Análisis automatizado de la calidad del conjunto mínimo de datos básicos. Implicaciones para los sistemas de ajuste de riesgos

ResumenFundamentosJunto a la edad del paciente, el diagnóstico principal, los diagnósticos secundarios (comorbilidad y complicaciones) y los procedimientos realizados son las variables críticas para el ajuste de riesgos. De ahí la importancia de su correcta incorporación al CMBD. Sin embargo, diversos trabajos, especialmente en Estados Unidos, pero también en España, han puesto en evidencia importantes problemas de calidad en estos datos, dificultades para su mejora y las limitaciones que ello conlleva para evaluar la calidad o la eficiencia de los hospitales. El objetivo de este trabajo es realizar una aproximación a la calidad de la información administrativa y clínica recogida en el CMBD del Servei Valencià de la Salut (SVS) mediante un proceso automatizado de análisis de los datos del propio CMBD, y discutir tanto sus implicaciones para la gestión, como las posibles estrategias de mejora.Material y métodoSe realizó un análisis automatizado de la calidad del CMBD 1994 del SVS (20 hospitales, 241.341 altas), utilizando indicadores de cumplimentación válida de los valores de los campos, relaciones entre campos del mismo episodio, relaciones entre variables en diferentes episodios y volumen y especificidad de la información clínica.ResultadosEl CMBD analizado contiene escasos errores en las variables administrativas, con excepción de la residencia, pero presenta importantes problemas de volumen y especificidad de la información clínica, así como una alta variabilidad en su cumplimentación y calidad en diferentes hospitales.ConclusionesLa calidad de los datos clínicos del CMBD pueden suponer sesgos en su utilización con finalidades de gestión o evaluación de la calidad, así como en los estudios epidemiológicos, de evaluación de tecnologías o utilización de servicios.SummarySettingTogether with the age of the patient, the main diagnosis, secondary diagnosis (comorbility and complications) and the procedures performed are the critical variables for risk-adjusting. Therefore, its correct incorporation to CMBD is of great importance. However, several studies, especially in the United States, but also in Spain, have made evident the existence of important problems of quality in these data, difficulties for its improvement and the limitations which this has to assess the quality or the efficiency of hospitals. The objective of this study is to approach the quality of administrative and clinical collected in the CMBD of the Valencian Health Service (VHS) using an automatized process of analysis of data from the same CMBD, and discuss the implications for its management, as well as possible improvement strategies.Material and methodAn automatized analysis of the quality of CMBD 1994 of the VHS (20 hospitals, 241,341 admissions) was performed, using indicators of valid fulfilling of field values, relationship between fields of the same episode, relationship between variables in different episodes and volume and specificity of clinical information.ResultsThe analysed CMBD contains few errors in management variables, with the exception of residence, but it shows important problems of volume and specificity of clinical information, as well as a high variability in its fulfilling and quality in different hospitals.ConclusionsThe quality of the clinical data of CMBD may be biased in its use with management aims or when assessing quality, as well as in epidemiological studies, evaluation of technology or use of services

A model for the future: Ecosystem services provided by the aquaculture activities of Veta la Palma, Southern Spain

