Long-term mental health resource utilization and cost of care following group psychoeducation or unstructured group support for bipolar disorders: a cost-benefit analysis.

OBJECTIVE: To explore the short- and long-term mental health resource utilization and cost of care in a sample of 120 individuals with bipolar disorders who participated in a randomized controlled efficacy trial of group psychoeducation versus unstructured group support. METHOD: Prospective, independent monitoring of DSM-IV bipolar disorder type I or II patients aged 18 to 65 years was conducted during the intervention phase (6 months) and follow-up phase (5-year postintervention) of a randomized controlled trial reporting clinical outcomes and inpatient and outpatient mental health service utilization, with estimation of cost of treatment per patient. The study was conducted from October 1997 through October 2006. RESULTS: Compared with individuals with bipolar disorder receiving the control intervention, psychoeducated patients had twice as many planned outpatient appointments, but the estimated mean cost of emergency consultation utilization was significantly less. There were trends for psychoeducated patients to opt for self-funded psychotherapy after completing group psychoeducation and to utilize more medications. However, inpatient care accounted for 40% estimated total cost in the control group but only about 15% in the psychoeducation group. CONCLUSIONS: This study demonstrates the importance of taking a long-term overview of the cost versus benefits of adjunctive psychological therapy in bipolar disorders. If viewed only in the short-term, the psychoeducation group used more mental health care resources without clear additional health gain. However, extended follow-up demonstrated a long-term advantage for psychoeducated individuals, such that, compared to an unstructured support group intervention, group psychoeducation is less costly and more effective.

[Validation of the EuroSCORE probabilistic model in patients undergoing coronary bypass grafting]. / Validación del modelo probabilístico EuroSCORE en pacientes intervenidos de injerto coronario.

INTRODUCTION AND OBJECTIVES: EuroSCORE utilizes a probabilistic model for predicting the risk of in-hospital mortality in patients undergoing cardiac surgery. It is a useful instrument for evaluating quality of care. The model has two variants: the logistic EuroSCORE and the additive EuroSCORE. The aim of this study was to validate the EuroSCORE model in patients undergoing surgery at Hospital Clínic in Barcelona, Spain, and to compare the results obtained with the two variants. METHODS: The study included all patients who received a coronary artery bypass graft (CABG) at Hospital Clínic in Barcelona in two consecutive years. The model's validity was assessed on the basis of its calibration (using the Hosmer-Lemeshow test) and its discrimination (using the receiver operating characteristic [ROC] curve). The two models were compared by carrying out a descriptive analysis of mortality for the whole group and for different risk groups, and by determining the models' discriminative power. RESULTS: A total of 498 patients underwent CABG surgery and were included in the study. The Hosmer-Lemeshow test showed that the model's calibration was satisfactory (P=.32) and the area under the ROC curve was 0.83. The observed in-hospital mortality rate was 5.8%. The predicted rate was 4.2% with the logistic EuroSCORE and 3.9% with the additive EuroSCORE. Large differences were observed in high-risk patients. In these patients, the mortality predicted by the logistic variant was closer to the actual mortality. CONCLUSIONS: EuroSCORE's validity was found to be satisfactory and the model can be used to evaluate quality of care. In high-risk patients, mortality estimated using the logistic model was closer to the actual mortality.

Validación del modelo probabilístico EuroSCORE en pacientes intervenidos de injerto coronario / Validation of the EuroSCORE Probabilistic Model in Patients Undergoing Coronary Bypass Grafting

Introducción y objetivos. EuroSCORE es un modeloprobabilístico para estimar la probabilidad de mortalidadhospitalaria en pacientes sometidos a cirugía cardiaca.Es un instrumento útil para evaluar la calidad asistencial. Existen dos variantes del modelo, el EuroSCORE logístico (EU-L) y el EuroSCORE aditivo (EU-A). El objetivo del estudio es validar el modelo EuroSCORE en pacientes intervenidos en el Hospital Clínic de Barcelona y comparar los resultados de las dos variantes del modelo.Métodos. Se ha incluido a los pacientes intervenidosde injerto coronario en el Hospital Clínic de Barcelona durante 2 años consecutivos. Se ha validado el modelo apartir de su capacidad de calibración (prueba de Hosmer-Lemeshow) y discriminación (área bajo la curva ROC).Se han comparado los dos modelos con un análisis descriptivo de la media de la mortalidad para el total y según grupos de riesgo y mediante su poder de discriminación.Resultados. Un total de 498 pacientes fueron intervenidose incluidos en el estudio. La calibración del modeloes satisfactoria (p = 0,32) y el área bajo la curva ROC es de 0,83. La mortalidad hospitalaria observada alcanzó el 5,8% y la estimada, el 4,2% (EU-L) y el 3,9% (EU-A). Se han observado mayores diferencias en el grupo de pacientes de alto riesgo, en los que la mortalidad predicha por la variante logística se aproxima más a la mortalidad real.Conclusiones. EuroSCORE ha sido validado adecuadamentey puede utilizarse para medir los resultados dela práctica asistencial. El modelo logístico se aproximamás a la mortalidad real en el grupo de pacientes de altoriesgo

