The value of telephone consultations during COVID-19 pandemic. An observational study.

BACKGROUND: Many Spanish hospitals converted scheduled in-person visits to telephone visits during the COVID-19 lockdown. There is scarce information about the performance of those visits. AIM: To compare telephone visits during the COVID-19 lockdown period with previous in-person visits. DESIGN: Retrospective descriptive study. METHODS: Telephone visits from 15 March to 31 May 2020 were compared with in-person visits during the same period in 2019. MAIN MEASURES: The proportions of both groups were compared in term of failure to contact patient, requested diagnostic tests/referrals, discharges, admissions and emergency visits within 30-60 days. A sample of patients, and all participating physicians completed surveys. Z-score test was used (statistical significance P<0.05). RESULTS: A total of 5602 telephone visits were conducted. In comparison to in-person visits, telephone visits showed higher rates of visit compliance (95.9% vs. 85.2%, P<0.001) and discharges (22.12% vs. 11.82%; P<0.001), and lower number of ancillary tests and referrals. During the 30- and 60-day periods following the telephone visit, a reduction of 52% and 47% in the combined number of emergency department visits and hospital admissions was observed compared to in-person visits (P<0.01). Of the 120 patients surveyed, 95% were satisfied/very satisfied with the telephone visits. Of the 26 physicians, 84.6% considered telephone visits were useful to prioritize patients. CONCLUSIONS: During health emergencies, previously scheduled outpatient in-person visits can be converted to telephone visits, reducing absenteeism, increasing the rate of discharges and reducing ancillary tests and referrals without increasing the rate of hospital admissions or emergency department visits.

Validation of the PROFUND index to predict early post-hospital discharge mortality.

BACKGROUND: The PROFUND index (PI) is a prognostic scale for polypathological patients at 12 months. The objective of the study was to validate the PI as a predictor of 1-year mortality in a current cohort of polypathological patients and analyse its prognostic usefulness in the short-term (1 month and 3 months) after discharge from Internal Medicine. DESIGN: We conducted a prospective observational study and all polypathological patients discharged from an Internal Medicine Department between 01 March 2016 and 28 February 2017 were enrolled. METHODS: The variables recorded for each patient were age, sex, diseases and diagnostic categories defining patients as polypathological patients, PI at discharge, number of hospital admissions, length of stay, vital status at 1 year, and date and place of death if applicable. Follow-up lasted 1 year from the time of enrolment. RESULTS: Six hundred and ten polypathological patients were enrolled. Mortality was 41% and the patients who died were older, their length of stay was longer and their PI was higher compared with those who survived. The discrimination of the PI for predicting mortality was good, with a C-statistic of 0.718 [95% confidence interval (CI) 0.67-0.76]. In addition, a subgroup of patients with early mortality after discharge was identified, with a C-statistic of 0.74 (95% CI 0.67-0.80) at 30 days and 0.73 (95% CI 0.68-0.78) at 90 days. CONCLUSIONS: The PI is a valid tool for predicting early and 1-year mortality in polypathological patients after discharge from Internal Medicine.

Analysis of patients shared in consultations of internal medicine and other medical specialties. / Análisis de pacientes compartidos en consultas de medicina interna y otras especialidades médicas.

BACKGROUND AND OBJECTIVE: The aging population is resulting in an increasing number of patients with multiple diseases that require treatment by various specialties. We examined the evolution of consultations and of the percentage of patients treated by several medical specialties. METHODS: We analysed internal medicine (IM) consultations and those of other medical specialties in a hospital during 1997, 2007 and 2017 for the general population and for those older than 65 years. RESULTS: Over the course of 20 years, the rate of first IM consultations per 1000 inhabitants increased 44%, and that of other medical specialties increased 137%. The percentage of patients seen by more than one specialty went from 13.8% in 1997 to 32.6% in 2017 and reached 45.5% for those older than 65 years. CONCLUSIONS: The care for populations with growing comorbidity has a major impact on health systems and requires organisational changes for their care.