© 2015 Elsevier B.V. The lack of space and opportunity for development has been identified as key reasons behind the stagnation of the European aquaculture industry. With the historical loss and degradation of current European wetlands there is an opportunity for harnessing the commercial investment of the aquaculture industry in construction of dual purpose wetlands that incorporate both conservation and extensive aquaculture activities. These wetlands can be used to expand the area available to suitable aquaculture into ecologically sensitive areas, such as Natura 2000 sites. Veta la Palma (VLP) situated in the Doñana Natural Park (and a Natura 2000 site) is an example of such an aquaculture development and a possible model for future opportunities. In the current study some of the important ecosystem services that are provided by VLP are assessed. The provisioning services of VLP were the economic rationale for the investment and more than 820tonnesyr-1 of fish and shrimp is produced, through a mixture of semi-extensive and extensive aquaculture. The regulating services include nutrient absorption, and the flow of river water through VLP and high primary production results in the absorption of 377tonnes of dissolved inorganic nitrogen yr-1, and 516tonnes of Cyr-1. Supporting services include the provision of habitat for more than 94 bird and 21 fish species. The primary production that supports the birds, extensive and semi-extensive aquaculture production was also estimated to be 167,000tonnes, 50,000tonnes and 133,000tonnesyr-1, respectively. The losses to birds are substantial and these estimates indicate that almost half of the primary production supports the wetland birds which directly consume 249tonnes of fish and 2578tonnes of invertebrates per annum. However it is the ecological credentials of the farm that enable premium prices and hence ensure the economic viability of the farm. The study demonstrates the possibility of using aquaculture to mitigate the historical loss of wetlands, provide significant ecosystem services and contribute to achievement of the European environmental legislative goals, and furthers the opportunity for the expansion of aquaculture into sensitive but impacted habitats.Peer Reviewe

Timing of surgery for hip fracture and in-hospital mortality: a retrospective population-based cohort study in the Spanish National Health System

<p>Abstract</p> <p>Background</p> <p>While the benefits or otherwise of early hip fracture repair is a long-running controversy with studies showing contradictory results, this practice is being adopted as a quality indicator in several health care organizations. The aim of this study is to analyze the association between early hip fracture repair and in-hospital mortality in elderly people attending public hospitals in the Spanish National Health System and, additionally, to explore factors associated with the decision to perform early hip fracture repair.</p> <p>Methods</p> <p>A cohort of 56,500 patients of 60-years-old and over, hospitalized for hip fracture during the period 2002 to 2005 in all the public hospitals in 8 Spanish regions, were followed up using administrative databases to identify the time to surgical repair and in-hospital mortality. We used a multivariate logistic regression model to analyze the relationship between the timing of surgery (< 2 days from admission) and in-hospital mortality, controlling for several confounding factors.</p> <p>Results</p> <p>Early surgery was performed on 25% of the patients. In the unadjusted analysis early surgery showed an absolute difference in risk of mortality of 0.57 (from 4.42% to 3.85%). However, patients undergoing delayed surgery were older and had higher comorbidity and severity of illness. Timeliness for surgery was not found to be related to in-hospital mortality once confounding factors such as age, sex, chronic comorbidities as well as the severity of illness were controlled for in the multivariate analysis.</p> <p>Conclusions</p> <p>Older age, male gender, higher chronic comorbidity and higher severity measured by the Risk Mortality Index were associated with higher mortality, but the time to surgery was not.</p

Trends and area variations in Potentially Preventable Admissions for COPD in Spain (2002-2013): A significant decline and convergence between areas

Background: Potentially Preventable Hospitalizations (PPH) are hospital admissions for conditions which are preventable with timely and appropriate outpatient care being Chronic Obstructive Pulmonary Disease (COPD) admissions one of the most relevant PPH. We estimate the population age-sex standardized relative risk of admission for COPD-PPH by year and area of residence in the Spanish National Health System (sNHS) during the period 2002–2013. Methods: The study was conducted in the 203 Hospital Service Areas of the sNHS, using the 2002 to 2013 hospital admissions for a COPD-PPH condition of patients aged 20 and over. We use conventional small area variation statistics and a Bayesian hierarchical approach to model the different risk structures of dependence in both space and time. Results: COPD-PPH admissions declined from 24.5 to 15.5 per 10, 000 persons-year (Men: from 40.6 to 25.1; Women: from 9.1 to 6.4). The relative risk declined from 1.19 (19 % above 2002–2013 average) in 2002 to 0.77 (30 % below average) in 2013. Both the starting point and the slope were different for the different regions. Variation among admission rates between extreme areas dropped from 6.7 times higher in 2002 to 4.6 times higher in 2013. Conclusions: COPD-PPH conditions in Spain have undergone a strong decline and a reduction in geographical variation in the last 12 years, suggesting a general improvement in health policies and health care over time. Variability among areas still remains, with a substantial room for improvement

