Weekend and holiday admissions for decompensated heart failure and in-hospital mortality. A cumulative effect of "nonworking" days?

INTRODUCTION AND OBJECTIVES: The aim of this study was to analyze whether nonelective admissions in patients with heart failure (HF) on nonworking days (NWD) are associated with higher in-hospital mortality. METHODS: We conducted a retrospective (2018-2019) observational study of episodes of nonelective admissions in patients aged 18 years and older discharged with a principal diagnosis of HF in acute general hospitals of the Spanish National Health System. NWD at admission were defined as Fridays after 14:00hours, Saturdays, Sundays, and national and regional holidays. In-hospital mortality was analyzed with logistic regression models. The length of NWD was considered as an independent continuous variable. Propensity score matching was used as a sensitivity analysis. RESULTS: We selected 235 281 episodes of nonelective HF admissions. When the NWD periods were included in the in-hospital mortality model, the increases in in-hospital mortality compared with weekday admission were as follows: 1 NWD day (OR, 1.11; 95%CI, 1.07-1.16); 2 days (OR, 1.13; 95%CI, 1.09-1.17); 3 (OR, 1.16; 95%CI, 1.05-1.27); and ≥4 days (OR, 1.20; 95%CI, 1.09-1.32). There was a statistically significant association between a linear increase in NWD and higher risk-adjusted in-hospital mortality (chi-square trend P=.0002). After propensity score matching, patients with HF admitted on NWD had higher in-hospital mortality than those admitted on weekdays (OR, 1.11; average treatment effect, 12.2% vs 11.1%; P<.001). CONCLUSIONS: We found an association between admissions for decompensated HF on an NWD and higher in-hospital mortality. The excess mortality is likely not explained by differences in severity. In this study, the "weekend effect" tended to increase as the NWD period became longer.

Knowledge of physiological aspects, clinical management, and nutrition among patients with type 2 diabetes mellitus

Objective: To evaluate the knowledge about physiological aspects, clinical management, and nutrition of primary care patients with type 2 diabetes mellitus by sociodemographic, economic, and clinical variables. Material and methods: We conducted an observational cross-sectional study in 22 Family Health Strategy units in the city of Montes Claros, Minas Gerais, in 2015 among 353 patients registered with type 2 diabetes mellitus. A structured questionnaire was used to assess sociodemographic and clinical characteristics. Knowledge was assessed using the diabetes knowledge scale questionnaire. Data were presented with absolute frequencies and percentages and analyzed using Poisson regression. Results: Most respondents demonstrated satisfactory knowledge in the field of physiology (60.30%) and unsatisfactory knowledge in clinical management (67.7%) and nutrition (61.5%). Schooling was associated with knowledge in the areas of physiology, clinical management and nutrition, and treatment associated with clinical management. Conclusion: Knowledge about type 2 diabetes mellitus was related to sociodemographic characteristics and treatment. The importance of health education for coping with this chronic condition is evident.

Objetivo: Evaluar los conocimientos sobre aspectos fisiológicos, manejo clínico y nutrición de usuarios con diabetes mellitus tipo 2 registrados en unidades de Atención Primaria y su análisis según variables sociodemográficas, económicas y clínicas. Métodos: Se trata de un estudio observacional y transversal realizado en 22 unidades de la Estrategia Salud de la Familia de la ciudad de Montes Claros, Minas Gerais, en 2015 con 353 pacientes registrados con diabetes mellitus tipo 2. Se utilizó un cuestionario estructurado para evaluar las características sociodemográficas y clínicas. El conocimiento se evaluó mediante el cuestionario de la escala de conocimiento de la diabetes. Los datos se presentaron en frecuencias absolutas y porcentajes. El análisis de datos utilizó la regresión de Poisson. Resultados: La mayoría de los encuestados demostró conocimientos satisfactorios en el campo de fisiología (60,30%) y conocimientos insatisfactorios en manejo clínico (67,7%) y nutrición (61,5%). La escolaridad se asoció con conocimientos en las áreas de Fisiología, Manejo Clínico y Nutrición e treatment con Manejo Clínico. Conclusión: El conocimiento sobre la diabetes mellitus tipo 2 está relacionado con las características sociodemográficas y el. tratamento. La importancia de la educación en salud para el enfrentamiento de esta condición crónica es evidente.

[Management optimization of neovascular age-related macular degeneration in Spain: Evolution towards proactive treatment models]. / Optimización del manejo de la degeneración macular asociada a la edad neovascular en España: evolución hacia modelos proactivos de tratamiento.

INTRODUCTION AND OBJECTIVE: Healthcare resources optimization is crucial to assume the growing demand of neovascular age-related macular degeneration (nAMD). This work provides guidelines and support so that each hospital can lead its change management. METHODS: The OPTIMUS project (n=10 hospitals) was based on face-to-face interviews with the key staff of the ophthalmology services, and alignment with the main responsible for each centre (nominal group) to identify potential needs for improving nAMD. The OPTIMUS nominal group was expanded to 12 centres (eVOLUTION). Through different remote work sessions, different guides and tools were defined and developed to implement proactive treatment strategies, one-step treatment administration and potential for remote visits (eConsult) in nAMD. RESULTS: The information collected from the OPTIMUS interviews and working groups (n=10 centres) defined roadmaps to promote the development of protocols and proactive treatment strategies, including healthcare workload optimization and one-stop treatment administration in nAMD. With eVOLUTION, processes and tools were developed to promote eConsult: (i) healthcare burden calculator; (ii) definition of potential patients for telematic management; (iii) definition of nAMD management archetypes; (iv) definition of processes for implementation of eConsult by archetype; and (v) key performance indicators for changing evaluation. CONCLUSIONS: Managing change is an internal task that requires an adequate diagnosis of processes and feasible implementation roadmaps. OPTIMUS and eVOLUTION provide the basic tools for an autonomous advance of hospitals in the optimization of AMD management, with the available resources.

