Alex Guarga

Razones para acudir a los servicios de urgencias hospitalarios. La población opina

OBJETIVO: Conocer por que las personas acuden a los servicios de urgencia hospitalarios (SUH) por problemas de salud de baja complejidad. METODO: Se realizo una investigacion cualitativa de tipo fenomenologica interaccionista. La muestra teorica pertenecia a un area urbana y otra rural de Cataluna. Se escogieron personas (n = 36) que habian acudido a los SUH o a servicios de urgencia de la atencion primaria de salud (SUAP) en el mes previo a su seleccion. Se recogieron datos en 8 grupos focales. Se realizo un analisis inductivo descriptivo-interpretativo, construyendo categorias emergentes a partir de la triangulacion. RESULTADOS: Emergieron 5 categorias: sintomas, elaboracion de autodiagnostico, percepcion de necesidad, conocimiento de la oferta y contexto global de la persona. Los sintomas generan la consideracion de perdida de salud y desencadenan la accion. La elaboracion del autodiagnostico determina la necesidad-tipo de atencion. Del contraste entre la percepcion-tipo de necesidad y el conocimiento de la oferta de los servicios, asi como de la situacion vital de la persona, surge la decision de acudir a un servicio u otro y se genera la accion. El conocimiento de la oferta de los SUH es mejor que el de los SUAP. El tiempo parece basico en la toma de decisiones. CONCLUSIONES: La elaboracion de un autodiagnostico es critica en la determinacion de la accion, pero el conocimiento de la oferta de los servicios, las experiencias previas y la situacion vital de la persona modulan el tipo de demanda.

The extension of smoke-free areas and acute myocardial infarction mortality: before and after study

Objectives Recent studies suggest that comprehensive smoking regulations to decrease exposure to second-hand smoke reduce the rates of acute myocardial infarction (AMI). The objective of this paper is to analyse if deaths due to AMI in Spain declined after smoking prevention legislation came into force in January 2006. Design Information was collected on deaths registered by the Instituto Nacional de Estadística for 2004–2007. Age- and sex-specific annual AMI mortality rates with 95% CIs were estimated, as well as age-adjusted annual AMI mortality rates by sex. Annual relative risks of death from AMI were estimated with an age-standardised Poisson regression model. Results Adjusted AMI mortality rates in 2004 and 2005 are similar, but in 2006 they show a 9% decline for men and a 8.7% decline for women, especially among those over 64 years of age. In 2007 there is a slower rate of decline, which reaches statistical significance for men (−4.8%) but not for women (−4%). The annual relative risk of AMI death decreased in both sexes (p<0.001) from 1 to 0.90 in 2006, and to 0.86 in 2007. Conclusion The extension of smoke-free regulations in Spain was associated with a reduction in AMI mortality, especially among the elderly. Although other factors may have played a role, this pattern suggests a likely influence of the reduction in population exposure to second-hand smoke on AMI deaths.

Measuring the performance of urban healthcare services: results of an international experience

The objective of this paper is to apply a framework for country-level performance assessment to the cities of Montreal, Canada, and Barcelona, Spain, and to use this framework to explore and understand the differences in their health systems. The UK National Health Service Performance Assessment Framework was chosen. Its indicators went through a process of selection, adaptation and prioritisation. Most of them were calculated for the period 2001–3, with data obtained from epidemiological, activity and economic registries. Montreal has a higher number of old people living alone and with limitations on performing one or more activities of daily life, as well as longer hospital stays for several conditions, especially in the case of elderly patients. This highlights a lack of mid-term, long-term and home care services. Diabetes-avoidable hospitalisation rates are also significant in Montreal, and are likely to improve following reforms in primary care. Efficient health policies such as generic drug prescription and major ambulatory surgery are lower in Barcelona. Rates of caesarean deliveries are higher in Barcelona, owing to demographics and clinical practice. Waiting times for knee arthroplasty are longer in Barcelona, which has triggered a plan to reduce them. In both cities, avoidable mortality and the prevalence of smoking have been identified as areas for improvement through preventive services. In conclusion, performance assessment fits perfectly in an urban context, as it has been shown to be a useful tool in designing and monitoring the accomplishment of programmes in both cities, to assess the performance of the services delivered, and for use in policy development.

