Víctor Soria-Aledo

Associated Factors and Cost of Inappropriate Hospital Admissions and Stays in a Second-Level Hospital

The objective of this study was to analyze the variables related to inappropriate admissions and hospital stays and their financial repercussions. This was a descriptive retrospective study in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative sample of 725 hospital admissions and 1350 hospital stays. The cost of inappropriate stays was calculated by cost accounting. The study found that 7.4% of admissions and 24.6% of stays were inappropriate. Inappropriate admissions were significantly related to medical specialties and younger patient age. Inappropriate stays were related to these factors, plus patients being outside their corresponding areas, nonurgent admissions, and low occupancy rate. The cost of the inappropriate admissions and stays was 147 044 euros. Extrapolated to the hospital as a whole this would represent 2125638 euros per year. Steps must be taken to reduce inappropriate admissions and stays to lower health care costs and to reserve hospital resources for patients who genuinely need them. (Am J Med Qual 2009;24:321-332)

Sistema POSSUM. Un instrumento de medida de la calidad en el paciente quirúrgico

Resumen Introduccion La escala POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) es un sistema de clasificacion de pacientes que se utiliza para predecir la mortalidad y la morbilidad ajustada a riesgo en gran variedad de procesos quirurgicos. El objetivo de este trabajo es valorar su utilidad en los pacientes quirurgicos de un servicio de cirugia general. Pacientes y metodos La escala se ha aplicado, de forma prospectiva, a los pacientes intervenidos por laparotomia programada y urgente en nuestro departamento de cirugia general (hospital nivel II) durante un periodo de 8 meses. Se han incluido 105 casos de los que 81 fueron operados de forma programada y los 24 restantes, de forma urgente. Posteriormente, se han comparado, utilizando el test exacto de Fisher, los resultados predichos por la escala con los observados en la realidad. Resultados La puntuacion fisiologica media fue de 23,4 puntos (rango: 12-40 puntos), y la quirurgica de 11,3 puntos (rango: 6-24 puntos). Fallecieron 3 pacientes y 47 presentaron morbilidad. Al comparar los resultados observados con los predichos por el sistema POSSUM, en cuanto a mortalidad, no se hallaron diferencias significativas en el analisis por grupos de riesgo, excepto en el grupo de riesgo Conclusion El sistema POSSUM es una herramienta util para los analisis de morbimortalidad en nuestros pacientes quirurgicos.

Colonografía tomográfica computarizada frente a enema opaco en el estudio preoperatorio del cáncer colorrectal en pacientes con colonoscopia incompleta

BACKGROUND AND OBJECTIVE: The complete preoperative evaluation of the colon is necessary in colorectal cancer owing to the frequency of synchronous tumors. The objective of this paper was to evaluate the utility of the computed tomography colonography (CTC) as opposed to barium enema (BEDC) when the colonoscopy was incomplete or impossible to perform. PATIENTS AND METHOD: Group A: 50 patients with colorectal cancer with subsequent incomplete colonoscopy and BEDC. Group B: 40 patients with colorectal cancer with subsequent incomplete colonoscopy and CTC. As gold standard to match the tests, we carried out the pathological study of the surgical piece and the colonoscopy 3 months after surgery. In addition, we studied the degree of satisfaction, indirect effect and cost by test. RESULTS: There were no synchronous tumors. For the detection of colonic polyps, we obtained for the CTC the following values: Sensitivity = 85.7%, Specificity = 96.1%, PPV = 92.3%, NPV = 92.6%, CPP = 21,97 and CPN =0,15. And for BEDC, the values were: Sensitivity = 23.5%, Specificity = 92.8%, PPV = 80%, NPV = 71.7%, CPP = 3.26 and CPN = 0.82 (p < 0.001). The degree of satisfaction was greater with CTC than with BEDC (p < 0.05). There were no differences as far as indirect effect was concerned. The cost of CTC was 33.18 Euros and it was 42.42 Euros for BEDC. CONCLUSION: CTC is better than BEDC both to confirm the presence of polyps in colon and to rule out the absence of them in patients in whom a complete the study of the colon by colonoscopy has not been possible.

