Predictors of Enrollment in Cardiac Rehabilitation Programs in Spain.

PURPOSE: Cardiac rehabilitation (CR) is very effective for secondary prevention of cardiovascular disorders. The objective of this study was to analyze population factors associated with nonenrollment of cardiac patients in these programs. METHODS: Retrospective study of 756 patients referred to the cardiac rehabilitation program (CRP) of a tertiary referral hospital with a service area population of more than 640 000 from January 2009 to June 2012. We assessed the relationship between population characteristics of these patients and nonenrollment by logistic regression analysis. RESULTS: There were 2386 hospital admissions for an acute coronary syndrome during the study period. Out of the 2355 patients who were alive at discharge, 756 (632 men and 124 women) were referred for CR (32.1% vs 3% state average and vs 51% European average). Of these patients, 20.9% did not enroll. The referral rate was lower among women than among men (P < .001). The characteristics associated with a lower rate of enrollment in the program were age (OR: 1.05; 95% CI: 1.02-1.09), living alone (OR: 4.54; 95% CI: 2.53-8.16), living further than 50 km from the CR unit (OR: 2.90; 95% CI: 1.29-6.41) and, in women, having a history of cardiovascular disease (recurrent myocardial infarction) (OR: 6.35; 95% CI: 2.53-11.81). CONCLUSIONS: The rate of referral for CR in our setting is well above the national average but still could be improved. We identified older age, living alone, travel distance to the cardiac rehabilitation unit, and, in women, a history of a previous myocardial infarction as barriers to enrollment in CRPs.

Interhospital variation in appropriateness of cataract surgery.

OBJECTIVE: The aim of this study was to analyse the inter-hospital variation in the appropriateness of cataract phacoemulsification in Spain. METHODS: This observational, multicentre, prospective study involved patients aged 18-90 years. Each phacoemulsification intervention was classified as 'necessary', 'appropriate', 'uncertain' or 'inappropriate' according to explicit appropriateness criteria previously established using the RAND/UCLA methodology. A descriptive statistical analysis was performed, followed by univariate and multivariate logistic regression analysis, in order to examine the differences between hospitals. RESULTS: In total, 5063 patients from 15 hospitals were enrolled. The percentage of patients in each hospital who inappropriately underwent phacoemulsification varied from 1.2% to 24.0% (P < 0.0001). The most common inappropriate scenario was that of patients with a simple, unilateral cataract with no limitation of their visual function, with a pre-surgery visual acuity of ≥ 0.5 in both eyes, and for whom surgical correction would involve low technical complexity. CONCLUSIONS: The variation in appropriateness of phacoemulsification cannot be attributed solely to the clinical differences between the hospitals' patients. There is room for improvement in the appropriate indication of phacoemulsification. Measures based on the dissemination of appropriateness criteria might improve quality of care.

Waiting time for cataract extraction: Predictive factors and influence on outcomes.

PURPOSE: To identify variables related to time spent on a waiting list for cataract extraction and the effect of waiting time on some outcomes. SETTING: Twelve ophthalmology units throughout Spain. DESIGN: Cohort study. METHODS: This study included consecutive patients scheduled to have cataract removal by phacoemulsification. Sociodemographic and clinical data, including visual acuity, and Visual Function Index 14 (VF-14) results were collected before and after cataract extraction. Univariate and multivariate linear regression was performed to identify variables related to time on the waiting list for cataract extraction and the influence of waiting time on postoperative visual acuity, visual function, and complications. RESULTS: The study comprised 3787 patients. Patients with social support spent significantly more time (1.04 times) on the waiting list (P = .0188), while those with contralateral visual acuity better than 0.5 and those with vision-related daily living difficulties spent less time on the waiting list. Patients who waited longer than 5 months for cataract extraction had smaller gains in visual acuity than those who waited fewer than 3 months (P = .0348). Time on the waiting list did not significantly influence changes in the VF-14 results or complications from surgery. CONCLUSIONS: The finding that some contradictory sociodemographic factors influence time spent on a waiting list for cataract extraction suggests that rational, explicit, and homogeneous appropriateness and priority criteria are not being applied to these patients. Use of such criteria could improve waiting times and order waiting lists so patients who need cataract extraction the most would receive it soonest. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Effect of hospital on variation in visual acuity and vision-specific quality of life after cataract surgery.

