Territorial gaps on quality of causes of death statistics over the last forty years in Spain.

BACKGROUND: The quality of the statistics on causes of death (CoD) does not present consolidated indicators in literature further than the coding group of ill-defined conditions of the International Classification of Diseases. Our objective was to assess the territorial quality of CoD by reliability of the official mortality statistics in Spain over the years 1980-2019. METHODS: A descriptive epidemiological design of four decades (1980-, 1990-, 2000-, and 2010-2019) by region (18) and sex was implemented. The CoD cases, age-adjusted rates and ratios (to all-cause) were assigned by reliability to unspecific and ill-defined quality categories. The regional mortality rates were contrasted to the Spanish median by decade and sex by the Comparative Mortality Ratio (CMR) in a Bayesian perspective. Statistical significance was considered when the CMR did not contain the value 1 in the 95% credible intervals. RESULTS: Unspecific, ill-defined, and all-cause rates by region and sex decreased over 1980-2019, although they scored higher in men than in women. The ratio of ill-defined CoD decreased in both sexes over these decades, but was still prominent in 4 regions. CMR of ill-defined CoD in both sexes exceeded the Spanish median in 3 regions in all decades. In the last decade, women's CMR significantly exceeded in 5 regions for ill-defined and in 6 regions for unspecific CoD, while men's CMR exceeded in 4 and 2 of the 18 regions, respectively on quality categories. CONCLUSIONS: The quality of mortality statistics of causes of death has increased over the 40 years in Spain in both sexes. Quality gaps still remain mostly in Southern regions. Authorities involved might consider to take action and upgrading regional and national death statistics, and developing a systematic medical post-grade training on death certification.

Influence of size and complexity of the hospitals in an enhanced recovery programme for colorectal resection.

PURPOSE: The aim of this study was to see whether the application of the enhanced recovery programme for colorectal resection improves the results and, in turn, the influence of complexity and size of the hospitals in applying this and its results. METHODS: A multi-centric prospective study was controlled with a retrospective group. The prospective operation group included 300 patients with elective colorectal resection due to cancer. The centres were divided depending on size and complexity in large reference centres (group 1) and area and basic general hospitals (group 2). The retrospective control group included 201 patients with the same characteristics attended before the application of the programme. Completion of categories of the protocol, complications, perioperative mortality and stay in hospital were recorded. RESULTS: The introduction of the programme achieved a reduction in mortality (1 vs. 4 %), morbidity (26 vs. 39 %) and preoperative (<24 h vs. 3 days) and postoperative (7 vs. 11 days) stays (p < 0.01). There was greater fulfilment of protocol in group 2 with the mean number of items completed at 8.46 and 60 % completed compared with the hospitals in group 1 (7.70 completed items and 55 % completion). The size of the hospital had no relation to the rate of complications (21.3 vs. 26.5 %). In smaller sized and less complex hospitals, the average length of stay was 1.88 days less than in those of greater size (6.45 vs. 8.33 days). CONCLUSION: Patients treated according to an enhanced recovery programme develop significantly fewer complications and have a shorter hospital stay. The carrying out of protocol is greater in smaller and less complex hospitals and is directly related to a shorter stay in hospital.

Esophageal Doppler monitoring during colorectal resection offers cost-effective improvement of hemodynamic control.

OBJECTIVES: Hemodynamic control can improve the outcome of surgery. Esophageal Doppler monitoring measures blood flow by ultrasound waves. This work investigates the cost-effectiveness of this procedure during colorectal resection. METHODS: Meta-analyses of randomized controlled trials of esophageal Doppler monitoring used in colorectal resection were conducted to help determine its cost-effectiveness. An analytical decision model was used to compare the cost-effectiveness of strategies involving conventional clinical assessment with or without the measurement of central venous pressure, with or without esophageal Doppler monitoring. Avoided mortality and avoided major complications were used as measures of clinical effectiveness. RESULTS: In the meta-analyses comparing conventional clinical assessment plus central venous pressure monitoring with or without esophageal Doppler monitoring, statistically significant differences in total and major complications favoring the use of Doppler were found. No differences were seen in mortality. The use of esophageal Doppler monitoring was associated with lower costs, mainly due to fewer complications, shorter hospital stays and shorter surgery times. CONCLUSIONS: Although the information regarding the clinical effectiveness of esophageal Doppler monitoring in colorectal resection is limited, strategies including this form of blood flow monitoring may be cost-effective. Further comparisons of Doppler monitoring against other hemodynamic monitoring systems should be undertaken.

Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis.

AIM: The main aim of this review was to compare the safety and efficacy of the Da Vinci Surgical System (DVSS) and conventional laparoscopic surgery (CLS) in different types of abdominal intervention. SUMMARY OF BACKGROUND DATA: DVSS is an emerging laparoscopic technology. The surgeon directs the robotic arms of the system through a console by means of hand controls and pedals, making use of a stereoscopic viewing system. DVSS is currently being used in general, urological, gynecologic, and cardiothoracic surgery. METHODS: This systematic review analyses the best scientific evidence available regarding the safety and efficacy of DVSS in abdominal surgery. The results found were subjected to meta-analysis whenever possible. RESULTS: Thirty-one studies, 6 of them randomized control trials, involving 2166 patients that compared DVSS and CLS were examined. The procedures undertaken were fundoplication (9 studies, one also examining cholecystectomy), Heller myotomy (3 studies), gastric bypass (4), gastrectomy (2), bariatric surgery (1), cholecystectomy (4), splenectomy (1), colorectal resection (7), and rectopexy (1). DVSS was found to be associated with fewer Heller myotomy-related perforations, a more rapid intestinal recovery time after gastrectomy-and therefore a shorter hospital stay, a shorter hospital stay following cholecystectomy (although the duration of surgery was longer), longer colorectal resection surgery times, and a larger number of conversions to open surgery during gastric bypass. CONCLUSIONS: The publications reviewed revealed DVSS to offer certain advantages with respect to Heller myotomy, gastrectomy, and cholecystectomy. However, these results should be interpreted with caution until randomized clinical trials are performed and, with respect to oncologic indications, studies include variables such as survival.

Evaluación del impacto asistencial de una vía clínica de trasplante renal / Evaluation of the impact of a clinical pathway for kidney transplantation

Objetivo: Revaluar el impacto asistencial de una vía clínica (VC) de trasplante renal en un hospital universitario tras 4 años de implantación. Material y método: Estudio experimental tipo antes-después con control retrospectivo. El grupo de estudio estuvo formado por los pacientes sometidos a trasplante renal con posterioridad a la implantación de la VC en 1999 en el Hospital Universitario La Paz y como grupo control, los pacientes trasplantados antes de su establecimiento. Resultados: Se estudió a 32 pacientes del grupo control y 121 del grupo de estudio. La estancia se redujo de 20 días del primer grupo a 14 días del segundo. Se observó una reducción en la incidencia de infección de localización quirúrgica (el 12,5 contra el 1,7%). No hubo diferencias en las complicaciones quirúrgicas ni en los eventos posteriores al alta. La reducción observada en el uso inadecuado de antimicrobianos no fue significativa, mientras que ésta sí lo fue con los protectores gástricos. También disminuyó entre ambos grupos el tiempo transcurrido entre el trasplante y la retirada de la sonda vesical y la vía central (de 12 a 8 días en ambos casos). Conclusiones: La VC ha demostrado ser una herramienta efectiva y eficiente, pues con su implantación se observó una reducción en la estancia hospitalaria y de otros efectos adversos para el paciente, con lo que se estima una mejora en la calidad asistencial

Aim: To reassess the impact of a clinical pathway for kidney transplantation in a university hospital after a 4-year period. Material and method: We performed an experimental "before and after" study with a retrospective control group. The experimental group was composed of patients who underwent kidney transplantation after the starting date of implementation of the clinical pathway (1999) at the Hospital La Paz (Madrid, Spain). The control group included a selection of patients who underwent the same procedure before 1999. Results: There were 32 patients in the control group and 121 in the experimental group. The length of stay before discharge was reduced from 20 days in the control group to 14 days in the experimental group. The surgical site infection rate decreased from 12.5% to 1.7%. No differences were found in the development of other surgical complications or undesired events after discharge. The reduction observed in antibiotic use was non-significant, whilst a significant reduction was found in the use of gastric protectors. Moreover, the time elapsed from kidney transplantation to withdrawal of the vesical and central catheters diminished in both groups (from 12 to 8 days). Conclusions: The clinical pathway has proved to be an effective and efficient tool to reduce the length of hospital stay and the development of undesired events, thus improving health care quality