiempo transcurrido desde el diagn&#243;stico no deber&#237;a afectar a las tasas de registro de la informaci&#243;n&#44; dado que con independencia del tiempo desde el diagn&#243;stico los pacientes deber&#237;an tener registradas el &#250;ltimo a&#241;o las variables de estudio&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Otra de las limitaciones es la falta de informaci&#243;n sobre los datos socioecon&#243;micos de los pacientes&#44; lo que dificulta el an&#225;lisis de dicho factor en el control de la glucemia&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusiones</span><p id="par0195" class="elsevierStylePara elsevierViewall">La conclusi&#243;n principal de nuestro estudio es que el control de los indicadores de calidad en la atenci&#243;n de la diabetes mellitus es m&#225;s deficiente en algunos grupos de inmigrantes que en los aut&#243;ctonos&#46; Los hallazgos nos muestran la necesidad de monitorizar los resultados en estos grupos poblacionales y evaluar las intervenciones necesarias para mejorar los resultados en salud&#46; Tambi&#233;n ser&#237;a interesante conocer en profundidad los factores que influyen en estas diferencias&#44; mediante la realizaci&#243;n de estudios cualitativos&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Contribuciones de autor&#237;a</span><p id="par0210" class="elsevierStylePara elsevierViewall">Todos los autores participaron en el dise&#241;o&#44; la adquisici&#243;n de los datos y la escritura del art&#237;culo o su revisi&#243;n cr&#237;tica con importantes contribuciones intelectuales&#46; Todos los autores revisaron y aprobaron la versi&#243;n final para su publicaci&#243;n&#46; J&#46;R&#46; Marsal y A&#46; L&#243;pez realizaron el an&#225;lisis estad&#237;stico&#46; J&#46; Soler-Gonz&#225;lez es el responsable del art&#237;culo&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> fue utilizada por J&#46; Soler-Gonz&#225;lez en la ponencia sobre desigualdades en salud de la poblaci&#243;n inmigrante del XXIII Congreso CAMFIC realizado en Matar&#243; el d&#237;a 6 de noviembre de 2011&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Financiaci&#243;n</span><p id="par0220" class="elsevierStylePara elsevierViewall">Nuestro grupo ha recibido financiaci&#243;n del 6&#232; Ajut a l&#8217;impuls d&#8217;estrat&#232;gies de recerca a l&#8217;Atenci&#243; Prim&#224;ria de l&#8217;IDIAP Jordi Gol&#46; GREDELL&#58; Grup de Recerca en Desigualtats en Salut a Lleida&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflictos de intereses</span><p id="par0225" class="elsevierStylePara elsevierViewall">Ninguno&#46;</p></span></span>"
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              "identificador" => "sec0015"
              "titulo" => "Criterios de inclusi&#243;n"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "An&#225;lisis estad&#237;stico"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "&#201;tica"
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        6 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Resultados"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Descripci&#243;n de la muestra"
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            1 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Registro de indicadores de control"
            ]
            2 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Control de los pacientes diab&#233;ticos"
            ]
            3 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Control de los indicadores de calidad seg&#250;n grupos"
            ]
          ]
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        7 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Discusi&#243;n"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Resultados relevantes"
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            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Comparaci&#243;n con otros estudios publicados"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Limitaciones"
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            3 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Conclusiones"
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        ]
        8 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Contribuciones de autor&#237;a"
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        9 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Financiaci&#243;n"
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        10 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Conflictos de intereses"
        ]
        11 => array:1 [
          "titulo" => "Bibliograf&#237;a"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-10-11"
    "fechaAceptado" => "2011-12-27"
    "PalabrasClave" => array:2 [
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec12774"
          "palabras" => array:4 [
            0 => "Inmigraci&#243;n"
            1 => "Diabetes"
            2 => "Desigualdades en salud"
            3 => "Manejo del diab&#233;tico"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec12773"
          "palabras" => array:4 [
            0 => "Immigration"
            1 => "Diabetes"
            2 => "Healthcare disparities"
            3 => "Diabetes complications"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Se sabe que hay diferencias entre los grupos de inmigrantes en lo que respecta a la prevalencia de diabetes&#44; pero no disponemos de suficiente evidencia para afirmar que&#44; una vez diagnosticada&#44; sea distinto el grado de control&#46; El objetivo de este estudio es analizar si hay diferencias en la detecci&#243;n y el grado de control de los pacientes diab&#233;ticos entre inmigrantes y aut&#243;ctonos en nuestra regi&#243;n sanitaria&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio poblacional observacional transversal que incluye a todos los pacientes diagnosticados de diabetes mellitus de tipo 2 asignados y atendidos durante 2010&#46; Se analizaron los indicadores de calidad de la diabetes y se utilizaron modelos de regresi&#243;n log&#237;stica multivariada que se ajustaron por la edad&#44; el sexo y el n&#250;mero de visitas&#46; El m&#233;todo de ajuste fue forzado y se comprob&#243; la no presencia de colinealidad mediante la curva ROC y el test de Hosmer &#38; Lemeshow&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">77&#46;999 