[Hospital at home and conventional hospitalization. An economic evaluation]. / Hospitalización a domicilio y hospitalización convencional. Una evaluación económica.

BACKGROUND: To carry out an economic evaluation of hospital at home (HH) vs. conventional hospitalization (CH) from the hospital cost perspective. METHODS: A minimization cost analysis were performed in 2 groups of patients (HH: 148 patients, 1,776 days of care; CH: 148 patients, 1,113 days) with similar characteristics. We used cost per hospital episode (only for the comparable period in HH and HC) and cost per day as outcome measures. The costs of health care professionals, pharmacy, sanitary material, diagnostic and therapeutic tests and transport were directly estimated for each patient. Other costs were indirectly assigned from the hospital accountability information system. RESULTS: The average episode cost at home was 172,043 ptas. (about $1,300) less compared to the conventional hospitalization. Cost per diem for HH was 25,565 ptas. less than CH. Marginal costs were 14,987 and 2,913 ptas. minor in HH than CH, per episode and day respectively. When we consider HH staff as a differential cost (i.e. to establish a new hospital at home unit with new staff) marginal cost per episode was 2,276 pesetas higher than CH. CONCLUSIONS: HH is a cost-effective option when decisions take into account the average cost (establishment of a new unit vs. a new ward) or when the HH unit is created as a substitute service through the conversion of pre-existent resources. However, HH is a disadvantaged cost option when it is created as an additional resource.

[Identification of emergencies for asthma and chronic obstructive pulmonary disease in the emergency rooms of a hospital. A reliability study]. / Identificación de urgencias por asma y enfermedad pulmonar obstructiva crónica en el servicio de urgencias de un hospital. Estudio de concordancia.

OBJECTIVE: To analyse the reliability of the obtained results in the identification of cases of asthma and chronic obstructive pulmonary disease (COPD) diagnosed in the medical records of the emergency rooms of the <> of Valencia, Spain. METHODS: In the context of a study on the relationship between emergency rooms for asthma and COPD and specific environmental risks, we revised all the emergency rooms medical records of people aged over 14 attended at the <> of Valencia, Spain, during 1993 and 1994. The observers were two nurses who received previous training in the identification of cases. One observer revised the year 1993 and the other one 1994. To evaluate the reliability of the results we obtained a 24 days sample for each year and we estimated the inter-observer agreement using the Proportion of Observed Agreement (POA) and the Kappa Index (KI) and the 95 % confidence intervals (95% CI). We also carried out a specific analysis for each study category estimating the specific Kappa Index and the Proportions of Specific Agreement (PSA). To assess the inter-observer agreement we used the first 59 days of 1994, to estimate the same indexes mentioned above. RESULTS: In the total of emergency rooms, the POA for both observers was 0.99 and the KI was 0.91 (95% CI: 0.88-0.94) for the first observer and 0.79 (0.76-0.82) for the second one. In the specific analysis the PSA for <> versus <> were 0.92 (0.75-1) and 0.48 (0.31-0. 66) respectively. For the analysis of <> versus <> the PSA were 0.78 (0.69-0.87) and 0.75 (0.64-0.86). In the inter-observer agreement study we obtained, for the overall analysis, a POA equal to 0.99 and a KI to 0.87 (0.86-0.88). In the specific study the PSA for <> versus <> were 0.64 (0.53-0. 74) and 0.82 (0.77-0.87) for <> versus <>. CONCLUSIONS: The consistency of the results is good for both observers, but better for the first observer, particularly for asthma. For the COPD category the results are more homogeneous, showing a good concordance for both observers. The results for the inter-observer study also show a good reliability.

[Emergency department utilization by children aged less than two years old]. / Utilización de los servicios de urgencias hospitalarios por niños menores de dos años.

