Wide systematic variations in potentially avoidable hospitalizations of chronically ill patients: Ecological study of primary care areas and healthcare areas.

BACKGROUND AND OBJECTIVE: Potentially avoidable hospitalisations (PAHs) due to chronic conditions are a healthcare problem that could reflect healthcare of insufficient quality. This study reports the systematic variations in PAHs for the collection of providers of the Spanish National Health System. MATERIALS AND METHODS: We conducted an ecological study on government data, analysing the systematic variation in PAHs for 6 chronic conditions during 2013-2015. To determine the variation, we performed a small area analysis using Bayesian methodology. RESULTS: Between 2013 and 2015, 439,878 admissions for PAHs were recorded in the Spanish National Health System. There was an up to 4-fold difference in PAH rates between certain basic health areas (BHA), with highly variable differences depending on the analyzed condition. Forty percent of the BHAs showed a greater than expected risk of PAH. Beyond the systematic variation observed between BHAs, the healthcare areas of the patients' residence explained 33% of the variation in PAHs. We observed specific differences in these general results according to clinical condition, age and sex. CONCLUSIONS: The wide systematic variation in PAHs suggests a problem of quality in the care provided to chronically ill patients by the providers of healthcare areas in Spain. Identifying and analysing these areas and other healthcare areas with better results could provide a reference for improving the care of other suppliers with poorer performance.

Wide systematic variations in potentially avoidable hospitalisations of chronically ill patients: Ecological study of basic health areas and healthcare areas. / Amplias variaciones sistemáticas en hospitalizaciones potencialmente evitables en pacientes crónicos: estudio ecológico sobre zonas básicas de salud y áreas sanitarias.

BACKGROUND AND OBJECTIVE: Potentially avoidable hospitalisations (PAHs) due to chronic conditions are a healthcare problem that could reflect healthcare of insufficient quality. This study reports the systematic variations in PAHs for the collection of providers of the Spanish National Health System. MATERIALS AND METHODS: We conducted an ecological study on government data, analysing the systematic variation in PAHs for 6 chronic conditions during 2013-2015. To determine the variation, we performed a small area analysis using Bayesian methodology. RESULTS: Between 2013 and 2015, 439,878 admissions for PAHs were recorded in the Spanish National Health System. There was an up to 4-fold difference in PAH rates between certain basic health areas (BHA), with highly variable differences depending on the analysed condition. Forty percent of the BHAs showed a greater than expected risk of PAH. Beyond the systematic variation observed between BHAs, the healthcare areas of the patients' residence explained 33% of the variation in PAHs. We observed specific differences in these general results according to clinical condition, age and sex. CONCLUSIONS: The wide systematic variation in PAHs suggests a problem of quality in the care provided to chronically ill patients by the providers of healthcare areas in Spain. Identifying and analysing these areas and other healthcare areas with better results could provide a reference for improving the care of other suppliers with poorer performance.

Health Data for Public Health: Towards New Ways of Combining Data Sources to Support Research Efforts in Europe.

Objectives: To present the European landscape regarding the re-use of health administrative data for research. Methods: We present some collaborative projects and solutions that have been developed by Nordic countries, Italy, Spain, France, Germany, and the UK, to facilitate access to their health data for research purposes. Results: Research in public health is transitioning from siloed systems to more accessible and re-usable data resources. Following the example of the Nordic countries, several European countries aim at facilitating the re-use of their health administrative databases for research purposes. However, the ecosystem is still a complex patchwork, with different rules, policies, and processes for data provision. Conclusion: The challenges are such that with the abundance of health administrative data, only a European, overarching public health research infrastructure, is able to efficiently facilitate access to this data and accelerate research based on these highly valuable resources.

Análisis del exceso de consumo de recursos en pacientes con enfermedad tromboembólica tras cirugía, infección por uso de dispositivo vascular postoperatorio o sepsis post-quirúrgica en el Sistema Nacional de Salud / Analysis of excess resources in patients with catheter-related infection (bacteremia), postoperative pulmonary embolism or deep vein (DVT-PTE) or postoperative sepsis in the National Health System

Objetivo: Estimar el exceso de estancia atribuible a la presencia de eventos adversos en pacientes que han sido sometidos a una intervención quirúrgica en el mismo episodio. Población y métodos: Estudio observacional, transversal, sobre bases de datos clínico-administrativos al alta hospitalaria. Las altas elegidas fueron producidas en los años 2009 y 2010 en los centros hospitalarios de agudos de las 17 comunidades autónomas del SNS español, las cuales forman parte del proyecto Atlas de Variabilidad de la Práctica Médica en el Sistema Nacional de Salud (Atlas VPM). Resultados: El exceso de estancia fue de 28, 10 y 14 días en las altas con infección debida a uso de dispositivo vascular, altas con tromboembolismo o trombosis venosa profunda tras la cirugía y altas con sepsis post-quirúrgica, respectivamente. Las variables predictoras del paciente (edad, sexo, Elixhauser) influyen en el exceso de estancia. Conclusión: Los eventos adversos están asociados a un incremento significativo de exceso de estancia. El CMBD (Conjunto Mínimo Básico de Datos hospitalario) permite hacer una estimación del impacto que esto tiene en los hospitales españoles (AU)

