[Validation of the EuroSCORE probabilistic model in patients undergoing coronary bypass grafting]. / Validación del modelo probabilístico EuroSCORE en pacientes intervenidos de injerto coronario.

INTRODUCTION AND OBJECTIVES: EuroSCORE utilizes a probabilistic model for predicting the risk of in-hospital mortality in patients undergoing cardiac surgery. It is a useful instrument for evaluating quality of care. The model has two variants: the logistic EuroSCORE and the additive EuroSCORE. The aim of this study was to validate the EuroSCORE model in patients undergoing surgery at Hospital Clínic in Barcelona, Spain, and to compare the results obtained with the two variants. METHODS: The study included all patients who received a coronary artery bypass graft (CABG) at Hospital Clínic in Barcelona in two consecutive years. The model's validity was assessed on the basis of its calibration (using the Hosmer-Lemeshow test) and its discrimination (using the receiver operating characteristic [ROC] curve). The two models were compared by carrying out a descriptive analysis of mortality for the whole group and for different risk groups, and by determining the models' discriminative power. RESULTS: A total of 498 patients underwent CABG surgery and were included in the study. The Hosmer-Lemeshow test showed that the model's calibration was satisfactory (P=.32) and the area under the ROC curve was 0.83. The observed in-hospital mortality rate was 5.8%. The predicted rate was 4.2% with the logistic EuroSCORE and 3.9% with the additive EuroSCORE. Large differences were observed in high-risk patients. In these patients, the mortality predicted by the logistic variant was closer to the actual mortality. CONCLUSIONS: EuroSCORE's validity was found to be satisfactory and the model can be used to evaluate quality of care. In high-risk patients, mortality estimated using the logistic model was closer to the actual mortality.

Validación del modelo probabilístico EuroSCORE en pacientes intervenidos de injerto coronario / Validation of the EuroSCORE Probabilistic Model in Patients Undergoing Coronary Bypass Grafting

Introducción y objetivos. EuroSCORE es un modeloprobabilístico para estimar la probabilidad de mortalidadhospitalaria en pacientes sometidos a cirugía cardiaca.Es un instrumento útil para evaluar la calidad asistencial. Existen dos variantes del modelo, el EuroSCORE logístico (EU-L) y el EuroSCORE aditivo (EU-A). El objetivo del estudio es validar el modelo EuroSCORE en pacientes intervenidos en el Hospital Clínic de Barcelona y comparar los resultados de las dos variantes del modelo.Métodos. Se ha incluido a los pacientes intervenidosde injerto coronario en el Hospital Clínic de Barcelona durante 2 años consecutivos. Se ha validado el modelo apartir de su capacidad de calibración (prueba de Hosmer-Lemeshow) y discriminación (área bajo la curva ROC).Se han comparado los dos modelos con un análisis descriptivo de la media de la mortalidad para el total y según grupos de riesgo y mediante su poder de discriminación.Resultados. Un total de 498 pacientes fueron intervenidose incluidos en el estudio. La calibración del modeloes satisfactoria (p = 0,32) y el área bajo la curva ROC es de 0,83. La mortalidad hospitalaria observada alcanzó el 5,8% y la estimada, el 4,2% (EU-L) y el 3,9% (EU-A). Se han observado mayores diferencias en el grupo de pacientes de alto riesgo, en los que la mortalidad predicha por la variante logística se aproxima más a la mortalidad real.Conclusiones. EuroSCORE ha sido validado adecuadamentey puede utilizarse para medir los resultados dela práctica asistencial. El modelo logístico se aproximamás a la mortalidad real en el grupo de pacientes de altoriesgo

