A data infrastructure for the assessment of health care performance: Lessons from the BRIDGE-health project

The integration of different administrative data sources from a number of European countries has been shown useful in the assessment of unwarranted variations in health care performance. This essay describes the procedures used to set up a data infrastructure (e.g., data access and exchange, definition of the minimum common wealth of data required, and the development of the relational logic data model) and, the methods to produce trustworthy healthcare performance measurements (e.g., ontologies standardisation and quality assurance analysis). The paper ends providing some hints on how to use these lessons in an eventual European infrastructure on public health research and monitoring. Although the relational data infrastructure developed has been proven accurate, effective to compare health system performance across different countries, and efficient enough to deal with hundred of millions of episodes, the logic data model might not be responsive if the European infrastructure aims at including electronic health records and carrying out multi-cohort multi-intervention comparative effectiveness research. The deployment of a distributed infrastructure based on semantic interoperability, where individual data remain in-country and open-access scripts for data management and analysis travel around the hubs composing the infrastructure, might be a sensible way forward

Comparing hospital efficiency: An illustrative study of knee and hip replacement surgeries in Spain

WHO’s Health Systems Performance Assessment framework suggests monitoring a set of dimensions. This study aims to jointly assess productivity and quality using a treatment-based approach, specifically analyzing knee and hip replacement, two prevalent surgical procedures performed with consolidated technology and run in most acute-care hospitals. Focusing on the analysis of these procedures sets out a novel approach providing clues for hospital management improvements, covering an existing gap in the literature. The Malmquist index under the metafrontier context was used to estimate the productivity in both procedures and its decomposition in terms of efficiency, technical and quality change. A multilevel logistic regression was specified to obtain the in-hospital mortality as a quality factor. All Spanish public acute-care hospitals were classified according to their average severity attended, dividing them into three groups. Our study revealed a decrease in productivity mainly due to a decrease in the technological change. Quality change remained constant during the period with highest variations observed between one period to the next according to the hospital classification. The improvement in the technological gap between different levels was due to an improvement in quality. These results provide new insights of operational efficiency after incorporating the quality dimension, specifically highlighting a decreasing operational performance, confirming that the technological heterogeneity is a critical question when measuring hospital performance

Quality and technical efficiency do not evolve hand in hand in Spanish hospitals: Observational study with administrative data

Objective Recent evidence on the Spanish National Health System (SNHS) reveals a considerable margin for hospital efficiency and quality improvement. However, those studies do not consider both dimensions together. This study aims at jointly studying both technical efficiency (TE) and quality, classifying the public SNHS hospitals according to their joint performance. Methods Stochastic frontier analysis is used to estimate TE and multilevel logistic regressions to build a low-quality composite measure (LQ), which considers in-hospital mortality and safety events. All hospitalizations discharged in Spain in 2003 and 2013, in 179 acute-care general hospitals, were studied. Four scenarios of resulting performance were built setting yearly medians as thresholds for the overall sample, and according to hospital-complexity strata. Results Overall, since 2003, median TE improved and LQ reduced -from TE2003:0.89 to TE2013:0.93 and, from LQ2003:42.6 to LQ2013:27.7 per 1, 000 treated patients. The time estimated coefficient showed technical progress over the period. TE across hospitals showed scarce variability (CV2003:0.08 vs. CV2013:0.07), not so the rates of LQ (CV2003:0.64 vs. CV2013:0.76). No correlation was found between TE values and LQ rates. When jointly considering technical efficiency and quality, hospitals dealing with the highest clinical complexity showed the highest chance to be placed in optimal scenarios, also showing lesser variability between hospitals. Conclusions Efficiency and quality have improved in Spanish public hospitals. Not all hospitals experiencing improvements in efficiency equally improved their quality. The joint analysis of both dimensions allowed identifying those optimal hospitals according to this trade-off

Evolution of public hospitals expenditure by healthcare area in the Spanish National Health System: the determinants to pay attention to

