[Analysis of infectious diseases care in Spanish hospitals from 2016-2020, including the first year of the SARS-CoV-2 pandemic]. / Análisis de la atención a patologías infecciosas en los hospitales españoles en el periodo 2016-2020, incluyendo el primer año de pandemia por SARS-CoV-2.

Aims: This work aimed to review patients discharged from Spanish hospitals with a principal diagnosis of infection during a 5-year period, including the first year of the SARS-CoV-2 pandemic. Materials and method: This work analyzed the Basic Minimum Data Set (CMBD) of patients discharged during the 2016-2020 period from hospitals in the Spanish National Health Service in order to identify cases with a principal diagnosis of an infectious disease according to the ICD-10-S code. All patients older than 14 years of age admitted to a conventional ward or intensive care unit, excluding labor and delivery, were included in the analysis and were evaluated based on the discharging department. Results: Patients discharged with infectious diseases as the principal diagnosis have increased from 10% to 19% in recent years. A large part of the growth is due to the SARS-CoV-2 pandemic. Internal medicine departments cared for more than 50% of these patients, followed by pulmonology (9%) and surgery (5%). In 2020, 57% of patients with a principal diagnosis of infection were discharged by internists, who cared for 67% of patients with SARS CoV-2. Conclusions: At present, more than half of patients admitted with a principal diagnosis of infection are discharged from internal medicine departments. Given the growing complexity of infections, the authors advocate for an approach in which training allows for specialization, but within a generalist context, for the better management of these patients.

Análisis de la atención a patologías infecciosas en los hospitales españoles en el periodo 2016-2020, incluyendo el primer año de pandemia por SARS-CoV-2 / Analysis of infectious diseases care in Spanish hospitals from 2016–2020, including the first year of the SARS-CoV-2 pandemic

Objetivo Revisar los pacientes atendidos en los hospitales españoles dados de alta con un diagnóstico principal de infección en un periodo de 5 años, incluyendo el primer año de la pandemia por SARS-CoV-2. Material y métodos Se han analizado los datos del Conjunto Mínimo Básico de Datos (CMBD) de los pacientes dados de alta durante el periodo 2016-2020 de los hospitales del Sistema Nacional de Salud de España identificando aquellos que tuvieran un diagnóstico principal de enfermedad infecciosa según el código CIE-10-S. Se han incluido en el análisis todos los pacientes mayores de 14 años que hubieran ingresado en una planta convencional o de cuidados intensivos, excluyendo los partos, y se han evaluado las altas en función del servicio de alta. Resultados Los pacientes dados de alta con patología infecciosa han aumentado del 10% al 19% en los últimos años, y gran parte del crecimiento se debe a la epidemia por SARS-CoV-2. Los servicios de medicina interna atienden a más del 50% de estos pacientes, seguidos de neumología (9%) y cirugía general (5%). En el año 2020 el 57% de los pacientes con diagnóstico principal de infección fueron dados de alta por internistas, que atendieron al 67% de los pacientes con SARS-CoV-2. Conclusiones Actualmente más de la mitad de los pacientes que ingresan con diagnóstico principal de infección son dados de alta en medicina interna. Dada la complejidad creciente de las infecciones, abogamos por un abordaje en el que un área de capacitación permita una especialización, pero dentro de un contexto generalista, para el mejor manejo de estos pacientes (AU)

Aims This work aimed to review patients discharged from Spanish hospitals with a principal diagnosis of infection during a 5-year period, including the first year of the SARS-CoV-2 pandemic. Materials and method This work analyzed the Basic Minimum Data Set (CMBD) of patients discharged during the 2016-2020 period from hospitals in the Spanish National Health Service in order to identify cases with a principal diagnosis of an infectious disease according to the ICD-10-S code. All patients older than 14 years of age admitted to a conventional ward or intensive care unit, excluding labor and delivery, were included in the analysis and were evaluated based on the discharging department. Results Patients discharged with infectious diseases as the principal diagnosis have increased from 10% to 19% in recent years. A large part of the growth is due to the SARS-CoV-2 pandemic. Internal medicine departments cared for more than 50% of these patients, followed by pulmonology (9%) and surgery (5%). In 2020, 57% of patients with a principal diagnosis of infection were discharged by internists, who cared for 67% of patients with SARS CoV-2. Conclusions At present, more than half of patients admitted with a principal diagnosis of infection are discharged from internal medicine departments. Given the growing complexity of infections, the authors advocate for an approach in which training allows for specialization, but within a generalist context, for the better management of these patients (AU)

