Patient classification systems and hospital costs of care for knee replacement in 10 European countries.

Knee replacement is a common surgical procedure performed to relieve pain and disability from degenerative osteoarthritis. This study evaluates the ability of ten European diagnosis-related group (DRG) systems to explain variations in costs or in length of stay for knee replacements. We assessed three different models in predicting variation of cost and length of stay. The first model, M(D), included only DRG groups as explanatory variables; the second, M(P), used a set of patient-level variables; and the third, M(F), included all variables from both M(D) and M(P). The total number of DRGs used to group knee replacement is low, ranging from two to six. All DRG systems except one differentiate between primary knee replacement and revision surgery. Considerable differences exist in the rate of revision surgery. There is also high variation in mean cost (from € 3809 to € 8158) and in mean length of stay (LoS) (from 4.2 to 13.6 days). The explanatory power of DRGs varies from 21.5 to 72.5% with values of around 40% in most countries of the study. Findings suggest that DRG systems could be enhanced either by the inclusion of patient-level variables, by the use of measures of clinical outcome or by improving cost and administrative information.

Patrones de utilización de los servicios sanitarios en Cataluña / Health services’ utilization patterns in Catalonia, Spain

El objetivo de este artículo es conocer el uso de servicios sanitarios de la población catalana según necesidades de salud y analizar patrones de utilización por niveles asistenciales de atención primaria, atención especializada, atención hospitalaria y atención urgente. Con los datos de la Encuesta de Salud de Cataluña 2006 se construyeron modelos de regresión logística de cada nivel asistencial para la población general y la de hombres, mujeres, adultos y menores. Las variables explicativas fueron: necesidad de salud, estilos de vida, demográficas, nivel socioeconómico, país de origen y lugar de residencia. Las mujeres utilizan más los servicios en todas las líneas asistenciales. Los menores y los adultos mayores de 64 años utilizan más atención primaria, que se asocia a clase social desfavorecida. Los jóvenes, los adultos-jóvenes y los inmigrantes infrautilizan todos los servicios excepto el de atención urgente. La atención especializada se asocia a la clase social acomodada, a personas con estudios universitarios, seguro sanitario privado y residencia en Barcelona, mientras que la atención hospitalaria se asocia a necesidad de salud. Se concluye que la utilización de servicios sanitarios no sólo se explica en función de la necesidad percibida, sino también por factores demográficos, socioeconómicos y territoriales (AU)

The purpose of this article is disclose services utilization patterns among the Catalan population with particular emphasis on primary care, specialised care, hospital care and emergency care. A number of logistic regression models were used to explain the utilization of the various types of services. Variables in the analysis included self-perceived need, lifestyles, and sociodemographic variables. Separate analyses were performed for male, female, adults, and children as well as for the general population. Women use all types of services more often than men. Children and people over 64 are more frequent users of primary care. Primary care is also associated to lower socioeconomic conditions. Young adults and the migrant population in general are found to be under users of services, except of emergency care services. The use of specialised care is associated to the better-off, to those with university level education attainment, individual private insurance, and those living in the city of Barcelona. Hospital care is largely associated to need variables. The use of health services is explained by self-perceived need as well as by demographic, socioeconomic and geographical factors (AU)

[Health services' utilization patterns in Catalonia, Spain]. / Patrones de utilización de los servicios sanitarios en Cataluña.

The purpose of this article is disclose services utilization patterns among the Catalan population with particular emphasis on primary care, specialised care, hospital care and emergency care. A number of logistic regression models were used to explain the utilization of the various types of services. Variables in the analysis included self-perceived need, lifestyles, and sociodemographic variables. Separate analyses were performed for male, female, adults, and children as well as for the general population. Women use all types of services more often than men. Children and people over 64 are more frequent users of primary care. Primary care is also associated to lower socioeconomic conditions. Young adults and the migrant population in general are found to be under users of services, except of emergency care services. The use of specialised care is associated to the better-off, to those with university level education attainment, individual private insurance, and those living in the city of Barcelona. Hospital care is largely associated to need variables. The use of health services is explained by self-perceived need as well as by demographic, socioeconomic and geographical factors.