Background: In Spain, hospital expenditure represents the biggest share of overall public healthcare expenditure, the most important welfare system directly run by the Autonomous Communities (ACs). Since 2001, public healthcare expenditure has increased well above the GDP growth, and public hospital expenditure increased at an even faster rate. This paper aims at assessing the evolution of need-adjusted public hospital expenditure at healthcare area level (HCA) and its association with utilisation and ''price'' factors, identifying the relative contribution of ACs, as the main locus of health policy decisions. Methods: Ecological study on public hospital expenditure incurred in 198 (HCAs) in 16 Spanish ACs, between 2003 and 2015. Aggregated and annual log-log multilevel models, considering ACs as a cluster, were modelled using administrative data. HCA expenditure was analysed according to differences in population need, utilization and price factors. Standardised coefficients were also estimated, as well as the variance partition coefficients. Results: Between 2003 and 2015, over 59 million hospital episodes were produced in Spain for an overall expenditure of (sic) 384, 200 million. Need-adjusted public hospital expenditure, at HCA level, was mainly associated to medical and surgical hospitalizations (standardized coefficients 0.32 and 0.28, respectively). The ACs explained 42% of the variance not explained by HCA utilization and ''price'' factors. Conclusions: Utilization, rather than ''price'' factors, may be explaining the difference in need-adjusted public hospital expenditure at HCA level in Spain. ACs, third-payers in the fully devolved Spanish National Health System, are responsible for a great deal of the variation in hospital expenditure

Construction of Empirical Care Pathways Process Models from Multiple Real-World Datasets

Care pathways (CPWs) are "multidisciplinary care plans that detail essential care steps for patients with specific clinical problems." While CPWs impact on health or cost outcomes is vastly studied, an in-depth analysis of the real-world implementation of the CPWs is an area that still remains underexplored. The present work describes how to apply an existing process mining methodology to construct the empirical CPW process models. These process models are a unique piece of information for health services research: for example to evaluate their conformance against the theoretical CPW described on clinical guidelines or to evaluate the impact of the process in health outcomes. To this purpose, this work relies on the design and implementation of a solution that a) synthesizes the expert knowledge on how health care is delivered within and across providers as an activity log, and b) constructs the CPW process model from that activity log using process mining techniques. Unlike previous research based on ad hoc data captures, current approach is built on the linkage of various heterogeneous real-world data (RWD) sets that share a minimum semantic linkage. RWD, defined as secondary use of routinely collected data as opposite to ad hoc data extractions, is a unique source of information for the CPW analysis due to its coverage of the caregiving activities and its wide availability. The viability of the solution is demonstrated by constructing the CPW process model of Code Stroke (Acute Stroke CPW) in the Aragon region (Spain)

Limiting health-care access to undocumented immigrants: A wise option?

The number of undocumented migrants in high-income countries has increased in recent decades, imposing considerable political, fiscal, and social pressures on governments. This has fostered discussions on whether and to what extent undocumented migrants should get access to public programs and public benefits. Looking at the 2012 Spanish health reform, this is the first paper to document the impacts of a restriction on access to the health-care system for undocumented migrants on health-care utilization, health-care system perceptions, and self-reported health in a high-income country. We show that such restrictions may significantly reduce planned care for undocumented migrants and result in sharp fall in positive opinions about the health-care services still left available to them. We also exploit the heterogeneity in implementing the policy across regions and report stronger effects in regions that enforced the national ban more fully. Furthermore, in the first 3 years since the implementation of the reform, we find suggestive evidence of a worsening in self-assessed health. This study is relevant for policymakers in the developed world, especially in countries that have recently implemented initiatives aimed at reducing the health-care coverage for targeted groups, such as the United Kingdom and the United States

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

Efecto de las soluciones irrigantes de quitosano en la liberación de proteínas bioactivas de la dentina radicular

