Evaluación poblacional del impacto del nivel socioeconómico en los resultados clínicos en pacientes con insuficiencia cardiaca en entornos de atención integrada / Population-based evaluation of the impact of socioeconomic status on clinical outcomes in patients with heart failure in integrated care settings

Introduction and objectives: Low socioeconomic status (SES) is associated with poor outcomes in patients with heart failure (HF). We aimed to examine the influence of SES on health outcomes after a quality of care improvement intervention for the management of HF integrating hospital and primary care resources in a health care area of 209 255 inhabitants.MethodsWe conducted a population-based pragmatic evaluation of the implementation of an integrated HF program by conducting a natural experiment using health care data. We included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January 1, 2015 and December 31, 2019. We compared outcomes between patients exposed to the new HF program and those in the remaining health care areas, globally and stratified by SES.ResultsA total of 77 554 patients were included in the study. Death occurred in 37 469 (48.3%), clinically-related hospitalization in 41 709 (53.8%) and HF readmission in 29 755 (38.4%). On multivariate analysis, low or very low SES was associated with an increased risk of all-cause death and clinically-related hospitalization (all Ps <.05). The multivariate models showed a significant reduction in the risk of all-cause death (HR, 0.812; 95%CI, 0.723-0.912), clinically-related hospitalization (HR, 0.886; 95%CI, 0.805-0.976) and HF hospitalization (HR, 0.838; 95%CI, 0.745-0.944) in patients exposed to the new HF program compared with patients exposed to the remaining health care areas and this effect was independent of SES.ConclusionsAn intensive transitional HF management program improved clinical outcomes, both overall and across SES strata. (AU)

Introducción y objetivos: El nivel socioeconómico (NSE) bajo se asocia con malos resultados en pacientes con insuficiencia cardiaca (IC). Nuestro objetivo es examinar la influencia del NSE en los resultados de salud tras una intervención de mejora de la calidad en el abordaje de la IC en un área de salud integrada de 209.255 habitantes.MétodosSe efectuó una evaluación pragmática poblacional utilizando bases de datos administrativas y sanitarias. Se incluyó a todas las personas consecutivas hospitalizadas con un código CIE-9-CM de IC como diagnóstico principal y dadas de alta vivas en Cataluña entre el 1 de enero de 2015 y el 31 de diciembre de 2019. Se compararon los resultados entre los pacientes expuestos al nuevo programa de IC y los de las demás áreas asistenciales, en general y según su NSE.ResultadosSe incluyó a 77.554 pacientes. Los eventos adversos fueron: muerte en 37.469 (48,3%), hospitalización clínicamente relacionada en 41.709 (53,8%) y reingreso por IC en 29.755 (38,4%). El NSE bajo o muy bajo se asoció con un mayor riesgo de eventos clínicos adversos (p <0,05). Se observó una reducción significativa del riesgo de muerte (HR=0,812; IC95%, 0,723-0,912), hospitalización relacionada con la clínica (HR=0,886; IC95%, 0,805-0,976) y por IC (HR=0,838; IC95%, 0,745-0,944) en los pacientes expuestos al nuevo programa frente a los de las demás áreas sanitarias y este efecto fue independiente del NSE.ConclusionesUn programa de atención transicional para la IC mejoró los resultados clínicos, tanto en general como en todos los estratos de NSE. (AU)

Population-based evaluation of the impact of socioeconomic status on clinical outcomes in patients with heart failure in integrated care settings.

