A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study.

AIM: The oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia (Spain). METHODS: This was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years. RESULTS: Of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery. CONCLUSIONS: Laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials.

Influence of age on variation in patterns of care in patients with rectal cancer in Catalonia (Spain)

Background: Population ageing is a relevant concern in people diagnosed with rectal cancer. This study evaluates the adherence to clinical practice guidelines (CPGs) and patient outcomes in rectal cancer, with a particular focus on variation according to age. Methods: This is a multicentre retrospective cohort study of all patients surgically treated for the first time for primary rectal cancer with curative intent in public hospitals in Catalonia during two study periods: first, with data from 2005 to 2007, and then with data from 2011 to 2012. We obtained the study data through a comprehensive review of patients’ clinical records. Information on diagnosis, treatment and follow-up was collected and then compared with the relevant CPGs. We then performed a descriptive analysis of the categorical variables followed by a univariate and multivariate logistic regression analysis to calculate the odds ratio. Finally, we calculated the recurrence and death rates per person-year at 2 years’ follow-up. Results: In total, 3770 people were included in this study. The participants aged 70 and under were more likely to receive neoadjuvant therapy than those aged over 80 (2005/2007, 63 vs 17.4% p < 0.001; 2011/2012, 72 vs 41.1% p < 0.001); however, in the second study period there was less imbalance between the two groups in this regard, showing improved administration of neoadjuvant therapy in the elderly. The quality of surgery was suboptimal in a larger proportion of the elderly population, and the choice of surgical technique was dependent to some extent on the age of the participant. Recurrence and survival rates were significantly better in the second study period. Conclusions: Compared to younger patients, the most elderly were less likely to receive the recommended adjuvant treatment, laparoscopy and total mesorectal excision. However, we observed improved adherence to the recommended treatment regimen in the most elderly participants, resulting in decreased recurrence and increased survival rates in this population

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Influence of age on variation in patterns of care in patients with rectal cancer in Catalonia (Spain).

BACKGROUND: Population ageing is a relevant concern in people diagnosed with rectal cancer. This study evaluates the adherence to clinical practice guidelines (CPGs) and patient outcomes in rectal cancer, with a particular focus on variation according to age. METHODS: This is a multicentre retrospective cohort study of all patients surgically treated for the first time for primary rectal cancer with curative intent in public hospitals in Catalonia during two study periods: first, with data from 2005 to 2007, and then with data from 2011 to 2012. We obtained the study data through a comprehensive review of patients' clinical records. Information on diagnosis, treatment and follow-up was collected and then compared with the relevant CPGs. We then performed a descriptive analysis of the categorical variables followed by a univariate and multivariate logistic regression analysis to calculate the odds ratio. Finally, we calculated the recurrence and death rates per person-year at 2 years' follow-up. RESULTS: In total, 3770 people were included in this study. The participants aged 70 and under were more likely to receive neoadjuvant therapy than those aged over 80 (2005/2007, 63 vs 17.4% p < 0.001; 2011/2012, 72 vs 41.1% p < 0.001); however, in the second study period there was less imbalance between the two groups in this regard, showing improved administration of neoadjuvant therapy in the elderly. The quality of surgery was suboptimal in a larger proportion of the elderly population, and the choice of surgical technique was dependent to some extent on the age of the participant. Recurrence and survival rates were significantly better in the second study period. CONCLUSIONS: Compared to younger patients, the most elderly were less likely to receive the recommended adjuvant treatment, laparoscopy and total mesorectal excision. However, we observed improved adherence to the recommended treatment regimen in the most elderly participants, resulting in decreased recurrence and increased survival rates in this population.

Improving survival and local control in rectal cancer in Catalonia (Spain) in the context of centralisation: A full cycle audit assessment.

BACKGROUND: Rectal cancer surgery in Catalonia has been involved in a process of centralisation. We assessed the impact of this health policy strategy on quality of care and clinical results. METHODS: We compared patterns of care and clinical outcomes of all rectal cancer patients receiving radical surgery for the first time in public hospitals in two time periods, before (2005 and 2007) and after (2011-2012) centralisation, analysing indicators of care quality according to the regional clinical practice guidelines. Clinical outcomes at two years were also assessed. RESULTS: A total of 3780 patients were included. From 2005 to 2012, the proportion of patients treated surgically for the first time in centres whose annual surgical caseload was more than 11 increased from 84.0% to 90.4%. The rate of locoregional recurrence at two years fell from 4.5 to 3.06/100 person-years (p = 0.005). The crude mortality rate at three months, one and two years was reduced by 55%, 40% and 34% (p < 0.001). CONCLUSION: Improvements in quality of care might be associated with the centralisation of surgery and with the selective focus effect derived from the process of auditing. Our results support the continuation of clinical auditing and surveillance of authorised centres.