Introduction and objectives. EuroSCORE utilizes aprobabilistic model for predicting the risk of in-hospital mortality in patients undergoing cardiac surgery. It is a useful instrument for evaluating quality of care. The model has two variants: the logistic EuroSCORE and the additive EuroSCORE. The aim of this study was to validate the EuroSCORE model in patients undergoing surgery at Hospital Clínic in Barcelona, Spain, and to compare the results obtained with the two variants.Methods. The study included all patients who receiveda coronary artery bypass graft (CABG) at Hospital Clínicin Barcelona in two consecutive years. The model’svalidity was assessed on the basis of its calibration (using the Hosmer-Lemeshow test) and its discrimination (using the receiver operating characteristic [ROC] curve). The two models were compared by carrying out a descriptive analysis of mortality for the whole group and for different risk groups, and by determining the models’ discriminative power.Results. A total of 498 patients underwent CABGsurgery and were included in the study. The Hosmer-Lemeshow test showed that the model’s calibration wassatisfactory (P=.32) and the area under the ROC curvewas 0.83. The observed in-hospital mortality rate was5.8%. The predicted rate was 4.2% with the logisticEuroSCORE and 3.9% with the additive EuroSCORE.Large differences were observed in high-risk patients. Inthese patients, the mortality predicted by the logisticvariant was closer to the actual mortality.Conclusions. EuroSCORE’s validity was found to besatisfactory and the model can be used to evaluatequality of care. In high-risk patients, mortality estimated using the logistic model was closer to the actual mortality5

Organización en institutos de gestión clínica (centros orientados al paciente): descripción de la utilización hospitalaria / Clinical management institutes (patient focused centers): description of hospital utilization

Objetivos: Conocer las características determinantes de la inadecuación de los ingresos y las estancias presentada al aplicar un nuevo modelo de gestión clínica. Métodos: La población objeto de estudio han sido los enfermos dados de alta en el Hospital Clínico Universitario de Barcelona. El instrumento de revisión utilizado ha sido el protocolo AEP médico-quirúrgico. El proceso de evaluación ha consistido en la revisión retrospectiva de la historia clínica por parte de dos evaluadores médicos. Se ha realizado un análisis multivariable de regresión logística múltiple para las variables dependientes ingreso y estancia inadecuada. Resultados: De los 401 ingresos, 28 (6,9%) se consideraron inadecuados. La admisión programada, durante el fin de semana y en las áreas médicas han sido las variables predictivas identificadas para el ingreso inadecuado. De las 2.187 estancias estudiadas, a 267 (12,2%) se las evaluó como inadecuadas. La propia inadecuación del ingreso, la duración de la estancia, la cobertura asistencial y el tipo de alta han sido las variables predictivas identificadas para la estancia inadecuada. Conclusiones: El modelo organizativo desarrollado por los institutos de gestión clínica presenta unos niveles de inadecuación de ingresos y estancias muy aceptables. La actividad asistencial quirúrgica se ha encontrado influida favorablemente por la mayor actuación protocolizada del modelo. La actividad asistencial dirigida a pacientes con enfermedades médicas, asociadas y crónicas, sintetiza el patrón principal de la inadecuación

Objectives: To assess the main features and determining factors of inappropriate admission and hospital stay in relationship with a new clinical management model. Methods: Study population included all patients discharged from the Hospital Clinic-University of Barcelona. The review tool was the medical and surgical Appropriateness Evaluation Protocol (AEP). We reviewed the clinical records of a representative sample of all discharged patients. Two independent and well trained AEP reviewers were used for each record review. A multivariate analysis was performed, using admission and inappropriate hospital stay as independent variables. Results: A total of 401 admissions were reviewed. Twenty-eight (6.9%) were deemed to be inappropriate. Elective admission, admission over the week-end and being admitted to a medical ward were the predictive variables identified for inappropriate admissions. Of all 2,187 hospital stays reviewed, 267 (12.2%) were deemed to be inappropriate. An inappropriate admission, total length of stay, type of insurance coverage and discharge type were the predictive variables identified for inappropriate hospital stays. Conclusions: The new organization and clinical management model, developed by the Patient Focused Care Institutes, showed very acceptable levels of inappropriate admissions and hospital stays. Surgical services have benefited most from this new organization. Care provided to patients with medical conditions, notably those patients with multiple and chronic conditions, make up most of the inappropriateness identified

[Not Available]. / Organización en institutos de gestión clínica (centros orientados al paciente): descripción de la utilización hospitalaria.

