Los estudios del coste del alcoholismo: marco conceptual, limitaciones y resultados en España / Cost of illness studies: conceptual framework, limits and results in Spain

Los estudios sobre las consecuencias económicas del alcoholismo utilizan usualmente la metodología de “estudio del coste de la enfermedad”, donde el impacto de un determinado problema de salud sobre el bienestar de la sociedad se valora mediante la cuantificación de los costes de los recursos empleados para su prevención y tratamiento, los costes legales atribuibles, las pérdidas de productividad derivadas de la morbilidad y mortalidad específicas y la pérdida de años de vida ajustados por calidad. En España, y siguiendo esta metodología, se han valorado los costes del alcoholismo en más de 630.000 millones de pesetas anuales. Estos estudios han recibido críticas en relación con la identificación, medida y cuantificación de los costes, y su utilidad es discutida. Sin embargo, y pese a determinadas limitaciones, los estudios del coste de la enfermedad aproximan a la magnitud del problema, contribuyen a identificar los aspectos del problema que suponen un coste más elevado y, ayudan a orientar las políticas. El ajuste a las guías metodológicas y la explicitación detallada de las fuentes y métodos utilizados es un requisito necesario para su credibilidad (AU)

Studies on economic consequences of alcoholism usually use “cost-of-illness studies” methodology, where impact on society’s well-being of a certain problem of health is valued by means of quantifying the costs of resources used for its prevention and treatment, the attributable legal costs, the productivity losses derived from specific morbidity and mortality and the loss of quality adjusted life years. In Spain, and following this methodology, costs of alcoholism have been valued in more than 630,000 annual million pesetas. These studies have received critics in relation to the identification, measurement and quantification of costs, and their utility is been discussed. Nevertheless, and in spite of certain limitations, cost-of-illness studies approximate to the magnitude of the problem, contribute to identify aspects of the problem that suppose a higher cost and help to orient policies. Adjustment to methodology guides and explicit sources and used methods are necessary requirements for its credibility (AU)

[The health costs of alcoholism]. / Costes sanitarios del alcoholismo.

OBJECTIVE: To evaluate the economic effect in terms of health costs of alcohol abuse in Spain. DESIGN: The most up-to-date available, secondary sources of information were used. The period for the costs calculation was a natural year, with the prices adjusted to pesetas in 1996. The focus was based on the prevalence of cases per period. All the information referred to the whole of Spain. SETTING: Health costs were broken down into out-patient attendance, hospital emergencies, admissions, treatment at special centres and other health expenditure. MEASUREMENTS AND MAIN RESULTS: The total health cost attributable to alcoholism was 177,084 million pesetas, broken down as follows: a) cost of hospital admissions: 93,644 million pesetas (52.88%); b) cost of out-patient attendance: 34,600 million (19.53%); c) cost of treatment at special centres: 18,029 million (10.18%); d) cost of hospital emergencies: 10,481 million (5.91%); and e) other health expenditure: 20,330 million pesetas (11.48%). CONCLUSIONS: The figures arrived at do not cover the total cost of alcohol abuse, since a conservative approach was adopted. They stand as a minimum of the expenditure in our country. Some are direct costs on health authorities, whereas others can be managed as a cost-opportunity problem.

Utilizaçäo do ativador do plasminogênio tecidual (TPA) em cirurgia oftalmológica / Use of tissure plasminogen activator (TPA) in ophthalmology surgery

A formaçäo de fibrina em cirurgia oftalmológica é uma frequente complicaçäo e pode comprometer definitivamente o resultado visual final. Com o objetivo de avaliar a açäo do ativador do plasminogênio tecidual (TPA) na destruiçäo da fibrina, 25 mcg 0,1 ml de TPA foi injetado na câmara anterior de 50 pacientes submetidos à cirurgia oftalmológica. Significante reduçäo de fibrina foi observada em 42 pacientes (84 por cento). Em 5 pacientes (10 por cento) näo houve resposta ao TPA e 3 pacientes (6 por cento) evoluiram para hifema. Näo foi observado efeitos adversos. A pressäo ocular näo sofreu alteraçäo significativa (p=0,37). O TPA é efetivo e tem uma fácil aplicaçäo no tratamento da formaçäo de fibrina

[Structural analysis of the new model of primary care in the community of Valencia]. / Análisis estructural del nuevo modelo de atención primaria en la comunidad Valenciana.

