Structural Model of Biomedical and Contextual Factors Predicting In-Hospital Mortality due to Heart Failure.

Background: Among the clinical predictors of a heart failure (HF) prognosis, different personal factors have been established in previous research, mainly age, gender, anemia, renal insufficiency and diabetes, as well as mediators (pulmonary embolism, hypertension, chronic obstructive pulmonary disease (COPD), arrhythmias and dyslipidemia). We do not know the role played by contextual and individual factors in the prediction of in-hospital mortality. Methods: The present study has added hospital and management factors (year, type of hospital, length of stay, number of diagnoses and procedures, and readmissions) in predicting exitus to establish a structural predictive model. The project was approved by the Ethics Committee of the province of Almeria. Results: A total of 529,606 subjects participated, through databases of the Spanish National Health System. A predictive model was constructed using correlation analysis (SPSS 24.0) and structural equation models (SEM) analysis (AMOS 20.0) that met the appropriate statistical values (chi-square, usually fit indices and the root-mean-square error approximation) which met the criteria of statistical significance. Individual factors, such as age, gender and chronic obstructive pulmonary disease, were found to positively predict mortality risk. Isolated contextual factors (hospitals with a greater number of beds, especially, and also the number of procedures performed, which negatively predicted the risk of death. Conclusions: It was, therefore, possible to introduce contextual variables to explain the behavior of mortality in patients with HF. The size or level of large hospital complexes, as well as procedural effort, are key contextual variables in estimating the risk of mortality in HF.

Algunas reflexiones sobre las reuniones masivas (mass gatherings) y su investigación en España / Reflections on mass gatherings and Spanish research on this topic

No disponible

Laboratorios y servicios hospitalarios de urgencias: en búsqueda de la eficiencia / No disponible

No disponible

Retraso en solicitar y acceder al soporte coronario: 30 años después / No disponible

No disponible

El intervencionismo coronario percutáneo previo no aumenta la mortalidad hospitalaria en cirugía coronaria: análisis de una serie de 63.420 casos / Previous Percutaneous Coronary Intervention Does Not Increase In-Hospital Mortality After Surgical Revascularization: Analysis of 63420 Cases

Introducción En diversas publicaciones de los últimos años se señala una mortalidad hospitalaria mayor de la cirugía de revascularización miocárdica en pacientes con antecedente de intervencionismo coronario percutáneo previo exitoso; por su parte, los modelos de riesgo de mortalidad en cirugía cardíaca publicados hasta la actualidad no han incluido este antecedente como factor de riesgo. Objetivo Analizar si el intervencionismo coronario percutáneo previo es un factor de riesgo de mortalidad hospitalaria en la cirugía de revascularización coronaria. Material y métodos Entre enero de 1997 y diciembre de 2007 se analizaron un total de 78.794 pacientes sometidos a cirugía coronaria, recogidos en la base de datos del Ministerio de Sanidad de España. Tras aplicar los criterios de exclusión, el estudio se realizó sobre un total de 63.420 pacientes, de los que 2.942 (4,6%) tenían intervencionismo coronario percutáneo previo. Las variables continuas se compararon con las pruebas de U de Mann-Whitney o de la t de Student y las variables categóricas, mediante chi cuadrado. Se realizó un análisis de regresión logística univariado y multivariado y un análisis multivariado que incluía un índice de propensión. Resultados El intervencionismo coronario percutáneo previo no fue un predictor independiente de mortalidad hospitalaria en el análisis multivariado (odds ratio 0,88; intervalo de confianza del 95% 0,72-1,07; p = 0,20) ni en el modelo que incluía un índice de propensión (odds ratio 0,9; intervalo de confianza 95% 0,75-1,08; p = 0,27). Conclusión El intervencionismo coronario percutáneo previo parece no ser un factor de riesgo independiente de mortalidad hospitalaria en pacientes con intervención quirúrgica coronaria.

