Differences in acute ischaemic stroke in-hospital mortality across referral stroke hospitals in Spain: a retrospective, longitudinal observational study

Objective To assess differences in acute ischaemic stroke (AIS) in-hospital mortality between referral stroke hospitals and provide evidence on the association of those differences with the overtime adoption of effective reperfusion therapies.Design Retrospective, longitudinal observational study using administrative data for virtually all hospital admissions from 2003 to 2015.Setting Thirty-seven referral stroke hospitals in the Spanish National Health System.Participants Patients aged 18 years and older with a hospital episode with an admission diagnosis of AIS in any referral stroke hospital (196 099 admissions).Main endpoints (1) Hospital variation in 30-day in-hospital mortality measured in terms of the intraclass correlation coefficient (ICC); and (2) the difference in mortality between the hospital of treatment and the trend of utilisation of reperfusion therapies (including intravenous fibrinolysis and endovascular mechanical thrombectomy) in terms of median OR (MOR).Results Adjusted 30-day AIS in-hospital mortality decreased over the study period. Adjusted in-hospital mortality after AIS rates varied from 6.66% to 16.01% between hospitals. Beyond differences in patient characteristics, the relative contribution of the hospital of treatment was higher in the case of patients undergoing reperfusion therapies (ICC=0.031 (95% Bayesian credible interval (BCI)=0.017 to 0.057)) than in the case of those who did not (ICC=0.016 (95% BCI=0.010 to 0.026)). Using the MOR, the difference in risk of death was as high as 46% between the hospital with the highest risk and the hospital with the lowest risk of patients undergoing reperfusion therapy (MOR 1.46 (95% BCI 1.32 to 1.68)); in patients not undergoing any reperfusion therapy, the risk was 31% higher (MOR 1.31 (95% BCI 1.24 to 1.41)).Conclusions In the referral stroke hospitals of the Spanish National Health System, the overall adjusted in-hospital mortality decreased between 2003 and 2015. However, between-hospital variations in mortality persisted

Acknowledging the role of patient heterogeneity in hospital outcome reporting:Mortality after acute myocardial infarction in five European countries

Background Hospital performance, presented as the comparison of average measurements, dismisses that hospital outcomes may vary across types of patients. We aim at drawing out the relevance of accounting for patient heterogeneity when reporting on hospital performance. Methods An observational study on administrative data from virtually all 2009 hospital admissions for Acute Myocardial Infarction (AMI) discharged in Denmark, Portugal, Slovenia, Spain, and Sweden. Hospital performance was proxied using in-hospital risk-adjusted mortality. Multilevel Regression Modelling (MLRM) was used to assess differences in hospital performance, comparing the estimates of random intercept modelling (capturing hospital general contextual effects (GCE)), and random slope modelling (capturing hospital contextual effects for patients with and without congestive heart failure -CHF). The weighted Kappa Index (KI) was used to assess the agreement between performance estimates. Results We analysed 46,875 admissions of AMI, 6,314 with coexistent CHF, discharged from 107 hospitals. The overall in-hospital mortality rate was 5.2%, ranging from 4% in Sweden to 6.9% in Portugal. The MLRM with random slope outperformed the model with only random intercept, highlighting a much higher GCE in CHF patients [VPC = 8.34 (CI95% 4.94 to 13.03) and MOR = 1.69 (CI95% 1.62 to 2.21) vs. VPC = 3.9 (CI95% 2.4 to 5.9), MOR of 1.42 (CI95% 1.31 to 1.54) without CHF]. No agreement was observed between estimates [KI = -0,02 (CI95% -0,08 to 0.04]. Conclusions The different GCE in AMI patients with and without CHF, along with the lack of agreement in estimates, suggests that accounting for patient heterogeneity is required to adequately characterize and report on hospital performance

Developing and testing a protocol using a common data model for federated collection and analysis of national perinatal health indicators in Europe

