Amplias variaciones sistemáticas en hospitalizaciones potencialmente evitables en pacientes crónicos: estudio ecológico sobre zonas básicas de salud y áreas sanitarias

Antecedentes y objetivo Las hospitalizaciones potencialmente evitables (HPE) por condiciones crónicas constituyen un problema sanitario que puede ser reflejo de una atención sanitaria de insuficiente calidad. En este trabajo se describen las variaciones sistemáticas en HPE para el conjunto de proveedores del Sistema Nacional de Salud. Materiales y métodos Estudio ecológico sobre datos administrativos en el que se analiza la variación sistemática en las HPE por 6 condiciones crónicas en el período 2013-2015. Para la estimación de la variación se realiza análisis de área pequeña utilizando metodología bayesiana. Resultados Entre 2013 y 2015 se registraron 439.878 ingresos por HPE en el Sistema Nacional de Salud. La variación de tasas de HPE entre zonas básicas de salud (ZBS) extremas fue de hasta 4 veces, con diferencias muy variables dependiendo de la condición analizada El 40% de las ZBS presentó un riesgo de HPE por encima de la esperado. Más allá de la variación sistemática observada entre ZBS, las áreas sanitarias de residencia de los pacientes explicaron un 33% de la variación en las HPE. Sobre estos resultados generales, se observaron diferencias específicas en función de la condición clínica, edad y sexo. Conclusiones La amplia variación sistemática en HPE indica la existencia de un problema de calidad en la atención prestada a pacientes crónicos por el conjunto de proveedores de las áreas sanitarias. La identificación y análisis de aquellas zonas y áreas sanitarias con mejores resultados podría servir de referencia para la mejora de los cuidados en otros proveedores con peor desempeño. Background and objective: Potentially avoidable hospitalisations (PAHs) due to chronic conditions are a healthcare problem that could reflect healthcare of insufficient quality. This study reports the systematic variations in PAHs for the collection of providers of the Spanish National Health System. Materials and methods: We conducted an ecological study on government data, analysing the systematic variation in PAHs for 6 chronic conditions during 2013–2015. To determine the variation, we performed a small area analysis using Bayesian methodology. Results: Between 2013 and 2015, 439, 878 admissions for PAHs were recorded in the Spanish National Health System. There was an up to 4-fold difference in PAH rates between certain basic health areas (BHA), with highly variable differences depending on the analysed condition. Forty percent of the BHAs showed a greater than expected risk of PAH. Beyond the systematic variation observed between BHAs, the healthcare areas of the patients’ residence explained 33% of the variation in PAHs. We observed specific differences in these general results according to clinical condition, age and sex. Conclusions: The wide systematic variation in PAHs suggests a problem of quality in the care provided to chronically ill patients by the providers of healthcare areas in Spain. Identifying and analysing these areas and other healthcare areas with better results could provide a reference for improving the care of other suppliers with poorer performance

Factors associated with hospitalisations in chronic conditions deemed avoidable: Ecological study in the Spanish healthcare system

Objectives: Potentially avoidable hospitalisations have been used as a proxy for primary care quality. We aimed to analyse the ecological association between contextual and systemic factors featured in the Spanish healthcare system and the variation in potentially avoidable hospitalisations for a number of chronic conditions. Methods: A cross-section ecological study based on the linkage of administrative data sources from virtually all healthcare areas (n=202) and autonomous communities (n=16) composing the Spanish National Health System was performed. Potentially avoidable hospitalisations in chronic conditions were defined using the Spanish validation of the Agency for Health Research and Quality (AHRQ) preventable quality indicators. Using 2012 data, the ecological association between potentially avoidable hospitalisations and factors featuring healthcare areas and autonomous communities was tested using multilevel negative binomial regression. Results: In 2012, 151 468 admissions were flagged as potentially avoidable in Spain. After adjusting for differences in age, sex and burden of disease, the only variable associated with the outcome was hospitalisation intensity for any cause in previous years (incidence risk ratio 1.19 (95% CI 1.13 to 1.26)). The autonomous community of residence explained a negligible part of the residual unexplained variation (variance 0.01 (SE 0.008)). Primary care supply and activity did not show any association. Conclusions: The findings suggest that the variation in potentially avoidable hospitalisations in chronic conditions at the healthcare area level is a reflection of how intensively hospitals are used in a healthcare area for any cause, rather than of primary care characteristics. Whether other non-studied features at the healthcare area level or primary care level could explain the observed variation remains uncertain