Perfil clínico-epidemiológico de pacientes con covid-19 hospitalizados en un hospital universitario de referencia / Clinical-epidemiological profile of patients with covid-19 admitted to a university hospital reference

Objetivo: Caracterizar el perfil epidemiológico de los pacientes hospitalizados con COVID-19 en una unidad de emergencia de referencia en el norte de Paraná; analizar el perfil de los pacientes afectados por COVID-19 en términos de: sexo, color/raza, edad, estado civil, procedencia y tipo de derivación; medir el promedio de estancia hospitalaria, desde la fecha de ingreso hasta el alta del paciente, determinar el porcentaje de los principales resultados hospitalarios. Método: Se trata de una investigación de campo con abordaje cuantitativo, observacional, unicéntrica, descriptiva, exploratoria y retrospectiva, realizada en el Hospital Universitario de la Universidad Estadual de Londrina, ubicado en el norte de Paraná. La población de estudio estuvo constituida por los datos de 2.800 pacientes ingresados y hospitalizados con diagnóstico confirmado de COVID-19 en el Servicio de Urgencias del hospital en cuestión, según registros del núcleo de epidemiología y el Servicio de Estadísticas y Archivo Médico, desde enero de 2021 hasta julio de 2021. de 2021. Resultados: Se observó que la mayoría de los afectados eran del sexo masculino, de raza blanca, solteros y tenían entre 58 y 67 años. La estancia hospitalaria media fue de 16 días. El Servicio Móvil de Atención de Urgencias presentó los mayores registros de derivaciones y los desenlaces de alta y muerte tuvieron valores muy similares. Conclusión: Se concluye que la segunda ola de COVID-19 fue devastadora en todos los seguimientos, reflejando el cambio en el perfil etario de los afectados, el aumento de las tasas de hospitalización, las altas tasas de mortalidad y la estrecha relación entre el período de hospitalización y progresión a la muerte. (AU)

Objetivo: Caracterizar o perfil epidemiológico dos pacientes internados com COVID-19 em uma unidade de pronto socorro referência do norte do Paraná; analisar o perfil dos pacientes acometidos por COVID-19 quanto ao: gênero, cor/raça, idade, estado civil, procedência e tipo de encaminhamento; mensurar o tempo médio de internação hospitalar, desde a data da admissão do paciente até sua alta, determinar o percentual dos principais desfechos hospitalares. Método: Tratou-se de uma pesquisa de campo com abordagem quantitativa, do tipo observacional, unicêntrica, descritiva, exploratória e retrospectiva, realizada no Hospital Universitário da Universidade Estadual de Londrina, localizado no norte do Paraná. A população do estudo consistiu dos dados de 2.800 pacientes admitidos e internados com diagnóstico confirmado de COVID-19 no Pronto Socorro do hospital em questão, conforme registros do núcleo de epidemiologia e Serviço de Arquivo Médico e Estatística, no período de janeiro de 2021 a julho de 2021. Resultados: Observou-se que maioria dos acometidos eram do sexo masculino, possuíam cor branca, eram solteiros e tinham entre 58 e 67 anos. O tempo médio de internação foi de 16 dias. O Serviço de Atendimento Móvel de Urgência obteve os maiores registros de encaminhamentos e os desfechos de alta e óbito possuíram valores muito próximos. Conclusão: Conclui-se que a segunda onda da COVID-19 se mostrou devastadora em todos os seguimentos, refletindo na mudança do perfil etário dos acometidos, no aumento das taxas de internação, nos altos índices de mortalidade e na a estreita relação entre o período de internação e a evolução ao óbito. (AU)

Objective: To characterize the epidemiological profile of patients hospitalized with COVID-19 in a referral emergency unit in northern Paraná; analyze the profile of patients affected by COVID-19 regarding gender, color/race, age, marital status, origin and type of referral; measure the average length of hospital stay, from the date of admission of the patient until discharge, determine the percentage of the main hospital outcomes. Method: It was field research with a quantitative, observational, unicentric, descriptive, exploratory and retrospective approach, carried out at the University Hospital of the State University of Londrina, located in the north of the Paraná. The study population consisted of data from 2,800 patients admitted and hospitalized with a confirmed diagnosis of COVID-19 in the Emergency Room of the hospital in question, according to records of the epidemiology center and Medical and Statistical Archive Service, from January 2021 to July 2021. Results: It was observed that most of those affected were male, had a white color, were single and were between 58 and 67 years old. The mean length of hospitalization was 16 days. The Mobile Emergency Care Service obtained the highest referral records and the discharge and death outcomes had very close values. Conclusion: It is concluded that the second wave of COVID-19 was devastating in all segments, reflecting the change in the age profile of those affected, the increase in hospitalization rates, high mortality rates and the close relationship between the hospitalization period and the evolution to death. (AU)

Influencia de las reclamaciones en la gestión asistencial de un servicio de cirugía ortopédica y traumatología / Influence of claims on the management of an orthopaedic surgery and traumatology service

Introducción: Las reclamaciones constituyen una de las principales fuentes de información para evaluar la calidad percibida en los centros asistenciales, siendo la cirugía ortopédica y traumatología (COT) una de las especialidades con mayor probabilidad de recibirlas por su elevada demanda quirúrgica que genera importantes listas de espera. Objetivos: Mostrar la evolución de las reclamaciones presentadas en un servicio de COT, clasificar los motivos expuestos e identificar las oportunidades de mejora derivadas de las mismas. Metodología: Estudio epidemiológico descriptivo, observacional y de orientación temporal retrospectiva. Revisión de los registros correspondientes a las reclamaciones presentadas durante el periodo 2014-2018 en el servicio de COT de un hospital universitario. Para la clasificación de las reclamaciones se han utilizado los motivos establecidos por la aseguradora pública CatSalut. El análisis estadístico se ha realizado mediante el programa Excel® y el software R-Project (versión 4.0.2), considerándose un nivel de significación estadística de p<0,05. Resultados: El servicio de COT ha recibido un total de 424 reclamaciones durante el periodo 2014-2018, mostrando una tasa global de 3,18 reclamaciones por cada 1.000 episodios asistenciales considerados. Los principales motivos de reclamación han sido los organizativos (73%) y los asistenciales (20%). A partir del año 2016 se evidencia un descenso en el número de las reclamaciones presentadas. Conclusión: La implantación de procedimientos informativos estables para modular las expectativas de los pacientes incorporados a las listas de espera, y una comunicación más empática que facilite una buena relación paciente-profesional son acciones de mejora identificadas para reducir su frecuencia de presentación.(AU)

Introduction: Claims constitute one of the main sources of information to evaluate the perceived quality in healthcare centres, being Orthopaedic and Traumatology Surgery (OTS) one of the specialties with greater probability of receiving them due to its high surgical demand generating long waiting lists. Objectives: To display the evolution of the filed claims addressed to the OTS department, to classify the reasons stated in the complaint, and to identify the opportunities for improvement derived from the forementioned. Methodology: Descriptive, observational and retrospective epidemiological study. The target population has been configured by those citizens who have submitted a claim addressed to the OTS Service of a University Hospital of Barcelona from 2014 to 2018. In reference with the classification of claims, it has been used the reasons established by the public service CatSalut: assistance, treat, information, organisation, documentation and hospitality/habitability/comfort. Results: OTS service received a total of 424 claims during the study period, showing an overall rate of 3.18 claims per 100 assistance episodes considered. The main reasons for claiming were organizational (73%) and assistance (20%). No claims regarding dissatisfaction of hospitality/habitability/comfort were registered. A noticeable decrease in the number of claims submitted is observed since 2016. Conclusion: Actions in the management of waiting lists and standardised information procedures that improve the doctor–patient relationship have been identified as measures of improvement to reduce the claim presentation rate.(AU)

