Impacto económico de la variabilidad clínica en la petición de pruebas preoperatorias en cirugía mayor ambulatoria / Economic impact of clinical variability in preoperative testing for major outpatient surgery

INTRODUCCIÓN: Con el propósito de disminuir la variabilidad en la petición de pruebas preoperatorias y facilitar la toma de decisiones, nuestro centro ha establecido un protocolo de pruebas preoperatorias para pacientes ASA I y ASA II tratados mediante cirugía mayor ambulatoria (CMA). El objetivo del estudio fue calcular el impacto económico relacionado con la falta de adherencia de los profesionales al protocolo establecido. MÉTODOS: Estudio de costes retrospectivo con un muestreo aleatorizado simple de 353 pacientes atendidos en la consulta de anestesia durante un año. Se analizaron aspectos relacionados con los costes, así como el perfil de pacientes y especialidades según el grado de cumplimiento del protocolo establecido. RESULTADOS: La falta de adherencia al protocolo fue del 70%. Se realizaron 138 radiografías de tórax y 218 electrocardiogramas no indicados, lo que supuso un exceso de coste medio de 34 € por paciente. Teniendo en cuenta el coste de ambas pruebas y la población atendida en CMA durante el año evaluado, la falta de adherencia al protocolo supuso un exceso de coste anual para el centro entre 69.337 € y 84.727 €. CONCLUSIONES: Es preciso reducir la variabilidad clínica y favorecer la creación de sinergias entre los diferentes servicios para adecuar la petición de pruebas complementarias, disminuir los costos de la atención y mejorar la calidad asistencial

BACKGROUND: With the purpose of decreasing the existing variability in the criteria of preoperative evaluation and facilitating the clinical decision-making process, our hospital has a protocol of preoperative tests to use with ASA I and ASA II patients. The aim of the study was to calculate the economic impact caused by clinicians' non-adherence to the protocol for the anaesthesiological evaluation of ASA 1 and ASA II patients. METHODS: A retrospective study of costs with a random sample of 353 patients that were seen in the consultation for Anesthesiology over a period of one year. Aspects related to the costs, patient's profiles and specialties were analysed, according to the degree of fulfillment of the protocol. RESULTS: The lack of adherence to the the protocol was 70%. 130 chest X-rays and 218 ECG were performed without indication. This generated an excess costs of 34 € per patient. Taking into account the expenses of both tests and the attended population undergoing ambulatory surgery during the one-year period, an excess spending for the hospital of between 69.164 € and 83.312 € was estimated. CONCLUSIONS: Clinical variability should be reduced and the creation of synergies between the different departments should be enhanced in order to adjust the request for unnecessary complementary tests to decrease health care and to improve the quality of patient care

Economic impact of clinical variability in preoperative testing for major outpatient surgery. / Impacto económico de la variabilidad clínica en la petición de pruebas preoperatorias en cirugía mayor ambulatoria.

BACKGROUND: With the purpose of decreasing the existing variability in the criteria of preoperative evaluation and facilitating the clinical decision-making process, our hospital has a protocol of preoperative tests to use with ASA I and ASA II patients. The aim of the study was to calculate the economic impact caused by clinicians' non-adherence to the protocol for the anaesthesiological evaluation of ASA 1 and ASA II patients. METHODS: A retrospective study of costs with a random sample of 353 patients that were seen in the consultation for Anesthesiology over a period of one year. Aspects related to the costs, patient's profiles and specialties were analysed, according to the degree of fulfillment of the protocol. RESULTS: The lack of adherence to the the protocol was 70%. 130 chest X-rays and 218 ECG were performed without indication. This generated an excess costs of 34 € per patient. Taking into account the expenses of both tests and the attended population undergoing ambulatory surgery during the one-year period, an excess spending for the hospital of between 69.164 € and 83.312 € was estimated. CONCLUSIONS: Clinical variability should be reduced and the creation of synergies between the different departments should be enhanced in order to adjust the request for unnecessary complementary tests to decrease health care and to improve the quality of patient care.

La gestión de un Instituto de Investigación Sanitaria: hacia la investigación de excelencia a través de la mejora continua / Managing a health research institute: towards research excellence through continuous improvement

Los institutos de investigación sanitaria son una apuesta estratégica que se configura como el entorno idóneo para el desarrollo de una investigación traslacional de excelencia. Una investigación de calidad no sólo requiere una estructura científica e investigadora potente, sino también calidad e integridad en los sistemas de gestión que le dan soporte. Los instrumentos esenciales en nuestra institución fueron una planificación estratégica sólida, estructurada, integrada y coherente con el sistema de gestión de la calidad, una evaluación sistemática con indicadores periódicos, la medida de la satisfacción de los principales usuarios y las auditorías internas, y la implantación de un sistema innovador de gestión de la información. Las herramientas de gestión implementadas han supuesto un impulso estratégico en nuestro centro, además de asegurar un nivel de calidad y de eficiencia en el desarrollo y la gestión de la investigación que permite el avance hacia una investigación biomédica de excelencia (AU)

