Is clinical coordination across care levels different according to the secondary care medical speciality? Results from the Catalan health system.

BACKGROUND: Despite the scarce evidence, some studies suggest that cross-level clinical coordination may vary among secondary care (SC) doctors, influenced by their speciality and organisational model, including degree of decentralisation to primary care (PC). The aim was to determine the differences in experience and perception of cross-level clinical coordination and related factors according to the SC doctor's speciality in the Catalan health system. METHODS: Cross-sectional study, based on an on-line survey using the COORDENA-CAT questionnaire, to SC doctors (n = 1666). Descriptive and multivariate analysis were used to compare five groups of SC specialities (decentralised, hospital-based, internists/geriatricians, gynaecologist, and paediatricians), for experience, perception and factors related to coordination. RESULTS: When comparing with decentralised specialities, hospital-based specialities and internal medicine/geriatrics reported lower care consistency and follow up across levels, while gynaecology and paediatrics, higher accessibility. General perception of cross-level coordination was lower in hospital-based specialities (PR:0.80, 95% CI 0.72-0.89) and higher in gynaecology (PR:1.36, 95% CI 1.18-1.56). Moreover, hospital-based specialities reported a lower use of some coordination mechanisms and lower knowledge of the primary care doctors (PR:0.42, 95% CI 0.23-0.72), while gynaecology a higher knowledge (PR:2.04, 95% CI 1.22-3.45). CONCLUSIONS: Results show differences in experience, perception of coordination, organisational and interactional factors across specialities. These differences may be explained by their complexity, coordination needs and organisational model. Further research is needed to clarify and understand the causes of such differences and the particular needs of coordination of each speciality to identify strategies to improve cross-level clinical coordination.

Understanding How to Improve the Use of Clinical Coordination Mechanisms between Primary and Secondary Care Doctors: Clues from Catalonia.

Clinical coordination between primary (PC) and secondary care (SC) is a challenge for health systems, and clinical coordination mechanisms (CCM) play an important role in the interface between care levels. It is therefore essential to understand the elements that may hinder their use. This study aims to analyze the level of use of CCM, the difficulties and factors associated with their use, and suggestions for improving clinical coordination. A cross-sectional online survey-based study using the questionnaire COORDENA-CAT was conducted with 3308 PC and SC doctors in the Catalan national health system. Descriptive bivariate analysis and logistic regression models were used. Shared Electronic Medical Records were the most frequently used CCM, especially by PC doctors, and the one that presented most difficulties in use, mostly related to technical problems. Some factors positively associated with frequent use of various CCM were: working full-time in integrated areas, or with local hospitals. Interactional and organizational factors contributed to a greater extent among SC doctors. Suggestions for improving clinical coordination were similar between care levels and related mainly to the improvement of CCM. In an era where management tools are shifting towards technology-based CCM, this study can help to design strategies to improve their effectiveness.

Do primary and secondary care doctors have a different experience and perception of cross-level clinical coordination? Results of a cross-sectional study in the Catalan National Health System (Spain).

BACKGROUND: Clinical coordination across care levels is a priority for health systems around the world, especially for those based on primary health care. The aim of this study is to analyse the degree of clinical information and clinical management coordination across healthcare levels in the Catalan national health system experienced by primary (PC) and secondary care (SC) doctors and explore the associated factors. METHODS: Cross-sectional study based on an online survey using the self-administered questionnaire COORDENA-CAT. DATA COLLECTION: October-December 2017. STUDY POPULATION: PC and SC (acute and long term) doctors of the Catalan national health system. Participation rate was 21%, with a sample of 3308 doctors. OUTCOME VARIABLES: cross-level clinical information coordination, clinical management coordination, and perception of cross-level coordination within the area. Explanatory variables: socio-demographic, employment characteristics, attitude towards job, type of area (according to type of hospital and management), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression. RESULTS: The degree of clinical coordination experienced across levels of care was high for both PC and SC doctors, although PC doctors experienced greater exchange and use of information and SC doctors experienced greater consistency of care. However, only 32.13% of PC and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctors of the other level, working in an area where the same entity manages SC and majority of PC, and holding joint clinical case conferences were factors positively associated with perceiving high levels of clinical coordination. Other associated factors were specific to the care level, such as being informed of a patient's discharge from hospital for PC doctors, or trusting in the clinical skills of the other care level for SC doctors. CONCLUSIONS: Interactional and organizational factors are positively associated with perceiving high levels of clinical coordination. Introducing policies to enhance such factors can foster clinical coordination between different health care levels. The COORDENA questionnaire allows us to identify fields for improvement in clinical coordination.