OBJECTIVES: To analyse the structure of the new model of primary care (NMPC) in the Community of Valencia, and to identify the strategic importance of its characteristic variables and the possibilities of intervention to affect these variables. DESIGN: A qualitative study through a method of structural analysis (crossed impact method-multiplication applied to a classification) of the relationships between 37 variables characterising the NMPC which were identified by prior qualitative research, with interpretation of the results using the Téniere-Buchot Model. SETTING: Community of Valencia. RESULTS: The structural variables identified were those relating to the political-legal framework and to the allocation of primary care resources; and the resultant variables, those relating to efficiency and primary care quality. Between these two categories, the intervention variables covered management, NMPC professionals, health needs and the community's use of services. CONCLUSIONS: The structural analysis gives the legal-political and economical framework a determining role in NMPC, which can hardly be influenced from within the system. Management and organisation are identified as key variables from which an intervention can be made in the short or medium term to achieve the aims of the system.

[Validity of the protocol for evaluating the inappropriate use of hospitalization]. / Validez del protocolo de evaluación del uso inapropiado de la hospitalización.

BACKGROUND: The study was carried out in order to assess the inter-observer reliability and validity in respect of clinical appraisal given by the Appropriateness Evaluation Protocol (AEP), in the context of the Spanish Public Hospital System. MATERIAL AND METHOD: In order to assess the reliability a total of 614 hospital stays chosen at random from 56 hospital admissions were independently analysed by three reviewers (two doctors and one nurse). In order to assess the validity, the findings obtained by the nurse were compared with the majority opinion given by the 7 hospital specialists in respect of each of hospital stays under evaluation. As part of the analytical procedure, indices for observed agreement, and specific agreement were calculated, as well as the Kappa statistic, all forming of various random samples of 614 hospital stays. In order to assess the predictive validity of the AEP, its sensitivity, specificity and predictive values were all measured against the majority clinical judgement. RESULTS: The study exhibited a high degree of inter-observer reliability (specific agreement > 64%, kappa > 0.75) and a reasonable validity in comparison with the consensus of opinions formed by a least 4 or 5 of its 7 clinical reviewers (specific agreement > 61%, kappa > 0.64), these values decreasing notably when the consensus of 6 or 7 of the reviewers was required. The AEP revealed a high degree of sensitivity and a low degree of specificity in comparison with the majority clinical assessment, thus minimising the occurrence of false results when the stay was regarded as appropriate, and producing false negatives (appropriate hospital stays regarded as inappropriate) varying in degree from moderate to very high. CONCLUSIONS: The results showing high reliability and moderate validity regarding clinical assessment shows the AEP to be a useful instrument in the sifting-out of inappropriate use of hospitalisation, although they do not allow a definitive judgement to be made concerning the efficiency of hospital services nor judgements regarding individual cases.

[How much and how are we using the Hospital Morbidity Survey?]. / Cuánto y cómo estamos utilizando la encuesta de Morbilidad hospitalaria?

OBJECTIVE: The Hospital Morbidity Survey (HMS) is the only national level systematic statistic of morbidity attended in Spanish hospitals. The aim of this work is to describe publications related with HMS. METHODS: A review was carried out of Spanish scientific literature by means of an automatic literature search with the Spanish Medical Index (1971-1993), completed manually. RESULTS: 31 publications were found related to the HMS of which 10 are applied works directly using its results, other 13 publications deal with the quality (compliance diagnosis agreement between sources or others) of the HMS and 8 are reflections on the utility and limitations of the survey. CONCLUSIONS: Despite de number of scientific articles that use the HMS represents an underestimation of the real use of HMS, we conclude that the scientific utilization of HMS is very low.

How many days of hospitalization for an appendectomy?

The length of stay (LOS) of a surgical procedure is influenced both by the real need for medical and nursing care of the patient and also by the practice style of each unit, which can include unjustified stays. The aim of this work was to estimate the appropriate LOS for appendectomy and its differences with the LOS observed in practice. Two hundred and forty-nine medical records (249 admission days and 1447 successive stays) for patients over 6 years old who had had an appendectomy in 1992 were classified by Diagnosis Related Groups (DRG) and reviewed using the Appropriateness Evaluation Protocol. 1.6% of admission days and 31.7% of successive stays were assessed inappropriate. The appropriate LOS for appendectomy was 4.7 days as opposed to 6.8 days of observed LOS. For the DRG 167 (76.3% of the sample) appropriate LOS was 3.4 days (observed LOS 4.9 days). These results suggest the existence of an important proportion of avoidable hospital stays and provides a simple and low cost methodology for assessing the suitability of local hospitalization practices.

