Analysis of bupivacaine and ropivacaine-related cardiac arrests in regional anesthesia: A systematic review of case reports.

Regional anesthesia as a component of multimodal analgesia protocols has become more and more a part of modern perioperative pain management. The widespread adoption of ultrasound guidance in regional anesthesia has surely played an important role in that growth and it has significantly improved patient safety, decreased the incidence of block failure, cardiac arrest, and reduced complication rates. The objective of this systematic review is to extract, analyze, and synthesize clinical information about bupivacaine and ropivacaine related cardiac arrest that we might have a clearer picture of the clinical presentation. The literature search identified 268 potentially relevant publications and 22 relevant case reports were included in the review. Patients' demographics, types of regional anesthesia, hypotension, heart rhythm disorders, seizures, cardiac arrest, fatal outcome, recommendations and limitations on prevention and treatment of bupivacaine and ropivacaine related cardiac arrest are analyzed and discussed in the systematic review. Both bupivacaine and ropivacaine-induced local anesthetic toxicity can result in cardiac arrest. Lipid emulsion, telemetry, local anesthetic toxicity resuscitation training appears to be promising in improvement of survival but more research is needed. Improvement and encouragement of reporting the local anesthetic toxicity are warranted to improve the quality of information that can be analyzed in order to make more precise conclusion.

Side effects of continuous intra-arterial infusion of nimodipine for management of resistant cerebral vasospasm in subarachnoid hemorrhage patients: A systematic review.

BACKGROUND: Cerebral vasospasm is a common complication of subarachnoid hemorrhage. Nimodipine is the most frequently used drug for cerebral vasospasm management and is the only approved medication that has been demonstrated to reduce ischemic complications, infarct size and improve neurological outcome after aneurismal subarachnoid hemorrhage. The main purpose of this systematic review was to conduct a comprehensive analysis of the main cerebral and extracerebral side effects of continuous intra-arterial infusion of nimodipine in management of delayed cerebral ischemia in subarachnoid hemorrhage patients. MATERIALS AND METHODS: A protocol with the inclusion and exclusion criteria for matched cases and the method of analysis were established and agreed by all authors. We defined the scope of this review to include articles (prospective and retrospective) reporting the side effects of continuous intra-arterial infusion of nimodipine in human subjects. PRISMA guidelines were used to conduct this systematic review. RESULTS: A total of 8 articles reporting 136 patients were included in the review and analyzed. The side effects associated with continuous intra-arterial infusion of nimodipine were arterial hypotention, heparin-induced thrombocytopenia, atrial fibrillation or flutter, infections, acute kidney injury, hepatic and gastro-intestinal side effects. CONCLUSION: The most frequent side effects reported in the articles included in this systematic review associated with the continuous intra-arterial infusion of nimodipine were arterial hypotension and heparin-induced thrombocytopenia. Intracerebral hemorrhage, the elevation of ICP, heart rhythm disorders, infectious complications, and thrombosis of the catheter might be also associated with CIAN. Future prospective studies are warranted to establish the risks and incidence of procedure-related side effects.

Implementation of evidence-based recommendations to reduce elective surgical case cancellations.

BACKGROUND: Cancellation of elective surgical cases leads to a waste of resources, financial burden, patient dissatisfaction, extended hospital stay, and unnecessary repetition of preoperative preparations. AIM: The objective of this study was to identify, analyze and manage the causes of cancellation of elective surgical cases in our institution. METHODS: This quality improvement study compared preoperative cardiovascular event and case cancellation rates before and after implementing the practice of perioperative cardiovascular risk management. The study included the following phases: (1) Screening and identification of the most important reason for case cancellation; (2) Developing the strategy and internal protocol based on the international recommendations to minimize perioperative cardiovascular risk; (3) Implementing the internal protocol and monitoring preoperative cardiovascular events and case cancellation rate. RESULTS: We achieved a reduction in surgical case cancellation rate: 83 (3.7%) out of 2242 in 2018 and 28 (1.1%) out of 2538 cases in 2019 were cancelled after the patient had been delivered to the operating room area. CONCLUSION: Screening and identification of gaps in perioperative care as well as implementation of evidence-based recommendations can significantly improve the quality of patient care. In our case, implementing the internal protocol of cardiovascular risk management in perioperative period resulted in a reduction of preoperative hypertensive crisis, myocardial ischemia, heart rhythm disorder rates and in subsequently reduction in case cancellation rate.

