Función renal al ingreso como marcador pronóstico en pacientes hospitalizados por un primer episodio de insuficiencia cardíaca. Resultados del estudio PREDICE / Renal function at admission as a prognostic marker for patients hospitalised for a first episode of heart failure. Results of the PREDICE study

ANTECEDENTES Y OBJETIVO: La insuficiencia cardíaca (IC) es una enfermedad frecuente que deteriora la calidad de vida de los pacientes que la padecen y condiciona una elevada morbimortalidad. En los últimos años, se están desarrollando gran cantidad de trabajos para determinar qué factores influyen en el pronóstico de la IC. Sin embargo, son escasos los que evalúan el pronóstico de los pacientes hospitalizados por su primer episodio de IC. El objetivo de nuestro estudio es analizar el impacto pronóstico de la función renal en pacientes hospitalizados por un primer episodio de IC. MATERIALES Y MÉTODOS: Se recogió a 600 pacientes hospitalizados por un primer episodio de IC en 3hospitales españoles de tercer nivel. Se analizó el riesgo de mortalidad durante el primer año de seguimiento en función del grado de función renal en el momento del ingreso. RESULTADOS: Los pacientes con mayor grado de insuficiencia renal en el momento del ingreso presentaban edad más avanzada (p < 0,001) eran más frecuentemente mujeres (p = 0,01), presentaban un mayor grado de dependencia (p < 0,05) y mayor prevalencia de hipertensión arterial (p < 0,001), insuficiencia renal crónica (p < 0,001) y anemia (p < 0,001). En el análisis multivariante, el grado de insuficiencia renal al ingreso se mantuvo como predictor independiente de mayor riesgo de mortalidad durante el primer año de seguimiento. CONCLUSIONES: La presencia de insuficiencia renal en el momento del ingreso es un marcador de mal pronóstico en nuestra cohorte de pacientes hospitalizados por un primer episodio de IC

BACKGROUND AND OBJECTIVE: Heart failure (HF) is a frequent condition that deteriorates quality of life and results in high morbidity and mortality. A considerable number of studies have been implemented in recent years to determine the factors that affect the prognosis of HF; however, few studies have assessed the prognosis of patients hospitalised for their first episode of HF. The aim of our study was to analyse the prognostic impact of renal function on patients hospitalised for a first episode of HF. MATERIAL AND METHODS: We recruited 600 patients hospitalised for a first episode of HF in 3 tertiary Spanish hospitals. We analysed the mortality risk during the first year of follow-up according to renal function at the time of admission. RESULTS: The patients with the highest degree of kidney failure at admission were older (P<.001), were more often women (p=.01) and presented a higher degree of dependence (P<.05), as well as a higher prevalence of arterial hypertension (P<.001), chronic renal failure (P<.001) and anaemia (P<.001). In the multivariate analysis, the degree of kidney failure at admission remained an independent predictor of increased mortality risk during the first year of follow-up. CONCLUSIONS: The presence of kidney failure at admission was a marker of poor prognosis in our cohort of patients hospitalised for a first episode of HF

Renal function at admission as a prognostic marker for patients hospitalised for a first episode of heart failure. Results of the PREDICE study. / Función renal al ingreso como marcador pronóstico en pacientes hospitalizados por un primer episodio de insuficiencia cardíaca. Resultados del estudio PREDICE.

BACKGROUND AND OBJECTIVE: Heart failure (HF) is a frequent condition that deteriorates quality of life and results in high morbidity and mortality. A considerable number of studies have been implemented in recent years to determine the factors that affect the prognosis of HF; however, few studies have assessed the prognosis of patients hospitalised for their first episode of HF. The aim of our study was to analyse the prognostic impact of renal function on patients hospitalised for a first episode of HF. MATERIAL AND METHODS: We recruited 600 patients hospitalised for a first episode of HF in 3 tertiary Spanish hospitals. We analysed the mortality risk during the first year of follow-up according to renal function at the time of admission. RESULTS: The patients with the highest degree of kidney failure at admission were older (P<.001), were more often women (p=.01) and presented a higher degree of dependence (P<.05), as well as a higher prevalence of arterial hypertension (P<.001), chronic renal failure (P<.001) and anaemia (P<.001). In the multivariate analysis, the degree of kidney failure at admission remained an independent predictor of increased mortality risk during the first year of follow-up. CONCLUSIONS: The presence of kidney failure at admission was a marker of poor prognosis in our cohort of patients hospitalised for a first episode of HF.

