A critical review of the birth plan use in Catalonia.

INTRODUCTION: The birth plan allows the woman to express her expectations and needs with regards to the childbearing continuum but its use has been debated in the clinical context and in published literature. The birth plan was first introduced in the Spanish Health Service in 2008 through the Strategy for the Care in Normal Childbirth. In Catalonia, the Normal Childbirth Care Programme has promoted the use of birth plans in hospitals participating in this Programme. OBJECTIVE: This works describes and analyses the birth plans produced by the participating hospitals in order to gather knowledge about the options available to women. METHOD: Qualitative study in which the content of birth plans is systematically and quantitatively described in order to evaluate options available to women. The final sample includes all the birth plans provided by 30 Catalonian public hospitals. Following an initial assessment, it was decided to devise a grading scale which allowed to code and assign a value to each of the items contained in the birth plans. RESULTS: Three different types of birth plan are identified: a) those which present a list of items with no (or very little) associated explanations, b) list of items with some explanations and c) plans without items which only explain normal working practices in the hospital and/or protocols.

Cross-sectional study comparing public and private hospitals in Catalonia: is the practice of routine episiotomy changing?

BACKGROUND: In Spain, the Strategy for Assistance in Normal Childbirth (SANC) promoted a model of care, which respects the physiological birth process and discards unnecessary routine interventions, such as episiotomies. We evaluated the rate of episiotomy use and perineal trauma as indicators of how selective introduction of the SANC initiative has impacted childbirth outcomes in hospitals of Catalonia. METHODS: Cross-sectional study of all singleton vaginal term deliveries without instrument registered in the Minimum Basic Data Set (MBDS) of Catalonia in 2007, 2010 and 2012. Hospitals were divided into types according to funding (public or private), and four strata were differentiated according to volume of births attended. Episiotomies and perineal injury were considered dependent variables. The relationship between qualitative variables was analysed using the chi-squared test, and Student's t-test was used for quantitative variables. Comparison of proportions was performed on the two hospital groups between 2007 and 2012 using a Z-test. Logistic regression models were used to analyse the relationship between episiotomy or severe perineal damage and maternal age, volume of births and hospital type, obtaining odds ratios (OR) and 95% confidence intervals (CI). RESULTS: The majority of normal singleton term deliveries were attended in public hospitals, where maternal age was lower than for women attended in private hospitals. Analysis revealed a statistically significant (P < 0.001) decreasing trend in episiotomy use in Catalonia for both hospital types. Private hospitals appeared to be associated with increased episiotomy rate in 2007 (OR = 1.099, CI: 1,057-1,142), 2010 (OR = 1.528, CI: 1,472-1,587) and 2012 (OR = 1.459, CI: 1,383-1,540), and a lower rate of severe perineal trauma in 2007 (OR = 0.164, CI: 0.095-0.283), 2010 (OR = 0.16, CI: 0.110-0.232) and 2012 (OR = 0.19, CI: 0.107-0.336). Regarding severe perineal injury, when independent variables were adjusted, maternal age ceased to have a significant correlation in 2012 (OR = 0.994, CI: 0.970-1.018). CONCLUSIONS: Episiotomy procedures during normal singleton vaginal term deliveries in Catalonia has decreased steadily since 2007. Study results show a stable incidence trend below 1% for severe perineal trauma over the study period.

Atención a las enfermedades músculo-esqueléticas: distintas visiones del mismo problema / Attention to musculoskeletal diseases. Different visions of the same problem