Introduction Recent publications indicate higher in-hospital mortality following myocardial revascularization in patients with previous history of successful percutaneous coronary intervention. Yet, no risk models of surgical mortality have included percutaneous intervention as a risk factor. Objectives The purpose of this study was to analyze whether previous percutaneous coronary intervention is a risk factor of in-hospital mortality in coronary artery bypass grafting. Methods The study included 78794 patients retrieved from the Spanish Ministry of Health database, who underwent coronary artery bypass graft surgery between January 1997 and December 2007. After applying exclusion criteria, 63420 patients were included in the study, 2942 (4.6%) of whom had previously undergone percutaneous coronary intervention. Continuous variables were compared using the Mann-Whitney U test or Student's t test, and categorical variables using the chi-square test. Univariate and multivariate logistic regression analyses and a multivariate analysis including a propensity score were performed. Results Previous percutaneous coronary intervention was not an independent risk factor of in-hospital mortality in the multivariate logistic regression analysis (odds ratio 0.88; 95% confidence interval, 0.72-1.07; p = 0.20) or after adjusting for propensity score (odds ratio 0.9; 95% confidence interval, 0.75-1.08; p = 0.27). Conclusion Previous percutaneous coronary intervention is not an independent risk factor of in-hospital mortality in patients undergoing coronary artery bypass grafting.

El intervencionismo coronario percutáneo previo no aumenta la mortalidad hospitalaria en cirugía coronaria: análisis de una serie de 63.420 casos / Previous Percutaneous Coronary Intervention Does Not Increase In-Hospital Mortality After Surgical Revascularization: Analysis of 63420 Cases

Introducción En diversas publicaciones de los últimos años se señala una mortalidad hospitalaria mayor de la cirugía de revascularización miocárdica en pacientes con antecedente de intervencionismo coronario percutáneo previo exitoso; por su parte, los modelos de riesgo de mortalidad en cirugía cardíaca publicados hasta la actualidad no han incluido este antecedente como factor de riesgo. Objetivo Analizar si el intervencionismo coronario percutáneo previo es un factor de riesgo de mortalidad hospitalaria en la cirugía de revascularización coronaria. Material y métodos Entre enero de 1997 y diciembre de 2007 se analizaron un total de 78.794 pacientes sometidos a cirugía coronaria, recogidos en la base de datos del Ministerio de Sanidad de España. Tras aplicar los criterios de exclusión, el estudio se realizó sobre un total de 63.420 pacientes, de los que 2.942 (4,6%) tenían intervencionismo coronario percutáneo previo. Las variables continuas se compararon con las pruebas de U de Mann-Whitney o de la t de Student y las variables categóricas, mediante chi cuadrado. Se realizó un análisis de regresión logística univariado y multivariado y un análisis multivariado que incluía un índice de propensión. Resultados El intervencionismo coronario percutáneo previo no fue un predictor independiente de mortalidad hospitalaria en el análisis multivariado (odds ratio 0,88; intervalo de confianza del 95% 0,72-1,07; p = 0,20) ni en el modelo que incluía un índice de propensión (odds ratio 0,9; intervalo de confianza 95% 0,75-1,08; p = 0,27). Conclusión El intervencionismo coronario percutáneo previo parece no ser un factor de riesgo independiente de mortalidad hospitalaria en pacientes con intervención quirúrgica coronaria.(AU)

Introduction Recent publications indicate higher in-hospital mortality following myocardial revascularization in patients with previous history of successful percutaneous coronary intervention. Yet, no risk models of surgical mortality have included percutaneous intervention as a risk factor. Objectives The purpose of this study was to analyze whether previous percutaneous coronary intervention is a risk factor of in-hospital mortality in coronary artery bypass grafting. Methods The study included 78794 patients retrieved from the Spanish Ministry of Health database, who underwent coronary artery bypass graft surgery between January 1997 and December 2007. After applying exclusion criteria, 63420 patients were included in the study, 2942 (4.6%) of whom had previously undergone percutaneous coronary intervention. Continuous variables were compared using the Mann-Whitney U test or Students t test, and categorical variables using the chi-square test. Univariate and multivariate logistic regression analyses and a multivariate analysis including a propensity score were performed. Results Previous percutaneous coronary intervention was not an independent risk factor of in-hospital mortality in the multivariate logistic regression analysis (odds ratio 0.88; 95% confidence interval, 0.72-1.07; p = 0.20) or after adjusting for propensity score (odds ratio 0.9; 95% confidence interval, 0.75-1.08; p = 0.27). Conclusion Previous percutaneous coronary intervention is not an independent risk factor of in-hospital mortality in patients undergoing coronary artery bypass grafting.(AU)

[Prevalence of processes and pathologies in emergency hospital care]. / Prevalencia de procesos y patologías en la atención urgente hospitalaria.