Guía de práctica clínica multidisciplinar española sobre la enfermedad de Anderson-Fabry en adultos. I: Método y recomendaciones / Spanish multidisciplinary clinical practice guidelines for Anderson-Fabry Disease in Adults. I. Method and recommendations

La enfermedad de Anderson-Fabry es una afección multisistémica progresiva y grave de origen genético que afecta tanto a hombres como a mujeres y que reduce sus expectativas y calidad de vida. La gran variabilidad en su expresión clínica, las dificultades para su diagnóstico y la disponibilidad actual de varias alternativas para su tratamiento suponen un gran reto que justifica la realización de una guía de práctica clínica basada en la evidencia que pueda ayudar a los profesionales sanitarios en la toma de decisiones en el manejo de estos pacientes. Para elaborarla se ha realizado una búsqueda sistemática en las principales bases de datos bibliográficas mediante estrategias adaptadas a cada una de las 32 preguntas clínicas consideradas. Se confeccionaron fichas para la síntesis y evaluación de la calidad de las evidencias para cada una de las preguntas. La metodología empleada se basa en el Manual metodológico español para la elaboración de guías de práctica clínica e incorpora en la evaluación de la evidencia científica y en la elaboración de las recomendaciones la metodología GRADE, considerando la calidad de la evidencia, el balance entre beneficios y riesgos, valores y preferencias de los pacientes, equidad y uso de recursos. Para la elaboración definitiva de las recomendaciones se llevó a cabo un proceso de consenso estructurado basado en la metodología Delphi-RAND en 2 rondas, con un panel de expertos propuesto por diferentes sociedades científicas, centros de investigación y asociaciones de pacientes. Finalmente, se han elaborado 92 recomendaciones específicas para el manejo de la enfermedad de Fabry

Anderson-Fabry disease is a severe progressive multisystem condition of genetic origin that affects men and women, reducing their life expectancy and quality of life. The considerable variability in its clinical expression, the difficulties in diagnosing the condition and the current availability of several alternatives for its treatment represent a considerable challenge that justifies the development of evidence-based clinical practice guidelines that can help health professionals in the decision-making process for managing these patients. To develop these guidelines, we conducted a systematic search of the main reference databases using strategies adapted to each of the 32 clinical questions considered. We prepared documents to synthesise the evidence and assess its quality for each of the questions. The methodology employed is based on the Spanish methodology manual for preparing clinical practice guidelines, incorporating the GRADE methodology in the assessment of the scientific evidence and the preparation of the recommendations, considering the quality of the evidence, the risk-benefit balance, patient values and preferences, equity and use of resources. For the definitive preparation of the recommendations, we conducted a structured consensus process based on the Delphi-RAND methodology in 2 rounds, with an expert panel proposed by various scientific societies, research centres and patient associations. Ultimately, we developed 92 specific recommendations for managing Fabry disease

Spanish multidisciplinary clinical practice guidelines for Anderson-Fabry Disease in Adults. I. Method and recommendations. / Guía de práctica clínica multidisciplinar española sobre la enfermedad de Anderson-Fabry en adultos. I: Método y recomendaciones.