[Hip and knee arthroplasties in Catalonia [Spain] from 1994 to 2005]. / Artroplastias de cadera y rodilla en Cataluña desde 1994 a 2005.

OBJECTIVE: Hip and knee arthroplasties are the most frequent surgical procedures in Catalonia. The aim of this study was to describe changes in the rates of these procedures and in their characteristics between 1994 and 2005. METHODS: We performed a cross-sectional study of total hip (THR) and knee (TKR) primary and revision joint replacement discharges using the Minimum Data Set (ICD-9-CM codes 81.51, 81.53, 81.54 and 81.55). Standardized THR and TKR rates by age and sex and revision burden were calculated and changing trends were analyzed through joinpoint regression. Four time periods were defined and patient and hospital stay characteristics were analyzed by comparing period 4 with period 1 through logistic regression models. RESULTS: In THR, the rates per 10,000 inhabitants increased from 4.1 to 6.6 between 1994 and 2000. In TKR, rates increased from 2.6 to 15.5 between 1994 and 2005. Hip revision burden increased until 2001, whereas knee revision burden increased for the entire period. The main reason for surgery was osteoarthritis. In both THR and TKR, the number of patients aged 75 or older and comorbidity increased. CONCLUSIONS: The increase in the rates and the change in patients' profile may reflect broadening of the indication criteria for these procedures. The impact of the foreseeable increase in revision surgery could be reduced by developing systems to evaluate prosthesis survival and clinical practice guidelines.

Artroplastias de cadera y rodilla en Cataluña desde 1994 a 2005 / Hip and knee arthroplasties in Catalonia [Spain] from 1994 to 2005

Objetivo: Las artroplastias de cadera y rodilla están entrelos procedimientos quirúrgicos más frecuentes en Cataluña.El objetivo de este estudio fue describir su evolución y los cambiosen sus características entre 1994 y 2005.Métodos: Estudio transversal de altas por artroplastias totalesprimarias de cadera (ATC) o rodilla (ATR) y de revisiónseleccionadas del Conjunto Mínimo Básico de Datos al AltaHospitalaria: códigos 81.51, 81.53, 81.54 y 81.55 (CIE-9-MC).Se calcularon las tasas de ATC y ATR estandarizadas por edady sexo, y la carga de revisión, analizando su evolución mediantela regresión de joinpoint. Se definieron 4 períodos yse analizaron las características de los pacientes y de los episodiosasistenciales comparando los períodos 4 y 1 a partirde modelos de regresión logística.Resultados: Las tasas por 10.000 habitantes se incrementaronentre 1994 y 2000 en ATC, pasando de 4,1 a 6,6, y entre1994 y 2005 en ATR, pasando de 2,6 a 15,5. La carga de revisiónaumentó en la cadera hasta 2001 y en la rodilla durantetodo el período de estudio. El principal motivo de artroplastiaprimaria fue la artrosis. Los pacientes de 75 años o mayoresy la comorbilidad aumentaron en ATC y ATR.Conclusiones: El incremento de las tasas y el cambio delperfil de los pacientes reflejan una posible ampliación de loscriterios de indicación. El previsible aumento de la cirugía derevisión se podría reducir mediante sistemas de evaluaciónde la supervivencia de las prótesis y el desarrollo de guíasde práctica clínica(AU)