Atlas de prescripción farmacéutica en diabetes en Navarra - Atlas of pharmaceutical prescription in diabetes in Navarra

ES: Este Atlas de prescripción farmacéutica en diabetes en Navarra, describe la atención sanitaria recibida por la población diabética en Navarra en términos del tratamiento farmacológico prescrito. Los indicadores representados recogen el patrón de prescripción general en la población diabética y con morbilidades y prácticas de prescripción no recomendadas o de bajo valor. Atlas de prescripción farmacéutica en diabetes ofrece análisis específicos por nivel socioeconómico y en hombres y mujeres por separado, permitiendo su comparación. El grupo de Ciencia de datos para la investigación en servicios y políticas sanitarias del Instituto Aragonés de Ciencias de la Salud reporta la variación y la evolución de la atención sanitaria que presta el Sistema de Salud a través del Atlas de Variaciones de Práctica Médica en el SNS español. cienciadedatosysalud.org/atlas/prescripcion-diabetes-navarra/ EN: This Atlas of pharmaceutical prescription in diabetes in Aragon describes the health care received by the diabetic population in Navarra in terms of the pharmacological treatment prescribed. The indicators represented reflect the general prescribing pattern in the diabetic population and with morbidities and prescribing practices that are not recommended or of low value. Atlas of pharmaceutical prescription in diabetes offers specific analyses by socioeconomic level and in men and women separately, allowing for comparison.Editado por el Instituto Aragonés de Ciencias de la Salud y el Instituto Investigación Sanitaria Aragón; Financiado principalmente a través de convocatorias públicas competitivas, por la Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), el Instituto de Salud Carlos III, el Instituto Aragonés de Ciencias de la Salud; Con la participación de profesionales de las Comunidades Autónomas: https://cienciadedatosysalud.org/atlas-vpm

Work like a Doc: A comparison of regulations on residents' working hours in 14 high-income countries

Background: Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents’ work hours. Objectives: We aimed to review residents' work hours regulations in different countries with an emphasis on night shifts Methods Standardized qualitative data on residents’ working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed. Results: All countries reviewed limit the weekly working hours; North-American countries limit to 60-80 hours, European countries limit to 48 hours. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies- ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it. Conclusions: In the countries analyzed residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents’ quality of life with mixed effects on quality of care and residents' education

Potentially avoidable hospitalizations in five European countries in 2009 and time trends from 2002 to 2009 based on administrative data

Introduction: Potentially avoidable hospitalizations in chronic conditions are used to evaluate health-care performance. However, evidence comparing different countries at small geographical areas is still scarce. The aim of the present study is to describe and discuss differences in rates and time-trends across health-care areas from five European countries. Methods: Observational, ecological study, on virtually all discharges produced in five European countries between 2002 and 2009. Potentially avoidable hospitalizations were operationally defined as a joint indicator composed of six chronic conditions. Episodes flagged as potentially avoidable were allocated to 913 geographical health-care areas. Age-sex standardized rates and standardized hospitalization ratios, as well as several statistics of variation, were estimated. Results: Four hundred sixty-two thousand seven hundred and ninety-two episodes were flagged as potentially avoidable. Variation in rates across countries was notable, from 93.7 cases per 10 000 inhabitants in Denmark to 34.8 cases per 10 000 inhabitants in Portugal. Within-country variation was also noteworthy, from 3.12 times among extreme areas in Spain to a 1.46-fold difference in Denmark. The highest systematic variation was found in Denmark (empirical Bayes 0.45) and the lowest in England (empirical Bayes 0.08). Rates and systematic variation remained fairly stable over time, with Denmark and England experiencing a statistically significant decrease (20% and 10%, respectively). Income and educational level, hospital utilization propensity, and region of residence were found to be associated with avoidable admissions. Conclusion: The dramatic variation across countries, beyond age and sex differences, and its consistency over time, implies systemic, although differential, behaviour of the five health-care systems with regard to chronic care