Quality of care assessment for people with multimorbidity.

Multimorbidity, the simultaneous presence of multiple health conditions in an individual, is an increasingly common phenomenon globally. The systematic assessment of the quality of care delivered to people with multimorbidity will be key to informing the organization of services for meeting their complex needs. Yet, current assessments tend to focus on single conditions and do not capture the complex processes that are required for providing care for people with multimorbidity. We conducted a scoping review on quality of care and multimorbidity in selected databases in June 2018 and identified 87 documents as eligible for review, predominantly original research and reviews from North America, Europe and Australasia and mostly frequently related to primary care settings. We synthesized data qualitatively in terms of perceived challenges, evidence and proposed metrics. Findings reveal that the association between quality of care and multimorbidity is complex and depends on the conditions involved (quality appears to be higher for those with concordant conditions, and lower in the presence of discordant conditions) and the approach used for measuring quality (quality appears to be higher in people with multimorbidity when measured using condition/drug-specific process or intermediate outcome indicators, and worse when using patient-centred reports of experiences of care). People with discordant multimorbidity may be disadvantaged by current approaches to quality assessment, particularly when they are linked to financial incentives. A better understanding of models of care that best meet the needs of this group is needed for developing appropriate quality assessment frameworks. Capturing patient preferences and values and incorporate patients' voices in the form of patient-reported experiences and outcomes of care will be critical towards the achievement of high-performing health systems that are responsive to the needs of people with multimorbidity.

Utilización de los servicios de urgencias en zonas rurales y urbanas / Use of emergency departments in rural and urban areas in Spain

Objetivos: Describir la utilización de los servicios de urgencias (SU) y analizar las diferencias entre zonas rurales y urbanas. Material y métodos: Con la Encuesta Nacional de Salud de los años 2006 y 2011 se describen los perfiles de los pacientes que tienen visitas al SU según tamaño del municipio de residencia y se identifican las variables asociadas con tener una visita a los SU para determinar el efecto del tamaño del municipio de residencia. Resultados: En ambos años, la mayor utilización de SU se observa en las personas que utilizan más Atención Primaria u hospitales, que tienen peor salud autopercibida y estado funcional, con más enfermedades crónicas, de clases sociales más bajas, y de menor edad. Ajustando por el resto de las variables, los residentes en municipios de más habitantes o capitales de provincia tienen una mayor frecuentación de SU que los residentes en municipios más pequeños, que tienen una mayor utilización de SU públicos y no hospitalarios, que los residentes en zonas urbanas. Discusión: Existe una utilización más elevada de los SU por los habitantes de zonas urbanas que no puede justificarse por su peor estado de salud, lo que indicaría no una infrautilización en zonas rurales, sino sobreutilización en zonas urbanas (AU)

Objectives: Describe the use of emergency departments (ED), and analyse the differences in use between residents in rural and urban areas. Material and methods: Using data from the National Health Survey of 2006 and 2011, the profiles of patients with ED visits by population size of place of residence were obtained. The variables associated with making one visit to the ED were also evaluated, in order to determine the effect of the population size of place of residence. Results: A higher use of ED is observed in persons with a higher frequency of use of Primary Care and hospital admissions, and increases with worse self-perceived health and functional status, with more chronic diseases, in people from lower social classes, and younger ages. Adjusting for the other variables, residents in larger cities have a higher use of ED than residents in rural areas, who show a higher use of public and non-hospital based ED, than residents in urban areas. Discussion: There is a higher use of ED by inhabitants of urban areas that cannot be justified by a worst health status of that population. This tends to indicate that the use of ED is not under-used in rural areas, but overused in urban areas (AU)

[Use of emergency departments in rural and urban areas in Spain]. / Utilización de los servicios de urgencias en zonas rurales y urbanas.

