Evolución de la productividad del sistema hospitalario en España antes y después de la culminación de las transferencias de competencias: una aproximación

Fundamentos: A partir de la actual crisis económica se ha acrecentado el debate sobre la idoneidad del modelo de competencias sanitarias en España En este contexto, el objetivo del presente trabajo es analizar los cambios de productividad de los sectores hospitalarios de las comunidades autónomas, consideradas en dos grupos (las comunidades cuyas competencias en salud fueron transferidas antes de 2002 y las comunidades en las que dichas competencias fueron transferidas en 2002), durante el periodo previo a la culminación de transferencias (1997-2001) y durante el periodo posterior (2002-2007) Métodos: Aplicación del índice de Malmquist para los dos preiodos considerados utilizando como variables el capital, el trabajo, la actividad y la calidad de los servicios sanitarios construidas cada una de ellas a partir de un total de 29 indicadores para cada una de las 17 CCAA. Resultados: La productividad de los sectores hospitalarios durante el periodo 1998-2007 creció un 0,4% en las comunidades cuyas competencias en salud fueron transferidas antes de 2002 y decreció un 0,5% en las demás. Las diferencias en la evolución de la productividad de ambos grupos de comunidades autónomas se evidencian durante el periodo 2002-2007. Conclusiones: Los descensos de productividad en los sistemas de salud con competencias transferidas desde 2002 –en contraposición a los ascensos de las comunidades que más tiempo llevan gestionándola- pueden indicar que existe un coste inicial de organización y dotación del nuevo sistema.Background: The current economic crisis has increased the debate on the suitability of the health competency model in Spain. To analyse the productivity changes within the Hospital system in the diferent spanish regions, in two groups (regions where health competences were transferred before 2002 and regions where these competences were transferred at the beginning of 2002) during the period prior to the completion of transfers (1997-2001) and during the subsequent period (2002-2007) Methods: Use of Malmquist Index with the following variables: capital, labour, activity and quality of healthcare services, each constructed from a total of 29 indicators for each of the 17 regions. Results: The productivity in the hospitals during the period 1998-2007 grew by 0.4% in the regions where health competences were transferred before 2002 and it decreased by 0.5% in the other group. The differences in the evolution of the productivity ofor both groups of regions became evident during the period of 2002-2007. Conclusions: The decrease in productivity in the healthcare systems where competences were transferred after 2002 –as opposed to the rise in the regions that have been managing it for a longer period– may indicate that there is an initial cost for organizing the new system

Singularitats dels recursos d’assistència sanitària a les Illes Balears

Es descriu la infraestructura de recursos d’assistència sanitària a les Illes Balears i se n’examina l’evolució al llarg del període 1999-2009. Les Illes es configuren com una regió singular pel fet que disposen d’una de les més àmplies xarxes hospitalàries d’aguts de l’Estat, tant pública com privada, amb un nombrós grup de professionals, i altament dotada tecnològicament, que contrasta amb el pes relatiu menor que presenta l’atenció primària i els hospitals de mitjana i llarga estada. L’evolució dels recursos durant el període 1999-2008 s’ha caracteritzat pel notable creixement del sector públic a l’atenció hospitalària d’aguts, amb l’obertura de quatre hospitals de nova planta i amb la multiplicació per dos del nombre de professionals.The infrastructure of resources in health assistance of the Balearic Islands is described and the evolution of it through the period 1999-2009 examined. The Balearic Islands are configured as an outstanding area because they boast one of the most complete nets of acute hospitalisation in the whole State in terms of public and private sector. They have a large group of professionals and it is technologically highly equipped, which contrasts with the low relative weight of primary care as well as medium and long-stay hospitals. The evolution of resources during the period of 1999-2008 is characterised by the significant growth of the public sector in acute care hospitalisation, with the opening of four new hospitals and with the doubling in the number of professionals

Singularitats i determinants de la demanda d'assistència sanitària a les Illes Balears

Es descriuen els aspectes determinants de demanda d’assistència sanitària i d’assegurament privat a les Illes Balears, així com s’examina la seva evolució al llarg del període 1999-2009. D’acord amb l’anàlisi d’aquests determinants, les Illes es configuren com una regió singular ja que presenten característiques diferents respecte a la resta de comunitats autònomes en relació a variables com el major nombre de població estacional i estrangera, la menor proporció de persones majors, el baix nivell d’estudis o l’elevat augment demogràfic i escàs creixement econòmic. Els notables canvis experimentats en els determinants durant el període considerat han modificat el tipus de demanda d’assistència sanitària cap a una major presència del sector públic en relació al sector privat i una disminució de l’assegurament privat.We describe the key aspects of the demand for health services and of the private health insurance in the Balearic Islands. We also examine the changes in these aspects throughout the period 1999-2009. The analysis of these aspects suggests that the Islands are a singular region, with different characteristics compared to the other Spanish regions. These differences are related to variables such as the seasonal and foreign population, the proportion of older people, the low levels of education and the demographic and economic growth. The important changes in the aspects during the analyzed period have modified the type of demand for health services, leading to a greater presence of the public sector than the private sector and a decrease of private health insurance.Se describen los aspectos determinantes de demanda de asistencia sanitaria y de la compra de seguro privado en las Illes Balears, así como se examina su evolución a lo largo del periodo 1999-2009. De acuerdo con el análisis de estos determinantes, las Illes se configuran como una región singular dado que presentan características diferentes respecto al resto de comunidades autónomas en relación a variables como el mayor número de población estacional y extranjera, la menor proporción de personas mayores, el bajo nivel de estudios o el elevado aumento demográfico y escaso crecimiento económico. Los notables cambios experimentados en los determinantes durante el periodo considerado han modificado el tipo de demanda de asistencia sanitaria hacia una mayor presencia del sector público en relación al sector privado y una disminución de aseguramiento privado