Improving clinical outcomes through centralization of rectal cancer surgery and clinical audit: a mixed-methods assessment.

BACKGROUND The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective. METHODS A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September-December 2014, with healthcare professionals, managers and experts. RESULTS From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level. CONCLUSION The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to strengthen the centralization strategy.

Planificación de los servicios de alta especialización en Cataluña

Uno de los retos mas importantes de los sistemas sanitarios es decidir que prestaciones se han de concentrar, ateniendonos a su baja frecuencia, complejidad, riesgo, experiencia acumulada y costes, entre otros factores. La concentracion ha de permitir garantizar la calidad de la prestacion y los mejores resultados posibles. En este articulo se describen los elementos conceptuales, los criterios de referencia, el impacto en los centros y las condiciones necesarias que han de reunir los dispositivos, y que se han tenido en cuenta en la reordenacion de la alta complejidad en Cataluna. Tambien se exponen algunos de los temas que se han tratado en el proceso de reordenacion, como la cardiologia terciaria, tanto en el apartado de la cirugia cardiaca como en el de la angioplastia coronaria terapeutica, y la oncologia, en el apartado de las cirugias oncologicas poco frecuentes. Tambien se abordan el trasplante renal, la atencion al politraumatismo grave y el despliegue de la tomografia por emision de positrones.One of the principal challenges in healthcare systems is deciding which services have to be concentrated, taking into account, among other things, their low-frequency, complexity, risk, accumulated experience and costs., Concentration must make it possible to guarantee the quality of the service and the best results possible. This article describes, the conceptual elements, the benchmark criteria, the impact on the centres and the minimum conditions that the mechanisms must meet, which have been taken into account in the reorganisation of high-complexity services in Catalonia. Some of those issues that have been dealt with in the restructuring process are also considered, such as tertiary cardiology, in both the cardiac surgery and therapeutic coronary angioplasty sections, and oncology in the section of infrequent oncological surgery. Renal transplants, serious multiple-trauma care and the use of positron emission tomography are also dealt with.

Reasons for attending emergency departments: people speak out

OBJECTIVE To ascertain why people attend hospital emergency departments (ED) for low complexity health problems. METHOD A phenomenological, interactionist, qualitative study was performed. A theoretical sample that selected one urban and one rural area from Catalonia (Spain) was designed. In each setting, persons (n = 36) who had used the ED or a primary care emergency service 1 month before the beginning of the study were chosen. Data were obtained through 8 focus groups. An interpretative content analysis was performed, and emergent categories were constructed through research triangulation. RESULTS Five categories emerged: symptoms, whether or not self-diagnosis was involved, perception of needs, awareness of the health services available, and the overall context of the person. Symptoms generated feelings of failing health and thus initiated care seeking. Self-diagnosis determined perceived need and the type of care sought. People contrasted their self-perception of need with their own opinion about the health services available. The decision to go to one or other service was made as a result of this contrast, but the individuals family, work, and social situations also played a part. Informants were more familiar with the service provided by the ED than with that provided by primary care. Time consumption also figured heavily in decision making. CONCLUSIONS The presence or absence of self-diagnosis is a determining factor in attendance at EDs. Other factors that influence demand are the level of awareness of the health services available, previous experiences, and the life situation of the individual.

