European value-based healthcare benchmarking: moving from theory to practice.

BACKGROUND: Value-based healthcare (VBHC) is a conceptual framework to improve the value of healthcare by health, care-process and economic outcomes. Benchmarking should provide useful information to identify best practices and therefore a good instrument to improve quality across healthcare organizations. This paper aims to provide a proof-of-concept of the feasibility of an international VBHC benchmarking in breast cancer, with the ultimate aim of being used to share best practices with a data-driven approach among healthcare organizations from different health systems. METHODS: In the VOICE community-a European healthcare centre cluster intending to address VBHC from theory to practice-information on patient-reported, clinical-related, care-process-related and economic-related outcomes were collected. Patient archetypes were identified using clustering techniques and an indicator set following a modified Delphi was defined. Benchmarking was performed using regression models controlling for patient archetypes and socio-demographic characteristics. RESULTS: Six hundred and ninety patients from six healthcare centres were included. A set of 50 health, care-process and economic indicators was distilled for benchmarking. Statistically significant differences across sites have been found in most health outcomes, half of the care-process indicators, and all economic indicators, allowing for identifying the best and worst performers. CONCLUSIONS: To the best of our knowledge, this is the first international experience providing evidence to be used with VBHC benchmarking intention. Differences in indicators across healthcare centres should be used to identify best practices and improve healthcare quality following further research. Applied methods might help to move forward with VBHC benchmarking in other medical conditions.

Clinical experience of bendamustine treatment for non-Hodgkin lymphoma and chronic lymphocytic leukemia in Spain.

Bendamustine is a alkylating agent with a purine-like benzamidazole ring currently approved in Europe for indolent non-Hodgkin lymphoma (NHL), chronic lymphocytic leukemia (CLL) and multiple myeloma. Our aim was to analyze retrospectively the efficacy and toxicity of bendamustine in NHL and CLL in Spain in the bendamustine Compassionate Use Program. Patients with relapsed/refractory NHL or CLL were eligible. Any regimen containing bendamustine was eligible. 109 patients were included from 22 institutions. Forty-nine patients had indolent NHL, 18 aggressive NHL and 42 CLL, being 44 patients (40%) refractory to previous treatment. 63% of patients had adverse events grade 3-4, mainly hematological. Overall response rate (ORR) was 66%, complete responses 30%. ORR observed in refractory patients was 45%. The median progression-free survival (PFS) was 13 months. Outcome was influenced by histology, number of previous treatments, resistance to previous chemotherapy and type of response achieved with bendamustine. Alone or in combination, bendamustine shows a meaningful clinical antitumor activity in patients with relapsed or refractory NHL or CLL, with an acceptable toxicity profile.

Guía clínica de actuación de la interrupción del embarazo / Clinical guidelines for pregnancy terminations

En marzo de 2010 entró en vigor la nueva ley orgánica de salud sexual y reproductiva y de la interrupción voluntaria del embarazo en nuestro país, que entre otros cambios nos permite realizar interrupciones de embarazo a partir de las 22 semanas en determinados supuestos. Este cambio ha provocado que se planteen nuevos protocolos para el manejo de las interrupciones de embarazo tardías. En la mayoría de centros autorizados para la realización de interrupciones de embarazo de nuestro país abogan por un tratamiento médico, especialmente en aquellas gestaciones que superan las 12 semanas. Después de realizar una revisión de la literatura, hemos encontrado diferentes protocolos de actuación y dosis farmacológicas, especialmente en gestaciones avanzadas de tercer trimestre. Presentamos nuestro protocolo de interrupción de embarazo, fruto de nuestra experiencia asícomo resultado de la revisión de los protocolos y trabajos publicados(AU)

In March 2010 the new law on sexual and reproductive health and of the voluntary termination of pregnancy became effective in our country. Among other things this law allows us to carry out pregnancy terminations after the 22nd week of pregnancy under certain circumstances. This has meant that new guidelines for the management of late pregnancy terminations have had to be introduced. In the majority of centers in our country that are allowed to practice pregnancy terminations medical treatment is the first option, especially in those cases that do exceed the 12th week. After reviewing the literature, we have found varying guidelines and drug doses, particularly in third trimester advanced pregnancies. We present our guidelines for pregnancy termination based on our clinical experience and a review of published guidelines and medical studies(AU)