BACKGROUND: Emergency department visits are rising although birth rate is decreasing. OBJECTIVE: To compare emergency department.(ED) utilization in the cohorts of children born in 1991 and 1996 in a health district. METHOD: We performed a two-year retrospective cohort study in the health district of Mieres (Spain). All children born in the health district in 1991 (n 600) and 1996 (n 423) were included. The number of visits to the ED was obtained and the frequency and mean number of visits in the first 2 years of life were calculated according to age, sex, and area of residence. RESULTS: The gross number of visits did not vary (1991: 852; 1996: 853), despite a decrease in birth rate. The number of children who attended the ED at least once increased by 34.8 % (1991, 60.6 %; 1996, 82 %) and the frequency of visits increased by 41.7 % (1991, 142.2 %; 1996, 201.4 %). More than 60 % of visits were made by 20 % (1991) of the children and by 29 % (1996). The percentage of children who attended the ED, the frequency rate and the mean number of visits were significantly higher in the municipality nearest the hospital than in the remaining municipalities in the health district. CONCLUSIONS: Although the gross number of visits to the ED remained unchanged, ED utilization increased substantially in only 5 years.

[Nursing care in the home and in conventional hospitalization]. / Cuidados de enfermería en hospitalización a domicilio y hospitalización convencional.

BACKGROUND: Nursing care is of especial importance in hospital care in the home (HH). This is as due to the characteristics of the patient as it is to the transfer to the informal carers for the patient. The aim of this study is to analyse the quantity and type of nursing care administered and required by patients in HH and conventional hospitalisation (CH). METHODS: Project Research Nursing (PRN) was used to quantify the amount and types of nursing care administered and required in 2 groups of patients (HH: 148 patients, 1776 stays; CH: 148 patients, 1113 stays) having similar characteristics and treated in each way, together with how they evolved, analysing differences in terms of forms of attention and the characteristics of the patients. RESULTS: In terms of the care administered, those patients in HH (647.8 minutes/episode) received less care than those in CH (1030 minutes/episode). This difference was fundamentally due to the fact that they received less basic care (HH: 96.6 min./episode; CH: 464.3 min./episode) and diagnostic work (HH: 84.4 min./episode; CH: 177.3). On the other hand, patients in HH received a greater quantity of communicational care (238.8 min., as opposed to 107.4 in CH). No significant differences were found between the care administered and that which was required. CONCLUSIONS: Patients in HH received less nursing care than did those in CH, mainly due to the fact that they received less basic care from nurses, as this work was transferred to their careers. They also received less care associated with diagnostic tests (depending on styles of medical practice), although they received more care in the form of communication (health education). The lack of differences between the care that was actually administered and that which was required suggests that the quality of care provided is sufficient in both forms of hospitalisation.

[Senior citizen health conditions and hospitalization on geriatric, general and surgical floors, a population study conducted in Toledo]. / Estado de salud de las personas ancianas y hospitalización en servicios geriátricos, médicos y quirúrgicos. Estudio poblacional en Toledo.

BACKGROUND: The health condition and some clinical aspects configure a group of senior citizens in need of further care who could benefit from specialized geriatric care, although no consensus exists as to how to identify these patients. The aim of this study is to describe the profile of those patients over 64 years of age who are hospitalized in a geriatric unit and to compare this profile to the senior citizens hospitalized in general medical and surgical units. METHOD: A cohort representative of the population over age 64 in the Judicial District of Toledo (n = 3214) was studied over an eighteen-month period for the purpose of identifying the income and length of stays at the public hospitals in the health care district in question. The health condition-related variables were gathered by means of personal interviews, and the income and the different aspects thereof by way of hospital admissions department data. RESULTS: A total of 410 individuals were admitted (12.8%), 168 patients (30.7%) in geriatrics, 204 (37.3%) in medical units and 174 (32.0%) in surgical units. In geriatrics, the average age was significantly higher (age 77.4), there being no differences in the average length of stay (12.8 days; CI 95%) 10.6-14.0), 44 patients (8.1%) having died, 26 (59.1%) hospitalized in geriatrics. More females, younger patients having minor vision and hearing impairments were admitted to the surgical units. In geriatrics, as compared to the medical units, more patients over 80 years of age, living in senior citizen living facilities, having no spouse, moderate-to-severe functional dependence, impaired cognitive function, depression, poor quality of life and scanty social resources. CONCLUSIONS: No differences were found to exist between the health conditions of those over age 64 who were hospitalized in non-surgical and surgical units. In geriatrics, as compared to the other groups of units, the patients were older, in worse condition, had a higher death rate and similar average length of stay.

