Caracterización y evaluación de adherencia al programa Get With The Guidelines en pacientes con insuficiencia cardíaca aguda en un hospital de Bogotá, 2016-2018: Cohorte HUN-ICA

Introducción: la adherencia a estándares de manejo en insuficiencia cardiaca como la iniciativa Get With the Guidelines (GWTG) de la AHA puede disminuir los reingresos y mortalidad. Objetivo: describir las características clínicas de pacientes hospitalizados por insuficiencia cardiaca aguda y evaluar la adherencia a estándares de práctica clínica del programa "Get With The Guidelines", en un hospital universitario de Bogotá. Materiales y métodos: estudio observacional de la cohorte retrospectiva HUN-ICA correspondiente a 493 pacientes adultos hospitalizados entre abril 2016 y diciembre 2018 por insuficiencia cardiaca aguda, se registraron variables clínicas, tratamiento, mortalidad, reingresos y se evaluó adherencia a estándares de calidad del programa GWTG. Resultados: 52,1 % de la población fueron mujeres con una media de edad 75 años y el 67,8 % con FEVI >40 %. La etiología más común fue hipertensiva 58,5 % y la mayor causa de descompensación infecciosa (28,8 %). Aumentó la adherencia al uso de betabloqueadores en pacientes con fracción de eyección reducida al egreso de 46 % respecto al ingreso y al uso de antagonistas de receptor mineralocorticoide en pacientes con FEVI reducida de 61,1 %. Discusión: la cohorte evaluada presentó un perfil hemodinámico, clínico y adherencia en el manejo similar a cohortes nacionales. Las dosis subóptimas de la medicación al egreso justifican la necesidad de clínicas ambulatorias de insuficiencia cardíaca. Conclusiones: Se encontró menor adherencia para uso y dosis óptimas de betabloqueadores y antagonista mineralocorticoide que la de la cohorte GWTG, con incremento del uso de terapia farmacológica entre el ingreso y el egreso hospitalario.

Introduction: adherence to management standards in heart failure such as the AHA´s Get With the Guidelines-Heart failure initiative can reduce readmissions and mortality. Objective: To describe the clinical characteristics of patients hospitalized for acute heart failure and to assess adherence to program quality standards of the Get With The Guidelines Program in a university hospital in Bogotá. Methods: observational, descriptive and retrospective HUN-ICA cohort study. 493 adult patients hospitalized for acute heart failure, between April 2016 to December 2018. Clinical variables, treatment, mortality, readmissions and adherence to program quality standards defined by the GWTG program criteria were evaluated. Results: 52,1 % of the population were women, mean age was 75 years, (67,8 %) cases of heart failure with LVEF > 40 %. The most common etiology of heart failure was hypertensive (58,5 %). The most frequent etiology of decompen- sation was infectious (28,8 %). Adherence to beta-blockers use increased in patients with reduced ejection fraction at discharge of 46 %, and to the use of mineralocorticoid receptor antagonists in 61,1 %, compared to admission. Discussion: the evaluated cohort presented a hemodynamic, clinical profile and adherence similar to colombian cohorts. Suboptimal doses of medication upon discharge justify the need for outpatient heart failure clinics. Conclusions: lower adherence for use and optimal doses of beta-blockers and mineralocorticoid receptor antagonists than GWTG cohort was found, with increased use of guidelines recommended pharmacological therapy between hospital admission and discharge.

Thirty-day unplanned readmission after spine surgery: analysis of 650 cases / Readmissão não planejada em 30 dias após cirurgias da coluna: análise de 650 casos / Reingreso no planificado a los 30 días después de cirugías de la columna: análisis de 650 casos

ABSTRACT: Objective: Postoperative readmission rates can be used to assess hospital care quality. The rates of unplanned readmission within 30 days after spine surgery are variable in the literature, and no studies have evaluated such rates in a single Latin American center. This study aimed to assess the rate of unplanned hospital readmission within 30 days after a spine surgery at a single Brazilian institution and to identify possible risk factors. Methods: Patients who underwent spine surgery at a single private hospital between January 2018 and December 2020 were retrospectively analyzed, and those with unplanned readmissions within 30 days of discharge were identified. Risk factors were determined, and the reoperation rate was assessed. Results: 650 patients were included in the analysis, and 74 (11.28%) were readmitted within 30 days after surgery. Higher readmission rates were observed after vertebroplasty and surgeries involving spinal or bone tumors. The risk factors found in the series were older age, longer hospital stays, higher ASA scores, instrumented surgeries, diabetes mellitus, and surgeries involving primary or secondary spinal tumors. The most common causes of unplanned readmission were infection and pain. Of the readmissions, 28.37% required a return to the operating room. Conclusions: This study suggests infection and pain management were the most common causes of unplanned readmission after spine surgery. Strategies to improve perioperative and postoperative care are required to reduce unplanned readmissions. Level of Evidence III; Retrospective Comparative Study.

RESUMO: Objetivo: As taxas de readmissão pós-operatórias podem ser usadas para avaliação da qualidade assistencial hospitalar. As taxas de readmissão não planejada em 30 dias após cirurgias de coluna são variáveis na literatura, e não há estudos avaliando tais taxas em centros únicos da América Latina. Este estudo teve como objetivo avaliar as taxas de readmissões não planejadas em 30 dias após cirurgias de coluna em uma única instituição brasileira e identificar possíveis fatores de risco. Métodos: Pacientes submetidos a cirurgias de coluna em um único hospital privado entre janeiro de 2018 e dezembro de 2020 foram avaliados retrospectivamente, e aqueles readmitidos dentro de 30 dias foram identificados. Fatores de risco foram determinados e a taxa de reoperação foi avaliada. Resultados: 650 pacientes foram incluídos na análise, e 74 (11,28%) foram readmitidos dentro de 30 dias após a cirurgia. Maiores taxas de readmissão foram observadas após vertebroplastia e cirurgias envolvendo tumores espinhais ou tumores ósseos. Os fatores de risco encontrados em nossa série foram idade mais elevada, maior tempo de hospitalização, maior escore ASA, cirurgias com instrumentação, diabetes mellitus e cirurgias envolvendo tumores vertebrais primários ou secundários. As causas mais comuns de readmissão não planejada foram infecção e dor. Dentre os pacientes reinternados, 28,37% necessitaram de reoperação. Conclusões: Este estudo sugere que infecção e manejo de dor foram as causas mais comuns de readmissão não planejada após cirurgias de coluna. Estratégias para melhorar os cuidados pre e pós-operatórios são necessárias para reduzir readmissões não planejadas. Nível de Evidência III; Estudo Retrospectivo Comparativo.

