Effectiveness of a brief phone intervention to increase participation in a population-based colorectal cancer screening programme: a randomized controlled trial.

AIM: Although colorectal cancer (CRC) screening reduces mortality and morbidity the uptake in target populations is suboptimal. The aim was to assess whether adding a brief phone intervention to the usual invitation process increases participation in a CRC screening programme based in Catalonia. METHOD: This was a non-blinded prospective randomized control study of patients eligible for their first CRC screening test (immunochemical faecal occult blood test). Between March and December 2017, 512 invitees (age range 50-69 years) were randomized to receiving either a brief informative phone call prior to receiving the standard screening invitation (letter and informative brochure) or the standard screening invitation alone. The primary outcome was participation in the screening programme at 6 months. RESULTS: In all, 492/512 patients (54.7% women; 45.3% men) could be analysed (239/256 intervention group; 253/256 control group). On an intention to treat basis, the intervention group (55% women; 45% men) saw an 11% increase in the participation rate (51.05% vs 40.32%, P = 0.017). The intervention was more effective in male patients (50.93% vs 33.91%, P = 0.01) and those patients aged between 50 and 54 years (54.32% vs 37.77%, P = 0.03). After adjusting for sex, age and geographic area, the benefit of the intervention remained statistically significant (adjusted OR 1.54, 95% CI 1.07-2.20). CONCLUSION: Our data suggest that a brief, informative intervention by phone in addition to the usual invitation process is effective in increasing participation in a CRC screening programme. It may be a useful strategy to improve uptake in groups which are less likely to participate in CRC screening (clinicaltrials.gov NCT03082911).

A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study.

AIM: The oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia (Spain). METHODS: This was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years. RESULTS: Of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery. CONCLUSIONS: Laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials.

Adherence to capecitabine in preoperative treatment of stage II and III rectal cancer: do we need to worry?

BACKGROUND: Preoperative oral capecitabine plus radiotherapy has been progressively adopted in oncology units to provide more convenient care to patients with rectal cancer, but little is known about adherence to this therapy. PATIENTS AND METHODS: Prospective, multicentre observational study in six hospitals in metropolitan Barcelona (Spain), in patients with stage II and III rectal cancer. Assessment of adherence was based on the medical report in the clinical history, a patient questionnaire and a pill count in the pharmacy service upon finalization of treatment. Patients were considered adherent if they had taken 80%-110% of the prescribed treatment. We evaluated clinical variables, adverse effects, anxiety and depression (using the hospital anxiety depression scale [HADS]), and quality of life (EORTC QLQ-30). We analysed adherence-associated variables using a logistic regression model and concordance between adherence measures by means of the modified Kappa index. RESULTS: We included 119 participants. Adherence measures showed little concordance between the assessment methods used: adherence was 100% according to the clinical history, 83.2% according to self-report and 67.9% according to the pill count. In the multivariable analysis, the most relevant variable associated with non-adherence was anxiety prior to treatment (adjusted odds ratio [ORa] 6.96, 95% confidence interval [CI] 1.48-32.7). We did not observe any relevant association between adherence and clinical variables and baseline quality of life parameters. CONCLUSIONS: Adherence to short-term oral neoadjuvant treatment in rectal cancer may be a clinical problem, and it should be acknowledged and systematically evaluated by clinicians during treatment. The limited concordance between different measures of adherence highlights the challenges in monitoring it and the need to use different approaches to assess its impact in clinical practice.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication.

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Prescription refill, patient self-report and physician report in assessing adherence to oral endocrine therapy in early breast cancer patients: a retrospective cohort study in Catalonia, Spain.

AIMS: To compare different methods in order to assess adherence and persistence with oral endocrine therapy in women diagnosed with breast cancer (BC) in Catalonia. MATERIALS AND METHODS: This study covered all women newly diagnosed with stage I, II or IIIa BC and positive hormone receptors at six hospitals in Catalonia (Spain) in 2004. Adherence was assessed on the basis of physician report and patient self-report using a telephone questionnaire. Persistence was measured by refill prescriptions. We used the Kappa index to compare adherence measures and logistic regression to evaluate adherence-related risk factors. RESULTS: The study covered a total of 692 women. Adherence ranged from 92% (self-report) to 94.7% (physician report), depending on the measure used; persistence was 74.7% at 5 years of follow-up. Low concordance between measures was observed (Kappa range: 0.018-0.267). Patients aged 50-74 years showed higher adherence than those aged <50 years. Adherence was also associated with: adjuvant chemotherapy and sequential hormonal therapy. CONCLUSIONS: Concordance between the different measures was remarkably low, indicating the need for further research. Adherence is an issue in the management of BC patients taking oral drugs, and should be assessed in clinical practice.

Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study.

BACKGROUND: The Cancer Fast-track Programme's aim was to reduce the time that elapsed between well-founded suspicion of breast, colorectal and lung cancer and the start of initial treatment in Catalonia (Spain). We sought to analyse its implementation and overall effectiveness. METHODS: A quantitative analysis of the programme was performed using data generated by the hospitals on the basis of seven fast-track monitoring indicators for the period 2006-2009. In addition, we conducted a qualitative study, based on 83 semistructured interviews with primary and specialised health professionals and health administrators, to obtain their perception of the programme's implementation. RESULTS: About half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track, though the cancer detection rate declined across the period. Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009). Professionals associated with the implementation of the programme showed that general practitioners faced with suspicion of cancer had changed their conduct with the aim of preventing lags. Furthermore, hospitals were found to have pursued three specific implementation strategies (top-down, consensus-based and participatory), which made for the cohesion and sustainability of the circuits. CONCLUSION: The programme has contributed to speeding up diagnostic assessment and treatment of patients with suspicion of cancer, and to clarifying the patient pathway between primary and specialised care.

Factors associated with initial participation in a population-based screening for colorectal cancer in Catalonia, Spain: a mixed-methods study.

OBJECTIVE: To identify barriers and facilitators associated with participation in the first round of a population-based program for colorectal cancer (CRC) in Catalonia, Spain and to identify strategies for motivating and supporting behavioral change. MATERIAL AND METHODS: A two-part, mixed-methods design was used. In first place, a prospective study of individuals aged 50-69 years (n=1961) was conducted in 2006-2007. Secondly, focus groups were undertaken with participants and non-participants of the CRC screening, in 2008. RESULTS: Intention to participate was an important determinant of participation (82.9% vs 65.9%, OR=2.56, 95%CI:1.95-3.36) in addition to knowledge about CRC and its early detection. Respondents who reported that CRC may be asymptomatic in early stages enrolled in the screening program more frequently than those who thought CRC is always symptomatic (49.4% vs 44.8%, OR:1.82; 95%CI:1.3-2.6). Barriers for participation mentioned in focus groups were competing perceived for other health problems and other demands as well as misunderstanding about personal relevance of the screening. CONCLUSION: Individuals' perceptions of CRC are amenable to change through education-based interventions. Increasing public knowledge related to the burden of CRC and its preventive potential may be an effective way for improving participation in a population-based screening program.

A population perspective on the use of external beam radiotherapy in Catalonia, Spain.

PURPOSE: To assess the use of external beam radiotherapy in Catalonia (Spain), overall and by health management area. METHODS: We assessed radiotherapy treatments in a cohort of patients diagnosed with cancer from 2009 to 2011, using the population-based cancer registries in Girona and Tarragona. Participants had to have a minimum follow-up of 5 years from the time the cancer registry database was linked to the catalan health service database for financing radiation oncology. Outcomes included the proportion of patients receiving radiotherapy within 1 and 5 years of diagnosis. A log-binomial model was used to assess age-related trends in the use of radiotherapy by tumour site. Finally, we calculated the standardized utilization rate and 95% confidence intervals by health management area covered by the radiation oncology services, using indirect methods. RESULTS: At 1 and 5 years from diagnosis, 21.4 and 24.4% of patients, respectively, had received external beam radiotherapy. Patients aged 40-64 years had the most indications for the treatment, and there was a negative correlation between the patients' age and the use of radiotherapy for most tumour sites (exceptions were cervical, thyroid, and uterine cancers). There were no statistically significant differences in the use of radiotherapy according to th health management area. CONCLUSIONS: Population-based data show that external beam radiotherapy is underutilized in Catalonia. This situation requires a careful analysis to understand the causes, as well as an improvement of the available resources, oriented toward achieving realistic targets for the optimal use of external beam radiotherapy in our country.

Cause-specific mortality after a breast cancer diagnosis: a cohort study of 10,195 women in Girona and Tarragona.