Geographical distribution and evolution of deaths in hospitals in Spain, 1996-2015. / Distribución geográfica y evolución de las muertes en hospitales en España, 1996-2015.

BACKGROUND AND OBJECTIVE: The location where death occurs varies widely among societies. The aim of this study was to describe the evolution in the hospital mortality rate (HMR) in Spain over the course of 20years and its distribution by province during a more recent period and to explore its relationship with potential explanatory variables. METHODS: This was an ecological study. The population mortality rates were obtained from the Natural Population Movement (Movimiento Natural de la Población), and the hospital mortality rates were obtained from the Specialised Care Information System (Sistema de Información en Atención Especializada), which includes information from all hospitals in Spain. We calculated the mortality rates for patients who were not surveyed and the HMR at the national level between 1996 and 2015 and for provinces between 2013 and 2015. The relationship between the provincial distribution of HMR and various demographic, socioeconomic and healthcare variables were analysed through simple and multiple linear regression. RESULTS: The HMR in Spain increased from 49% in 1996 to 56% in 2007, having remained stable from 1996 to 2015. The variation among provinces was 40% to 70%. The multivariate analysis showed a higher HMR in the less rural provinces and in those with a larger availability of hospital beds. CONCLUSIONS: There is considerable provincial heterogeneity in Spain in terms of the probability of dying in hospital or at home. This result could be partly explained by demographics (percentage of rural population) and the healthcare structure (number of hospital beds per population).

Five-year economic evaluation of non-melanoma skin cancer surgery at the Costa del Sol Hospital (2006-2010).

BACKGROUND: The cost associated with treatment of non-melanoma skin cancer is expected to rise considerably over the coming decades. This important public health problem is therefore expected to have an enormous economic impact for the various public health services. OBJECTIVES: To estimate the cost of the surgical-care process of non-melanoma skin cancer at the Costa del Sol Hospital and seek areas to improve its efficiency, using the activity-based costing (ABC) method and the tools designed for decision analysis. SECONDARY OBJECTIVE: To compare the costs for hospitalized patients obtained using the ABC method with the data published by the Spanish Ministry of Health, using the diagnosis-related groups (DRG) classification system. MATERIAL AND METHODS: Retrospective analysis of the cost of non-melanoma skin cancer surgery at the Costa del Sol Hospital. RESULTS: The total estimated cost from 2006 to 2010 was 3 398 540€. Most of the episodes (47.3%) corresponded to minor outpatient surgery. The costs of the episodes varied greatly according to the type of admission: 423€ (minor outpatient surgery), 1267€ (major outpatient surgery), and 1832€ (inpatient surgery). The average cost of an inpatient episode varied significantly depending on the calculation system used (ABC: 2328€ vs. DRG: 5674€). CONCLUSIONS: The ABC cost analysis system favours standardization of the care process for these tumours and the detection of areas to improve efficiency. This would enable more reliable economic studies than those obtained using traditional methods, such as the DRG.

Variability in hospital mortality prior to admission in Spanish hospitals.

BACKGROUND: Deaths in Emergency Departments (ED) should only occur in rare cases. The aim of the study was to describe the distribution of deaths in Spanish hospitals in two locations: the ED or pre-admission and in-hospital or post-admission, and their geographical distribution and possible conditioning factors. PATIENTS AND METHODS: The study was ecological. The percentage of hospital deaths prior to admission (PHDPA) compared to total hospital deaths for each center was calculated. The information was obtained from the "2009 Survey of Health Care Establishments with In-Patient facilities". This survey included information for all the Spanish hospitals. It analyzed geographical variability and its relation to the characteristics of the centers and various indicators of health care activity using non-parametric tests. RESULTS: The PHDPA was 13.4%, with wide variability between regions: from 7.4% to 16.4%. PHDPA was higher in hospitals with fewer than 100 beds and those with a higher average of emergencies per ED physician. CONCLUSIONS: Our study reveals the important variability in PHDPA. We estimate that if 80% of those patients who had died in the ED had died in the hospital ward, hospital stays would only have been increased by less than 0.1%.