RESUMEN: Objetivo: Las tasas de reingreso después de la cirugía de columna son variables y ningún estudio ha evaluado tales tasas en un solo centro latinoamericano. Este estudio tuvo como objetivo evaluar la tasa de reingreso hospitalario no planificado dentro de los 30 días posteriores a la cirugía de columna en una sola institución brasileña e identificar posibles factores de riesgo. Métodos: Se analizaron retrospectivamente los pacientes que se sometieron a cirugía de columna en un solo hospital entre enero de 2018 y diciembre de 2020, y se identificaron aquellos con reingresos no planificados dentro de los 30 días posteriores al alta. Se determinaron los factores de riesgo y se evaluó la tasa de reoperación. Resultados: En el análisis se incluyeron un total de 650 pacientes, y 74 (11,28%) reingresaron dentro de los 30 días posteriores a la cirugía. Se observaron tasas de reingreso más altas después de la vertebroplastia y las cirugías que involucraron tumores espinales u óseos. Los factores de riesgo encontrados en nuestra serie fueron la edad avanzada, la estancia hospitalaria más prolongada, las puntuaciones ASA más altas, las cirugías instrumentadas, la diabetes mellitus y las cirugías de tumores espinales. Las causas más frecuentes de reingreso fueron la infección y el dolor. De los reingresos, el 28,37% requirieron volver al quirófano. Conclusiones: Este estudio sugiere que la infección y el manejo del dolor fueron las causas más comunes de reingreso. Se requieren estrategias para mejorar la atención perioperatoria y posoperatoria y así reducir las readmisiones no planificadas. Nivel de Evidencia III; Estudio comparativo retrospectivo.

Determinación de los factores asociados con el reingreso temprano de pacientes con enfermedad mental en dos ciudades de Colombia durante 2018 / Determination of Factors Associated with Early Readmission of Patients with Mental Illness in Two Cities in Colombia During 2018

RESUMEN Introducción: La rehospitalización temprana en unidades de salud mental (USM) es la necesidad de hospitalización de un paciente en los primeros 30 días tras el alta, principalmente por descompensación recurrente de su enfermedad mental. Este fenómeno se relaciona con un peor pronóstico y tiene impacto en el entorno familiar, social y laboral. El ausentismo laboral y las estancias hospitalarias adicionales son gastos para el sistema de salud y de empleo que han hecho de la rehospitalización un fenómeno de especial interés. El presente estudio se llevó a cabo con el objetivo de explorar los factores asociados con el reingreso de los pacientes con enfermedad psiquiátrica atendidos en 2 USM en 2018, así como aquellos modificables que actúen como protección contra esta condición. Métodos: Estudio observacional descriptivo con componente analítico de tipo casos y controles en 2 USM de distintas ciudades de Colombia. Se obtuvo información por medio de una ficha de recolección de datos tomados de los registros de historias clínicas de los pacientes que ingresaron entre el 1 de enero y el 31 de diciembre de 2018. La recolección de datos se hizo del 20 de febrero al 27 de mayo de 2019. Compusieron la muestra todos los pacientes que cumplían los criterios de reingreso temprano en ambas instituciones. El grupo de estudio estuvo conformado por 113 pacientes: 28 casos y 85 controles, emparejados por las variables edad, sexo, lugar de hospitalización y diagnóstico. Resultados: En las 2 USM hospitalarias, los diagnósticos encontrados fueron: depresión (15,5%), trastorno afectivo bipolar (33,1%) y esquizofrenia (37,3%); en Bogotá la más prevalente fue la depresión (31,1%) y en Tunja, la esquizofrenia (44,8%). Para ambas instituciones, el factor que más se asocia con el reingreso es el consumo de alcohol, pero otras variables de tratamiento, núcleo familiar e intervención individual también se asociaron con mayor probabilidad de reingreso temprano. Conclusiones: Se pudo demostrar que el uso de antipsicóticos atípicos y/o de depósito, las hospitalizaciones de más de 15 días y la prescripción de menos de 3 medicamentos al alta disminuyen el número de reingresos tempranos en las USM.

ABSTRACT Introduction: Early rehospitalisation in mental health units (SMHUs) is when a patient needs to be readmitted in the first 30 days after receiving discharge, and is mainly due to recurrent decompensation of their mental illness. This phenomenon is related to a worse prognosis and has an impact on the family, social and work environment. Absenteeism from work and additional hospital time are expenses for the health and employment system which have made rehospitalisation a phenomenon of special interest. The present study was carried out with the objective of exploring the factors associated with the readmission of patients with psychiatric illnesses treated in two MHUs during 2018, as well as those modifiable factors that act as protection for this condition. Methods: Observational, descriptive study with analytical component of cases and controls in two MHUs in different cities of Colombia. Information was obtained by collecting data from the medical records of patients who were admitted between 1 January 2018 and 31 December 2018. The data were collected between 20 February and 27 May 2019. The sample was composed of all the patients who met the criteria for early readmission in both institutions. The study group consisted of 113 patients: (28 cases and 85 controls), matched by the variables: age, sex, place of hospitalisation and diagnosis. Results: In the two hospital MHUs the diagnoses found were: depression (15.5%), bipolar affective disorder (33.1%) and schizophrenia (37.3%). In Bogotá, the most prevalent was depression (31.1%) and, in Tunja, it was schizophrenia (44.8%). For both institutions, the factor most associated with readmission was alcohol consumption, but other variables of treatment, family nucleus, and individual intervention were also associated with a greater probability of early readmission. Conclusions: It was possible to demonstrate that the use of atypical and/or depot antipsychotics, hospitalisations longer than 15 days, and prescriptions of less than three drugs at discharge, reduce the number of early readmissions to MHUs.