Anderson-Fabry disease is a severe progressive multisystem condition of genetic origin that affects men and women, reducing their life expectancy and quality of life. The considerable variability in its clinical expression, the difficulties in diagnosing the condition and the current availability of several alternatives for its treatment represent a considerable challenge that justifies the development of evidence-based clinical practice guidelines that can help health professionals in the decision-making process for managing these patients. To develop these guidelines, we conducted a systematic search of the main reference databases using strategies adapted to each of the 32 clinical questions considered. We prepared documents to synthesise the evidence and assess its quality for each of the questions. The methodology employed is based on the Spanish methodology manual for preparing clinical practice guidelines, incorporating the GRADE methodology in the assessment of the scientific evidence and the preparation of the recommendations, considering the quality of the evidence, the risk-benefit balance, patient values and preferences, equity and use of resources. For the definitive preparation of the recommendations, we conducted a structured consensus process based on the Delphi-RAND methodology in 2 rounds, with an expert panel proposed by various scientific societies, research centres and patient associations. Ultimately, we developed 92 specific recommendations for managing Fabry disease.

Consenso Delphi-RAND de la Sociedad Española de Medicina Interna sobre controversias en terapia y profilaxis anticoagulante en enfermedades médicas. Proyecto INTROMBIN (INcertidumbre en TROMBoprofilaxis en Medicina INterna) / Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine)

El objetivo de este estudio ha sido conocer la opinión de los internistas sobre el manejo de la anticoagulación y profilaxis tromboembólica en escenarios clínicos complejos en los que el balance riesgo/beneficio de la intervención es estrecho y elaborar un documento de consenso sobre el uso de fármacos anticoagulantes en este grupo de pacientes. Para ello, se identificaron por consenso las áreas clínicas de mayor incertidumbre, se elaboró una encuesta con 20 escenarios desplegados en 40 preguntas clínicas y se realizó una revisión bibliográfica específica. La encuesta se distribuyó entre los internistas de la Sociedad Española de Medicina Interna (SEMI) y fue cumplimentada por 290 de sus miembros. El proceso de consenso se desarrolló mediante una modificación del método Delphi-RAND de adecuación en un proceso anonimizado de doble ronda que permite al panel de expertos identificar áreas de acuerdo y de incertidumbre. En nuestro caso, además, se incorporaron al panel los resultados de la encuesta, innovación metodológica que permite aportar información adicional de la práctica clínica habitual. El resultado del proceso es un conjunto de 19 recomendaciones formuladas por expertos de la SEMI que permite establecer pautas de actuación sobre el tratamiento anticoagulante en escenarios complejos (alto riesgo o hemorragia activa, corta expectativa vital, coexistencia de tratamiento antiagregante o comorbilidades como enfermedad renal, hepática, etc.), que no son infrecuentes en la práctica clínica habitual

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice

Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine). / Consenso Delphi-RAND de la Sociedad Española de Medicina Interna sobre controversias en terapia y profilaxis anticoagulante en enfermedades médicas. Proyecto INTROMBIN (INcertidumbre en TROMBoprofilaxis en Medicina INterna).

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice.

Lectura crítica de artículos observacionales / Critical reading of analytical observational studies

Los estudios observacionales analíticos aportan información muy relevante sobre la práctica clínica en la vida real, la historia natural de las enfermedades y la sospecha de causalidad. Además, son muy habituales en las revistas científicas. El objetivo de este artículo es revisar los conceptos principales para una lectura crítica de los artículos con diseño observacional en radiología. Se revisan las características exigibles a los artículos de buena calidad con diseño de casos y controles o estudios de cohortes. Se sigue una metodología de lectura crítica mediante el chequeo de los atributos que hay que valorar en cada tipo de artículo, estructurado en un listado de preguntas específicas. Se resaltan las principales características que confieren credibilidad y confianza al artículo evaluado. Se dota al lector de herramientas para el análisis crítico de los estudios observacionales publicados en revistas científicas (AU)

Analytical observational studies provide very important information about real-life clinical practice and the natural history of diseases and can suggest causality. Furthermore, they are very common in scientific journals. The aim of this article is to review the main concepts necessary for the critical reading of articles about radiological studies with observational designs. It reviews the characteristics that case-control and cohort studies must have to ensure high quality. It explains a method of critical reading that involves checking the attributes that should be evaluated in each type of article using a structured list of specific questions. It underlines the main characteristics that confer credibility and confidence on the article evaluated. Readers are provided with tools for the critical analysis of the observational studies published in scientific journals (AU)