[Translated article] Influence of claims on the management of an orthopaedic surgery and traumatology service / Influencia de las reclamaciones en la gestión asistencial de un servicio de cirugía ortopédica y traumatología

Introducción: Las reclamaciones constituyen una de las principales fuentes de información para evaluar la calidad percibida en los centros asistenciales, siendo la cirugía ortopédica y traumatología (COT) una de las especialidades con mayor probabilidad de recibirlas por su elevada demanda quirúrgica que genera importantes listas de espera. Objetivos: Mostrar la evolución de las reclamaciones presentadas en un servicio de COT, clasificar los motivos expuestos e identificar las oportunidades de mejora derivadas de las mismas. Metodología: Estudio epidemiológico descriptivo, observacional y de orientación temporal retrospectiva. Revisión de los registros correspondientes a las reclamaciones presentadas durante el periodo 2014-2018 en el servicio de COT de un hospital universitario. Para la clasificación de las reclamaciones se han utilizado los motivos establecidos por la aseguradora pública CatSalut. El análisis estadístico se ha realizado mediante el programa Excel® y el software R-Project (versión 4.0.2), considerándose un nivel de significación estadística de p<0,05. Resultados: El servicio de COT ha recibido un total de 424 reclamaciones durante el periodo 2014-2018, mostrando una tasa global de 3,18 reclamaciones por cada 1.000 episodios asistenciales considerados. Los principales motivos de reclamación han sido los organizativos (73%) y los asistenciales (20%). A partir del año 2016 se evidencia un descenso en el número de las reclamaciones presentadas. Conclusión: La implantación de procedimientos informativos estables para modular las expectativas de los pacientes incorporados a las listas de espera, y una comunicación más empática que facilite una buena relación paciente-profesional son acciones de mejora identificadas para reducir su frecuencia de presentación.(AU)

Introduction: Claims constitute one of the main sources of information to evaluate the perceived quality in healthcare centres, being Orthopaedic and Traumatology Surgery (OTS) one of the specialties with greater probability of receiving them due to its high surgical demand generating long waiting lists. Objectives: To display the evolution of the filed claims addressed to the OTS department, to classify the reasons stated in the complaint, and to identify the opportunities for improvement derived from the forementioned. Methodology: Descriptive, observational and retrospective epidemiological study. The target population has been configured by those citizens who have submitted a claim addressed to the OTS Service of a University Hospital of Barcelona from 2014 to 2018. In reference with the classification of claims, it has been used the reasons established by the public service CatSalut: assistance, treat, information, organisation, documentation and hospitality/habitability/comfort. Results: OTS service received a total of 424 claims during the study period, showing an overall rate of 3.18 claims per 100 assistance episodes considered. The main reasons for claiming were organizational (73%) and assistance (20%). No claims regarding dissatisfaction of hospitality/habitability/comfort were registered. A noticeable decrease in the number of claims submitted is observed since 2016. Conclusion: Actions in the management of waiting lists and standardised information procedures that improve the doctor–patient relationship have been identified as measures of improvement to reduce the claim presentation rate.(AU)

Impacto COVID-19 en la urgencia y hospitalización de un hospital terciario. Lecciones de gestión aprendidas / COVID-19 impact on the emergency and hospitalization of a tertiary hospital. Management lessons learned

Introducción: El objetivo es analizar el impacto de la pandemia COVID-19 en las urgencias e ingresos hospitalarios pediátricos. Métodos: Estudio de cohortes retrospectivo, de los pacientes atendidos en un hospital terciario, desde el 14 de marzo hasta el 26 de abril de 2020 comparándose con el mismo periodo de los 3 años anteriores. Resultados: Se observa una notable reducción global de las visitas a urgencias e ingresos en todas las áreas pediátricas, manteniéndose la asistencia en neonatología y los ingresos programados en oncología. Discusión: La reducción de la actividad global en la urgencia pediátrica no es solo explicable por la disminución de las enfermedades transmisibles. Ha podido contribuir la disminución de la demanda inadecuada y de los ingresos inapropiados. La disponibilidad de camas pediátricas haría innecesaria la reducción de la actividad quirúrgica programada y permitiría redistribuir recursos a áreas con mayor presión asistencial.(AU)

Introduction: The objective is to analyze the impact of the COVID-19 pandemic on the pediatric emergencies and hospital admissions. Methods: Retrospective cohort study of patients treated in a tertiary hospital, from March 14 to April 26, 2020, compared to the same period of the previous 3 years. Results: A notable overall reduction in emergency room visits and admissions is observed in all pediatric areas, maintaining care in neonatology and scheduled admissions in oncology. Discussion: The reduction in global activity in pediatric emergencies is not only explained by the decrease in contagious diseases. The decrease in inadequate demand and inappropriate income may have contributed. The availability of pediatric beds would make the reduction of programmed surgical activity unnecessary and would allow the redistribution of resources to areas with greater healthcare pressure.(AU)

Asistencia biventricular en el manejo de la disfunción ventricular izquierda secundaria a ECMO-VA periférica: a propósito de 2 casos / Peripheral VA-ECMO left ventricular dysfunction: A combined biventricular assistance two case-report

Presentamos a 2pacientes con shock cardiogénico que desarrollaron disfunción ventricular izquierda severa debido a una válvula aórtica disfuncionante mientras estaban en extra-corporeal membrane oxygenation (ECMO)-VA periférica. Los pacientes fueron tratados combinando un dispositivo de asistencia mecánica para el ventrículo izquierdo (VI) y ECMO-VA central para apoyar el ventrículo derecho, proporcionando así una asistencia respiratoria y circulatoria adecuada que les permitió optar a una recuperación completa, o bien llegar a ser candidatos a trasplante cardiaco. Por lo tanto, recomendamos dicha combinación en aquellos pacientes que desarrollan disfunción grave del VI mientras reciben apoyo de ECMO-VA periférica.(AU)

We report 2patients with cardiogenic shock that developed severe left ventricular dysfunction due to a non-opening aortic valve while on peripheral VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenator). Patients were managed combining a LV (Left Ventricle) mechanical assist device, and central VA – ECMO to support the right ventricle, thus providing full circulatory and respiratory assistance. Patients were able to bridge to cardiac transplantation. We therefore recommend such combination in patients with severe LV dysfunction while on p-ECMO (peripheral ECMO) support.(AU)

Peripheral VA-ECMO left ventricular dysfunction: A combined biventricular assistance two case-report.

