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

Wake dynamics of external flow past a curved circular cylinder with the free stream aligned with the plane of curvature

Accepted versio

Sistemas de clasificación de pacientes en centros de media y larga estancia: evolución y perspectivas de futuro

ResumenLa atención de media y larga estancia es un sector cada vez más importante de la prestación de cuidados sanitarios. La utilización de sistemas de clasificación de pacientes se contempla cada vez más como un elemento necesario tanto en la planificación como en la gestión de servicios en el sector de atención a enfermos crónicos y geriátricos.Aunque mucho menos conocidos, los sistemas de clasificación de pacientes han tenido en el sector de la atención de media y larga estancia un desarrollo mucho más rico y precoz que en el sector hospitalario. De este modo, puede verse la evolución desde clasificaciones basadas exclusivamente en la valoración de la capacidad funcional de los residentes, hacia clasificaciones que incluyen progresivamente variables de complejidad asistencial, hasta sistemas elaborados como la clasificación RUG-III.Los sistemas de clasificación de pacientes se utilizaron inicialmente como instrumentos para soportar los sistemas de financiación de los centros de media y larga estancia basándose en las características de paciente. Posteriormente, sus aplicaciones se han ido extendiendo hacia otros objetivos relacionados con la gestión de los centros, la evaluación de la calidad asistencial, la determinación de niveles de dotación de personal, el control del acceso a la atención y la formulación de políticas gubernamentales. En España, la única experiencia de utilización de un sistema de clasificación de pacientes es la del Programa Vida Als Anys en Cataluña, que desde 1990 utiliza una clasificación para la financiación de los centros acogidos al mismo.SummaryThe importance of long term care sector is increasingly growing. Actually, the use of patient classification systems is a useful tool for the planning and management of health services for chronic and geriatric patients.Despite being much less known, patient classification systems have had a richer and earlier development in the long term care sector than in the acute care sector. Thus, one could see the evolution from classifications based on the assessment of functional dependency to classifications progressively including variables corresponding to clinical complexity, and finally to complex systems such as RUG-III.Patient classification systems were first utilised as tools for the financing of long term centres, based on the patients' characteristics. Later, their applications have spread out to objectives related to the management of centres, assessment of quality of care, staff allocation level, control of access and national policies. In Spain, the only experience in the use of a patient classification system is the one used by the Catalan Health Care Administration which uses a classification for the financing of their centres

Spatial eigensolution analysis of discontinuous Galerkin schemes with practical insights for under-resolved computations and implicit LES

The study focusses on the dispersion and diffusion characteristics of discontinuous spectral element methods - specifically discontinuous Galerkin (DG) - via the spatial eigensolution analysis framework built around a one-dimensional linear problem, namely the linear advection equation. Dispersion and diffusion characteristics are of critical importance when dealing with under-resolved computations, as they affect both the numerical stability of the simulation and the solution accuracy. The spatial eigensolution analysis carried out in this paper complements previous analyses based on the temporal approach, which are more commonly found in the literature. While the latter assumes periodic boundary conditions, the spatial approach assumes inflow/outflow type boundary conditions and is therefore better suited for the investigation of open flows typical of aerodynamic problems, including transitional and fully turbulent flows and aeroacoustics. The influence of spurious/reflected eigenmodes is assessed with regard to the presence of upwind dissipation, naturally present in DG methods. This provides insights into the accuracy and robustness of these schemes for under-resolved computations, including under-resolved direct numerical simulation (uDNS) and implicit large-eddy simulation (iLES). The results estimated from the spatial eigensolution analysis are verified using the one-dimensional linear advection equation and successively by performing two-dimensional compressible Euler simulations that mimic (spatially developing) grid turbulence

Strain-driven elastic and orbital-ordering effects on thickness-dependent properties of manganite thin films

We report on the structural and magnetic characterization of (110) and (001) La2/3Ca1/3MnO3 (LCMO) epitaxial thin films simultaneously grown on (110) and (001)SrTiO3 substrates, with thicknesses t varying between 8 nm and 150 nm. It is found that while the in-plane interplanar distances of the (001) films are strongly clamped to those of the substrate and the films remain strained up to well above t=100 nm, the (110) films relax much earlier. Accurate determination of the in-plane and out-of-plane interplanar distances has allowed concluding that in all cases the unit cell volume of the manganite reduces gradually when increasing thickness, approaching the bulk value. It is observed that the magnetic properties (Curie temperature and saturation magnetization) of the (110) films are significantly improved compared to those of (001) films. These observations, combined with 55Mn-nuclear magnetic resonance data and X-ray photoemission spectroscopy, signal that the depression of the magnetic properties of the more strained (001)LCMO films is not caused by an elastic deformation of the perovskite lattice but rather due to the electronic and chemical phase separation caused by the substrate-induced strain. On the contrary, the thickness dependence of the magnetic properties of the less strained (110)LCMO films are simply described by the elastic deformation of the manganite lattice. We will argue that the different behavior of (001) and (110)LCMO films is a consequence of the dissimilar electronic structure of these interfaces.Comment: 16 pages, 15 figure

High quality InAlN single layers lattice-matched to GaN grown by molecular beam epitaxy

We report on properties of high quality ~60 nm thick InAlN layers nearly in-plane lattice-matched to GaN, grown on c-plane GaN-on-sapphire templates by plasma-assisted molecular beam epitaxy. Excellent crystalline quality and low surface roughness are confirmed by X-ray diffraction, transmission electron microscopy, and atomic force microscopy. High annular dark field observations reveal a periodic in-plane indium content variation (8 nm period), whereas optical measurements evidence certain residual absorption below the band-gap. The indium fluctuation is estimated to be +/- 1.2% around the nominal 17% indium content via plasmon energy oscillations assessed by electron energy loss spectroscopy with sub-nanometric spatial resolution

Structural properties of InAlN single layers nearly latice-matched to GaN grown by plasma assisted molecular beal epitaxy

The high lattice mismatch between III-nitride binaries (InN, GaN and AlN) remains a key problem to grow high quality III-nitride heterostructures. Recent interest has been focused on the growth of high-quality InAlN layers, with approximately 18% of indium incorporation, in-plane lattice-matched (LM) to GaN. While a lot of work has been done by metal-organic vapour phase epitaxy (MOVPE) by Carlin and co-workers, its growth by molecular beam epitaxy (MBE) is still in infanc

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