INTRODUCTION: Evidence suggests an excess of long-term mortality due to cardiovascular diseases, second tumours and other causes in patients diagnosed with invasive breast cancer (BC). Our aim was to assess this risk of death in a cohort of patients diagnosed with BC in Girona and Tarragona, northeastern Spain. MATERIALS AND METHODS: Using data from the cancer registries in these areas, a population-based cohort study was carried out including all the women diagnosed with BC during 1985-2004 and followed up until December 31st 2014 (N = 10,195). The standardised mortality ratios (SMRs) were calculated for causes other than BC in the cohort at 10 years (periods 1985-1994/1995-2004) and 20 years (period 1985-1994). The impact of competing causes of death in the long-term survival was evaluated through competing risk analysis. RESULTS: The SMRs at 10 and 20 years for all-cause mortality, except BC, were 1.21 and 1.22. The main causes of mortality showing statistically significant SMR at 10 years were other tumours (colon, lung, corpus uteri, ovary, and haematological), diabetes mellitus, diseases of the nervous system, cardiovascular diseases (after BC, the second competing cause of death among patients diagnosed > 69 years) and diseases of the kidney. Globally, the 10-year SMR was higher in the first period. After 20 years of follow-up (1985-1994 cohort), there were 48.5 excess deaths per 10,000 patient-years for causes other than BC. CONCLUSIONS: Women who did not die from BC at 10 or 20 years after the BC diagnosis had 20% higher risk of dying from other causes than women without BC. This excess risk must be clinically considered during 20 years after the BC diagnosis.

[Impact of cancer in Catalonia: consequences for priorities in the prevention, diagnosis and treatment of cancer]. / Impacto del cáncer en Cataluña: consecuencias para las prioridades en prevención, diagnóstico y tratamiento.

BACKGROUND: The results of analysis of incidence, survival and mortality should be applied to set the priorities in cancer prevention and screening and improvement of cancer care in Catalonia. POPULATION AND METHODS: A review of the impact of cancer in Catalonia and its foreseeable tendencies, as well as the recent proposals made across Europe regarding cancer prevention and care, was carried out. RESULTS: The main priority in prevention continues to be smoking prevention in all age groups but especially among young women and people with a low socioeconomic position, together with overweight and obesity reduction, dietary improvements, and avoidance of excessive sun exposure. Colorectal cancer screening should cover all people aged 50 to 69 years old. Cancer care should be based on a multidisciplinary approach, with clinical practice guidelines, and should take into account the psychosocial and rehabilitation aspects of care. Areas that deserve greater efforts to improve oncology care are outcomes assessment among hospitals and improvements in coordination among centers and health professionals. CONCLUSIONS: The main priority should be to apply current knowledge to clinical practice, both in diagnosis and in treatment, within a multidisciplinary framework to improve outcomes. Other priorities aimed at reducing the impact of cancer in Catalonia are reducing the prevalence of smoking and obesity and extending the coverage of colorectal cancer screening to the target population.

[Colonoscopic findings from a pilot screening study for colorectal cancer in Catalonia]. / Hallazgos colonoscópicos del estudio piloto de cribado de cáncer colorrectal realizado en Cataluña.

OBJECTIVE: to evaluate lesions detected in two screening rounds performed in a pilot screening programme for colorectal cancer in Catalonia, Spain. MATERIAL AND METHODS: a colorectal cancer screening programme was initiated in 2000. The target population included men and women aged 50-69 years. Screening consisted of biennial guaiac-based fecal occult blood testing (FOBT), and colonoscopy for participants with a positive FOBT. Any polyps found were removed, and biopsies were performed for any masses. RESULTS: colonoscopies were performed in 442 of 495 people with positive FOBT. In 213 (48.2%), 36 invasive cancers, 121 high-risk adenomas, 29 low-risk adenomas, and 27 hyperplastic polyps were diagnosed. Lesion size was smaller than 10 mm in 25.8% of cases. Most detected lesions (37.2%) were located in the distal colon, followed by the proximal colon (5.7%) and both locations (5.2%). Advanced neoplasm was significantly associated with male gender and distal location. The prevalence of advanced proximal neoplasms among patients with no distal polyps was 5.1%. CONCLUSIONS: the most common lesions detected by colonoscopy were high-risk adenomas located in the distal colon. FOBT is a suitable method for detecting small precancer lesions during population screening, and is thus a key factor in reducing the incidence of colorectal cancer.