Introduction and objectives. EuroSCORE utilizes aprobabilistic model for predicting the risk of in-hospital mortality in patients undergoing cardiac surgery. It is a useful instrument for evaluating quality of care. The model has two variants: the logistic EuroSCORE and the additive EuroSCORE. The aim of this study was to validate the EuroSCORE model in patients undergoing surgery at Hospital Clínic in Barcelona, Spain, and to compare the results obtained with the two variants.Methods. The study included all patients who receiveda coronary artery bypass graft (CABG) at Hospital Clínicin Barcelona in two consecutive years. The model’svalidity was assessed on the basis of its calibration (using the Hosmer-Lemeshow test) and its discrimination (using the receiver operating characteristic [ROC] curve). The two models were compared by carrying out a descriptive analysis of mortality for the whole group and for different risk groups, and by determining the models’ discriminative power.Results. A total of 498 patients underwent CABGsurgery and were included in the study. The Hosmer-Lemeshow test showed that the model’s calibration wassatisfactory (P=.32) and the area under the ROC curvewas 0.83. The observed in-hospital mortality rate was5.8%. The predicted rate was 4.2% with the logisticEuroSCORE and 3.9% with the additive EuroSCORE.Large differences were observed in high-risk patients. Inthese patients, the mortality predicted by the logisticvariant was closer to the actual mortality.Conclusions. EuroSCORE’s validity was found to besatisfactory and the model can be used to evaluatequality of care. In high-risk patients, mortality estimated using the logistic model was closer to the actual mortality5

Induction therapy with trizivir plus efavirenz or lopinavir/ritonavir followed by trizivir alone in naive HIV-1-infected adults.

BACKGROUND: Induction-maintenance strategies were associated with a low response rate. We compared the virological response with two different induction regimens with trizivir plus efavirenz or lopinavir/ritonavir. METHODS: A randomized, multicentre, open-label clinical trial with 209 antiretroviral-naive HIV-infected patients assigned to trizivir plus either efavirenz or lopinavir/ritonavir during 24-36 weeks. Patients reaching undetectable plasma viral loads during induction entered a 48-week maintenance on trizivir alone. The primary endpoint was the proportion of patients without treatment failure at 72 weeks using an intent to treat (ITT) analysis (switching equals failure). RESULTS: Patients were randomly assigned (efavirenz 104; lopinavir/ritonavir 105), and 114 (55%) entered the maintenance phase (efavirenz 54; lopinavir/ritonavir 60). Baseline characteristics were balanced between groups. The response rate at 72 weeks was 31 and 43% (ITT analysis, P = 0.076) and 63 and 75% (on-treatment analysis, P = 0.172) in the efavirenz and lopinavir/ritonavir arms, respectively. Virological failure occurred in 27 patients: six during induction (efavirenz, three; lopinavir/ritonavir, three; P = 1.0) and 21 during maintenance (efavirenz, 14; lopinavir/ritonavir, seven; P = 0.057). Thirty-four patients in the efavirenz arm switched treatment because of adverse events compared with 25 in the lopinavir/ritonavir arm (P = 0.17). CONCLUSION: Trizivir plus either efavirenz or lopinavir/ritonavir followed by maintenance with trizivir achieved a low but similar response at 72 weeks, with a high incidence of adverse events leading to drug discontinuation during the induction phase in both arms. The study showed a trend towards an increased virological failure rate in the efavirenz arm during the maintenance phase.

Organización en institutos de gestión clínica (centros orientados al paciente): descripción de la utilización hospitalaria / Clinical management institutes (patient focused centers): description of hospital utilization

Objetivos: Conocer las características determinantes de la inadecuación de los ingresos y las estancias presentada al aplicar un nuevo modelo de gestión clínica. Métodos: La población objeto de estudio han sido los enfermos dados de alta en el Hospital Clínico Universitario de Barcelona. El instrumento de revisión utilizado ha sido el protocolo AEP médico-quirúrgico. El proceso de evaluación ha consistido en la revisión retrospectiva de la historia clínica por parte de dos evaluadores médicos. Se ha realizado un análisis multivariable de regresión logística múltiple para las variables dependientes ingreso y estancia inadecuada. Resultados: De los 401 ingresos, 28 (6,9%) se consideraron inadecuados. La admisión programada, durante el fin de semana y en las áreas médicas han sido las variables predictivas identificadas para el ingreso inadecuado. De las 2.187 estancias estudiadas, a 267 (12,2%) se las evaluó como inadecuadas. La propia inadecuación del ingreso, la duración de la estancia, la cobertura asistencial y el tipo de alta han sido las variables predictivas identificadas para la estancia inadecuada. Conclusiones: El modelo organizativo desarrollado por los institutos de gestión clínica presenta unos niveles de inadecuación de ingresos y estancias muy aceptables. La actividad asistencial quirúrgica se ha encontrado influida favorablemente por la mayor actuación protocolizada del modelo. La actividad asistencial dirigida a pacientes con enfermedades médicas, asociadas y crónicas, sintetiza el patrón principal de la inadecuación

