Solicitud de pruebas de laboratorio para el diagnóstico y manejo de los desórdenes del metabolismo fosfocálcico en España

Background: Knowledge about the variability in the request of calcium-phosphate metabolism laboratory tests in primary care is important to design strategies to improve health system efficiency. Aim: To compare the inter-practice variability in calcium-phosphate metabolism laboratory tests requested by general practitioners from diverse regions across Spain. Material and Methods: One hundred and forty one clinical laboratories were invited to participate in an observational cross-sectional study. They informed the number of serum calcium, phosphate, parathyroid hormone and 25-hydroxyvitamin D requested by general practitioners. Appropriateness indicators were calculated as number of test requests per 1,000 inhabitants and ratio of related tests requests. The differences according to hospital setting, region and type of management were analyzed. Results: We recruited 76 laboratories (17,679,195 inhabitants). General practitioners requested 3,260,894 calcium-phosphate metabolism tests. The rate of request ranged from 2.97 per 1,000 inhabitants for 25-hydroxyvitamin D to 98.89 per 1,000 inhabitants for calcium. The rates of request for calcium, phosphate, parathyroid hormone in some areas were 30, 100 and 340 times higher than in other areas. Parathyroid hormone and 25-hydroxyvitamin D were highly requested in private management areas. There were also differences in phosphate, parathyroid hormone and 25-hydroxyvitamin D requesting between regions across Spain. Conclusions: The high variability observed is difficult to explain by differences in patient case mix between regions. Depending on the area, calcium could be under requested to detect primary hyperparathyroidism.Objetivo: Conocer la variabilidad en la solicitud de pruebas de laboratorio en atención primaria es importante para diseñar estrategias que mejoren la eficiencia del sistema de salud. La propuesta de este estudio fue comparar la variabilidad en la solicitud de pruebas para la evaluación del metabolismo fosfocálcico por médicos de atención primaria de diversas regiones de España. Material y Método: Se invitó a participar a 141 laboratorios clínicos de diversas regiones españolas. Completaron una encuesta con el número de determinaciones de calcio, fósforo, hormona paratiroidea y 25-hidroxivitamina D solicitadas por médicos de atención primaria de sus áreas. Se calcularon las tasas en relación a la población y se construyeron indicadores de adecuación. Los resultados se compararon por características del hospital, región y tipo de gestión. Resultados: Obtuvimos los datos de 76 laboratorios (17.679.195 habitantes). Los médicos de atención primaria solicitaron 3.260.894 pruebas de metabolismo fosfocálcico. La tasa de solicitud varió de 2,97 por 1.000 habitantes de 25-hidroxivitamin D a 98,89 por 1.000 habitantes de calcio. Las tasas de calcio, fósforo, hormona paratiroidea en algunas áreas fue 30, 100 y 340 veces más alta respecto a otras. Hormona paratiroidea y 25-hidroxivitamina D fueron más solicitadas significativamente en hospitales con gestión privada. También hubo diferencias en fósforo, hormona paratiroidea y 25-hidroxivitamina D solicitas entre distintas regiones de España. Discusión: La alta variabilidad observada es difícil de explicar por las diferencias de las características de los pacientes. Dependiendo de la región podría haber una infra solicitud para la detección del hiperparatiroidismo primario