pacientes aut&#243;ctonos &#40;6846 diab&#233;ticos&#41; y 30&#46;748 pacientes inmigrantes &#40;415 diab&#233;ticos&#41;&#46; El 8&#44;78&#37; de los pacientes aut&#243;ctonos eran diab&#233;ticos &#40;1&#44;35&#37; de los inmigrantes&#44; p &#60;0&#44;001&#41;&#46; La HbA1c &#60;7&#44;5&#37; era del 68&#44;04&#37; en la poblaci&#243;n aut&#243;ctona y del 54&#44;76&#37; en los inmigrantes&#46; Los inmigrantes tienen un riesgo un 27&#37; inferior de alcanzar el control &#243;ptimo de HbA1c &#40;OR ajustada<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;73&#41;&#46; El riesgo de tener un buen control de HbA1c fue un 30&#37; inferior en el grupo inmigrante&#46; El modelo discriminaba moderadamente &#40;ROC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;65 y contraste de Hosmer &#38; Lemeshow&#59; p &#62;0&#44;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hay un peor control y un peor registro de los indicadores de calidad en la atenci&#243;n de la diabetes mellitus en algunos grupos de inmigrantes&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ethnic differences are known to exist in the prevalence of diabetes&#44; but little is known about possible differences in the degree of diabetes control among ethnic groups&#46; The aim of this study was to determine whether there are differences in diabetes detection and control between immigrants and the autochthonous population in our health region&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We performed a cross-sectional&#44; observational&#44; population-based study of all patients diagnosed with diabetes mellitus type 2 registered and treated in 2010&#46; We analyzed diabetes quality indicators and used multivariate logistic regression models adjusted for age&#44; sex and number of visits&#46; The adjustment method was forced and the absence of collinearity was identified through the ROC curve and Hosmer and Lemeshow&#39;s test&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There were 77&#44;999 autochthonous patients &#40;6&#44;846 diabetics&#41; and 30&#44;748 immigrant patients &#40;415 diabetics&#41;&#46; A total of 8&#46;78&#37; of the autochthonous patients were diabetic versus 1&#46;35&#37; of immigrants &#40;p &#60;0&#46;001&#41;&#46; HbA1c &#60;7&#46;5&#37; was found in 68&#46;04&#37; of the native population compared with 54&#46;76&#37; of immigrants&#46; The probability of achieving optimal HbA1c control was 27&#37; lower in immigrants &#40;adjusted OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;73&#41;&#44; while the probability of achieving good HbA1c control was 30&#37; lower in the immigrant cohort&#46; The model showed moderate discrimination &#40;ROC &#61;0&#46;65 and Hosmer and Lemeshow&#39;s contrast&#44; p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diabetes control and quality indicators are poorer in some immigrant groups&#46;</p>"
      ]
    ]
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Control de los indicadores de calidad de los pacientes diab&#233;ticos inmigrantes respecto a los aut&#243;ctonos &#40;ajustado por edad&#44; sexo y n&#250;mero de visitas&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">IC95&#37;&#58; intervalo de confianza del 95&#37;&#59; DM-2&#58; diabetes mellitus de tipo 2&#59; IMC&#58; &#237;ndice de masa corporal&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Aut&#243;ctonos&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#46;999&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="6" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Inmigrantes</td><td class="td" title="\n
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                  \t\t\t\t">p<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Totalinmigrantes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Asia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Europa del Este&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Magreb&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#193;frica subsahariana&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Latinoam&#233;rica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#46;748&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;215&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#46;696&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;441&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;588&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;808&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo &#40;mujeres&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&#46;671&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;074&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">352&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;492&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;165&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">839&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;226&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">52&#44;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#44;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">51&#44;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29&#44;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55&#44;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Colesterol LDL&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara">OR de inmigrantes y zona geogr&#225;fica ajustada por edad&#44; sexo&#44; hipertensi&#243;n&#44; dislipidemia&#44; tabaquismo&#44; presi&#243;n arterial sist&#243;lica y diast&#243;lica&#44; triglic&#233;ridos&#44; riesgo cardiovascular &#40;ecuaci&#243;n de Framingham&#41;&#44; retinopat&#237;a diab&#233;tica&#44; cardiopat&#237;a y n&#250;mero de visitas el &#250;ltimo a&#241;o&#46; Los valores de OR mayores de 1 indican un mayor riesgo de tener la HbA1c bien controlada&#46;</p>"
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                      "titulo" => "Crossing the quality chasm&#46; A new health care system for the 21st century"
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La población inmigrante controla peor su diabetes que la población autóctona
Poorer diabetes control among the immigrant population than among the autochthonous population
Jorge Soler-González
Autor para correspondencia
jorgesolergonzalez@gmail.com

Autor para correspondencia.
