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

Las ideas parentales sobre educación y desarrollo: un estudio longitudinal.

The aim of this study is to examine parental beliefs throughout the main developmental stages of children. A longitudinal 16-year follow up study has been done of 102 parents (55 mothers and 47 fathers). They responded to the Parents’ Ideas questionnaire at the main stages of child development: at birth (Time 1), at 22 months old (Time 2), at 7 years old (Time 3), and at 16 years old (Time 4). While, in general terms, configurational patterns tend to be stable over time, there are specific configurational patterns associated with the developmental stages of children, and more similarities can be found between Time 1 and Time 4, on one hand, and between Time 2 and Time 3 on the other. These results are discussed, arguing that big moments of change or parental insecurity contribute to reinforcing traditional ideology, and the utility of taking into account parental beliefs on development, upbringing and education when developing parent psychoeducational programs is considered.   El presente estudio tiene como objetivo conocer cómo se configuran las ideas parentales a lo largo de las principales etapas de desarrollo de los hijos e hijas. Durante dieciséis años se realiza un seguimiento longitudinal a 102 progenitores (55 madres y 47 padres). Se les administra el CIP (Cuestionario de Ideas de Padres) en cuatro momentos de las vidas de sus hijos e hijas: nacimiento (Tiempo 1), 22 meses (Tiempo 2), 7 años (Tiempo 3) y 16 años (Tiempo 4). Aunque, en líneas generales, el contenido de las ideas de los padres y madres tiende a mantenerse estable a lo largo del tiempo, existen patrones de configuración específicos asociados al momento evolutivo de los hijos e hijas, encontrándose más semejanzas entre Tiempo 1 y Tiempo 4, por un lado, y entre Tiempo 2 y Tiempo 3, por otro. Se discuten estos resultados argumentando que los grandes momentos de cambio o de inseguridad en el ejercicio de la paternidad contribuyen a subrayar los planteamientos de la ideología tradicional y se plantea la utilidad de conocer las ideas evolutivo-educativas de los progenitores de cara al desarrollo de programas psicoeducativos para padres y madres

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

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

Anorexia nervosa and cancer: a protocol for a systematic review and meta-analysis of observational studies

This is the final version of the article. Available from the publisher via the DOI in this record.BACKGROUND: Anorexia nervosa is characterized by a severe restriction of caloric intake, low body weight, fear of gaining weight or of becoming fat, and disturbance of body image. Pathogenesis of the disorder may include genetic predisposition, hormonal changes and a combination of environmental, psychosocial, and cultural factors. Cancer is the second leading cause of death worldwide. At present, no systematic reviews and meta-analyses have evaluated the risk of cancer in people with anorexia nervosa. The objective of this study will be to evaluate the association between anorexia nervosa and the risk of developing or dying from cancer. METHODS/DESIGN: This study protocol is part of a systematic collection and assessment of multiple systematic reviews and meta-analyses (umbrella review) evaluating the association of cancer and multiple central nervous system disorders. We designed a specific protocol for a new systematic review and meta-analysis of observational studies of anorexia nervosa with risk of developing or dying from any cancer. Data sources will be PubMed, Embase, Scopus, Web of Science, and manual screening of references. Observational studies (case-control and cohort) in humans that examined the association between anorexia nervosa and risk of developing or dying from cancer will be sought. The primary outcomes will be cancer incidence and cancer mortality in association with anorexia nervosa. Secondary outcomes will be site-specific cancer incidence and mortality, respectively. Screening of abstracts and full texts, and data abstraction will be performed by two team members independently. Conflicts at all levels of screening and abstraction will be resolved through discussion. The quality of studies will be assessed by using the Ottawa-Newcastle scale by two team members independently. Random effects models will be conducted where appropriate. Subgroup and additional analyses will be conducted to explore the potential sources of heterogeneity. The World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for cancer outcomes. DISCUSSION: Findings from this systematic review will inform an ongoing umbrella review on cancer and central nervous system disorders. Our systematic review and meta-analysis of observational studies will establish the extent of the epidemiological evidence underlying the association between anorexia nervosa and cancer. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017067462.Specific funding from the Generalitat Valenciana (PROMETEOII/2015/021) and CIBERSAM/Institute of Health Carlos III was received for this work. The funders were not involved in the design of the protocol or decision to submit the protocol for publication, nor will they be involved in any aspect of the conduct of the review. BH is supported by a New Investigator Award from the Canadian Institutes of Health Research and the Drug Safety and Effectiveness Network. MR is partially funded by the Spanish Health Services Research on Chronic Patients Network (REDISSEC)/Institute of Health Carlos III. The views expressed in this article are the views of the authors and may not be understood or quoted as being made on behalf of, or reflecting the position of, the funder(s) or any institution

Income level and regional policies, underlying factors associated with unwarranted variations in conservative breast cancer surgery in Spain

<p>Abstract</p> <p>Background</p> <p>Geographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant. This would be the case of the prescription of conservative surgery in breast cancer patients. In these cases, when variation is larger than expected by need, socioeconomic factors have been argued as an explanation. Objectives: Using an ecologic design, our study aims at describing the variability in the use of surgical conservative versus non-conservative treatment. Additionally, it seeks to establish whether the socioeconomic status of the healthcare area influences the use of one or the other technique.</p> <p>Methods</p> <p>81,868 mastectomies performed between 2002 and 2006 in 180 healthcare areas were studied. Standardized utilization rates of breast cancer conservative (CS) and non-conservative (NCS) procedures were estimated as well as the variation among areas, using small area statistics. Concentration curves and dominance tests were estimated to determine the impact of income and instruction levels in the healthcare area on surgery rates. Multilevel analyses were performed to determine the influence of regional policies.</p> <p>Results</p> <p>Variation in the use of CS was massive (4-fold factor between the highest and the lowest rate) and larger than in the case of NCS (2-fold), whichever the age group. Healthcare areas with higher economic and instruction levels showed highest rates of CS, regardless of the age group, while areas with lower economic and educational levels yielded higher rates of NCS interventions. Living in a particular Autonomous Community (AC), explained a substantial part of the CS residual variance (up to a 60.5% in women 50 to 70).</p> <p>Conclusion</p> <p>The place where a woman lives -income level and regional policies- explain the unexpectedly high variation found in utilization rates of conservative breast cancer surgery.</p