Objectives: To assess the main features and determining factors of inappropriate admission and hospital stay in relationship with a new clinical management model. Methods: Study population included all patients discharged from the Hospital Clinic-University of Barcelona. The review tool was the medical and surgical Appropriateness Evaluation Protocol (AEP). We reviewed the clinical records of a representative sample of all discharged patients. Two independent and well trained AEP reviewers were used for each record review. A multivariate analysis was performed, using admission and inappropriate hospital stay as independent variables. Results: A total of 401 admissions were reviewed. Twenty-eight (6.9%) were deemed to be inappropriate. Elective admission, admission over the week-end and being admitted to a medical ward were the predictive variables identified for inappropriate admissions. Of all 2,187 hospital stays reviewed, 267 (12.2%) were deemed to be inappropriate. An inappropriate admission, total length of stay, type of insurance coverage and discharge type were the predictive variables identified for inappropriate hospital stays. Conclusions: The new organization and clinical management model, developed by the Patient Focused Care Institutes, showed very acceptable levels of inappropriate admissions and hospital stays. Surgical services have benefited most from this new organization. Care provided to patients with medical conditions, notably those patients with multiple and chronic conditions, make up most of the inappropriateness identified

[Not Available]. / Organización en institutos de gestión clínica (centros orientados al paciente): descripción de la utilización hospitalaria.

OBJECTIVES: To assess the main features and determining factors of inappropriate admission and hospital stay in relationship with a new clinical management model. METHODS: Study population included all patients discharged from the Hospital Clinic-University of Barcelona. The review tool was the medical and surgical Appropriateness Evaluation Protocol (AEP). We reviewed the clinical records of a representative sample of all discharged patients. Two independent and well trained AEP reviewers were used for each record review. A multivariate analysis was performed, using admission and inappropriate hospital stay as independent variables. RESULTS: A total of 401 admissions were reviewed. Twenty-eight (6.9%) were deemed to be inappropriate. Elective admission, admission over the week-end and being admitted to a medical ward were the predictive variables identified for inappropriate admissions. Of all 2,187 hospital stays reviewed, 267 (12.2%) were deemed to be inappropriate. An inappropriate admission, total length of stay, type of insurance coverage and discharge type were the predictive variables identified for inappropriate hospital stays. CONCLUSIONS: The new organization and clinical management model, developed by the Patient Focused Care Institutes, showed very acceptable levels of inappropriate admissions and hospital stays. Surgical services have benefited most from this new organization. Care provided to patients with medical conditions, notably those patients with multiple and chronic conditions, make up most of the inappropriateness identified.

La retribución variable / The variable salary

Es este trabajo se presenta la retribución variable como parte del contexto de la teoría motivacional y como factor extrínseco al propio trabajo y en definitiva, un factor que sólo satisface necesidades básicas. No obstante, existen otros factores mucho más motivadores en la relación del sujeto con su trabajo: el logro, el reconocimiento, la responsabilidad, el ascenso o la promoción. Por tanto la retribución variable nunca será el factor principal o más relevante para la motivación del trabajador. Los efectos deseables de los incentivos económicos sólo se obtendrán si se definen con claridad los aspectos esenciales que debe contemplar la retribución variable. Ése es el objetivo de este artículo (AU)

This work presents the variable salary as part of the motivational theory context and as a factor extrinsic to the work itself and, in short, a factor which only metes basic needs. There are other factors, however, which generate much more motivation in a person´s relation with his work: achievement, recognition, responsibility, rises or promotion. The variable salary will, therefore, never be the principal or most relevant factor for the worker´s motivation. The desirable effects of financial incentives will only be obtained if the essential aspects which the variable salary should contemplate are defined. This is the objective of this article (AU)

[Estimation of emergency department activity and its relationship with inhospital bed disposition]. / Estimación de la actividad en urgencias y su relación con la provisión de camas de hospitalización.