, Josep Ramon Marsal, Caty Serna, Jordi Real, Inés Cruz, Albert López
GREDELL (Grupo de Estudio en Desigualdades en Salud de Lleida), Atención Primaria de Lleida, Institut Català de la Salut, IDIAP Jordi Gol, Universidad de Lleida, Lleida, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Espa&#241;a es el pa&#237;s de Europa que m&#225;s inmigrantes ha recibido en los &#250;ltimos a&#241;os<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; En la Regi&#243;n Sanitaria de Lleida&#44; la poblaci&#243;n inmigrante ha pasado de representar el 2&#44;6&#37; de los residentes en el a&#241;o 2000 al 19&#37; en el a&#241;o 2010<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; El impacto de la poblaci&#243;n inmigrante en el sistema sanitario espa&#241;ol ha sido importante&#44; aunque por ser todav&#237;a un fen&#243;meno reciente se ha evaluado poco&#46; Este cambio de tanta magnitud en la demograf&#237;a puede hacer aumentar las inequidades en salud&#44; definidas como las diferencias que son evitables&#44; injustas e innecesarias&#46; En 2001&#44; el American Institute of Medicine<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> describi&#243; seis dimensiones para la asistencia sanitaria de calidad&#46; Una de ellas es la equidad del sistema&#44; comprendiendo que no debe verse influida por las caracter&#237;sticas personales de sexo&#44; etnia&#44; recursos econ&#243;micos&#44; etc&#46; Sin embargo&#44; hasta la fecha&#44; la existencia de desigualdades en salud ha sido muy bien documentada en todo el mundo&#44; y de igual forma ha sucedido en nuestro pa&#237;s<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; Por ejemplo&#44; en el caso de los inmigrantes se han publicado varios art&#237;culos en Espa&#241;a que muestran claras desigualdades en el uso de los servicios sanitarios<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; de farmacia<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> y bajas laborales<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En lo que respecta al manejo de los factores de riesgo cardiovascular&#44; como ejemplo&#44; en un estudio realizado en Barcelona<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> se ha encontrado que hay un mejor control de la hipertensi&#243;n entre los aut&#243;ctonos&#44; si bien este efecto desaparece cuando se tienen en cuenta otras variables que se distribuyen de forma heterog&#233;nea entre los aut&#243;ctonos y los inmigrantes&#44; en especial la edad y el tabaquismo&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Los estudios que se realizan sobre desigualdades en salud nos indican que la calidad asistencial en ciertos colectivos tiende a ser peor que en la poblaci&#243;n aut&#243;ctona&#46; As&#237;&#44; se ha visto que se les hacen menos mamograf&#237;as&#44; se les prescriben menos betabloqueantes tras un infarto y el grado de control de la hemoglobina glucosilada o del colesterol LDL es peor en algunos pacientes diab&#233;ticos seg&#250;n su etnia<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En el caso de la diabetes&#44; una de las enfermedades cr&#243;nicas m&#225;s comunes y que supone una carga considerable tanto para los pacientes como para los sistemas de salud y la sociedad&#44; hasta la fecha se sabe que hay diferencias entre los grupos de inmigrantes en cuanto a su prevalencia<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; si bien no disponemos de suficiente evidencia para afirmar que&#44; una vez diagnosticada&#44; sea distinto el grado de control<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El objetivo de este estudio es conocer si hay diferencias en la detecci&#243;n y el control de la diabetes entre la poblaci&#243;n aut&#243;ctona y la poblaci&#243;n inmigrante en la Regi&#243;n Sanitaria de Lleida&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">M&#233;todo</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se realiz&#243; un estudio poblacional observacional y transversal entre los 260&#46;843 habitantes de la Regi&#243;n Sanitaria de Lleida que pose&#237;an la tarjeta sanitaria activa a 31 de diciembre de 2010&#44; a partir de la base de datos de la historia cl&#237;nica informatizada&#46; El requisito para pertenecer a dicho registro es hallarse empadronado en un municipio de la regi&#243;n&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Criterios de inclusi&#243;n</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se incluyeron todos los pacientes diagnosticados de diabetes mellitus de tipo 2 asignados y atendidos en la Regi&#243;n Sanitaria de Lleida&#44; al menos una vez entre el 1 de enero de 2010 y el 31 de diciembre de 2010&#46; Se excluyeron los pacientes que no ten&#237;an registrado el pa&#237;s de origen en la historia cl&#237;nica y los que no acudieron a ninguna visita durante el periodo de estudio&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Los datos considerados fueron&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Variables sociodemogr&#225;ficas&#58; pa&#237;s de origen categorizado en aut&#243;ctonos e inmigrantes &#40;variable independiente principal&#41;&#46; El grupo de inmigrantes fue desagregado en cinco grandes regiones geogr&#225;ficas &#40;Asia&#44; Europa del Este&#44; Magreb&#44; &#193;frica subsahariana y Am&#233;rica del Sur&#41;&#44; y por edad y sexo&#46; Se consideraron inmigrantes los procedentes de pa&#237;ses de renta media o baja seg&#250;n la clasificaci&#243;n del Banco Mundial basada en el producto interior bruto per c&#225;pita<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Factores de riesgo cardiovascular asociados a la diabetes&#58; hipertensi&#243;n&#44; dislipidemia&#44; microalbuminuria&#44; h&#225;bito tab&#225;quico y sobrepeso-obesidad&#44; mediante el &#237;ndice de masa corporal &#40;IMC&#41; categorizado en dos grupos &#40;&#60;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> y &#8805;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; como variables de ajuste se consideraron el riesgo cardiovascular &#40;puntuaci&#243;n de la ecuaci&#243;n de Framingham&#41;&#44; los triglic&#233;ridos &#40;mg&#47;dl&#41;&#44; el colesterol total &#40;mg&#47;dl&#41;&#44; el colesterol LDL &#40;mg&#47;dl&#41;&#44; la presi&#243;n arterial diast&#243;lica y sist&#243;lica &#40;mmHg&#41;&#44; el registro del diagn&#243;stico de hipertensi&#243;n y la dislipidemia&#46; Se consider&#243; paralelamente el diagn&#243;stico de cardiopat&#237;a si se registraba alguno de los diagn&#243;sticos I20-25 de la CIE-10 &#40;angina&#44; infarto