Assessing predicted age-specific breast cancer mortality rates in 27 European countries by 2020.

BACKGROUND: We assessed differences in predicted breast cancer (BC) mortality rates, across Europe, by 2020, taking into account changes in the time trends of BC mortality rates during the period 2000-2010. METHODS: BC mortality data, for 27 European Union (EU) countries, were extracted from the World Health Organization mortality database. First, we compared BC mortality data between time periods 2000-2004 and 2006-2010 through standardized mortality ratios (SMRs) and carrying out a graphical assessment of the age-specific rates. Second, making use of the base period 2006-2012, we predicted BC mortality rates by 2020. Finally, making use of the SMRs and the predicted data, we identified a clustering of countries, assessing differences in the time trends between the areas defined in this clustering. RESULTS: The clustering approach identified two clusters of countries: the first cluster were countries where BC predicted mortality rates, in 2020, might slightly increase among women aged 69 and older compared with 2010 [Greece (SMR 1.01), Croatia (SMR 1.02), Latvia (SMR 1.15), Poland (SMR 1.14), Estonia (SMR 1.16), Bulgaria (SMR 1.13), Lithuania (SMR 1.03), Romania (SMR 1.13) and Slovakia (SMR 1.06)]. The second cluster was those countries where BC mortality rates level off or decrease in all age groups (remaining countries). However, BC mortality rates between these clusters might diminish and converge to similar figures by 2020. CONCLUSIONS: For the year 2020, our predictions have shown a converging pattern of BC mortality rates between European regions. Reducing disparities, in access to screening and treatment, could have a substantial effect in countries where a non-decreasing trend in age-specific BC mortality rates has been predicted.

Long-term crude probabilities of death among breast cancer patients by age and stage: a population-based survival study in Northeastern Spain (Girona-Tarragona 1985-2004).

BACKGROUND: We provide population-based long-term survival indicators of breast cancer patients by quantifying the observed survival, and the probabilities of death due to breast cancer and to other causes by age and tumor stage at diagnosis. METHODS: We included a total of 10,195 female patients diagnosed before 85 years with invasive primary breast cancer in Girona and Tarragona during the periods 1985-1994 and 1995-2004 and followed-up until December 31st 2014. The survival indicators were estimated at 5, 10, 15 and 20 years of follow-up comparing diagnostic periods. RESULTS: Comparing diagnostic periods: I) the probability of death due to other causes did not change; II) the 20-year survival for women diagnosed ≤ 49 years increased 13% (1995-2004 = 68%; 1985-1994:55%), whereas their probability of death due to breast cancer decreased at the same pace (1995-2004 = 29%; 1985-1994 = 42%); III) at 10 years of follow-up, decreases in the probabilities of death due to breast cancer across age groups switched from 11 to 17% resulting in a risk of death reduction of 19% after adjusting by stage. During 1995-2004, the stage-specific 10-year probabilities of death due to breast cancer switched from: 3-6% in stage I, 18-20% in stage II, 34-46% in stage III and surpassed 70% in stage IV beyond 5 years after diagnosis. CONCLUSIONS: In our study, women diagnosed with breast cancer had higher long-term probability to die from breast cancer than from other causes. The improvements in treatment and the lead-time bias in detecting cancer in an early stage resulted in a reduction of 19% in the risk of death between diagnostic periods.

Predicting the cancer burden in Catalonia between 2015 and 2025: the challenge of cancer management in the elderly.

BACKGROUND: Developing effective cancer control programmes requires information on the future cancer burden in an ageing population. In our study we predicted the burden of cancer in Catalonia from 2015 to 2025. METHODS: Bayesian age-period-cohort models were used to predict the burden of cancer from 2015 to 2025 using incidence data from the Girona and Tarragona cancer registries and cancer mortality data from the Catalan mortality registry. Using the Bashir-Estève method, we divided the net change in the number of cases between 2015 and 2025 into changes due to population size (S), cancer risk (R) and age (A) distribution. RESULTS: By 2025, there will be 21,743 new cancer cases in men (40% aged > 74 years) and 17,268 in women (37% aged > 74 years). More than 40% of the new cases will be diagnosed among population aged 74 and older in prostate, colorectal, lung, bladder, pancreatic and stomach cancers in men, and in colorectal, pancreatic and bladder cancers and leukaemia in women. During 2015-2025, the number of new diagnoses will increase by 5.5% in men (A + R + S = 18.1% - 13.3% + 0.7% = 5.5%) and 11.9% in women (A + R + S = 12.4% - 1.1% + 0.6% = 11.9%). Overall cancer mortality rates will continue to decrease during 2015-2025. Lung cancer will be the most lethal cancer among men (N = 2705) and women (N = 1174). CONCLUSIONS: The increase in the number of cancer cases in Catalonia from 2015 to 2025 will mostly affect the elderly, prompting the need for increased collaboration between geriatricians and oncologists.