[Clarity of recommendations for patients in the hospital discharge report]. / Claridad de las recomendaciones al paciente en el informe de alta hospitalaria.

BACKGROUND: Recommendations for patients (RP) are one of the key parts of the hospital discharge report (HDR). The objective was to study the frequency of RP in the HDR of different specialties and the proportion of them considered to be easy to understand. MATERIAL AND METHOD: Observational and cross-sectional study. SETTING: General acute care hospital. INTERVENTIONS: Review of a sample of HDR, analysis of the frequency and types of PR based on their content and clarity. RESULTS: A total of 840 HDR and 2,097 PR were analysed with an average of 2.5 RP per report. The most common RP referred to the patient follow-up (46% of total), followed by specific recommendations for the days immediately following discharge (37%), with only 16% related to lifestyle. Reports by surgical specialties contained 3.2 RP compared to 2.3 in medical specialties. The large majority (90.3%) of the RP were considered clear to understand for a standard patient. CONCLUSIONS: The HDR analysed contained few RP, in particular those related to lifestyles. A substantial proportion of the RP were not expressed with enough clarity.

[Information systems for clinicians I. How to know what type of patients are attended in our hospitals]. / Sistemas de información para clínicos i. Cómo conocer qué tipo de pacientes se atienden en nuestros hospitales.

We describe a series of tools to study the types of patients treated in hospitals: the Minimum Basic Data Set (MBDS), International Classification of Diseases (ICD) and the more used patient classification system: Diagnosis Related Groups (DRG) and suggest their possible applications in the fields of management and clinical research.

[Information systems for clinicians II. How to analyze the efficiency and quality of in-hospital care]. / Sistemas de información para clínicos II. Cómo analizar la eficiencia y calidad de la asistencia intrahospitalaria.

We describe four possible readings of the analysis of case-mix in hospitals: variability of pathologies treated, assessment of the complexity of patients and efficiency in their care and analysis of quality of care in terms of clinical outcomes, as hospital mortality. We analyze the concept of risk adjustment, essential for comparison of results from different hospital services.

[Priority of prescribed medication in patients with heart failure in an Internal Medicine Department]. / Prioridad de las prescripciones farmacéuticas a pacientes con insuficiencia cardíaca en un Servicio de Medicina Interna.

BACKGROUND AND OBJECTIVE: Prescriptions provided to elderly patients with comorbidity on hospital discharge are usually complex. This study has aimed to know what proportion of drugs is considered essential by the prescribing doctors and the existing agreement on this qualification. METHODS: Cross-sectional study. SETTING: general acute care hospital. STUDY SUBJECTS: random sample of 60 hospital discharges in patients hospitalized due to heart failure between 2004 to 2006 with 540 prescribed drugs. INTERVENTIONS: independent review by two internal medicine specialists and qualification of each of prescribed drugs as essential, advisable or not indicated. Calculation of the proportion of prescriptions according to priority, global and by therapeutic groups, and of the agreement between reviewers. RESULTS: An average of 9 drugs (statistical deviation [SD] 2.4) and 13.5 daily takings (SD 4.6) by patient were prescribed on hospital discharge. The reviewers considered 68.4% of the prescriptions essential (95% confidence interval [CI], 65.5-71.2), advisable 25% (95% CI, 22.4-27.6) and not indicated 6.6% (95% CI, 5.1-8.1). An inverse relation between number of prescribed drugs and their proportion considered as essential was observed. Global agreement between reviewers in the classification of priority was relatively low: weighed Kappa 0.27 (95% CI, 0.19-0.36). More than 90% of the prescriptions were considered as essential in only 6 of the 15 therapeutic groups prescribed most, and good agreements in the qualification of their priority was only reached in 3 groups. CONCLUSIONS: A considerable proportion of the prescribed medication on hospital discharge in patients with heart failure was not considered essential. Agreement reached between the reviewers in this qualification was low.

