Gender differences, inequalities and biases in the management of Acute Coronary Syndrome.

OBJECTIVE: The approach to Acute Coronary Syndrome from a gender perspective is relatively recent. Research is extensive at epidemiological and clinical levels. However, available evidence, besides neglecting the social dimensions of the disease, has made women invisible. The objective of this review was to analyze the inequalities and gender biases in Acute Coronary Syndrome, from the beginning of the disease process to the final resolution. METHODS: An exhaustive review of the literature of the entire health care process, from risk factors to rehabilitation and recovery, was carried out. The search for articles on gender, gender inequalities, or gender bias was conducted in indexed journals of social and health sciences. Also, a specific search was performed for each stage of the process, such as risk factors, prehospital phase, diagnosis, treatment, and rehabilitation. RESULTS: Results showed the presence of gender biases throughout the entire health care process in Acute Coronary Syndrome. It is shown gender inequalities in the access to medical care, including a poor recognition among women themselves as well as among health professionals; longer prehospital delays; inadequate diagnoses and treatments; or less assistance to cardiac rehabilitation programmes. These biases occurred at the different levels of the health services involved. Finally, this review included recommendations proposed or arising from the revised papers. CONCLUSIONS: Reducing gender biases in Acute Coronary Syndrome implies developing strategies to raise awareness among women, improve training of professionals serving at the different levels of health services, reduce delays, develop health management measures, and promote a research agenda.

Réplica de los autores a la carta: No hacer: de las recomendaciones a la acción / Reply: Do not do: from recommendations to action

No disponible

[Identifying indicators of good practice in clinical and healthcare management]. / Identificación de indicadores de buenas prácticas en gestión clínica y sanitaria.

OBJECTIVE: To identify good practices in order to develop and implement indicators of health outcomes for clinical and healthcare management, as well as the characteristics for an indicator to be considered adequate. METHODOLOGY: A scoping review was performed, with the following phases: 1) Search and identification of bibliography. 2) Selection of relevant documents. Including those studies that discussed issues related to good practices for the use of health indicators in the management field. Those published in a language other than English or Spanish or before 2006 were excluded. 3) Analysis and extraction of information. 4) Consultation with stakeholders, using a qualitative methodology through Concept Mapping, with the participation of 40 experts (decision-makers, scientific societies, and health professionals). The data collection process included an inductive and structured procedure, with prioritisation of ideas grouped into clusters, according to feasibility and importance criteria (0-10 scale). RESULTS: Good practices identified 2 levels: 1) macro-management: Define a framework for the evaluation of indicators and establish a benchmark of indicators. 2) meso-management: Establish indicators according to evidence and expert consensus, taking into account priority areas and topics, testing before final use, and communicate results adequately. The characteristics of a suitable indicator are: 1) Approach of an important issue, 2) Scientific validity, 3) Possibility of measurement with reliable data, 4) Meaning of useful and applicable measurement, and 5) Wide scope. CONCLUSIONS: The best practices for the use of indicators in clinical and healthcare management can make it easier to monitor performance and accountability, as well as to support the decision-making addressed at the development of initiatives for quality improvement.

[Prioritization of non-recommended clinical activities in Primary Care]. / Priorización de actividades clínicas no recomendadas en Atención Primaria.

OBJECTIVE: To prioritize non-recommended clinical activities in Primary Care (PC), from "Do not do" recommendations listed by the Sociedad Española de Medicina de Familia y Comunitaria (Semfyc), according to expert consensus (physicians, nurses and pharmacists). METHODS: The consensus for the prioritization of non-recommended practices in PC was performed through an online procedure. We used as a base the list of "do not-do" recommendations of the SEMFYC. We asked the experts to prioritize practices that should be de-adopted in PC, based on four prioritization criteria: frequency of occurrence, cost of the activity, ease of disposal and damage caused, which were scored from one to five, according to their recommendation. Scores were summarized in median and quartile values. Two rounds were necessary to obtain a consensus. A modified e-Delphi technique was used. RESULTS: 34 experts (62%) participated in the first consultation round and prioritized 19 recommendations with a score = 3.5. These recommendations were again analyzed in a second round, in which 32 panelists agreed to prioritize 17 practices (13 related to prescription, three diagnostic tests, and one clinical analysis). The high priority list included seven practices with values = 4: 1) Prescription of a new drug in elderly patients without having reviewed the previous treatments; 2) Lipid-lowering drugs without calculating the overall cardiovascular risk; 3) Not systematically prescribing gastric protection with proton pump inhibitors to patients consuming Nonsteroidal anti-inflammatory drugs (NSAIDs); 4) Glucose self-analysis in non-insulinized type 2 diabetics; 5) Benzodiazepines in the long term; 6) Bisphosphonates in patients with low risk of fracture; and 7) Antibiotics in lower respiratory tract infections. CONCLUSION: This study provides information for the prioritization of 17 non-AP activities in which short-term de-adoption would significantly increase the efficiency of the public health system.