OBJECTIVES: Describe the use of emergency departments (ED), and analyse the differences in use between residents in rural and urban areas. MATERIAL AND METHODS: Using data from the National Health Survey of 2006 and 2011, the profiles of patients with ED visits by population size of place of residence were obtained. The variables associated with making one visit to the ED were also evaluated, in order to determine the effect of the population size of place of residence. RESULTS: A higher use of ED is observed in persons with a higher frequency of use of Primary Care and hospital admissions, and increases with worse self-perceived health and functional status, with more chronic diseases, in people from lower social classes, and younger ages. Adjusting for the other variables, residents in larger cities have a higher use of ED than residents in rural areas, who show a higher use of public and non-hospital based ED, than residents in urban areas. DISCUSSION: There is a higher use of ED by inhabitants of urban areas that cannot be justified by a worst health status of that population. This tends to indicate that the use of ED is not under-used in rural areas, but overused in urban areas.

Risk factors for hospital readmissions in elderly patients: a systematic review.

Population ageing is associated with an increase in hospital admissions. Defining the factors that affect the risk of hospital readmission could identify individuals at high risk and enable targeted interventions to be designed. This aim of this study was to identify the risk factors for hospital readmission in elderly people. A systematic review of the literature published in English or Spanish was performed by electronically searching EMBASE, MEDLINE, CINAHL, SCI and SSCI. Some keywords were aged, elder, readmission, risk, etc. Selection criteria were: prospective cohort studies with suitable statistical analysis such as logistic regression, that explored the relationship between the risk of readmission with clinical, socio-demographic or other factors in elderly patients (aged at least 75 years) admitted to hospital. Studies that fulfilled these criteria were reviewed and data were extracted by two reviewers. We assessed the methodological quality of the studies and prepared a narrative synthesis. We included 12 studies: 11 were selected from 1392 articles identified from the electronic search and one additional reference was selected by manual review. Socio-demographic factors were only explanatory in a few models, while prior admissions and duration of hospital stay were frequently relevant factors in others. Morbidity and functional disability were the most common risk factors. The results demonstrate the need for increased vigilance of elderly patients who are admitted to hospital with specific characteristics that include previous hospital admissions, duration of hospital stay, morbidity and functional disability.

Distribución por grupos diagnósticos (CIE-9, Cód. 290-319) en la hospitalización psiquiátrica española, 1980-2004 / No disponible

Introducción: El análisis de la evolución de la morbilidadhospitalaria para los diferentes grupos diagnósticosrefleja cambios importantes en la asistencia y preocupantesindicadores en la morbilidad hospitalaria.Material y métodos: Estudio descriptivo. Explotaciónde datos de la Encuesta de Morbilidad Hospitalaria(1980-2004) y del Conjunto Mínimo Básico de Datos(2000-2004). Datos desagregados en 30 grupos diagnósticos(CIE-9, Cód.290-319) y agrupados en 5 quinquenios.Variables analizadas: altas, estancias totales yestancias medias hospitalarias causadas en el conjuntode hospitales españoles y en las áreas de agudos de hospitalesgenerales, así como reingresos causados en áreasde agudos de hospitales generales.Resultados: Cambio sustancial en los indicadores demorbilidad a lo largo de la serie temporal, diferencialsegún el grupo diagnóstico analizado. Para el conjunto depatologías psiquiátricas se refleja un incremento de lasaltas hospitalarias y descenso de estancias totales ymedias. El perfil de los diagnósticos psiquiátricos asistidoshospitalariamente ha cambiado a lo largo de la serie.Al desagregar la morbilidad hospitalaria en grupos diagnósticospsiquiátricos se observan preocupantes indicadores,como incremento exponencial en la morbilidad causadapor algunas de las patologías analizadas, estanciasmedias muy elevadas para determinadas patologías enhospital monográfico o área de larga estancia y focalizacióndel tratamiento hospitalario en estos centros. Seobservan así mismo, niveles elevados de reingresos enáreas de agudos de hospitales generales en relación a algunosde los grupos diagnósticos analizados en este estudio(AU)