agudo de miocardio&#44; complicaciones del infarto agudo de miocardio&#44; isquemia cr&#243;nica&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Para las variables de diagn&#243;stico de diabetes se utilizaron las recomendaciones de la American Diabetes Association de 2010<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;HbA1c &#62;6&#44;5&#37;&#44; glucemia en ayunas &#62;126<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; &#62;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl tras una sobrecarga oral de glucosa o con los s&#237;ntomas cl&#225;sicos de hiperglucemia&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Con el fin de evaluar la atenci&#243;n a los pacientes con diabetes y el control de sus posibles complicaciones&#44; se analizaron los siguientes indicadores de calidad&#58; realizaci&#243;n o no de an&#225;lisis de sangre con determinaci&#243;n de la glucosa basal&#44; determinaci&#243;n de HbA1c&#44; fondo de ojo y presi&#243;n arterial&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">La variable principal del estudio fue el buen o mal control de la diabetes seg&#250;n la &#250;ltima hemoglobina glucosilada &#40;&#60;7&#44;5&#37;&#41;&#46; Se consider&#243;&#44; adem&#225;s&#44; un buen control de la presi&#243;n arterial si la sist&#243;lica era &#60;130<span class="elsevierStyleHsp" style=""></span>mmHg y la diast&#243;lica era &#60;85<span class="elsevierStyleHsp" style=""></span>mmHg&#46; En cuanto al colesterol&#44; se valor&#243; el LDL &#60;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Tambi&#233;n se consider&#243; un IMC &#60;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; colesterol total &#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y no tener h&#225;bito tab&#225;quico&#46; Todas las variables hab&#237;an sido registradas en el &#250;ltimo a&#241;o&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Para valorar la frecuentaci&#243;n de los pacientes se agregaron todas las visitas realizadas durante el a&#241;o de estudio&#44; tanto al m&#233;dico como a la enfermera&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lisis estad&#237;stico</span><p id="par0080" class="elsevierStylePara elsevierViewall">Los datos cuantitativos se describieron mediante la media y su intervalo de confianza del 95&#37;&#46; Las variables cualitativas se describieron como frecuencias y porcentajes&#44; y se contrastaron sus diferencias entre aut&#243;ctonos e inmigrantes mediante el estad&#237;stico ji al cuadrado&#46; Se contrastaron las diferencias en el n&#250;mero de visitas entre grupos a partir de los contrastes no param&#233;tricos U de Mann-Whitney o Kruskal-Wallis&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Con el objetivo de estimar la asociaci&#243;n entre el correcto control de los diferentes par&#225;metros y la variable de inter&#233;s&#44; se utilizaron modelos de regresi&#243;n log&#237;stica y los resultados se presentaron como <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; crudas y ajustadas con su intervalo de confianza&#46; El ajuste de dicha asociaci&#243;n se realiz&#243; mediante regresi&#243;n log&#237;stica multivariada ajustando por edad&#44; sexo y n&#250;mero de visitas al m&#233;dico de cada paciente&#46; El m&#233;todo de ajuste fue forzado &#40;ENTER&#41; y se comprob&#243; la no presencia de colinealidad&#44; y posteriormente la validaci&#243;n del modelo mediante la curva ROC y el test de Hosmer &#38; Lemeshow&#46; Se repitieron los c&#225;lculos con la variable independiente de la zona geogr&#225;fica&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En todos los an&#225;lisis se utiliz&#243; el programa SPSS 15&#46;0 para Windows&#46; En todos los c&#225;lculos se consider&#243; un alfa de 0&#44;05&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#201;tica</span><p id="par0095" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el Comit&#233; &#201;tico de la Fundaci&#243;n IDIAP Jordi Gol en Atenci&#243;n Primaria&#46; Los autores certifican que cumplen los principios &#233;ticos de publicaci&#243;n y las responsabilidades &#233;ticas desarrolladas por <span class="elsevierStyleSmallCaps">gaceta sanitaria</span>&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Descripci&#243;n de la muestra</span><p id="par0100" class="elsevierStylePara elsevierViewall">La muestra fue constituida por 108&#46;747 pacientes mayores de 18 a&#241;os&#44; con registro de pa&#237;s&#44; en situaci&#243;n activa y visitados durante 1 a&#241;o &#40;28&#44;3&#37; inmigrantes&#41;&#46; La consulta a la historia cl&#237;nica identific&#243; 77&#46;999 pacientes aut&#243;ctonos &#40;6846 diab&#233;ticos&#41; y 30&#46;748 pacientes inmigrantes &#40;415 diab&#233;ticos&#41;&#46; El 8&#44;78&#37; de los aut&#243;ctonos eran diab&#233;ticos&#44; frente al 1&#44;35&#37; de los inmigrantes &#40;p &#60;0&#44;001&#41;&#46; No obstante&#44; la muestra de inmigrantes fue muy diferente a la aut&#243;ctona&#58; mayor proporci&#243;n de hombres&#44; m&#225;s j&#243;venes&#44; menor IMC&#44; menos hipertensos&#44; menos dislipid&#233;micos y m&#225;s fumadores&#46; Se observ&#243; que los procedentes de los pa&#237;ses de Europa del Este eran los m&#225;s representados &#40;34&#44;79&#37; de los inmigrantes&#41;&#44; seguidos de los del Magreb &#40;24&#44;2&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">El n&#250;mero medio de visitas al a&#241;o para los pacientes aut&#243;ctonos diab&#233;ticos fue de 11 visitas al m&#233;dico y enfermer&#237;a&#44; y en el caso de los inmigrantes diab&#233;ticos fue 10&#44;9 &#40;diferencia estad&#237;sticamente no significativa&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Registro de indicadores de control</span><p id="par0110" class="elsevierStylePara elsevierViewall">Cumpl&#237;an criterios de diabetes mellitus de tipo 2 un total de 6846 aut&#243;ctonos y 415 extranjeros &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Los par&#225;metros que se monitorizan habitualmente en los diab&#233;ticos se registraban con menor frecuencia en la poblaci&#243;n inmigrante que en la aut&#243;ctona&#44; y destacaba que en la poblaci&#243;n aut&#243;ctona diab&#233;tica se hab&#237;a determinado el colesterol total al 70&#44;8&#37; &#40;inmigrantes 54&#44;9&#37;&#41; y se hab&#237;a valorado el fondo de ojo al 27&#44;6&#37; &#40;inmigrantes 15&#44;7&#37;&#41;&#46; Se ajustaron modelos log&#237;sticos por edad y sexo para estimar la asociaci&#243;n entre ser inmigrante y la existencia de registro de cada uno