Objetivo. Detectar los principales problemas que afectan a los médicos de familia (MF) y a los especialistas hospitalarios, en la atención de las principales enfermedades del aparato locomotor en Cataluña. Método. Estudio descriptivo transversal realizado mediante una encuesta auto-administrada dirigida a MF y a especialistas hospitalarios de 4 ámbitos (cirugía ortopédica y traumatología [COT], reumatología [RMT], medicina física y rehabilitación [MFR] y unidades del dolor [UD]). Las variables recogidas evalúan datos socio-demográficos, dedicación asistencial, destreza autodeclarada, el proceso de derivación, los mecanismos de coordinación y las principales dificultades para ofrecer una atención de calidad. Resultados. Los MF consideran bueno su nivel de destreza en el manejo de las enfermedades del aparato locomotor (6,7±1,0 en una escala del 1 al 10). Menos del 25% refieren coordinarse con especialistas hospitalarios. Para los MF el mayor problema son las listas de espera en las especialidades citadas (8,2±1,6/10), seguido de la falta de información de retorno (8±1,9/10) y de la escasa coordinación (7,8±1,9/10). Según su criterio, la especialidad de referencia debería cambiar en algunas patologías (como la lumbalgia y la artrosis). Los especialistas hospitalarios son críticos respecto al papel de los MF. Para ellos, los principales problemas son la propia sobrecarga asistencial (7,8±2/10) y la ineficiencia de los sistemas de información (7,4±2/10). Conclusiones. La opinión sobre los problemas que afectan a la atención de las enfermedades del aparato locomotor difiere entre los MF y los especialistas hospitalarios. La falta de accesibilidad y la sobrecarga asistencial de la atención especializada, las deficiencias en el flujo de información y la escasa coordinación son los problemas más destacados (AU)

Objective: To identify the main problems affecting general practitioners (GPs) and specialists in the care of the main musculoskeletal problems in Catalonia. Method: Cross-sectional, self-administered survey in a representative sample of GPs and all specialists in four areas (orthopedic surgery, rheumatology, physical medicine and rehabilitation and pain units). Variables evaluated in the survey were related to socio-demographic data, attention to musculoskeletal diseases, self-declared expertise, referral process, coordination mechanisms and major constraints to provide high quality care. Results: GPs value well their expertise in the management of musculoskeletal diseases (6,7 ± 1,0 on a scale of 1 to 10). Less than 25% of GPs are coordinated with hospital specialists. For them, waiting lists are the main problem (8.2 ± 1,6/10) followed by lack of feedback (8 ± 1,9/10) and poor coordination (7.8 ± 1,9/10). Referenced specialties should change for some diseases (back pain and osteoarthritis). Specialists are critical for GPs. For specialists, the main problems are excessive workload (7,8 ± 2/10) and the inefficiency of healthcare information systems (7.4 ± 2/10). Conclusions: The vision of the problems affecting the care of musculoskeletal diseases differs between GPs and hospital specialists. The limited accessibility and workload excess, deficiencies in the flow of information and poor coordination are the most important problems in the proper care for musculoskeletal diseases (AU)

Attention to musculoskeletal diseases. Different visions of the same problem.

OBJECTIVE: To identify the main problems affecting general practitioners (GPs) and specialists in the care of the main musculoskeletal problems in Catalonia. METHOD: Cross-sectional, self-administered survey in a representative sample of GPs and all specialists in four areas (orthopedic surgery, rheumatology, physical medicine and rehabilitation and pain units). Variables evaluated in the survey were related to socio-demographic data, attention to musculoskeletal diseases, self-declared expertise, referral process, coordination mechanisms and major constraints to provide high quality care. RESULTS: GPs value well their expertise in the management of musculoskeletal diseases (6,7±1,0 on a scale of 1 to 10). Less than 25% of GPs are coordinated with hospital specialists. For them, waiting lists are the main problem (8.2±1,6/10) followed by lack of feedback (8±1,9/10) and poor coordination (7.8±1,9/10). Referenced specialties should change for some diseases (back pain and osteoarthritis). Specialists are critical for GPs. For specialists, the main problems are excessive workload (7,8±2/10) and the inefficiency of healthcare information systems (7.4±2/10). CONCLUSIONS: The vision of the problems affecting the care of musculoskeletal diseases differs between GPs and hospital specialists. The limited accessibility and workload excess, deficiencies in the flow of information and poor coordination are the most important problems in the proper care for musculoskeletal diseases.

Análisis de coste-utilidad e impacto presupuestario de la prevención primaria con alendronato de la fractura osteoporótica de cadera en Cataluña / Cost-utility and budget impact analysis of primary prevention with alendronate of osteoporotic hip fractures in Catalonia