OBJECTIVE: To evaluate the contribution of hospital-to-hospital variability in changes in clinical and health-related quality of life outcomes among patients undergoing cataract extraction by phacoemulsification. METHODS: Prospective observational study of 14 public hospitals. We recruited consecutive patients on waiting lists for cataract extraction. Clinical data were collected prior to the intervention and 6 weeks afterward. Subjects completed the visual function index (VF-14) prior to the procedure and 3 months afterward. Univariate and multivariate analysis were performed for visual acuity and VF-14 scores. RESULTS: Substantial differences were observed across the 14 hospitals. At baseline, mean visual acuity ranged from 0.16 to 0.34, and mean VF-14 scores ranged from 48.06 to 75.89. Following cataract extraction, the mean improvement in visual acuity ranged from 0.35 to 0.57 and in VF-14 scores from 10.94 to 41.70. The ranges were even more pronounced among patients with low visual acuity or low VF-14 scores prior to the intervention. Significant differences remained in multivariate analysis. Within the multivariate analysis, the variable 'hospitals' had an R(2) of 0.069 for the visual acuity model and of 0.073 for the VF-14 model, 20% and 13%, respectively, of the total variability explained. Variation was also observed within geographic regions. CONCLUSIONS: Outcomes of patients undergoing cataract extractions vary widely from hospital to hospital, even within the same geographic region, explaining an important part of the results. Quality improvement efforts should concentrate on patients with low pre-intervention visual acuity or vision-related disability to reduce this variability in outcomes.

Validity of newly developed appropriateness criteria for cataract surgery.

OBJECTIVE: The introduction of phacoemulsification in the early 1990s significantly changed the treatment of cataract. It is possible that appropriateness criteria for cataract extraction developed before the widespread adoption of phacoemulsification no longer is as accurate or valid as possible. The objective of this study was to validate newly developed explicit appropriateness criteria. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Consecutive patients with a diagnosis of cataract who were on waiting lists to undergo cataract extraction by phacoemulsification were recruited. METHODS: Newly developed explicit appropriateness criteria for cataract extraction, following Research and Development methodology, were applied in this study conducted in 17 public teaching hospitals. Data necessary to classify the appropriateness of the intervention, including demographic and clinical data and that related to the surgery and complications, were recorded by previously trained ophthalmologists in all centers before the intervention and at the 6-week visit afterward. MAIN OUTCOME MEASURES: Subjects completed 2 questionnaires that measure health-related quality of life--the Short Form 36 and the Visual Function Index 14 (VF-14)--before the procedure and 3 months afterward. Also, visual acuity was recorded by ophthalmologists previous to the intervention and at 6 weeks after. RESULTS: Five thousand two hundred fifty-seven cases were included in the study. At 3 months after cataract extraction, 4335 (82.5%) patients had responded to the questionnaires. Patients whose procedures were classified as necessary or appropriate by the new appropriateness criteria had greater improvements in visual acuity and VF-14 scores than those undergoing procedures classified as inappropriate. These differences seemed to be clinically relevant by measures such as the minimal clinically important difference and minimal detectable change. Complications rates were similar among all appropriateness categories, except for complications occurring in the peri-intervention period. CONCLUSIONS: These results suggest a direct relationship between the newly developed explicit appropriateness criteria for cataract extraction and outcomes, as measured by clinical evaluation and health-related quality-of-life instruments. The results support the use of these criteria for clinical evaluation or the development of clinical guidelines.