[Cancer pain management: Systematic review and critical appraisal of clinical practice guidelines]. / Manejo del dolor oncológico: revisión sistemática y valoración crítica de las guías de práctica clínica.

OBJECTIVE: Although several clinical practice guidelines have been developed in the last decades, cancer pain management is still deficient. The purpose of this work was to carry out a comprehensive and systematic literature review of current clinical practice guidelines on cancer pain management, and critically appraise their methodology and content in order to evaluate their quality and validity to cope with this public health issue. MATERIALS AND METHODS: A systematic review was performed in the main databases, using English, French and Spanish as languages, from 2008 to 2013. Reporting and methodological quality was rated with the Appraisal of Guidelines, Research and Evaluation II (AGREE-II) tool, including an inter-rater reliability analysis. Guideline recommendations were extracted and classified into several categories and levels of evidence, aiming to analyse guidelines variability and evidence-based content comprehensiveness. RESULTS: Six guidelines were included. A wide variability was found in both reporting and methodological quality of guidelines, as well as in the content and the level of evidence of their recommendations. The Scottish Intercollegiate Guidelines Network guideline was the best rated using AGREE-II, while the Sociedad Española de Oncología Médica guideline was the worst rated. The Ministry of Health Malaysia guideline was the most comprehensive, and the Scottish Intercollegiate Guidelines Network guideline was the second one. CONCLUSIONS: The current guidelines on cancer pain management have limited quality and content. We recommend Ministry of Health Malaysia and Scottish Intercollegiate Guidelines Network guidelines, whilst Sociedad Española de Oncología Médica guideline still needs to improve.

Development and pilot test of a new set of good practice indicators for chronic cancer pain management.

BACKGROUND: Pain is among the most important symptoms in terms of prevalence and cause of distress for cancer patients and their families. However, there is a lack of clearly defined measures of quality pain management to identify problems and monitor changes in improvement initiatives. METHODS: We built a comprehensive set of evidence-based indicators following a four-step model: (1) review and systematization of existing guidelines to list evidence-based recommendations; (2) review and systematization of existing indicators matching the recommendations; (3) development of new indicators to complete a set of measures for the identified recommendations; and (4) pilot test (in hospital and primary care settings) for feasibility, reliability (kappa), and usefulness for the identification of quality problems using the lot quality acceptance sampling (LQAS) method and estimates of compliance. RESULTS: Twenty-two indicators were eventually pilot tested. Seventeen were feasible in hospitals and 12 in all settings. Feasibility barriers included difficulties in identifying target patients, deficient clinical records and low prevalence of cases for some indicators. Reliability was mostly very good or excellent (k > 0.8). Four indicators, all of them related to medication and prevention of side effects, had acceptable compliance at 75%/40% LQAS level. Other important medication-related indicators (i.e., adjustment to pain intensity, prescription for breakthrough pain) and indicators concerning patient-centred care (i.e., attention to psychological distress and educational needs) had very low compliance, highlighting specific quality gaps. CONCLUSIONS: A set of good practice indicators has been built and pilot tested as a feasible, reliable and useful quality monitoring tool, and underscoring particular and important areas for improvement.

[Analysis of the patient safety culture in hospitals of the Spanish National Health System]. / Análisis de la cultura sobre seguridad del paciente en los hospitales del Sistema Nacional de Salud español.