La aplicabilidad de los resultados / The applicability of results

La lectura crítica de la literatura médica tiene por objeto último la utilización de los avances científicos en la práctica asistencial o innovadora. Ello conlleva la evaluación de la aplicabilidad de los resultados de los estudios publicados, comenzando por un claro entendimiento de los resultados. Cuando los estudios no ofrecen suficientes garantías de rigor en su desarrollo y análisis no se dan las condiciones necesarias para su aplicación, pero que sean fiables los resultados no es suficiente para tratar de utilizar sus conclusiones. En el presente artículo se explica cómo el desarrollo en condiciones experimentales o artificiales de los estudios suele alejarlos de las condiciones reales en las que se pretendan aplicar sus conclusiones. Para valorar dicha aplicabilidad se propone evaluar un conjunto de atributos, que permita discernir al lector la probabilidad de que los beneficios y riesgos que describen los estudios se den con la menor incertidumbre en el entorno asistencial en el que se pretenden poner en práctica (AU)

The ultimate aim of the critical reading of medical literature is to use the scientific advances in clinical practice or for innovation. This requires an evaluation of the applicability of the results of the studies that have been published, which begins with a clear understanding of these results. When the studies do not provide sufficient guarantees of rigor in design and analysis, the conditions necessary for the applicability of the results are not met; however, the fact that the results are reliable is not enough to make it worth trying to use their conclusions. This article explains how carrying out studies in experimental or artificial conditions often moves them away from the real conditions in which they claim to apply their conclusions. To evaluate this applicability, the article proposes evaluating a set of items that will enable the reader to determine the likelihood that the benefits and risks reported in the studies will yield the least uncertainty in the clinical arena where they aim to be applied (AU)

[The applicability of results]. / La aplicabilidad de los resultados.

The ultimate aim of the critical reading of medical literature is to use the scientific advances in clinical practice or for innovation. This requires an evaluation of the applicability of the results of the studies that have been published, which begins with a clear understanding of these results. When the studies do not provide sufficient guarantees of rigor in design and analysis, the conditions necessary for the applicability of the results are not met; however, the fact that the results are reliable is not enough to make it worth trying to use their conclusions. This article explains how carrying out studies in experimental or artificial conditions often moves them away from the real conditions in which they claim to apply their conclusions. To evaluate this applicability, the article proposes evaluating a set of items that will enable the reader to determine the likelihood that the benefits and risks reported in the studies will yield the least uncertainty in the clinical arena where they aim to be applied.

[Critical reading of analytical observational studies]. / Lectura crítica de artículos observacionales.

Analytical observational studies provide very important information about real-life clinical practice and the natural history of diseases and can suggest causality. Furthermore, they are very common in scientific journals. The aim of this article is to review the main concepts necessary for the critical reading of articles about radiological studies with observational designs. It reviews the characteristics that case-control and cohort studies must have to ensure high quality. It explains a method of critical reading that involves checking the attributes that should be evaluated in each type of article using a structured list of specific questions. It underlines the main characteristics that confer credibility and confidence on the article evaluated. Readers are provided with tools for the critical analysis of the observational studies published in scientific journals.

Adecuación de tromboprofilaxis en pacientes médicos hospitalizados en Andalucía. Estudio multicéntrico / Assessment of thromboprophylaxis in medical patients hospitalized in Andalusia. A multicenter study