Objective: To estimate the excess of length of stay (LOS) attributable to the presence of adverse events in patients who were operated. Methodology: Observational, cross-sectional study on the basis of clinical and administrative hospital discharge data. Discharge chosen were produced in 2009 and 2010 in acute hospitals of the 17 Spanish autonomous communities of the National Health System, which are part of the project Atlas of Variability in Medical Practice in the National Health System (Atlas VPM Group). Results: Excess of LOS was 28 days, 10 days and 14 days in the catheter-related infection (bacteremia), postoperative pulmonary embolism or deep vein (DVT-PTE) or postoperative sepsis stays. The predictor variables of the patient (age, sex and Elixhauser) influence in the excess of LOS. Conclusion: Adverse events are associated with a significant increase of excess of LOS. The discharge minimum basic dataset (CMBD) allows to estimate the impact of adverse events in the Spanish hospitals (AU)

ECHO: health care performance assessment in several European health systems.

BACKGROUND: Strengthening health-care effectiveness, increasing accessibility and improving resilience are key goals in the upcoming European Union health-care agenda. European Collaboration for Health-Care Optimization (ECHO), an international research project on health-care performance assessment funded by the seventh framework programme, has provided evidence and methodology to allow the attainment of those goals. This article aims at describing ECHO, analysing its main instruments and discussing some of the ECHO policy implications. METHODS: Using patient-level administrative data, a series of observational studies (ecological and cross-section with associated time-series analyses) were conducted to analyze population and patients' exposure to health care. Operationally, several performance dimensions such as health-care inequalities, quality, safety and efficiency were analyzed using a set of validated indicators. The main instruments in ECHO were: (i) building a homogeneous data infrastructure; (ii) constructing coding crosswalks to allow comparisons between countries; (iii) making geographical units of analysis comparable; and (iv) allowing comparisons through the use of common benchmarks. CONCLUSION: ECHO has provided some innovations in international comparisons of health-care performance, mainly derived from the massive pooling of patient-level data and thus: (i) has expanded the usual approach based on average figures, providing insight into within and across country variation at various meaningful policy levels, (ii) the important effort made on data homogenization has increased comparability, increasing stakeholders' reliance on data and improving the acceptance of findings and (iii) has been able to provide more flexible and reliable benchmarking, allowing stakeholders to make critical use of the evidence.

Evidence based educational outreach visits: effects on prescriptions of non-steroidal anti-inflammatory drugs.

AIMS: To evaluate the effectiveness of an evidence based group educational outreach visit on prescription patterns of non-steroidal anti-inflammatory drugs (NSAIDs) in primary care. DESIGN: Randomised controlled simple blind trial, with randomisation into three groups: experimental (evidence based educational outreach visit), placebo (conventional education session), and control (without intervention). SETTING: The 24 primary care centres of the National Institute of Healthcare Network in a rural province of Aragon, Spain. PARTICIPANTS: The 24 primary health care teams of the network, with 158 general practitioners (GPs). The teams were randomised into the groups, experimental (8 teams, 48 GPs), placebo (8 teams, 54 GPs), and control (8 teams, 56 GPs). INTERVENTION: Experimental group: one group educational outreach visit, conveying data based on a systematic review of the literature that was reinforced with printed material; placebo group: one non-structured educational session; control group: no intervention. Both educational sessions emphasised that there are no differences in the effectiveness of the NSAIDs reviewed (diclofenac, piroxicam, and tenoxicam); a recommendation was made to prescribe diclofenac over tenoxicam because of price differences. MAIN OUTCOME MEASURES: Changes in the number of packages prescribed for each of the drugs and changes in the cost per package of NSAIDs prescribed during the six months before, and after the intervention. RESULTS: There were no differences in the basal characteristics of the three groups, except for the number of prescriptions during the six months before the intervention. Prescriptions for NSAIDs decreased homogeneously in the three groups. For tenoxicam, the experimental group reduced prescriptions by 22.5% (95%CI: 34.42 to -10.76), compared with a reduction of 9.78% (95%CI: -17.70 to -1.86) in the placebo group and an increase of 14.44% (95%CI: 5.22 to 23.66) in the control group. The average cost per prescription decreased by 1.91% (95%CI: -0.33% to -3.49%) in the experimental group, 0.16% (95%CI: -0.27% to -2.93%) in the placebo group, and rose by 1.76% (95%CI: 0.35% to 3.17%) in the control group. CONCLUSIONS: Evidence based educational outreach visits are more effective than no intervention at all. Results suggest that evidence based educational outreach visits are incrementally more effective than conventional educational sessions, which in turn are more effective than no intervention at all.