INTRODUCTION AND OBJECTIVES: Low socioeconomic status (SES) is associated with poor outcomes in patients with heart failure (HF). We aimed to examine the influence of SES on health outcomes after a quality of care improvement intervention for the management of HF integrating hospital and primary care resources in a health care area of 209 255 inhabitants. METHODS: We conducted a population-based pragmatic evaluation of the implementation of an integrated HF program by conducting a natural experiment using health care data. We included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January 1, 2015 and December 31, 2019. We compared outcomes between patients exposed to the new HF program and those in the remaining health care areas, globally and stratified by SES. RESULTS: A total of 77 554 patients were included in the study. Death occurred in 37 469 (48.3%), clinically-related hospitalization in 41 709 (53.8%) and HF readmission in 29 755 (38.4%). On multivariate analysis, low or very low SES was associated with an increased risk of all-cause death and clinically-related hospitalization (all Ps <.05). The multivariate models showed a significant reduction in the risk of all-cause death (HR, 0.812; 95%CI, 0.723-0.912), clinically-related hospitalization (HR, 0.886; 95%CI, 0.805-0.976) and HF hospitalization (HR, 0.838; 95%CI, 0.745-0.944) in patients exposed to the new HF program compared with patients exposed to the remaining health care areas and this effect was independent of SES. CONCLUSIONS: An intensive transitional HF management program improved clinical outcomes, both overall and across SES strata.

To return or to discard? Randomised trial on gastric residual volume management.

BACKGROUND: The control of gastric residual volume (GRV) is a common nursing intervention in intensive care; however the literature shows a wide variation in clinical practice regarding the management of GRV, potentially affecting patients' clinical outcomes. The aim of this study is to determine the effect of returning or discarding GRV, on gastric emptying delays and feeding, electrolyte and comfort outcomes in critically ill patients. METHOD: A randomised, prospective, clinical trial design was used to study 125 critically ill patients, assigned to the return or the discard group. Main outcome measure was delayed gastric emptying. Feeding outcomes were determined measuring intolerance indicators, feeding delays and feeding potential complications. Fluid and electrolyte measures included serum potassium, glycaemia control and fluid balance. Discomfort was identified by significant changes in vital signs. RESULTS: Patients in both groups presented similar mean GRV with no significant differences found (p=0.111), but participants in the intervention arm showed a lower incidence and severity of delayed gastric emptying episodes (p=0.001). No significant differences were found for the rest of outcome measurements, except for hyperglycaemia. CONCLUSIONS: The results of this study support the recommendation to reintroduce gastric content aspirated to improve GRV management without increasing the risk for potential complications.

Umbral de pericia requerido para la ejecución competencia enfermera / Expertise threshold required for nursing competency performance

Objetivo: analizar la relación entre los elementos del instrumento COM_VA© (competencia y valoración) de evaluación de competencias asistenciales con los niveles de pericia, de aprendiz a experto, mediante el establecimiento del umbral de competencia. Método: estudio descriptivo transversal con una muestra de más de 400 enfermeras, que respondieron a un cuestionario estructurado en el que debían asociar a cada elemento competencial un nivel de pericia, siendo 1 aprendiz y 5 expertos. El análisis estadístico se realizó con la determinación de medidas de tendencia central (porcentajes, media, varianza, moda y desviación típica). Resultados: los elementos competenciales que requieren un mayor grado de pericia se incluyen en las competencias: (4) contribuir a garantizar la seguridad y el proceso asistencial, (2) valorar, diagnosticar y abordar situaciones clínicas cambiantes, (3) ayudar al paciente a cumplir el tratamiento y (5) facilitar los procesos de adaptación y afrontamiento. El umbral mínimo identificado es de 2,3 (principiante) y el máximo de 3,9 (proeficiente). Ninguno de los elementos competenciales se asocia a un umbral extremo (aprendiz/experto). Conclusiones: el umbral de pericia identifica nivel mínimo necesario de interacción de conocimientos, habilidades y actitudes para la toma de decisiones en la práctica asistencial. Los elementos identificados con un mayor umbral de pericia se corresponden con contenidos competenciales que precisan de una desarrollada habilidad de juicio clínico, una marcada capacidad analítica, un amplio conocimiento disciplinar y una importante capacidad de juicio intuitivo (AU)