de los par&#225;metros&#46; Observamos que los par&#225;metros se registraban con menor frecuencia en los inmigrantes que en los aut&#243;ctonos&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control de los pacientes diab&#233;ticos</span><p id="par0115" class="elsevierStylePara elsevierViewall">Al comparar los indicadores de calidad de los dos grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#44; observamos que hab&#237;a diferencias estad&#237;sticamente significativas entre ellos a favor de un mayor control en los aut&#243;ctonos&#46; En el caso de la HbA1c &#60;7&#44;5&#37;&#44; era del 68&#44;04&#37; en la poblaci&#243;n aut&#243;ctona y del 54&#44;76&#37; en los inmigrantes&#46; Sin embargo&#44; la presi&#243;n arterial obtuvo mayor tasa de control en los inmigrantes&#44; quienes ten&#237;an menor prevalencia de obesidad &#40;&#62;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; y los resultados fueron muy parecidos en ambos en cuanto a colesterol total &#40;&#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#44; colesterol LDL &#40;&#60;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; y microalbuminuria &#40;&#60;20<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Aun as&#237;&#44; en los inmigrantes se encontr&#243; una mayor proporci&#243;n de fumadores&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control de los indicadores de calidad seg&#250;n grupos</span><p id="par0120" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> se presentan las OR ajustadas por edad&#44; sexo y n&#250;mero de visitas estimadas para el control de cada uno de los indicadores de calidad por el hecho de ser inmigrante&#46; Podemos observar que los inmigrantes tienen un riesgo un 27&#37; inferior de alcanzar un control &#243;ptimo de la HbA1c &#40;OR ajustada<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;73&#41;&#46; No se detectaron diferencias significativas en cuanto al control del colesterol LDL&#44; la microalbuminuria y la presi&#243;n arterial diast&#243;lica&#46; En el caso de la presi&#243;n arterial sist&#243;lica&#44; el colesterol total&#44; el IMC y el tabaquismo&#44; se comprob&#243; que los inmigrantes ten&#237;an un mayor control que los aut&#243;ctonos&#44; teniendo en cuenta la edad&#44; el sexo y la frecuentaci&#243;n al centro de atenci&#243;n primaria&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Finalmente&#44; dada la heterogeneidad hallada entre el grupo inmigrante y el aut&#243;ctono&#44; se ajust&#243; un modelo considerando todas las variables analizadas &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Los factores que se asociaron de forma significativa a tener un buen control de la HbA1c &#40;&#60;7&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#41; fueron la edad&#44; el sexo&#44; la hipertensi&#243;n&#44; la dislipidemia&#44; el tabaquismo&#44; la presi&#243;n arterial&#44; los triglic&#233;ridos&#44; el riesgo cardiovascular &#40;Framingham&#41; y la cardiopat&#237;a &#40;ICD-10&#58; I20-I25&#41;&#46; Una vez ajustado por las variables mencionadas&#44; se estim&#243; que el riesgo de tener un buen control de HbA1c era un 30&#37; inferior en el grupo inmigrante que en el aut&#243;ctono&#44; de lo que se desprende que los inmigrantes tienen una menor probabilidad de alcanzar un control &#243;ptimo&#46; El modelo discriminaba moderadamente &#40;curva ROC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;65&#41; y estaba bien calibrado &#40;contraste de Hosmer &#38; Lemeshow&#59; p &#62;0&#44;05&#41;&#46; Teniendo en cuenta la zona geogr&#225;fica de origen&#44; los pacientes latinoamericanos y de Europa del Este se comportaban de forma parecida a los aut&#243;ctonos&#46; En el caso de los inmigrantes de origen asi&#225;tico&#44; magreb&#237; o subsahariano&#44; ten&#237;an un riesgo estad&#237;sticamente inferior de alcanzar el control de la HbA1c&#44; o lo que es lo mismo&#44; presentaban determinaciones de HbA1c m&#225;s altas&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados relevantes</span><p id="par0130" class="elsevierStylePara elsevierViewall">Hemos observado que a los pacientes diab&#233;ticos de origen inmigrante se les determinan los par&#225;metros de calidad asistencial con menor frecuencia que a los aut&#243;ctonos&#44; ajustando los valores por edad&#44; sexo y frecuentaci&#243;n&#46; Tambi&#233;n hemos comprobado&#44; al comparar ambos colectivos&#44; que los inmigrantes tienen peores valores de HbA1<span class="elsevierStyleHsp" style=""></span>C y&#44; sin embargo&#44; su presi&#243;n arterial est&#225; mejor controlada que la de los aut&#243;ctonos&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La prevalencia de diabetes mellitus de tipo 2 en la poblaci&#243;n inmigrante es del 1&#44;35&#37; y en los aut&#243;ctonos del 8&#44;78&#37;&#46; La menor prevalencia en la poblaci&#243;n inmigrante se justifica por la menor edad de esta poblaci&#243;n&#44; con una media de 35&#44;5 a&#241;os&#44; y es similar a las publicadas en el estudio REGICOR al estudiar una poblaci&#243;n cercana y parecida a la nuestra<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comparaci&#243;n con otros estudios publicados</span><p id="par0140" class="elsevierStylePara elsevierViewall">Hasta la fecha sab&#237;amos que hab&#237;a diferencias en la prevalencia de diabetes entre la poblaci&#243;n extranjera y la aut&#243;ctona<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#44; y son numerosos los factores que pueden contribuir a ello<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; entre los que destacan las caracter&#237;sticas f&#237;sicas&#44; el tipo de dieta y la actividad realizada&#46; Tambi&#233;n se ha detectado que los valores de HbA1c pueden ser distintos entre las diversas etnias&#44; esencialmente por cuestiones biol&#243;gicas<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Por ejemplo&#44; en Londres se ha encontrado que las poblaciones asi&#225;tica<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> y africana<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> tienen m&#225;s riesgo de desarrollar diabetes que la poblaci&#243;n europea&#44; aunque de forma parad&#243;jica pueden tener cifras m&#225;s altas de colesterol HDL y m&#225;s bajas de triglic&#233;ridos<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Conviene recordar que estas diferencias empiezan en la infancia y se mantienen cuando llegan a la vida adulta<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los pacientes inmigrantes tienen un peor