Comparación de equipos de atención primaria de barcelona según formulas de gestión / Comparison of primary health care teams in barcelona according different managemental formulas

Objetivo. El objetivo del estudio es comparar, para zonas socioeconómicamente similares, el resultado en la utilización de servicios, la práctica clínica y los costes de farmacia, cuando los equipos de atención primaria encargados de la provisión de servicios se organizan según formulas de gestión diferenciadas. Diseño. Estudio descriptivo de evaluación de servicios sanitarios. Pacientes y métodos. Se seleccionaron EAP comparables de ambas fórmulas de gestión (Institut Català de la Salut/Otros proveedores públicos) de acuerdo con el nivel socioeconómico de la población. Se evaluó el resultado de indicadores relacionados con la utilización de servicios, práctica clínica y costes de farmacia. Resultados principales. Se observan diferencias en la oferta de servicios a la población entre las diferentes formas de provisión. La utilización de servicios por la población se relaciona con sus características socioeconómicas y no con la forma de provisión de servicios sanitarios. Respecto a la práctica asistencial, aunque globalmente no se detectan diferencias relevantes entre las diferentes formas de provisión de servicios, se observa variabilidad entre los distintos equipos seleccionados, no siguiendo un patrón atribuible a la fórmula de gestión. La mayor fuente de variabilidad en el gasto farmacéutico parece relacionarse con un condicionante externo. Conclusiones. Los datos analizados no permiten identificar diferencias relevantes entre las distintas formas de provisión de servicios. Las variaciones observadas parecen relacionarse principalmente con las características de la población, su patrón de uso de los servicios públicos u otros condicionantes externos (AU)

[Comparison of primary care teams in Barcelona according to management formulas]. / Comparación de equipos de atención primaria de Barcelona según formulas de gestión.

OBJECTIVE: The aim of the study is to compare, among socio-economically similar areas, the use of medical services, clinical practice and pharmacy costs depending on the how the primary healthcare teams, that provide these services, are organized according to different managemental formulas. DESIGN: Descriptive study of the evaluation of health care services. PATIENTS AND METHODS: The population units (basic health areas) attended by the reformed primary health care services in Barcelona were classified into three levels according to the population's socioeconomic status (high, medium or low). For each level, two primary health care teams were selected representing different primary health care providers: "Institut Catala de la Salut"; and others. The influence of both the provision option and the population characteristics on service use, clinical practice and costs of prescription were compared. MAIN RESULTS: The services offered by the two provision options differ. However, the use of medical services is related to the socioeconomic characteristics and not to the option for service provision. Whilst there are no relevant differences in clinical practice between the different options, we observed variations among different primary care teams, notably in referrals to specialists and influenza vaccine coverage. The greater source of variation in prescription costs seems to be related to an external confounding factor. CONCLUSIONS: Empirical data have not identified relevant differences in the pattern of use, clinical practice, or costs between the different options for service provision within the model of reformed primary care services. Observed variations seem to be associated mainly with the population's characteristics, its pattern of health service use or other external confounding factors.

[An evaluation of the impact of primary care reform on health]. / Evaluación del impacto de la reforma de la atención primaria sobre la salud.

OBJECTIVE: Evaluation of the impact of the reform of primary health care services on the population health. DESIGN: Comparative analysis of mortality rates for the 1984-96 period in three zones of homogeneous socioeconomic level, assessing the effect of the differential development of the reform of public primary health care services. SETTING: The study is restricted to the 23 health areas with lower socioeconomic status in the city of Barcelona (443092 inhabitants). MEASUREMENTS AND MAIN RESULTS: The study areas are categorized in three groups, according to the sequence of the reform: reformed between 1984 and 1989, RAP1 zone, reformed between 1990 and 1991, RAP2 zone, and those still served by the old scheme in 1992, NORAP zone. General mortality rates are analyzed, and also mortality rates by those avoidable conditions. Significant differences among the three zones are initially visible. The mortality decline is 13.6% in the RAP1 zone and 10.3% in the NORAP zone, so that the decline in the RAP1 zone is 32% greater than in the NORAP zone. At the end of the study, mortality due to stroke and hypertension is lower in the RAP zones than in the NORAP zone. Perinatal mortality shows a clear decline in the three zones. No relevant changes are seen for tuberculosis or cervical cancer. Lung cancer mortality increases except in RAP1 zone where it declines, to the point that the excess mortality from that cause estimated by comparison with the NORAP zone in the initial phase of the study vanishes. Death rates from cirrhosis and motor vehicle accident decline in all zones. CONCLUSIONS: There is a clear association between the process of reform of primary care and the decrease in general mortality in these zones of low socioeconomic level. These results suggest that the reform of primary health care services in Spain may have a significant impact in the mortality of the population of lower socioeconomic level. The study highlight the cost in health and human lives of maintaining obsolete and overburdened services for some segments of the population, and justify the need and urgency of completing the process of reform initiated in 1984 and still unfinished in 1999.