OBJECTIVES: To assess the main features and determining factors of inappropriate admission and hospital stay in relationship with a new clinical management model. METHODS: Study population included all patients discharged from the Hospital Clinic-University of Barcelona. The review tool was the medical and surgical Appropriateness Evaluation Protocol (AEP). We reviewed the clinical records of a representative sample of all discharged patients. Two independent and well trained AEP reviewers were used for each record review. A multivariate analysis was performed, using admission and inappropriate hospital stay as independent variables. RESULTS: A total of 401 admissions were reviewed. Twenty-eight (6.9%) were deemed to be inappropriate. Elective admission, admission over the week-end and being admitted to a medical ward were the predictive variables identified for inappropriate admissions. Of all 2,187 hospital stays reviewed, 267 (12.2%) were deemed to be inappropriate. An inappropriate admission, total length of stay, type of insurance coverage and discharge type were the predictive variables identified for inappropriate hospital stays. CONCLUSIONS: The new organization and clinical management model, developed by the Patient Focused Care Institutes, showed very acceptable levels of inappropriate admissions and hospital stays. Surgical services have benefited most from this new organization. Care provided to patients with medical conditions, notably those patients with multiple and chronic conditions, make up most of the inappropriateness identified.

Phenotypic differences between male physicians, surgeons, and film stars: comparative study.

OBJECTIVES: To test the hypothesis that, on average, male surgeons are taller and better looking than male physicians, and to compare both sets of doctors with film stars who play doctors on screen. DESIGN: Comparative study. SETTING: Typical university hospital in Spain, located in Barcelona and not in a sleepy backwater. PARTICIPANTS: Random sample of 12 surgeons and 12 physicians plus 4 external controls (film stars who play doctors), matched by age (50s) and sex (all male). INTERVENTIONS: An independent committee (all female) evaluated the "good looking score" (range 1-7). MAIN OUTCOME MEASURES: Height (cm) and points on the good looking score. RESULTS: Surgeons were significantly taller than physicians (mean height 179.4 v 172.6 cm; P=0.01). Controls had significantly higher good looking scores than surgeons (mean score 5.96 v 4.39; difference between means 1.57, 95% confidence interval 0.69 to 2.45; P=0.013) and physicians (5.96 v 3.65; 2.31, 1.58 to 3.04; P=0.003). Surgeons had significantly higher good looking scores than physicians (4.39 v 3.65; 0.74; 0.25 to 1.23; P=0.010). CONCLUSIONS: Male surgeons are taller and better looking than physicians, but film stars who play doctors on screen are better looking than both these groups of doctors. Whether these phenotypic differences are genetic or environmental is unclear.

[Cost analysis of cardiac transplantation in a Spanish hospital]. / Análisis del coste del trasplante cardíaco en un hospital español.

BACKGROUND AND OBJECTIVE: Heart transplant requires a heavy use of high cost resources. Economic data related to this procedure had not been specifically addressed and there are very few publications which analyze this topic. The aim of this study was to analyze the costs related to heart transplant in a series of patients from a single institution. PATIENTS AND METHOD: Data from all patients included in the Hospital Clínic heart transplant programme in which a cardiac transplant was effectively performed between 1999 and 2000 were analyzed, including one year of follow-up. Patients who died within this first year were also included. Organ procurement costs were excluded. Cost analysis was performed by micro-costing techniques. RESULTS: A total of 21 patients undergoing a heart transplant were included. One year survival rate was 76%. Mean (standard deviation) of total cost (procedure costs + one year follow-up cost) was 59,349 (18,881) euros (range: 29,380-113,470 euros). Procedure mean cost was 41,724 (17,584) euros (70% of total costs) and one year follow up mean cost was 17,625 (10,096) euros (30% of total costs) per patient. When the initial episode (heart transplant procedure) was analyzed, main cost drivers were personnel costs euros 59% of all costs; mean: 24,795 (7,633) euros and treatment costs -20% of all costs; mean: 8,386 (7,250) euros. CONCLUSIONS: Costs of heart transplant in Barcelona (Spain) are similar to those published for other European Union countries, and well below the costs related to the procedure in the United States.

[Analysis of Spanish hospital's reputation: relationship with their scientific production in different subspecialities]. / Análisis de la reputación de los hospitales españoles: relación con su producción científica en cuatro especialidades.