control a pesar de acudir a las consultas con igual frecuencia que los aut&#243;ctonos&#46; Estos datos son concordantes con los aportados por otros autores<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#46; Por ejemplo&#44; un trabajo poblacional que analiz&#243; 4309 pacientes diab&#233;ticos de atenci&#243;n primaria en Reino Unido hall&#243;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> como nosotros&#44; diferencias en el seguimiento de la presi&#243;n arterial&#44; el colesterol y la HbA1c&#46; En la poblaci&#243;n negra&#44; los pacientes ten&#237;an menos probabilidad de lograr los objetivos de prevenci&#243;n que la poblaci&#243;n aut&#243;ctona&#44; a pesar de ser atendidos por los mismos profesionales&#46; Tambi&#233;n al analizar el resultado encontrado en poblaci&#243;n asi&#225;tica se observaron diferencias similares&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Wilf-Miron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> evaluaron en Israel las disparidades de salud de 75&#46;000 pacientes diab&#233;ticos y hallaron diferencias en la prevalencia de la diabetes y en su posterior tratamiento&#44; siempre en detrimento de ciertos grupos socioecon&#243;micos y &#233;tnicos&#46; En consecuencia&#44; se evidenciaron una vez m&#225;s las desigualdades en salud que sufren algunos grupos&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Carrasco-Garrido et al<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> atribuyen estas diferencias en el control de la diabetes a la existencia de un concepto de salud y enfermedad por parte del colectivo inmigrante diferente al de la poblaci&#243;n aut&#243;ctona<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46; Estos estudios encuentran que la poblaci&#243;n inmigrante tiene una mejor percepci&#243;n de buena salud y presentan mejores estilos de vida&#46; Como explican Gimeno-Feliu et al&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> es posible que la frecuentaci&#243;n del sistema sanitario responda a necesidades de atenci&#243;n por enfermedad aguda&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Deber&#237;amos aceptar que la salud y la enfermedad son conceptos construidos socialmente y&#44; por lo tanto&#44; var&#237;an mucho seg&#250;n el entorno sociocultural&#46; Tal y como nosotros tenemos organizado el sistema sanitario&#44; parece que las actividades preventivas no son prioritarias para los inmigrantes al no reconocerlas como necesidades<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&#46; Tanto la barrera idiom&#225;tica como los factores culturales pueden afectar a la percepci&#243;n de enfermedad y&#44; por consiguiente&#44; a la estrategia de autocontrol de la diabetes<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Tambi&#233;n es cierto que no todas las diferencias observadas son atribuibles a las caracter&#237;sticas individuales de los pacientes extranjeros&#44; puesto que las caracter&#237;sticas de los m&#233;dicos que les atienden influyen notablemente en el &#233;xito o el fracaso de las visitas<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Igualmente&#44; hemos observado que los inmigrantes tienen un mejor control de la presi&#243;n arterial que los diab&#233;ticos aut&#243;ctonos&#44; hallazgo que coincide con otros estudios recientes realizados en Espa&#241;a<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#59; sin embargo&#44; hay autores extranjeros que han aseverado exactamente lo contrario&#44; explicando que las desigualdades del sistema sanitario en el control de la presi&#243;n arterial han mejorado en las &#250;ltimas d&#233;cadas&#44; pero no en todos los grupos por igual<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#44; como en los pacientes de raza negra y en la poblaci&#243;n asi&#225;tica&#44; que presentan cifras m&#225;s altas que la poblaci&#243;n blanca&#46; Una posible explicaci&#243;n ser&#237;a lo que la antropolog&#237;a americana denomin&#243; <span class="elsevierStyleItalic">Hispanic paradox</span><a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;34</span></a>&#44; la situaci&#243;n en la cual ciertos grupos deprimidos socialmente ten&#237;an mucho mejores resultados en salud que lo que era previsible&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Limitaciones</span><p id="par0175" class="elsevierStylePara elsevierViewall">Como limitaciones de nuestro estudio debemos destacar que la selecci&#243;n de la muestra no es representativa de toda la poblaci&#243;n inmigrante de la regi&#243;n&#44; sino de la empadronada&#44; puesto que todos los datos de esta investigaci&#243;n fueron extra&#237;dos de la base de historias cl&#237;nicas&#44; cuyas limitaciones ya fueron estudiadas por Ribera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> En dicho an&#225;lisis&#44; estos autores concluyen que los estudios a partir de bases de datos administrativas infraestiman determinadas prevalencias&#44; si bien sus asociaciones pueden estimarse de manera satisfactoria&#46; Al trabajar con un n&#250;mero de efectivos tan alto&#44; aseguramos una potencia estad&#237;stica dif&#237;cilmente alcanzable en estudios observacionales prospectivos&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Tambi&#233;n nos parece importante destacar que podr&#237;a haber cierto sesgo de selecci&#243;n de la muestra al no incluir aquellos pacientes que no acudieron a ninguna visita&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Por otro lado&#44; no dispusimos de los tratamientos farmacol&#243;gicos que nos permitieran contrastar las variables estudiadas con los tratamientos recibidos&#46; Tampoco incluimos en el estudio el tiempo transcurrido desde el diagn&#243;stico&#44; variable que tiene un gran inter&#233;s en el pron&#243;stico de esta enfermedad&#46; Consideramos que el tiempo transcurrido desde el diagn&#243;stico no deber&#237;a afectar a las tasas de registro de la informaci&#243;n&#44; dado que con independencia del tiempo desde el diagn&#243;stico los pacientes deber&#237;an tener registradas el &#250;ltimo a&#241;o las variables de estudio&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Otra de las limitaciones es la falta de informaci&#243;n sobre los datos socioecon&#243;micos de los pacientes&#44; lo que dificulta el an&#225;lisis de dicho factor en el control de la glucemia&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusiones</span><p id="par0195" class="elsevierStylePara elsevierViewall">La conclusi&#243;n principal de nuestro estudio es que el control de