Analysis of the safety culture in a Cardiology Unit managed by processes

La cultura sobre seguridad se perfila como uno de los requisitos para evitar la aparición de efectos adversos, sin embargo no se ha estudiado en el ámbito de la cardiología. El objetivo es evaluar la cultura de seguridad en una unidad de cardiología que tiene implantado y certificado un sistema integrado de gestión de calidad y riesgos para la seguridad del paciente. Método: Se realizó un estudio observacional trasversal en 2 años consecutivos utilizando la encuesta Hospital Survey on Patient Safety Culture de la «Agency for Healthcare Research and Quality» en su versión española (42 ítems agrupados en 12 dimensiones) sobre todo el personal. Se comparó el porcentaje de respuestas positivas de cada dimensión en 2014 y 2015, así como con los datos a nivel nacional y en EE. UU., siguiendo las recomendaciones establecidas. Resultados: La valoración global, sobre un máximo de 5, fue de 4.5 en 2014 y de 4.7 en 2015. Identificamos 7 dimensiones como fortaleza. Las peor valoradas fueron: Dotación de personal, Apoyo de la gerencia y Trabajo en equipo entre unidades. La comparación mostró superioridad en todas las dimensiones a nivel nacional, y en 8 respecto a los datos del registro americano. Conclusiones: La cultura de seguridad en una unidad de cardiología con un sistema integrado de gestión de calidad y riesgos y seguridad del paciente es elevada, superior a la nacional en todas sus dimensiones y en la mayoría de ellas respecto al registro de EE. UU.The safety culture is one of the requirements to prevent the occurrence of adverse effects, however has not been studied in the field of cardiology. The objective is to evaluate the safety culture in a cardiology unit has implemented and certified an integrated quality and risk management for patient safety system. Methods: A transversal observational study was made in 2 consecutive years using the survey “Hospital Survey on Patient Safety Culture” of the “Agency for Healthcare Research and Quality” in its Spanish version (42 items grouped into 12 dimensions) in all staff. The percentage of positive responses in each dimension in 2014 and 2015 were compared, as well as national data and United States data, following the established rules. Results: The overall assessment of a possible 5, was 4.5 in 2014 and 4.7 in 2015. We identified seven dimensions as a fortress. The worst rated were: staffing, management support and teamwork between units. The comparison showed superiority in all dimensions respect to national data, and 8 respect to American data. Conclusions: The safety culture in a Cardiology Unit with an integrated quality and risk management and patient safety system is high, higher than the national in all its dimensions and in most of them respect to the United States

Primary care use of laboratory tests in Spain: measurement through appropriateness indicators

Background: To compare the inter-practice and inter-regional variability in laboratory test requests by general practitioners in Spain, through the measure of appropriateness indicators. Methods: A call for data was posted on the Redconlab website. We obtained production statistics for 2010 from laboratories in 37 different hospitals from diverse Spanish regions. The following appropriateness indicators were calculated: test re-quests per 1000 inhabitants, ratios of related tests requests and index of variability. The results obtained in the laboratories in the region of authors were com-pared to the rest of the participating laboratories in order to establish whether there were regional differences in the test requesting patterns. Results: The rate of request of the tests ranged from 31.5 per 1000 inhabitants for vitamin B12 to 372.6 per 1000 inhabitants for glucose. The index of variability ranged from 1.53 for glucose and triglycerides to 7.4 for alkaline phosphatase. Regarding the ratios of related test requests, the variability index ranged from 1.24 for folic acid/vitamin B12 to 26.38 for lactate dehydrogenase/alanine transaminase. The most frequently ordered tests were the ones with less variability, except for uric acid and urinalysis. No significant differences were identified between the results of the laboratories in the region of authors and the rest, except for urinalysis (p < 0.001), folic acid/vitamin B12 (p = 0.030), and transferrin/ferritin (p = 0.018). Conclusions: A considerable variability exists in laboratory test ordering patterns by general practitioners across Spanish regions. Local habits must have been decisive as shown by the regional differences in the results of indicators of some tests. The study results bring out the need to accomplish interventions to improve appropriate use of laboratory tests

Redesigning the hospital discharge process

Objetivo: Mostrar que el rediseño y la planificación del proceso de alta hospitalaria adelantan la hora de salida del paciente del medio hospitalario. Material y método: Estudio cuasiexperimental, realizado entre enero de 2011 y abril de 2013, en un hospital comarcal. Los casos analizados fueron de las unidades de enfermería médicas y quirúrgicas. El proceso fue rediseñado para coordinar a todos los profesionales que intervienen en el proceso. La mejora del proceso de alta hospitalaria se realizó a través de la creación de un grupo de trabajo, el análisis de los datos retrospectivos y la identificación de las áreas de mejora y rediseño. La variable dependiente fue la hora de alta administrativa del paciente. La muestra fue clasificada en preintervención, intraintervención y postintervención en función del momento temporal del estudio. Resultados: La muestra, tras aplicar los criterios de inclusión y exclusión, fue de 14.788 pacientes. El tiempo medio de salida de alta disminuyó de forma significativa en 50 min entre los periodos preintervención y postintervención. La salida en pacientes con alta planificada fue una hora y 25 min menor que en los pacientes no planificados. Conclusiones: El rediseño de procesos es una estrategia útil para mejorar el proceso de alta hospitalaria. Además, la planificación del alta se muestra como un elemento clave para que el paciente abandone el centro sanitario antes de las 12 de la mañana.Objective: The aim of this article is to show that the redesign and planning process of hospital discharge advances the departure time of the patient from a hospital environment. Material and method: Quasi-experimental study conducted from January 2011 to April 2013, in a local hospital. The cases analysed were from medical and surgical nursing units. The process was redesigned to coordinate all the professionals involved in the process. The hospital discharge improvement process improvement was carried out by forming a working group, the analysis of retrospective data, identifying areas for improvement, and its redesign. The dependent variable was the time of patient administrative discharge. The sample was classified as pre-intervention, inter-intervention, and post-intervention, depending on the time point of the study. Results: The final sample included 14,788 patients after applying the inclusion and exclusion criteria. The mean discharge release time decreased significantly by 50 min between pre-intervention and post-intervention periods. The release time in patients with planned discharge was one hour and 25 min less than in patients with unplanned discharge. Conclusions: Process redesign is a useful strategy to improve the process of hospital discharge. Besides planning the discharge, it is shown that the patient leaving the hospital before 12 midday is a key factor