BACKGROUND AND OBJECTIVES: A safety culture is essential to minimize errors and adverse events. Its measurement is needed to design activities in order to improve it. This paper describes the methods and main results of a study on safety climate in a nation-wide representative sample of public hospitals of the Spanish NHS. MATERIAL AND METHOD: The Hospital Survey on Patient Safety Culture questionnaire was distributed to a random sample of health professionals in a representative sample of 24 hospitals, proportionally stratified by hospital size. Results are analyzed to provide a description of safety climate, its strengths and weaknesses. Differences by hospital size, type of health professional and service are analyzed using ANOVA. RESULTS: A total of 2503 responses are analyzed (response rate: 40%, (93% from professionals with direct patient contact). A total of 50% gave patient safety a score from 6 to 8 (on a 10-point scale); 95% reported < 2 events last year. Dimensions "Teamwork within hospital units" (71.8 [1.8]) and "Supervisor/Manager expectations and actions promoting safety" (61.8 [1.7]) have the highest percentage of positive answers. "Staffing", "Teamwork across hospital units", "Overall perceptions of safety" and "Hospital management support for patient safety" could be identified as weaknesses. Significant differences by hospital size, type of professional and service suggest a generally more positive attitude in small hospitals and Pharmacy services, and a more negative one in physicians. CONCLUSIONS: Strengths and weaknesses of the safety climate in the hospitals of the Spanish NHS have been identified and they are used to design appropriate strategies for improvement.

Reducing time delay in the thrombolysis of myocardial infarction: an internal quality improvement project. ARIAM Project Group. Analisis del Retraso en Infarto Agudo de Miocardio.

The objectives of this study were to improve thrombolytic therapy in acute myocardial infarction by reducing the "door-to-needle" time in a 285-bed university hospital in Spain. A quality management approach was used involving all the relevant staff. Target standard was set at 35 minutes. Baseline data, intervention effect, and continuous monitoring were analyzed using x control charts. Analysis of baseline data showed a wide out-of-control variation and 72 minutes' average delay. Cause analysis revealed organizational and clinical problems that were subjected to intervention. Postintervention data showed a stable process, with an average of 30 minutes. Continuous monitoring showed further improvement in average time and predictable variation. The template of the current control chart has an average of 26 minutes. Quality management methods, particularly staff involvement in problem analysis and intervention design, and the use of control charts were useful to understand, solve, and continuously monitor an important clinical problem whose existence was evident only after it was measured.

Quality of the information contained in the minimum basic data set: results from an evaluation in eight hospitals.

To assess the quality of the information included in the minimum basic data set (MBDS) of the eight public hospitals of the Murcia region in order to ascertain what should be improved to be valid and reliable. An external encoder performed a recoding of a random sample of hospital discharges, using the patients hospital records and comparing afterwards the information obtained with the one reflected in the MBDS databases. Quality was assessed using 12 criteria. The reviewed discharges sample consisted at least of 96 cases per hospital (Type I error = 0.05, Type II = 0.10, for the most unfavorable case). A total of 796 cases were reviewed. The MBDS disagreement percentages with the patient record data were higher for the clinical data, with 41.6% for the main diagnosis and 33.5% for the main surgical procedure, being in both cases higher in those hospitals that had used to codify just the discharge record with regard to those that did so with the complete patient record. The variation rate in the diagnosis-related group (DRG) assignment was of 29.6%, and there was a decrease in the case-mix index of 1.07397 when reviewing with the patient record to 1.05555 in the MBDS. Within the administrative data, the highest disagreement rate was for the physician that signs the discharge (60.5%) and the patient's address (31.6%). In many of these assessed aspects there are significant differences between hospitals. A reliability problem was identified in the collected data, which mainly affects the clinical variables. It is therefore advisable to carefully assess the use of this information (both the MBDS directly as well as its grouping through the use of patient classification systems), and the indicators derived from it as its quality is not guaranteed. Systematic assessment and quality control of the MBDS production is advised.

Training for quality management: report on a nationwide distance learning initiative for physicians in Spain.

Under the sponsorship of a pharmaceutical firm, a distance-learning course on Quality Management methods was developed at the University of Murcia (Spain) and offered nationwide to primary health care physicians working in the public system. A total of 7104 physicians (47.7% of the census) signed up (at least one in 92.2% of the health centres). The course content follows the author's model of quality improvement, monitoring and design trilogy, but focuses mainly on methods for a quality improvement cycle using a learning-by-doing and problem-solving approach. The unexpected success of this initiative has led us to reflect on the interest in learning about quality improvement methods shown by physicians, the usefulness of the distance-learning approach, and also to continue the project with new initiatives such as: a summary poster, software containing all the necessary tools and data analysis for quality improvement, and a manual.