Introduction: The analysis of hospital morbidity evolutionfor the different diagnostic groups reflects importantchanges in hospital assistance and worrying morbidityindicators.Materials and methods: Descriptive study. Exploitationof two databases, Survey of Disease Hospital(1980-2004) and the Minimum Basic Data Set (2000-2004). Disaggregated data in 30 diagnostic groups(ICD-9, Cód.290-319) and grouped into 5 groups of 5years-period each one. Variables analyzed: discharges,total and average hospital stay caused in all Spanishhospitals and in acute areas of general hospitals, andreadmissions caused in acute areas of general hospitals.Results: It is observed important changes in morbidityindicators along the time series, differential evolutionaccording to the group analyzed. For all psychiatric disordersis observed an increase in hospital discharge anddeclining totals and averages stays. The profile of psychiatricdiagnoses assisted hospitably has changed overthe series. It is observed worrying indicators, such asexponential increase in morbidity caused by some of thepathologies analyzed, high average stays for certain diseasesand treatment focus on monographic or long stayhospital area. It was also observed, high levels of readmissionsin acute areas of general hospitals in relationto some of the diagnostic groups analyzed in this study(AU)

Indicadores hospitalarios por Comunidades Autónomas, 1980-2004 (Análisis longitudinal de indicadores de morbilidad y dotación hospitalaria en salud mental) / Hospital indicators by Regional Communities, 1980-2004 (Longitudinal analysis of morbidity indicators and hospital staffing in mental health)

Introducción. Análisis comparativo entre Comunidades Autónomas (CCAA) de indicadores asistenciales relativos a la morbilidad y dotación hospitalaria en la atención psiquiátrica a lo largo de un período de tiempo (1980-2004) marcado por el inicio y desarrollo de políticas desinstitucionalizadoras y traspaso de competencias a las CCAA. Metodología. Estudio longitudinal. Análisis descriptivo de variables desagregadas por CCAA, relativas a la morbilidad hospitalaria por patología psiquiátrica (CIE-9, códigos 290-319) e indicadores de dotación hospitalaria a lo largo de un período de 25 años. Fuente de información: Encuesta de Morbilidad Hospitalaria, 1980-2004 y Estadística de Establecimientos Sanitarios en Régimen de Internado, 1980-2004. Resultados. Las diferencias entre CCAA son sustanciales en todas las variables analizadas: altas, estancia total y media, consultas totales y primeras consultas, tasa de psiquiatras en atención hospitalaria, número de hospitales psiquiátricos y camas en funcionamiento. Para el conjunto de las CCAA, cabe destacar un incremento en las altas, descenso de las estancias totales y medias, incremento notable de consultas, escaso incremento de psiquiatras en atención hospitalaria y estancamiento en la disminución de hospitales psiquiátricos y camas en funcionamiento en hospital psiquiátrico durante el último período de la serie temporal, así como el escaso aumento de camas en funcionamiento en los hospitales no clasificados como hospital psiquiátrico. Conclusiones. Encontramos indicios de modelos de atención cualitativamente diferentes entre CCAA y cambios sustanciales en los principales indicadores asistenciales a lo largo de la serie temporal (AU)

Introduction. Comparative analysis by Spanish Regional Communities (RC) of indicators related to morbidity and staffing in psychiatric care hospital over a period of time (1980-2004) marked by the initiation and development of deinstitutionalization policies and handover of powers to RC. Methodology. Longitudinal study. Descriptive analysis of variables, broken down by RC, related to psychiatric morbidity (ICD-9, codes 290-319) and indicators of hospital staffing over a 25-year period. Database source: Hospital Morbidity Survey, 1980-2004 and Statistics for care facilities providing in-patient care regime, 1980-2004. Results. Differences between Regional Communities are substantial in all the analyzed variables: discharges, total and average stay, total and initial consultations, rate of psychiatrists in hospital care, number of beds and psychiatric hospitals. For all the Regional Communities as a whole, an increase is observed in hospital discharges, decrease of total and mean stays, notable increase of consultations, little increase in psychiatric staff in hospital care and stagnation in the decline of psychiatric hospitals and beds in operation in psychiatric hospital during the last period of time series and low increase in beds for the hospitals that are not classified as a psychiatric hospital. Conclusions. We found evidence of qualitatively different care models between Regional Communities and substantial changes in major indicators over time series (AU)