We report 2 patients with cardiogenic shock that developed severe left ventricular dysfunction due to a non-opening aortic valve while on peripheral VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenator). Patients were managed combining a LV (Left Ventricle) mechanical assist device, and central VA - ECMO to support the right ventricle, thus providing full circulatory and respiratory assistance. Patients were able to bridge to cardiac transplantation. We therefore recommend such combination in patients with severe LV dysfunction while on p-ECMO (peripheral ECMO) support.

Análisis y recomendaciones para la mejora de la gestión clínica y la atención del cáncer de mama metastásico en España / Analysis and recommendations for improved clinical management and care of metastatic breast cancer in Spain

El cáncer de mama metastásico (CMM) constituye la primera causa de muerte por cáncer entre las mujeres y plantea importantes retos en la práctica clínica y en la convivencia con la enfermedad para pacientes y familiares. Con la participación de un amplio panel de oncólogos médicos y representantes de pacientes, en este proyecto se analizaron los recursos (herramientas de planificación, registros de cáncer), proceso asistencial (diagnóstico, tratamiento, cuidados paliativos) y procesos transversales (atención psicosocial, hábitos de vida saludables, rol de las asociaciones de pacientes) en el abordaje del CMM en el contexto sanitario español. El trabajo realizado permitió identificar una serie de áreas de mejora y proponer 42 recomendaciones orientadas a mejorar la calidad asistencial y la atención de los pacientes con CMM y sus cuidadores organizadas en las siguientes áreas de acción: registros de cáncer, coordinación entre niveles asistenciales, diagnóstico de la metástasis, comunicación y habilidades interpersonales, accesibilidad a fármacos, ensayos clínicos, el papel de la enfermería en el CMM, cuidados paliativos, atención psicosocial y promoción de estilos de vida saludables. Estas recomendaciones, elaboradas desde una perspectiva integral y centradas en las características del entorno sanitario en España, ofrecen un punto de partida para la mejora de la calidad asistencial y pueden ser de gran valor en otros entornos sanitarios que se enfrenten a las mismas necesidades en el abordaje del CMM. (AU)

Metastatic breast cancer (MBC) is the first cause of cancer-related mortality among women and poses major challenges in clinical practice and for persons with the disease and their families. With the collaboration of a wide panel of medical oncologists and patient representatives, this project analysed the resources (planning tools, cancer registries), healthcare processes (diagnosis, treatment, palliative care) and related processes (psychosocial care, healthy lifestyles, role of patient associations) in the approach to MBC in the Spanish healthcare setting. The work carried out allowed identification a series of areas for improvement and a proposal for 42 recommendations aimed at improving healthcare quality and the care of patients with MBC and their carers organized in the following areas: cancer registries, liaison between healthcare levels, diagnosis of metastasis, communication and interpersonal skills, drug access, clinical trials, the role of nurses in MBC, palliative care, psychosocial care, and promotion of healthy lifestyles. These recommendations, drafted from an integrated perspective and based on the characteristics of the Spanish healthcare setting, provide a springboard for healthcare improvement and could be of strong value to other healthcare settings facing the same challenges in the approach to MBC. (AU)

[Translated article] Influence of claims on the management of an orthopaedic surgery and traumatology service.

INTRODUCTION: Claims constitute one of the main sources of information to evaluate the perceived quality in healthcare centres, being Orthopaedic and Traumatology Surgery (OTS) one of the specialties with greater probability of receiving them due to its high surgical demand generating long waiting lists. OBJECTIVES: To display the evolution of the filed claims addressed to the OTS department, to classify the reasons stated in the complaint, and to identify the opportunities for improvement derived from the forementioned. METHODOLOGY: Descriptive, observational and retrospective epidemiological study. The target population has been configured by those citizens who have submitted a claim addressed to the OTS Service of a University Hospital of Barcelona from 2014 to 2018. In reference with the classification of claims, it has been used the reasons established by the public service CatSalut: assistance, treat, information, organisation, documentation and hospitality/habitability/comfort. RESULTS: OTS service received a total of 424 claims during the study period, showing an overall rate of 3.18 claims per 100 assistance episodes considered. The main reasons for claiming were organisational (73%) and assistance (20%). No claims regarding dissatisfaction of hospitality/habitability/comfort were registered. A noticeable decrease in the number of claims submitted is observed since 2016. CONCLUSION: Actions in the management of waiting lists and standardised information procedures that improve the doctor-patient relationship have been identified as measures of improvement to reduce the claim presentation rate.

¿La integración de la gestión de servicios sanitarios mejora la coordinación clínica? Experiencia en Cataluña / Does the integration of health services management improve clinical coordination? Experience in Catalonia

Objetivo: Analizar la experiencia y la percepción de coordinación clínica entre niveles asistenciales y los factores relacionados, organizativos y de interacción entre profesionales, según el tipo de integración de la gestión de los servicios de salud del área en Cataluña. Método: Estudio transversal basado en una encuesta on-line mediante autoadministración del cuestionario COORDENA-CAT (octubre-diciembre 2017). Población de estudio: médicos/as de atención primaria y especializada de agudos y media y larga estancia del sistema sanitario catalán. Muestra: 3308 médicos/as. Variables de resultado: experiencia y percepción de coordinación clínica, conocimiento y uso de mecanismos de coordinación y factores relacionados. Variables explicativas: área según tipo de gestión (integrada, semiintegrada, no integrada), sociodemográficas, laborales y de actitud. Análisis descriptivos por tipo de área y multivariados mediante regresión de Poisson robusta. Resultados: Se observaron mejores resultados de experiencia y percepción de coordinación clínica en áreas integradas que en semiintegradas, en especial en la transferencia de información y el seguimiento adecuado entre niveles. En cambio, no se encontraron diferencias entre áreas integradas y no integradas en la experiencia, aunque sí en la percepción de coordinación y algunos factores. Algunos problemas identificados son comunes a todas las áreas, como la accesibilidad entre niveles. Conclusiones: Las pocas diferencias entre áreas integradas y no integradas parecen indicar que la integración de la gestión puede facilitar la coordinación clínica, pero no es condición suficiente. Las diferencias con áreas semiintegradas parecen indicar la necesidad de promover la cooperación entre todos los proveedores de un territorio, con objetivos y mecanismos de coordinación comunes, para evitar desigualdades en la calidad asistencial. (AU)