Antecedentes y objetivos: Los pacientes hospitalizados constituyen una población de riesgo para la enfermedad tromboembólica venosa (ETV). La guía de práctica clínica PRETEMED-2007 permite identificar a los pacientes médicos de alto riesgo susceptibles de tromboprofilaxis, y asídisponer de un estándar de profilaxis en tales pacientes. Hemos evaluado el riesgo de ETV y la adecuación de tromboprofilaxis a los estándares de la guía PRETEMED-2007 en los pacientes hospitalizados en servicios de medicina interna. Pacientes y métodos: Estudio observacional transversal y multicéntrico realizado en 2010 en 16 hospitales de Andalucía que incluyen 20 pacientes consecutivos por centro. Variables: edad, sexo, factores de riesgo de ETV y hemorragia, riesgo ajustado PRETEMED de ETV, adecuación de profilaxis tromboembólica al ingreso y al alta y mortalidad intrahospitalaria. Resultados: Se incluyeron 293 pacientes (57,8% varones, edad media de 69±15 años). Los factores precipitantes de ETV más frecuentes fueron: infección aguda grave (27,3%) y neoplasia (16,4%). El 43,4% presentaba riesgo de hemorragia. El riesgo de ETV al ingreso y alta fue elevado en el 47,8 y 31% y moderado en el 8,2 y 10,6% respectivamente. Recibieron profilaxis con heparina de bajo peso molecular el 91,7% al ingreso y el 17,3% al alta. La prescripción fue adecuada en el 59,9% al ingreso (sobreuso 38,4%, infrauso 1,7%) y en el 74,7% al alta (sobreuso 5,4%, infrauso 19,9%). La adecuación fue mayor en pacientes mayores de 60 años y con mayor riesgo hemorrágico. Conclusiones: En el 60% de los enfermos que ingresan en los servicios de medicina interna de Andalucía la tromboprofilaxis es adecuada. La inadecuación de tromboprofilaxis (40%) es mayoritariamente por sobreindicación. Estos resultados sugieren un amplio campo de mejora (AU)

Background and objectives: Hospitalized patients are a population at risk for venous thromboembolism (VTE). The PRETEMED-2007 clinical practice guidelines help identify high-risk medical patients who are suited to thromboprophylaxis. These guidelines therefore provide a standard for prophylaxis in such patients. We evaluated the risk of VTE and the adjustment of thromboprophylaxis to the standards of the PRETEMED-2007 guidelines in patients hospitalized in internal medicine departments. Patients and methods: An observational, cross-sectional multicenter study was performed in 2010 in 16 hospitals in Andalusia and included 20 consecutive patients per center. The study variables were age, sex, risk factors for VTE and hemorrhage, the risk-adjusted PRETEMED of VTE, adjustment of thromboembolic prophylaxis at admission and at discharge and hospital mortality. Results: The study included 293 patients (57.8% men) with a mean age of 69 (±15) years. The most common triggers for VTE were acute severe infection (27.3%) and neoplasia (16.4%). Some 43.4% of the patients presented a risk of hemorrhage. The risk of VTE at admission and discharge was high in 47.8% and 31% and moderate in 8.2% and 10.6%, respectively. A total of 91.7% and 17.3% of the patients underwent prophylaxis with low-molecular-weight heparin on admission and at discharge, respectively. The prescription was appropriate for 59.9% of the patients at admission (overutilization 38.4%, underutilization 1.7%) and for 74.7% at discharge (overutilization 5.4%, underutilization 19.9%). The adjustment was greater in patients older than 60 years and with greater hemorrhagic risk. Conclusions: For 60% of the patients admitted to the departments of internal medicine in Andalusia, the thromboprophylaxis was appropriate. The inadequacy of thromboprophylaxis (40%) is mostly due to overutilization. These results suggest significant space for improvement (AU)

Assessment of thromboprophylaxis in medical patients hospitalized in Andalusia. A multicenter study. / Adecuación de tromboprofilaxis en pacientes médicos hospitalizados en Andalucía. Estudio multicéntrico.