los indicadores de calidad en la atenci&#243;n de la diabetes mellitus es m&#225;s deficiente en algunos grupos de inmigrantes que en los aut&#243;ctonos&#46; Los hallazgos nos muestran la necesidad de monitorizar los resultados en estos grupos poblacionales y evaluar las intervenciones necesarias para mejorar los resultados en salud&#46; Tambi&#233;n ser&#237;a interesante conocer en profundidad los factores que influyen en estas diferencias&#44; mediante la realizaci&#243;n de estudios cualitativos&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Contribuciones de autor&#237;a</span><p id="par0210" class="elsevierStylePara elsevierViewall">Todos los autores participaron en el dise&#241;o&#44; la adquisici&#243;n de los datos y la escritura del art&#237;culo o su revisi&#243;n cr&#237;tica con importantes contribuciones intelectuales&#46; Todos los autores revisaron y aprobaron la versi&#243;n final para su publicaci&#243;n&#46; J&#46;R&#46; Marsal y A&#46; L&#243;pez realizaron el an&#225;lisis estad&#237;stico&#46; J&#46; Soler-Gonz&#225;lez es el responsable del art&#237;culo&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> fue utilizada por J&#46; Soler-Gonz&#225;lez en la ponencia sobre desigualdades en salud de la poblaci&#243;n inmigrante del XXIII Congreso CAMFIC realizado en Matar&#243; el d&#237;a 6 de noviembre de 2011&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Financiaci&#243;n</span><p id="par0220" class="elsevierStylePara elsevierViewall">Nuestro grupo ha recibido financiaci&#243;n del 6&#232; Ajut a l&#8217;impuls d&#8217;estrat&#232;gies de recerca a l&#8217;Atenci&#243; Prim&#224;ria de l&#8217;IDIAP Jordi Gol&#46; GREDELL&#58; Grup de Recerca en Desigualtats en Salut a Lleida&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflictos de intereses</span><p id="par0225" class="elsevierStylePara elsevierViewall">Ninguno&#46;</p></span></span>"
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              "titulo" => "Control de los pacientes diab&#233;ticos"
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              "titulo" => "Control de los indicadores de calidad seg&#250;n grupos"
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    "fechaRecibido" => "2011-10-11"
    "fechaAceptado" => "2011-12-27"
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            2 => "Desigualdades en salud"
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    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Se sabe que hay diferencias entre los grupos de inmigrantes en lo que respecta a la prevalencia de diabetes&#44; pero no disponemos de suficiente evidencia para afirmar que&#44; una vez diagnosticada&#44; sea distinto el grado de control&#46; El objetivo de este estudio es analizar si hay diferencias en la detecci&#243;n y el grado de control de los pacientes diab&#233;ticos entre inmigrantes y aut&#243;ctonos en nuestra regi&#243;n sanitaria&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio poblacional observacional transversal que incluye a todos los pacientes diagnosticados de diabetes mellitus de tipo 2 asignados y atendidos durante 2010&#46; Se analizaron los indicadores de calidad de la diabetes y se utilizaron modelos de regresi&#243;n log&#237;stica multivariada que se ajustaron por la edad&#44; el sexo y el n&#250;mero de visitas&#46; El m&#233;todo de ajuste fue forzado y se comprob&#243; la no presencia de colinealidad mediante la curva ROC y el test de Hosmer &#38; Lemeshow&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">77&#46;999 pacientes aut&#243;ctonos &#40;6846 diab&#233;ticos&#41; y 30&#46;748 pacientes inmigrantes &#40;415 diab&#233;ticos&#41;&#46; El 8&#44;78&#37; de los pacientes aut&#243;ctonos eran diab&#233;ticos &#40;1&#44;35&#37; de los inmigrantes&#44; p &#60;0&#44;001&#41;&#46; La HbA1c &#60;7&#44;5&#37; era del 68&#44;04&#37; en la poblaci&#243;n aut&#243;ctona y del 54&#44;76&#37; en los inmigrantes&#46; Los inmigrantes tienen un riesgo un 27&#37; inferior de alcanzar el control &#243;ptimo de HbA1c &#40;OR ajustada<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;73&#41;&#46; El riesgo de tener un buen control de HbA1c fue un 30&#37; inferior en el grupo inmigrante&#46; El modelo discriminaba moderadamente &#40;ROC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;65 y contraste de Hosmer &#38; Lemeshow&#59; p &#62;0&#44;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hay un peor control y un peor registro de los indicadores de calidad en la atenci&#243;n de la diabetes mellitus en algunos grupos de inmigrantes&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ethnic differences are known to exist in the prevalence of diabetes&#44; but little is known about possible differences in the degree of diabetes control among ethnic groups&#46; The aim of this study was to determine whether there are differences in diabetes detection and control between immigrants and the autochthonous population in our health region&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We performed a cross-sectional&#44; observational&#44; population-based study of all patients diagnosed with diabetes mellitus type 2 registered and treated in 2010&#46; We analyzed diabetes quality indicators and used multivariate logistic regression models adjusted for age&#44; sex and number of visits&#46; The adjustment method was forced and the absence of collinearity was identified through the ROC curve and Hosmer and Lemeshow&#39;s test&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There were 77&#44;999 autochthonous patients &#40;6&#44;846 diabetics&#41; and 30&#44;748 immigrant patients &#40;415 diabetics&#41;&#46; A total of 8&#46;78&#37; of the autochthonous patients were diabetic versus 1&#46;35&#37; of immigrants &#40;p &#60;0&#46;001&#41;&#46; HbA1c &#60;7&#46;5&#37; was found in 68&#46;04&#37; of the native population compared with 54&#46;76&#37; of immigrants&#46; The probability of achieving optimal HbA1c control was 27&#37; lower in immigrants &#40;adjusted OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;73&#41;&#44; while the probability of achieving good HbA1c control was 30&#37; lower in the immigrant cohort&#46; The model showed moderate discrimination &#40;ROC &#61;0&#46;65 and Hosmer and Lemeshow&#39;s contrast&#44; p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diabetes control and quality indicators are poorer in some immigrant groups&#46;</p>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Control de los indicadores de calidad de los pacientes diab&#233;ticos inmigrantes respecto a los aut&#243;ctonos &#40;ajustado por edad&#44; sexo y n&#250;mero de visitas&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">IC95&#37;&#58; intervalo de confianza del 95&#37;&#59; DM-2&#58; diabetes mellitus de tipo 2&#59; IMC&#58; &#237;ndice de masa corporal&#46;</p>"