Cold ischemia >4 hours increases heart transplantation mortality. An analysis of the Spanish heart transplantation registry

[Abstract] Background. Cold ischemia time (CIT) has been associated to heart transplantation (HT) prognosis. However, there is still uncertainty regarding the CIT cutoff value that might have relevant clinical implications. Methods. We analyzed all adults that received a first HT during the period 2008–2018. CIT was defined as the time between the cross-clamp of the donor aorta and the reperfusion of the heart. Primary outcome was 1-month mortality. Results. We included 2629 patients, mean age was 53.3 ± 12.1 years and 655 (24.9%) were female. Mean CIT was 202 ± 67 min (minimum 20 min, maximum 600 min). One-month mortality per CIT quartile was 9, 12, 13, and 19%. One-year mortality per CIT quartile was 16, 19, 21, and 28%. CIT was an independent predictor of 1-month mortality, but only in the last quartile of CIT >246 min (odds ratio 2.1, 95% confidence interval 1.49–3.08, p < .001). We found no relevant differences in CIT during the study period. However, the impact of CIT in 1-month and 1-year mortality decreased with time (p value for the distribution of ischemic time by year 0.01), particularly during the last 5 years. Conclusions. Although the impact of CIT in HT prognosis seems to be decreasing in the last years, CIT in the last quartile (>246 min) is associated with 1-month and 1-year mortality. Our findings suggest the need to limit HT with CIT > 246 min or to use different myocardial preservation systems if the expected CIT is >4 h

Safety and vaccine-induced HIV-1 immune responses in healthy volunteers following a late MVA-B boost 4 years after the last immunization

Background: We have previously shown that an HIV vaccine regimen including three doses of HIV-modified vaccinia virus Ankara vector expressing HIV-1 antigens from clade B (MVA-B) was safe and elicited moderate and durable (1 year) T-cell and antibody responses in 75% and 95% of HIV-negative volunteers (n = 24), respectively (RISVAC02 study). Here, we describe the long-term durability of vaccine-induced responses and the safety and immunogenicity of an additional MVA-B boost. Methods: 13 volunteers from the RISVAC02 trial were recruited to receive a fourth dose of MVA-B 4 years after the last immunization. End-points were safety, cellular and humoral immune responses to HIV-1 and vector antigens assessed by ELISPOT, intracellular cytokine staining (ICS) and ELISA performed before and 2, 4 and 12 weeks after receiving the boost. Results: Volunteers reported 64 adverse events (AEs), although none was a vaccine-related serious AE. After 4 years from the 1st dose of the vaccine, only 2 volunteers maintained low HIV-specific T-cell responses. After the late MVA-B boost, a modest increase in IFN-γ T-cell responses, mainly directed against Env, was detected by ELISPOT in 5/13 (38%) volunteers. ICS confirmed similar results with 45% of volunteers showing that CD4+ T-cell responses were mainly directed against Env, whereas CD8+ T cell-responses were similarly distributed against Env, Gag and GPN. In terms of antibody responses, 23.1% of the vaccinees had detectable Env-specific binding antibodies 4 years after the last MVA-B immunization with a mean titer of 96.5. The late MVA-B boost significantly improved both the response rate (92.3%) and the magnitude of the systemic binding antibodies to gp120 (mean titer of 11460). HIV-1 neutralizing antibodies were also enhanced and detected in 77% of volunteers. Moreover, MVA vector-specific T cell and antibody responses were boosted in 80% and 100% of volunteers respectively. Conclusions: One boost of MVA-B four years after receiving 3 doses of the same vaccine was safe, induced moderate increases in HIV-specific T cell responses in 38% of volunteers but significantly boosted the binding and neutralizing antibody responses to HIV-1 and to the MVA vector

Risk factors associated with moderate-to-severe renal dysfunction among heart transplant patients: results from the CAPRI study

[Abstract] The longer survival of patients with heart transplantation (HT) favors calcineurin inhibitor–related chronic kidney disease (CKD). It behoves to identify risk factors. At 14 Spanish centers, data on 1062 adult patients with HT (age 59.2 ± 12.3 yr, 82.5% men) were collected at routine follow-up examinations. Glomerular filtration rate, GFR, was estimated using the four-variable MDRD equation, and moderate-or-severe renal dysfunction (MSRD) was defined as K/DOQI stage 3 CKD or worse. Time since transplant ranged from one month to 22 yr (mean 6.7 yr). At assessment, 26.6% of patients were diabetic and 63.9% hypertensive; 53.9% were taking cyclosporine and 33.1% tacrolimus; and 61.4% had MSRD. Among patients on cyclosporine or tacrolimus at assessment, multivariate logistic regression identified male sex (OR 0.44), pre- and post-HT creatinine (2.73 and 3.13 per mg/dL), age at transplant (1.06 per yr), time since transplant (1.05 per yr), and tacrolimus (0.65) as independent positive or negative predictors of MSRD. It is concluded that female sex, pre- and one-month post-HT serum creatinine, age at transplant, time since transplant, and immunosuppression with cyclosporine rather than tacrolimus may all be risk factors for development of CKD ≥ stage 3 by patients with HT