OBJECTIVES: To study the behavioural differences between scheduled and emergency admissions in the processes most prevalent in Spanish hospitals and their relationship with the age of patients, comparing 2002 and 2007. METHODS: Observational and descriptive design for those years. Diagnostic related groups (DRGs) were classified into high prevalence (the 25 most frequent) and the rest; four subgroups were prepared according to this (high or low) and admission (elective or not). Mean length of stay was analyzed, together with relative weight, number of diagnoses and procedures and mortality by age, using the Student and/or ANOVA tests for quantitative variables and Pearson's chi(2) qualitative comparison of means and proportions for tabular data, assuming statistical significance at p <0.05. RESULTS: The high prevalence and emergency admission subgroup has higher age, ratio of males, mean length of stay, mortality, number of diagnoses and procedures (all p <0.0001), in both 2002 and 2007. The complexity and resource consumption measured by such variables peaks in the 65-69 and 70-74 cohorts respectively, with emergency admission. CONCLUSIONS: There are clear differences between the processes according to their prevalence and accessibility; priority must be given to knowledge and information on the most frequent and urgent admissions to improve the effectiveness, efficiency and quality.

Hospital utilization and aging in Spain (2006).

OBJECTIVES: The main objective of this study is to verify the existence of a direct relation between age, ageing and hospital resources utilization. METHODS: For this purpose, we use not only population variables, but also clinical parameters such as severity and complexity, as proxy of consumption and hospital costs. Through a comprehensive statistical analysis, quantitative variables of the Spanish Minimum Data Set of year 2006 (length of stay, relative weight, number of diagnoses and procedures) according to age groups and gender, types of admission (emergency or scheduled) and discharge (alive or dead), measuring the severity by weight, complications, comorbidities and mortality, and complexity by weight and length of stay. RESULTS: The highest severity was observed in 65-69 year-old males and the highest complexity in 75-79 year-old males and 85-89 year-old females (p<.0001). The severity and complexity are also higher among 65-69 year-old males and 70-79 year-old patients of both sexes with emergency access (p<.0001). The deceased patients are more aged with higher severity and complexity than the survivors (p<.0001). CONCLUSIONS: The age per se is not directly related to consumption of hospital resources. Therefore, aging does not necessarily imply higher consumption or increased hospital costs. Emergency admitted in-patients are older and more severe and complex than the scheduled ones, thus consuming more resources and implying higher hospital costs; the same is true for the deceased versus the survivors.

Congresos de la Sociedad Española de Medicina de Urgencias y Emergencias (I): recuerdos y reflexiones de 20 años de actividad institucional / Conferences of the Spanish Society of Emergency Medicine (SEMES), Part 1: recollections and reflections on 20 years' labor

El pasado mes de junio se celebró el vigésimo congreso de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). Al hilo de esta efemérides, en este artículo, con claros matices intimistas, los tres presidentes que SEMES ha tenido hacemos un repaso a la evolución de nuestra sociedad durante estos últimos 20 años, a los principales hitos conseguidos y a los principales retos para el futuro. A la vez, quiere ser un justo homenaje a todos aquellos quienes con su esfuerzo hicieron posible, no sólo la celebración de esos 20 congresos, sino el crecimiento año tras año de la calidad de los mismos (AU)

The 20th conference of the Spanish Society of Emergency Medicine (SEMES) was held this past June. On the occasion of this anniversary, the 3 presidents who have led SEMES during these first 20 years of activity offer their personal account of the society's progress, highlighting both achievements and challenges for the future. Well-deserved thanks are given to all those who have contributed to the organization of the societys' meetings and to their ever-growing excellence (AU)

Variación de la estancia preoperatoria en España según grupos de edad, sexo y modo de acceso hospitalario (urgente o programado) / Variation in preoperative stay in Spain according to age group, sex and type of hospital admission (urgent or scheduled)