[What does the average stay say about the diagnosis-related groups?]. / Qué mide la estancia media de los grupos relacionados de diagnóstico?

BACKGROUND: The systems for classifying patients into homogeneous groups of resource consumption such as diagnosis related groups (DRG) use mean stay (MS) as the principal predictive variable of this consumer entity. The standard of MS for each DRG is usually defined as the MS of this DRG in one group of hospitals. This method omits the existence of unnecessary days of hospitalization which are added to the standard and may be identified by review of hospitalary use. METHODS: A retrospective review of the clinical need for 933 days of hospitalization (190 days of admission plus 743 successive stays for the same) in 190 cases of 167 DRG (appendicectomy without complications or comorbidity in those under the age of 70 years) in 8 public hospitals in Valencia (Spain) was performed by the Appropriateness Use Evaluation Protocol. RESULTS: Four days of admission (2.1%) and 284 successive stays (38.2%) were considered unnecessary from a clinical point of view. Necessary MS was estimated as 3.4 days for GRD vs the 5.1 days of MS observed. CONCLUSIONS: The common construction of standards of mean stay per disease demonstrates an important proportion of unnecessary use of hospitalization, the correction of which would allow a reduction in the mean costs of the process without a reduction in the quality of care.

[Evaluation of a program for reducing the surgical waiting list on the basis of on the spot payment]. / Evaluación de un programa de reducción de la lista de espera quirúrgica basado en el pago por acto.

BACKGROUND: The aim of this study was to evaluate a program to shorten the surgical waiting list on the basis of on the spot payment for each intervention performed outside the ordinary time schedule. The evaluation was based on preestablished hypothesis concerning the possible beneficial and adverse effects of on the spot payment. METHODS: Eighty-four units corresponding to 6 surgical specialties in 14 hospitals of the Valencian Public Health Care Department were included in the study. The effects of this program were compared between the units which carried out the program from March to June 1992 (experimental group: EG) and the units which did not undertake the program (control group: CG). RESULTS: The interventions performed in the program constituted 31% of the initial waiting list of the EG units. Bed profitability increased in the EG with surgeon productivity decreasing within the ordinary time schedule in the units of general surgery in the EG (16%) and the selection of diagnoses did not coincide with clinical priorities (positive selection of fimosis, fallopian tube tieing and negative selection of goiter and prostatic hyperplasia). CONCLUSIONS: The design of programs based on the spot payment should take the possible adverse effects into account establishing mechanisms to avoid the decrease in ordinary activity and the selection of patients on the basis of criteria different to clinical priorities.

[Evaluation of the design and reliability of a questionnaire to identify elderly individuals in need for social and health services]. / Evaluación del diseño y de la fiabilidad de un cuestionario para la detección de ancianos con necesidades de servicios sociosanitarios.

BACKGROUND: To assess the construction of a short screening questionnaire designed for the detection of elderly people living in the community and in need of social and health care, and to test the reliability of the scores obtained on the scales of Activities of Daily Living (ADL) and mobility through its application. METHODS: A short screening questionnaire of 11 items was designed to score elderly community dwellings on the scales of ADL and mobility of the International Classification of Impairments, Disabilities and Handicaps of the WHO (ICIDH). A random sample of 1,000 people aged 65 and over from the community of a geographical area of Catalonia (Spain) were interviewed in 1989, either by telephone or in-home personal interview, by non-professional trained interviewers on the basis of the mentioned schedule, and scored on the ICIDH ADL and Mobility scales. The design of the screening questionnaire was evaluated on the construction, content and wording through a 16 opinion statements questionnaire upon which 12 professionals, familiarized with questionnaire construction, expressed agreement or disagreement. To test reliability, each interviewer re-scored, one month apart, 20 subjects based on the information they had registered on the questionnaires, and following the same procedure, a gold standard observer re-scored all 1,000 interviews. In addition, a number of interviews were tape recorded, with previous consent of the subjects, and re-scored by 9 different observers. Interobserver and intraobserver reliability was measured with Cohen's weighted kappa coefficient. RESULTS: The average time of questionnaire administration was approximately 10 +/- 5 min. Although the instrument was said to be a good tool for the interviewer to score the subjects on the scales, wording of some items of the questionnaire need to be reviewed. Both intraobserver and interobserver reliability were high: kappa coefficients of 0.79-0.97 and > 0.75 respectively. CONCLUSIONS: The use of a simple and reliable ADL and mobility questionnaire is a practical way to obtain information on the functional status of elderly people living at home, and to select elderly people for a further comprehensive assessment of their social and health care needs for planning the appropriate services in the community.