Reduction in inappropriate hospital use based on analysis of the causes

BackgroundTo reduce inappropriate admissions and stays with the application of an improvement cycle in patients admitted to a University Hospital. The secondary objective is to analyze the hospital cost saved by reducing inadequacy after the implementation of measures proposed by the group for improvement.MethodsPre- and post-analysis of a sample of clinical histories studied retrospectively, in which the Appropriateness Evaluation Protocol (AEP) was applied to a representative hospital sample of 1350 clinical histories in two phases. In the first phase the AEP was applied retrospectively to 725 admissions and 1350 stays. The factors associated with inappropriateness were analysed together with the causes, and specific measures were implemented in a bid to reduce inappropriateness. In the second phase the AEP was reapplied to a similar group of clinical histories and the results of the two groups were compared. The cost of inappropriate stays was calculated by cost accounting. Setting: General University Hospital with 426 beds serving a population of 320,000 inhabitants in the centre of Murcia, a city in south-eastern Spain.ResultsInappropriate admissions were reduced significantly: 7.4% in the control group and 3.2% in the intervention group. Likewise, inappropriate stays decreased significantly from 24.6% to 10.4%. The cost of inappropriateness in the study sample fell from 147,044 euros to 66,642 euros. The causes of inappropriateness for which corrective measures were adopted were those that showed the most significant decrease.ConclusionsIt is possible to reduce inadequacy by applying measures based on prior analysis of the situation in each hospital.

Abdominopelvic actinomycosis: a serious complication in intrauterine device users

Actinomycosis is an infrequent chronic suppurative granulomatous disease (1). The human form of actinomycosis is nearly always caused by Actinomyces israelii, a saprophyte Gram-positive anaerobic filamentous bacterium of the oral cavity, pharynx, tracheobronchial tree, digestive tract and vagina. The normal guest situation of actinomyces is altered when it penetrates into deep tissues through a solution of continuity in the mucosa. Colonization of the female genital tract facilitated by the presence of an intrauterine device (IUD) as a prior pathogenic factor triggers a much more insidious clinical presentation (2).

El humo quirúrgico: riesgos y medidas preventivas

The application of the advanced technologies in medicine has led to the appearance of new risk factors for health personnel. One of these could be the surgical smoke produced by electrosurgical instruments, ultrasounds or laser. However, there is still insufficient evidence in the published population studies on the detrimental effects of chronic exposure to surgical smoke. The main concern on the possible damage to the health of operating room staff is mainly based on the components currently detected until the date and laboratory experiments. Caution must also be used when extrapolating the results of in vitro studies to daily clinical practice. The organisations responsible for protecting the health of the workers in different countries have still not issued guidelines for the treatment and removal of the surgical smoke generated in both open and laparoscopic procedures. In this article we try to present a view of the consequences that surgical smoke has on health and the preventive measures that can be adopted.

Mejora de la calidad de vida en los pacientes con incontinencia fecal tratados con estimulación de raíces sacras

INTRODUCTION Faecal incontinence (FI) is a highly prevalent disorder that severely affects the health related quality of life (HRQOL) of the patients who suffer from it. Neuromodulation is a minimally invasive treatment that has demonstrated its efficacy in the treatment of FI symptoms over the past 10 years. The aim of this study is to check whether there is an improvement in the quality of life, using EuroQuol (EQ-5D), in patients with faecal incontinence treated with sacral root neuromodulation. METHODOLOGY An observational study with prospective recording of quality of life data, before and after, using the EQ-5D on a series of patients diagnosed with moderate to severe FI with a complete or repaired sphincter who had a definitive MEDTRONIC Interstim(®) 3023 implant after a subchronic stimulation phase with a good response. RESULTS The initial mean number of leaks was 3.1±1, and the final was 0.5±0.6. The mean number of escapes per week decreased to 2.6 escapes (CI 95%: 2.1-3.1) after the definitive implant of the sacral root stimulator (P<.001). The mean baseline health status score was 55.9±13, and after neuromodulation it was 63.1±13. Thus, the visual analogue scale score increased by 7.1 points (CI 95%: 0.37-14) after the definitive implant of the sacral root stimulator (P<.05). In the HRQOL variables studied with the EQ-5D questionnaire, we found an improvement with neuromodulation in the mobility and the presence of anxiety and/or depression variables. On the other hand we found an improvement with the neurostimulator implant, which was not significant, in personal care, performing daily activities and the presence of pain and/or discomfort. The current health was better in 11 patients (57.9%), the same in 7 (36.8%) and worse in 1 (5.3%). CONCLUSIONS Neuromodulation is a therapy that has demonstrated a significant improvement in HRQOL measured with the EQ-5D.