BACKGROUND AND OBJECTIVE: To find out if the daily emergency department (ED) census and daily ED admittances can accurately be foreseen based on the number of visits arrived on ED within the first shift hours. PATIENTS AND METHOD: For 6 consecutively months, the number of ED visits from 6 AM to 10 AM (early visits), and from 10 AM to next day 6 AM (daily ED census) was recorded, along with the number of both daily hospital and ED admittances from 6 AM to 6 AM. The analysis was performed for the ED as a whole, and for each one of its sections. RESULTS: A significant direct correlation was seen between the early visits and daily ED census. This relationship was even greater as considered the ED as a whole (R2 = 0.25; p < 0.001). A direct correlation was also found between daily ED census and daily admittances (R2 = 0.19; p < 0.001). CONCLUSIONS: The number of early ED visits is an important tool to accurately predict the daily ED census and the number of in-hospital beds needed for ED patients.

[Cost analysis of cardiac transplantation in a Spanish hospital]. / Análisis del coste del trasplante cardíaco en un hospital español.

BACKGROUND AND OBJECTIVE: Heart transplant requires a heavy use of high cost resources. Economic data related to this procedure had not been specifically addressed and there are very few publications which analyze this topic. The aim of this study was to analyze the costs related to heart transplant in a series of patients from a single institution. PATIENTS AND METHOD: Data from all patients included in the Hospital Clínic heart transplant programme in which a cardiac transplant was effectively performed between 1999 and 2000 were analyzed, including one year of follow-up. Patients who died within this first year were also included. Organ procurement costs were excluded. Cost analysis was performed by micro-costing techniques. RESULTS: A total of 21 patients undergoing a heart transplant were included. One year survival rate was 76%. Mean (standard deviation) of total cost (procedure costs + one year follow-up cost) was 59,349 (18,881) euros (range: 29,380-113,470 euros). Procedure mean cost was 41,724 (17,584) euros (70% of total costs) and one year follow up mean cost was 17,625 (10,096) euros (30% of total costs) per patient. When the initial episode (heart transplant procedure) was analyzed, main cost drivers were personnel costs euros 59% of all costs; mean: 24,795 (7,633) euros and treatment costs -20% of all costs; mean: 8,386 (7,250) euros. CONCLUSIONS: Costs of heart transplant in Barcelona (Spain) are similar to those published for other European Union countries, and well below the costs related to the procedure in the United States.

[Analysis of Spanish hospital's reputation: relationship with their scientific production in different subspecialities]. / Análisis de la reputación de los hospitales españoles: relación con su producción científica en cuatro especialidades.

BACKGROUND AND OBJECTIVE: To assess the relationship between reputation of hospitals, as determined by specialists' opinion, and their scientific production. MATERIAL AND METHOD: A questionnaire was sent to a sample of members of the Spanish Societies of Cardiology, Digestive Diseases, Neurology and Otorhinolaryngology. Each member had the possibility to nominate 5 hospitals with the greatest reputation amongst his/her specialty. Final score for those hospitals with more than 5% of all votes was used for the development of a reputation index. We assess the scientific production (number of publications and citations) for nominated hospitals and analyze the possible correlation between the reputation index and the scientific production. RESULTS: We received 151 (30%) answers for cardiology, 227 (27%) for digestive diseases, 148 (30%) for neurology and 177 (18%) for otorhinolaryngology. The number of published articles and the number of citations for each nominated hospital showed a positive and statistically significant correlation with the reputation index. CONCLUSIONS: This is the first approach to analyze reputation parameters for Spanish hospitals. Scientific production and reputation index showed a positive correlation.

Estimación de la actividad en urgencias y su relación con la provisión de camas de hospitalización / Estimation of emergency department activity and its relationship with inhospital bed disposition

Fundamento y objetivo: Investigar si es posible predecir en urgencias el número de consultas e ingresos diarios a partir del número de consultas que se atienden a primera hora del día. Pacientes y método: Durante 6 meses consecutivos se contabilizó el número de visitas a primera hora (de 6 a 10 h) y durante el resto del día (de 10 a 6 h del día siguiente), así como el número de ingresos diarios (de 6 a 6 h) totales en el hospital y cuántos de éstos procedían de urgencias. Los cálculos se realizaron de forma global y de forma parcial para la sección de medicina de urgencias y para el resto de secciones de urgencias. Resultados: Se observó una relación directa y estadísticamente significativa entre el número de visitas a primera hora y el número total de visitas, que fue mayor cuando se consideró urgencias de forma global (R2 = 0,25; p < 0,001). A mayor número de consultas en urgencias, mayor número de ingresos generados (R2 = 0,19; p < 0,001). Conclusiones: La actividad realizada a primera hora en urgencias permite predecir la actividad de aquel día y las necesidades de camas para ingreso

