Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016.

INTRODUCTION AND OBJECTIVES: ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI. METHODS: This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality. RESULTS: From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95). CONCLUSIONS: Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

Prevalence of illicit drug use at the end of pregnancy: a cross-sectional study at the time of birth.

BACKGROUND: Drug use during pregnancy is associated with adverse perinatal outcomes. This study was conducted to assess the prevalence of consumption of drugs of abuse in pregnant women at the end of gestation. METHODS: Cross-sectional study of all consecutive pregnant women in labor admitted to a regional hospital in Calella (Barcelona, Spain) in labor over one year (2014-2015). Women who gave written consent to take part in the study provided a urine sample on admission and completed a questionnaire with toxic-habit-related questions. RESULTS: The study population included 862 women, 721 (83.6%) of which agreed to participate. Of the 721 urine samples obtained, 719 (99.7%) were valid for analysis. The prevalence of drugs of abuse was 5.4% (N.=39). Cannabis was the most frequently detected substance. No participant tested positive for opioids. In the multivariate analysis, predictors of illicit drug use were history of more than two abortions, premature delivery, self-reporting of consumption during pregnancy, poor obstetric control during gestation, and consideration of vulnerable pregnant woman. Based on the ß coefficients of these five factors, a scoring system for discriminating positivity or negativity of drugs of abuse in urine testing was calculated (area under the ROC 0.84). CONCLUSIONS: The prevalence of consumption of drugs of abuse at the end of pregnancy was 5.4%. A simple test based on five anamnestic variables is useful to discriminate women with positive and negative results of urine testing for drugs of abuse tested in this study.

[The transformation of the healthcare model in Catalonia to improve the quality of care]. / La transformación del modelo asistencial en Cataluña para mejorar la calidad de la atención.

The changes taking place in western countries require health systems to adapt to the public's evolving needs and expectations. The healthcare model in Catalonia is undergoing significant transformation in order to provide an adequate response to this new situation while ensuring the system's sustainability in the current climate of economic crisis. This transformation is based on converting the current disease-centred model which is fragmented into different levels, to a more patient-centred integrated and territorial care model that promotes the use of a shared network of the different specialities, the professionals, resources and levels of care, entering into territorial agreements and pacts which stipulate joint goals or objectives. The changes the Catalan Health Service (CatSalut) has undergone are principally focused on increasing resolution capacity of the primary level of care, eliminating differences in clinical practice, evolving towards more surgery-centred hospitals, promoting alternatives to conventional hospitalization, developing remote care models, concentrating and organizing highly complex care into different sectors at a territorial level and designing specific health codes in response to health emergencies. The purpose of these initiatives is to improve the effectiveness, quality, safety and efficiency of the system, ensuring equal access for the public to these services and ensuring a territorial balance. These changes should be facilitated and promoted using several different approaches, including implementing shared access to clinical history case files, the new model of results-based contracting and payment, territorial agreements, alliances between centres, harnessing the potential of information and communications technology and evaluation of results.

La transformación del modelo asistencial en Cataluña para mejorar la calidad de la atención / The transformation of the healthcare model in Catalonia to improve the quality of care

Los cambios que se están produciendo en los países occidentales obligan a los sistemas sanitarios a adaptarse a las nuevas necesidades y expectativas de la población. En Cataluña se está produciendo una profunda transformación del modelo asistencial, con el fin de poder dar una respuesta adecuada a esta nueva situación y a la vez garantizar la sostenibilidad del sistema en un contexto de crisis económica. Esta transformación se basa en convertir el actual modelo asistencial centrado en la enfermedad y fraccionado por niveles en otro centrado en la persona, integrado y de base territorial, que promueva el trabajo compartido en red de los diferentes profesionales, dispositivos y niveles asistenciales, estableciendo objetivos comunes explicitados en acuerdos y pactos territoriales. Los cambios que ha llevado a cabo el Servei Català de la Salut (CatSalut) pasan principalmente por incrementar la capacidad de resolución de la atención primaria, reducir la variabilidad de la práctica clínica, evolucionar hacia hospitales más quirúrgicos, potenciar las alternativas a la hospitalización convencional, desarrollar modalidades de atención no presencial, concentrar y sectorizar territorialmente la atención de alta complejidad y diseñar códigos sanitarios específicos, como respuesta a situaciones de emergencia. La finalidad de estas actuaciones es mejorar la efectividad, la calidad, la seguridad y la eficiencia del sistema asegurando la equidad de acceso de la población y el equilibrio territorial. Entre los instrumentos que deben facilitar y promover estos cambios cabe destacar la historia clínica compartida, el nuevo modelo de contratación y pago por resultados, los pactos territoriales, las alianzas entre centros, el aprovechamiento de las potencialidades de las tecnologías de la información y la comunicación, y la evaluación de resultados (AU)

The changes taking place in western countries require health systems to adapt to the public's evolving needs and expectations. The healthcare model in Catalonia is undergoing significant transformation in order to provide an adequate response to this new situation while ensuring the system's sustainability in the current climate of economic crisis. This transformation is based on converting the current diseasecentred model which is fragmented into different levels, to a more patient-centred integrated and territorial care model that promotes the use of a shared network of the different specialities, the professionals, resources and levels of care, entering into territorial agreements and pacts which stipulate joint goals or objectives. The changes the Catalan Health Service (CatSalut) has undergone are principally focused on increasing resolution capacity of the primary level of care, eliminating differences in clinical practice, evolving towards more surgery-centred hospitals, promoting alternatives to conventional hospitalization, developing remote care models, concentrating and organizing highly complex care into different sectors at a territorial level and designing specific health codes in response to health emergencies. The purpose of these initiatives is to improve the effectiveness, quality, safety and efficiency of the system, ensuring equal access for the public to these services and ensuring a territorial balance. These changes should be facilitated and promoted using several different approaches, including implementing shared access to clinical history case files, the new model of results-based contracting and payment, territorial agreements, alliances between centres, harnessing the potential of information and communications technology and evaluation of results (AU)

[Case mix analysis of patients who can be referred from emergency department triage to primary care]. / Análisis de la casuística de los pacientes derivables desde urgencias a atención primaria.