[Clinical and performance results of functional endoscopic sinus surgery]. / Resultados clínicos y asistenciales de la cirugía endoscópica nasosinusal.

Our aim was to know the clinical performance and management results of Functional Endoscopic Sinus Surgery (FESS) in Spanish hospitals. We sent a survey on the use and results of FESS to 160 Spanish public hospitals in June of 2002, obtaining a response rate of 69%. 82.9% of the interviewed hospitals carried out FESS and 17.1% of the remaining used the classic techniques of approaching the paranasal sinuses. The reported length of stay in hospital was 1.4 days for the FESS and 2.4 for the traditional surgery. The surgical time was 15 minutes shorter for the CENS, and the rate of recurrence was 16% less than for the classic surgery. As years of experience in the practice of the CENS go by, the surgical times tend to decrease, that didn't happen with the rate of recurrence. In conclusion, we consider that FESS seems to improve the analyzed clinical performance and assistential results.

[The implementation of endoscopic sinus surgery in Spain]. / Implantación de la cirugía endoscópica nasosinusal en España.

The purpose of this study is to find out more about the implementation of functional endoscopic sinus surgery (FESS) in our country. To do that, we designed a survey which was sent to 160 public hospitals (June 2002). We received the answers of 111 hospitals. 82.9% of hospitals and 58% of surgeons performed FESS, with some differences among autonomic regions. The percentage of surgeons who performed FESS was higher in small hospitals and their mean experience time was 6.2 years. We consider the implementation of endoscopic sinus surgery very high, this can reflect that there are evident advantages for those who specialists who use it.

[Quality of inpatient care and risk of early readmission in acute exacerbation of COPD]. / Calidad de la asistencia hospitalaria y riesgo de ingreso precoz en la exacerbación aguda de la EPOC.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is one of the diseases that causes more readmissions in our hospitals. The objective of our study was to establish the influence of quality of inpatient care on the risk of early readmission in the acute exacerbation of COPD. DESIGN: case and controls study. SETTING: general acute care hospital. SUBJECTS OF STUDY: random sample of admissions with acute exacerbation of COPD and discharged alive. CASES: patients who were readmitted within 30 days with a related diagnosis. CONTROLS: patients who were not readmitted and finished alive the mentioned period. INTERVENTIONS: audit of clinical charts with evaluation of clinical severity and adherence to explicit criteria of quality of inpatient care in OCFA. Bivariate and multivariate logistic regression (LR) analysis. RESULTS: 45 cases and 45 controls were analyzed. LR model detected the risk of readmission within 1 month was explained by the higher severity of patients (Apache III: OR 1,03) and their principal diagnosis(emphysema: OR 6,9 and bronchiectasias: OR 2,2, respect to chronic bronchitis). The less score of quality of care scale was predictive of the risk of readmission in the subgroup of patients who were readmitted within 1 week (OR 0,9). CONCLUSIONS: Risk of readmission within 1 month in the acute exacerbation of COPD were explained mainly by the clinical characteristics of patients. Otherwise, readmissions within 1 week were related to quality of care, so it could be a valid indicator of quality of inpatient care.

Lifestyles, environmental and phenotypic factors associated with lip cancer: a case-control study in southern Spain.

The aim of this study was to identify factors related to lip cancer (LC) considering individual characteristics and sociodemographic factors. A case-control study was carried out in the province of Granada (Andalusia, southern Spain). The cases were 105 males with squamous-cell carcinoma of the lip, diagnosed between 1987 and 1989 (aged 20-70 years) and identified by means of a population-based Cancer Registry. As controls, a randomised populational sample of 239 males, stratified by age, was used. Multiple logistic regression analysis showed that risk factors are lifetime cumulative tobacco consumption and alcohol consumption. An interaction was found between alcohol consumption and the smoking habit (leaving the cigarette on the lip): OR=23.6; 95% CI: 3.9-142.0. Other risk factors identified are clear eyes (OR=3.5; CI: 95% 1.5-8.0), sun exposure early in life and cumulative sun exposure during outdoor work (OR=11.9; 95%: CI: 1.3-108.9), and skin reaction to sun exposure (Fitzpatrick levels). Another interaction was found between skin reaction and a previous history of common sporadic warts (OR=4.4; 95% CI: 1.01-19.1). We conclude that LC is related to phenotype, skin reaction to sun exposure, cumulative and early sunlight exposure, and tobacco and alcohol consumption, as well as a low educational level. Leaving the cigarette on the lip is predictive of LC risk irrespective of cumulative tobacco consumption.