BACKGROUND AND OBJECTIVE: To assess the relationship between reputation of hospitals, as determined by specialists' opinion, and their scientific production. MATERIAL AND METHOD: A questionnaire was sent to a sample of members of the Spanish Societies of Cardiology, Digestive Diseases, Neurology and Otorhinolaryngology. Each member had the possibility to nominate 5 hospitals with the greatest reputation amongst his/her specialty. Final score for those hospitals with more than 5% of all votes was used for the development of a reputation index. We assess the scientific production (number of publications and citations) for nominated hospitals and analyze the possible correlation between the reputation index and the scientific production. RESULTS: We received 151 (30%) answers for cardiology, 227 (27%) for digestive diseases, 148 (30%) for neurology and 177 (18%) for otorhinolaryngology. The number of published articles and the number of citations for each nominated hospital showed a positive and statistically significant correlation with the reputation index. CONCLUSIONS: This is the first approach to analyze reputation parameters for Spanish hospitals. Scientific production and reputation index showed a positive correlation.

Análisis de la reputación de los hospitales españoles: relación con su producción científica en cuatro especialidades / Analysis of Spanish hospital's reputation: relationship with their scientific production in different subspecialities

Fundamento y objetivo: Evaluar la reputación de los hospitales y analizar su posible relación con la producción científica (artículos y citaciones) de dichos hospitales. Material y método: Encuesta a miembros de las Sociedades Españolas de Cardiología, Patología Digestiva, Neurología y Otorrinolaringología. Cada socio podía votar 5 hospitales que consideraba de mayor reputación asistencial en su especialidad. La puntuación final de los 15 hospitales con más del 5% de los votos constituye el índice de reputación. Se evaluó la producción científica (publicaciones y citaciones) en cada especialidad y para cada hospital más votado y se analizó la posible relación entre ambos parámetros. Resultados: Se obtuvieron 151 (30%) respuestas en cardiología, 227 (27%) en patología digestiva, 148 (30%) en neurología y 177 (18%) en otorrinolaringología. Los índices de publicaciones y de citaciones mostraron mayoritariamente una relación positiva y estadísticamente significativa con el índice de reputación. Conclusiones: El trabajo presentado realiza una primera aproximación al estudio de la reputación como medida indirecta de la calidad de los hospitales españoles. La producción científica de éstos mostró una relación positiva con el índice de reputación

Background and objective: To assess the relationship between reputation of hospitals, as determined by specialists' opinion, and their scientific production. Material and method: A questionnaire was sent to a sample of members of the Spanish Societies of Cardiology, Digestive Diseases, Neurology and Otorhinolaryngology. Each member had the possibility to nominate 5 hospitals with the greatest reputation amongst his/her specialty. Final score for those hospitals with more than 5% of all votes was used for the development of a reputation index. We assess the scientific production (number of publications and citations) for nominated hospitals and analyze the possible correlation between the reputation index and the scientific production. Results: We received 151 (30%) answers for cardiology, 227 (27%) for digestive diseases, 148 (30%) for neurology and 177 (18%) for otorhinolaryngology. The number of published articles and the number of citations for each nominated hospital showed a positive and statistically significant correlation with the reputation index. Conclusions: This is the first approach to analyze reputation parameters for Spanish hospitals. Scientific production and reputation index showed a positive correlation

[Central-venous catheter-related infections and intensive care unit organization systems (EPIC Study, Spain)]. / Infecciones relacionadas con el uso de catéteres venosos centrales y sistemas organizativos de las unidades de cuidados intensivos (estudio EPIC).