Physician attitudes, self-estimated performance and actual compliance with locally peer-defined quality evaluation criteria.

BACKGROUND: Physicians' agreement with quality evaluation criteria, and estimates of their own and their colleagues' compliance with these criteria were compared with actual compliance. METHODS: Physicians practicing in 10 health centers in Spain defined 13 quality evaluation criteria for two patient conditions (upper respiratory infections and high serum cholesterol). Compliance with criteria was measured by an external team, using random samples of medical records stratified by condition in each health center (n= 1,000). Concurrently, physicians were surveyed regarding agreement with the criteria, and were asked to estimate their own and their health center's rate of compliance with these criteria. RESULTS: Agreement ratings varied from 5.9 to 9.1 on a 10-point scale. Actual compliance rates ranged from 1.8 to 91.7% of records. Agreement correlated significantly with self-reported compliance but not with actual compliance. Estimates of one's own and one's health center compliance were positive and significantly correlated for all criteria, but were significantly higher for oneself than for one's health center for six of 13 criteria. CONCLUSIONS: Wide variation in physicians' agreement on quality criteria and in actual performance reveal a lack of clear guidelines. Agreement on criteria did not always translate into compliance with criteria. Physicians tended to rate their own performance as better than the average of their peers, suggesting that aggregate data may not influence physicians to change. Self-estimate of one's own or one's colleagues performance is not a good proxy for actual performance so that peer ratings are of dubious value for performance appraisal.

Training health professionals to implement quality improvement activities. Results of a randomized controlled trial after one year of follow-up.

STUDY OBJECTIVE: To test the advantages of training and of a trainee-centered educational strategy for the implementation of quality evaluation and improvement (QI) activities in Health Centres (HCs). DESIGN: Experimental, with random assignment of HCs to three different groups, two for two different training methods and one as control group. Each group had 10 HCs. SETTING: HCs network of the region of Murcia (Spain). STUDY SUBJECTS: Selected PHC personnel, grouped by study groups. INTERVENTIONS: One of the groups (GI) received trainee-centered training on QI methods with problem-solving oriented methodology. A second group (GII) received more traditional training. The third group (GIII) received no training. MEASUREMENTS: 1. Knowledge test before and after the seminars. 2. Post-seminar survey to assess trainees' appraisal of the seminar experience and attitudes towards implementation of QI activities. 3. One year follow-up survey to assess actual implementation of QI activities and attitude towards more training. RESULTS: GI showed significantly higher scores than GII regarding both their subjective appraisal of the training experience, and actual implementation of activities. No QI activity was found in any GIII Center. We conclude that the importance of training in the implementation of QI activities has been confirmed, and also that training method does matter.

Towards evaluation of the quality of care in health centres.

There is wide acknowledgement that quality assurance is desirable in primary health care. Considerable success has been achieved in this field by the Iberian Programme of Training and Implementation of Quality Assurance Activities in Primary Health Care, the basis for which is outlined below.

PIP: In accordance with Spanish and Portuguese conditions, a strategy was designed to implement quality assurance in health centers on a voluntary basis, with particular attention to internal involvement. The main elements of this project, which became known as the Iberian Program of Training and Implementation of Quality Assurance Activities in Primary Health Care, were training, involving problem-solving, a phased approach, and the use of real cases; internal commitment; professional leadership; teamwork; external support; and intrinsic professional incentives. Training was the most important strategic factor. Also probably significant was the adequate ad hoc implementation of the principles of planned change. A high degree of reliance was placed upon the intrinsic motivation and self-determination of professionals. The complete training program reached 213 professionals attached to 203 health centers. Program elements are described.

[A quality evaluation in requests for thoracic radiology in chronic pathology at a health center]. / Evaluación de la calidad en la solicitud de radiología de tórax en patología crónica en un centro de salud.