Restarting more routine hospital activities during covid-19: approaches from six countries.

Background During the COVID-19 pandemic, hospitals face the concurrent challenges of maintaining routine services while attending to COVID-19 patients. Method This article shares approaches taken in six countries to resume hospital care after the first wave of the pandemic by surveying country experts and using data extracted from the COVID-19 Health Systems Response Monitor (HSRM). Results Four strategies were observed in all six countries: prioritisation or rationing of treatments, converting clinical spaces to separate patients, using virtual treatments, and implementing COVID-19 free hospitals or floors. Conclusion Clear guidance about how to prioritise activities would support hospitals in the next phases of the pandemic

(Pro)renin Receptor Is a Novel Independent Prognostic Marker in Invasive Urothelial Carcinoma of the Bladder

(Pro)renin receptor (PRR) is being investigated in several malignancies as it activates pathogenic pathways that contribute to cell proliferation, immunosuppressive microenvironments, and acquisition of aggressive neoplastic phenotypes. Its implication in urothelial cancer (UC) has not been evaluated so far. We retrospectively evaluate the prognostic role of PRR expression in a series of patients with invasive UC treated with radical cystectomy and other clinical and histopathological parameters including p53, markers of immune-checkpoint inhibition, and basal and luminal phenotypes evaluated by tissue microarray. Cox regression analyses using stepwise selection evaluated candidate prognostic factors and disease-specific survival. PRR was expressed in 77.3% of the primary tumors and in 70% of positive lymph nodes. PRR expression correlated with age (p = 0.006) and was associated with lower preoperatively hemoglobin levels. No other statistical association was evidenced with clinical and pathological variables (gender, ASA score, Charlson comorbidity index, grade, pT, pN) or immunohistochemical expressions evaluated (CK20, GA-TA3, CK5/6, CD44, PD-L1, PD-1, B7-H3, VISTA, and p53). PRR expression in primary tumors was associated with worse survival (log-rank, p = 0.008). Cox regression revealed that PRR expression (HR 1.85, 95% CI 1.22–2.8), pT (HR 7.02, 95% CI 2.68–18.39), pN (HR 2.3, 95% CI 1.27–4.19), and p53 expression (HR 1.95, 95% CI 1.1–3.45) were independent prognostic factors in this series. In conclusion, we describe PRR protein and its prognostic role in invasive UC for the first time. Likely mechanisms involved are MAPK/ERK activation, Wnt/β-catenin signaling, and v-ATPAse function.Fundación para la Investigación en Urología, Asociación Española de Urología (FIU-EAU 2017; FIU-EAU 2019 Spain)Ministerio de Economía y Competitividad (MINECO, SAF2016-79847R; Spain and Fondo Europeo de Desarrollo Regional)(Instituto de Salud Carlos III, CP20/00008; Spain and The European Social Fund)6.639 JCR (2020) Q1, 51/242 Oncology1.349 SJR (2021) Q1, 72/369 OncologyNo data IDR 2020UE

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges

This paper conducts a comparative review of the (curative) health systems’ response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the ‘Health System Response Monitor’ platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy “flexible” intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care. © 202

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges

This paper conducts a comparative review of the (curative) health systems’ response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the ‘Health System Response Monitor’ platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy “flexible” intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care