Background and objective: To find out if the daily emergency department (ED) census and daily ED admittances can accurately be foreseen based on the number of visits arrived on ED within the first shift hours. Patients and method: For 6 consecutively months, the number of ED visits from 6 AM to 10 AM (early visits), and from 10 AM to next day 6 AM (daily ED census) was recorded, along with the number of both daily hospital and ED admittances from 6 AM to 6 AM. The analysis was performed for the ED as a whole, and for each one of its sections. Results: A significant direct correlation was seen between the early visits and daily ED census. This relationship was even greater as considered the ED as a whole (R2 = 0.25; p < 0.001). A direct correlation was also found between daily ED census and daily admittances (R2 = 0.19; p < 0.001). Conclusions: The number of early ED visits is an important tool to accurately predict the daily ED census and the number of in-hospital beds needed for ED patients

Análisis de la reputación de los hospitales españoles: relación con su producción científica en cuatro especialidades / Analysis of Spanish hospital's reputation: relationship with their scientific production in different subspecialities

Fundamento y objetivo: Evaluar la reputación de los hospitales y analizar su posible relación con la producción científica (artículos y citaciones) de dichos hospitales. Material y método: Encuesta a miembros de las Sociedades Españolas de Cardiología, Patología Digestiva, Neurología y Otorrinolaringología. Cada socio podía votar 5 hospitales que consideraba de mayor reputación asistencial en su especialidad. La puntuación final de los 15 hospitales con más del 5% de los votos constituye el índice de reputación. Se evaluó la producción científica (publicaciones y citaciones) en cada especialidad y para cada hospital más votado y se analizó la posible relación entre ambos parámetros. Resultados: Se obtuvieron 151 (30%) respuestas en cardiología, 227 (27%) en patología digestiva, 148 (30%) en neurología y 177 (18%) en otorrinolaringología. Los índices de publicaciones y de citaciones mostraron mayoritariamente una relación positiva y estadísticamente significativa con el índice de reputación. Conclusiones: El trabajo presentado realiza una primera aproximación al estudio de la reputación como medida indirecta de la calidad de los hospitales españoles. La producción científica de éstos mostró una relación positiva con el índice de reputación

Background and objective: To assess the relationship between reputation of hospitals, as determined by specialists' opinion, and their scientific production. Material and method: A questionnaire was sent to a sample of members of the Spanish Societies of Cardiology, Digestive Diseases, Neurology and Otorhinolaryngology. Each member had the possibility to nominate 5 hospitals with the greatest reputation amongst his/her specialty. Final score for those hospitals with more than 5% of all votes was used for the development of a reputation index. We assess the scientific production (number of publications and citations) for nominated hospitals and analyze the possible correlation between the reputation index and the scientific production. Results: We received 151 (30%) answers for cardiology, 227 (27%) for digestive diseases, 148 (30%) for neurology and 177 (18%) for otorhinolaryngology. The number of published articles and the number of citations for each nominated hospital showed a positive and statistically significant correlation with the reputation index. Conclusions: This is the first approach to analyze reputation parameters for Spanish hospitals. Scientific production and reputation index showed a positive correlation

[Direct discharge from triage in emergency departments: assessment, risks and patient satisfaction]. / Derivación sin visita desde los servicios de urgencias hospitalarios: cuantificación, riesgos y grado de satisfacción.

BACKGROUND AND OBJECTIVE: After triage assessment, some hospitals refer emergency department (ED) patients with minor chief complaints to off-site clinics. The potential for 2 different referral models introduced in 2 urban hospitals was assessed, as well as the suitability of this measure. PATIENTS AND METHOD: After triage assessment, patients with minor complaints were identified. ED from Hospital Clínic of Barcelona (HCB) proposed that these patients should be referred to a hospital affiliated off-site clinic, whereas ED from Hospital Mútua de Terrassa (HMT) tried to refer such patients to their primary care setting. Within a year, we assessed on both ED the following items: number of arrivals, percentage of proposed referrals (PR), percentage of accepted referrals (AR), percentage of carried-out referrals (CR: patients who, once discharged, really attended the other setting), and percentage of returned referrals (RR) to the ED, as well as return reasons, and the percentage of returned patients finally admitted. The degree of patient satisfaction was evaluated by means of a telephone survey. RESULTS: From both ED, 44,764 arrivals and 7,297 (16.3%) PR were registered. The percentage of AR and CR was 94.3% and 75.3%, respectively. The percentage of PR from HMT was higher (18.7% vs 13.1%; p < 0.001), yet HCB obtained a greater percentage of AR (98.9% vs 92%, p < 0.001) and CR (93.7% vs 65%; p < 0.001). The percentage of RR from both ED was 1.5% (2.8% vs 0.4%; p < 0.001). Among returned patients, 12 of them (0.17% respect to AR) were finally admitted. Only 41% of patients who were found to be eligible for direct discharge would have agreed with being referred to another clinical setting, but after the experience, up to 93% of them said they would go through it again. HMT gave referral information to patients faster than HCB (p < 0.05), but HCB got a better model evaluation (p < 0.01), a greater medical complaint solution (p < 0.05), and generated a smaller number of subsequent consultations (p < 0.05). CONCLUSIONS: After a rapid triage assessment, a percentage of patients arriving on EDs may be directly and safely discharged and referred to other clinical settings. This is achieved by both proposed models without additional risks for patients. However, patients feel more satisfied with an hospital-affiliated off-site clinic instead of their primary care setting.