Priorización de actividades clínicas no recomendadas en Atención Primaria / Prioritization of non-recommended clinical activities in Primary Care

Fundamento: Priorización de las recomendaciones «no hacer» procedentes de la lista de la Sociedad Española de Medicina de Familia y Comunitaria (Semfyc) de actividades preventivas, diagnósticas, terapéuticas o de cuidados que no es correcto hacer en Atención Primaria (AP), a través de un consenso de profesionales expertos de medicina, farmacia y enfermería. Método: Mediante un procedimiento online se solicitó a los expertos la valoración de cada una de las prácticas «no hacer» con cuatro criterios de priorización: frecuencia de ocurrencia, coste de la actividad, facilidad para la eliminación y daño ocasionado. Cada práctica se puntuó de uno a cinco en función de su recomendación para la eliminación, y las puntuaciones se resumieron en mediana y cuartiles. Fueron necesarias dos rondas para obtener consenso. Se utilizó la técnica e-Delphi modificada. Resultados: En la primera ronda de consulta participaron 34 expertos (62%) que priorizaron 19 recomendaciones (puntuación ≥ 3,5) que fueron analizadas en una segunda ronda en la que consensuaron priorizar 17 prácticas para no hacer en AP (13 de prescripción de medicamentos, tres de pruebas diagnósticas, y una de análisis clínico). La lista de muy alta prioridad incluyó siete prácticas con valores ≥ 4, 1) prescripción de nuevo medicamento en mayores sin haber revisado los tratamientos previos, 2) prescripción de hipolipemiantes sin calcular el riesgo cardiovascular global, 3) prescripción de protección gástrica con inhibidores de la bomba de protones a los pacientes que consumen antiinflamatorios no esteroideos, 4) autoanálisis de la glucosa en diabéticos tipo 2 no insulinizados, 5) prescripción de benzodiacepinas a largo plazo, 6) prescripción de bifosfonatos en pacientes con bajo riesgo de fractura y 7) prescripción de antibióticos en infecciones del tracto respiratorio inferior. Conclusiones. Este estudio ofrece información para la priorización de diecisiete actividades «no hacer» en AP cuya desadopción en el corto plazo aumentaría considerablemente la eficiencia del sistema sanitario público (AU)

Background: To prioritize non-recommended clinical activitiesin Primary Care (PC), from «Do not do» recommendations listed by the Sociedad Española de Medicina de Familia y Comunitaria (Semfyc), according to expert consensus (physicians, nurses and pharmacists). Methods. The consensus for the prioritization of non-recommended practices in PC was performed through an online procedure. We used as a base the list of «do not-do» recommendations of the SEMFYC. We asked the experts to prioritize practices that should be de-adopted in PC, based on four prioritization criteria: frequency of occurrence, cost of the activity, ease of disposal and damage caused, which were scored from one to five, according to their recommendation. Scores were summarized in median and quartile values. Two rounds were necessary to obtain a consensus. A modified e-Delphi technique was used. Results. 34 experts (62%) participated in the first consultation round and prioritized 19 recommendations with a score ≥ 3.5. These recommendations were again analyzed in a second round, in which 32 panelists agreed to prioritize 17 practices (13 related to prescription, three diagnostic tests, and one clinical analysis). The high priority list included seven practices with values ≥ 4.1) Prescription of a new drug in elderly patients without having reviewed the previous treatments; 2) Lipidlowering drugs without calculating the overall cardiovascular risk; 3) Not systematically prescribing gastric protection with proton pump inhibitors to patients consuming Nonsteroidal anti-inflammatory drugs (NSAIDs); 4) Glucose self-analysis in non-insulinized type 2 diabetics; 5) Benzodiazepines in the long term; 6) Bisphosphonates in patients with low risk of fracture; and 7) Antibiotics in lower respiratory tract infections. Conclusion. This study provides information for the prioritization of 17 non-AP activities in which short-term de-adoption would significantly increase the efficiency of the public health system (AU)

[Identification of health outcome indicators in Primary Care. A review of systematic reviews]. / Identificación de indicadores de resultado en salud en atención primaria. Una revisión de revisiones sistemáticas.