[Neonatal screening of hemoglobinopathies and G6PD deficiency in Catalonia (Spain). Molecular study of sickle cell disease associated with alpha thalassemia and G6PD deficiency]. / Cribado neonatal de hemoglobinopatías y déficit de glucosa-6-fosfato deshidrogenasa (G6PD) en Cataluña. Estudio molecular de la anemia falciforme asociada a alfatalasemia y déficit de G6PD.

BACKGROUND AND OBJECTIVE: The prevalence of hemoglobinopathies and glucose-6-phosphate dehidrogenase (G6PD) deficiency in the Catalan neonatal population is increasing due to immigration. Coinheritance of more than a single RBC genetic defect is becoming more frequent and diagnostic pitfalls are also increasing. We intended to demonstrate the need to perform an early diagnosis of sickle cell disease (SCD) by means of neonatal screening, to establish the prevalence of SCD associated with alpha thalassemia and G6PD deficiency and to identify genotypes associated with sickle cell disease and G6PD deficiency. PATIENTS AND METHOD: 4,020 blood samples from newborns were screened. For the screening of hemoglobinopathies the high performance liquid chromatography method was used and for G6PD deficiency the fluorescent spot test was employed. We studied the association between betaS gene and alpha thalassaemia del-3.7 Kb. SCD and G6PD deficiency genotypes were established. RESULTS: Prevalence of SCD in population at risk was 1/475 newborns. Prevalence of G6PD deficiency in population at risk was 1/43, and in autochthonous population was 1/527 newborns. In all the cases, sickle hemoglobin was confirmed by ARMS (amplification refractory mutation system). Association between betaS gene and alpha thalassaemia del-3.7 Kb was found in 32.2% of the samples, and an association between betaS gene and G6PD deficiency was observed in 7% of the samples. CONCLUSIONS: This study confirms the high prevalence of SCD and G6PD deficiency in population at risk as well as their genetic and clinical heterogeneity. The study of genotype/phenotype relationships allows a better knowledge of molecular mechanism and is useful to establish suitable criteria of diagnosis.

Cribado neonatal de hemoglobinopatías y déficit de glucosa-6-fosfato deshidrogenasa (G6PD) en Cataluña. Estudio molecular de la anemia falciforme asociada a alfatalasemia y déficit de G6PD / Neonatal screening of hemoglobinopathies and G6PD deficiency in Catalonia (Spain). Molecular study of sickle cell disease associated with alpha thalassemia and G6PD deficiency

Fundamento y objetivo: Con los flujos inmigratorios se ha elevado la prevalencia de hemoglobinopatías y déficit de glucosa-6-fosfato deshidrogenasa (G6PD) en nuestra población. La probabilidad de encontrar en un individuo más de un defecto del eritrocito es elevada, lo que comporta una mayor heterogeneidad clínica y dificultades diagnósticas. El objetivo de este trabajo ha sido realizar el diagnóstico precoz de la anemia falciforme mediante cribado neonatal, analizar la prevalencia de herencia conjunta de alfatalasemia, déficit de G6PD y hemoglobina S e identificar los genotipos asociados. Pacientes y método: Se ha estudiado a 4.020 recién nacidos (RN) de población de riesgo y autóctona. El cribado neonatal de hemoglobinopatías se realizó mediante cromatografía líquida de alta resolución y el de déficit de G6PD mediante la técnica de la mancha fluorescente. Se analizó molecularmente la asociación entre el gen ßS y alfatalasemia con deleción ­3.7 Kb. Finalmente se estableció el genotipo de los casos de déficit de G6PD. Resultados: La prevalencia de anemia falciforme en población de riesgo fue de 1/475 RN, y la de déficit de G6PD, de 1/43 RN en población de riesgo y de 1/527 RN en población autóctona. La hemoglobina S se confirmó mediante ARMS (amplification refractory mutation system). La asociación entre el gen ßS y la alfatalasemia con deleción ­3.7 Kb fue de un 32,2%, y entre el gen ßS y el déficit de G6PD, de un 7%. Conclusiones: Se confirma la elevada prevalencia de la anemia falciforme y del déficit de G6PD en población de riesgo, así como la elevada heterogeneidad molecular de ambos defectos. El conocimiento de los genotipos asociados y su relación con la expresión clínica es de gran utilidad para establecer criterios adecuados de diagnóstico y pronóstico