Variation in laboratory tests ordered for patients treated in hospital emergency departments

Objetivo: Comparar los patrones de solicitud de pruebas de laboratorio (PL) en pacientes que acuden al servicio de urgencias hospitalario (SUH) en España. Métodos: Estudiamos 20 PL en pacientes que acudieron al SUH de 76 hospitales españoles, durante el año 2012. Calculamos el número de solicitudes de cada prueba por 1.000 pacientes atendidos y ciertas tasas de pruebas relacionadas. Comparamos dichos valores con los objetivos a alcanzar (AST/ALT = 0,25 y urea/creatinina = 0,1). Comparamos la demanda entre hospitales según su tipo de gestión, localización y tamaño. Resultados: La variabilidad en la utilización de PL fue elevada, y fue mayor en las menos solicitadas. En 12 hospitales sólo se procesaba una transaminasa, en 9 sólo alanina amino-transferasa y en 3 aspartato amino-transferasa únicamente. Además de amilasa, la mitad de los hospitales procesaban lipasa. En la mayoría de los centros se solicitó más número de creatinquinasa que de troponina. La urea y creatinina eran pedidas de forma redundante en la mayoría de servicios. En un tercio de hospitales no se procesaba albúmina ni péptido natriurético de tipo B y en un cuarto tampoco procalcitonina. Discusión: Existe variabilidad en el numero de PL solicitadas desde los SUH y en las que están disponibles para solicitar. Por tanto, es necesario establecer cuáles son las PL que más contribuyen al manejo del paciente urgente mediante la protocolización de los procesos clínicos y la comunicación entre los profesionales del SUH y laboratorio.Objective: To compare laboratory test request patterns for patients treated in Spanish hospital emergency departments. Methods: We studied the number of laboratory tests ordered for patients treated in 76 hospital emergency departments in 2012. We calculated the number of times each test was ordered per 1000 patients and the frequency ratios between certain related tests. The ratios were compared with targets (aspartate aminotransferase [AST]/alanine aminotransferase [ALT], 0.25; urea/creatinine, 0.1). Testing patterns were compared between hospitals grouped by type of administration, geographic location, and size. Results: Variation in demand for the different tests was high between hospitals, especially for the less frequently ordered tests. Only 1 transaminase test was ordered in 12 hospitals (only ALT in 9 hospitals; only AST in 3 hospitals). Both lipase and amylase tests were ordered in half the hospitals. Creatine kinase testing was ordered more often than troponin testing in most hospitals. Most of the hospitals also ordered urea and creatinine tests. A third of the hospitals did not test for either albumin or type B natriuretic peptide levels; a quarter of the hospitals did not order procalcitonin tests. Conclusions: The pattern of laboratory testing, in relation to available tests, varies between emergency departments. Which tests contribute the most to emergency care management should be determined through better communication between emergency department physicians and laboratory staff so that clinical care protocols can be followed.El trabajo presentado ha recibido una ayuda a la Investigación Ignacio H de Larramendi de la Fundación Mapfre

Variation in laboratory tests ordered for patients treated in hospital emergency departments