BACKGROUND AND OBJECTIVES: Hospitalized patients are a population at risk for venous thromboembolism (VTE). The PRETEMED-2007 clinical practice guidelines help identify high-risk medical patients who are suited to thromboprophylaxis. These guidelines therefore provide a standard for prophylaxis in such patients. We evaluated the risk of VTE and the adjustment of thromboprophylaxis to the standards of the PRETEMED-2007 guidelines in patients hospitalized in internal medicine departments. PATIENTS AND METHODS: An observational, cross-sectional multicenter study was performed in 2010 in 16 hospitals in Andalusia and included 20 consecutive patients per center. The study variables were age, sex, risk factors for VTE and hemorrhage, the risk-adjusted PRETEMED of VTE, adjustment of thromboembolic prophylaxis at admission and at discharge and hospital mortality. RESULTS: The study included 293 patients (57.8% men) with a mean age of 69 (±15) years. The most common triggers for VTE were acute severe infection (27.3%) and neoplasia (16.4%). Some 43.4% of the patients presented a risk of hemorrhage. The risk of VTE at admission and discharge was high in 47.8% and 31% and moderate in 8.2% and 10.6%, respectively. A total of 91.7% and 17.3% of the patients underwent prophylaxis with low-molecular-weight heparin on admission and at discharge, respectively. The prescription was appropriate for 59.9% of the patients at admission (overutilization 38.4%, underutilization 1.7%) and for 74.7% at discharge (overutilization 5.4%, underutilization 19.9%). The adjustment was greater in patients older than 60 years and with greater hemorrhagic risk. CONCLUSIONS: For 60% of the patients admitted to the departments of internal medicine in Andalusia, the thromboprophylaxis was appropriate. The inadequacy of thromboprophylaxis (40%) is mostly due to overutilization. These results suggest significant space for improvement.

¿Interesa a los oncólogos incorporarse con entusiasmo al mundo de las guías de práctica clínica? / Is a matter of interest to oncologist to join enthusiastically to the world of clinical practice guides?

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Carta al Director / Letter to the Editor

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Los informes de alta hospitalaria médica pueden ser una fuente insuficiente de información para evaluar la calidad de la asistencia / Hospital discharge reports may be an inadequate source of information to evaluate care quality

Objetivos. Examinar si en los informes médicos de alta hospitalaria (IMAH) hay disponible suficiente información para evaluar retrospectivamente la adecuación de la asistencia a pacientes con cardiopatía isquémica (CI), así como para relacionar la calidad con las decisiones de los médicos.Material y métodos. Estudio transversal en el que se evalúan 690 IMAH de pacientes ingresados por cardiopatía isquémica en tres hospitales universitarios de Sevilla. Se estimó la cumplimentación de 15 variables que representaban una adaptación de la normativa del conjunto mínimo básico de datos (CMBD) a la CI. El criterio de suficiencia de información se fijó en el 80 por ciento de los datos.Resultados. Sólo el 2,8 por ciento de los IMAH disponen de suficiente información. Se observa una importante variabilidad en la cumplimentación según el tipo de dato analizado. Hay diferencias significativas en la cumplimentación dependiendo del hospital y el tipo de enfermo, con mayor información en hombres de menor edad y comorbilidad. Conclusiones. El IMAH contiene poca información para evaluar la asistencia médica (AU)

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La historia clínica en la evaluación de la calidad asistencial de la cardiopatía isquémica: ¿es una fuente de información válida? / The clinical record in the evaluation of care quality in ischemic heart disease: is it a valid information source?

Objetivo. Examinar la disponibilidad de información en las historias clínicas (HC) para evaluar la calidad de la asistencia a la cardiopatía isquémica. Material y métodos. Se evalúan 722 historias de pacientes ingresados por cardiopatía isquémica. A partir de una revisión bibliográfica y los criterios de un panel de expertos se seleccionaron los datos necesarios para evaluar la asistencia. Se consideró una HC suficiente cuando disponía de al menos el 80 por ciento de los datos considerados necesarios por el panel. Resultados. El 78,5 por ciento de las HC disponen de suficientes datos. Los ancianos, la presentación clínica como equivalente isquémico y uno de los hospitales estudiados presentaban las HC más deficientes. Conclusiones. La HC es válida para evaluar retrospectivamente la asistencia médica. Las diferencias entre hospitales son importantes y deben tenerse en consideración antes de realizarse estudios sobre calidad clínica (AU)

[Hospital discharge reports may be an inadequate source of information to evaluate care quality]. / Los informes de alta hospitalaria médica pueden ser una fuente insuficiente de información para evaluar la calidad de la asistencia.