Hospitales monográficos en atención psiquiátrica (análisis de indicadores hospitalarios desagregados por finalidad y área asistencial psiquiátrica. Explotación de base de datos EESRI, serie temporal 1979-2004) / No disponible

Introducción: En 1986, a través de la Ley General de Sanidad, se formulan las líneas directrices en la desintitucionalización de la psiquiatría y se traspasan las competencias a las CCAA en materia sanitaria. Se propugna por un modelo de atención ambulatorio, asertivo y comunitario, y el desmantelamiento de la antigua red de hospitales monográficos en atención psiquiátrica. Con el presente estudio se ofrece una serie de indicadores, de interés en la evaluación de la atención psiquiátrica por lo que se refiere al modelo de atención hospitalario adoptado. Material y métodos: Explotación de datos de la Encuesta de Establecimientos Sanitarios en Régimen de Internado (EESRI) relativos al área de atención psiquiátrico. Marco temporal de análisis: 1979-2004. Dentro de este marco temporal, presentamos el análisis de las tasas de establecimientos sanitarios, camas en funcionamiento, consultas, altas, estancias y estancias medias desagregadas entre hospital psiquiátrico y el resto de establecimientos hospitalarios que disponen de área de atención psiquiátrica. Resultados: Descenso en el número de hospitales psiquiátricos particularmente entre los años 1986-1992 ya que durante el período 1993-2004 el decremento es poco significativo. Acusado descenso en las camas en funcionamiento en el hospital psiquiátrico mitigado en el período 1992-2004, al tiempo que se produce un mínimo incremento de camas en las áreas psiquiátricas del resto de hospitales. Punto de inflexión en la proporcioón de altas en tre hospital psiquiátrico/no psiquiátrico en 1990. Progresivo decremento de las estancias totales y medias en hospital psiquiátrico. Elevadas tasas de altas, estancias totales y estancias medias en hospital psiquiátrico al final de la serie temporal analizada. Incremento de primeras consultas y consultas totales en el área asistencial en su conjunto acentuado a partir de 1990. Elevada proporción en los indicadores de uso de los hospitales psiquiátricos en relación a los hospitales no clasificados como psiquiátricos. En síntesis, el modelo asistencial español en salud mental recae en gran medida en el hospital psiquiátrico, a pesar de las directrices desintitucionalizadoras

Introduction: In 1986, the General Health Law for mulated the guidelines on the psychiatric deinstitutional isation and the health public power are transferred to the Spanish regions administration on health. The guidelines establish an ambulatory care, assertive and community model, and the dismantling of the old psychiatric hospital network. The present study provides a number of indicators, interested in the evaluation of psychiatric care as regards the use of hospital resources and hospital care model. Material and methods: Explotation of data from the Survey of Health Establishments in Boarding Regime (EESRI) for the domains of psychiatric care. Timeframe analysis: 1979-2004. Within this time frame, we present the analysis of the rates of health facilities, beds in operation, consultation, income, average stays and stays broken down between psychiatric hospital and other hospitals that have psychiatric care area. Results: Decrease in the number of psychiatric hospitals particularly between the years 1986-1992 as the period 1993-2004 the decrease is not very significant. Accused decrease in beds in operation at the psychiatric hospital mitigated in the period 1992-2004, while there is a minimal increase in psychiatric beds in the areas of the remaining hospitals. Turning point in the proportion of hospital income among psychiatric hospital/non-psychiatric hospital is found in 1990. Progressive decrease of placements totals and averages in psychiatric hospital. Elevated rates income, total stays and stays in psychiatric hospital averages at the end of the time series analysis. Increased total initial consultation and consultations in the area of care as a whole increased from 1990. High proportion in the use of indicators of psychiatric hospitals in relation to hospital not classified as psychiatric. In short, the Spanish model of care in mental health rests largely on the psychiatric hospital, despite deinstitutionalisation directives