[Factors associated with the use and adaptation of hospitalization in people over than 64 years of age]. / Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años.

BACKGROUND: Some social, medical or functional aspects are associated with a greater use of health care resources, although this does not necessarily imply an inappropriate usage of the same. The aim of this research is that of ascertaining the influence of health condition on hospital stays and inappropriate stays among the population over 64 years of age. METHODS: A cohort representative of the population over age 64 in the Judicial District of Toledo (n = 3214) whose health condition had been previously evaluated was studied over an eighteen-month period identifying the income and length of stays at the public hospitals, the appropriateness of which was evaluated by the Appropriateness Evaluation Protocol. Associations analyzed were those of the cohort socio-demographic characteristics, health condition-related variables and morbidity with frequency and hospitalization rates and with inappropriate stays and admissions. RESULTS: During the 18 months of study 410 individuals were hospitalized, who generated 546 admissions (frequency rate = 17.0 admissions/100 rooms) and 7015 stay days (hospitalization rate = 218.3 stays/100 rooms), 18.9% of the admissions and 49.9% of the stays were evaluated as inappropriate. Hospitalization was associated with a worse health condition, institutionalization, male sex, certain pathologies and previous health services usage. Patients characteristics were not associated with the percentage of inappropriate stays. 97.5% of inappropriate stays were attributed to hospital scheduling problems and physicians' practices. CONCLUSIONS: Socio-demographic factors, morbidity, health condition and previous health service usage are shown as good hospitalization predictors for senior citizens, but these factors are not related to inappropriate hospitalization usage.

Does better access to primary care reduce utilization of hospital accident and emergency departments? A time-series analysis.

BACKGROUND: Availability of primary care emergency facilities has been improved to help curb heavy growth in the use of Accident and Emergency Departments (A&EDs). The aim of this paper is to analyse the relationship between time series for visits to hospital A&EDs and primary care centres. METHODS: Using a co-integration time series we analyse the visits to the emergency services of the county hospital and seven healthcare primary centres in the healthcare district of Mieres, Asturias, España, during the period 1992-1999. The main outcome measured is the relationship between the time series for emergency visits to the primary care centres and the hospital A&ED, for groups aged 0-14 years, over 14 years and the total. RESULTS: A total of 506,158 visits to the emergency services of the primary care centres (62.4%) and hospital A&ED (37.6%) have been studied. Emergency visits rose by 40.9% during the period studied (50.3% in primary care centres and 26.5% in the hospital). The gross rise in visits was higher for adults (51.2%) than for 0-14 year olds (6.6%). The co-integration time-series analysis showed that in both age groups and in the total, there was a significant and positive relationship between the primary care and hospital series, indicating that the use of both services had grown simultaneously. The use of the hospital services did not decrease as a result of the increase in primary care services. CONCLUSIONS: The rise in use of primary care emergency services did not reduce use of the hospital A&ED.

[Evolution of childhood hospitalization in Spain. Variation among autonomous communities]. / Evolución de la hospitalización infantil en España. Variabilidad entre comunidades autónomas.

BACKGROUND: To describe trends in children hospitalization in Spain during 1985-1994 and its variability among regions. METHODS: Description between 1985 and 1994, by autonomous regions, of the evolution in the rates of available beds, discharges, stays and visits and average length of stay, from data provided by the health care centres with inpatient statistics. RESULTS: The average length of stay decreased 23.9%, but there was a 4.5% increase in bed availability, a 39.5% increase in the discharges rate and 36.8% in the visits rate. Regions showed large differences in all indicators, that trends to converge in beds availability and discharges, but not in length of stay and visits rate. CONCLUSIONS: There has been an increase in hospital performance with strong variation among regions. Differences tends to reduce in some indicators but not in others.