Analysis of infectious diseases care in Spanish hospitals from 2016 to 2020, including the first year of the SARS-CoV-2 pandemic.

AIMS: This work aimed to review patients discharged from Spanish hospitals with a principal diagnosis of infection during a 5-year period, including the first year of the SARS-CoV-2 pandemic. MATERIALS AND METHOD: This work analyzed the Basic Minimum Data Set (CMBD) of patients discharged during the 2016⬜2020 period from hospitals in the Spanish National Health Service in order to identify cases with a principal diagnosis of an infectious disease according to the ICD-10-S code. All patients older than 14 years of age admitted to a conventional ward or intensive care unit, excluding labor and delivery, were included in the analysis and were evaluated based on the discharging department. RESULTS: Patients discharged with infectious diseases as the principal diagnosis have increased from 10% to 19% in recent years. A large part of the growth is due to the SARS-CoV-2 pandemic. Internal medicine departments cared for more than 50% of these patients, followed by pulmonology (9%) and surgery (5%). In 2020, 57% of patients with a principal diagnosis of infection were discharged by internists, who cared for 67% of patients with SARS CoV-2. CONCLUSIONS: At present, more than half of patients admitted with a principal diagnosis of infection are discharged from internal medicine departments. Given the growing complexity of infections, the authors advocate for an approach in which training allows for specialization, but within a generalist context, for the better management of these patients.

Más que internistas / More than just internists

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Utility of lateral flow tests in SARS-CoV-2 infection monitorization.

OBJECTIVE: The diagnosis of SARS-CoV-2 infection is crucial for medical and public health reasons, to allow the best treatment of cases and the best control of the pandemic. Serology testing allows for the detection of asymptomatic infections and 19-COVID cases once the virus has been cleared. We analyzed the usefulness of the SARS-CoV-2 rapid test of Autobio and tried to correlate its pattern with the severity of COVID19 infection. METHODS: We analyzed the accuracy and clinical usefulness of a point-of-care IgM and/or IgG test for SARS-CoV-2 in 35 COVID-19 patients [12 (34.3%) mild-moderate and 23 (65.7%) severe-critical] admitted to a field hospital in Madrid, as well as in 5 controls. RESULTS: The mean time from the first day of symptoms to the antibody test was 28 days (SD: 8.7), similar according to the severity of the disease. All patients with SARS-CoV-2 PCR+ showed the corresponding IgG positivity, while these results were negative in all control individuals. A total of 26 (74%) cases also presented with positive IgM, 19 (83%) were severe-critical cases and 7 (58%) were mild-moderate cases. The IgM response lasted longer in the severe critical cases (mean: 29.7 days; SD: 8.4) compared to the moderate cases (mean: 21.2 days; SD: 2.0).. CONCLUSIONS: Rapid serology tests are useful for the diagnosis of patients with COVID-19 (mainly IgG detection) and may also be correlated with the severity of the infection (based on IgM detection).

Modelos colaborativos hospitalarios de asistencia compartida e interconsultas a demanda. ¿Cuál ofrece mejores resultados en Cirugía Ortopédica y Traumatología? / Collaborative hospital models for shared care and on-demand interconsultations. Which offer the best results for Orthopaedic Surgery and Trauma?