[Preventive activities in primary health care: identifying the agreement among evidence-based guidelines]. / Actividades preventivas en atención primaria: identificación de áreas de concordancia entre guías de práctica clínica basadas en la evidencia.

BACKGROUND: The purpose of this article is to identify the agreement among evidence-based guidelines about recommendations on preventive activities in low risk adults. METHODS: For which we identified, from the 1996 US Task Force on Preventive Services Guide those preventives activities classified like A or B (recommendation in favour of provision) and like D or E (recommendation against provision), excepting those D and E recommendations based on descriptives studies or expert opinions. Both preventive activities aimed at pregnant women and children and those which are not applicable to our context were excluded. Selected preventive services were compared with the range of age, sex and periodicity in which agreement with the recommendations of American College of Physicians and Canadian Task Force on Preventive Services existed. RESULTS: We found the following agreements. Screening activities. In favour: screening for hypercholesterolemia, hypertension, breast cancer, colorectal cancer, uterine cervix cancer, rubella, visual and hearing impairment and problem drinking. Against: cancer of prostate, lung, bladder and thyroid, and asymptomatic bacteriuria. Counseling activities. In favour: smoking, motor-vehicles injuries, alcohol consumption, unintended pregnancy. Immunizations and quimioprophylaxis. In favour: Vaccines for influenza, tetanus-diphtheria, hepatitis B and measles-mumps-rubella. Postexposure prophylaxis to hepatitis A, hepatitis B, meningococcal, rabies and tetanus. CONCLUSIONS: We see then, that a high degree in agreement among the main guidelines exists; about the preventive activities to perform in Primary Health Services, nevertheless we observed low fulfillment of certain preventive activities in Primary Health Services, different barriers for the accomplishment from these activities were described.

The association between vasectomy and prostate cancer: a systematic review of the literature.

OBJECTIVE: To evaluate the possible association between vasectomy and prostate cancer. DESIGN: Systematic review of the literature. PATIENT(S): Fourteen original studies published between January 1985 and December 1996 that addressed the association between vasectomy and prostate cancer. MAIN OUTCOME MEASURE(S): The strength of the association was estimated with the use of a meta-analysis (DerSimonian and Laird method). A sensitivity analysis was conducted to assess the impact of different sources of heterogeneity. RESULT(S): Fourteen original papers were reviewed (5 cohort and 9 case-control studies). Relative risks ranged between 0.44 (95% confidence interval [CI] = 0.1-4.0) and 6.70 (95% CI = 2.1-21.6). The overall relative risk (DerSimonian and Laird estimate) was 1.23 (95% CI = 1.01-1.49). The sensitivity analysis showed that this measure was very sensitive to the study base, the type of design used, and the possibility of bias. Further, the funnel plot demonstrated the probable existence of publication bias. CONCLUSION(S): No causal association was found between vasectomy and prostate cancer. Individuals who have undergone vasectomy are not at high risk for the development of prostate cancer.

PIP: The absence of a plausible biologic model, methodologic problems, and lack of consistency between the results of different studies have created skepticism about any association between vasectomy and prostate cancer. To clarify further the possibility of such a link, a systematic review of the empirical literature published in 1988-96 was conducted. 14 such studies (5 cohort and 9 case-control) were identified, 11 of which found an excess risk of prostate cancer in men who had undergone vasectomy. Relative risks ranged from 0.44 (95% confidence interval (CI), 0.1-4.0) and 6.70 (95% CI, 2.1-21.6). The risk was statistically significant in 6 studies. The weighted relative risk obtained using the age-adjusted results of the individual studies was 1.23 (95% CI, 1.01-1.49). However, both the statistical tests and the qualitative analysis detected heterogeneity between the studies. Possible sources of this heterogeneity include type of design, study base, presence of detection bias, and inadequate selection of controls. Moreover, the sensitivity analysis indicated that the detected effect depends to a great extent on studies that are more vulnerable to bias (i.e., case-control and hospital-based studies) and those that have internal validity problems. Further, the funnel plot demonstrated the possible existence of publication bias. Finally, when the relative risk was recalculated to exclude early stage tumors (located by active detection in vasectomy cases), the previously found association between vasectomy and prostate cancer disappeared. It is concluded that the available empiric evidence is of low quality because of multiple sources of bias that favor the overestimation of the effect of vasectomy on prostate cancer risk. These validity problems, along with the lack of a biologic model to explain the association, strongly suggest the association is not causal.