Derivación sin visita desde los servicios de urgencias hospitalarios: cuantificación, riesgos y grado de satisfacción / Direct discharge from triage in emergency departments: assessment, risks and patient satisfaction

Fundamento y objetivo: Desde hace unos años, algunos centros hospitalarios redirigen a los pacientes que acuden a urgencias con enfermedades menores hacia niveles asistenciales más adecuados sin que se les visite. A continuación se presenta la experiencia de 2 hospitales que aplican modelos diferenciales y se analiza la idoneidad de esta medida. Pacientes y método: A los pacientes con síntomas menores que consultan en la Unidad de Urgencias de Medicina (UUM) del Servicio de Urgencias Hospitalario (SUH), del Hospital Clínic de Barcelona (HCB), se les propone que se les visite en un centro externo de urgencias extrahospitalarias que depende del propio hospital, mientras que el Hospital Mútua de Terrassa (HMT) los remite a los centros de asistencia primaria correspondientes. Durante un año, se ha medido la actividad de ambos hospitales, se ha cuantificado el porcentaje de derivaciones propuestas (DP) por los médicos de la UUM, de derivaciones aceptadas (DA) por los pacientes, de derivaciones consumadas (DC, pacientes que acuden realmente al centro externo), de derivaciones retornadas (DR) al SUH, la causa de las DR y el porcentaje de ingresos. Además se ha realizado una encuesta de satisfacción. Resultados: Durante el período de estudio se visitaron 44.764 pacientes y a un 16,3% se les propuso acudir al centro externo sin visita previa. El porcentaje de DA y DC fue del 94,3 y del 75,3%, respectivamente. El de DP fue superior en el HMT (el 18,7 frente al 13,1%; p < 0,001), mientras que el HCB tuvo mayores porcentajes de DA (el 98,9 frente al 92,0%; p < 0,001) y DC (el 93,7 frente al 65,0%; p < 0,001). Se registró un 1,5% de DR, que fueron superiores en el HCB (el 2,8 frente al 0,4%; p < 0,001). El índice global de ingresos fue del 0,17%. Sólo al 41% de los pacientes le pareció bien de entrada acudir a otro recurso asistencial, pero tras la experiencia el 93% afirmó que volvería a aceptarla. El HMT fue más rápido en facilitar la información (p < 0,05), mientras que el HCB tuvo una mejor valoración global del sistema (p < 0,01) y del grado de resolución del problema (p < 0,05) y generó un menor número de consultas médicas posteriores (p < 0,05). Conclusiones: Es posible derivar sin visita previa a un porcentaje sustancial de pacientes que consultan por situaciones menores desde una UUM del SUH a un centro externo, sin que ello signifique un riesgo para ellos. Estos pacientes muestran mayor satisfacción con un modelo en el que el centro externo depende del propio hospital que con uno en que el centro externo sea el propio centro de asistencia primaria

Background and objective: After triage assessment, some hospitals refer emergency department (ED) patients with minor chief complaints to off-site clinics. The potential for 2 different referral models introduced in 2 urban hospitals was assessed, as well as the suitability of this measure. Patients and method: After triage assessment, patients with minor complaints were identified. ED from Hospital Clínic of Barcelona (HCB) proposed that these patients should be referred to a hospital affiliated off-site clinic, whereas ED from Hospital Mútua de Terrassa (HMT) tried to refer such patients to their primary care setting. Within a year, we assessed on both ED the following items: number of arrivals, percentage of proposed referrals (PR), percentage of accepted referrals (AR), percentage of carried-out referrals (CR: patients who, once discharged, really attended the other setting), and percentage of returned referrals (RR) to the ED, as well as return reasons, and the percentage of returned patients finally admitted. The degree of patient satisfaction was evaluated by means of a telephone survey. Results: From both ED, 44,764 arrivals and 7,297 (16.3%) PR were registered. The percentage of AR and CR was 94.3% and 75.3%, respectively. The percentage of PR from HMT was higher (18.7% vs 13.1%; p < 0.001), yet HCB obtained a greater percentage of AR (98.9% vs 92%, p < 0.001) and CR (93.7% vs 65%; p < 0.001). The percentage of RR from both ED was 1.5% (2.8% vs 0.4%; p < 0.001). Among returned patients, 12 of them (0.17% respect to AR) were finally admitted. Only 41% of patients who were found to be eligible for direct discharge would have agreed with being referred to another clinical setting, but after the experience, up to 93% of them said they would go through it again. HMT gave referral information to patients faster than HCB (p < 0.05), but HCB got a better model evaluation (p < 0.01), a greater medical complaint solution (p < 0.05), and generated a smaller number of subsequent consultations (p < 0.05). Conclusions: After a rapid triage assessment, a percentage of patients arriving on EDs may be directly and safely discharged and referred to other clinical settings. This is achieved by both proposed models without additional risks for patients. However, patients feel more satisfied with an hospital-affiliated off-site clinic instead of their primary care setting