A cross-sectional study on vaccine coverage and seroprevalence in schoolchildren in Andorra.

A cross-sectional study on vaccine coverage and vaccine effectiveness was carried out on a randomized sample of the cohort of schoolchildren born in 1983 attending school in Andorra, prior to the introduction of a Systematic Immunisation Plan that included centralised import and delivery of vaccines to vaccinating clinics, surveillance of the cold-chain during vaccine delivery, and a clearly-defined immunization schedule against diphtheria, tetanus, -pertussis, polio, mumps, rubella and measles. Vaccine coverage was estimated from vaccination card records; history of disease and sociodemographic variables were obtained through a questionnaire to the children's parents and vaccine effectiveness was estimated through serum antibody testing. Vaccine coverage levels for DTP and OPV were 97.8% for both. Protective serum antibody prevalence was correspondingly high except for the polio viruses. The authors suggest that decreased vaccine effectiveness, probably due to poor preservation of the cold chain, might be the cause of this finding. In countries or regions with an otherwise developed organisation of health services, an important issue like this can still be overlooked.

[The reasons for consultation and active problems. A key for the understanding of information in primary care]. / Motivos de consulta y problemas activos. Una clave para la comprensión de la información en atención primaria.

The aim of this work is to assess the major differences found in the information content of the registers in primary care according to whether the registration includes the Reason (s) For Encounter (as ascertained by the professional) or the Active Health Problem (s). The information used is based on an observational study of a representative sample of the consultations to eight general practitioners from the Principate of Andorra. The study was performed during the period of May-June 1989. 547 consultations are analysed. A better specificity and information content is observed when both approaches are registered. Active Health Problems seem to be barely related to Reasons for Encounter and it seems that they could have as much, if no more. Influence in the process of care, than the RFEs it selves.

[Minimum sets of data in primary care: an exploration of their feasibility]. / Conjuntos mínimos de datos en atención primaria: una exploración de su factibilidad.

OBJECTIVE: To evaluate the different "costings" of several different strategies for gathering a Minimum Set of Data (MSD) at the Primary Care level. DESIGN: A simulation study using a hypothetical MSD with 16 items together with the findings on demand and interventions made by General Physicians in an observational study in Andorra. Different gathering strategies were applied using these data and with the MSD register covering visits as the starting-point. Measurement of the "costing" or work-load involved in the gathering and transmission of each of the items was carried out by means of a nominal group. SITE. General and paediatric consulting-rooms. PATIENTS OR OTHERS PARTICIPANTS: The simulation was carried out among the catchment population of PAMEM and used data on what was done in 1988. MAIN MEASUREMENTS AND RESULTS: Strategies based on sampling of visits or individuals are those which show a greater reduction in cost (99.3% and 98.1% respectively). Sampling individuals additionally allows for the MSD to be added to during periods of illness. Other options with their respective results are: "gathering information from alternative sources", with a reduction of 22%, "reduction of the number of data to record", with 20% reduction and "separation of stable information" with 18%. CONCLUSIONS: The systematic collection of data on each visit has important and much more efficient alternatives. The choice of one of them will depend on how feasible it is to introduce, on the available resources and above all on objectives.

[Strategies in measuring nursing care]. / Estrategias de medida de los cuidados de enfermería.

When resources are limited, the balance between the supply and the demand of nursing care is becoming more and more necessary. This situation justifies the use of tools to measure work charges in nursing. This article analyses the relationship between work charges and time estimation in nursing care. From a bibliographical review on this topic it discusses possibilities and techniques of time estimation for the nursing care given to a patient, as well as the caring time he or she requires. Two different approaches and some conclusions from the analysis of both of them are showed: first; the direct method, i.e. that of measuring caring levels; and secondly, the indirect method, that is a system for classifying patients. The interest of the direct method is advocated because of its clarity, external validation possible integration in nursing care plans.