Evolución de las hospitalizaciones potencialmente evitables por condiciones crónicas en España

ResumenObjetivosAnalizar la evolución de las tasas de hospitalizaciones potencialmente evitables (HPE) que afectan a pacientes crónicos o frágiles en España durante el periodo 2002-2013.MétodosEstudio observacional, ecológico, sobre la evolución de las tasas estandarizadas de hospitalizaciones por seis condiciones clínicas, y su variación, en las 203 áreas sanitarias del Sistema Nacional de Salud.ResultadosEn el periodo estudiado hubo un descenso relativo del 35% en las tasas de HPE, pero la variación sistemática se mantuvo en cifras moderadas, alrededor de un 13% sobre lo esperado por azar. Las admisiones por angina experimentaron la mayor reducción, seguidas de las de asma y enfermedad pulmonar obstructiva crónica. Por el contrario, las hospitalizaciones por deshidratación doblaron su frecuencia.ConclusionesA pesar del descenso observado en las tasas de HPE, sigue existiendo una variación sistemática entre áreas, que apuntaría a un manejo diferencial de las condiciones crónicas que conduciría a resultados sanitarios distintos.AbstractObjectiveTo analyse the trend in potentially avoidable hospitalisations (PAH) in frail patients or those with chronic conditions in Spain during the period 2002-2013.MethodsAn observational, ecological study was conducted to analyse the trend in age-sex standardised rates of PAH affecting six clinical conditions, and their variation, in the 203 health care areas composing the publicly-funded health system in Spain.ResultsDuring the period 2002-2013, overall PAH standardised rates decreased by 35%, but systematic variation remained moderately high, around 13% above that expected by chance. Angina admissions showed the largest reduction, followed by those for asthma and chronic obstructive pulmonary disease. In contrast, the prevalence of admissions for dehydration doubled.ConclusionsDespite the decrease in PAH rates, systematic variation among areas remains, indicating differences in chronic care management that lead to distinct healthcare outcomes

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 h, European countries limit to 48 h. 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

Variabilidad y coste de oportunidad de las alternativas quirúrgicas en cáncer de mama

Objetivos: Analizar la variabilidad poblacional del tratamiento quirúrgico del cáncer de mama, tanto en régimen de ingreso como ambulatorio, mediante cirugía conservadora más radioterapia y cirugía no conservadora, y estimar el coste de oportunidad asociado a la utilización de una u otra. Métodos: Estudio observacional de las variaciones geográficas en las tasas estandarizadas de cirugía conservadora y no conservadora realizadas en 199 áreas de salud españolas durante 2008-2009. Los costes se calcularon de manera indirecta, mediante All-Patients Diagnosis Related Groups (AP-DRG) y de manera directa a partir de costes registrados por la Red Española de Costes Hospitalarios (RECH). Resultados: Las tasas estandarizadas de cirugía conservadora y no conservadora por cada 10.000 mujeres fueron 6,84 y 4,35, respectivamente, con un rango de variación entre áreas de 2,95 y 3,11. En el año 2009, el 9% de la cirugía conservadora se realizó mediante cirugía mayor ambulatoria, pero más de un tercio de las áreas no registraron ninguna intervención de este tipo. Según RECH, el coste medio de la cirugía conservadora fue de 7078 €, y el de la cirugía no conservadora fue de 6161 €. Utilizando AP-DRG, estos costes fueron de 9036 € y 8526 €, respectivamente. Sin embargo, el coste de oportunidad de la cirugía conservadora resultó inferior al coste de la cirugía no conservadora, a partir de un 46% de utilización de cirugía mayor ambulatoria según RECH o un 23% según AP-DRG. Conclusiones: La cirugía conservadora realizada mediante cirugía mayor ambulatoria se perfila como la opción con menor coste de oportunidad en el tratamiento quirúrgico del cáncer de mama, a partir de cierto umbral, cuando ambas, conservadora y no conservadora, son de elección

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

Potential of geographical variation analysis for realigning providers to value-based care:ECHO case study on lower-value indications of C-section in five European countries

BACKGROUND: Although C-section is a highly effective procedure, literature abounds with evidence of overuse and particularly misuse, in lower-value indications such as low-risk deliveries. This study aims to quantify utilization of C-section in low-risk cases, mapping out areas showing excess-usage in each country and to estimate excess-expenditure as a proxy of the opportunity cost borne by healthcare systems. METHODS: Observational, ecologic study on deliveries in 913 sub-national administrative areas of five European countries (Denmark, England, Portugal, Slovenia and Spain) from 2002 to 2009. The study includes a cross-section analysis with 2009 data and a time-trend analysis for the whole period. Main endpoints: age-standardized utilization rates of C-section in low-risk pregnancies and deliveries per 100 deliveries. Secondary endpoints: Estimated excess-cases per geographical unit of analysis in two scenarios of minimized utilization. RESULTS: C-section is widely used in all examined countries (ranging from 19% of Slovenian deliveries to 33% of deliveries in Portugal). With the exception of Portugal, there are no systematic variations in intensity of use across areas in the same country. Cross-country comparison of lower-value C-section leaves Denmark with 10% and Portugal with 2%, the highest and lowest. Such behaviour was stable over the period of analysis. Within each country, the scattered geographical patterns of use intensity speak for local drivers playing a major role within the national trend. CONCLUSION: The analysis conducted suggests plenty of room for enhancing value in obstetric care and equity in women's access to such within the countries studied. The analysis of geographical variations in lower-value care can constitute a powerful screening tool

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

Balancing financial incentives during COVID-19 : a comparison of provider payment adjustments across 20 countries

Objective Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. Method We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. Findings We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. Conclusions We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care