Juanjo Zamora: “Emergency waiting rooms are full of people who need social resources”

Doctor in Nursing, he is an expert in fragility, a topic to which he dedicated his doctoral thesis, awarded by the Catalan Society of Family and Community Medicine

The Catalan Society of Family and Community Medicine (CAMFiC) has recognized, ex aequo, the doctoral thesis of the nurse Juanjo Zamora as the best of 2023 during the presentation of its annual awards at the end of the academic year of the Academy of Sciences Doctors from Catalonia and the Balearic Islands. This is the first doctoral thesis in the field of nursing recognized by CAMFiC. The work deals with the approach to frailty in Primary Care and its results will serve to adapt care to people with complex or advanced chronicity according to their physical, psychological and social situation. In this interview, Dr. Zamora tells us about his research.

Why are you interested in studying fragility?

In my work in a home care unit in Barcelona I detected the need to stratify the population we served. The aging we are experiencing means that we increasingly have older people, who have chronic diseases that are often accompanied by dependency and multimorbidity. This mix means that complex care needs appear, but our care model is very homogeneous and has difficulty to adapt caring to the needs of each person. We don't have to treat every situation in the same way in every case, but we must be able to offer each person what they need, according to their situation.

And how did you approach this issue in your doctoral thesis?

The thesis deals with the care of frailty in the environment of Primary Care and responds to this need to adapt the care of fragile people to their situation.

In 2017 I knew a tool that was very much in line with what we needed. It was the Fràgil-VIG, a multidimensional instrument for assessing frailty that stratifies the population, designed by the geriatrician Jordi Amblàs, based on the comprehensive geriatric assessment, which is now recommended by the Catalan Ministry of Health. The first line of study of the thesis was to evaluate this instrument, which had been developed and tested in the hospital environment, in home care. This line of research made it possible to provide new evidence of its validity for use in Primary Care. It has also allowed us to identify six profiles of frailty in people cared at home that allow a more adjusted care planning to individual needs.

The second line of research was to identify what had been published in the world about multidimensional instruments for the assessment of frailty. We initiated a systematic psychometric review of articles that discussed tools with this holistic perspective, which consider physical, psychological and social factors. The main instruments have been developed in Europe, Canada and Asia, which are the regions of the world where the aging population is increasing the most. The pandemic came and we had to redo this study and, instead of taking all the instruments we had identified, we focused on the most cited instrument in previous reviews, the Tilburg Frailty Indicator, developed in the Netherlands. We analysed the strengths and weaknesses of this tool.

What were the conclusions of the analysis of this reference instrument?

The Tilburg considers the comprehensive approach to health, and contemplates the physical, cognitive and social dimensions. We have seen that in this instrument the first dimension is very robust, the cognitive one works moderately and would need revision, and the social part is the one with the least robustness. We published the results in Aging Research Reviews, the first reference journal in geriatrics and gerontology, and the author who developed the Tilburg indicator, Dr. Gobbens, a Dutch nurse, immediately contacted us to learn about our work. He fitted well the criticism, which was constructive, because there are some knowledge gaps in several relevant measurement properties of the instrument.

What results have you obtained from the evaluation of the effectiveness of Fràgil-VIG in Primary Care?

We have detected strengths and weaknesses in this instrument and have provided new evidence that reinforces its recommendation for use in Primary Care. This has served to consolidate the tool and demonstrate that it is a valid instrument for the first level of care. The stratification of people cared for by levels of frailty is an advance, but, nevertheless, we detected that within the same level they also detected heterogeneity. For this reason, we designed a complex cluster analysis with big data techniques from all the multidimensional variables and identified six frailty profiles (one corresponding to initial frailty, three to intermediate and two to advanced), which allow care planning more adjusted to individual needs.

What are the particularities of fragility in our environment?

If we have this biopsychosocial view, social determinants have a huge impact on the health and vulnerability of the person. Every day we see news about investments in very expensive health technologies, which are oriented to satisfy the needs of few people and, on the other hand, we are not offering the most basic social resources to many people who need them: adequate nutrition, support... This is not high technology, and it is much cheaper. Unfortunately, these are social resources that respond to a health need that is not sufficiently resolved. Emergency waiting rooms are full of people with social problems.

Now that we are in the age of aging, the solution must come from this community vision. Our health system is integrative, but, on the other hand, the social system is not so much, and it ends up depending on the resources of each municipality. The Barcelona City Council has an economic capacity that the city council next door does not have, and you may find that a person who lives on one side of the street has services and the person who lives on the other side does not. This is not fair. We should bet more on the social side and on its coordination with health care.

Is there any model of health and social care in our environment that is exemplary?

At European level and within Catalonia itself there are interesting experiences. For example, here, in the ICS North Metropolitan area, the ProPCC model has been created, which focuses on the identification of people with advanced chronic diseases and pivots on Primary Care, which gives great importance to network work with different healthcare and social levels, and which has been recognized as good practice both by the Catalan Ministry of Health and at European level.

What influence has the pandemic had on attention to frailty?

It has highlighted the ageism of the system. In Madrid we saw how during the pandemic instructions were given to not send people who lived in nursing homes over a certain age to hospitals. In Catalonia, criteria were also adopted that limited access to ICUs to people according to age. This was a mistake. From this experience we have learned that the criteria for indicating intensive care, or certain therapies should not be age, but the individual situation.

There are aspects such as therapeutic treatment and quaternary prevention that have a lot to do with addressing fragility. How are these issues integrated into the models you have studied?

The Fràgil-VIG index helps in this regard, because it stratifies by levels of frailty. In the case of a robust person, the aim of care will be to get him cured, in a person who is in an intermediate situation, the aim will be to improve or maintain his functionality and the one in which he is in a situation of very advanced frailty, the main goal of care will be comfort and well-being. The model gives an objective score that provides with a common language.

How do you see the situation of nursing research?

For nurses doing research is difficult for several reasons. One of these reasons is that, as a profession, Nursing is younger than Medicine and we are not as used to doing research. Another reason is that it is an eminently female profession; almost nine out of ten nurses are women, and among women the phenomenon of double presence is, unfortunately, much more common, which implies that they take on more domestic tasks than men and this makes it difficult for them to dedicate themselves to research, which requires many hours and a lot of institutional and family support.

The hours my wife has filled in for me at home are not paid. I hope to be able to return it one day. She is also a nurse and would be delighted if she could do the PhD as well. I owe a lot to my wife.

How do you see the IDIAPJGol?

Doing research is not a personal success, but a collective one. For those who want to do research, I recommend that they surround themselves with a team of qualified people, who can help you, who know more than you. IDIAP provides a lot of support in this. I contacted Edurne Zabaleta, who is a research nurse at the IDIAP, who has been my thesis director. She demanded a lot from me, but I learned a lot from her. It has helped me to ask myself questions, to pose challenges and to contact people and institutions that would have been difficult for me to reach on my own. I am very grateful to him for the work he has done.

There are other things that could go well, such as being able to integrate into research groups. In this sense although I have knocked on doors, it has not been possible for me to join IDIAP groups that address the same type of research that I do. I think this could be improved.

In any case, the balance has been very positive. The IDIAP has allowed me to enjoy predoc scholarships, both financial and for intensification. The economy is important, because the publications are not cheap, but the intensification ones are too, because they free health professionals from the care work. Thanks to this I was able to enjoy the thesis. Otherwise, he would have suffered.