Alberto Jiménez-Puente

Readmission rate as an indicator of hospital performance: The case of Spain

OBJECTIVES Hospital readmission rate is currently used as a quality of care indicator, although its validity has not been established. Our aims were to identify the frequency and characteristics of potential avoidable readmissions and to compare the assessment of quality of care derived from readmission rate with other measure of quality (judgment of experts). METHODS DESIGN cross-sectional observational study; SETTING acute care hospital located in Marbella, South of Spain; STUDY PARTICIPANTS random sample of patients readmitted at the hospital within six months from discharge (n = 363); INTERVENTIONS review of clinical records by a pair of observers to assess the causes of readmissions and their potential avoidability; MAIN MEASURES logistic regression analysis to identify the variables from the databases of hospital discharges which are related to avoidability of readmissions. Determination of sensitivity and specificity of different definitions of readmission rate to detect avoidable situations. RESULTS Nineteen percent of readmissions were considered potentially avoidable. Variables related to readmission avoidability were (i) time elapsed between index admission and readmission and (ii) difference in diagnoses of both episodes. None of the definitions of readmission rate used in this study provided adequate values of sensitivity and specificity in the identification of potentially avoidable readmissions. CONCLUSIONS Most readmissions in our hospital were unavoidable. Thus, readmission rate might not be considered a valid indicator of quality of care.

Geographic variability of fatal road traffic injuries in Spain during the period 2002-2004: an ecological study

BackgroundThe aim of the present study is to describe the inter-province variability of Road Traffic Injury (RTI) mortality on Spanish roads, adjusted for vehicle-kilometres travelled, and to assess the possible role played by the following explicative variables: sociodemographic, structural, climatic and risk conducts.MethodsAn ecological study design was employed. The mean annual rate of RTI deaths was calculated for the period 2002–2004, adjusted for vehicle-kilometres travelled, in the 50 provinces of Spain. The RTI death rate was related with the independent variables described above, using simple and multiple linear regression analysis with backward step-wise elimination. The level of statistical significance was taken as p < 0.05.ResultsIn the period 2002–2004 there were 12,756 RTI deaths in Spain (an average of 4,242 per year, SD = 356.6). The mean number of deaths due to RTI per 100 million vehicle-kilometres (mvk) travelled was 1.76 (SD = 0.51), with a minimum value of 0.66 (in Santa Cruz de Tenerife) and a maximum of 3.31 (in the province of Lugo). All other variables being equal, a higher proportion of kilometres available on high capacity roads, and a higher cultural and education level were associated with lower death rates due to RTI, while the opposite was true for the rate of alcohol consumers and the road traffic volume of heavy vehicles. The variables included in the model accounted for 55.4% of the variability in RTI mortality.ConclusionAdjusting RTI mortality rates for the number of vehicle-kilometres travelled enables us to identify the high variability of this cause of death, and its relation with risk factors other than those inherent to human behaviour, such as the type of roads and the type of vehicles using them.

Geographical variations in the benefit of applying a prioritization system for cataract surgery in different regions of Spain

BackgroundIn Spain, there are substantial variations in the utilization of health resources among regions. Because the need for surgery differs in patients with appropriate surgical indication, introducing a prioritization system might be beneficial. Our objective was to assess geographical variations in the impact of applying a prioritization system in patients on the waiting list for cataract surgery in different regions of Spain by using a discrete-event simulation model.MethodsA discrete-event simulation model to evaluate demand and waiting time for cataract surgery was constructed. The model was reproduced and validated in five regions of Spain and was fed administrative data (population census, surgery rates, waiting list information) and data from research studies (incidence of cataract). The benefit of introducing a prioritization system was contrasted with the usual first-in, first-out (FIFO) discipline. The prioritization system included clinical, functional and social criteria. Priority scores ranged between 0 and 100, with greater values indicating higher priority. The measure of results was the waiting time weighted by the priority score of each patient who had passed through the waiting list. Benefit was calculated as the difference in time weighted by priority score between operating according to waiting time or to priority.ResultsThe mean waiting time for patients undergoing surgery according to the FIFO discipline varied from 1.97 months (95% CI 1.85; 2.09) in the Basque Country to 10.02 months (95% CI 9.91; 10.12) in the Canary Islands. When the prioritization system was applied, the mean waiting time was reduced to a minimum of 0.73 months weighted by priority score (95% CI 0.68; 0.78) in the Basque Country and a maximum of 5.63 months (95% CI 5.57; 5.69) in the Canary Islands. The waiting time weighted by priority score saved by the prioritization system varied from 1.12 months (95% CI 1.07; 1.16) in Andalusia to 2.73 months (95% CI 2.67; 2.80) in Aragon.ConclusionThe prioritization system reduced the impact of the variations found among the regions studied, thus improving equity. Prioritization allocates the available resources within each region more efficiently and reduces the waiting time of patients with greater need. Prioritization was more beneficial than allocating surgery by waiting time alone.