Objetivo Identificar el efecto de dos soluciones de quitosano en la liberación de proteínas de la matriz dentinaria radicular y describir los cambios químicos observados tras el acondicionamiento con agentes quelantes. Materiales y métodos Se investigó la liberación de sialoproteína dentinaria (DSP), factor de crecimiento transformante-beta 1 (TGF-β1), factor de crecimiento endotelial vascular (VEGF) y factor de crecimiento derivado de plaquetas-BB (PDGF-BB) con diferentes agentes quelantes, incluyendo ácido etilendiaminotetraacético (EDTA), solución de quitosano (CS) y quitosano nanoparticulado (CSnp). La DSP se cuantificó mediante un ensayo inmunoenzimático (ELISA). El TGF-β1, el VEGF y el PDGF-BB se cuantificaron mediante un panel de microesferas de citoquinas (CBA). Se realizó espectroscopia Raman para identificar cambios químicos en la superficie. El análisis estadístico se realizó mediante la prueba de Kruskal-Wallis con la prueba de suma de rangos de Mann-Whitney-Wilcoxon (p<0,05). Resultados El TGF-β1, el VEGF y el DSP se solubilizaron en todos los irrigantes probados. CSnp mostró la mayor concentración de DSP. El PDGFBB no superó los límites de detección. La espectroscopia Raman reveló una disminución de los picos de fosfato y carbonato, lo que representa el efecto quelante del EDTA, CS y CSnp. Además, la CSnp mostró la mayor preservación del contenido de amidas I y III. Conclusión Las proteínas pueden liberarse de la dentina mediante el acondicionamiento con EDTA, CS y CSnp. La espectroscopia Raman reveló cambios en el contenido inorgánico de la dentina radicular tras la quelación. Además, el uso de CSnp facilitó la conservación del contenido orgánico. Importancia clínica La quelación permite la liberación de proteínas, lo que justifica el uso de agentes quelantes en endodoncia regenerativa. La interacción quitosano-matriz dentinaria también promueve la protección del contenido orgánico como un beneficio adicional a su efecto liberador de proteínas.Objective To identify the efect of two chitosan solutions on the release of root dentin matrix proteins and to describe the chemical changes observed following conditioning with chelating agents. Materials and methods The release of dentin sialoprotein (DSP), transforming growth factor-beta 1 (TGF-β1), vascular endothelial growth factor (VEGF), and platelet-derived growth factor-BB (PDGF-BB) with diferent chelating agents, including ethylenediaminetetraacetic acid (EDTA), chitosan solution (CS), and nanoparticulate chitosan (CSnp), was investigated. DSP was quantifed using an enzyme-linked immunosorbent assay (ELISA). TGF-β1, VEGF, and PDGF-BB were quantifed using a cytokine bead panel (CBA). Raman spectroscopy was performed to identify surface chemical changes. Statistical analysis was performed using Kruskal–Wallis test with Mann–Whitney–Wilcoxon rank-sum test (p<0.05). Results TGF-β1, VEGF, and DSP solubilized in all irrigants tested. CSnp showed the highest concentration of DSP. PDGFBB did not exceed the detection limits. Raman spectroscopy revealed a decrease in the phosphate and carbonate peaks, representing the chelating efect of EDTA, CS, and CSnp. Additionally, CSnp showed the greatest preservation of the amide I and III content. Conclusion Proteins can be released from dentin via EDTA, CS, and CSnp conditioning. Raman spectroscopic revealed changes in the inorganic content of the root dentin after chelation. Furthermore, use of CSnp facilitated a preservation of the organic content. Clinical relevance Chelation allows the release of proteins, justifying the use of chelating agents in regenerative endodontics. The chitosan–dentin matrix interaction also promotes the protection of the organic content as an additional beneft to its protein releasing efect

Supersymmetry phenomenology beyond the MSSM after 5/fb of LHC data

We briefly review the status of motivated beyond-the-MSSM phenomenology in the light of the LHC searches to date. In particular, we discuss the conceptual consequences of the exclusion bounds, of the hint for a Higgs boson at about 125 GeV, and of interpreting the excess of direct CP violation in the charm sector as a signal of New Physics. We try to go into the various topics in a compact way while providing a relatively rich list of references, with particular attention to the most recent developments.Comment: 20 pages + refs. v2: minor modifications, published versio