Efecto de una intervención de alta programada sobre los reingresos de pacientes con insuficiencia cardíaca: estudio APRICA / Effect of a planned discharge intervention on readmissions of patients with heart failure APRICA study / Efeito de uma intervenção de alta planejada nas readmissões de pacientes com insuficiência cardíaca estudo APRICA

Introducción. La insuficiencia cardíaca (IC) es una enfermedad con alta incidencia, prevalencia y mortalidad. Es primera causa de hospitalización en mayores de 65 años y 25% de los pacientes que reingresan antes de 30 días. La implementación de varios planes de transición al alta han mostrado beneficios respecto a los reingresos, no habiendo datos al respecto en Uruguay. Se diseñó un estudio para analizar el efecto de un Plan de Alta Programada sobre los reingresos en pacientes internados con IC en un Hospital. Material y métodos. Estudio prospectivo, controlado y randomizado, incluyendo pacientes ingresados en servicios de medicina del Hospital de Clínicas Dr. Manuel Quintela con diagnóstico de IC. Criterios de exclusión: negativa a participar, discapacidad cognitiva, hospitalización d"24 horas o muerte en internación. Se randomizaron dos grupos (intervención y control) con seguimiento a 18 meses. En el grupo intervención se aplicó un plan de alta programada y en el grupo control el criterio de médico tratante. Se registraron reingresos, muerte y calidad de vida a los 3, 6, 9, 12 y 18 meses. Se consideró significativo un valor de p<0,05. Se utilizó la prueba de T- student para muestras independientes. Resultados. Se incluyeron 149 pacientes, 78 en el grupo intervención. Se registraron 19 (24,4%) reingresos en el grupo intervención y 38 (53,5%) en el grupo control (RR 1,85 [IC 1,337-2,583] p<0,05). Ocurrieron 6 muertes en el grupo intervención y 7 en el grupo control (RR: 1,024 [IC 0,926-1,32] p=0,640). La calidad de vida por Test de Minnesota fue 50,98; 49,71 y 49,07 en el grupo intervención a los 3, 6 y 18 meses, respectivamente, y 55,04; 55,32 y 54,91 en el grupo control, con un valor de p no significativo. Conclusiones. La implementación de un Plan de Alta Programada reduce de manera significativa los reingresos por IC. Dado que parece ser una herramienta costo/efectiva para el sistema de salud la misma podría tener un impacto beneficioso en la calidad asistencial del paciente con IC.

Background. Heart failure (HF) is a disease with a high incidence, prevalence and mortality. It is the first cause of hospitalization in people over 65 years and 25% of patients are readmitted within 30 days. The implementation of various discharge transition plans has shown benefits with respect to readmissions, and there is no data in this regard in Uruguay. A study was designed to analyze the effect of a Scheduled Discharge Plan on readmissions in hospitalized patients with HF. Material and methods. Prospective, controlled and randomized study, including patients admitted to the medical services of the Hospital de Clínicas Dr. Manuel Quintela with a diagnosis of HF. Exclusion criteria: refusal to participate, cognitive disability, hospitalization d"24 hours or death in hospital. Two groups (intervention and control) were randomized with 18-month follow-up. In the intervention group, a planned discharge plan was applied and the criterion of treating physician was applied in control. Readmissions, death and quality of life were recorded at 3, 6, 9, 12 and 18 months. A value of p <0.05 was considered significant. The student s T-test was used for independent samples. Results. 149 patients were included, 78 in the intervention group. There were 19 (24.4%) readmissions in the intervention group and 38 (53.5%) in the control group (RR 1.85 [CI 1.337-2.583] p <0.05). There were 6 deaths in the intervention group and 7 in the control group, (RR: 1,024 [CI 0.926-1.32] p = 0.640). The quality of life by Minnesota Test was 50.98; 49.71 and 49.07 in intervention at 3, 6 and 18 months respectively and 55.04; 55.32 and 54.91 in the control group, with a non-significant p value. Conclusions. The implementation of a Scheduled Discharge Plan significantly reduces readmissions for HF. Given that it appears to be a cost/effective tool for the health system, it could have a beneficial impact on the quality of care for patients with HF.

Introdução. A insuficiência cardíaca (IC) é uma doença com alta incidência, prevalência e mortalidade. É a primeira causa de hospitalização em pessoas com mais de 65 anos e 25% dos pacientes são readmitidos em 30 dias. A implementação de vários planos de transição de alta mostrou benefícios no que diz respeito às readmissões, e não há dados a esse respeito no Uruguai. Um estudo foi desenhado para analisar o efeito de um Plano de Alta Planejado nas readmissões em pacientes hospitalizados com IC. Material e métodos. Estudo prospectivo, controlado e randomizado, incluindo pacientes internados nos serviços médicos do Hospital de Clínicas Dr. Manuel Quintela com diagnóstico de IC. Critérios de exclusão: recusa em participar, deficiência cognitiva, internação d"24 horas ou óbito no hospital. Dois grupos foram randomizados (intervenção e controle) com seguimento de 18 meses. No grupo de intervenção, um plano de alta planejado foi aplicado e o critério de médico assistente foi aplicado no controle. Readmissões, óbito e qualidade de vida foram registrados aos 3, 6, 9, 12 e 18 meses. Um valor de p<0,05 foi considerado significativo. O teste T do aluno foi usado para amostras independentes. Resultados. Foram incluídos 149 pacientes, 78 no grupo de intervenção. Houve 19 (24,4%) readmissões no grupo de intervenção e 38 (53,5%) no grupo de controle (RR 1,85 [IC 1,337-2,583] p <0,05). Houve 6 mortes no grupo de intervenção e 7 no grupo controle, (RR: 1,024 [IC 0,926-1,32] p=0,640). A qualidade de vida pelo teste de Minnesotafoi de 50,98; 49,71 e 49,07 na intervenção em 3, 6 e 18 meses, respectivamente, e 55,04; 55,32 e 54,91 no grupo controle, com um valor de p não significativo. Conclusões. A implementação de um Plano de Descarga Planejado reduz significativamente as readmissões para IC. Visto que parece ser uma ferramenta econômica para o sistema de saúde, pode ter um impacto benéfico na qualidade do atendimento aos pacientes com IC.