Objective: To analyze the experience and perception of clinical coordination across care levels and doctor's organizational and interactional related factors, according to the type of management integration of the healthcare services of the area, in Catalonia. Method: Cross-sectional study based on an online survey by self-administration of the questionnaire COORDENA-CAT. Data collection: October-December 2017. Study population: primary and secondary care (acute and long-term care) doctors of the public Catalan health system. Sample: 3308 doctors. Outcome variables: experience and perception of clinical coordination, knowledge and use of coordination mechanisms and organizational and interactional factors; explanatory variables: area according to type of management (integrated, semi-integrated, non-integrated), socio-demographic, employment characteristics and attitude toward work. Descriptive analysis by type of area and multivariate analysis by robust Poisson regression. Results: Better clinical coordination was observed in integrated areas compared to those semi-integrated, mainly in relation to information transfer, adequate follow-up and perception of coordination in the area. No differences were found between integrated and non-integrated areas in the clinical coordination experience, although there were differences in perception and some related factors. There are common problems across areas, such as accessibility to secondary care. Conclusions: Few differences were found between integrated and non-integrated areas, revealing that management integration may facilitate clinical coordination but is not enough. Differences with semi-integrated areas indicate the need to promote cooperation formulas between all the providers of the territory, with common objectives and coordination mechanisms, in order to avoid inequalities in quality of care. (AU)

COVID-19 impact on the emergency and hospitalization of a tertiary hospital. Management lessons learned.

INTRODUCTION: The objective is to analyze the impact of the COVID-19 pandemic on the pediatric emergencies and hospital admissions. METHODS: Retrospective cohort study of patients treated in a tertiary hospital, from March 14 to April 26, 2020, compared to the same period of the previous 3 years. RESULTS: A notable overall reduction in emergency room visits and admissions is observed in all pediatric areas, maintaining care in neonatology and scheduled admissions in oncology. DISCUSSION: The reduction in global activity in pediatric emergencies is not only explained by the decrease in contagious diseases. The decrease in inadequate demand and inappropriate income may have contributed. The availability of pediatric beds would make the reduction of programmed surgical activity unnecessary and would allow the redistribution of resources to areas with greater healthcare pressure.

Influence of claims on the management of an orthopaedic surgery and traumatology service. / Influencia de las reclamaciones en la gestión asistencial de un servicio de cirugía ortopédica y traumatología.

INTRODUCTION: Claims constitute one of the main sources of information to evaluate the perceived quality in healthcare centres, being Orthopaedic and Traumatology Surgery (OTS) one of the specialties with greater probability of receiving them due to its high surgical demand generating long waiting lists. OBJECTIVES: To display the evolution of the filed claims addressed to the OTS department, to classify the reasons stated in the complaint, and to identify the opportunities for improvement derived from the forementioned. METHODOLOGY: Descriptive, observational and retrospective epidemiological study. The target population has been configured by those citizens who have submitted a claim addressed to the OTS Service of a University Hospital of Barcelona from 2014 to 2018. In reference with the classification of claims, it has been used the reasons established by the public service CatSalut: assistance, treat, information, organisation, documentation and hospitality/habitability/comfort. RESULTS: OTS service received a total of 424 claims during the study period, showing an overall rate of 3.18 claims per 100 assistance episodes considered. The main reasons for claiming were organizational (73%) and assistance (20%). No claims regarding dissatisfaction of hospitality/habitability/comfort were registered. A noticeable decrease in the number of claims submitted is observed since 2016. CONCLUSION: Actions in the management of waiting lists and standardised information procedures that improve the doctor-patient relationship have been identified as measures of improvement to reduce the claim presentation rate.

Toma de decisiones en la práctica clínica: Propuesta de un enfoque basado en evidencia "4E" / Decision-making in clinical practice: "4E" evidence-based framework proposal

Introducción: Las decisiones humanas son parcialmente racionales. En medicina, los escenarios críticos dificultan la toma de decisiones (TD). En esta revisión, proponemos el enfoque "4E" para mejorar la TD de intervenciones. Las "4E" incluyen decisiones: "eficaces" cuando las intervenciones han sido probadas en entornos controlados, "efectivas" cuando las intervenciones han sido probadas en entornos clínicos no controlados o pragmáticos, "eficientes" cuando los beneficios de una nueva intervención se evalúan con relación a sus costos, y decisiones que promuevan "equidad" cuando estas intervenciones se recomiendan de acuerdo con las necesidades del paciente, evitando barreras. El uso de este enfoque podría mejorar la TD en la práctica clínica, pero no es suficiente para garantizar su incorporación y uso. También es importante promover una dinámica organizativa, institucional y política de los sistemas de salud que promuevan el uso crítico de la evidencia para tomar decisiones.

Background:Human decisions are partially rational. In medicine, critical scenarios make decide-making (DM) difficult. In this review, we propose the "4E" approach to improve the DM of interventions. The "4E" approach includes decisions: "effectual" when interventions have been tested in controlled settings, "effective" when interventions have been tested in uncontrolled or pragmatic clinical settings, "efficient" when the benefits of a new intervention are evaluated by its costs, and decisionsthatpromote"equity"whentheseinterventionsare recommended according to the needs of the patient, avoiding barriers. Using this approach could improve DM in clinical practice, but it is not enough to guarantee its incorporation and use. It is also essential to promote the organizational, institutional, and political dynamics of health systems that promote evidence's critical use to make decisions

[Does the integration of health services management improve clinical coordination? Experience in Catalonia]. / ¿La integración de la gestión de servicios sanitarios mejora la coordinación clínica? Experiencia en Cataluña.

OBJECTIVE: To analyze the experience and perception of clinical coordination across care levels and doctor's organizational and interactional related factors, according to the type of management integration of the healthcare services of the area, in Catalonia. METHOD: Cross-sectional study based on an online survey by self-administration of the questionnaire COORDENA-CAT. DATA COLLECTION: October-December 2017. STUDY POPULATION: primary and secondary care (acute and long-term care) doctors of the public Catalan health system. SAMPLE: 3308 doctors. OUTCOME VARIABLES: experience and perception of clinical coordination, knowledge and use of coordination mechanisms and organizational and interactional factors; explanatory variables: area according to type of management (integrated, semi-integrated, non-integrated), socio-demographic, employment characteristics and attitude toward work. Descriptive analysis by type of area and multivariate analysis by robust Poisson regression. RESULTS: Better clinical coordination was observed in integrated areas compared to those semi-integrated, mainly in relation to information transfer, adequate follow-up and perception of coordination in the area. No differences were found between integrated and non-integrated areas in the clinical coordination experience, although there were differences in perception and some related factors. There are common problems across areas, such as accessibility to secondary care. CONCLUSIONS: Few differences were found between integrated and non-integrated areas, revealing that management integration may facilitate clinical coordination but is not enough. Differences with semi-integrated areas indicate the need to promote cooperation formulas between all the providers of the territory, with common objectives and coordination mechanisms, in order to avoid inequalities in quality of care.