Introducción: El incremento del gasto amenaza la sostenibilidad financiera de los sistemas de salud y condiciona reformas en la utilización hospitalaria. La duración de la estancia preoperatoria depende de factores de programación (intervenciones, rendimiento quirúrgico, cancelaciones, preanestesia) y, posiblemente, también de elementos del propio proceso asistencial (gravedad, complejidad, complicaciones) y del paciente (edad, sexo, comorbilidad, acceso), que repercuten en la estancia total y los costes directos. Se ha pretendido investigar la duración de la estancia preoperatoria en España y sus relaciones con estas variables, el modo de ingreso (urgente o programado) y el tipo clínico (inicialmente médico o quirúrgico). Material y métodos: Estudio descriptivo y analítico (con ANOVA y regresión lineal) de episodios del CMBD de 2005 (mediante agrupador GRD) que ocasionaron intervención quirúrgica, a través de variables (peso relativo, coste, número de diagnósticos secundarios y procedimientos, mortalidad, estancia, edad y sexo) con un paquete SPSS. Se consideró significación estadística si p < 0,05. Resultados: La estancia preoperatoria media fue de 2,92 días, más elevada en los procesos urgentes quirúrgicos (5,8) y médicos (5,44), y por edad y sexo fue más alta en varones (7,51) y mujeres (6,31) quirúrgicos urgentes de 70-74 años, mientras en los programados médicos crecía con la edad. Hay relación estadísticamente significativa de la estancia preoperatoria con la estancia total, el peso relativo, el coste y demás variables expresivas de la gravedad y la complejidad. Conclusiones: La estancia preoperatoria depende de determinantes de planificación y organización hospitalarias, pero también de factores del proceso y del paciente, sobre todo su forma de acceso, sin relación con la edad. Así, el envejecimiento no debería suponer problema en la hospitalización quirúrgica urgente, aunque debe gestionarse mejor en la electiva. La programación de los estudios preoperatorios debe disminuir la estancia preoperatoria, pero también la gestión de los pacientes desde el servicio de urgencias y, con ella, la estancia total y los costes directos (AU)

Introduction: The increase in health care expenditure threatens the financial sustainability of health systems, and is leading to reforms in hospital use. The length of preoperative stay (POS) depends on the number of interventions and cancellations, but also possibly related to the care process itself (complexity, severity) and the patient (age, sex, comorbidity) with repercussions on the total stay and direct costs. There have been investigations on the length of POS in Spain and its possible relationships with these variables, hospital access (urgent or scheduled) and clinical type (originally medical or surgical). Materials and methods: Descriptive and comparative analysis with ANOVA and linear regression of the episodes of the Minimal Data Set 2005 which have resulted in surgery, through variables (relative weight, cost, number of secondary diagnoses and procedures, mortality, stay, age and sex) using SPSS version 15 for Windows, a p < 0.05 being established as statistically significant. Results: The POS averaged 2.92 days, higher in urgent in-patient surgical (5.80) and medical (5.44) procedures, and by age groups and gender was higher in men (7.51) and women (6.31) of 70-74 years with surgical emergencies, but there is a direct link with age in scheduled medical inpatients. There was statistically significant relationship of POS with the length of stay, the relative weight, cost and other variables, all dependent on the severity and complexity. Conclusions: The POS depends on determining factors such as hospital planning and organization, but also depends on some factors of the process and the patient. Ageing should not cause problems in the emergency surgical in-patient, but must be best managed in the scheduled ones. Adequate management of preoperative studies is essential to reduce the POS, the length of stay and the direct costs of hospitalization (AU)

¿Y si adaptáramos los servicios hospitalarios de urgencias a la demanda social y no a las necesidades de salud? / Why not adapt hospital emergency departments to social demands instead of health needs?