Objective: to analyze the relationship between the elements of the COM_VA© (COMpetencia [COMpetency] and VAloración [Assessment]) healthcare delivery competencies assessment tool and the levels of expertise, spanning from trainee to expert, by means of the establishment of the competency threshold. Method: cross-sectional, descriptive study using a sample of over 400 nurses, who responded to a structured questionnaire in which they had to associate each competency element to a level of expertise, 1 corresponding to trainee and 5 to expert. The statistical analysis was carried out using central tendency measures (percentages, mean, variance, trend and typical deviation). Results: the competency elements which require a higher level of expertise are included in the following competences: (4) to contribute in guaranteeing safety and the healthcare delivery process, (2) to assess, diagnose and tackle changing clinical situations, (3) to help the patient comply with the treatment and (5) to facilitate adaptation and coping processes. The minimum threshold identified was 2,3 (beginner) and the maximum was 3,9 (proficient). None of the competency elements were associated with an extreme threshold (trainee/expert). Conclusions: the expertise threshold identifies the necessary minimum level of interaction of knowledge, skills and attitudes for decision-making in healthcare delivery practice. The elements identified with a higher thresh- old of expertise correspond to competence contents which require developed clinical judgement ability, strong analytical capacity, broad disciplinary knowledge and an excellent capacity for intuitive judgement (AU)

Análisis del contexto organizativo de la práctica enfermera. El Nursing Work Index en los hospitales públicos / Analysis of an organisational context in nursing practice. The Nursing Work Index in public hospitals

El contexto organizativo para la prestación de cuidados incluye los factoresorganizativos y estructurales que facilitan la práctica profesionalenfermera y tienen un impacto significativo en los resultados de los pacientesy de los centros.Objetivo: analizar el contexto organizativo para la prestación de cuidadosen los hospitales del sistema público de salud.Método: los datos se recogieron en los talleres organizados por laCoordinación de Enfermería del Institut Català de la Salut, empleandoun cuestionario que contenía los elementos del Nursing Work Index-Revised.La estrategia de análisis es eminentemente descriptiva, incluyendotambién la exploración de la correlación entre las subescalas delinstrumento.Resultados: se analizaron 405 cuestionarios. El resultado principal delestudio indica un bajo grado de desarrollo del contexto organizativo enlos hospitales estudiados. Los factores organizativos más desarrolladosson la “Autonomía” y el “Control sobre la práctica enfermera”. Losfactores organizativos menos desarrollados incluyen el “Reconocimientoprofesional” y la “Formación”. Ninguno de los factores evaluados obtuvouna puntuación sobresaliente.Conclusiones: el Nursing Work Index-Revised es una buena herramientapara efectuar una estimación aproximada del contexto organizativopara la prestación de cuidados. Los gestores deberían hacer unaprofunda reflexión sobre el coste de no considerar los aspectos que facilitanla práctica enfermera en los hospitales

The organisational context for the delivery of care includes organisationaland structural factors that facilitate the professional practice of nursingand have a significant impact on the results for patients and centres.Objective: analyse the organisational context for the delivery of healthcarein public hospitals belonging to the national health system.Method: data were gathered at the workshops organised by the NursingCoordination division of the Catalan Health Institute, utilising aquestionnaire that contained the items from the Nursing Work Index-Revised. The analysis strategy is eminently descriptive, including the explorationof the correlation between the element’s subscales.Results: 405 questionnaires were analysed. The main result of thisstudy shows a low degree of development in the organisational contextin the studied hospitals. The most developed organisational factorsare “Autonomy” and “Control on the Nursing Practice”. The least developedorganisational factors include “Professional Recognition” and“Training”. None of the studied factors obtained an excellent score.Conclusions: the Nursing Work Index-Revised is a good tool to makea close estimation of the organisational context for the delivery ofhealthcare. Managers should give some serious thought to cost whenother aspects that facilitate nursing practice in hospitals are not considered (AU)