ANTECEDENTES Y OBJETIVO: Los enfermos quirúrgicos hospitalizados están aumentando su complejidad médica, incrementando la necesidad de apoyo por Medicina Interna. Este apoyo se realiza mediante la interconsulta, la cual presenta problemas que han inducido el desarrollo de la asistencia compartida (AC). Nuestro objetivo es comparar los resultados asistenciales alcanzados por los modelos de interconsulta y AC en Cirugía Ortopédica y Traumatología. MATERIAL Y MÉTODO: Estudio observacional, prospectivo, multicéntrico, de los enfermos hospitalizados de urgencia en Cirugía Ortopédica y Traumatología recogidos en el registro REINA-SEMI, atendidos por Medicina Interna mediante interconsulta o AC. Se registraron las características demográficas, comorbilidad, complicaciones médicas, estancia hospitalaria y mortalidad. RESULTADOS: Se incluyeron 697 pacientes, 415 con AC y 282 con interconsulta. Los de AC tenían más edad (78,9 vs. 74,3; p <0,001), se operaron más (89,9 vs. 78,7%; p <0,001), tuvieron menos complicaciones médicas (50,4 vs. 62,8%; p <0,001) y su estancia hospitalaria fue menor (10 vs. 18 días; p <0,001), sin diferencias en la comorbilidad ni mortalidad. Los factores independientes asociados a estancia superior a 15 días fueron: insuficiencia cardiaca (OR: 3,4; IC 95%: 1,8-6,1; p <0,001), sexo (hombre) (OR: 1,9; IC 95%: 1,2-3,1; p = 0,004), trastorno electrolítico (OR: 2,4; IC 95%: 1,3-4,4; p = 0,003), infección respiratoria (OR: 1,9; IC 95%: 1,04-3,7; p = 0,035), demora quirúrgica (OR: 1,1; IC 95%: 1,08-1,2; p <0,001) y ser atendido mediante el modelo de interconsulta a demanda (OR: 3,5; IC 95%: 2,3-5,4; p <0,001). CONCLUSIONES: La AC ofrece mejores resultados asistenciales que las interconsultas en pacientes ingresados de urgencia en Cirugía Ortopédica y Traumatología

BACKGROUND AND OBJECTIVES: Hospitalized surgical patients are increasing in medical complexity, thereby increasing the need for support by internal medicine departments. This support is provided through interconsultations, which present problems that have resulted in the development of shared care (SC). Our objective was to compare the healthcare results achieved by the SC and interconsultation models in Orthopaedic Surgery and Trauma. MATERIALS AND METHODS: We conducted an observational, prospective, multicentre study of patients hospitalized for emergency Orthopaedic Surgery and Trauma recorded in the REINA-SEMI registry, treated by internal medicine departments through interconsultation or SC. We recorded the demographic characteristics, comorbidity, medical complications, hospital stay and mortality. RESULTS: The study included 697 patients, 415 with SC and 282 with interconsultations. The SC patients were older (78.9 vs. 74.3; P<.001) underwent more operations (89.9 vs. 78.7%; P<.001), had fewer medical complications (50.4 vs. 62.8%; P<.001) and had shorter hospital stays (10 vs. 18 days; P<.001), with no differences in comorbidity or mortality. The following independent factors were associated with stays longer than 15 days: heart failure (OR 3.4; 95% CI 1.8-6.1; P<.001), the male sex (OR 1.9; 95% CI 1.2-3.1; P=.004), electrolyte disorder (OR 2.4; 95% CI 1.3-4.4; P=.003), respiratory infection (OR 1.9; 95% CI 1.04-3.7; P=.035), surgical delay (OR 1.1; 95% CI 1.08-1.2; P<.001) and treatment using the interconsultation on demand model (OR 3.5; 95% CI 2.3-5.4; P<.001). CONCLUSIONS: SC offers better healthcare results than interconsultations for patients hospitalized for emergency Orthopaedic Surgery and Trauma

Collaborative hospital models for shared care and on-demand interconsultations. Which offer the best results for Orthopaedic Surgery and Trauma? / Modelos colaborativos hospitalarios de asistencia compartida e interconsultas a demanda. ¿Cuál ofrece mejores resultados en Cirugía Ortopédica y Traumatología?