OBJECTIVE: To improve the quality of thoracic x-ray requests during chronic illness, presenting criteria for indication in HTA, LCFA and TBC. DESIGN: Intervention study of quality improvement. SETTING: Can Misses Health Centre in Ibiza. PARTICIPANTS: The General Practitioners at the above centre. MEASUREMENTS AND MAIN RESULTS: In this study we proposed to evaluate the work of the doctors at our Health Centre in correctly requesting x-ray explorations on the basis of two explicit, standard criteria: 1) the reason for the thorax x-ray request must be stated in the clinical notes. 2) Thorax x-rays requested for LCFA, HTA and TBC must be correctly indicated. CONCLUSION: The use of structured criteria in thorax x-ray requests for chronic patients appears to lead to greater quality in requests for this complementary exploration.

Costo-eficacia de las estrategias de vacunación en servicios ordinarios y en campañas en el Ecuador / Cost-effectiveness of routine and campaing vaccination strategies in Ecuador

En julio de 1986 se realizó una encuesta domiciliaria nacional sobre cobertura de vacunación de 3 697 niños ecuatorianos, que brindó la oportunidad de realizar un análisis de costo-eficacia de (1) los servicios de vacunación ordinarios en establecimientos fijos (2) de las campañas de inmunización en masa. Una de las principales finalidades de las campañas fue complementar los servicios de vacunación ordinarios y acelerar las actividades de inmunización. Basándose en la encuesta de la cobertura, el Programa para la Reduccion de la Enfermedad Maternoinfantil (PREMI) y varias campañas anteriores aumentaron la proporción de niños menores de cinco años completamente vacunados de 43 a 64 por ciento. En un año, la campaña del PREMI se encargó de vacunar completamente a 11 por ciento de los niños menores de un año, 21 por ciento de los de 1 a 2 años y 13 por ciento de todos los menores de 5 años. La campaña también ayudó a completar el programa de vacunación cuando los niños eran todavía muy pequeños y estaban expuestos al máximo riesgo. El costo medio por dosis de vacuna (en $US de 1985) fue aproximadamente de $0,29 en los establecimientos fijos y de $0,83 en la campaña del PREMI. El total de los costos nacionales fue de $675 000 y de 1 665 000 en los servicios de vacunación ordinarios y en las campañas, respectivamente. El costo por niño completamente vacunado fue de $44,39 en los primeros y de $8,60 en las últimas. El costo de cada defunción evitada fue de unos $1 900 en los servicios de vacunación ordinarios, de $4 200 en la campaña del PREMI y de $3 200 en el programa combinado. A causa de las menores tasas de mortalidad del Ecuador, los costos por cada defunción evitada en ese país con ambas estrategias no son tan bajos como los observados en estudios pertinentes efectuados en Africa. Las campañas, pese a ser menos eficaces en función del costo que los servicios de vacunación ordinarios, mejoraron significativamente la cobertura de vacunación de los niños menores que no habían sido vacunados en los servicios ordinarios. Al comparar los costos por niño completamente vacunado en ambos servicios con los de programas similares en otros países, los resultados fueron favorables

Costo-eficacia de las estrategias de vacunación en servicios ordinarios y en campañas en el Ecuador / Cost-effectiveness of routine and campaing vaccination strategies in Ecuador