Association between long travel and venous thromboembolic disease: a systematic review and meta-analysis of case-control studies

The term “economy-class syndrome” defines an infrequent episode of venous thromboembolism (VTED) related to a long travel, namely by plane. However, this relation has not clearly been demonstrated by investigators. We carried out a systematic review and a meta-analysis of cases-control studies that had studied this topic. We realised a systematic review of the literature and selected all the case-control studies published. Two authors carried out a methodological evaluation according to the Scottish Intercollegiate Guidelines Network items (concordance was analysed by weighted kappa index), and a systematic analysis of the potential biases of each study was assessed. We carried out the meta-analysis with the data extracted from the studies. We recovered eight cases-control studies. The relation between the antecedent of a long travel and subsequent VTED varied from OR = 1.1 to OR = 4.0 and was found to be significant in four studies. The studies were highly heterogeneous in methodology and so the results obtained about the relation between the long travel and the VTED and the score at SIGN50. Two meta-analysis were carried out: only with travels by plane in which the relation was not significant (OR = 1.21; CI 95%, 0.95–1.55) and with all types of transport, with a slightly significant relation (OR = 1.46; CI95%, 1.24–1.72). We may deduce from this systematic review that there does exist a weak association between episodes of VTED and a long travel, but not by plane specifically. The heterogeneity and the methodological quality of the studies published preclude of more robust conclusions.

Estimation of the real population and its impact on the utilisation of healthcare services in Mediterranean resort regions: an ecological study

BackgroundThe demographic structure has a significant influence on the use of healthcare services, as does the size of the population denominators. Very few studies have been published on methods for estimating the real population such as tourist resorts. The lack of information about these problems means there is a corresponding lack of information about the behaviour of populational denominators (the floating population or tourist load) and the effect of this on the use of healthcare services. The objectives of the study were: a) To determine the Municipal Solid Waste (MSW) ratio, per person per day, among populations of known size; b) to estimate, by means of this ratio, the real population in an area where tourist numbers are very significant; and c) to determine the impact on the utilisation of hospital emergency healthcare services of the registered population, in comparison to the non-resident population, in two areas where tourist numbers are very significant.MethodsAn ecological study design was employed. We analysed the Healthcare Districts of the Costa del Sol and the island of Menorca. Both are Spanish territories in the Mediterranean region.ResultsIn the two areas analysed, the correlation coefficient between the MSW ratio and admissions to hospital emergency departments exceeded 0.9, with p < 0.001. On the basis of MSW generation ratios, obtained for a control zone and also measured in neighbouring countries, we estimated the real population. For the summer months, when tourist activity is greatest and demand for emergency healthcare at hospitals is highest, this value was found to be double that of the registered population.ConclusionThe MSW indicator, which is both ecological and indirect, can be used to estimate the real population in areas where population levels vary significantly during the year. This parameter is of interest in planning and dimensioning the provision of healthcare services.