Aportación del proyecto CARDIORISC al manejo del paciente hipertenso de Atención Primaria en España / Contribution of the CARDIORISC project to the management of hypertensive patients in Primary Health Care in Spain

El proyecto CARDIORISC es una iniciativa de la Sociedad Española de Hipertensión (SEH-LELHA), avalado por la Sociedad Europea de Hipertensión (ESH), iniciado en el año 2004 y que tiene como objetivo general optimizar la asistencia al paciente hipertenso en España. Comprende los registros MAPAPRES que pretende introducir la monitorización ambulatoria de la presión arterial (MAPA) como herramienta rutinaria en la valoración del paciente hipertenso en la práctica clínica en España, el registro AMPAPRES que evaluará el grado de control de la hipertensión arterial (HTA) mediante la automedida de la presión arterial (AMPA) por parte del paciente y el registro piloto FAPRES que evaluará la prevalencia de fibrilación auricular en la población hipertensa en la Comunidad Valenciana. El registro MAPAPRES está generando numerosas evidencias basadas en el análisis de la base de datos de más de 60.000 pacientes, aportadas por más de 1.000 investigadores, que se han incluido hasta la fecha. Se presentan, de manera resumida, en esta publicación algunas de las líneas de investigación más relevantes para la práctica clínica diaria del médico de Atención Primaria

The CARDIORISC project is an initiative of the Spanish Society of Hypertension (SEH-LELHA), endorsed by the European Society of Hypertension (ESH). It was established in the year 2004 and its general purpose is to improve care to the hypertensive patient in Spain. It includes the MAPAPRES registry that aim to introduce ambulatory blood pressure monitoring (ABPM) as a routine tool in the assessment of the hypertensive patient in the clinical practice in Spain, the AMPAPRES registry that will evaluate the control rate of arterial hypertension (AHT) using the self-measurement of blood pressure (SMBP) by the patient and the pilot registry FAPRES that will evaluate the prevalence of atrial fibrillation in the hypertensive population in the Spanish Valencian Community. The MAPAPRES registry is generating a great deal of evidence based on the analysis of the database of more than 60,000 patients provided by more than 1000 investigators. A summary of some of the most relevant lines of research for the daily clinical practice of the Primary Health Care physician are presented in this publication

[Epidemiology and costs of severe sepsis in Madrid. A hospital discharge study]. / Epidemiología y costes de la sepsis grave en Madrid. Estudio de altas hospitalarias.

BACKGROUND AND OBJECTIVE: Severe sepsis is a complex syndrome to define, diagnose and treat. This population-based study describes the epidemiology of sepsis in the Region of Madrid, estimates its incidence and mortality, and assesses its impact on hospital stays and costs. PATIENTS AND METHODS: The source of information was the Minimum Basic Hospital Data Set from the Region of Madrid in 2001. Severe sepsis cases were defined as discharges with a combination of organic failure and presence or suspicion of infection through a combination of codes previously proposed and utilized. A descriptive study was performed, incidence rates were calculated, lengths of stay and costs were estimated, and mortality was analyzed. RESULTS: 6,968 episodes were identified. Mean age was 62.5 year. 59.7% were male. Annual incidence was 14.1/10,000 inhabitants, being highest for those 84 and older (230.8/10,000). 1.7 infections per episode were detected. More frequently identified microorganisms were Streptococcus sp., Staphylococcus sp., Escherichia coli and Candida sp. The most frequent organic dysfunctions were renal (39.7%) and respiratory (35.7%). Mortality was 33%. Mortality was higher in cases with more than one organic failure, hepatic dysfunction or cancer. Mean length of stay was 28.9 day. Annual overall costs were 70 million euros. CONCLUSIONS: Severe sepsis is a frequent process, with a high mortality and a significant impact on health care resource utilization.