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                  \t\t\t\t">Aut&#243;ctonos&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#46;999&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Inmigrantes</td><td class="td" title="\n
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                  \t\t\t\t">p<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Totalinmigrantes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Europa del Este&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Inmigrantes</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ORa &#40;IC95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total inmigrantes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Europa del Este&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Magreb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;frica subsahariana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Latinoam&#233;rica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#46;846&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>415&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>114&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>156&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HbA1c&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#44;64&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#44;84&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#44;75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#44;28&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#44;92&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#44;31&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#44;03&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;61 &#40;0&#44;48-0&#44;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#44;05&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#44;06&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#44;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#44;47&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#44;33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#44;31&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&#44;92&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;31 &#40;0&#44;22-0&#44;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">93&#44;98&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">85&#44;06&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#44;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">89&#44;47&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">83&#44;33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#44;31&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&#44;92&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;32 &#40;0&#44;23-0&#44;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Peso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#44;14&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#44;06&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#44;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#44;47&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#44;33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#44;38&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#44;12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;43 &#40;0&#44;31-0&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IMC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;007&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;48 &#40;0&#44;35-0&#44;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tabaquismo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">86&#44;54&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">68&#44;83&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;31 &#40;0&#44;24-0&#44;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Colesterol total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;49 &#40;0&#44;39-0&#44;61&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Colesterol LDL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;50 &#40;0&#44;40-0&#44;61&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Fondo de ojo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;43 &#40;0&#44;32-0&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Microalbuminuria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&#44;19&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;80 &#40;0&#44;58-1&#44;11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;181&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Glucosa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">73&#44;88&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55&#44;42&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">54&#44;39&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55&#44;77&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Para inmigrante &#40;s&#237;&#47;no&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Para zona geogr&#225;fica</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;IC95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;IC95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;IC95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Inmigrante &#40;s&#237;&#47;no&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;45-0&#44;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;009&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;0&#44;45-0&#44;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Zona geogr&#225;fica &#40;ref&#46; Espa&#241;a&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;004&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">0&#44;014&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#40;0&#44;01-0&#44;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Europa del Este&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#44;74-2&#44;90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Magreb&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#44;30-0&#44;90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#193;frica subsahariana&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#44;21-1&#44;20&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Latinoam&#233;rica&nbsp;\t\t\t\t\t\t\n
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