Sistema GRADE: clasificación de la calidad de la evidencia y graduación de la fuerza de la recomendación

The acquisition and classification of scientific evidence, and subsequent formulation of recommendations constitute the basis for the development of clinical practice guidelines. There are several systems for the classification of evidence and strength of recommendations; the most commonly used nowadays is the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE). The GRADE system initially classifies the evidence into high or low, coming from experimental or observational studies; subsequently and following a series of considerations, the evidence is classified into high, moderate, low or very low. The strength of recommendations is based not only on the quality of the evidence, but also on a series of factors such as the risk/benefit balance, values and preferences of the patients and professionals, and the use of resources or costs.

Utilidad de la biopsia intraoperatoria en el tratamiento quirúrgico del nódulo tiroideo

Resumen Objetivo Presentar nuestra experiencia en la utilizacion de la biopsia intraoperatoria (BIO) en el manejo diagnostico del nodulo tiroideo, a la hora de decidir la extension de la tiroidectomia. Pacientes y metodo Estudio prospectivo y comparativo. Se estudia la biopsia intraoperatoria de pacientes intervenidos por nodulo tiroideo entre enero de 1999 y diciembre de 2002. El resultado se compara con el estudio citologico preoperatorio y con el resultado de la biopsia diferida. Hemos calculado la sensibilidad, la especificidad y los valores predictivos positivos y negativos (VPP y VPN), asi como la exactitud diagnostica, tanto para la BIO como para la puncion-aspiracion con aguja fina (PAAF), en el diagnostico de cancer tiroideo. Resultados Se realizaron 179 BIO sobre un total de 469 tiroidectomias. Los valores obtenidos para PAAF y BIO son, respectivamente: VPP, el 100 y el 100%; VPN, el 89 y el 90%; exactitud diagnostica, el 89,5 y el 91%. Si incluimos solo los diagnosticos de “proliferacion folicular” en la PAAF, los VPP y VPN para la BIO son del 100 y el 86,7%, respectivamente. Conclusiones La exactitud diagnostica es similar para la BIO y la PAAF. En los casos de proliferacion folicular la BIO, debido a su baja sensibilidad, tiene poco valor para descartar cancer.

Unnoticed small bowel perforation as a complication of lumbar discectomy

BACKGROUND CONTEXT Surgery for disc herniation is one of the most common traumas and neurosurgical procedures. Although discectomy has low morbidity, serious intra-abdominal complications can affect retroperitoneal structures, such as the large vessels, small intestine, and ureters. CASE REPORT A 36-year-old woman in uncontrollable pain presented with left sciatic neuralgia in the L5 region. Magnetic resonance imaging revealed an extruded left paracentral hernia at L5-S1. With the patient in the decubitus prone position, trauma surgeons specializing in spine surgery performed an L5-S1 flavectomy and a simple discectomy. Intraoperative complications were not observed. About 4 hours after surgery, the patient reported sharp abdominal pain and had persistent hypotension. Emergency abdominal computed tomography showed hemoperitoneum in the pouch of Douglas and left parietocolic space. Laparoscopic exploration confirmed hemoperitoneum without visible cause, a seton perforation of the small intestine, and a few adhesions in the right iliac fossa that were consequences of previous appendectomy. A laparotomy was then performed. A lesion was discovered in the mesentery of the rectosigmoid junction coinciding with the S5-L1 space. A segmental bowel resection and mechanical side-to-side anastomosis, with drainage, were done. The patient recovered satisfactorily despite a surgical wound infection. DISCUSSION Although bowel perforation after discectomy rarely occurs, spine surgeons must try to prevent them by being more cautious during surgery. General surgeons must be highly suspicious of the presence of an intra-abdominal complication when there are signs and symptoms of a postoperative acute abdomen.