Improving survival and local control in rectal cancer in Catalonia (Spain) in the context of centralisation: A full cycle audit assessment.

BACKGROUND: Rectal cancer surgery in Catalonia has been involved in a process of centralisation. We assessed the impact of this health policy strategy on quality of care and clinical results. METHODS: We compared patterns of care and clinical outcomes of all rectal cancer patients receiving radical surgery for the first time in public hospitals in two time periods, before (2005 and 2007) and after (2011-2012) centralisation, analysing indicators of care quality according to the regional clinical practice guidelines. Clinical outcomes at two years were also assessed. RESULTS: A total of 3780 patients were included. From 2005 to 2012, the proportion of patients treated surgically for the first time in centres whose annual surgical caseload was more than 11 increased from 84.0% to 90.4%. The rate of locoregional recurrence at two years fell from 4.5 to 3.06/100 person-years (p = 0.005). The crude mortality rate at three months, one and two years was reduced by 55%, 40% and 34% (p < 0.001). CONCLUSION: Improvements in quality of care might be associated with the centralisation of surgery and with the selective focus effect derived from the process of auditing. Our results support the continuation of clinical auditing and surveillance of authorised centres.

Cardiac surgical mortality: comparison among different additive risk-scoring models in a multicenter sample.

OBJECTIVE: To compare the performance of several risk-scoring models to predict surgical mortality following open heart surgery. DESIGN: A prospective observational study. SETTING: Seven tertiary cardiac centers (3 private and 4 public and teaching hospitals) in Catalonia (Spain). PATIENTS: A consecutive sample of 1287 patients submitted to open heart surgery during a 6 1/2-month period (February 14, 1994, to August 31, 1994). INTERVENTION: None. MAIN OUTCOME MEASURE: Model discrimination capability was assessed with the c-statistic. A chi(2) test to compare observed and predicted mortality rates was used as a measure of model calibration. Performance of centers was evaluated through the standardized mortality ratio and using the center as an indicator variable in a logistic regression model. The agreement among models for individual predictions was tested using weighted K statistics. RESULTS: Models developed in other health care contexts showed, as expected, lower c-statistics and an inappropriate calibration. There were no statistically significant differences among hospitals after adjusting for baseline patients' risk factors with the use of any of the different models. Models also agree in the standardized rank of centers. Weighted K statistics indicated poor agreement among models for individual patient risk prediction. CONCLUSIONS: Models can be a useful tool to compare providers' performance and to give a more in-depth look at the process of care when appropriately customized to the context. Severity-adjusted models can also play a role in supporting the informed and subjective surgeon's assessment, but it is inappropriate to use them for individual predictions.

Subjective versus statistical model assessment of mortality risk in open heart surgical procedures.

BACKGROUND: The aim of this study was to compare the predictive accuracy for open heart surgical mortality between a statistical model based on collection of clinical data and surgeons' subjective risk assessment. METHODS: Predictive discrimination of both risk assessments (surgeons' and model) was compared through the area under the receiver operating characteristic curve. Logistic regression analysis was used to assess the relation between surgeons' and model predictions to actual outcomes. Calibration of the subjective estimates was evaluated with a chi2 test. RESULTS: Overall, the area under the receiver operating characteristic curve was 0.76 for the statistical model and 0.70 for the subjective assessment. Logistic regression analysis showed that the statistical model remained significant after accounting for the subjective assessment. Calibration of subjective mortality predictions was poor. CONCLUSIONS: Surgeons' risk assessment tends to cluster in the middle ranges of risk. Subjective assessment seems accurate in identifying the two extremes of risk but is inaccurate for intermediate risk levels. A multivariate statistical model improves the accuracy of subjective predictions.

Assessing open heart surgery mortality in Catalonia (Spain) through a predictive risk model.