BACKGROUND AND OBJECTIVES: Hospitalized surgical patients are increasing in medical complexity, thereby increasing the need for support by internal medicine departments. This support is provided through interconsultations, which present problems that have resulted in the development of shared care (SC). Our objective was to compare the healthcare results achieved by the SC and interconsultation models in Orthopaedic Surgery and Trauma. MATERIALS AND METHODS: We conducted an observational, prospective, multicentre study of patients hospitalized for emergency Orthopaedic Surgery and Trauma recorded in the REINA-SEMI registry, treated by internal medicine departments through interconsultation or SC. We recorded the demographic characteristics, comorbidity, medical complications, hospital stay and mortality. RESULTS: The study included 697 patients, 415 with SC and 282 with interconsultations. The SC patients were older (78.9 vs. 74.3; P<.001) underwent more operations (89.9 vs. 78.7%; P<.001), had fewer medical complications (50.4 vs. 62.8%; P<.001) and had shorter hospital stays (10 vs. 18 days; P<.001), with no differences in comorbidity or mortality. The following independent factors were associated with stays longer than 15 days: heart failure (OR 3.4; 95% CI 1.8-6.1; P<.001), the male sex (OR 1.9; 95% CI 1.2-3.1; P=.004), electrolyte disorder (OR 2.4; 95% CI 1.3-4.4; P=.003), respiratory infection (OR 1.9; 95% CI 1.04-3.7; P=.035), surgical delay (OR 1.1; 95% CI 1.08-1.2; P<.001) and treatment using the interconsultation on demand model (OR 3.5; 95% CI 2.3-5.4; P<.001). CONCLUSIONS: SC offers better healthcare results than interconsultations for patients hospitalized for emergency Orthopaedic Surgery and Trauma.

Más que internistas / More than just internists

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La importancia de evaluar la fragilidad y la dependencia / The importance of evaluating fragility and dependence

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Compresión medular metastásica: incidencia, epidemiología y factores pronóstico / Metastatic spinal cord compression: incidence, epidemiology and prognostic factors

Introducción: La compresión medular metastásica (CMM) es una complicación severa en pacientes con cáncer cuya incidencia es difícil de estimar con exactitud. El objetivo del presente estudio es describir la incidencia, las características epidemiológicas y el pronóstico de la compresión medular metastásica en pacientes con cáncer. Material y métodos: Analizamos una cohorte con un total de 1.736 pacientes con diagnóstico de cáncer de cualquier origen ingresados en una unidad de cuidados paliativos. De los pacientes con diagnóstico de CMM, se recogieron datos epidemiológicos, signos y síntomas, tiempo medio hasta el diagnóstico, régimen de tratamiento, respuesta al tratamiento y mortalidad. Resultados: De un total de 1.736 pacientes, se identificaron 28 (1,6%) casos de CMM. La edad promedio fue de 67,2 (DE: 12,7) años siendo el cáncer de pulmón el tumor primario más frecuente (42,8%). La columna torácica fue la localización más afectada (42,8%; n=12) y el dolor el síntoma predominante (46,4%, n=13). La mediana de supervivencia después del diagnóstico de CMM fue de 84,5 días. Conclusiones: Hemos obtenido una incidencia del 1,6% (N=28) de CMM en una cohorte de 1.736 pacientes con cáncer. La CMM es un marcador de mal pronóstico con una supervivencia media menor de 3 meses desde el diagnóstico y una mortalidad intrahospitalaria del 32,4%