Analysis of Plasma MicroRNAs as Predictors and Biomarkers of Aging and Frailty in Humans

Although circulating microRNAs (miRNAs) can modulate gene expression and affect immune system response, little is known about their participation in age-associated frailty syndrome and sarcopenia. The aim of this study was to determine miRNAs as possible biomarkers of age and frailty and their correlation with oxidative and inflammatory state in human blood. Three inflammation-related miRNAs (miR-21, miR-146a, and miR-223) and one miRNA related with the control of melatonin synthesis (miR-483) were analyzed. Twenty-two healthy adults, 34 aged robust, and 40 aged fragile patients were selected for this study. The expression of plasma miRNAs was assessed by RT-qPCR; plasma cytokines (IL-6, IL-8, IL-10, and TNFα) were analyzed by commercial kits, and plasma advanced oxidation protein products (AOPP) and lipid oxidation (LPO) were spectrophotometrically measured. Fragile subjects had higher miR-21 levels than control subjects, whereas miR-223 and miR- 483 levels increased at a similar extend in both aged groups. All cytokines measured increased in aged groups compared with controls, without differences between robust and fragile subjects. The fragile group had a TNFα/IL-10 ratio significantly higher than robust and control groups. Aged groups also had higher AOPP and LPO levels than controls. Women presented higher AOPP and LPO levels and increased expression of miR-483 compared with men. Positive correlations between miR-21 and AOPP and between miR-483 and IL-8 were detected. The expression of miR-21 and the TNFα/IL-10 ratio were correlated positively with the presence of frailty, which suggests that these markers can be considered as possible biomarkers for age-related frailty.This work was partially supported by grants from the Ministerio de Economía, Industria y Competitividad y por el Fondo de Desarrollo Regional Feder, Spain nos. RD12/ 0043/0005, PI13-00981, and CB16-10-00238 and from the Universidad de Granada, Spain no. CEI2014-MPBS3

Initial therapy, regimen change, and persistence in a spanish cohort of newly treated type 2 diabetes patients: A retrospective, observational study using real-world data

The World Health Organization considers the non-adherence to medication a significant issue with global impact, especially in chronic conditions such as type 2 diabetes. We aim to study antidiabetic treatment initiation, add-on, treatment switching, and medication persistence. We conducted an observational study on 4247 individuals initiating antidiabetic treatment between 2013 and 2014 in the EpiChron Cohort (Spain). We used Cox regression models to estimate the likelihood of non-persistence after a one-year follow-up, expressed as hazard ratios (HRs). Metformin was the most frequently used first-line antidiabetic (80% of cases); combination treatment was the second most common treatment in adults aged 40–79 years, while dipeptidyl peptidase-4 inhibitors were the second most common in individuals in their 80s and over, and in patients with renal disease. Individuals initiated on metformin were less likely to present addition and switching events compared with any other antidiabetic. Almost 70% of individuals initiated on monotherapy were persistent. Subjects aged 40 and over (HR 0.53–0.63), living in rural (HR 0.79) or more deprived areas (HR 0.77–0.82), or receiving polypharmacy (HR 0.84), were less likely to show discontinuation. Our findings could help identify the population at risk of discontinuation, and offer them closer monitoring for proper integrated management to improve prognosis and health outcomes

Shared component modelling as an alternative to assess geographical variations in medical practice: gender inequalities in hospital admissions for chronic diseases

