Joan M.V. Pons

Arthroplasty registers: A review of international experiences

OBJECTIVES Registers have proven to be a valuable instrument in the evaluation of arthroplasty procedures and the performance of implants. The aim of this study was to describe the structure, functioning, and content of arthroplasty registers in Europe and other parts of the world. METHODS A search of technical reports was carried out through the Internet and in Medline/PubMed. The exhaustiveness of the information was confirmed using the links to Web pages of other registers and contacts with key people. Aims, methods in data collection and evaluation, internal structure and organization, participants, validity of the data, and other variables were assessed for each arthroplasty register using a qualitative content analysis of the texts. RESULTS Fifteen arthroplasty registers were identified which published sufficient information to conduct a comparative analysis. Eight additional registers were identified but no information was available on the Internet or in English. Most registers were initiatives of an orthopaedic society receiving governmental funding. Data were collected using standardized clinical forms and additional information from clinical-administrative datasets or other registers (mortality, implant costs, hip fractures). The main outcome measure of these registers is survival of the prostheses. Registers use the Internet and their annual reports as the main strategy for the dissemination and feed-back of their results. CONCLUSIONS Scientific or professional societies and the public health administration should collaborate in the development of arthroplasty registers. To adequately assess the results of observational data information on the structure, the process of arthroplasty interventions and patients characteristics should be collected.

Efficacy and safety of viscosupplementation with Hylan G-F 20 for the treatment of knee osteoarthritis: a systematic review.

OBJECTIVES To review the scientific evidence on the efficacy, effectiveness, and safety of intra-articular injections of Hylan G-F 20 for the treatment of knee osteoarthritis. METHODS Systematic review of experimental and observational studies performed in humans up to December 1999. Qualitative and quantitative (meta-analytic) techniques were used for data synthesis. RESULTS A single course of intra-articular Hylan G-F 20 provides a statistically significant and clinically relevant short-term decrease of the painful symptomatology of knee osteoarthritis and improves joint function. It also seems to delay the need for knee replacement, if results observed in noncontrolled studies are confirmed. Hylan G-F 20 has a comparable efficacy to that of oral NSAID, and a smaller risk of gastrointestinal adverse effects. It seems to be well tolerated and safe, but the short follow-up in most studies limits any extrapolation of the effectiveness and safety over the longer term. There is also scarce evidence on the effect of multiple courses of Hylan G-F 20, and the scientific rigor of both experimental and nonexperimental studies reviewed is somewhat limited. CONCLUSIONS Whereas there is good quality scientific evidence showing that Hylan G-F 20 is a safe and well-tolerated therapy providing a short-term decrease of the pain symptoms while improving joint function, the delay of the need for knee replacement as well as the durability of the effect over the longer term have only been demonstrated in noncontrolled clinical series. The available evidence is not sufficient to reach firm conclusions on the effect of multiple courses of intra-articular injections of Hylan G-F 20 on health outcomes.

Predicting In-Hospital Mortality With Coronary Bypass Surgery Using Hospital Discharge Data: Comparison With a Prospective Observational Study

INTRODUCTION AND OBJECTIVES The aim was to determine the usefulness of the hospital discharge Minimum Basic Data Set (MBDS) for predicting in-hospital mortality with coronary bypass surgery by using data from a prospective observational study as a reference. METHODS The observational study involved collecting data on all patients undergoing first coronary bypass surgery at five hospitals in Catalonia, Spain between November 2001 and November 2003. In addition, data covering the same period and hospitals were obtained from the MBDS for procedure code 36.1. We investigated the concordance between the information from the two data sources and logistic regression was used to derive predictive models for in-hospital mortality. The model derived using MBDS data was validated using data from the prospective observational study and MBDS data for the years 2004-2006. Model validity was evaluated using discrimination and calibration indices. RESULTS Some 4.1% of cases in the observational study could not be found in the MBDS. The concordance between the two data sources was highly variable and generally low (kappa values ranged from 0.16 to 0.79). The discriminative ability of the MBDS model was equivalent to that of the observational study model (c=0.80 vs. c=0.79), but when the validity of the former was tested using prospective data and MBDS data for 2004-2006, the discrimination c-index decreased to 0.76 and 0.65, respectively, and the calibration worsened significantly (P< .001). CONCLUSIONS The risk of in-hospital mortality following coronary surgery cannot be accurately evaluated using MBDS data. However, our results indicate that their use as a predictive tool could be improved.