Del desencanto a la esperanza / From disillusion to hope

No disponible

[Emergency department activity during the 2003 summer heat wave]. / Impacto de la ola de calor del verano de 2003 en la actividad de un servicio de urgencias hospitalario.

BACKGROUND AND OBJECTIVE: Several thousands deaths were attributed to a heatwave during the summer of 2003 in Europe. The aim of this study was to analyze its consequences in an emergency department. PATIENTS AND METHOD: We performed a descriptive observational study of the patients admitted to our emergency unit between 15 July and 31 August, 2003. We also carried out a comparative study of these patients with those admitted during the same period of 2002. RESULTS: A total of 5197 patients were admitted in our unit during the summer of 2003, in comparison with 4672 in the same interval in 2002. An increase in rates of total fever (17% versus 12%; p < 0.001), non-infectious fever (29% versus 26%; p < 0.001), decompensation of a chronic cardiovascular or respiratory disease (14% versus 11%; p < 0.001), admission (28% versus 22%; p < 0.001), and mortality (2% versus 1%; p < 0.001) were registered during the summer of 2003, in comparison with the previous year. A multivariate study showed a higher risk of death in patients older than 70 years (p < 0.01), in fragile dependent people (p < 0.05), and upon the presence of abnormal blood levels of creatinine (p < 0.05) on arrival at the emergency department. We also found an association between daily maxim temperature and number of daily emergency visits (R2 = 0.15; p < 0.001), total percentage of patients with fever (R2 = 0.26; p < 0.001), percentage of patients with non-infectious fever (R2 = 0.07; p = 0.01), percentage of decreases (R2 = 0.04; p < 0.05), and percentage of hospital admissions (R2 = 0.15; p < 0.001). CONCLUSIONS: The summer 2003 heatwave resulted in an elevation of the total number of emergency visits and hospital admissions, and higher mortality and morbidity rates, especially in old people. In the future, preventive measures must be taken to limit the health consequences of any heatwaves to come.

Impacto de la ola de calor del verano de 2003 en la actividad de un servicio de urgencias hospitalario / Emergency department activity during the 2003 summer heat wave

Fundamento y objetivo: Durante la ola de calor del verano de 2003 se registraron varios miles de fallecimientos en Europa. Se analizan las consecuencias de esta ola de calor en una sección de urgencias de medicina de un servicio de urgencias hospitalario. Pacientes y método: Estudio descriptivo de las características de los pacientes visitados en una sección de urgencias de medicina entre el 15 de julio y el 31 de agosto de 2003, y se compara con las de los que fueron atendidos durante el mismo intervalo en 2002. Resultados: El número total de pacientes atendidos en el verano de 2003 fue de 5.197, frente a los 4.672 del año anterior. Durante 2003 aumentó, con respecto al año 2002, el porcentaje total de pacientes con fiebre (el 17 frente al 12%; p < 0,001), fiebre de causa no infecciosa (el 29 frente al 26%; p < 0,001), descompensación de enfermedad crónica (el 14 frente al 11%; p < 0,001), ingresados (el 28 frente al 22%; p < 0,001) y fallecidos (el 2 frente al 1%; p < 0,001). Los factores predictivos independientes de mortalidad para los pacientes con fiebre visitados durante la ola de calor de 2003 fueron la edad superior a 70 años (p < 0,01), la dependencia para las actividades de la vida diaria (p < 0,05) y la alteración de las concentraciones de creatinina a su llegada a urgencias (p < 0,05). Además, encontramos una asociación lineal con significación estadística entre la temperatura máxima diaria y el número de visitas diarias a urgencias (R2 = 0,15; p < 0,001), así como con el porcentaje total de pacientes que se visitaron por fiebre (R2 = 0,26; p < 0,001), fiebre de causa no infecciosa (R2 = 0,07; p = 0,01), fallecidos (R2 = 0,04; p < 0,05) e ingresados (R2 = 0,15; p < 0,001). Conclusiones: Durante la ola de calor del verano de 2003 se produjo un aumento del número de visitas a urgencias y de ingresos hospitalarios, así como una mayor tasa de morbimortalidad, especialmente en las personas de edad avanzada. Las autoridades sanitarias deberían llevar a cabo medidas preventivas para limitar las consecuencias sobre la salud pública que pudieran derivarse de futuras olas de calor