BACKGROUND AND OBJECTIVE: Central venous catheter (CVC)-related nosocomial bacteremia is an important problem at the ICU. The possible role of organizational factors, as well as health care workers experience, for developing these infections is not well known. We aimed to identify the possible relationships and differences between the health care process, organizational features of the institutions and the development of CVC-related nosocomial infections. We also compared the results of the Spanish participating hospital with those of an international group of hospitals. PATIENTS AND METHOD: The EPIC study (Evaluation of Processes and Indicators in Infection Control) includes a total of 56 hospitals from different countries. The Hospital Clínic of Barcelona was the only Spanish participant. Each Hospital selects, by means of a random process, 5 ICU patients per month with a recently placed CVC. Data related to the CVC insertion process, follow-up and care of the CVC, time dedication of nursing personnel, days of stay and episodes of CVC-related bacteremia per 1000 patient-days of CVC use were recorded. RESULTS: A total of 3,298 patients with a CVC were included, and 89 episodes of CVC-related nosocomial bacteremia were identified (3.86 episodes per 1000 CVC-days). The Hospital Clínic included 67 patients with a CVC and identified 1.96 episodes of CVC-related nosocomial bacteremia per 1000 CVC-days. When compared to the international group of hospitals, the Spanish centre used sterile drapes more frequently for fixing the CVC (70% vs. 23%), each Health Care Worker inserted fewer CVC (average over last 6 months: 24 vs 50) and CVC were more frequently inserted by Registered Nurses (48% vs. 4%). The type of CVC more commonly used in Spain was a peripherically-inserted CVC (48% vs. 6%), and the CVC was withdrawn from patients less commonly before discharge from the ICU (16% vs. 43%). Mean total number of hours of nursing dedication was lower in Spain, with lower personnel ratios (number of nurses' hours) per day of stay (12 vs. 15). CONCLUSIONS: The EPIC study provides a valid tool for assessing the results of the process of health care, and for linking the outcomes to this process. The results registered at the Spanish hospital seem to be adequate, yet some differences in the health care process are identified.

Infecciones relacionadas con el uso de catéteres venosos centrales y sistemas organizativos de las unidades de cuidados intensivos (estudio EPIC) / Central-venous catheter-related infections and intensive care unit organization systems (EPIC Study, Spain)

FUNDAMENTO Y OBJETIVO: La bacteriemia nosocomial relacionada con el empleo de catéteres venosos centrales (CVC) es un problema importante en las unidades de cuidados intensivos (UCI). El papel que desempeñan el sistema organizativo y la experiencia de los profesionales sanitarios en este proceso es poco conocido. El objetivo de este estudio fue identificar posibles relaciones y diferencias entre los procesos asistenciales, la organización de las UCI y el desarrollo de bacteriemia nosocomial relacionada con el uso de CVC y analizar los resultados de un hospital español junto a los registrados en un grupo internacional de hospitales. PACIENTES Y MÉTODO: El estudio EPIC (Evaluation of Processes and Indicators in Infection Control) incluyó hospitales de distintos países. El Hospital Clínic de Barcelona fue el único participante español. Cada centro seleccionó, mediante un muestreo aleatorio, a 5 pacientes por mes, ingresados en una misma UCI, a los que se había colocado recientemente (en un intervalo inferior a 24 h) un CVC. Se obtuvieron datos relativos al proceso de inserción del CVC, su seguimiento y sus cuidados, dedicación del personal de enfermería, número de días de estancia en UCI y episodios de bacteriemia nosocomial por 1.000 días de uso de CVC. RESULTADOS: Se incluyó a un total de 3.298 pacientes portadores de CVC, en los que se registraron 89 episodios de bacteriemia nosocomial (3,86 episodios por 1.000 días de uso de catéter). El Hospital Clinic incluyó a 67 pacientes, en los que se registraron 1,96 episodios de bacteriemia nosocomial por 1.000 días de uso de CVC. El centro español empleaba con más frecuencia gasa estéril y cinta adhesiva para la fijación del CVC que el grupo internacional de 55 hospitales (70 frente al 23 por ciento), cada profesional sanitario español colocaba menos CVC en promedio en los 6 meses precedentes que sus colegas internacionales (24 frente a 50) y los CVC eran colocados en el Hospital Clínic con mayor frecuencia por personal de enfermería (48 frente al 4 por ciento). El tipo de CVC más empleado en el Hospital Clínic era el de inserción periférica (48 frente al 6 por ciento), y era retirado antes del alta del paciente de la UCI en menos ocasiones (16 frente al 43 por ciento). La media de horas totales de dedicación de personal de enfermería era más baja en España, con índices de personal (número de horas de enfermería) por día de estancia del paciente también inferiores a los internacionales (12 frente a 15). CONCLUSIONES: El estudio EPIC proporciona un conjunto de instrumentos válidos para evaluar el proceso asistencial y relacionar este proceso con sus resultados. Los resultados finales observados en el hospital español son adecuados, y se observan diferencias notables en el proceso asistencial (AU)