[Health care for the children population in Asturias based on levels and health care areas. Primary health care]. / La asistencia a la población infantil en Asturias por niveles y áreas sanitarias. Atención primaria.

The resources available to the public health network in Asturias are presented for each health area in the level of pediatric primary care. Demographic analysis, age distribution and density of the ageing index for health areas are reported. In addition, the coverage, the number of families and children of care per physician, the rate of children per family, the care demand and the frequentation are evaluated. Imbalances are disclosed between the health centers and the outpatients clinics and between the health areas. The most important changes to be effected are pointed out.

[Health care for the children population in Asturias based on levels and health care areas. Hospital health care]. / La asistencia a la población infantil en Asturias por niveles y áreas sanitarias. Atención hospitalaria.

The general situation of pediatric care in Asturias is characterized by the imbalance between the two levels of care, with a high number of hospital beds and staff members, requiring a redistribution in number and functions, and a deficit in staff and material resources at the primary care level, with massified practices and overburdened care activities. The reform of the primary care generates an imbalance between health centers and outpatients clinics owing to the strategic situation of the former and the fact that care is given up to age 14. This problem should be carefully considered. These imbalances between the levels of care are not homogeneous, and they are more or less marked depending on the different health areas; there are wide geographical differences. Therefore, an increase in resources as well as redistribution depending on the attention levels and health areas are required.

Variations in diagnostic and therapeutic intensity between home and conventional hospitalization.

OBJECTIVE: To analyse the variations in diagnostic and therapeutic intensity in patients with similar clinical conditions depending on whether they had hospitalization at home (HH) or remained in conventional hospitalization (CH). DESIGN: Observational study of two patient cohorts (HH and CH) selected prospectively. SETTING: University Hospital in the Valencia Health Service network, and the Hospital at Home Unit that it administers. STUDY PARTICIPANTS: One hundred and forty-eight consecutive patients admitted to a Hospital at Home Unit, and 148 patients (matched by age, sex, disease group and hospital department) who remained in hospital in spite of fulfilling clinical criteria for HH as assessed by the nurses who normally evaluate suitability of admission to HH. MAIN OUTCOME MEASURES: Number and cost of diagnostic tests, and cost of drugs and nursing materials per hospitalization in HH and CH. RESULTS: The average number of tests for admission was significantly lower at home than in hospital (HH, 0.89; CH, 3.53); this translated into significant differences in the average diagnostic cost per hospitalization (HH, Pesetas 131; CH, Pesetas 3.316; US$1 approximately 130 Pesetas in 1994). Expenditures on drugs per episode (HH, Pesetas 7028; CH, Pesetas 16684) was also lower at home, but the differences were not significant for this or for expenditure for nursing materials (HH, Pesetas 3329; CH, Pesetas 2556). CONCLUSIONS: Although some limitations of the study do not make it possible to establish unequivocal conclusions, the results point to the existence of different diagnostic and therapeutic patterns in HH and CH, which translate into significant differences in hospitalization costs.

[Is it necessary to hospitalize so many children for so many days? Unnecessary pediatric hospitalization]. / Es necesario hospitalizar a tantos niños, durante tantos días?. La hospitalización innecesaria en pediatría.