Continuidade da gestão clínica entre níveis assistenciais: experiências dos usuários de uma rede municipal de saúde / Continuity of care between care levels: experiences of users in a municipal health network / Continuidad de la atención entre niveles asistenciales: experiencias de usuarios de una red municipal de salud

Este estudo analisa as experiências dos usuários sobre a continuidade da gestão clínica entre níveis assistenciais. Trata-se de um estudo transversal, quantitativo, que utiliza dados de um inquérito realizado com 407 usuários de uma rede pública de saúde de Recife, Pernambuco, Brasil, nos anos de 2017 e 2018. As experiências sobre a continuidade da gestão clínica foram exploradas a partir de duas dimensões: coerência da atenção e acessibilidade entre níveis assistenciais. Os usuários apresentaram opiniões mais positivas sobre a coerência da atenção que sobre a acessibilidade. Quanto à coerência da atenção, a maioria dos usuários referiu que os médicos da atenção primária e da especializada concordam entre si quanto a diagnóstico, tratamento e recomendações, e que o médico da atenção primária encaminha ao especialista quando necessário. Apenas 43% dos usuários relataram existir colaboração entre os médicos para resolução dos seus problemas de saúde. Quanto à acessibilidade, a maioria dos usuários (77,2%) referiu um longo tempo de espera para a consulta com o especialista e menos da metade (48,9%) referiu demora para atendimento na atenção primária. Os resultados deste estudo coincidem com outras investigações e evidenciam a necessidade de fomentar estratégias para alcançar uma integração efetiva das redes assistenciais e assim conferir ao usuário uma maior continuidade dos cuidados em saúde.

This study analyzes the experiences of users on the continuity of clinical management between care levels. This is a cross-sectional quantitative study that uses data from a survey conducted with 407 users of a public health network in Recife, Pernambuco State, Brazil, in 2017 and 2018. The experiences on the continuity of clinical management were explored from two dimensions: coherence of care and accessibility between levels of care. Users presented more positive opinions about coherence of care than accessibility. Regarding coherence of care, most users reported that primary and specialized care physicians agree on diagnosis, treatment, and recommendations, and that the primary care physician refers them to a specialist when necessary. Only 43% of users reported collaboration between physicians to solve their health problems. Concerning accessibility, most users (77.2%) reported a long waiting time for the consultation with a specialist and less than half (48.9%) reported delay for primary care. The results of this study coincide with other investigations and highlight the need to promote strategies for achieving effective integration of care networks and thus provide users with greater continuity of health care.

Este estudio analiza las experiencias de los usuarios sobre la continuidad de la gestión clínica entre los niveles asistenciales. Se trata de un estudio transversal, de carácter cuantitativo, realizado con datos de una encuesta aplicada a 407 usuarios de una red pública de salud en Recife, Pernambuco, Brasil, en los años de 2017 y 2018. Las experiencias sobre la continuidad de la gestión clínica fueron exploradas desde dos dimensiones: la consistencia de la atención y la accesibilidad entre niveles asistenciales. Los usuarios tenían opiniones más positivas sobre la consistencia de la atención que sobre la accesibilidad. En cuanto a la consistencia de la atención, la mayoría de los usuarios reportó que los médicos de atención primaria y de la atención especializada concuerdan entre sí en el diagnóstico, tratamiento y recomendaciones, y que los médicos de atención primaria realizan la derivación al especialista cuando necesario. Solamente el 43% de los usuarios reportaron percibir una colaboración entre los médicos para la búsqueda de soluciones a sus problemas de salud. Respecto a la accesibilidad, la mayoría de los encuestados (77,2%) refirió un largo tiempo de espera para la consulta con el especialista y menos de la mitad (48,9%) mencionó que tardaba la atención primaria. Los resultados de este estudio coinciden con el de otras investigaciones y muestran la necesidad de promover estrategias para lograr una efectiva integración de las redes de atención y, así, brindarle al usuario una mayor continuidad de la atención en salud.

Evolución de la productividad quirúrgica en el Hospital Maciel durante la crisis sanitaria SARS-CoV-2 / Evolution of surgical services at the Maciel Hospital during the SARS-CoV-2 health emergency / Evolução da produtividade cirúrgica no Hospital Maciel durante a crise de saúde por SARS-CoV-2

Resumen: Introducción: la pandemia por COVID-19 ha producido un fuerte impacto en la práctica quirúrgica mundial y luego de trascurridos 15 meses de diferir cirugías y seleccionar pacientes, aún no está bien establecida la magnitud del problema. Objetivo: conocer la evolución de la cirugía programada y su perfil de comportamiento en los servicios del Hospital Maciel (HM) durante el período de pandemia COVID-19. Método: se estudia la productividad quirúrgica del HM durante los períodos de prepandemia (2019) y pandemia (2020/2021), a partir del análisis de la oportunidad y especialidad de la cirugía realizada y la demanda de camas de Unidad de Cuidados Intensivos (UCI). Resultado: durante el período de pandemia (13/3/2020-30/6/2021) se operaron 5.302 pacientes; solo 132 (2,5%) se realizaron en pacientes COVID-19 positivos. La actividad quirúrgica global descendió 22,2% y en cirugías coordinadas 37,4%. Se mantuvo incambiado el volumen de cirugías de urgencias en relación al período prepandemia. Se constató un incremento exponencial de actividad en traumatología, (214%) y otorrinolaringología (57,4%); leve aumento en cirugías de tórax (12,7%), la cirugía vascular y la neurocirugía mantuvieron su actividad (0,3% y -7,8% respectivamente). Las clínicas de cirugía general descendieron su producción en forma importante: 63,5%. Conclusiones: se cumplió con la asistencia a pacientes oncológicos e impostergables, lo cual cambio el perfil de la cirugía, aumentando la actividad en las especialidades en detrimento marcado de la cirugía general y de las disciplinas que operan fundamentalmente patologías postergables y benignas de alta prevalencia.