Context: International comparisons of the health of mothers and babies provide essential benchmarks for guiding health practice and policy, but statistics are not routinely compiled in a comparable way. These data are especially critical during health emergencies, such as the coronavirus disease (COVID-19) pandemic. The Population Health Information Research Infrastructure (PHIRI) project aimed to promote the exchange of population data in Europe and included a Use Case on perinatal health. Objective: To develop and test a protocol for federated analysis of population birth data in Europe. Methods: The Euro-Peristat network with participants from 31 countries developed a Common Data Model (CDM) and R scripts to exchange and analyse aggregated data on perinatal indicators. Building on recommended Euro-Peristat indicators, complemented by a three-round consensus process, the network specified variables for a CDM and common outputs. The protocol was tested using routine birth data for 2015 to 2020; a survey was conducted assessing data provider experiences and opinions. Results: The CDM included 17 core data items for the testing phase and 18 for a future expanded phase. 28 countries and the four UK nations created individual person-level databases and ran R scripts to produce anonymous aggregate tables. Seven had all core items, 17 had 13-16, while eight had ≤12. Limitations were not having all items in the same database, required for this protocol. Infant death and mode of birth were most frequently missing. Countries took from under a day to several weeks to set up the CDM, after which the protocol was easy and quick to use. Conclusion: This open-source protocol enables rapid production and analysis of perinatal indicators and constitutes a roadmap for a sustainable European information system. It also provides minimum standards for improving national data systems and can be used in other countries to facilitate comparison of perinatal indicators

Developing and testing a protocol using a common data model for federated collection and analysis of national perinatal health indicators in Europe

Context: International comparisons of the health of mothers and babies provide essential benchmarks for guiding health practice and policy, but statistics are not routinely compiled in a comparable way. These data are especially critical during health emergencies, such as the coronavirus disease (COVID-19) pandemic. The Population Health Information Research Infrastructure (PHIRI) project aimed to promote the exchange of population data in Europe and included a Use Case on perinatal health. Objective: To develop and test a protocol for federated analysis of population birth data in Europe. Methods: The Euro-Peristat network with participants from 31 countries developed a Common Data Model (CDM) and R scripts to exchange and analyse aggregated data on perinatal indicators. Building on recommended Euro-Peristat indicators, complemented by a three-round consensus process, the network specified variables for a CDM and common outputs. The protocol was tested using routine birth data for 2015 to 2020; a survey was conducted assessing data provider experiences and opinions. Results: The CDM included 17 core data items for the testing phase and 18 for a future expanded phase. 28 countries and the four UK nations created individual person-level databases and ran R scripts to produce anonymous aggregate tables. Seven had all core items, 17 had 13-16, while eight had ≤12. Limitations were not having all items in the same database, required for this protocol. Infant death and mode of birth were most frequently missing. Countries took from under a day to several weeks to set up the CDM, after which the protocol was easy and quick to use. Conclusion: This open-source protocol enables rapid production and analysis of perinatal indicators and constitutes a roadmap for a sustainable European information system. It also provides minimum standards for improving national data systems and can be used in other countries to facilitate comparison of perinatal indicators

International comparison of health spending and utilization among people with complex multimorbidity

Objective The objective of this study was to explore cross-country differences in spending and utilization across different domains of care for a multimorbid persona with heart failure and diabetes. Data Sources We used individual-level administrative claims or registry data from inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States (US). Data Collection/Extraction Methods Data collected by ICCONIC partners. Study Design We retrospectively analyzed age–sex standardized utilization and spending of an older person (65–90 years) hospitalized with a heart failure exacerbation and a secondary diagnosis of diabetes across five domains of care: hospital care, primary care, outpatient specialty care, post–acute rehabilitative care, and outpatient drugs. Principal Findings Sample sizes ranged from n = 1270 in Spain to n = 21,803 in the United States. Mean age (standard deviation [SD]) ranged from 76.2 (5.6) in the Netherlands to 80.3 (6.8) in Sweden. We observed substantial variation in spending and utilization across care settings. On average, England spent $10,956 per person in hospital care while the United States spent$30,877. The United States had a shorter length of stay over the year (18.9 days) compared to France (32.9) and Germany (33.4). The United States spent more days in facility-based rehabilitative care than other countries. Australia spent $421 per person in primary care, while Spain (Aragon) spent$1557. The United States and Canada had proportionately more visits to specialist providers than primary care providers. Across almost all sectors, the United States spent more than other countries, suggesting higher prices per unit. Conclusion Across 11 countries, there is substantial variation in health care spending and utilization for a complex multimorbid persona with heart failure and diabetes. Drivers of spending vary across countries, with the United States being the most expensive country due to high prices and higher use of facility-based rehabilitative care