Ethnic differences in the use of intrapartum epidural analgesia

BackgroundObstetric epidural analgesia (EA) is widely applied, but studies have reported that its use may be less extensive among immigrant women or those from minority ethnic groups. Our aim was to examine whether this was the case in our geographic area, which contains an important immigrant population, and if so, to describe the different components of this phenomenon.MethodsCross-sectional observational study. Setting: general acute care hospital, located in Marbella, southern Spain. Analysis of computer records of deliveries performed from 2004 to 2010. Comparison of characteristics of deliveries according to the mothers’ geographic origins and of vaginal deliveries noting whether EA was received, using univariate and bivariate statistical analysis and multiple logistic regression (MLR).ResultsA total of 21,034 deliveries were recorded, and 37.4% of these corresponded to immigrant women. EA was provided to 61.1% of the Spanish women and to 51.5% of the immigrants, with important variations according to geographic origin: over 52% of women from other European countries and South America received EA, compared with around 45% of the African women and 37% of the Asian women. These differences persisted in the MLR model after adjusting for the mothers age, type of labor initiation, the weight of the neonate and for single or multiple gestation. With the Spanish patients as the reference category, all the other countries of origin presented lower probabilities of EA use. This was particularly apparent for the patients from Asia (OR 0.38; 95%CI 0.31-0.46), Morocco (OR 0.49; 95%CI 0.43-0.54) and other Africa (OR 0.55; 95%CI 0.37-0.81).ConclusionsWe observed a different use of EA in vaginal deliveries, according to the geographic origin of the women. The explanation for this involves a complex set of factors, depending both on the patient and on the healthcare staff.

Distribución y tendencia de los fallecimientos en el medio hospitalario en España durante el periodo 1997-2003

Fundamento: El lugar en que se produce la muerte de una persona depende de circunstancias de naturaleza demografica, socioeconomica, cultural y asistencial El objetivo del estudio fue describir las variaciones en el porcentaje de muertes en hospitales entre las comunidades autonomas de Espana, diferenciando las que ocurrieron en urgencias y hospitalizacion, y explorar su relacion con posibles variables explicativas. Metodos: El estudio fue ecologico. Se estudio la tendencia del porcentaje de muertes en hospitales entre 1997 y 2003. Se calcularon los porcentajes de muertes en hospitales de cada comunidad autonoma en los anos 2000-2002 a partir del Movimiento Natural de la Poblacion y de la Encuesta de Establecimientos Sanitarios con Regimen de Internado que incluye informacion de todos los hospitales publicos y privados. Mediante regresion lineal simple se analizo su relacion con variables demograficas, socioeconomicas, y asistenciales. Resultados: El 53% de los fallecimientos ocurrieron en hospitales (variando entre 37,3 y 68,4% en las distintas comunidades). El 10,7% de ellos en el area de urgencias (variando entre 6 y 14,5%) y el resto en hospitalizacion. Conclusiones: El porcentaje de muertes en hospitales fue mayor en las comunidades con menos poblacion anciana y rural, mas poblacion extranjera y mayor frecuentacion de urgencias. El porcentaje de muertes hospitalarias en urgencias fue mayor en las comunidades con peores indicadores socioeconomicos. La tendencia en los 7 anos estudiados fue al aumento del porcentaje de muertes en hospitales.

Complications in immediate breast reconstruction after mastectomy.

OBJECTIVES Immediate post-mastectomy breast reconstruction (IBR) is a procedure that has proven advantages, but it also entails risks. The aim of this study was to identify risk factors for reconstruction failure. METHODS A review was made of all the IBR carried out at a general hospital from 2002 to 2009. Retrospective information was obtained about postoperative complications and the characteristics of patients and treatments applied. The minimum follow-up period was 9 months. Coxs regression analysis was performed on the variables related to the reconstruction failure requiring the removal of the prosthesis, with an explanatory model in which all the study variables were introduced and a predictive model that contained only the variables known before the intervention. RESULTS A total of 115 IRB interventions carried out on 112 women with breast cancer were analyzed. The mean follow-up period was 25.5 months. In sixty cases (52.2 percent), there were no complications; in sixteen cases (13.9 percent) minor complications appeared, and in 39 (33.9 percent) the complications were moderate. In twenty-six cases (22.6 percent), a reconstruction failure occurred. Coxs regression model revealed that the reconstruction failures were related to the patients age (Hazard Ratio 1.08), to neoadjuvant chemotherapy (HR 6.24) and to postoperative tamoxifen (HR 3.10). The predictive model included the age of the patient (HR 1.05) and the use of neoadjuvant chemotherapy (HR 5.11). CONCLUSIONS A significant proportion of the patients receiving IBR developed reconstruction failure. Multivariate analysis identified three variables related to this complication, two of which were known before the intervention.