Background and objective: Several thousands deaths were attributed to a heatwave during the summer of 2003 in Europe. The aim of this study was to analyze its consequences in an emergency department. Patients and method: We performed a descriptive observational study of the patients admitted to our emergency unit between 15 July and 31 August, 2003. We also carried out a comparative study of these patients with those admitted during the same period of 2002. Results: A total of 5197 patients were admitted in our unit during the summer of 2003, in comparison with 4672 in the same interval in 2002. An increase in rates of total fever (17% versus 12%; p < 0.001), non-infectious fever (29% versus 26%; p < 0.001), decompensation of a chronic cardiovascular or respiratory disease (14% versus 11%; p < 0.001), admission (28% versus 22%; p < 0.001), and mortality (2% versus 1%; p < 0.001) were registered during the summer of 2003, in comparison with the previous year. A multivariate study showed a higher risk of death in patients older than 70 years (p < 0.01), in fragile dependent people (p < 0.05), and upon the presence of abnormal blood levels of creatinine (p < 0.05) on arrival at the emergency department. We also found an association between daily maxim temperature and number of daily emergency visits (R2 = 0.15; p < 0.001), total percentage of patients with fever (R2 = 0.26; p < 0.001), percentage of patients with non-infectious fever (R2 = 0.07; p = 0.01), percentage of deceases (R2 = 0.04; p < 0.05), and percentage of hospital admissions (R2 = 0.15; p < 0.001). Conclusions: The summer 2003 heatwave resulted in an elevation of the total number of emergency visits and hospital admissions, and higher mortality and morbility rates, especially in old people. In the future, preventive measures must be taken to limit the health consequences of any heatwaves to come

Influencia del médico en la satisfacción del paciente: estudio de 471 casos / Influence of physician in patient satisfaction: study of 471 cases

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[Usefulness of risk indexes for the prediction of surgical site infection in patients undergoing neurosurgical procedures]. / Utilidad de los índices compuestos de riesgo para predecir el desarrollo de infección quirúrgica en neurocirugía.

BACKGROUND AND OBJECTIVE: The use of risk indexes, originally developed in the US for the assessment of SSI risk, is an useful instrument that must be analyzed according to each specific procedure. The addition of other possible SSI risk factors, like the use of perioperative antibiotic prophylaxis, could improve the predictive value of these indexes. The aim of this study was to determine the SSI incidence rate for craniotomy in patients admitted to the Neurosurgical Unit of the Hospital Clinic of Barcelona (Spain), to assess the use of standard NNIS and SENIC indexes, and to assess the possible effect of the addition of a new risk factor (adequate or inadequate use of perioperative antibiotic prophylaxis) to these indexes. PATIENTS AND METHOD: Risk factors for SSI were assessed following common standard definitions and procedures (CDC-NNIS) over a three-year period (1999-2001). NNIS and SENIC risk indexes were calculated. The effect of the addition of a new variable, namely perioperative antibiotic prophylaxis adequate (0 points) or inappropriate/no prophylaxis (1 point) on these indexes (modified indexes NNISa and SENICa) was also assessed. Statistical analysis included both parametric and non-parametric standard tests. RESULTS: The study included a total of 203 patients undergoing a craniotomy procedure (40% of all neurosurgical procedures). The overall SSI incidence rate was 6.8% (14 patients developed SSI). The cut-off point (75 percentile) for the duration of the procedure was 180 minutes instead of the commonly US reported 240 minutes. Patients who develop SSI had a trend towards having shorter operation times. For those patients in the lower risk groups, the SSI incidence rate was: NNIS (0, 1): 6.9%; SENIC (0, 1): 6.2%. If the modified indexes were used, the SSI incidence rate was: NNISa (0, 1): 4.2%; SENICa (0, 1): 4.9%. When NNIS and SENIC indexes, both standard and modified (NNISa and SENICa), were compared, no statistically significant differences between infected and non-infected patients were observed. CONCLUSIONS: When applied to a health system other than the US, SENIC and NNIS indexes could be useful if adapted to each specific situation and procedure. The added value of a new risk factor (perioperative antibiotic prophylaxis) on standard NNIS and SENIC indexes shows a slight improvement in their prediction rate for SSI in patients undergoing craniotomy, mainly in those patients at lower risk for developing superficial SSI.