INTRODUCTION: Outcome measures are being widely used by health services to assess the quality of health care. It is important to have a battery of useful performance indicators with high validity and feasibility. Thus, the objective of this study is to perform a review of reviews in order to identify outcome indicators for use in Primary Care. METHODOLOGY: A review of systematic reviews (umbrella review) was carried out. The following databases were consulted: MedLine, EMBASE, and CINAHL, using descriptors and free terms, limiting searches to documents published in English or Spanish. In addition, a search was made for free terms in different web pages. Those reviews that offered indicators that could be used in the Primary Care environment were included. RESULTS: This review included a total of 5 reviews on performance indicators in Primary Care, which consisted of indicators in the following areas or clinical care processes: in osteoarthritis, chronicity, childhood asthma, clinical effectiveness, and prescription safety indicators. A total of 69 performance indicators were identified, with the percentage of performance indicators ranging from 0% to 92.8%. None of the reviews identified performed an analysis of the measurement control (feasibility or sensitivity to change of indicators). CONCLUSIONS: This paper offers a set of 69 performance indicators that have been identified and subsequently validated and prioritised by a panel of experts.

Identificación de indicadores de resultado en salud en atención primaria. Una revisión de revisiones sistemáticas / Identification of health outcome indicators in Primary Care. A review of systematic reviews

Introducción. Las medidas de resultados están siendo ampliamente utilizadas por los servicios sanitarios para evaluar la calidad de la atención sanitaria. Disponer de una batería de indicadores de resultados de alta validez y factibilidad y que además sean de utilidad resulta de gran importancia. Así, el objetivo de este trabajo es realizar una revisión de revisiones para identificar indicadores de resultado susceptibles del ámbito de atención primaria. Metodología. Se realizó una revisión de revisiones sistemáticas (umbrella review) en la que se consultaron las siguientes bases de datos: MedLine, EMBASE y CINAHL, mediante descriptores y términos libres, limitando las búsquedas a documentos publicados en inglés o castellano. Además, se realizaron búsquedas mediante términos libres en diferentes páginas web. Se incluyeron aquellas revisiones que ofreciesen indicadores susceptibles de ser utilizados en el ámbito de la atención primaria. Resultados. Se incluyeron 5 revisiones sobre indicadores en atención primaria, que recopilaban indicadores sobre los siguientes ámbitos o procesos clínicos: atención en osteoartrosis, atención a la cronicidad, asma infantil, efectividad clínica e indicadores sobre seguridad de prescripción. Se identificaron un total de 69 indicadores de resultados, oscilando el porcentaje de indicadores de resultados sobre el total entre el 0 y el 92,8%, según la revisión analizada. Ninguna de las revisiones identificadas realizó un análisis del control de medición (factibilidad o sensibilidad al cambio de los indicadores). Conclusiones. Este trabajo ofrece un conjunto de 69 indicadores de resultados que han sido identificados y posteriormente validados y priorizados mediante un panel de expertos (AU)

Introduction. Outcome measures are being widely used by health services to assess the quality of health care. It is important to have a battery of useful performance indicators with high validity and feasibility. Thus, the objective of this study is to perform a review of reviews in order to identify outcome indicators for use in Primary Care. Methodology. A review of systematic reviews (umbrella review) was carried out. The following databases were consulted: MedLine, EMBASE, and CINAHL, using descriptors and free terms, limiting searches to documents published in English or Spanish. In addition, a search was made for free terms in different web pages. Those reviews that offered indicators that could be used in the Primary Care environment were included. Results. This review included a total of 5 reviews on performance indicators in Primary Care, which consisted of indicators in the following areas or clinical care processes: in osteoarthritis, chronicity, childhood asthma, clinical effectiveness, and prescription safety indicators. A total of 69 performance indicators were identified, with the percentage of performance indicators ranging from 0% to 92.8%. None of the reviews identified performed an analysis of the measurement control (feasibility or sensitivity to change of indicators). Conclusions. This paper offers a set of 69 performance indicators that have been identified and subsequently validated and prioritised by a panel of experts (AU)

Modelling the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis.