Background: Metastatic spinal cord compression (MSCC) is a severe complication in patients with cancer, and its incidence rate is difficult to accurately estimate. The aim of this study is to report the incidence and epidemiological and prognostic characteristics of MSCC in patients with cancer. Material and methods: We analysed a cohort of 1736 patients diagnosed with cancer of any origin who were hospitalised in a palliative care unit. We collected epidemiological data, signs and symptoms, mean time to diagnosis, treatment regimen, response to treatment and mortality for the patients diagnosed with MSCC. Results: In the 1736 patients, we identified 28 (1.6%) cases of MSCC. The average age was 67.2 (SD, 12.7) years, and lung cancer was the most common primary tumour (42.8%). The thoracic spine was the most affected location (12 cases, 42.8%), and pain was the predominant symptom (13 cases, 46.4%). The median survival after the MSCC diagnosis was 84.5 days. Conclusions: We observed an incidence rate of 1.6% (N=28) for MSCC in a cohort of 1736 patients with cancer. MSCC is a marker of poor prognosis, with a mean survival of less than 3 months from diagnosis and a hospital mortality of 32.4%

RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016) / RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013-2016)

Objetivos: Comparar la estructura, recursos y actividad de las Unidades de Medicina Interna (UMI) del Sistema Nacional de Salud (SNS) en 2013 y 2016. Analizar las diferencias entre UMI en 2016 por tamaño de hospital. Material y métodos: Comparativa de 2 estudios descriptivos transversales de UMI en hospitales generales de agudos del Sistema Nacional de Salud con datos referidos a 2013 y a 2016. Las variables fueron recogidas mediante un cuestionario «ad hoc» (encuesta RECALMIN). Resultados: Entre 2013 y 2016 aumentó notablemente la demanda asistencial (con un promedio anual del 11% en altas de hospitalización y del 16% en primeras consultas) y ligeramente la comorbilidad (2%). En el mismo período, aumentó un 16,7% la productividad media de las UMI (0,6+0,3 vs. 0,7+0,3; p=0,09) y la estancia media disminuyó un 10% (9+2,2 vs. 8,1+2,1 días; p=0,001). Los progresos en la implantación de buenas prácticas y de una atención sistemática al paciente crónico complejo fueron escasos. La variabilidad entre UMI y las notables diferencias entre UMI de hospitales de tamaño distinto fueron hallazgos de ambas encuestas. Conclusiones: Las UMI respondieron al aumento de la carga asistencial que soportaron en el período 2013-2016 mejorando su eficiencia y productividad, pero los avances en la implantación de buenas prácticas, incluyendo la atención al paciente crónico complejo, fueron escasos. La importante variabilidad en los indicadores de estructura, actividad y modelos de gestión encontrada en 2013 se mantuvo en 2016

Objectives: To compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyse the differences between IMUs in 2016 by hospital size. Material and methods: We conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). Results: Between 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; P=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; P=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. Conclusions: IMUs responded to the increased burden of care they supported during 2013-2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016

Análisis de las hospitalizaciones por enfermedad cardiovascular en población diabética en España / Analysis of hospitalizations by cardiovascular disease in the population with diabetes in Spain

Objetivos: Diabetes mellitus se asocia con un marcado incremento de enfermedad cardiovascular. En el presente estudio analizamos la prevalencia de diabetes mellitus en pacientes hospitalizados en España en 2015 y la carga de enfermedad cardiovascular asociada. Métodos: Mediante el análisis del conjunto mínimo básico de datos (CMBD) del Ministerio de Sanidad del año 2015, se incluyen todos los pacientes dados de alta con diagnóstico de diabetes mellitus. Se describen las características epidemiológicas, la distribución por los diferentes servicios hospitalarios y la presencia de enfermedad cardiovascular. Resultados: En el año 2015 hubo 3.727.583 altas en España; de ellas, 619.188 correspondían a diabéticos (16,7%); el 56,8% eran varones y la edad media era de 73,2años. La prevalencia de enfermedad cardiovascular fue del 40,8%, distribuida en insuficiencia cardiaca congestiva (20,1%), enfermedad cerebrovascular (10,3%), enfermedad coronaria (9,4%) y enfermedad arterial periférica (9,1%). La mayor parte de pacientes ingresaron en los servicios de medicina interna (34,2%), cardiología (9,5%) y cirugía general (8,9%). La estancia media global fue de 8,2días y los reingresos a 30días alcanzaron el 14%. La mortalidad fue del 6,8%. Los pacientes ingresados en medicina interna tienen un grado de severidad más alto (3-4), 41,9% vs 31,6%, que los ingresados en otros servicios médicos (p<0,01) y que los ingresados en servicios quirúrgicos (11,2%) (p<0,01). Conclusiones: La diabetes mellitus es una comorbilidad importante de los pacientes ingresados en medicina interna. Una proporción significativa de estos pacientes presenta enfermedad cardiovascular, y la más frecuente es la insuficiencia cardíaca