[Reorganising specialist care in the Ciutat Vella Health Sector: analysis of an experience]. / La reordenación de la atención especializada en el Sector Sanitario Ciutat Vella: análisis de una experiencia.

OBJECTIVE: Analysis of the results obtained in terms of improvement in the continuity of care, its resolutive capacity and accessibility, in the framework of the organisational change brought about by the reorganisation of specialist care (RSC) in the Ciutat Vella Health Sector. DESIGN: A descriptive study of the reorganised model of specialist care introduced in 1995 and comparison between this and the previous model (1993) in terms of activity, further tests made, referral to hospital, filling in the clinical history and waiting-list. T SETTING: The experience involved 4 PCTs in the Ciutat Vella Health sector of Barcelona (covering 74,449 people). MEASUREMENTS AND MAIN RESULTS: The volume of visits was in general less in 1995, while other types of activity had been incorporated: minor surgery, cryotherapy, consultations and sessions. CONCLUSIONS: The model of RSC satisfies the basic objectives for which it was designed. It increased the specialist's ability to resolve the case within Primary Care. It improved user accessibility to specialist care in terms of waiting time. Finally, the model favours ongoing care, thanks to a single clinical history for both levels.

[Correction of social inequalities in health: reform of primary health care as a strategy]. / Corregir las desigualdades sociales en salud: la reforma de la atención primaria como estrategia.

OBJECTIVES: To evaluate the impact of a policy to define priorities for the reform of primary health care services among small areas according to health and social indicators. DESIGN: Qualitative study of the changes in the provision of primary health care services after a priority setting exercise based in social and a health indicators. SETTING: The city of Barcelona (Catalonia, Spain). PARTICIPANTS: The 66 basic health areas in which the city is divided for health care planning. INTERVENTION: Areas are ranked according to their health and social indicators, giving greater priority to those areas with unfavorable indicators for the development of the reform of primary health care services and a associated allocation of resources. RESULTS: Although at first new investments were determined by preexisting processes based in opportunity criteria, clear changes are observed. Three years after, there are improvements in the provision for services in all priority areas, or they are in the midst of change. CONCLUSIONS: In a context of tightening resources and of resistance to change, it is possible to introduce objective criteria to set priorities to improve primary health care services selectively in areas with most unfavorable indicators. This process has the capacity to overrun obstacles and resistances.

[Vaccination against hepatitis B in health workers and other staff in Barcelona]. / Vacunación contra el virus de la hepatitis B del personal sanitario y no sanitario en el área de Barcelona ciudad.

OBJECTIVE: To analyse the results of a hepatitis B vaccination programme, in order to find the levels of acceptance of the programme and adherence to it, as well as the immunological response and the impact of age, gender and the index of corporal mass (ICM). DESIGN: This was a retrospective study. SETTING: Primary Care. PATIENTS AND OTHER PARTICIPANTS: 2,055 Primary Care professionals considered at risk (43.3% of the Area total). MEASUREMENTS AND MAIN RESULTS: Out of the total number of professionals at risk, 1,294 (63%) agreed to have the serological markers. The prevalence of markers of the hepatitis B virus (HBV) was 16.07% (208), which increased with age (p < 0.0001). 87% had three doses (961/1,106). 863 (89.8%) of these went through the post-vaccination controls and levels of HB antibodies above 10 IU/ml were found in 790 (91.5%). The fourth dose produced favorable results (66.7%) in individuals with HB antibodies between 10 and 100 IU/ml and unfavorable ones (3.8%) where the HB antibodies were below 10 IU/ml. CONCLUSIONS: The hepatitis B vaccination programme has not enjoyed total acceptance by Primary Care professionals, although a satisfactory level of adherence has been reached. Age is the variable linked most closely to the risk of a poor immunological response, though ICM and gender should not be ignored.