BACKGROUND: The aim of this study was to model the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis versus medical therapy based on 10-year data from the Asymptomatic Carotid Surgery Trial (ACST). METHODS: This was a cost-utility analysis based on clinical effectiveness data from the ACST with UK-specific costs and stroke outcomes. A Markov model was used to calculate the incremental cost-effectiveness ratio (ICER, or cost per additional quality-of-life year) for a strategy of early endarterectomy versus medical therapy for the average patient and published subgroups. An exploratory analysis considered contemporary event rates. RESULTS: The ICER was £7584 per additional quality-adjusted life-year (QALY) for the average patient in the ACST. At thresholds of £20,000 and £30,000 there was a 74 and 84 per cent chance respectively of early endarterectomy being cost-effective. The ICER for men below 75 years of age was £3254, and that for men aged 75 years or above was £71,699. For women aged under 75 years endarterectomy was less costly and more effective than medical therapy; for women aged 75 years or more endarterectomy was less effective and more costly than medical therapy. At contemporary perioperative event rates of 2·7 per cent and background any-territory stroke rates of 1·6 per cent, early endarterectomy remained cost-effective. CONCLUSION: In the ACST, early endarterectomy was predicted to be cost-effective in those below 75 years of age, using a threshold of £20,000 per QALY. If background any-territory stroke rates fell below 1 per cent per annum, early endarterectomy would cease to be cost-effective.

[An economic assessment of genetic testing for familial adenomatous polyposis]. / Evaluación económica de la prueba genética de la poliposis adenomatosa familiar.

OBJECTIVE: To analyze the cost-effectiveness of genetic testing for first-degree relatives of patients with colon cancer to identify mutations in the APC gene (Adenomatous Polyposis Coli). METHODOLOGY: Analyses were performed from the perspective of the health system. We used a Markov model. We compared genetic testing for the APC gene, the cause of familial adenomatous polyposis (FAP), which results in colon cancer, versus no genetic testing for said gene. The effectiveness measure used was quality-adjusted life-years (QALYs), and costs were measured in euros for 2005. The costs of interventions were extracted from the costs of health services provided by centers under the Andalusian Public Health System, and other parameters were obtained from the literature. RESULTS: The performance of genetic testing is the dominant strategy when compared to the absence of genetic testing given the latter option has an incremental cost of 7,676.34 euros and is less effective. A sensitivity analysis found that genetic testing remains the dominant strategy for a plausible range of costs of the test itself, and for the probability of developing adenocarcinoma. CONCLUSIONS: Our analysis showed that in this patient group genetic testing to detect APC gene mutations is on average less costly and improves QALYs versus no testing.

Evaluación económica de la prueba genética de la poliposis adenomatosa familiar / No disponible

Objetivo: analizar el coste-utilidad de la prueba genética a familiaresde primer grado de pacientes con cáncer de colon para determinarmutaciones del gen APC (Adenomatous Polyposis Coli).Metodología: los análisis se realizaron desde el punto de vistadel sistema sanitario. Se utilizó un modelo de Markov. Realizaciónde la prueba genética para el gen APC, causante de la poliposisadenomatosa familiar (PAF), que produce cáncer de colon frentea la no realización de la misma. La medida de efectividad utilizadafueron los años de vida ajustados por calidad (AVAC) y la unidadde coste los euros de 2005. Los costes de las intervenciones fueronextraídos de los precios públicos de los servicios sanitariosprestados por centros dependientes del Sistema Sanitario PúblicoAndaluz y los valores de la efectividad y de utilidad de la literatura.Resultados: la realización de la prueba genética se muestracomo una estrategia dominante a la no realización de la misma,ya que esta última tiene un coste incremental de 7.676,34 €, ademásde una menor efectividad. Los análisis de sensibilidad mostraronque la realización de la prueba genética se mantiene como laestrategia dominante dentro de un amplio rango de coste de laprueba y de probabilidad de desarrollar adenocarcinomas.Conclusiones: los análisis mostraron que, para este grupo depacientes, la realización de la prueba genética para la detecciónde la mutación del gen APC es en promedio menos costosa yademás produce una mejora en AVAC comparado con la no realizaciónde la misma