Background and objective: The prevalence of hemoglobinopathies and glucose-6-phosphate dehidrogenase (G6PD) deficiency in the Catalan neonatal population is increasing due to immigration. Coinheritance of more than a single RBC genetic defect is becoming more frequent and diagnostic pitfalls are also increasing. We intended to demonstrate the need to perform an early diagnosis of sickle cell disease (SCD) by means of neonatal screening, to establish the prevalence of SCD associated with alpha thalassemia and G6PD deficiency and to identify genotypes associated with sickle cell disease and G6PD deficiency. Patients and method: 4,020 blood samples from newborns were screened. For the screening of hemoglobinopathies the high performance liquid chromatography method was used and for G6PD deficiency the fluorescent spot test was employed. We studied the association between ßS gene and alpha thalassaemia del-3.7 Kb. SCD and G6PD deficiency genotypes were established. Results: Prevalence of SCD in population at risk was 1/475 newborns. Prevalence of G6PD deficiency in population at risk was 1/43, and in autochthonous population was 1/527 newborns. In all the cases, sickle hemoglobin was confirmed by ARMS (amplification refractory mutation system). Association between ßS gene and alpha thalassaemia del-3.7 Kb was found in 32.2% of the samples, and an association between ßS gene and G6PD deficiency was observed in 7% of the samples. Conclusions: This study confirms the high prevalence of SCD and G6PD deficiency in population at risk as well as their genetic and clinical heterogeneity. The study of genotype/phenotype relationships allows a better knowledge of molecular mechanism and is useful to establish suitable criteria of diagnosis

Reflujo vesico-ureteral en pediatría: ¿ha cambiado el papel de la cistografía? / Vesicoureteral reflux in pediatrics: has the role of voiding cystourethrogram changed?

Fundamento. El diagnóstico precoz del reflujo vesicoureteral(RVU) puede ayudar a evitar el desarrollo deReflux vesicoureteral en pediatria: ha canviat elpaper de la cistografia?Ester Parada, Nabil Abu-Hadwan, Francesc Mir, José Maria Inoriza, Teresa Carrión,Joan Manel Torres, Joan Agulló, Pere Plaja.Hospital de Palamós. Palamós (Girona)nefropatía de reflujo pero a la vez puede condicionar eluso demasiado generalizado de exploraciones complementariasinvasivas. Es necesario valorar periódicamente elrendimiento de las exploraciones complementarias que solicitamosen el marco de la mejora de las técnicas de diagnóstico,tanto prenatal como postnatal.Objetivo. Valorar las indicaciones y el rendimiento dela CUMS en el estudio de alteraciones renales de diagnósticoprenatal y en el seguimiento de las infecciones deltracto urinario (ITU).Método. Revisión retrospectiva de las historias clínicasde pacientes de 0-4 años en los que se ha realizado unaCUMS en nuestro hospital entre enero de 2001 y agosto de2004.Resultados. Se han estudiado 128 pacientes, en el 75%de los cuales se solicitó CUMS a raíz del diagnóstico de ITUy en el resto como seguimiento de alteraciones renales dediagnóstico prenatal. Se detectó RVU en el 17.2% de lospacientes: el 12.9% de los estudiados por diagnóstico prenataly el 18.7% por ITU. Dos de los pacientes presentaronuna infección de orina post-CUMS.Conclusiones. A pesar de los avances en el diagnósticoprenatal, la presencia de RVU en el 18.7% de los pacientescon antecedente de ITU avala el papel de la CUMS en el estudiode estos pacientes