Comportamiento de reingreso a 30 días en un centro de reemplazos articulares. Estudio de cohorte longitudinal / 30 days re-admission in an articular Joint Arthroplasty center. A cohort Study

Introducción Los reemplazos articulares son calificados como procedimientos seguros y exitosos para el tratamiento de la osteoartrosis severa de cadera y rodilla alrededor del mundo. Las tasas de reingreso en los primeros 30 días y las complicaciones se han descrito como una medida para evaluar estándares de calidad. En Colombia no se conoce el comportamiento de éstos estándares. Este estudio pretende aportar información de un centro especializado en reemplazos articulares en Bogotá DC, Colombia, Suramérica. Materiales & Métodos Se realizó un estudio observacional prospectivo de una cohorte de 1.126 pacientes con 626 reemplazos totales de cadera (RTC) y 500 de rodilla (RTR), operados entre los años 2011-2015 en el Hospital Universitario San Ignacio de Bogotá DC, Colombia. Se reportan las tasas de reingreso a 30 días y las complicaciones. Se analiza mediante un modelo de regresión las asociaciones entre variables sociodemográficas y clínicas con el reingreso y las complicaciones. Resultados El 71% de los pacientes fueron mujeres, el promedio de edad de 63 años en los hombres y 65 años en mujeres. La estancia hospitalaria promedio fue de 3,5 días (DE:0,81-6,29). La tasa de reingreso a 30 días por cualquier causa fue 10,8% y la tasa de complicaciones asociadas al procedimiento fue 5,8%, se requirió reintervención quirúrgica en 1,5% de los pacientes. Se encontró asociación estadísticamente significativa entre el índice de Charlson mayor a 2 (OR=2,33[IC95% 1,3-4,18], p=0.004) y el reingreso a 30 días. La principal complicación en RTC fue luxación (1,4%) y en RTR infección de sitio quirúrgico (4%). Se encontró una asociación significativa entre complicaciones a 30 días con los días de hospitalización (OR=1,17[IC95% 1,09-1,25], p=0,00); y con el cirujano 4 en RTR (OR=2,28[IC95% 1,29-4,01], p=0,04); las demás variables no mostraron diferencias significativas. No se aprecian grandes diferencias con lo reportado en la literatura, asociación con estancia hospitalaria y experiencia del cirujano. Discusión La experiencia del cirujano y la aplicación de guías clínicas que optimicen los procesos intrahospitalarios y regulen los días de estancia hospitalaria, se relacionan con un mejor desenlace en la evolución de los pacientes en cuanto al número de complicaciones y reingresos a 30 días.

Background Joint replacements are always defined as safe and successful procedures for the treatment of severe osteoarthritis of the hip and knee around the world. Rates of readmission within initial post surgical 30 days and complications are described as a measure to assess quality standards. In Colombia the behavior of the standards are mainly unknown. Aim of study is to provide information from a specialized in joint replacements center in Colombia. Methods A prospective observational study was carried out on a cohort of 1,126 patients with 626 total hip replacements (THR) and 500 knee replacements (TKR), who underwent surgery between 2011-2015 at a University Hospital in Bogotá, Colombia. 30-day readmission rates and complications were reported. The associations between sociodemographic and clinical variables with readmission and complications were analyzed using a regression model. Results 71% of the patients were women, the average age was 63 years for men and 65 years for women. The mean hospital stay was 3.5 days (SD: 0.81-6.29). The 30-day readmission rate for any cause was 10.8% and the rate of complications associated with the procedure was 5.8%. Additional surgical procedures were required in 1.5% of the patients. A statistically significant association was found between the Charlson index greater than 2 (OR=2.33 [95% CI 1.3-4.18], p=0.004) and readmission at 30 days. The main complication in THR was dislocation (1.4%) and surgical site infection (4%) in TKR. A significant association was found between complications at 30 days and days of hospitalization (OR=1.17 [95% CI 1.09-1.25], p=0.00); and with surgeon 4 in TKR (OR=2.28 [95% CI 1.29-4.01], p=0.04); the other variables did not show significant differences. No differences were found with what is reported in the literature, association with hospital stay and experience of the surgeon. Discussion The surgeon's experience and the application of clinical guidelines that optimize in-hospital processes and regulate the days of hospital stay are related to a better outcome in the evolution of patients in terms of the number of complications and readmissions after 30 days.

Caracterización de los pacientes reingresados por postoperatorio complicado en el servicio de Cirugía General. Hospital Universitario Comandante Faustino Pérez. Matanzas / Characterization of the patients readmitted in the service of General Surgery of the University Hospital "Faustino Perez Hernandez" of Matanzas, due to complicated post-surgery evolution

RESUMEN Introducción: la cirugía como ciencia médica tuvo grandes retos para llegar a tener una forma de tratamiento quirúrgico seguro y viable, entre estos uno de los mayores era como evitar los resultados adversos. Se realizó un análisis de los pacientes que reingresaron en el servicio de cirugía general por post operatorio complicado. Objetivo: determinar las causas de reingresos por postoperatorio complicado en el servicio de cirugía general. Material y métodos: se realizó un estudio prospectivo - descriptivo- observacional sobre el universo, que fueron todos los pacientes reingresados por postoperatorio complicados, por el servicio de Cirugía General. Se analizaron múltiples variables que pudieran estar en relación con los reingresos las cuales fueron obtenidas a través de una planilla de recolección de datos y procesadas por el programa computadorizado Microsoft Office 2009. Resultados: los pacientes que reingresaron, el mayor porcentaje son del sexo masculino, de la raza blanca y los mayores de 60 años. Los reingresos por complicaciones postquirúrgicas representan un bajo por ciento respecto al volumen de casos que son intervenidos y la principal causa de reingreso fue la infección del sitio quirúrgico, las variables analizadas las que más se relacionaron con los reingresos fueron las operaciones realizadas por vía convencional, atendidos en salas abiertas, con operaciones limpias contaminadas. Conclusiones: de los pacientes que reingresaron 6 de cada 10 son del sexo masculino de la raza blanca y su edad mayor de 60 años (AU).