From recommendation to action: psychosocial factors influencing physician intention to use Health Technology Assessment (HTA) recommendations

BackgroundEvaluating the impact of recommendations based upon health technology assessment (HTA) represents a challenge for both HTA agencies and healthcare policy-makers. Using a psychosocial theoretical framework, this study aimed at exploring the factors affecting physician intention to adopt HTA recommendations. The selected recommendations were prioritisation systems for patients on waiting lists for two surgical procedures: hip and knee replacement and cataract surgery.MethodsDeterminants of physician intention to use HTA recommendations for patient prioritisation were assessed by a questionnaire based upon the Theory of Interpersonal Behaviour. A total of 96 physicians from two medical specialties (ophthalmology and orthopaedic surgery) responded to the questionnaire (response rate 44.2%). A multiple analysis of variance (MANOVA) was performed to assess differences between medical specialties on the set of theoretical variables. Given the main effect difference between specialties, two regression models were tested separately to assess the psychosocial determinants of physician intention to use HTA recommendations for the prioritisation of patients on waiting lists for surgical procedures.ResultsFactors influencing physician intention to use HTA recommendations differ between groups of specialists. Intention to use the prioritisation system for patients on waiting lists for cataract surgery among ophthalmologists was related to attitude towards the behaviour, social norms, as well as personal normative beliefs. Intention to use HTA recommendations for patient prioritisation for hip and knee replacement among orthopaedic surgeons was explained by: perception of conditions that facilitated the realisation of the behaviour, personal normative beliefs, and habit of using HTA recommendations in clinical work.ConclusionThis study offers a model to assess factors influencing the intention to adopt recommendations from health technology assessment into professional practice. Results identify determinant factors that should be considered in the elaboration of strategies to support the implementation of evidence-based practice, with respect to emerging health technologies and modalities of practice. However, it is important to emphasise that behavioural determinants of evidence-based practice vary according to the specific technology considered. Evidence-based implementation of HTA recommendations, as well as other evidence-based practices, should build on a theoretical understanding of the complex forces that shape the practice of healthcare professionals.

Artroplastias de cadera y rodilla en Cataluña desde 1994 a 2005

Objetivo: Las artroplastias de cadera y rodilla estan entre los procedimientos quirurgicos mas frecuentes en Cataluna. El objetivo de este estudio fue describir su evolucion y los cambios en sus caracteristicas entre 1994 y 2005. Metodos: Estudio transversal de altas por artroplastias totales primarias de cadera (ATC) o rodilla (ATR) y de revision seleccionadas del Conjunto Minimo Basico de Datos al Alta Hospitalaria: codigos 81.51, 81.53, 81.54 y 81.55 (CIE-9-MC). Se calcularon las tasas de ATC y ATR estandarizadas por edad y sexo, y la carga de revision, analizando su evolucion mediante la regresion de joinpoint. Se definieron 4 periodos y se analizaron las caracteristicas de los pacientes y de los episodios asistenciales comparando los periodos 4 y 1 a partir de modelos de regresion logistica. Resultados: Las tasas por 10.000 habitantes se incrementaron entre 1994 y 2000 en ATC, pasando de 4,1 a 6,6, y entre 1994 y 2005 en ATR, pasando de 2,6 a 15,5. La carga de revision aumento en la cadera hasta 2001 y en la rodilla durante todo el periodo de estudio. El principal motivo de artroplastia primaria fue la artrosis. Los pacientes de 75 anos o mayores y la comorbilidad aumentaron en ATC y ATR. Conclusiones: El incremento de las tasas y el cambio del perfil de los pacientes reflejan una posible ampliacion de los criterios de indicacion. El previsible aumento de la cirugia de revision se podria reducir mediante sistemas de evaluacion de la supervivencia de las protesis y el desarrollo de guias de practica clinica.