Objetivo: Comparar los patrones de solicitud de pruebas de laboratorio (PL) en pacientes que acuden al servicio de urgencias hospitalario (SUH) en España. Métodos: Estudiamos 20 PL en pacientes que acudieron al SUH de 76 hospitales españoles, durante el año 2012. Calculamos el número de solicitudes de cada prueba por 1.000 pacientes atendidos y ciertas tasas de pruebas relacionadas. Comparamos dichos valores con los objetivos a alcanzar (AST/ALT = 0,25 y urea/creatinina = 0,1). Comparamos la demanda entre hospitales según su tipo de gestión, localización y tamaño. Resultados: La variabilidad en la utilización de PL fue elevada, y fue mayor en las menos solicitadas. En 12 hospitales sólo se procesaba una transaminasa, en 9 sólo alanina amino-transferasa y en 3 aspartato amino-transferasa únicamente. Además de amilasa, la mitad de los hospitales procesaban lipasa. En la mayoría de los centros se solicitó más número de creatinquinasa que de troponina. La urea y creatinina eran pedidas de forma redundante en la mayoría de servicios. En un tercio de hospitales no se procesaba albúmina ni péptido natriurético de tipo B y en un cuarto tampoco procalcitonina. Discusión: Existe variabilidad en el numero de PL solicitadas desde los SUH y en las que están disponibles para solicitar. Por tanto, es necesario establecer cuáles son las PL que más contribuyen al manejo del paciente urgente mediante la protocolización de los procesos clínicos y la comunicación entre los profesionales del SUH y laboratorio.Objective: To compare laboratory test request patterns for patients treated in Spanish hospital emergency departments. Methods: We studied the number of laboratory tests ordered for patients treated in 76 hospital emergency departments in 2012. We calculated the number of times each test was ordered per 1000 patients and the frequency ratios between certain related tests. The ratios were compared with targets (aspartate aminotransferase [AST]/alanine aminotransferase [ALT], 0.25; urea/creatinine, 0.1). Testing patterns were compared between hospitals grouped by type of administration, geographic location, and size. Results: Variation in demand for the different tests was high between hospitals, especially for the less frequently ordered tests. Only 1 transaminase test was ordered in 12 hospitals (only ALT in 9 hospitals; only AST in 3 hospitals). Both lipase and amylase tests were ordered in half the hospitals. Creatine kinase testing was ordered more often than troponin testing in most hospitals. Most of the hospitals also ordered urea and creatinine tests. A third of the hospitals did not test for either albumin or type B natriuretic peptide levels; a quarter of the hospitals did not order procalcitonin tests. Conclusions: The pattern of laboratory testing, in relation to available tests, varies between emergency departments. Which tests contribute the most to emergency care management should be determined through better communication between emergency department physicians and laboratory staff so that clinical care protocols can be followed.El trabajo presentado ha recibido una ayuda a la Investigación Ignacio H de Larramendi de la Fundación Mapfre

Reducing preanalytical laboratory sample errors through educational and technological interventions

Background: A correct preanalytical phase procedure is critical to get an adequate sample and consequently to achieve the most reliable laboratory results, promoting patient safety. Continuous laboratory staff changes create the need to establish improvement strategies to reduce the error risk. The objective was to show how the numbers of preanalytical errors related to unsuitable samples in a hospital setting decrease following two improvement strategies related to new technology and educational actions and how their effects were measured by monitoring indicators. Methods: Samples were drawn by the laboratory and other hospital departments’ nurses without previous patient appointment, therefore, prior tube preparation was not available before the phlebotomy. Corrective measures for these activities were established: educational program for nurses and a system of custom labels, which correlate each laboratory test in the Laboratory Information System (LIS) with the corresponding tube. Three phases were defined based on the implementation dates of the improvement actions to be assessed. The set of indicators de-signed to monitor the improvement related to clotted, hemolyzed, insufficient, and uncollected samples. Data were collected and indicators calculated from the LIS using a data warehouse application. Patient satisfaction with re-spect to phlebotomy was also measured annually using a scoring survey. Results: There was a reduction in all types of preanalytical sample errors related to the improvement strategies adopted. The indicators demonstrated that the unavailable, insufficient, and clotted samples decreased between two- and three-fold, whereas hemolysis errors benefited more from these improvement strategies. Patient satisfaction with the laboratory and phlebotomy procedures improved over the past several years as based on the annual satisfaction surveys. Conclusions: The educational program for nursing personnel is relevant and important as can be seen in the de-crease of sample errors and the resulting quality improvement. The custom label system minimizes the potential oversight of forgetting to draw a tube, which happens frequently when operating without appointments, by print-ing the labels according to requested tests. Detection, identification, and monitoring of the error and implement-ing strategies to improve preanalytical quality reduces error numbers and thereby improves patient safety and health system outcomes