SUMMARY Introduction: Surgery, as a medical science, faced big challenges to become a form of a safe, feasible surgical treatment; among them, one of the biggest was avoiding adverse outcomes. The authors carried out an analysis of the patients readmitted in the service of General Surgery of the University Hospital "Faustino Perez Hernandez" of Matanzas due to complicated post-surgery evolution in the period from January 2016 to December 2018. Objective: to determine the causes of readmissions due to complicated post-surgery evolution in the service of General Surgery of the University "Hospital Faustino Perez Hernandez". Materials and methods: a prospective, descriptive, observational study was carried out on a universe of all patients readmitted in the service of General Surgery due to complicated post-surgery evolution. The authors analyzed several variables that could be related to readmissions and were obtained from a data collection form and processed with the computer program Microsoft Office 2009. Results: the main results were that among readmitted patients, the highest percent were male, white and elder than 60 years old. Readmissions due to post-surgery complications represent a low percent with respect to the quantity of patients who underwent surgery, and the main cause of readmission was infection at the surgery site. From the analyzed variables the once related the most with readmissions were conventional surgeries, patients looked after in open wards, with contaminated clean operations. Conclusions: six from each ten patients were male, white, and aged more than 60 years (AU).

Factores asociados a reingreso hospitalario precoz posterior a resecciones hepáticas y pancreáticas / Hospital readmission rates after hepatic and pancreatic resections

Resumen Objetivo: Determinar la frecuencia de reingreso hospitalario y sus factores asociados en pacientes sometidos a resecciones hepáticas o pancreáticas en nuestro centro. Metodología: Se revisaron registros de pacientes sometidos a resecciones hepáticas o pancreáticas entre 2012 y 2014. Se registraron variables biodemográficas, quirúrgicas y reingresos hasta 30 días posalta. Se excluyó la cirugía de urgencia, pacientes fallecidos durante la hospitalización, pacientes sometidos a resecciones hepáticas menores a dos segmentos, cirugías no anatómicas o cirugía no resectiva. El análisis estadístico univariable se realizó con prueba χ2 para variables categóricas y T Student/Mann Whitney para variables continuas. El análisis multivariable se realizó con regresión logística. Resultados: Se incluyeron 116 pacientes, 50,9% mujeres. La estadía promedio fue de 14 días. El adenocarcinoma pancreático fue el diagnóstico más frecuente (25,9%) y 40,5% de los procedimientos quirúrgicos fueron pancreatoduodenectomías. La tasa de reingreso global fue 18,1%, mayor en pancreatectomías respecto a hepatectomías (23,7 vs 12,2% respectivamente p < 0,05). Los factores asociados a reingreso fueron: resección de páncreas, leucocitos preoperatorios, complicaciones posoperatorias y tiempo de estadía hospitalaria. Tras el análisis multivariable, sólo el tiempo hospitalario se asocia de forma independiente al reingreso precoz [OR 1,2 IC 95% 1,1-1,5 (p = 0,001)]. Conclusión: La estadía hospitalaria prolongada es un factor de riesgo consistente en la literatura para la rehospitalización posterior a resecciones hepáticas o pancreáticas. La tasa de reingreso posterior a resecciones hepáticas o pancreáticas es elevada, incluso en centros de alto volumen. Recomendamos el uso de este parámetro como un nuevo instrumento de medición de calidad en los resultados quirúrgicos en nuestro país.

Aim: To determine readmission rates and its associated factors in patients undergoing pancreatic and hepatic resections at our center. Matherial and Methods: Perioperative variables of patients undergoing pancreatic and hepatic resections between 2012-2014 were reviewed. Demographic and perioepartive data, as well as up —to postoperative day 30— readmisson rates were analyzed. Emergency cases, postoperative mortality and/or patients undergoing less extensive surgery (less than 2 Couinaud's segments, non-anatomical resections and non resective cases such as bilioenteric anastomoses) were excluded. Readmission associated factors were identified using both univariate (χ2 for categorical and t-student's/Mann-Whitney for continuous variables) and multivariate (logistic regression) analysis. Results: 116 cases were included, 50.9 % female. Mean postoperative stay was 14 days. Pancreatic adenocarcinoma was the most frequent diagnosis (25.9%), and the 40.5% of surgical procedures were pancreaticoduodenectomy. Overall 30-day readmission rate was 18.1%, with a 23.7% for pancreatic resections and 12.2% for hepatic resections. According to univariate analysis; readmission associated factors were: pancreatic resection, preoperative White cell count, the development of postoperative complications and postoperative length of stay. On Multivariate analysis only postoperative stay was the only significant associate factor [OR 1,2 CI 95% 1.1- 1.5 (p = 0.001)]. Conclussion: Readmission rates after pancreatic and hepatic resections are elevated, even in high-volume centers. Postoperative length of stay is a consistent risk factor for readmission after these type of surgeries. We highly recommend including this parameter as a quality marker of our surgical results in our country.

La comorbilidad y el reingreso en pacientes diabéticos / Comorbidity and re-entry in diabetic patients

Introducción: el reingreso de un paciente diabético es un indicador en el que interaccionan la calidad de la asistencia sanitaria, las características particulares del paciente y quienes le prestan ayuda. Implica también incrementos de complicaciones, mortalidad y costos para el sistema de salud y el paciente. Los reingresos más tardíos pueden obedecer a problemas derivados de la evolución de las enfermedades en los pacientes, como pueden ser la comorbilidad y la gravedad de la enfermedad. También a los cuidados recibidos fuera del hospital. Objetivo: identificar factores asociados al reingreso de pacientes diabéticos con alta comorbilidad. Método: estudio descriptivo de serie de casos, prospectivo, con 110 pacientes ingresados en una sala de Medicina Interna de un hospital en La Habana. Como variable resultado se consideró el reingreso hospitalario en tres meses de seguimiento. Resultados: el 35,5 por ciento de los casos reingresaron en menos de tres meses. La edad promedio de las 61 mujeres fue de 70,38 años y de los 49 hombres 66,19 años; las comorbilidades más frecuentes fueron la hipertensión 95,5 por ciento, cardiopatía isquémica 61,8 por ciento y obesidad central 56,4 por ciento; el puntaje del índice de Charlson fue de 4,41 en los casos reingresados y 3,54 en los no reingresados. Conclusiones: la alta frecuencia de reingresos en la serie se asocia a características que definen a los diabéticos en estudio como adultos mayores con altos índices de comorbilidades dependientes, fundamentalmente, de la presencia de complicaciones cardiovasculares de la diabetes asociada a hipertensión arterial(AU)