Indicadores de calidad relacionados con el reingreso y la muerte precoces tras la hospitalización por insuficiencia cardíaca

BACKGROUND AND OBJECTIVE To determine wether the quality of care criteria applied and the treatment provided to patients hospitalized after congestive heart failure were appropriate to reduce rates of premature readmission and death. PATIENTS AND METHOD We analyzed the epidemiologic, clinical and quality of care data proposed by 3 international organizations: JCAHO, AHA/ACC and ACOVE Project. The dependent variable was defined as readmission or death during the 30 days after discharge. A multivariate analysis was made using multiple binary logistic regression of the parameters of quality of care and treatment appropriateness. RESULTS 225 hospital discharge records were analyzed. There were 21 readmissions and 3 deaths (i.e., 24 cases [10.7%] with a positive dependent variable). 162 records (72%) corresponded to patients aged 65 years and over, who presented a total of 18 (8%) readmissions or premature deaths. A positive association between readmission or premature death was found with regard to 2 variables: appropriate treatment with beta-blockers (odds ratio [OR] = 0.34) and the Charlson index (OR = 3,79 for score of 3 or more vs. score of 2 or less). In the case of patients aged 65 years and over the same 2 variables were positively associated, with OR similar to those cited (OR = 0.31 and 3.21, respectively). No association was found between premature readmission or death and the overall evaluation of the criteria referred to by AHA/ACC, JCAHO or the ACOVE Project. CONCLUSIONS Premature readmission or death of patients with heart failure is more determined by the characteristics of the clinical state of patients (the Charlson comorbidity index) and by the appropriateness of the treatment applied (treatment with beta-blockers) than by the accomplishment of quality of care criteria as proposed by the cited scientific organizations.Fundamento y objetivo: Determinar si los criterios de calidad de cuidados y el tratamiento aplicados a los pacientes hospitalizados por insuficiencia cardiaca congestiva son apropiados para reducir la tasa de reingreso y muerte precoces. Pacientes y metodo: Analizamos los datos epidemiologicos, clinicos y de calidad de cuidados propuestos por 3 organizaciones internacionales: JCAHO, AHA/ACC y Proyecto ACOVE. La variable dependiente se definio como el reingreso o el fallecimiento en los 30 dias siguientes al alta. Se realizo un analisis multivariante mediante regresion logistica con los parametros de calidad de cuidados y lo apropiado del tratamiento. Resultados: Se registraron 225 altas hospitalarias. Se produjeron 21 reingresos y 3 fallecimientos (24 casos de variable dependiente positiva; 10,7%). Un total de 162 altas (72%) correspondian a pacientes mayores de 65 anos, que presentaron 18 (8%) reingresos o muertes precoces. Se hallo una asociacion de la variable dependiente con 2 variables: lo apropiado del tratamiento con bloqueadores beta (odds ratio [OR] = 0,34) y el indice de Charlson (OR = 3,79 para puntuaciones de 3 o superiores frente a 2 o inferiores). En el caso de pacientes mayores de 65 anos, las mismas 2 variables se comportaron como predictores independientes, con OR similares a las anteriores (OR = 0,31 y 3,21, respectivamente). No se hallo relacion con la valoracion global de los criterios indicados por JCAHO, AHA/ACC y el Proyecto ACOVE. Conclusiones: El reingreso y la muerte precoces de los pacientes con insuficiencia cardiaca estan mas determinados por las caracteristicas de la situacion clinica de los pacientes (indice de comorbilidad de Charlson) y lo apropiado del tratamiento aplicado (bloqueadores beta) que por el cumplimiento de los criterios de calidad de cuidados propuestos por diferentes organizaciones cientificas.

Claridad de las recomendaciones al paciente en el informe de alta hospitalaria

BACKGROUND Recommendations for patients (RP) are one of the key parts of the hospital discharge report (HDR). The objective was to study the frequency of RP in the HDR of different specialties and the proportion of them considered to be easy to understand. MATERIAL AND METHOD Observational and cross-sectional study. SETTING General acute care hospital. INTERVENTIONS Review of a sample of HDR, analysis of the frequency and types of PR based on their content and clarity. RESULTS A total of 840 HDR and 2,097 PR were analysed with an average of 2.5 RP per report. The most common RP referred to the patient follow-up (46% of total), followed by specific recommendations for the days immediately following discharge (37%), with only 16% related to lifestyle. Reports by surgical specialties contained 3.2 RP compared to 2.3 in medical specialties. The large majority (90.3%) of the RP were considered clear to understand for a standard patient. CONCLUSIONS The HDR analysed contained few RP, in particular those related to lifestyles. A substantial proportion of the RP were not expressed with enough clarity.