Evaluation of Risk-Adjusted Hospital Mortality After Coronary Artery Bypass Graft Surgery in the Catalan Public Healthcare System. Influence of Hospital Management Type (ARCA Study)

INTRODUCTION AND OBJECTIVES Previous studies suggest that the effectiveness of coronary surgery is influenced by the type of management at the healthcare centre where the intervention is performed. The present study assessed the risk-adjusted hospital mortality of coronary surgery in the Catalan healthcare system in hospitals under either private or public management. METHODS We carried out a prospective study of all consecutive patients receiving a first coronary artery bypass graft, with public financial support, in a period of 2 years at 5 hospitals under either public or private management. Preoperative risk was assessed using the EuroSCORE and Catalan Agency for Health Technology Assessment (CAHTA) predictive models. RESULTS Overall, 1605 patients underwent interventions, 21% of which were at private hospitals. The percentage of patients undergoing non-elective surgery was higher at private hospitals (64% vs 50%), as was the percentage needing intravenous nitrates (17% vs 11%) and the percentage in functional class IV (20% vs 11%). The odds ratio for in-hospital mortality in private compared with public hospitals was 0.56 (95% CI, 0.29-1.06) when adjusted for EuroSCORE, 0.56 (95% CI, 0.29-1.07) when adjusted for CAHTA score, and 0.43 (95% CI, 0.21-0.87) when adjusted for patient characteristics. The mortality observed, 4.8% (95% CI 3.8-5.6), was not significantly higher than that predicted. CONCLUSIONS a) Hospital mortality was equivalent to or lower than that expected after adjustment for the 2 risk scores; b) after adjustment for baseline patient characteristics, the results favored privately managed centers; and c) comparison with previous results suggests that coronary surgery effectiveness has improved in recent years.

¿Influye en el proceso y en los resultados el volumen de procedimientos en la cirugía del cáncer? Análisis basado en datos clínico-administrativos

Resumen Introduccion La cirugia continua siendo el tratamiento mas efectivo en la mayoria de canceres. Sin embargo, varios estudios han demostrado que existe una variabilidad en sus resultados y en los procedimientos quirurgicos empleados. Tambien se ha visto que hay una relacion entre volumen de casos, resultados en mortalidad hospitalaria y tipos de tecnica quirurgica, asi como en la supervivencia a largo plazo. El objetivo de este articulo es analizar la relacion entre volumen de casos y mortalidad quirurgica en los hospitales de Cataluna. Metodo Hemos estudiado los datos proporcionados por el CMBDAH durante los anos comprendidos entre 1996 y 2000 para algunos canceres (pancreas, esofago, metastasis hepaticas, recto, pulmon, mama, estomago y prostata) y tecnicas quirurgicas (mastectomia, prostatectomia y colostomia). La asociacion entre volumen y mortalidad intrahospitalaria por hospital se ha valorado utilizando un modelo de regresion logistica. Las variables independientes eran la edad, el numero de procedimientos (menos de 6, de 6 a 10 y mas de 10 procedimientos por ano) y el indice de Charlson. Resultados Se ha observado una tendencia estadisticamente significativa hacia menos mortalidad en hospitales de alto volumen en el cancer de pancreas y las metastasis hepaticas, y no en el cancer de estomago. En el cancer de esofago los mejores resultados se dan en hospitales de volumen intermedio. Tambien se ha observado una proporcion alta en cuanto a las mastectomias subtotales, las gastrectomias totales y las prostatectomias radicales en hospitales de alto volumen, y una tendencia inversa para las colostomias. Conclusiones Los resultados en nuestro entorno confirman los datos aportados en la bibliografia de otros paises sobre la existencia de dicha relacion, aunque solo en algunos tipos de cirugia del cancer. Las limitaciones inherentes a este estudio retrospectivo basado en datos administrativos y con dificultades en el ajuste del riesgo sugieren la conveniencia de un nuevo estudio especifico y prospectivo que permita un mejor ajuste de las caracteristicas de los pacientes.