Epidemiología y costes de la sepsis grave en Madrid. Estudio de altas hospitalarias / Epidemiology and costs of severe sepsis in Madrid. A hospital discharge study

Fundamento y objetivo. La sepsis grave es un síndrome complejo de definir, diagnosticar y tratar. Este trabajo de base poblacional describe la epidemiología de la sepsis grave en la Comunidad de Madrid, estima su incidencia y mortalidad y evalúa su impacto en estancias y costes. Pacientes y método. La fuente de información fue el conjunto mínimo básico de datos de la Comunidad de Madrid del año 2001. Se definieron como casos de sepsis grave aquellos en los que existía la presencia de fracaso orgánico y presencia o sospecha de infección a partir de la combinación de códigos de enfermedad y códigos de procedimientos utilizando criterios propuestos y utilizados previamente. Se efectuó un estudio descriptivo, se calcularon tasas poblacionales de incidencia de sepsis, se obtuvieron las estancias medias, se estimó el coste y se analizó la mortalidad por sepsis. Resultados. Se identificaron 6.968 episodios. La edad media fue de 62,5 años. El 59,7% eran hombres. La incidencia anual fue de 14,1/10.000 habitantes, siendo máxima en los mayores de 84 años (230,8/10.000). Se detectaron 1,7 infecciones por episodio. Los microorganismos más frecuentes fueron Streptococcus sp., Staphylococcus sp., Escherichia coli y Candida sp. Las disfunciones orgánicas más frecuentes fueron renal (39,7%) y respiratoria (35,7%). La mortalidad global fue de un 33% y era superior para los episodios con más de una disfunción orgánica, disfunción hepática, o neoplasia. La estancia media fue de 28,9 días. El coste anual de la atención a la sepsis grave en la Comunidad de Madrid es de 70 millones de euros. Conclusiones. La sepsis grave es un proceso frecuente, presenta una elevada mortalidad y tiene un importante impacto en consumo de recursos asistenciales

Background and objective. Severe sepsis is a complex syndrome to define, diagnose and treat. This population-based study describes the epidemiology of sepsis in the Region of Madrid, estimates its incidence and mortality, and assesses its impact on hospital stays and costs. Patients and methods. The source of information was the Minimum Basic Hospital Data Set from the Region of Madrid in 2001. Severe sepsis cases were defined as discharges with a combination of organic failure and presence or suspicion of infection through a combination of codes previously proposed and utilized. A descriptive study was performed, incidence rates were calculated, lengths of stay and costs were estimated, and mortality was analyzed. Results. 6,968 episodes were identified. Mean age was 62.5 year. 59.7% were male. Annual incidence was 14.1/10,000 inhabitants, being highest for those 84 and older (230.8/10,000). 1.7 infections per episode were detected. More frequently identified microorganisms were Streptococcus sp., Staphylococcus sp., Escherichia coli and Candida sp. The most frequent organic dysfunctions were renal (39.7%) and respiratory (35.7%). Mortality was 33%. Mortality was higher in cases with more than one organic failure, hepatic dysfunction or cancer. Mean length of stay was 28.9 day. Annual overall costs were 70 million euros. Conclusions. Severe sepsis is a frequent process, with a high mortality and a significant impact on health care resource utilization

[Can we improve management and control of chronic diseases?]. / Podemos mejorar el tratamiento y el control de las enfermedades crónicas?