[Clinical and analytic diagnostic evaluation of deep venous thrombosis of the lower limbs]. / Valoración diagnóstica clínica y analítica de la trombosis venosa profunda de miembros inferiores.

BACKGROUND: Diagnosis of deep-vein thrombosis (DVT) of lower limbs has changed in recent years. The objective of our study was to analyze the diagnostic accuracy of a combination of clinical and epidemiological data and the D-Dimer plasma levels in this entity. PATIENTS AND METHODS: Clinical (symptoms and signs) and epidemiological data, personal and family history, and D-dimer plasma levels or positivity were reviewed, on the admittance, in 108 patients to whom a phlebography was performed due to a suspected DVT. RESULTS: Phlebography was positive in 76 cases (70.37%). Logistic regression analysis determined a prediction model of the diagnostic of DVI including a combination of both D-dimer plasma levels or positivity and pain along the deep venous involved area. CONCLUSION: Combination of D-dimer testing and pain along the distribution of the deep venous area is useful as an initial diagnostic approach to the DVI of the lower limbs.

[Borderline between emergencies and hospitalization in the analysis of hospital mortality]. / La frontera entre urgencias y hospitalización en el análisis de la mortalidad hospitalaria.

BACKGROUND: The analysis of hospital mortality rate as a measure of care quality is usually restricted to death occurred at hospital wards, and no consideration is given to deaths occurred at the Emergency Department. Therefore, the information from a fundamental hospital area goes without analysis. METHODS: The following characteristics of decreased individuals at the Emergency Department (n = 79) and hospital wards (n = 280) in the Costa del Sol Hospital (Marbella, Málaga, Spain) during 1997 were compared: age, sex, main diagnosis at admission, main diagnosis specificity, and number of secondary diagnoses. A reevaluation of hospital mortality rates was made after data from ED deaths had been added. RESULTS: The addition of deaths occurred at the ED meant a relevant increase in hospital mortality rates: 57% for heart failure, 30% for stroke, and 25% for myocardial infarction. Twenty percent of deaths at the ED had non-specific diagnosis versus 5% at wards (p < 0.0001; 95%CI: 6.03; 24.15). Deaths at the ED had 2.9 +/- 1.3 secondary diagnoses versus 4.9 +/- 2.0 in deaths at hospital wards (p < 0.0001; 95%CI: 1.6; 2.4). CONCLUSIONS: Deaths at the ED make up a relevant proportion of the total deaths and should be incorporated to the hospital mortality analysis. Deficiencies in the collection of clinical information were observed in this ED. Therefore, adjustments for severity--an essential issue for comparing mortality rates between centers--might be precluded.

[Predictive variables of early hospital readmission in cardiac failure]. / Variables predictivas del reingreso hospitalario precoz en la insuficiencia cardíaca.