The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: A systematic review with network meta-analyses of randomised trials

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed psychiatric disorders in childhood. A wide variety of treatments have been used for the management of ADHD. We aimed to compare the efficacy and safety of pharmacological, psychological and complementary and alternative medicine interventions for the treatment of ADHD in children and adolescents. METHODS AND FINDINGS: We performed a systematic review with network meta-analyses. Randomised controlled trials (≥ 3 weeks follow-up) were identified from published and unpublished sources through searches in PubMed and the Cochrane Library (up to April 7, 2016). Interventions of interest were pharmacological (stimulants, non-stimulants, antidepressants, antipsychotics, and other unlicensed drugs), psychological (behavioural, cognitive training and neurofeedback) and complementary and alternative medicine (dietary therapy, fatty acids, amino acids, minerals, herbal therapy, homeopathy, and physical activity). The primary outcomes were efficacy (treatment response) and acceptability (all-cause discontinuation). Secondary outcomes included discontinuation due to adverse events (tolerability), as well as serious adverse events and specific adverse events. Random-effects Bayesian network meta-analyses were conducted to obtain estimates as odds ratios (ORs) with 95% credibility intervals. We analysed interventions by class and individually. 190 randomised trials (52 different interventions grouped in 32 therapeutic classes) that enrolled 26114 participants with ADHD were included in complex networks. At the class level, behavioural therapy (alone or in combination with stimulants), stimulants, and non-stimulant seemed significantly more efficacious than placebo. Behavioural therapy in combination with stimulants seemed superior to stimulants or non-stimulants. Stimulants seemed superior to behavioural therapy, cognitive training and non-stimulants. Behavioural therapy, stimulants and their combination showed the best profile of acceptability. Stimulants and non-stimulants seemed well tolerated. Among medications, methylphenidate, amphetamine, atomoxetine, guanfacine and clonidine seemed significantly more efficacious than placebo. Methylphenidate and amphetamine seemed more efficacious than atomoxetine and guanfacine. Methylphenidate and clonidine seemed better accepted than placebo and atomoxetine. Most of the efficacious pharmacological treatments were associated with harms (anorexia, weight loss and insomnia), but an increased risk of serious adverse events was not observed. There is lack of evidence for cognitive training, neurofeedback, antidepressants, antipsychotics, dietary therapy, fatty acids, and other complementary and alternative medicine. Overall findings were limited by the clinical and methodological heterogeneity, small sample sizes of trials, short-term follow-up, and the absence of high-quality evidence; consequently, results should be interpreted with caution. CONCLUSIONS: Clinical differences may exist between the pharmacological and non-pharmacological treatment used for the management of ADHD. Uncertainties about therapies and the balance between benefits, costs and potential harms should be considered before starting treatment. There is an urgent need for high-quality randomised trials of the multiple treatments for ADHD in children and adolescents. PROSPERO, number CRD42014015008

Cardiovascular and renal outcomes of renin-angiotensin system blockade in adult patients with diabetes mellitus: a systematic review with network meta-analyses

Medications aimed at inhibiting the renin-angiotensin system (RAS) have been used extensively for preventing cardiovascular and renal complications in patients with diabetes, but data that compare their clinical effectiveness are limited. We aimed to compare the effects of classes of RAS blockers on cardiovascular and renal outcomes in adults with diabetes

A new approach to use marine robotic networks for ecosystem monitoring and management: The PLOME Project

4th Marine Imaging Workshop, 3-6 October 2022, Brest, FranceOur understanding of marine ecosystem functioning and processes relies on adequate spatio-temporal multiparametric monitoring procedures. Over the next 3 years, the Project PLOME (Platforms for Long-lasting Observation of Marine Ecosystems) will implement a spatially adaptive and autonomous network of easy-to-use benthic landers with dockable Autonomous Underwater Vehicles (AUVs)ñ This network will be used to intelligently video-monitor and map marine ecosystems and their environment from coastal to deep-sea areas. All platforms will be connected via acoustic or optical communication and will operate over periods of weeks to months with real-time supervision. Stations will provide continuous and intensive temporal observations, while dockable AUVs (with battery recharge and data downloading capability) will provide intensive measurements at various spatial scales, using intelligent and adaptive trajectories to explore surrounding areas. Biological, geochemical and oceanographic data will be generated by an array of sensors including acoustic receivers and cameras. Images will be processed in real-time for species classification and tracking, using advanced data analysis and Deep Learning techniques. Metadata will be communicated between landers and AUVs and transmitted opportunistically whenever an Unmanned Surface Vehicle (USV) connects the platform via aerial communications (i.e. GSM and satellite communications, depending on form distance to shore). The unattended operation will also be possible with an innovation of pop-up buoys that will allow data transfer to the surface from landers and UAVs to be relayed once the pop-up buoys reach the surface. Complex ecological indicators for ecosystem management will be computed from the collected data, by applying advanced computer vision techniques to classify, count and size individuals in video images and to generate multimodal maps of the seabed. A pipeline for automated data treatment will be tailored for multiparametric analyses to derive cause-effect relationships between biological variables and the physical habitatsPeer reviewe