Introduction: The re-entry of a diabetic patient is an indicator in which the quality of health care, the particular characteristics of the patient and those who help them interact. It also implies increases in complications, mortality and costs for the health system and the patient. Later re-admissions may be due to problems derived from the evolution of diseases in patients, such as comorbidity and the severity of the disease, and also to the care received outside the hospital. Objective: to identify factors associated with the re-entry of diabetic patients with high comorbidity. Methods: This is a descriptive cases series study, prospective, with 110 patients admitted to the Internal Medicine ward of a hospital in Havana. As a result, variable, the hospital re-admission was considered in three months of follow-up. Results: 35.5 percent of the cases re-admitted in less than three months. Sixty-one were women and the average age was 70.38 years. Forty-nine were men and the average age was 66.19 years. The most frequent comorbidities were hypertension 95.5 percent, ischemic heart disease 61.8 percent and central obesity 56.4 percent. The score in Charlson index was 4.41 in the re-admitted cases and 3.54 in the non-re-admitted. Conclusions: The high frequency of readmissions in this series is associated with characteristics that define diabetics in the study as elderlies with high rates of dependent comorbidities, mainly, the presence of cardiovascular complications of diabetes associated with hypertension(AU)

Electroconvulsoterapia en el primer episodio de esquizofrenia: impacto en la evolución / Electroconvulsoterapia in the first episode of schizophrenia: impact on evolution

La esquizofrenia es una patología que evolucionade forma crónica, proclive al deterioro, siendo este último variable de acuerdo con comorbilidades presentes y adherencia al tratamiento integral. Genera alteraciones cognitivas e influye negativamente en el desempeño de quienes la padecen, causando detrimento global de los pragmatismos. La electroconvulsoterapia es una opción terapéutica ampliamente utilizada en nuestro país para tratar sintomatología del humor y episodios psicóticos agudos, entre otros. En la actualidad se sabe que la detección e intervención precoz de un episodio psicótico agudo —el cual puede corresponder al primer episodio psicótico de esquizofrenia —mejora el pronóstico a largo plazo. El objetivo es demostrar si existe un vínculo entre la indicación de electroconvulsoterapia durante el primer episodio psicótico de esquizofrenia y la duración del intervalo libre de internación. Este es un estudio de tipo analítico, observacional, retrospectivo (cohorte histórica) que busca aumentar las evidencias en este amplio campo de investigación. Observamos que el tiempo libre de internación luego de la primera hospitalización no tuvo relación con el hecho de si recibieron electroconvulsoterapia o no; sin embargo, al realizar el análisis de potencia estadístico surge que los resultados no son concluyentes. Se destaca el importante porcentaje de patología dual en este grupo de usuarios: un 39%.

Schizophrenia is a chronic disease, prone todeterioration, the latter being variable accordingto comorbidities and treatment adherence. It generates cognitive impairment and adverselyaffects overall performance, causing deterioration of pragmatisms. Electroconvulsive therapy is awidely used therapeutic option in our countryfor acute affective and psychotic episodes. It iswell known that early detection and interventionof an acute psychotic episode —which maycorrespond to the first psychotic episode of schizophrenia— improves long-term prognosis.This study intended to show whether there is alink between early indication of electroconvulsive therapy during the first episode and timeto relapse and hospital readmission. This is ananalytical, observational, retrospective (historical cohort) study, which aims to increase theevidence in this broad research field. As a resultthere was no link between time to relapse and electro convulsive therapy in the first episode; nevertheless after a post hoc analysis resultsare not conclusive. Dual diagnosis stands outin this group and corresponds to 39%.

Análisis de causas de reingreso en pacientes histerectomizadas / Causal analysis for reentry of patients with hysterectomy

Objetivo: analizar las causas más frecuentes de reingreso de las pacientes posthisterectomía del Servicio de Ginecología del Hospital México, entre enero 2009 y diciembre 2011.Métodos:se realizó un estudio retrospectivo descriptivo en 70 pacientes, las cuales reingresaron luego de que se les practicara una histerectomía, con el fin de analizar las principales causas de reingreso, así como los principales factores de riesgo asociados.Resultados:la principal causa de reingreso de las pacientes posthisterectomía fue la infección de la herida quirúrgica 74,3% (n=52), seguida por el absceso de la cúpula vaginal 11,4% (n=8), la evisceración y la dehiscencia de la herida quirúrgica, ambas con un 2,9% (n=2) de los casos. Los principales factores de riesgo encontrados fueron: tiempo quirúrgico prolongado, obesidad, cáncer y diabetes mellitus. La minoría de las participantes requirió ser llevada a sala de operaciones al reingreso. Conclusiones: en el estudio, la infección del sitio quirúrgico fue la principal causa de reingreso de las pacientes histerectomizadas. De las causas infecciosas, las más frecuentes fueron: infección de la herida quirúrgica y absceso de cúpula vaginal, hematoma de cúpula vaginal y evisceración.

Objective: To analyze the most frequent reasons for readmission of patients after a hysterectomy at the Department of Gynecology of the Mexico Hospital between January 2009 and December 2011.Methods: A retrospective descriptive study was conducted in 70 patients that were readmitted after a hysterectomy surgery in order to analyze the main causes of readmission and the main associated risk factors.Results: The main causes of readmission of patients after hysterectomy were infection of the surgical wound, in 74.3% of the cases (n52), followed by vaginal vault abscess in 11.4% (n8) of the cases and evisceration and dehiscence of the surgical wound, both accounting for 2.9% (n2) of cases. The main risk factors found were prolonged surgical time, obesity, cancer and diabetes mellitus. A minority of participants required reentry to the surgery room.Conclusions: Surgical site infection was the leading cause of readmission of hysterectomy patients in this study. The most common infectious causes were the infection of the surgical wound and abscess of the vaginal vault, followed by vaginal vault hematoma and evisceration.