OBJECTIVE: A tendency exists towards an increase in hospital admissions of children whereas evidence shows that some of the admissions could have been avoided or the length of stays reduced. The aim of this study was to identify the proportion of unnecessary pediatric stays and the motive behind them. PATIENTS AND METHODS: Three hundred eighty-eight hospital stays of 151 children between 6 months and 14 years of age which were discharged by the local pediatric hospital service have been reviewed. Patients and stays were selected at random. Admissions were stratified by age group and stays by episode length. The Pediatric Appropriateness Evaluation Protocol (PAEP) was used to evaluate the necessity of the hospital stay. RESULTS: Of the admissions, 27.8% (42/151) were evaluated as unnecessary, as were 48.7% (189/388) of the hospital stays. Long stays (except for hospitalizations longer than 9 days), programmed admissions (93.5%), first admissions to a hospital (59.9%) and admissions evaluated as unnecessary (80.6%) were significantly associated with unnecessary stays. Hospital organization and doctors' style of practice accounted for 74.1% of the unnecessary stays and children familiar circumstances for 21.7%. CONCLUSIONS: The high proportion of unnecessary stays and the motives, which explained them, justify the great concern about the criteria for the hospitalization of children and early discharge planning. To improve coordination among hospitals, central services, primary health care services and social services is probably required.

[Primary care resources use variation by under seven year old children in a rural and an urban area. Cohort study]. / Variaciones en el consumo de recursos de atención primaria por niños menores de 7 años en los medios rural y urbano. Estudio de cohortes.

OBJECTIVE: [corrected] To describe differences between two health districts in primary care resource use. DESIGN: Retrospective population cohort study. SETTING: A rural healthdistrict (RD) and an urban health district (UD). PARTICIPANTS: A cohort of children born in 1991 in a UD (n=104) and a cohort of children born in 1991 and 1992 in an RD (n=88), registered in their primary care centres between 0 and 6 years old. MAIN MEASUREMENTS: Attention episodes, requested visits, practicioner programmed visits, nursery programmed visits and diagnosis tests. RESULTS: Significative differences were noticed in the attention episode average(ZU=34.0; 95% CI, 31.5%-36.5%); (ZR=25.6; 95% CI, 22.7%-28.5%), in requested visits (ZU=45.8; 95% CI, 41.8%-49.9%); (ZR=28.8; 95% CI, 25.3%-31.9%), in practicioner programmed visits (ZU=7.1; 95% CI, 6.6%-7.5%), (ZR=11.2; 95% CI, 10.7%-11.7%) and in nursery programmed visits (ZU=9.8; 95% CI, 9.0%-10.6%) (ZR=12.0; 95% CI, 11.4%-12.5%). At least one diagnosis test was applied to 90.3% of children in the UD and to 64.8% of children in the RD; and in the UD for each attention episode 1.32 (95% CI, 1.28%-1.36%) requested visits were attended to and 0.2 (95% CI, 0.17%-0.23%) diagnosis tests were made; whereas in the RD 1.1 (95% CI, 1.08%-1.13%) requested visits and 0.09 (95% CI, 0.06%-0.12%) diagnosis tests. In both health districts the average of attention episodes, requested visits and tests was significantly higher in children who had been hospitalized. CONCLUSIONS: Primary care services utilization and the number of diagnosis test and attention episode visits are higher in the urban district than in the rural one.

[Pertinence of analysis requests in primary care]. / Pertinencia de las peticiones analíticas en atención primaria.

OBJECTIVE: To find the relevance of analytic tests requested by the Primary Care doctor. DESIGN: A descriptive crossover study. Relevance was decided by the definition of criteria through consensus techniques. SETTING: Three urban Health Centres in Area 4 of the City of Valencia. PARTICIPANTS: All the requests for analysis made by 31 general practitioners over four days were included in the study. MEASUREMENTS AND MAIN RESULTS: Relevance was evaluated by four assessors. The reliability of the method used was calculated through the simple concordance index (0.708-0.842) and the Kappa index (0.421-0.661). 355 path analyses were examined. Three of the assessors found between 60 and 63% of the requests relevant; the fourth found 48% relevant. The most frequent reason for irrelevance was that the request did not fit the requisite procedure. CONCLUSIONS: Relevance of requests for analytic tests could be improved. The present study is a starting-point, which allows us to deduce that an improvement in tests' relevance could be achieved with greater circulation of information on agreed diagnostic and follow-up procedures.