Objetivos. Determinar si la prevención farmacológica primaria de la fractura osteoporótica de cadera es una medida coste-útil en Cataluña y conocer cuál sería su impacto presupuestario. Material y métodos. Se realiza un análisis de coste-utilidad con perspectiva social y horizonte temporal de 10 y 20 años. Análisis de sensibilidad univariante. Se compara no hacer nada con una intervención que incluye el cribado de osteoporosis en mujeres > 64 años y, en las diagnosticadas, el tratamiento con alendronato genérico durante 10 años. Se elaboran árboles de decisión para los grupos de 65-69, 70-74 y 75-79 años. Los datos de FC provienen de las altas de 2009. Para los costes se utilizan las tasas pagadas por la aseguradora pública. Resultados. En 2009 hubo 9.262 FC. El coste directo fue de 55 millones de euros (5.943,4 €/paciente). El coste total es de 227 millones de euros en 10 años. La intervención domina en todos los grupos de edad en una perspectiva de 20 años. En cualquier horizonte y grupo de edad, los diferentes escenarios sitúan el valor por AVAC inferior o dentro de los valores propuestos para España. El impacto presupuestario se calcula en 8,9 millones de euros que incrementa en un 31% el coste directo actual, y en un 0,5% el presupuesto público de farmacia. Considerando los costes totales y la perspectiva de 20 años, el ahorro anual es de 7,4 millones de euros. Conclusiones. La prevención de FC con alendronato en mujeres osteoporóticas > 64 años es coste-útil a largo plazo (20 años) con bajo impacto presupuestario en el grupo de 75-79 años (AU)

Objectives. To determine whether primary drug prevention of osteoporotic hip fracture is a useful measure in Catalonia and what would be their budgetary impact. Material and methods. We performed a cost-utility social perspective study with a time horizon of 10 to 20 years. Univariate sensitivity analysis was performed. Doing nothing is compared with an intervention that includes screening for osteoporosis in women> 64 years and in those diagnosed and who received treatment with generic alendronate for 10 years. Decision trees are developed for groups of 65-69, 70-74 and 75-79. HF data is from 2009 hospital discharges .Costs are derived from fees paid by public insurance. Results. In 2009 there were 9262 HF. The direct cost was € 55 million (€ 5,943.4/patient). The total cost was € 227 million for 10 years. The intervention dominates in all age groups in a 20 year perspective. In any horizon and age group, the different scenario puts the value per QALY below or within the proposed values for Spain. The budgetary impact is estimated at € 8.9 million which increased by 31% the actual direct cost, and 0.5% of the public pharmacy budget. Considering the total costs and the prospect of 20 years, annual savings of 7.4 million € were seen. Conclusions. The prevention of HF with alendronate in osteoporotic women>64 years is cost-useful in the long term (20 years) with a low budgetary impact in the 75-79 year group (AU)

Planificación en enfermedades reumáticas. Elaboración del Plan director de las enfermedades reumáticas y del aparato locomotor de Cataluñaa / Health planning in rheumatic diseases. Elaboration of a master plan for rheumatic and musculoskeletal diseases of Catalonia

Introducción: Las enfermedades reumáticas son el problema de salud crónico más prevalente de la población adulta catalana. Conllevan importantes problemas para el individuo y para la sociedad, con elevados costes económicos directos e indirectos. Desde el Departamento de Salud de Cataluña se propuso la creación del Plan director de las enfermedades reumáticas y del aparato locomotor, como herramienta de planificación para abordar de forma integral estos problemas. Objetivo: Presentar la metodología de trabajo que se ha utilizado para el desarrollo del Plan y las propuestas finales de este. Métodos: Inicialmente se realizó un análisis de situación de estos problemas en nuestra comunidad y se establecieron los objetivos del Plan. Posteriormente, se definieron las líneas estratégicas y se organizaron grupos de trabajo para analizar las diferentes propuestas de mejora que fueron consensuadas con los actores implicados. Resultados: Las propuestas del Plan incluyen aspectos que van desde la prevención a la rehabilitación con el objetivo de racionalizar el uso de los recursos y aumentar la eficiencia en la atención. Se propone un nuevo modelo asistencial que acerca la asistencia especializada a la atención primaria en forma de consultorías y la organización de unidades funcionales de aparato locomotor, entre otras propuestas. Conclusiones: El Plan director establece las líneas de actuación de la política sanitaria y de la planificación en relación con estos trastornos a partir del análisis de la situación, el establecimiento de objetivos de mejora de la atención y la propuesta de acciones concretas para conseguirlos (AU)