Flujo reverso diastólico en arterias uterinas y engrosamiento placentario: marcadores de resultado perinatal desfavorable / Reversed diastolic flow in the uterine artery and thick heterogeneous placenta: predictors of adverse pregnancy outcome

El Doppler de las arterias uterinas permite estudiar de forma precoz el fenómeno de la invasión trofoblástica y constituye una herramienta muy útil para el cribado de retraso de crecimiento intrauterino y preeclampsia precoz. Existen numerosos estudios que asocian un engrosamiento de la placenta detectado ecográficamente con resultados perinatales desfavorables. Se presenta un caso clínico con Doppler arterias uterinas patológicas asociado a placenta engrosada que requirió de finalización urgente por desprendimiento prematuro de placenta normoinserta (AU)

Uterine artery Doppler allows an early study of trophoblastic invasion and constitutes a useful tool to assess the risk of pre-eclampsia and fetal growth restriction. Also, there are many studies that describe an association between the placental thickness and adverse pregnancy outcome. We present a case of a pregnant with a reversed diastolic flow in the uterine artery Doppler and a sonographically thick placenta that required an emergent cesarean section for abruptio placentae (AU)

La aplicación de la medicina basada en la evidencia reduce la tasa de cesáreas / Application of evidence-based medicine reduces the cesarean section rate

Objetivos: Comparar la tasa de cesáreas tras aplicar la medicina basada en la evidencia en el parto.Sujetos y métodos: Se incluyen todos los partos asistidos en nuestro hospital entre 2002 y 2007. Se establecen dos períodos, 2002-2004 y 2005-2007, considerando que nuestra práctica obstétrica se modificó en 2005.Resultados: Se asistieron 13.105 partos en el período 2002-2004 y 13.341 entre 2005 y 2007. En este período hubo una disminución significativa en las indicaciones por distocia (el 6,24 frente al 3,37%; p < 0,0001), riesgo de pérdida de bienestar fetal (el 4,35 frente al 3,14%; p < 0,0001), presentación de nalgas (el 4,48 frente al 3,7%;p = 0,04), cesárea anterior (el 1,2 frente al 0,4%;p < 0,0001) y tasa global de cesáreas (el 17,5 frente al 12,2%; p < 0,0001). No hubo diferencias en la mortalidad perinatal (el 6,62 frente al 7,1‰;p = 0,462), pH < 7 de arteria umbilical (el 3,1 frente al 4,0‰; p = 0,276), puntuación en la prueba de Apgar < 7 a los 5 min (el 1,8 frente al 1,8%; p = 0,743), ni ingresos en neonatología(el 2,95 frente al 3,0%; p = 0,87).Conclusión: La aplicación de la medicina basada en la evidencia reduce significativamente la tasa de cesáreas sin modificar los resultados perinatales (AU)

Objective: To compare cesarean rate in two different periods after introducing evidence based medicine in delivery.Subjects and methods: We include all the deliveries attended in our hospital between 2002 and 2007. We establish two different periods: 2002-2004 and 2005-2007 considering that our obstetric practice changed in 2005.Results: 13.105 births were attended in 2002-2004 and 13.341 in 2005-2007. In this period there was a significant reduction in indications for dystocia (6.24% vs 3.37%; P<.0001), nonreassuring fetal status (4.35% vs 3.14%; P<.0001), breech presentation (4,48 vs 3,7%; P=.04), previous cesarean (1,2% vs 0,4%; P<.0001), and overall cesarean rate (17.5 vs 12.2%; P<.0001). There were no differences in perinatal mortality(6,62‰ vs 7,1‰; P=.462), umbilical artery pH < 7 (3,1‰ vs 4,0‰; P=.276), 5 minutes Apgar test < 7 (1,8‰ vs 1,8‰; P=.743), or neonatal intensive care admission (2,95% vs 3,0%; P=.87). Conclusions: Applying an evidence based medicine model significantly reduces cesarean rate and does not affect perinatal outcomes (AU)