<p>Abstract</p> <p>Background</p> <p>Small area analysis is the most prevalent methodological approach in the study of unwarranted and systematic variation in medical practice at geographical level. Several of its limitations drive researchers to use disease mapping methods -deemed as a valuable alternative. This work aims at exploring these techniques using - as a case of study- the gender differences in rates of hospitalization in elderly patients with chronic diseases.</p> <p>Methods</p> <p>Design and study setting: An empirical study of 538,358 hospitalizations affecting individuals aged over 75, who were admitted due to a chronic condition in 2006, were used to compare Small Area Analysis (SAVA), the Besag-York-Mollie (BYM) modelling and the Shared Component Modelling (SCM). Main endpoint: Gender spatial variation was measured, as follows: SAVA estimated gender-specific utilization ratio; BYM estimated the fraction of variance attributable to spatial correlation in each gender; and, SCM estimated the fraction of variance shared by the two genders, and those specific for each one.</p> <p>Results</p> <p>Hospitalization rates due to chronic diseases in the elderly were higher in men (median per area 21.4 per 100 inhabitants, interquartile range: 17.6 to 25.0) than in women (median per area 13.7 per 100, interquartile range: 10.8 to 16.6). Whereas Utilization Ratios showed a similar geographical pattern of variation in both genders, BYM found a high fraction of variation attributable to spatial correlation in both men (71%, CI95%: 50 to 94) and women (62%, CI95%: 45 to 77). In turn, SCM showed that the geographical admission pattern was mainly shared, with just 6% (CI95%: 4 to 8) of variation specific to the women component.</p> <p>Conclusions</p> <p>Whereas SAVA and BYM focused on the magnitude of variation and on allocating where variability cannot be due to chance, SCM signalled discrepant areas where latent factors would differently affect men and women.</p

Variation in antiosteoporotic drug prescribing and spending across Spain. A population-based ecological cross-sectional study

Introduction: Evidence has shown that utilization of antiosteoporotic medications does not correspond with risk, and studies on other therapies have shown that adequacy of pharmaceutical prescribing might vary between regions. Nevertheless, very few studies have addressed the variability in osteoporotic drug consumption. We aimed to describe variations in pharmaceutical utilization and spending on osteoporotic drugs between Health Areas (HA) in Spain. Methods: Population-based cross-sectional ecological study of expenditure and utilization of the five therapeutic groups marketed for osteoporosis treatment in Spain in 2009. Small area variation analysis (SAVA) methods were used. The units of analysis were the 168 HA of 13 Spanish regions, including 7.2 million women aged 50 years and older. The main outcomes were the defined daily dose (DDD) per 1000 inhabitants and day (DDD/1000/Day) dispensed according to the pharmaceutical claims reimbursed, and the expenditure on antiosteoporotics at retail price per woman =50 years old and per year. Results: The average osteoporosis drug consumption was 116.8 DDD/1000W/Day, ranging from 78.5 to 158.7 DDD/1000W/Day between the HAs in the 5th and 95th percentiles. Seventy-five percent of the antiosteoporotics consumed was bisphosphonates, followed by raloxifene, strontium ranelate, calcitonins, and parathyroid hormones including teriparatide. Regarding variability by therapeutic groups, biphosphonates showed the lowest variation, while calcitonins and parathyroid hormones showed the highest variation. The annual expenditure on antiosteoporotics was €426.5 million, translating into an expenditure of €59.2 for each woman =50 years old and varying between €38.1 and €83.3 between HAs in the 5th and 95th percentiles. Biphosphonates, despite accounting for 79% of utilization, only represented 63% of total expenditure, while parathyroid hormones with only 1.6% of utilization accounted for 15% of the pharmaceutical spending. Conclusion: This study highlights a marked geographical variation in the prescription of antiosteoporotics, being more pronounced in the case of costly drugs such as parathyroid hormones. The differences in rates of prescribing explained almost all of the variance in drug spending, suggesting that the difference in prescription volume between territories, and not the price of the drugs, is the main source of variation in this setting. Data on geographical variation of prescription can help guide policy proposals for targeting areas with inadequate antiosteoporotic drug use