BACKGROUND: Heart failure (HF) is one of the diagnosis leading to a high number of readmissions in our hospitals. There is some controversy about the role played by two groups of variables on the risk or readmissions: patient-dependent variables, such as clinical severity, and the characteristics of medical care during the previous admission, in terms of care quality. STUDY POPULATION: admissions due to HF with home discharge. DESIGN: case-control study. CASES: episodes followed by emergent admission within 30 days because of related diagnosis ("early readmission") (n = 51). CONTROLS: random sample of episodes not followed by an early readmission (n = 51). Information collected: review of clinical records. Groups of predictive variables studied: demographics, clinical severity, clinical parameters prognostic of HF and characteristics of medical care. Bivariate and multivariate statistical analysis: logistic regression (LR). RESULTS: LR analysis detected only one variable predicting early readmission, the ischemic etiology. Odds ratio = 4.78 (95% CI: 1.44; 15.88). There were no differences between the study groups regarding age, sex, clinical instability at discharge, hospital stay length, severity (APACHE III and other evaluation methods) and other prognostic parameters of HF (ejection fraction, functional degree, cardiomegaly, concurrent diabetes, valvular disease, atrial fibrillation, hyponatremia, and use of anti-arrhythmic drugs). CONCLUSIONS: The risk for an early readmission is mainly explained by the clinical variables of patients, basically ischemic etiology, and not by the characteristics of medical care: clinical instability at discharge or hospital stay length.

[Factors relating to the cost and quality of drug prescriptions in primary care]. / Factores relacionados con el gasto y la calidad de la prescripción farmacéutica en atención primaria.

OBJECTIVES: To analyse, quantitatively and qualitatively, the pharmaceuticals prescribed by doctors within two models of Primary Care: the reformed (RM) and non-reformed (NRM). To study which variables of the doctor, work-centre or community attended explain prescription variations. DESIGN: An observational crossover study. SETTING: Primary Health Care centres in the province of Málaga. PARTICIPANTS: The prescriptions of 454 doctors were studied: 259 RM and 195 NRM. A univariant analysis was performed on the indicators of prescription of both health-care models, with afterwards a multiple linear regression analysis to study the effect of the rest of the variables. RESULTS: There were differences in two of the quantitative indicators studied, with more prescriptions and expense per insured person per day in the NRM, as well as higher prescription for several therapeutic groups, mainly of drugs against flu, and also of drugs against infections, tonics, restoratives and capillary protectors. The variables which best explained prescriptions in the multivariant analysis were: consultations per insured person per day and the percentage of pensioners on the doctor's list. CONCLUSIONS: We thought that the differences between the two health-care models in the quantitative analysis were of very little relevance. They were greater in the qualitative one and suggested higher quality of prescription in the RM. Pressure of numbers was identified as, among the studied variables, that which best explains prescription, over and above others like the health-care model or medical training. As for the percentage of pensioners on the doctor's list, it should be borne in mind at the hour of evaluating his/her prescriptions.

[Postvaccinal reactions to simultaneous administration of the triple viral, oral polio and diphtheria-tetanus vaccines compared with their administration in sequence]. / Reacciones posvacunales tras la administración simultánea de vacunas triple vírica y antipolio oral-difteria-tétanos, frente a su administración secuencial.

OBJECTIVE: To compare the frequency and characteristics of post-vaccination reactions, between on the one hand the simultaneous administration of the Oral Antipolio (OP), the Triple Virus (TV) and the Anti-Diphtheria and Anti-Tetanus (DT) vaccines; and on the other hand, their administration in sequence. DESIGN: Prospective study with interventions, with a non-random, non-blind determination. SITE. Survey covering the mothers of infants vaccinated at 24 vaccination centres in Mála province. PARTICIPANTS: 490 infants vaccinated during their second year of life. 263 had the vaccines administered simultaneously and 227 in sequence. INTERVENTIONS: Simultaneous administration of the TV, OP and DT vaccines at 15 months; as against the administration of TV at 15 months, followed by OP and DT at 18 months. MAIN RESULTS: 78 infants (29.66%) suffered a reaction that could be attributed to the vaccination after the simultaneous administration of TV, OP and DT; and 86 infants (37.88%) after one of the two occasions of vaccination in the administration in sequence: 27.31% after the TV, 17.18% after the OP-DT and 6.62% after both. CONCLUSIONS: The safety of simultaneous administration, taken together with data coming from other studies on its immunogenic effectiveness, reaffirms the usefulness of simultaneous administration of TV, OP and DT vaccines at 15 months, as a strategy to improve vaccine coverage of infants in their second year of life.