Objective: Hip and knee arthroplasties are the most frequentsurgical procedures in Catalonia. The aim of this study wasto describe changes in the rates of these procedures and intheir characteristics between 1994 and 2005.Methods: We performed a cross-sectional study of total hip(THR) and knee (TKR) primary and revision joint replacementdischarges using the Minimum Data Set (ICD-9-CM codes81.51, 81.53, 81.54 and 81.55). Standardized THR and TKRrates by age and sex and revision burden were calculated andchanging trends were analyzed through joinpoint regression.Four time periods were defined and patient and hospital staycharacteristics were analyzed by comparing period 4 with period1 through logistic regression models.Results: In THR, the rates per 10,000 inhabitants increasedfrom 4.1 to 6.6 between 1994 and 2000. In TKR, rates increasedfrom 2.6 to 15.5 between 1994 and 2005. Hip revision burdenincreased until 2001, whereas knee revision burden increasedfor the entire period. The main reason for surgery wasosteoarthritis. In both THR and TKR, the number of patientsaged 75 or older and comorbidity increased.Conclusions: The increase in the rates and the change inpatients’ profile may reflect broadening of the indication criteriafor these procedures. The impact of the foreseeable increasein revision surgery could be reduced by developing systemsto evaluate prosthesis survival and clinical practiceguidelines(AU)

[The final week of life in an acute care hospital: review of 401 consecutive patients]. / Ultima semana de vida en un hospital de agudos: revisión de 401 pacientes consecutivos.

INTRODUCTION: because of population ageing and sociocultural changes related to death, increasing the numbers of patients are dying in hospitals. OBJECTIVES: to analyze patient characteristics and end-of-life care in the final week of life in patients dying in an acute-care hospital. MATERIAL AND METHODS: all patients older than 18 years old who died in the hospital over a 1-year period were analyzed. Patients dying in intensive care and emergency units were excluded. The following variables were evaluated: demographic data, main illness, cause of admission, comorbidity, terminal illness, medication, delay in beginning palliative sedation, use of devices, adverse events, and do not attempt resuscitation orders. RESULTS: a total of 401 patients (mean age: 78 +/- 11 years) with numerous comorbidities were evaluated. Of these, 348 patients (87%) were considered to be terminal. The reason for admission was related to the main disease in 207 patients (52%). Terminal sedation was applied in 311 patients (78%), and informed consent from the relatives was documented in 294 patients (73%). Intervention by on-call physician was required to control symptom aggravation in 214 patients (55%). Active medication was maintained in addition to sedation in 145 patients (36%). Complementary examinations were performed in 109 patients (40%), but did not modify prognosis. CONCLUSIONS: reasonable therapeutics objectives relating to the patient's situation and guidelines to improve quality of life at the end of life should be established.

Última semana de vida en un hospital de agudos: revisión de 401 pacientes consecutivos / The final week of life in an acute care hospital: review of 401 consecutive patients

Introducción: el envejecimiento y el cambio sociocultural frente a la muerte hacen que cada vez sea mayor el número de personas que fallecen en los hospitales. Objetivos: analizar aspectos relacionados con la última semana de vida de los pacientes que fallecen en un hospital de agudos. Material y métodos: se evaluó a los pacientes mayores de 18 años que fallecieron en el hospital durante un año, excluyendo los fallecidos en cuidados intensivos y en urgencias. Se analizaron: datos demográficos, enfermedad principal, motivo de ingreso, enfermedad terminal, comorbilidad, medicación, inicio de sedación, instrumentaciones, incidencias y órdenes de no iniciar reanimación cardiopulmonar. Resultados: se evaluó a 401 pacientes, con una edad media ± desviación estándar de 78 ± 11 años y elevada comorbilidad. Eran terminales 348 (87%) pacientes y en 207 (52%) pacientes el motivo de ingreso estaba relacionado con su enfermedad principal. La sedación terminal fue necesaria en 311 (78%) pacientes y constaba en la historia clínica que se había consensuado con sus familiares en 294 (73%) pacientes. Para el control de síntomas, 214 (55%) pacientes requirieron la intervención del médico de guardia. En 145 (36%) pacientes se mantuvo la medicación activa además de la sedativa, y en 109 (40%) pacientes se realizaron exploraciones complementarias sin que éstas modificaran el pronóstico. Conclusiones: es preciso establecer objetivos terapéuticos razonables en relación con la situación del paciente y protocolizar las intervenciones para mejorar la calidad de vida al final de la vida