OBJECTIVE: To develop a risk stratification model to assess open heart surgery mortality in Catalonia (Spain) in order to use risk-adjusted hospital mortality rates as an approach to analyze quality of care. METHODS: Data were prospectively collected through a specific data-sheet during 6 1/2 months in consecutive adult patients subjected to open heart surgery. The dependent variable was surgical mortality, and independent variables included were presurgical (sociodemographic data, clinical antecedents, morphological and functional studies) and surgical. The model was built on a subsample (70% of study population) through univariate and logistic regression analysis and validated in the rest of the sample. RESULTS: The total sample was of 1309 procedures in seven hospitals; 47% of them were valve procedures. The overall crude mortality rate was 10.9% and varied among centers (range, 2.8-14.8%). Risk factors included in the model received a weight based on the logistic regression coefficient and a score was generated for each patient. The factors with the highest weight were patient older than 80 and second reoperation. Score was stratified in five categories of increasing risk. There was a good agreement between observed and predicted mortality rates in the validation group. Overall patient distribution was as follows: 52% low risk level, 16% fair, 13% high, 12% very high, and 6% extremely high risk level. Mortality rate increased from 4.2% in the low risk to 54.4% in the highest risk group. Case mix adjustment was performed through the risk score level. There were statistically significant differences in the risk profiles of patients admitted among centers. After adjustment by risk profiles, there were no differences in mortality by hospital. CONCLUSION: A risk stratification model through a multicentric, prospective and exhaustive collection of data in all types of open heart procedures was developed. In spite of wide differences on crude rates and in the risk profiles of patients admitted, we did not find statistically significant differences in adjusted mortality rates among centers. Timely and accurate information about surgical outcomes can lead to improvements in clinical practice and quality of care.

[Estimation of potential impact of ambulatory surgery in Catalonia]. / Estimación del impacto potencial de la cirugía ambulatoria en Cataluña.

BACKGROUND: In recent years, ambulatory surgery has received much attention in Catalonia, Spain, because of its potential to reduce unnecessary bed utilization. To estimate the number of potentially ambulatory procedures could be useful for planning and contracting health care services and could give an idea of its potential impact in the existing health care system. METHODS: The number of hospital discharges in Catalonia (1993) for 34 groups of procedures suitable for ambulatory surgery were obtained from the computerised uniform hospital discharge system. The percentage of procedures that could be carried out as day cases published in three delphi studies were applied to the number of hospital discharges to estimate a target number of ambulatory procedures. The number of hospital bed days that could be saved was calculated multiplying the estimated number of ambulatory procedures by the actual average length to stay for each procedure. Finally, Delphi substitution percentages were compared to those reported by a Catalan hospital with an ambulatory surgery unit. RESULTS: The estimated annual number of ambulatory procedures ranges from 37,453 to 44,752 (6.5 to 7.7% of the annual hospital discharges) and the estimated hospital day from 159,773 to 193,709 (3.3 to 4.0% of all hospital bed days). Among the procedures with the highest potential in ambulatory surgery there are: cataract surgery, inguinal hernia repair, uterine dilatation and curettage, and arthroscope. Most of the reported hospital substitution indexes are positioned between the highest and the lowest delphi indexes. CONCLUSIONS: A significant percentage of the procedures currently carried out on an inpatient basis could be performed in ambulatory arrangements. The hospital reported percentages of substitution suggest the feasibility of achieving the estimated number of ambulatory procedures. In the Catalan public health sector, ambulatory surgery has shown an increasing trend towards the estimated number of ambulatory procedures.

[The evidence on breast cancer screening: the story continues]. / La evidencia del cribado del cáncer de mama: la historia continúa.

The publication of the new Cochrane review on screening for breast cancer with mamography has revived the debate on breats screening and raised some new topics. Whereas the Cochrane reviewers reasserted on their previous conclusion of the lack of efficacy of breast screening, the new review of the Swedish studies, the new systematic review of the Agency for Healthcare Research and Quality commissioned by the US Preventive Services Task Force, and the recent review of an IARC working group supported the efficacy of breast screening after carefully considering the methodological quality of trials. Nevertheless, the efficacy of breast screening for younger women remains controversial. The present controversy has raised other issues like the measure of the benefit in screening trials or the potential adverse effects of screening, particularly, overdiagnosis and its impact on therapy that are discussed in this papers. It also stresses of evaluating screening before introducing it and the need to inform the population about the benefits and the potential harms and about uncertainties about cancer screening.