OBJECTIVES: To examine whether there is adequate available information in hospital discharge records (HDR) to retrospectively evaluate the adequacy of medical care to patients suffering from ischemic heart disease (IHD) and to relate care quality to physicians' decisions. MATERIAL AND METHODS: Cross-sectional study in which a total of 690 HDRs of patients admitted to three university teaching hospitals in Seville, Spain, on account of ischemic heart disease. The fulfillment of 15 parameters representing an adaptation to the CMBD regulation to IHD. The criterion of adequate information was set at 80% of data. RESULTS: Only 2.8% of HDRs contains adequate information. According to the analysed data, relevant fulfillment variability was observed. There were significant differences in fulfillment depending upon hospital and type of patient, with more information among younger patients and comorbidity. CONCLUSIONS: HDRs contain inadequate information to evaluate medical care.

[Medical history in the assessment of quality of care in ischemic cardiopathy: is it a valid information source?]. / La historia clínica en la evaluación de la calidad asistencial de la cardiopatía isquémica: es una fuente de información válida?

OBJECTIVE: To examine the availability of information in the clinical records (CR) to evaluate care quality in ischemic heart disease. MATERIAL AND METHODS: A total of 722 clinical records of patients admitted because of ischemic heart disease were evaluated. Based upon a bibliographic review and the criteria of an expert panel necessary data to evaluate care quality were selected. A CR was considered adequate when at least 80% of data considered necessary by the expert panel were available. RESULTS: 78.5% of CR had adequate data. The elderly, clinical presentation as ischemic equivalent and one of the hospitals studied had most deficient CR. CONCLUSIONS: The CR is valid to retrospectively evaluate medical care. Differences between hospitals were important and should be taken into consideration before studies on clinical quality are performed.

[Mapping the scientific evidence for bedside care to unstable angina. A preliminary step to develop clinical guidelines. The name of the study group CAMBIE Change in the Medical services based on the clinical practice guidelines]. / Mapa de evidencias para el tratamiento de la angina inestable en la cabecera del paciente. Etapa preliminar para el desarrollo de una guía de práctica clínica. Nombre del grupo del estudio CAMBIE (Cambio en la Actuación Médica Basado en la Información de Evaluación).

BACKGROUND: The uncertainty in clinical practice arise from the need of physicians to make decisions on a limited ground of knowledges. Guidelines are supposed to facilitate clinical decisions in such circumstances. Sharing knowledges on natural history of diseases and clinical expertise allow to define and array of steps structured on a formal flow-chart. The node of algorithms identifies decisions to analyze. This paper presents a taxonomy of specific questions related to each decision nodes for management of unstable angina and assesses the level of evidence available for each question. MATERIAL AND METHOD: A flow chart diagram display the conceptualized key nodes for clinical management of unstable angina. A set of specific question related to clinical exclusive circumstances, diagnostic approach, utility of diagnostic procedures, definition of prognosis and outcomes was raised for each decision node. From a systematic literature review the best available evidence was gathered. Each recommendation was linked to a level (A-C) of evidence, and to a body of consensus expert panel decisions. RESULTS: 34 decision nodes were identified, related with at least 1 question for appraisal of the best evidence. The solution to these questions yielded 40 recommendations scored by the strength of the evidence available. Five recommendations of diagnostic, 20 at prognostic and 15 at therapeutic step. The strength of evidence was A for 73% of recommendations at therapeutic step versus 40% at the two other steps. CONCLUSIONS: A clinical complex problem can be displayed in a continuous process, to allow identification and appraisal of decisions at different clinical nodes. The work-up to achieve a conceptualization of a clinical problem is the preliminary step to develop clinical practice guidelines. Identification of decision nodes allows to manage uncertainty in a explicit way and make policy statement more acceptable by managers and physicians.