Eventos coronarios agudos entre los espectadores de un estadio de fútbol

El objetivo de este estudio fue describir los sindromes coronarios agudos (SCA) que se presentan durante los partidos de competicion en un estadio de alto nivel en los que el componente emocional es importante. El estudio se realizo en el estadio del FC Barcelona. Se registraron los casos de SCA que se presentaron durante los partidos de competicion oficial en la temporada 2000-2001. Se presentaron 7 episodios de SCA, 1 con muerte subita, 4 con infarto agudo de miocardio y 2 con angina inicial. La confirmacion del diagnostico se realizo en el hospital de referencia. El paciente con muerte subita tenia antecedente de coronariopatia. El riesgo total de SCA fue de 0,0056 episodios por 100.000 personas-hora. En conclusion, disponer de un servicio de asistencia medica en el estadio facilita el diagnostico de los SCA, asegura su tratamiento inicial precoz y el traslado al hospital de referencia.

Acute Coronary Events Among Spectators in a Soccer Stadium

The aim of this study was to describe acute coronary syndromes (ACS) with a substantial emotional component in spectators of professional league competition sports events. The study was done at the Barcelona soccer teams home stadium. We recorded cases of ACS that occurred during official competition matches during the 2000-2001 season. A total of 7 episodes of ACS were recorded, 1 involving sudden death, 4 involving acute myocardial infarction and 2 involving angina pectoris. The victim of sudden death had a history of heart disease. The overall risk of ACS was 0.0056 episodes per 100,000 person-hours. We conclude that medical facilities at the stadium facilitated the initial diagnosis of ACS and ensured prompt initial treatment and transport to the reference hospital.

Impact of clinical and health services research projects on decision-making: a qualitative study

BackgroundThis article reports on the impact assessment experience of a funding program of non-commercial clinical and health services research. The aim was to assess the level of implementation of results from a subgroup of research projects (on respiratory diseases), and to detect barriers (or facilitators) in the translation of new knowledge to informed decision-making.MethodsA qualitative study was performed. The sample consisted of six projects on respiratory diseases funded by the Agency for Health Quality and Assessment of Catalonia between 1996 and 2004. Semi-structured interviews to key informants including researchers and healthcare decision-makers were carried out. Interviews were recorded, transcribed verbatim and analysed on an individual (key informant) and group (project) basis. In addition, the differences between achieved and expected impacts were described.ResultsTwenty-three semi-structured interviews were conducted. Most participants indicated changes in health services or clinical practice had resulted from research. The channels used to transfer new knowledge were mainly conventional ones, but also in less explicit ways, such as with the involvement of local scientific societies, or via debates and discussions with colleagues and local leaders. The barriers and facilitators identified were mostly organizational (in research management, and clinical and healthcare practice), although there were also some related to the nature of the research as well as personal factors. Both the expected and achieved impacts enabled the identification of the gaps between what is expected and what is truly achieved.ConclusionsIn this study and according to key informants, the impact of these research projects on decision-making can be direct (the application of a finding or innovation) or indirect, contributing to a more complex change in clinical practice and healthcare organization, both having other contextual factors. The channels used to transfer this new knowledge to clinical practice are complex. Local scientific societies and the relationships between researchers and decision-makers can play a very important role. Specifically, the relationships between managers and research teams and the mutual knowledge of their activity have shown to be effective in applying research funding to practice and decision-making. Finally the facilitating factors and barriers identified by the respondents are closely related to the idiosyncrasy of the human relations between the different stakeholders involved.