Summary: Introduction: the COVID19 pandemic has caused a strong impact on surgical practices around the world, and after 15 months of differing surgeries and selecting patients, the actual magnitude of the problem has not been defined yet. Objective: to learn about the evolution of elective surgeries and behaviour profiles at the Maciel Hospital during the COVID19 pandemic. Method: the study analyses the delivery of elective surgeries at Maciel Hospital during the pre-pandemic (2019) and pandemic (2020/2021) periods by studying timing and area of specialization of the surgery performed and demand ICU beds. Results: during the pandemic period (13.3.2020-30.6.2021) 5302 patients were operated; and only 132 of them (2.5%) were COVID 19 positive. Global surgical services dropped 22.2% and 37.4% in elective surgeries. The number of emergency surgeries remained the same when compared to the pre-pandemic period. A huge growth was seen in traumatology (214%) and otorhinolaryngology (57.4%) services, a slight increase in thoracic consultations (12.7%) and no change was observed in vascular surgery consultations (0.3%). Consultations in other areas of specialization, such as urology, neurosurgery and general surgery significantly dropped, between 7.8% and 65.5%. Conclusions: health services were delivered to oncologic patients given their urgency, which, modfied the surgical profile, increasing activity in specializations and at the expense of general surgeries and the specialization areas the mainly operate bening conditions that may be delayed that are highly prevalent.

Resumo: Introdução: a pandemia COVID-19 teve um forte impacto na prática cirúrgica global e, após 15 meses de adiamento de cirurgias e seleção de pacientes, a magnitude do problema ainda não está bem estabelecida. Objetivo: conhecer a evolução da cirurgia programada e seu perfil de comportamento nos serviços do Hospital Maciel (HM) durante o período pandêmico de COVID-19. Método: estudou-se a produtividade cirúrgica programada do HM, nos períodos pré-pandêmico (2019) e pandêmico (2020/2021), a partir da análise da oportunidade e especialidade da cirurgia realizada e da demanda por leitos de UTI. Resultado: durante o período pandêmico (13/3/2020-30/6/2021), um total de 5.302 pacientes foram operados; Apenas 132 (2,5%) foram realizadas em pacientes COVID-19 positivos. A atividade cirúrgica global diminuiu 22,2% e 37,4% nas cirurgias coordenadas. Com relação ao período pré-pandêmico a quantidade de cirurgias de emergência permaneceu inalterada. Um aumento exponencial da atividade foi encontrado em trauma (214%) e otorrinolaringologia (57,4%); um pequeno aumento em tórax (12,7%); a cirurgia vascular manteve-se estável (0,3%), enquanto as demais disciplinas: urologia, neurocirurgia e ambas as clínicas de cirurgia geral diminuíram significativamente, entre 7,8% e 63,5%. Conclusões: foi cumprida a assistência aos doentes oncológicos e não postergáveis, o que alterou o perfil da cirurgia, aumentando a atividade nas especialidades, em acentuado detrimento da cirurgia geral e das disciplinas que operam sobretudo patologias postergáveis e benignas de alta prevalência.

Direitos da criança e adolescente hospitalizados à luz da gestão da clínica / Derechos de los niños y adolescentes hospitalizados a la luz de la gestión de la clínica / Rights of hospitalized children and adolescents in light of clinic management

Resumo Objetivo Analisar o (des)cumprimento dos Direitos da Criança e Adolescente hospitalizados à luz da gestão da clínica. Métodos Pesquisa de métodos mistos, explanatória sequencial, realizada entre setembro e dezembro de 2019, em hospital universitário do Centro-Oeste do Brasil. Participaram 60 acompanhantes, oito profissionais e quatro estudantes da área da saúde, em setores de internação de crianças e adolescentes. Aplicou-se escala Likert com os vinte direitos na etapa quantitativa, e entrevista semiestruturada na qualitativa, com análise descritiva e de conteúdo, respectivamente. Os dados foram integrados por conexão e analisados à luz de princípios da gestão da clínica. Resultados Na etapa quantitativa, identificaram-se direitos com menores percentuais de cumprimento: permanecer ao lado da mãe ao nascer, receber aleitamento materno, apoio psicológico, recreação, acompanhamento do currículo escolar e morte digna. Nos resultados qualitativos identificou-se desconhecimento da resolução pelos participantes, considerando parcialmente cumpridos os direitos: não permanecer internado desnecessariamente, ter acompanhante, não ser separado da mãe ao nascer, receber aleitamento materno, não sentir dor, conhecimento da enfermidade, desfrutar de recreação e programas educacionais, receber informação, todos os recursos para cura, proteção contra maus tratos, preservação de imagem, não ser utilizado pela mídia e ter morte digna. Identificaram-se princípios da gestão da clínica limitados, exigindo estratégias de fomento no hospital. Conclusão Princípios da gestão da clínica mostraram-se fragilizados, especialmente os de orientação às necessidades de saúde e integralidade, transparência e responsabilização social..

Resumen Objetivo Analizar el (in)cumplimiento de los Derechos del Niño y del Adolescente hospitalizados a la luz de la gestión de la clínica. Métodos Investigación con métodos mixtos, explanatoria secuencial, realizada entre septiembre y diciembre de 2019, en un hospital universitario del medio oeste de Brasil. Participaron 60 acompañantes, ocho profesionales y cuatro estudiantes del área de la salud, en sectores de internación de niños y de adolescentes. Se aplicó una escala Likert con los veinte derechos en la etapa cuantitativa, y entrevista semiestructurada en la cualitativa, con análisis descriptivo y de contenido, respectivamente. Los datos se integraron por conexión y fueron analizados a la luz de principios de la gestión de la clínica. Resultados En la etapa cuantitativa, se identificaron derechos con menores porcentajes de cumplimiento: permanecer al lado de la madre al nascer, lactancia materna, apoyo psicológico, recreación, acompañamiento del currículum escolar y muerte digna. En los resultados cualitativos se identificó un desconocimiento de la resolución de parte de los participantes, considerando parcialmente cumplidos los derechos: no permanecer internado sin necesidad, tener un acompañante, no separarse de la madre en el nacimiento, lactancia materna, no sentir dolor, conocimiento de la enfermedad, disfrutar de la recreación y programas educativos, recibir información, todos los recorridos para la curación, protección contra malos tratos, preservación de la imagen, no ser utilizado por los medios y tener una muerte digna. Se identificaron principios de la gestión de la clínica limitados, exigiendo estrategias de fomento en el hospital. Conclusión Principios de la gestión de la clínica se mostraron fragilizados, especialmente los de orientación a las necesidades de salud e integralidad, transparencia y responsabilización social.