Objective: Diabetes mellitus is associated with a marked increase in cardiovascular disease. In this study, we analysed the prevalence of diabetes mellitus in hospitalised patients in Spain in 2015 and the burden of associated cardiovascular disease. Methods: By analysing the 2015 minimum basic data set (MBDS) of the Spanish Ministry of Health, we included all patients discharged with a diagnosis of diabetes mellitus. We describe the epidemiological characteristics, distribution by the various hospital departments and the presence of cardiovascular disease. Results: In 2015, there was 3,727,583 hospital discharges in Spain, 619,188 of which involved patients with diabetes (16.7%), 56.8% of whom were men and with a mean age of 73.2years. The prevalence of cardiovascular disease was 40.8%, distributed among congestive heart failure (20.1%), cerebrovascular disease (10.3%), coronary artery disease (9.4%) and peripheral arterial disease (9.1%). Most of the patients were admitted to internal medicine (34.2%), cardiology (9.5%) and general surgery (8.9%) departments. The mean overall stay was 8.2days, the readmission rate at 30days was 14%, and the mortality rate was 6.8%. The patients hospitalized in internal medicine had higher severity levels (3-4) than those hospitalized in other medical departments (41.9% vs. 31.6%, respectively; P<.01) and those hospitalized in surgical departments (11.2%; P<.01). Conclusions: Diabetes mellitus is a significant comorbidity for patients hospitalized in internal medicine. A significant proportion of these patients present cardiovascular disease, mostly heart failure

Los internistas y la muerte en el hospital / Internists and death in the hospital

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Metastatic spinal cord compression: Incidence, epidemiology and prognostic factors. / Compresión medular metastásica: incidencia, epidemiología y factores pronóstico.

BACKGROUND: Metastatic spinal cord compression (MSCC) is a severe complication in patients with cancer, and its incidence rate is difficult to accurately estimate. The aim of this study is to report the incidence and epidemiological and prognostic characteristics of MSCC in patients with cancer. MATERIAL AND METHODS: We analysed a cohort of 1736 patients diagnosed with cancer of any origin who were hospitalised in a palliative care unit. We collected epidemiological data, signs and symptoms, mean time to diagnosis, treatment regimen, response to treatment and mortality for the patients diagnosed with MSCC. RESULTS: In the 1736 patients, we identified 28 (1.6%) cases of MSCC. The average age was 67.2 (SD, 12.7) years, and lung cancer was the most common primary tumour (42.8%). The thoracic spine was the most affected location (12 cases, 42.8%), and pain was the predominant symptom (13 cases, 46.4%). The median survival after the MSCC diagnosis was 84.5 days. CONCLUSIONS: We observed an incidence rate of 1.6% (N=28) for MSCC in a cohort of 1736 patients with cancer. MSCC is a marker of poor prognosis, with a mean survival of less than 3 months from diagnosis and a hospital mortality of 32.4%.

RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013-2016). / RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016).

OBJECTIVES: To compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyse the differences between IMUs in 2016 by hospital size. MATERIAL AND METHODS: We conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). RESULTS: Between 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; P=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; P=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. CONCLUSIONS: IMUs responded to the increased burden of care they supported during 2013-2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016.