Reingreso por infección de sitio quirúrgico: una revisión integradora / Patient readmission for surgical site infection: integrative review

Background: Surgical site infections (SSI) represent an inherent risk after surgical procedures associated both to the surgical procedure and to the patient clinical conditions. Aim: To analyze in an integrative review the studies related to patient readmission due to SSI.Material and Method: The review was carried out by LILACS, CINHAL, MEDLINE and COCHRANE databases and articles published from 1966 to 2010 were selected. Results: It was analyzed 13 studies classified as transversal (7), cohort (4) and longitudinal (2). Few studies analyzed only the readmissions related to the SSI. Time to define the readmission ranged from 28 to 90 days after surgery and studies related to orthopedic procedures were more frequent. The ISS readmission rates were lower than 5%. The main aetiological agents isolated from ISS were Staphylococcus aureus and coagulase-negative staphylococci. Conclusion: Monitoring readmissions due to SSI could contribute to dimension the occurrence of ISS post-discharge, once about half of the SSI post-discharge was diagnosed at the readmission moment.

Introducción: Las infecciones de sitio quirúrgico (ISQ) representan un riesgo inherente a la realización de cualquier acto quirúrgico, asociado a factores propios del procedimiento, así como a condiciones del paciente. Objetivo. Analizar, en una revisión integradora, los estudios que abordaran aspectos epidemiológicos relacionados con el reingreso de pacientes por ISQ. Método: Se efectuó una revisión en las bases LILACS, SCOPUS, COCHRANE e MEDLINE con selección de artículos publicados desde 1966 hasta 2010. Resultados: Se analizaron 13 estudios, siendo siete estudios transversales, cuatro de cohortes y dos longitudinales. Escasos estudios se restringieron a analizar exclusivamente los reingresos relacionados a la ISQ. El tiempo para definir el reingreso varió de 28 a 90 días después de la cirugía y hubo un mayor número de estudios relacionados con procedimientos ortopédicos. La tasa de reingreso por ISQ en los estudios fue inferior a 5%. El principal agente aislado en las ISQ fue Staphylococcus aureus y Staphylococcus coagulasa negativas. Conclusión: La vigilancia de los reingresos por ISQ podría contribuir a dimensionar la ocurrencia de ISQ post-alta, ya que aproximadamente la mitad de las ISQ post-alta originaron reingresos a centros hospitalarios.

Costo-efectividad de intervenciones para esquizofrenia en México / Cost effectiveness of interventions for schizophrenia in Mexico

The World Health Organization estimates that the expense of attending mental illness problems in developed countries amounts to 3-4% out of the total GDP. The public expense for hospitalization of patients diagnosed with schizophrenia was three times higher in patients who decide to leave the treatment than those who continue with it; ambulatory patients amount to almost the same figures in public expenses whether they decide to continue the treatment or not. In the USA, there are 87 000 people hospitalized due to schizophrenia every year, which represent 93 000 hospital days with a cost of about 806 billion dollars a year; to stop patients from leaving the treatment, however, would cut the number of acute cases 12.3% and hospitalizations 13.1%. These two reductions would cut down the expenses in Medicaid as much as 106 million dollars. According to data gathered by the Organization for the Economical Cooperation and Development for Germany, the expense in mental health accounts for 10% of total health expenses, being schizophrenia, depression and anxiety the most costly illnesses. Finland doubled the expenses to attend those who suffered mental illnesses between 1990 and 2003. The total annual expenses for the treatment of schizophrenia in Latin American and Caribbean countries accounts for 1.81%, for Africa 0.47%, for Europe 1.32% and for southern Asia 0.52 in millions of dollars per every million people. In Mexico, a first estimate, based on the demand and the amount of money destined to attend this problem by every health institution, it was concluded that the average annual expenses in medical attention for schizophrenia was US97.54 per person. The Health Sector reports that the cost for a psychiatric evaluation or psychotherapy amounts to US1.42 and the estimated annual cost for the treatment of schizophrenia in a public institution amounts to somewhere between US60.34 and US2,1 86.83; all this would depend on the haloperidol or clozapine drug. In a private institution, the cost for a psychiatric evaluation is US63.44 and the annual estimated cost is somewhere between US1,695.79 and US5,988.58 including treatments with the aforementioned drugs. The cost-effectiveness analysis is a method which indentifies, quantifies and values the expenses of two or more alternatives of sanitary intervention available at the time to reach certain objectives. This will be possible as long as the effects are channeled to the same class of effects. The measure of the analysis summary concerning cost-effectiveness is the ratio cost-effectiveness which allows comparison of different action alternatives, identifying two types of indicators: average cost and increased cost. Regarding the methodological procedures, the research project was based in a length and descriptive study, though not statistical. It was designed to carry out an analysis of cost-effectiveness in the alternatives of treatment for patients who were diagnosed with schizophrenia at the Fray Bernardino Psychiatric Hospital. This study allowed the identification and quantification of costs of the demand, the treatment, hospitalization, and the ambulatory services. The effectiveness of the alternatives in treatment studied is measured in terms of the readmitted. Four non-statistical samples were taken of clinical files out of each studied service. External Consultation: 50 clinical files, 15 were discarded for not being diagnosed with schizophrenia; the other 35 were followed and analyzed for six months. Day Hospital: 65 files of the total of patients diagnosed with schizophrenia, 12 were discarded for being diagnosed differently. Therapeutic clinical adherence (TAC): a sample of 85 files of patients diagnosed with schizophrenia was taken. Patients with membership to ISSSTE diagnosed with schizophrenia who came out of hospitalization between June-October 2008 were followed during a period of six months in order to measure the readmitted to hospitalization; 67 patients were registered. The costs of personnel (doctor, nurses, social service, and psychology and hygiene staff) were obtained out of the coefficient of the total annual salary between the annual working day in minutes for the time destined to attention of each patient. The costs for catering and laundry were calculated directly. The laboratory cost was obtained taking into account cost-time destined to the study of administrative personnel, technicians and supervision, as well as materials and the necessary equipment. The indirect costs (security, hygiene, water, electric power, and municipal and biological waste) were obtained dividing the total annual costs in the average annual number of patients who needed hospitalization; this was done taking into account that the daily average in occupation is 296 patients. The external consultation was excluded for being deemed unimportant in terms of consumption. Analysis: descriptive statistics. Cost-effectiveness analysis. With respect to the main findings, the hospitalization costs are: emergency room US136.00, intensive care US1 62.72, and continuous hospitalization US68.83. The cost of day hospital is US34.57, US68.91 in TAC and external consultation US9.67. The semester consultation for patients undergoing external consultation, day hospital and TAC received 2.3, 23.5 and 7.5 each one. The readmitted in ambulatory services are 8.5%, 7.5%, and 5.8% for external consultation, day hospital, and TAC. The hospitalization days for patients who were readmitted due to an increase in symptoms was 42.5, 1 2.5, and 25 days in average for external consultation, day hospital and TAC. The effectiveness coefficient indicates that avoiding a readmitted to external consultation, day hospital, TAC and external consultation at ISSSTE amounted to US15.26, US518.84, US499.23 and US16.37 accordingly. The cost of making use of an additional hospital unit during the day is US 1321.41; it amounts to US11 66.31 for therapeutic care and US1 7.79 at ISSSTE. According to the main results, the costs for medical attention through the system of cascade primary costs differ too much when compared to the unitary costs published in the Diario Oficial; the ambulatory costs are very different in terms of costs but they show very similar results. The difference between the costs for attending patients diagnosed with schizophrenia is due to the number of patients and the personnel assigned to the area. These results are influenced by the number of semester consultations: 23.5 times in day care hospitalization against the 7.5 and 2.3 times in average of TAC and external consultation accordingly. The average rate of avoided readmitted is low in external consultation compared to the other three alternatives; this rate is affected by the largest number of people who abandoned TAC, which could empirically be explained by the need of the patient to buy his medication. Upon making a comparison of the costs of the alternatives of integral treatment for schizophrenia in the Fray Bernardino Psychiatric Hospital, we found that the average cost for external consultation is much clearer in terms of cost-effectiveness than day hospital and TAC; this means that the first option is much more effective and less money is required than the other two. Even though external consultation registers a very high rate of abandonment in terms of treatment by the patients, it still shows to be more effective. It is also slightly more effective than external consultation at ISSSTE; this is to say that if we only consider the effectiveness based on how much we avoid readmitted, it would be much more appropriate for patients who attend external consultation to be given the necessary medication and in doing so reducing the costs of day care hospitalization and TAC. The increased cost shows that avoiding an admitted to day hospital results in a cost of about US1321.41 which is almost the same as readmitted a patient attending external consultation whose symptoms have become more acute, and much more expensive than the total cost of attending that patient in that service over six months. The cost for avoiding a readmitted in TAC is US1166.31 whereas the cost for avoiding a readmitted in ISSSTE is US1 7.79 the strategy should be targeted to providing the necessary medication for patients who are attending external consultation.