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

Colombia diversidad biótica IX : Ciénagas de Córdoba: Biodiversidad ecología y manejo ambiental

ilustraciones, fotografías, gráficas, mapas, tablasLa variabilidad de las ciénagas en el departamento de Córdoba se relaciona con los montos de precipitación en un régimen de distribución unimodal bi-estacional, con valores entre 1000-1500 mm de precipitación anual (ciénagas del complejo grande de Lorica) bajo la influencia del Río Sinú, hasta valores entre > 2500-3000 mm como las de Ayapel y de Arcial bajo la influencia del Río San Jorge. Las ciénagas del río Sinú (charco Pescao, Bañó, Pantano Bonito) presentan una mayor eutrofización (nutrientes, materia orgánica) que las del San Jorge (El Porro, Cintura, Arcial) y en general hubo mayores recuentos de bacterias indicadoras de contaminación, que se incrementaron durante la época lluviosa. En el zooplancton predominan los rotíferos, seguidos por las fases juveniles de los copépodos, cladóceros y copépodos adultos. El establecimiento de la vegetación acuática esta relacionado con la cantidad de sólidos suspendidos en el agua, en aguas transparentes como Arcial, Cintura, Charco pescao hay elementos acuáticos sumergidos, enraizados emergentes y flotantes con los tapetes de Eichhornia crassipes. La vegetación de pantano está conformada por diferentes ensambles dominados por especies de Cyperaceae y Polygonaceae. En la vegetación de ribera son importantes los matorrales de mangle (Symmeria paniculata). La vegetación acuática y la de la llanura aluvial son las responsables del aporte de materia orgánica a la cubeta en el proceso anual de aguas altas y bajas. En el sedimento se encontraron representantes de Nematodos, Anélidos, Moluscos y Artrópodos y una concentración de materia orgánica relativamente baja, respecto al valor (%) de materia mineral. La vegetación de los bosques alrededor de los ciénagas se reúne en la gran formación dominada por Crateva tapia y Astronium graveolens, incluye diferentes bosques que cuentan entre sus elementos característicos y dominantes a Cavanillesia platanifolia, Bursera simarouba, Cochlospermum vitifolium, Apiba aspera, Cariniana pyriformis, Guazuma ulmifolia, Tapirira guianensis, Samanea saman, y Tabebuia rosea. En el paisaje son muy vistosos los palmares de Sabal mauritiformis, Bactris guianensis, Oenocarpus mapora y O. bataua. La riqueza de la flora se cifra en 1000 especies de plantas vasculares con mayor diversidad en las familias Fabaceae, Rubiaceae, Mimosaceae y Poaceae, patrón distintivo de la riqueza de las tierras bajas de Colombia. La fauna asociada a las ciénagas incluye 47 especies de reptiles, 39 del orden Squamata (Lagartos 46% y Serpientes 54%), una perteneciente al orden Crocodylia y siete al orden Testudinata (tortugas). Se registraron 49 especies de mamíferos, algunos grandes pertenecientes a los órdenes Carnívora, Primates, Phyllophaga (osos perezosos) y Vermilingua (osos hormigueros). Se registraron 180 especies de aves de 51 familias, con la mayor representatividad en Tyrannidae. Las ciénagas de Lorica y El Porro albergan grandes grupos de especies acuáticas, especialmente de las familias Ardeidae, Anatidae y Rallidae. No obstante la fuente importante de riqueza natural de las ciénagas y su entorno, la situación socioeconómica de la mayor parte del campesinado es crítica. Esta población necesita ayuda urgente del gobierno a nivel de inversiones y planes de desarrollo, en los cuales es fundamental considerar el capital natural que significa la biodiversidad de las ciénagas y la necesaria utilización de los servicios ambientales que prestan local, regional y nacionalmente estos ambientes siempre y cuando se les conserve. (Texto tomado de la fuente).ISBN de la versión impresa: 9789587194067Incluye anexosPrimera edició