Objective: to analyze the cost-effectiveness of genetic testingfor first-degree relatives of patients with colon cancer to identifymutations in the APC gene (Adenomatous Polyposis Coli).Methodology: analyses were performed from the perspectiveof the health system. We used a Markov model. We comparedgenetic testing for the APC gene, the cause of familialadenomatous polyposis (FAP), which results in colon cancer,versus no genetic testing for said gene. The effectiveness measureused was quality-adjusted life-years (QALYs), and costswere measured in euros for 2005. The costs of interventionswere extracted from the costs of health services provided bycenters under the Andalusian Public Health System, and otherparameters were obtained from the literature.Results: the performance of genetic testing is the dominantstrategy when compared to the absence of genetic testing giventhe latter option has an incremental cost of € 7,676.34 and is lesseffective. A sensitivity analysis found that genetic testing remainsthe dominant strategy for a plausible range of costs of the test itself,and for the probability of developing adenocarcinoma.Conclusions: our analysis showed that in this patient groupgenetic testing to detect APC gene mutations is on average lesscostly and improves QALYs versus no testing

Comparación de costes y supervivencia en pacientes intervenidos quirúrgicamente de cáncer colorrectal según diferentes modelos organizativos / A comparison of costs and survival in colorrectal cancer patients undergoing surgery according to different organizational models

Objetivo: determinar la efectividad y los costes de los diferentesmodelos organizativos en la atención a los pacientes con cáncercolorrectal, ya sea a través de las unidades funcionales de gestiónclínica o servicios clínicos tradicionales.Método: se analizó la mortalidad postoperatoria y a largo plazo(30 días y 5 años) en función del número de pacientes sometidosa tratamiento quirúrgico en el hospital para su cáncer colorrectal,ajustado por factores confundentes a nivel de pacientes.Para ello se realizó una revisión exhaustiva de la literatura y con lainformación obtenida se realizó un meta-análisis de efectos aleatorios.En cuanto a los costes se realizó una búsqueda bibliográficapara describir las diferencias entre los hospitales según el númerode pacientes atendidos al año.Resultados: se encontró que aquellas intervenciones realizadasen hospitales de gran volumen mostraban un menor coste porintervención y una menor media en días de estancia hospitalaria.El meta-análisis mostró que el riesgo de morir a los 30 días y5 años en los hospitales de alto volumen es menor que aquelloscon bajo volumen (OR: 1,112; IC95% 0,986-1,255 y OR:1,114; IC95% 1,105-1,183 respectivamente).Conclusiones: la mortalidad postoperatoria a corto y largoplazo es menor en hospitales con alto volumen de casos al año

Objective: to determine the effectiveness and costs of differentorganizational models in caring for colorectal cancer patientsthrough either clinical management functional units or traditionalclinical services.Method: post-operative and long-term (after 30 days and5 years) mortality was analyzed according to number of patientsundergoing surgery because of colorectal cancer. Mortality wasadjusted for patient-related confounding factors. With that purposea thorough review of the literature was conducted; informationobtained was used in a meta-analysis of randomiszd effects. Concerningcosts, a literature search was run to describe differences innumber of patients per year between hospitals.Results: surgery costs were found to be smaller, and meanhospital stay shorter, in big-sized hospitals. The meta-analysisshowed that the risk of death at 30 days and 5 years was lower inbig hospitals versus smaller ones (OR: 1.112; 95% CI 0.986-1.255, and OR: 1.114; 95% CI 1.105-1.183, respectively).Conclusions: short- and long-term postoperative mortality islower in hospitals with a high number of cases per year

[A comparison of costs and survival in colorectal cancer patients undergoing surgery according to different organizational models]. / Comparación de costes y supervivencia en pacientes intervenidos quirúrgicamente de cáncer colorrectal según diferentes modelos organizativos.

OBJECTIVE: To determine the effectiveness and costs of different organizational models in caring for colorectal cancer patients through either clinical management functional units or traditional clinical services. METHOD: Post-operative and long-term (after 30 days and 5 years) mortality was analyzed according to number of patients undergoing surgery because of colorectal cancer. Mortality was adjusted for patient-related confounding factors. With that purpose a thorough review of the literature was conducted; information obtained was used in a meta-analysis of randomized effects. Concerning costs, a literature search was run to describe differences in number of patients per year between hospitals. RESULTS: Surgery costs were found to be smaller, and mean hospital stay shorter, in big-sized hospitals. The meta-analysis showed that the risk of death at 30 days and 5 years was lower in big hospitals versus smaller ones (OR: 1.112; 95% CI 0.986-1.255, and OR: 1.114; 95% CI 1.105-1.183, respectively). CONCLUSIONS: Short- and long-term postoperative mortality is lower in hospitals with a high number of cases per year.