OBJECTIVE: Structured emergency department (ED) triage scales can be used to develop patient referral strategies from the ED to primary care. The objectives of the present study were to evaluate the percentage of patients who could potentially be referred from triage to primary care and to describe their clinical characteristics. METHODS: We analyzed all patients with low acuity (triage levels IV and V) and low complexity (patients discharged from the ED) triaged during 2003 with the Andorran Triage Model in the ED and estimated the percentage of patients who could potentially be referred on the basis of three primary care models: A, centers unable to deal with emergencies or perform complementary investigations; B, centers able to deal with emergencies and perform complementary investigations, and C, centers able to deal with emergencies but unable to perform complementary investigations. RESULTS: Of the 25,319 patients included in the study, 5.63% could be referred to model A, 75.22% to model B and 33.36% to model C. A total of 81.04% of these model C patients were classified in seven symptomatic categories: wounds and traumatisms, inflammation or fever, pediatric problems, rhinolaryngological infection or alterations, ocular symptoms, pain and cutaneous allergy or reactions. CONCLUSIONS: Casemix analysis, based on the level of acuity and discharge criteria, can be used to establish the percentage of patients that could potentially be referred to primary care. Analysis of their clinical profile is useful to design referral protocols.

Identificación de los conflictos éticos en la atención sociosanitaria. Un estudio exploratorio / Identification of ethical conflicts in health and social services. An exploratory study

Objetivo: El objetivo principal de este estudio es identificar y clasificar los conflictos éticos que más comúnmente se plantean y más preocupan a los profesionales de la atención sociosanitaria, tanto en la asistencia domiciliaria como en la asistencia institucionalizada. Material y método: Se obtuvo la opinión de profesionales expertos mediante reuniones semiestructuradas y las opiniones recogidas mediante encuesta después de la sesión de presentación del comité en centros sociosanitarios. Se realizó un estudio exploratorio con un total de 4 grupos de discusión semiestructurados (grupos focales), con la participación de distintos perfiles profesionales de la asistencia domiciliaria e institucionalizada en la atención sociosanitaria con experiencia reconocida. Resultados: Los conflictos más frecuentes y que más inquietud crean a los profesionales de la atención sociosanitaria, la mayoría de ellos comunes, entre los niveles institucional y de atención domiciliaria son la relación entre profesionales, la pertinencia de actividades terapéuticas, la relación con la familia, el respeto por las preferencias del paciente y las derivadas de la gestión de los recursos sociales y organizativos. Conclusiones: La identificación de conflictos éticos mediante estudios exploratorios permite diferenciar los temas con potencial riesgo ético en una especialidad terapéutica como, por ejemplo, la atención sociosanitaria. Que se produzca un conflicto u otro depende, en última instancia, del tipo de asistencia prestada

Objective: The main objective of this study was to identify and classify the most common ethical conflicts faced by health professionals working in outpatient and inpatient services. Material and method: a) Expert opinions gathered through semi-structured meetings; b) opinions gathered through a questionnaire distributed after a presentation by an ethics committee in health and social services' centers; and c) an exploratory study with 4 focus groups in which distinct professionals with recognized experience from home and hospital care services participated. Results: The most frequent conflicts faced by health and social services professionals, most of which were common to outpatient and inpatient care, concerned the relationship among health professionals, the appropriateness of therapeutic activities, the relationship with the patient's family, respect for patients' preferences, and conflicts arising from the management of social resources and organizational issues. Conclusions: Identifying ethical conflicts through exploratory studies allows topics likely to pose ethical dilemmas to be differentiated in a specific therapeutic area such as healthcare. The presence of one type of ethical conflict or another depends on the type of healthcare provided

Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the Principality of Andorra: Can triage parameters serve as emergency department quality indicators?

OBJECTIVE: To assess the performance of the newly implemented Canadian Emergency Department Triage and Acuity Scale (CTAS) triage system in a redesigned 200-bed community hospital emergency department (ED) and to evaluate the predictive validity of CTAS in this setting. METHODS: Triage system performance was analyzed on the basis of 4 quality indicators: time to triage; triage duration; proportion of patients who left without being seen by a physician; and waiting time to nurse and physician, stratified by triage level and reported as fractile response rates. The predictive validity of CTAS was evaluated by investigating the relationship between CTAS level, hospitalization index, ED length of stay (LOS) and diagnostic test utilization. RESULTS: During the study period, 32 574 patients were triaged and 32 261 were eligible for study. Eighty-five percent were triaged within 10 minutes, and 98% had a triage duration of < 5 minutes. Waiting times to nurse and physician were within CTAS time objectives in 96.3% and 92.3% of cases respectively. The left without being seen (LWBS) rate was 0.96%. Hospitalization rates were compatible with CTAS standards for adults in Levels I, II, III and V and for children in Level V. Median LOS and laboratory test utilization were highly correlated with CTAS Levels II to V (p < 0.01), and similar correlation between triage acuity and imaging utilization was noted in adult patients with non-traumatic non-musculoskeletal complaints (p < 0.01). CONCLUSIONS: The CTAS is adaptable to countries beyond Canada and its operating objectives are achievable. Time to triage and fractile response rates can be considered indicators of triage quality and ED performance. CTAS is a valid instrument for predicting admission rates, hospital LOS and diagnostic utilization.