La transformación del modelo asistencial en Cataluña para mejorar la calidad de la atención

The changes taking place in western countries require health systems to adapt to the publics evolving needs and expectations. The healthcare model in Catalonia is undergoing significant transformation in order to provide an adequate response to this new situation while ensuring the systems sustainability in the current climate of economic crisis. This transformation is based on converting the current disease-centred model which is fragmented into different levels, to a more patient-centred integrated and territorial care model that promotes the use of a shared network of the different specialities, the professionals, resources and levels of care, entering into territorial agreements and pacts which stipulate joint goals or objectives. The changes the Catalan Health Service (CatSalut) has undergone are principally focused on increasing resolution capacity of the primary level of care, eliminating differences in clinical practice, evolving towards more surgery-centred hospitals, promoting alternatives to conventional hospitalization, developing remote care models, concentrating and organizing highly complex care into different sectors at a territorial level and designing specific health codes in response to health emergencies. The purpose of these initiatives is to improve the effectiveness, quality, safety and efficiency of the system, ensuring equal access for the public to these services and ensuring a territorial balance. These changes should be facilitated and promoted using several different approaches, including implementing shared access to clinical history case files, the new model of results-based contracting and payment, territorial agreements, alliances between centres, harnessing the potential of information and communications technology and evaluation of results.

La concentración de tratamientos puede mejorar los resultados clínicos en cirugía compleja del cáncer

The most relevant challenge in healthcare is to continually improve the quality of care and clinical outcomes. In oncology, cancer population registries enable us to compare survival data, one of the main indicators of results, both in our country and internationally, as shown by the EUROCARE and CONCORD projects. The results of these studies show that our country has a significant margin for improvement according to criteria such as 5-year survival rates. Spain as a whole is slightly above the European average at 57.6%, while countries such as Holland or Belgium have survival rates of 62 and 64%, respectively, in the same period. On the other hand, we should highlight that the internal variability in our country is very important between autonomous communities; for example, in rectal cancer, the 5-year survival results varied between 63.5% and 50.1% in the period 2005–2009. These differences are clinically relevant and we must ask ourselves what we can do to improve them and place ourselves at the level of countries with the best results in our setting. In the vast majority of solid tumors, surgery plays a key role in the multidisciplinary treatment aimed at guaranteeing the best prognosis for patients diagnosed with cancer. One of the measures adopted to improve quality and results that has caused the greatest debate is the concentration of surgical treatments for patients with more complex and/or uncommon diseases. Repeated examples of these are surgical procedures for cancers of the esophagus, liver (primary tumor and metastasis), pancreas and rectum in the field of digestive surgery. Research has shown that the hospitals with the highest volume of cases have lower surgical mortality rates, which implies that the best manner to organize oncological medical services should involve assessing the benefits of concentrating surgical procedures at hospitals that accumulate enough experience to obtain excellent clinical results. In addition, this concentration of cases can facilitate the necessary clinical research to continue advancing in the fight against cancer in the field of surgery. However, this restructuring policy entails some controversial aspects that have hindered its application in clinical practice. Among the most relevant is the difficulty to determine what is the minimum/optimal volume of cases per hospital and/or per surgeon. Decisions to concentrate surgical treatment clearly depend on the scientific evidence of benefits as well as other factors, such as the organization of the national healthcare system, medical professionals and resources of each medical center, and the social factor of the distance between patients’ residences and the reference hospital. Centralization may also result in the loss of the capability for clinical-surgical response at hospitals where complex surgeries will no longer be performed. However, more and more countries, such as England, Holland, France or Germany, are reorganizing complex surgery centers to improve clinical outcomes and the quality of care in general. In each country, healthcare policy criteria are slightly different, as are the procedures chosen. The involvement of medical professionals in the process has likewise differed among these countries. In Holland, for instance, physicians have initiated the process and become the main proponents, while in Germany the relationships between hospitals and medical staff have been more conflictive. Also in Spain, specifically in Catalonia, a program initiated by the Catalan Health Service in 2012 has been developed to concentrate certain oncological surgical procedures (esophagus, pancreas, liver, rectum and stomach) at a limited number of hospitals, based on a previous evaluation of the activity volume and the surgical mortality results for each surgery type. The recently evaluated results have shown a reduction in 30-day surgical mortality (adjusted for other factors) between 30% and 50%. Although there are aspects of the model design c i r e s p . 2 0 1 8 ; 9 6 ( 6 ) : 3 1 5 – 3 1 6