El incremento producido en la utilización de los servicios de urgencias hospitalarios(SUH), en estos últimos años y en todos los países desarrollados –incluso para situaciones de baja complejidad que podrían ser atendidas en niveles inferiores– no obedece simplemente a los cambios demográficos (aumento de la población por envejecimiento y movimientos migratorios) ni epidemiológicos, sino que parecen existir otros factores que intentan explicar y se asocian a esta conducta, como la necesidad percibida de atención inmediata, la dificultad de acceso a otros recursos del sistema, la falta se aseguramiento público y el nivel socioeconómico y cultural. España no ha sido ajena a ese fenómeno que, sin duda, contribuye a la masificación de estos departamentos, pérdida de continuidad asistencial y de calidad, insatisfacción de profesionales, inadecuación y demora en la atención a las urgencias verdaderas, mayor gasto sanitario y repercusiones muy importantes sobre la gestión del resto del hospital. Investigadas las causas de ese incremento, tanto desde el punto de vista de la oferta como de la demanda, y analizadas las intervenciones realizadas hasta la actualidad para disuadir o evitar el aumento de la frecuentación a los SUH (facilitar la accesibilidad a la atención primaria, mejoras educativas, instauración de barreras, reformas organizativas) derivando buena parte de la misma a los centros extrahospitalarios, se ha comprobado su escasa efectividad cuando no su inutilidad. Dados estos resultados, y entendiendo las diferencias entre necesidad, demanda y oferta de salud, desde un punto de vista antropológico y social –y, por tanto, los intentos de justificación de las percepciones de los ciudadanos ante una urgencia– cabría plantearse el rediseño funcional de la asistencia a estos procesos en un nuevo escenario, donde el hospital fuera adaptado al modelo de gestión del SUH y no a la inversa (AU)

During recent years developed countries have witnessed a stepwise increase in the use of the hospital emergency departments(HED) even in low complexity situations that could have been managed in other healthcare levels. Apart from being a consequence of demographic changes (migration and ageing population) other factors may be associated with this situation such as the perceived need for immediate care, the difficulty of access to other resources of the system, the lack of public coverage and the socioeconomic and cultural level. This phenomenon contributes to HED overcrowding, loss of care continuity and quality, professionals dissatisfaction, delays in the attention of true emergency situations, higher health costs and has very important consequences on the management of the rest of the hospital. The interventions made to date to dissuade or to avoid the increase on the frequentation in HED (education improvements, reducing administrative barriers, copayment, implementation of primary care centres) have shown poor effectiveness or even uselessness. Considering the knowledge of the differences between the need, demand and supply of health care, from an anthropological and social point of view – and the attempts for justify citizen perceptions in an emergency – a new functional design should be implemented to manage these processes in a new scenario, in which the hospital should be adapted to the model of management of the HED and not vice versa (AU)

Gestión de la información y la comunicación en emergencias, desastres y crisis sanitarias / Information and communication management in emergencies, disasters and health care crises

Con cierta frecuencia solemos preguntarnos si estamos bien informados, en España, en relación con situaciones de emergencia sanitaria y crisis en salud. Entendiendo que existen, al menos, cuatro puntos de vista (técnico, administrativo, político y mediático)para originar la posible desinformación, pero admitiendo el buen funcionamiento de la actual red de alerta epidemiológica y vigilancia de salud pública española, se debe convenir que el principal motivo debe encontrarse en los fallos de comunicación de riesgos, especialmente durante la gestión de estas situaciones. En este trabajo se definen y analizan las estrategias de información de riesgos, y se comentan las fases de un adecuado plan de comunicación, comenzando por una auditoría de vulnerabilidad. Se expresan las características que debe poseer el portavoz de una organización para actuar como responsable de la transmisión del mensaje, y las peculiaridades del contenido y la forma para alcanzar la confianza de la opinión pública. Finalmente se elaboran los distintos modelos periodísticos y sustratos (prensa escrita, radio, televisión, Internet) para trasladar una información en momentos de crisis y emergencias en salud. Todos los profesionales de la atención urgente y emergente deben conocer estos aspectos, y evitar así posibles errores de credibilidad y garantía informativa, especialmente aquellos que, en razón de su nivel o cargo, son considerados responsables de la gestión de la comunicación en sus instituciones (AU)