Abstract Objective To analyze the (non)compliance with the rights of hospitalized children and adolescents in light of clinic management. Methods This is a mixed methods research, sequential explanatory, carried out between September and December 2019, in a university hospital in center-western Brazil. Sixty companions, eight professionals and four health care students participated in hospitalization sectors for children and adolescents. A Likert-type scale was applied with the twenty rights in the quantitative stage, and semi-structured interviews in the qualitative stage, with descriptive and content analysis, respectively. Data were integrated by connection and analyzed in light of clinic management principles. Results In the quantitative stage, rights were identified with the lowest percentages of compliance: staying by the mother's side at birth, being breastfed, psychological support, recreation, monitoring the school curriculum and dignified death. In the qualitative results, it was identified that participants did not know about the resolution, considering that the rights were partially complied with: not being hospitalized unnecessarily, having a companion, not being separated from the mother at birth, being breastfed, not feeling pain, knowing the disease, enjoying recreation and educational programs, receiving information, all resources for healing, protection against abuse, preservation of image, not being used by the media and having a dignified death. Limited principles of clinic management were identified, requiring development strategies in the hospital. Conclusion Principles of clinic management were weakened, especially those related to health needs and comprehensiveness, transparency and social accountability.

Coordenação da gestão clínica entre níveis: a perspectiva de médicos da atenção primária e especializada na cidade do Recife, Pernambuco, Brasil / Coordination of clinical management between levels: the views of physicians in primary and specialized care in Recife, Pernambuco State, Brazil / Coordinación de la gestión clínica entre niveles: la perspectiva de médicos de la atención primaria y especializada en la ciudad de Recife, Pernambuco, Brasil

Este estudo analisa a perspectiva dos profissionais médicos sobre a coordenação da gestão clínica entre níveis assistenciais. Trata-se de uma pesquisa transversal, quantitativa, que utiliza dados de um inquérito realizado com 182 médicos da atenção primária à saúde (APS) e especializada (AE) de Recife, Pernambuco, Brasil, em 2017. Os resultados apresentaram diferenças significativas na experiência dos médicos. Sobre encaminhamentos, a maioria (81,32%) considera que os médicos da APS encaminham os pacientes para AE quando necessário, sendo superior o percentual para médicos da APS (92,73%). Quanto à concordância, maior parte dos médicos da APS (67,27%) informou estar de acordo com o tratamento prescrito pelo profissional da AE, enquanto apenas 33,86% dos especialistas concordam com o médico da APS. Sobre a responsabilidade clínica, 89,09% dos médicos da APS afirmaram ser responsáveis clínicos pelo paciente, enquanto apenas 43,31% dos especialistas referiu o mesmo. Sobre a realização de recomendações, maior parte dos entrevistados (63,19%) considerou que os especialistas não fazem recomendações, sendo esse percentual maior entre os médicos da APS (81,82%). A respeito do tempo de espera, a maioria (82,42%) acha que o paciente espera muito para realizar a consulta na AE, sendo o percentual para médicos da APS (98,18%) superior ao da AE (75,59%). O tempo de espera para APS foi considerado longo por apenas 16,36% dos médicos da APS, em contraste com 38,58% dos médicos da AE. Os resultados deste estudo coincidem com investigações semelhantes e evidenciam a necessidade de fortalecer a coordenação clínica entre níveis para alcançar uma integração efetiva das redes assistenciais.

This study analyzed the views of physicians towards coordination of clinical management between different levels of care. This was a cross-sectional quantitative study using data from a survey of 182 physicians in primary healthcare (PHC) and specialized care in Recife, Pernambuco State, Brazil, in 2017. The results revealed significant differences in the physicians' experience. Considering referrals, the majority (81.32%) felt that PHC physicians referred patients to specialized care when necessary, and the proportion was higher in PHC physicians themselves (92.73%). As for agreement, two-thirds of PHC physicians (67.27%) reported that they agreed with the treatment prescribed by the specialist, while only 33.86% of the specialists agreed with the PHC physician. Concerning clinical responsibility, 89.09% of PHC physicians reported that they were clinically responsible for the patient, compared to only 43.31% of the specialists. As for recommendations, most of the interviewees (63.19%) felt that the specialists did not issue recommendations, and this proportion was higher among PHC physicians (81.82%). For waiting time, the majority (82.42%) felt that patients waited too long for appointments in specialized care, and the proportion was higher among PHC physicians (98.18%) than among specialists (75.59%). Only 16.36% of PHC physicians felt that waiting time was too long in PHC, compared to 38.58% of the medical specialists. The study's results are consistent with similar studies and highlight the need to strengthen coordination between levels of care to achieve effective integration in healthcare networks.

Este estudio analiza la perspectiva de los profesionales médicos sobre la coordinación de la gestión clínica entre niveles asistenciales. Se trata de una investigación transversal, cuantitativa, que utiliza datos de una encuesta realizada con 182 médicos de atención primaria en salud (APS) y especializada (AE) de Recife, Pernambuco, Brasil, en 2017. Los resultados presentaron diferencias significativas en la experiencia de los médicos. Sobre las derivaciones a especialistas, la mayoría (81,32%) considera que los médicos de la APS derivan a los pacientes hacia la AE cuando es necesario, siendo superior el porcentaje para médicos de la APS (92,73%). En cuanto a la concordancia, la mayor parte de los médicos de la APS (67,27%) informó estar de acuerdo con el tratamiento prescrito por parte del profesional de la AE, mientras que solamente un 33,86% de los especialistas están de acuerdo con el médico de la APS. Sobre la responsabilidad clínica, un 89,09% de los médicos de la APS afirmaron ser responsables clínicos del paciente, mientras que solamente un 43,31% de los especialistas informó sobre lo mismo. Sobre la realización de recomendaciones, la mayor parte de los entrevistados (63,19%) consideró que los especialistas no realizaron recomendaciones, siendo este porcentaje mayor entre los médicos de la APS (81,82%). Respecto al tiempo de espera, la mayoría (82,42%) cree que el paciente espera mucho para realizar la consulta en la AE, siendo el porcentaje para médicos de la APS (98,18%) superior al de la AE (75,59%). El tiempo de espera para la APS se consideró largo por solamente un 16,36% de los médicos de la APS, en contraste con un 38,58% de los médicos de la AE. Los resultados de este estudio coinciden con investigaciones semejantes y evidencian la necesidad de fortalecer la coordinación clínica entre niveles para alcanzar una integración efectiva de las redes asistenciales.