Background. The early diagnosis of vesicoureteral reflux(VUR) is important for the prevention of its progressionto reflux nephropathy; however, invasive and uncomfortabletechniques are required. The use of suchprocedures ought to be assessed periodically in the evolvingscenario of technological advances in prenatal andpostnatal diagnosis.Objective. To assess the yield of voiding cystourethrogram(VCUG) in the evaluation of congenital renal abnormalitiesand urinary tract infections (UTI).Method. We retrospectively reviewed the medicalcharts of patients younger than 4 years of age who underwentVCUG between January 2001 and August 2004 at ourhospital.Results. One-hundred and twenty-eight patients underwentVCUG during the study period, 75% of them aftera UTI and the rest because of prenatal diagnosis of renalmalformations. RVU was diagnosed in 17.2% of thepatients: 12.9% of patients with renal malformations and18.7% of patients with history of UTI. Two patients developeda UTI after the VCUG was performed. DMSA scanwas performed in 18 of the 22 patients with VUR, and 12of them were found to have renal scarring. Conclusions. Despite the improvements in prenataldiagnosis of renal malformations, the detection of VUR ina significant proportion of patients as a result of a UTIconfirms the importance of VCUG in the evaluation ofpatients with UTI

Diferencias en la morbilidad neonatal entre neonatos magrebíes y autóctonos / Differences in neonatal morbidity rates between native and magrebi newborns

Fundamento. Alto porcentaje de nacimientos de inmigrantesen nuestro entorno e impresión de mayor morbilidadperinatal. Objetivo. Valorar si existen diferencias entre la morbilidadneonatal de dos poblaciones y posibles factoresmodificables.Método. Estudio descriptivo retrospectivo a partir derevisiones de historias clínicas correspondientes a los partosdel año 2000 (596 partos) en el Hospital de Palamós.Análisis estadístico del resultado del parto en 115 gestantesmagrebíes y 115 autóctonas; y de la morbilidad neonatalen 114 neonatos magribíes y 457 autóctonos.Resultados. -Parto: En el grupo magrebí, mayor númerode partos eutócicos, menor de cesáreas y menor usode analgesia durante el parto (p<0,01). -Neonatal: En elgrupo magrebí, mayor porcentaje de ingresos neonatales(p<0,01). Los principales motivos de ingreso en los dos gruposson el riesgo de infección (50,9% entre los autóctonosy 73,07% entre los magrebíes, p<0,01) y la hiperbilirrubinemia(15,45% y 19,23% respectivamente). El índice deriesgo por madre portadora de estreptococo β hemolíticodel grupo B o desconocido es el resultado con mayor diferenciaentre los dos grupos (p<0,01), por encima de la roturaprolongada de membranas (p<0,05). Más neonatoscon peso por encima del percentil 90 (p<0,05).Conclusiones. Las diferencias halladas en el análisis delparto deben atribuirse a la mayor paridad de las magribins.En lo referente a la morbilidad neonatal es difícil igualarlos dos grupos dado que hay factores sobre los que no sepuede incidir. Creemos sería útil aplicar medidas especialessobre el grupo de inmigrantes y evaluar los resultados

Background. In recent years, there has been a significantincrease in the percentage of births from immigrantpopulation, with a perceived increased perinatal morbidity.Objective. To compare neonatal morbidity rates betweenimmigrant population of Magrebi origin and nativepopulation, and to determine possible modifiable factors.Method. Historical descriptive study based on a reviewof clinical records of infants born in 2000 (596 deliveries) atthe Palamos Hospital. The outcome of the pregnancies of115 Magrebi and 115 native women, and the neonatal morbidityin 114 and 457 native newborns, were compared.Results. Deliveries: In the Magrebi group, a higher proportionof eutocic deliveries, fewer cesarean sections, andless use of analgesics during the labour, were found(p<0.01). Neonatal morbidity: In the Magrebi group, wefound a higher percentage of neonatal admissions (p<0.01).In both groups, the main reasons for admission were therisk of infection (50.9% and 73.0% in the native and Magrebipopulations, respectively, p<0.01) and hyperbilirrubinemia(15.4% and 19.2%, respectively). The greatest difference in risk index in the Magrebi population was for mothers carryinggroup B β hemolytic streptococcus or with unknowncarrier status, (p<0.01), followed by prolonged membranerupture (p<0.05). A greater proportion of Magrebi newbornshad birth weight above the 90th percentile (p<0.05).Conclusions. The differences in the analysis of the deliveriesare probably related to the higher parity amongthe Magrebi families. Regarding the differences in neonatalmorbidity rates, interventions aiming at decreasing thisgap are challenging, given the disparities between bothpopulations. We suggest that special measures are appliedto the immigrant group