La Organización Mundial de la Salud estima que el gasto por la atención de los problemas de salud mental en países desarrollados corresponde a 3-4% del PIB. La Organización para la Cooperación y Desarrollo Económico reporta que, en la Unión Europea, 25% de los gastos en discapacidad se destinan a las ocasionadas por enfermedad mental. El costo anual total de la esquizofrenia para países de Latinoamérica y el Caribe es de 1.81, para África 0.47, para Europa 1.32 y para el Sur de Asia 0.52 en millones de dólares por millón de personas. En México, en una primera aproximación se concluyó que el costo anual promedio de atención médica de la esquizofrenia es de $1,230. En este contexto, se desarrolló un análisis de costo-efectividad de las tres alternativas de tratamiento de pacientes con diagnóstico de esquizofrenia. Respecto a los principales procedimientos metodológicos, el proyecto se basó en un estudio longitudinal y descriptivo. Se usaron cuatro grupos de expedientes clínicos de cada uno de los servicios estudiados. La efectividad de los tratamientos proporcionados se midió en términos de los reingresos a hospitalización en el periodo estudiado. Los costos calculados: personal, lavandería, alimentos, laboratorio, seguridad, limpieza, agua, energía eléctrica y residuos municipales y biológicos. Análisis costo-efectividad. Entre los principales resultados se encontraron los siguientes: Costo hospitalización: día/paciente en urgencias $1,715.00, en cuidados intensivos $2,052.00, y en hospitalización continua $868.00. El costo diario en hospital de día es de $436.00, en Clínica de Adherencia Terapéutica (CAT) $869.00 y en consulta externa $122.00 por consulta. Las consultas semestrales en consulta externa, hospital de día y CAT recibieron 2.3, 23.5 y 7.5, respectivamente. Los días de hospitalización de los pacientes que reingresaron por exacerbación de síntomas fueron 42.5, 12.5 y 25 en promedio para consulta externa, hospital de día y CAT, respectivamente. Reingresos 8.5, 7.5 y 5.8% para consulta externa, hospital de día y clínica de adherencia terapéutica, respectivamente. El coeficiente de efectividad para consulta externa, hospital de día, CAT y consulta externa del ISSSTE, es de $192.50, $6,542.60, $6,295.30 y $206.50, respectivamente. El costo de producir una unidad adicional en hospital de día es de $1 6,663; en clínica de adherencia terapéutica $ 14,707.20 y en el ISSSTE $224.40. A partir de estos resultados, el artículo retoma los principales hallazgos resaltando los indicadores de costo, de efectividad y del coeficiente costo-efectividad para cada intervención. Los costos de atención médica a través del sistema empleado en el presente documento difieren demasiado de los costos unitarios publicados en el Diario Oficial de la Federación. Los servicios ambulatorios son muy dispares en cuanto a costo pero de resultados similares, influidos por el número de consultas semestrales, 23.5 veces en hospital de día, contra las 7.5 y 2.3 veces en promedio de CAT y consulta externa, respectivamente. La tasa de reingresos evitados es baja en consulta externa respecto a las otras tres alternativas, afectada por el mayor abandono terapéutico atribuido empíricamente a la necesidad del paciente de comprar su medicación. Consulta externa es más costo-efectiva que hospital de día y CAT, esto es, con menos recursos es más efectiva que las otras dos, aun con elevado abandono de tratamiento; sólo considerando la efectividad en términos de evitar reingresos, convendría proporcionarles los medicamentos que requieran a pacientes que acuden a consulta externa, reduciendo los recursos destinados a hospital de día y CAT. Finalmente, es importante resaltar que el costo incremental muestra que evitar un ingreso en hospital de día genera un costo de $1 6,663.00 casi igual al costo de un internamiento; evitar un ingreso en CAT es de $14,707.00 mientras que el costo de evitar un reingreso en el ISSSTE es $224.40. La estrategia debería encaminarse a otorgar los medicamentos en consulta externa.