We rather frequently ask ourselves whether we are sufficiently well informed, here in Spain, regarding situations of healthcare emergencies and crises. Considering that there are at least four different poits of view (technical, administrative, political and mass-media) that may originate a possible disinformation, yet admitting the good functioning of the present Spanish epidemiological alert and public health vigilance network, we should agree that the main reason for disinformation must be found in deficiencies in the communication of risks, particularly during the management of such situations. We here define and analyse the risk information strategies and discuss the phases of an adequate communication plan, beginning with a true audit of vulnerability the characteristics are discussed that the spokesman of an organisation should have in order to act as the person responsible for the transmission of the message, together with the peculiarities of the message’s contents and the mode of presentation in order to achieve the confidence of the public. Finally, the various journalistic models and substrates (written press, radio, television, Internet) are presented and elaborated that will allow the transfer of information at times of crises and health emergencies. All professionals of urgent and emergent care should be fully aware of these aspects, thus avoiding and preventing possible errors in credibility and informative guarantee, but most particularly those who, because of their level or position, are held to be responsible for communication management within their respective institutions (AU)

[Not Available]. / Variación de la estancia preoperatoria en España según grupos de edad, sexo y modo de acceso hospitalario (urgente o programado).

INTRODUCTION: The increase in health care expenditure threatens the financial sustainability of health systems, and is leading to reforms in hospital use. The length of preoperative stay (POS) depends on the number of interventions and cancellations, but also possibly related to the care process itself (complexity, severity) and the patient (age, sex, comorbidity) with repercussions on the total stay and direct costs. There have been investigations on the length of POS in Spain and its possible relationships with these variables, hospital access (urgent or scheduled) and clinical type (originally medical or surgical). MATERIALS AND METHODS: Descriptive and comparative analysis with ANOVA and linear regression of the episodes of the Minimal Data Set 2005 which have resulted in surgery, through variables (relative weight, cost, number of secondary diagnoses and procedures, mortality, stay, age and sex) using SPSS version 15 for Windows, a p<0.05 being established as statistically significant. RESULTS: The POS averaged 2.92 days, higher in urgent in-patient surgical (5.80) and medical (5.44) procedures, and by age groups and gender was higher in men (7.51) and women (6.31) of 70-74 years with surgical emergencies, but there is a direct link with age in scheduled medical inpatients. There was statistically significant relationship of POS with the length of stay, the relative weight, cost and other variables, all dependent on the severity and complexity. CONCLUSIONS: The POS depends on determining factors such as hospital planning and organization, but also depends on some factors of the process and the patient. Ageing should not cause problems in the emergency surgical in-patient, but must be best managed in the scheduled ones. Adequate management of preoperative studies is essential to reduce the POS, the length of stay and the direct costs of hospitalization.

Medical care at the VIIth International Amateur Athletics Federation World Championships in Athletics 'Sevilla '99'.

INTRODUCTION: The World Athletics Championships are considered to be the third most important sporting event on the planet. Before the celebration of their seventh meeting in Seville, Spain, the need for medical care, as in the Olympic Games, was supposed to be low and of minimal complexity. It was nevertheless judged necessary to install strategically located assistance points, and to evaluate the results of this intervention. METHODOLOGY AND DESIGN: Following the planning phase carried out by a multidisciplinary commission of health, set up by the Organizer Committee, which prepared protocols, that were elaborated by five working groups, the operation developed during the World Championships in Athletics is described. Five clinics and several first aid stations were set up in the stadium and its surroundings, in hotels, warm-up and training tracks, the high-speed train station and the airport, as well as strategic points in the city. RESULTS: There were 1338 medical consultations, and 35 patients (2.6%) were transferred to hospitals. 21 codes of the International Classification of Disease constituted 50.4% of the case mix. Injuries, which accounted for 36.1% of all medical visits, were more common among athletes (48.9%) than among other groups. Injuries accounted for 30.5% of all other groups combined. Spectators and other groups accounted for most (86.8 and 63.1%, respectively) of the 276 visits concerning contusions and 165 visits for heat-related illness. The overall physician treatment rate was 19.3% for athletes and 4.5/10 000 for spectators. CONCLUSION: The preparation of a potent pre-hospital service, strategically located and dedicated to the event, was able to solve the problems that occurred. Nevertheless, a hospital alert and a coordination centre are also necessary. These data should be useful in planning medical resources for future mass sporting events.