[Study of diffuse chronic hepatopathy in the outpatient context]. / Estudio de la hepatopatía crónica difusa en el medio extrahospitalario.

OBJECTIVE: Description of the general characteristics of patients with Diffuse Chronic Hepatopathy (DCH) in an ABS. DESIGN: Empirical study of a prospective and retrospective type. Site. Primary Care. ABS La Mina. Sant Adrià de Besòs. PATIENTS AND OTHER PARTICIPANTS: All patients diagnosed as suffering DCH since 1984, in line with histological or clinical--morphological criteria accepted in the literature. MAIN MEASUREMENTS AND RESULTS: Using a data base of the centre's morbidity and mortality register, 287 reports of patients over 14 years old defined as having DCH were examined. 222 cases met the established criteria. Most of these were males (68%), and to an even higher proportion in the group with alcoholic etiology (84%), which was the most common cause of DCH (64.4%). There was a lower number of complications and deaths attributable to DCH than in published hospital series. CONCLUSIONS: Among the characteristics of DCH in a natural population using the health services, it is important to note the predominance of compensated forms having a rate of complications and deaths attributable to DCH significantly lower than what was observed in hospital series. This information may be of use in planning activities at the ABS level.

[A tumor registry at a primary care center]. / Registro de tumores en un centro de asistencia primaria.

AIM: We analysed the data obtained from a tumor register kept in a Primary Care Centre (PCC) to find out the variables which contribute to the diagnostic and therapeutic evolution of our patients. DESIGN: Retrospective study on every Neoplasia registered in the Centre. PATIENTS: 293 malignant Neoplasias were recorded in the period between June 1984 and June 1990 (184 in males--62.8%; and 109 in women--37.2%). MEASUREMENTS AND MAIN RESULTS: The intervals between symptom and consultation (ISC), between consultation and referral (ICR), between referral and diagnosis (IRD) and between diagnosis and treatment (IDT) were evaluated. The average age at the moment of diagnosis was 59 (SD:13). There were 3.9% double neoplasias. The most frequent type was lung cancer with 41 cases (14%). This also occupied first place among men, whereas breast cancer did so among women. 10 tumours were diagnosed by screening: 4 breast, 5 cervix and 1 endometrium, which represent 16%, 50% and 14.3% respectively of these cancers. For all neoplasias taken together, the average time of ISC was 44.09 days (SD 73.48) and of IDT 25.75 days (SD:61.55). Given the wide variations, we assessed the most common types of tumour. CONCLUSIONS: The usefulness of keeping a tumour register in a Primary Care Centre, which could identify the factors which affect diagnostic delays and find possible corrective measures to reduce the delays, was appraised.

[The evaluation of different methods for rapid diagnosis in the detection of asymptomatic bacteriuria in pregnant women]. / Evaluación de diferentes métodos de diagnóstico rápido en la detección de bacteriuria asintomática en la gestante.

We compared the effectiveness of different methods of rapid diagnosis in the detection of asymptomatic bacteriuria in 74 females during the first trimester of pregnancy. The sensitivity, specificity and negative predictive value for the visual reading of nitrites, leukocyte sterase, bacteriuria and leukocyturia in the sediment and bacteria in Gram stain were 77%, 22%, 33%, 22% and 88%, 98%, 85%, 82%, 91% and 86%, and 97%, 89%, 90% and 90%, with and accuracy of 96%, 77%, 76%, 82% and 86%, respectively. The combination of visual readings of nitrites and Gram stain showed a sensitivity and negative predictive value of 100%. We conclude that if the reading of the reactive strip is negative, the likelihood of a positive culture is very small, and it is minimal when combined with Gram stain.

[Request for a hemogram as a marker of the quality of health care]. / La solicitud del hemograma como indicador de calidad del proceso asistencial.

The evaluation of markers of the health care activity, such as the reason for requesting a peripheral blood count in everyday practice and its inclusion in the clinical record, constitutes an estimate of the quality of care. To this end, we have reviewed the requests of 160 peripheral blood counts in our center during one month. It was found that the request itself and/or its cause had not been mentioned in the clinical record in 32.5% of instances. In the cases where the indication could be ascertained, it was not justified in 58.4%. Overall 72.5% of peripheral blood counts were normal. It was concluded that peripheral blood count is an over-utilized test, while its request is insufficiently recorded. This makes diagnostic decisions and the evaluation of the quality of care difficult.