OBJECTIVE: To evaluate the effectiveness of interventions aimed at improving the quality and outcome of chronic disease management. METHODS: Systematic review of the literature. INCLUSION CRITERIA: Clinical trials in English and Spanish that assess the effectiveness of 1 or more strategies for improving quality and outcome in asthma, diabetes, hypertension, and congestive heart failure. Interventions were classified in line with a conceptual model in 6 categories: organizational changes, community participation, information systems, clinical practice design, decision-making support, and self-management. The outcomes considered were: health service utilization, chronic disease management, clinical outcomes, quality of life, satisfaction, and self-management indicators. RESULTS: Thirty seven studies with 38 interventions were included. The most common interventions were those that investigated changes in health care design, followed by those analysing information systems and decision-making support. The most complex interventions, in terms of the overall number of strategies, including support for self-management, showed more likelihood of positive effects in clinical management and clinical outcomes. Few interventions achieved improvements in use of health care services, though patients perceived substantial improvements. CONCLUSIONS: In order to improve quality and effectiveness of chronic disease management, it is necessary to take a systematic view including proactive health care systems and patients taking an active role in managing their disease. These programmes should combine, at the least, organizational strategies, design of clinical practice and patient self-management.

¿Podemos mejorar el tratamiento y el control de las enfermedades crónicas? / Can we improve management and control of chronic diseases?

Objetivo. Investigar la efectividad de diferentes estrategias destinadas a mejorar la calidad y los resultados de las intervenciones en el tratamiento de las enfermedades crónicas. Metodología. Revisión sistemática de la bibliografía. Criterios de inclusión. Ensayos clínicos en lengua inglesa o española que evalúen la efectividad de distintas intervenciones para mejorar los resultados asistenciales del asma, la diabetes, la hipertensión y la insuficiencia cardíaca. Las intervenciones se clasifican de acuerdo con un modelo conceptual en 6 categorías: cambios organizativos, participación comunitaria, sistemas de información, diseño de la práctica clínica, apoyo a la toma de decisiones y de autocontrol. Los resultados evaluados fueron: utilización de servicios de salud, tratamiento clínico, resultados clínicos, calidad de vida, satisfacción e indicadores de capacidad de autocontrol. Resultados. Se incluyeron 37 estudios que incorporaban 38 intervenciones. Las intervenciones más frecuentes son las que investigan los cambios en el de diseño asistencial, seguidas de las que analizan el efecto de los sistemas de información y apoyo a la toma de decisiones. Las intervenciones más complejas en número de intervenciones, incluido el apoyo para el autocontrol, mostraron una mayor probabilidad de tener efectos positivos en el tratamiento y en los resultados clínicos. Pocas intervenciones consiguen mejoras en utilización de servicios, aunque sí se observaron sustanciales mejoras en los resultados percibidos. Conclusiones. Para mejorar la calidad asistencial y la efectividad en el control de las enfermedades crónicas es preciso adoptar una visión sistemática que incluya un sistema sanitario proactivo y pacientes protagonistas activos del tratamiento de su enfermedad. Los programas así diseñados deben combinar, al menos, estrategias organizativas, de diseño asistencial y de autocontrol

Objective. To evaluate the effectiveness of interventions aimed at improving the quality and outcome of chronic disease management. Methods. Systematic review of the literature. Inclusion criteria. Clinical trials in English and Spanish that assess the effectiveness of 1 or more strategies for improving quality and outcome in asthma, diabetes, hypertension, and congestive heart failure. Interventions were classified in line with a conceptual model in 6 categories: organizational changes, community participation, information systems, clinical practice design, decision-making support, and self-management. The outcomes considered were: health service utilization, chronic disease management, clinical outcomes, quality of life, satisfaction, and self-management indicators. Results. Thirty seven studies with 38 interventions were included. The most common interventions were those that investigated changes in health care design, followed by those analysing information systems and decision-making support. The most complex interventions, in terms of the overall number of strategies, including support for self-management, showed more likelihood of positive effects in clinical management and clinical outcomes. Few interventions achieved improvements in use of health care services, though patients perceived substantial improvements. Conclusions. In order to improve quality and effectiveness of chronic disease management, it is necessary to take a systematic view including proactive health care systems and patients taking an active role in managing their disease. These programmes should combine, at the least, organizational strategies, design of clinical practice and patient self-management

Frecuentación en atención primaria. Un replanteamiento conceptual / Frequency of Attendance at Primary Care Clinics. A New Conceptual Framework

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