An evaluation of hemoglobin A1c test ordering patterns in a primary care setting

Background: To evaluate the hemoglobin A1c (HbA1c) prescription patterns by primary care physicians before the International Expert Committee (IEC) guidelines and how they have changed. Materials and Methods: The number of HbA1c tests ordered from January 2002 to December 2009 was examined in a cross-sectional study. The percentage of HbA1c results <6% and <5.5% were calculated. These cutoffs were decided after consultation of the literature regarding HbA1c values that were unlikely to have diabetic patients. Repeat HbA1c orders per patient were also tabulated. Results: 95,321 HbA1c tests were ordered. The percentage of HbA1c results <6% and <5.5%, respectively, were 36.2% and 13.8%. The percentage of HbA1c tests ordered with a result of <6% differed significantly between January 2009 to July 2009 and August 2009 to December 2009 (picked specifically because of the timing of the IEC guideline). Only 16% of patients had repeat HbA1c tests in 2009. Conclusions: It is necessary to conduct studies of HbA1c testing patterns in order to establish corrective measures to ensure proper use of the tests

Request of thyroid function tests from Primary Care in Spain

Antecedentes y objetivos: Las pruebas de laboratorio son cruciales en el diagnóstico y seguimiento de las disfunciones tiroideas, lo que hace necesario estudiar cuál es el patrón de su demanda y la variabilidad en la solicitud. Los objetivos del trabajo fueron comparar la variabilidad en la solicitud de pruebas de función y autoinmunidad tiroidea (tirotropina tiroxina libre [T4L], triyodotironina libre [T3L], anticuerpos frente a la tiroglobulina [TgAb] y anticuerpos antiperoxidasa [TPOAb]) por parte de los médicos de atención primaria entre diferentes departamentos de salud españoles, y calcular el potencial ahorro económico que supondría alcanzar las metas de algunos indicadores de adecuación descritos previamente en la literatura. Métodos: Se compararon el número de pruebas por 1.000 habitantes y las ratios de pruebas relacionadas (T4L/TSH, T3L/TSH, TgAb/TPOAb) entre los diferentes departamentos en función de su ubicación, tipo de gestión y la región. Se calculó el ahorro generado si cada departamento alcanzara la meta propuesta en la literatura para los indicadores T4L/TSH (0,25) y T3L/TSH (0,1). Resultados: Un total de 76 laboratorios que atienden a una población de 17.679.195 habitantes participaron en el estudio. La solicitud de TSH fue significativamente menor en los departamentos de salud rurales-urbanos y la solicitud de T3L, la ratio T3L/TSH y la ratio TgAb/TPOAb fueron mayores en los departamentos con gestión privada. El ahorro que se generaría si se cumplieran las especificaciones para las ratios de pruebas relacionadas ascendería a 937.260,5 €. Conclusiones: La elevada variabilidad descrita en la solicitud de pruebas de función y autoinmunidad tiroidea en España hace necesario implementar estrategias para mejorar esta solicitud.Background and objectives: Laboratory tests are crucial for diagnosis and monitoring of thyroid disorders. It is therefore necessary to study the pattern and variability in requests of thyroid function tests. The study objectives were to compare the inter-regional variability in the request of laboratory thyroid tests by general practitioners (GPs) in Spain, and to investigate the potential economic savings if the goals set for some suitability indicators were reached. Methods: Test requests per 1,000 inhabitants and test ratios (free thyroxine (FT4)/thyrotropin (TSH), free triiodothyronine (FT3)/TSH, thyroglobulin antibody (TgAb)/peroxidase antibody (TPOAb)) were compared between the different areas, according to their setting, location, and management. The resulting savings if each department achieved the goals for indicator (0.25 for FT4/TSH, 0.1 for FT3/TSH) were estimated. Results: Seventy-six laboratories covering a population of 17,679,195 inhabitants participated in the study. TSH was requested significantly less in urban-rural areas, and the requests for FT3/1,000 inhabitants, FT3/TSH, and TgAb/TPOAb were higher in departments with private management. The savings generated if specifications for the ratios of related tests were met would be 937,260.5 €. Conclusions: The high variability reported in requests for thyroid function and autoimmunity tests in Spain suggests the need for implementing strategies to improve use of such tests.Esta investigación ha recibido una beca (Ayudas a la Investigación Ignacio H. de Larramendi) de la Fundación MAPFRE

Gestión de los procesos de soporte asistencial, septiembre 2009

Material docent de la Universitat Oberta de Catalunya.Material docente de la "Universitat Oberta de Catalunya".Learning material of the "Universitat Oberta de Catalunya"