Introduction: because of population ageing and sociocultural changes related to death, increasing the numbers of patients are dying in hospitals. Objectives: to analyze patient characteristics and end-of-life care in the final week of life in patients dying in an acute-care hospital. Material and methods: all patients older than 18 years old who died in the hospital over a 1-year period were analyzed. Patients dying in intensive care and emergency units were excluded. The following variables were evaluated: demographic data, main illness, cause of admission, comorbidity, terminal illness, medication, delay in beginning palliative sedation, use of devices, adverse events, and ¿do not attempt resuscitation orders¿. Results: a total of 401 patients (mean age: 78 ± 11 years) with numerous comorbidities were evaluated. Of these, 348 patients (87%) were considered to be terminal. The reason for admission was related to the main disease in 207 patients (52%). Terminal sedation was applied in 311 patients (78%), and informed consent from the relatives was documented in 294 patients (73%). Intervention by on-call physician was required to control symptom aggravation in 214 patients (55%). Active medication was maintained in addition to sedation in 145 patients (36%). Complementary examinations were performed in 109 patients (40%), but did not modify prognosis. Conclusions: reasonable therapeutics objectives relating to the patient's situation and guidelines to improve quality of life at the end of life should be established (AU)

Relationship between hospital structural level and length of stay outliers. Implications for hospital payment systems.

BACKGROUND: Hospital structural level has been suggested as a factor that could explain part of the resource use variation left unexplained by diagnosis related groups (DRGs). However, the relationship between hospital structural level and the presence of cases of extreme resource use (outliers) is not known. Some prospective payment systems pay these cases separately. OBJECTIVES: To analyze the relationship between different hospital structural levels, defined according to hospital size, teaching activity and location, and the presence of length of stay (LOS) outliers. RESEARCH DESIGN: A logit model was used to analyze the patient discharge records of the acute care public hospitals' Minimum Data Set in Catalonia (Spain) in 1998. The final population contained 631,096 discharges grouped in 329 adjacent DRGs. MEASURES: LOS outliers were defined as cases with a LOS exceeding the geometric mean plus two standard deviations of all the stays in the same DRG. The 64 public hospitals of the Catalan health system were classified into large urban teaching hospitals, medium-sized teaching and community hospitals, and small community hospitals according to their structural complexity. The model also controlled for patient and health care process characteristics. RESULTS: Outliers accounted for 4.5% of total discharges distributed as follows: large urban teaching hospitals (5.6%), medium-sized teaching and community hospitals (4.6%), small community hospitals (3.6%). The probability of a patient being an outlier was higher in hospitals with greater structural complexity: large urban teaching hospitals (OR = 1.59), medium teaching and community hospitals (OR = 1.30) and small community hospitals (OR = 1). Adjustment through the control variables reduced differences among hospitals: large urban teaching hospitals (OR = 1.32), medium-sized teaching and community hospitals (OR = 1.22), and small community hospitals (OR = 1), but the differences remained significant (P < 0.01). CONCLUSIONS: Hospital structural level influences the presence of outliers even when controlling for patient and process characteristics. Thus, some outliers are due to hospital structural level and are not justified by patient characteristics.

Missed breast carcinoma: pitfalls and pearls.

Mammography is the standard of reference for the detection of breast carcinoma, yet 10%-30% of breast cancers may be missed at mammography. Possible causes for missed breast cancers include dense parenchyma obscuring a lesion, poor positioning or technique, perception error, incorrect interpretation of a suspect finding, subtle features of malignancy, and slow growth of a lesion. Recent studies have emphasized the use of alternative imaging modalities to detect and diagnose breast carcinoma, including ultrasonography (US), magnetic resonance imaging, and nuclear medicine studies. However, the radiologist can take a number of steps that will significantly enhance the accuracy of image interpretation at mammography and decrease the false-negative rate. These steps include performing diagnostic as well as screening mammography, reviewing clinical data and using US to help assess a palpable or mammographically detected mass, strictly adhering to positioning and technical requirements, being alert to subtle features of breast cancers, comparing recent images with earlier mammograms to look for subtle increases in lesion size, looking for additional lesions when one abnormality is seen, and judging a lesion by its most malignant features.