Background: Rheumatic diseases (RDs) are among the most common chronic health problems of the Catalan adult population. They cause important problems for individuals, their families and for the society overall, with high direct and indirect economic costs. The Department of Health of Catalonia promoted the creation of a Master Plan for the rheumatic diseases, as a tool for planning an integral approach to these problems. Objective: To present the work methodology that has been used in the development of the Master Plan and its final proposals. Methods: First an analysis of the burden caused by these problems in our community was performed and the objectives of the Plan were established. Later, strategic lines were defined and work groups organized to analyze proposals for improvement, which after consensus were accepted. Results: The proposals of the Plan comprise actions in the scope of prevention, rationalization in the use of resources and the formation of professionals among others. Changes in the health care model for RDs were proposed in order to improve specialized and primary care coordination with clinics and musculoskeletal functional units. Conclusions: The Master Plan recommends actions to improve the attention of the population through operative planning and the services to different providers. The Master Plan will establish the health policy action lines directed against these disorders (AU)

Cost-utility and budget impact analysis of primary prevention with alendronate of osteoporotic hip fractures in Catalonia.

OBJECTIVES: To determine whether primary drug prevention of osteoporotic hip fracture is a useful measure in Catalonia and what would be their budgetary impact. MATERIAL AND METHODS: We performed a cost-utility social perspective study with a time horizon of 10 to 20 years. Univariate sensitivity analysis was performed. Doing nothing is compared with an intervention that includes screening for osteoporosis in women> 64 years and in those diagnosed and who received treatment with generic alendronate for 10 years. Decision trees are developed for groups of 65-69, 70-74 and 75-79. HF data is from 2009 hospital discharges .Costs are derived from fees paid by public insurance. RESULTS: In 2009 there were 9262 HF. The direct cost was € 55 million (€ 5,943.4/patient). The total cost was € 227 million for 10 years. The intervention dominates in all age groups in a 20 year perspective. In any horizon and age group, the different scenario puts the value per QALY below or within the proposed values for Spain. The budgetary impact is estimated at € 8.9 million which increased by 31% the actual direct cost, and 0.5% of the public pharmacy budget. Considering the total costs and the prospect of 20 years, annual savings of 7.4 million € were seen. CONCLUSIONS: The prevention of HF with alendronate in osteoporotic women>64 years is cost-useful in the long term (20 years) with a low budgetary impact in the 75-79 year group.

Health planning in rheumatic diseases. Elaboration of a master plan for rheumatic and musculoskeletal diseases of Catalonia.

BACKGROUND: Rheumatic diseases (RDs) are among the most common chronic health problems of the Catalan adult population. They cause important problems for individuals, their families and for the society overall, with high direct and indirect economic costs. The Department of Health of Catalonia promoted the creation of a Master Plan for the rheumatic diseases, as a tool for planning an integral approach to these problems. OBJECTIVE: To present the work methodology that has been used in the development of the Master Plan and its final proposals. METHODS: First an analysis of the burden caused by these problems in our community was performed and the objectives of the Plan were established. Later, strategic lines were defined and work groups organized to analyze proposals for improvement, which after consensus were accepted. RESULTS: The proposals of the Plan comprise actions in the scope of prevention, rationalization in the use of resources and the formation of professionals among others. Changes in the health care model for RDs were proposed in order to improve specialized and primary care coordination with clinics and musculoskeletal functional units. CONCLUSIONS: The Master Plan recommends actions to improve the attention of the population through operative planning and the services to different providers. The Master Plan will establish the health policy action lines directed against these disorders.

Practical access to the proline analogs (S,S,S)- and (R,R,R)-2-methyloctahydroindole-2-carboxylic acids by HPLC enantioseparation.

An efficient methodology for the preparation of the α-tetrasubstituted proline analog (S,S,S)-2-methyloctahydroindole-2-carboxylic acid, (S,S,S)-(αMe)Oic, and its enantiomer, (R,R,R)-(αMe)Oic, has been developed. Starting from easily available substrates and through simple transformations, a racemic precursor has been synthesized in excellent yield and further subjected to HPLC resolution using a cellulose-derived chiral stationary phase. Specifically, a semipreparative (250 mm × 20 mm ID) Chiralpak® IC column has allowed the efficient resolution of more than 4 g of racemate using a mixture of n-hexane/tert-butyl methyl ether/2-propanol as the eluent. Multigram quantities of the target amino acids have been isolated in enantiomerically pure form and suitably protected for incorporation into peptides.