En julio de 1986 se realizó una encuesta domiciliaria nacional sobre cobertura de vacunación de 3 697 niños ecuatorianos, que brindó la oportunidad de realizar un análisis de costo-eficacia de (1) los servicios de vacunación ordinarios en establecimientos fijos (2) de las campañas de inmunización en masa. Una de las principales finalidades de las campañas fue complementar los servicios de vacunación ordinarios y acelerar las actividades de inmunización. Basándose en la encuesta de la cobertura, el Programa para la Reduccion de la Enfermedad Maternoinfantil (PREMI) y varias campañas anteriores aumentaron la proporción de niños menores de cinco años completamente vacunados de 43 a 64 por ciento. En un año, la campaña del PREMI se encargó de vacunar completamente a 11 por ciento de los niños menores de un año, 21 por ciento de los de 1 a 2 años y 13 por ciento de todos los menores de 5 años. La campaña también ayudó a completar el programa de vacunación cuando los niños eran todavía muy pequeños y estaban expuestos al máximo riesgo. El costo medio por dosis de vacuna (en $US de 1985) fue aproximadamente de $0,29 en los establecimientos fijos y de $0,83 en la campaña del PREMI. El total de los costos nacionales fue de $675 000 y de 1 665 000 en los servicios de vacunación ordinarios y en las campañas, respectivamente. El costo por niño completamente vacunado fue de $44,39 en los primeros y de $8,60 en las últimas. El costo de cada defunción evitada fue de unos $1 900 en los servicios de vacunación ordinarios, de $4 200 en la campaña del PREMI y de $3 200 en el programa combinado. A causa de las menores tasas de mortalidad del Ecuador, los costos por cada defunción evitada en ese país con ambas estrategias no son tan bajos como los observados en estudios pertinentes efectuados en Africa. Las campañas, pese a ser menos eficaces en función del costo que los servicios de vacunación ordinarios, mejoraron significativamente la cobertura de vacunación de los niños menores que no habían sido vacunados en los servicios ordinarios. Al comparar los costos por niño completamente vacunado en ambos servicios con los de programas similares en otros países, los resultados fueron favorables

Disponible en inglés en: Bull. WHO 67(6), 1989

Cost-effectiveness of routine and campaign vaccination strategies in Ecuador.

A national household coverage survey of 3697 Ecuadorean children, carried out in July 1986, provided an opportunity for a cost-effectiveness analysis of (1) routine vaccination services based in fixed facilities and (2) mass immunization campaigns. A major purpose of the campaigns was to complement the routine services and to accelerate immunization activities. Based on the coverage survey, the Program for Reduction of Maternal and Childhood Illness (PREMI) and earlier campaigns increased the proportion of children under 5 years who were fully vaccinated from 43% to 64%. In one year, the PREMI campaign was responsible for fully vaccinating 11% of children under one year, 21% of 1-2-year-old children, and 13% of all children under 5 years. The campaign also helped ensure that vaccinations were completed when children were still very young and at greatest risk. The average cost per vaccination dose (in 1985 US$ prices) was approximately $0.29 for fixed facilities and $0.83 for the PREMI campaign. Total national costs were $675,000 and $1,665,000 for routine and campaign services respectively. The cost per fully vaccinated child (FVC) was $4.39 for routine vaccination services and $8.60 for the campaign. The cost per death averted was about $1900 for routine vaccination services, $4200 for the PREMI campaign, and $3200 for the combined programme. Because of Ecuador's lower mortality rates, the costs per death averted in Ecuador from both vaccination strategies are not as low as those from studies of vaccinations in Africa. The campaigns, though less cost-effective than routine services, significantly improved the vaccination coverage of younger children who had been missed by the routine services. The costs per FVC of both the campaign and the routine services compare favourably with such programmes in other countries.

Cost-effectiveness of routine and campaign vaccination strategies in Ecuador

A national household coverage survey of 3697 Ecuadorean children, carried out in July 1986, provided an opportunity for a cost-effectiveness analysis of (1) routine vaccination services based in fixed facilities and (2) mass immunization campaigns. A major purpose of the campaigns was to complement the routine services and to accelerate immunization activities. Based on the coverage survey, the Program for Reduction of Maternal and Childhood Illness (PREMI) and earlier campaigns increased the proportion of children under 5 years who were fully vaccinated from 43 per cent to 64 per cent. In one year, the PREMI campaign was responsible for fully vaccinating 11 per cent of children under one year, 21 per cent of 1-2-year-old children, and 13 per cent of all children under 5 years. The campaign also helped ensure that vaccinations were completed when children were still very young and at greatest risk

The average cost per vaccination dose (in 1985 US$ prices) was approximately $0.20 for fixed facilities and $0.83 for the PREMI campaign. Total national costs were $675,000 and $1,665,000 for routine and campaign services respectively. The cost por fully vaccinated child (FVC) was $4.39 for routine vaccination services and $8.60 for the campaign. The cost per death avered was about $1,900 for routine vaccination services ...(AU)