Health research institutes are a strategic commitment considered the ideal environment to develop excellence in translational research. Achieving quality research requires not only a powerful scientific and research structure but also the quality and integrity of management systems that support it. The essential instruments in our institution were solid strategic planning integrated into and consistent with the system of quality management, systematic evaluation through periodic indicators, measurement of key user satisfaction and internal audits, and implementation of an innovative information management tool. The implemented management tools have provided a strategic thrust to our institute while ensuring a level of quality and efficiency in the development and management of research that allows progress towards excellence in biomedical research (AU)

[Managing a health research institute: towards research excellence through continuous improvement]. / La gestión de un Instituto de Investigación Sanitaria: hacia la investigación de excelencia a través de la mejora continua.

Health research institutes are a strategic commitment considered the ideal environment to develop excellence in translational research. Achieving quality research requires not only a powerful scientific and research structure but also the quality and integrity of management systems that support it. The essential instruments in our institution were solid strategic planning integrated into and consistent with the system of quality management, systematic evaluation through periodic indicators, measurement of key user satisfaction and internal audits, and implementation of an innovative information management tool. The implemented management tools have provided a strategic thrust to our institute while ensuring a level of quality and efficiency in the development and management of research that allows progress towards excellence in biomedical research.

Comparación entre 2 sistemas analíticos para la determinación de la hemoglobina A1c: inmunoturbidimetría versus cromatografía líquida de alta eficiencia / Comparison of 2 analytical systems for hemoglobin A1c: An immunoturbidimetric method versus high performance liquid chromatography

Introducción. La hemoglobina A1c (HbA1c) es ampliamente utilizada en la determinación del estado glucémico de pacientes con diabetes mellitus. El objetivo de este estudio fue comparar 2 métodos automatizados para medir HbA1c basados en diferentes principios de medida, evaluar la correlación entre ambos y su practicabilidad. Métodos. Se analizaron 622 muestras mediante 2 sistemas analíticos con fundamentos diferentes de medición: cromatografía líquida de alta eficiencia (HPLC) (analizador ADAMS A1c HA-8160; A. Menarini Diagnostics, Italia) e inmunoturbidimetría (Tina-quant Hemoglobin A1c Gen.3, plataforma Cobas 6000; Roche Diagnostics, Suiza). Ambos métodos fueron calibrados según el procedimiento de referencia de la IFCC. Se valoró la correlación entre ambos métodos mediante los análisis de regresión de mínimos cuadrados y Passing-Bablok (R programa v.2.11.1). También se registró el tiempo de puesta en marcha, las tareas de mantenimiento diario y el rendimiento de los 2 instrumentos. Resultados. La correlación fue muy alta tanto por mínimos cuadrados (ordenada en el origen 0.05, pendiente 0.98) como en Passing-Bablok (ordenada en el origen 0,10, pendiente 1,00). El tiempo invertido diariamente para la puesta en marcha del analizador HA-8160 fue de 25 min y el tiempo de finalización fue de 15 min. Las tareas de mantenimiento del Cobas 6000 al inicio y fin del día son procesos automatizados. El rendimiento de los analizadores fue 20 muestras/h en el HA-8160 y 100 muestras/h en el Cobas 6000. El sistema analítico cuyo principio de medida es HPLC incluye también el análisis manual de cada cromatograma. Conclusiones. Existe una correlación excelente entre los métodos de HPLC e inmunoturbidimétrico. La ventaja del sistema analítico que utiliza la inmunoturbidimetría es la optimización del tiempo de procesamiento de las determinaciones de HbA1c, lo que reduce el coste unitario de la prueba (AU)

Introduction. Hemoglobin A1c (HbA1c) is widely used to assess glycemic status in patients with diabetes mellitus. The purpose of this study was to compare 2 automated analytical systems to measure HbA1c that use different measurement principles, evaluating the correlation between the two methods, as well as their ease of use. Methods. A total of 622 samples were analyzed using 2 methods: high performance liquid chromatography (HPLC) (analyzer ADAMS A1c HA-8160; A. Menarini Diagnostics, Italy) and an immunoturbidimetric assay (Tina-quant Hemoglobin A1c Gen.3, Cobas 6000 analyzer; Roche Diagnostics, Switzerland). Both methods were calibrated in accordance with IFCC reference measurement procedure. The correlation between the two methods was assessed by least squares and Passing-Bablok linear regression analyses (R program v.2.11.1). The daily start-up time of the 2 instruments used, daily maintenance tasks, and determination of throughput were also recorded. Results. There was a strong correlation between the results generated by the two test methods using both the least squares (intercept 0.54; slope 0.98) and Passing-Bablok (intercept 0.10; slope 1.00) regression methods. The time spent daily for the start-up of the HA-8160 analyzer was 25 min and completion time was 15 min. Maintenance tasks for the Cobas 6000 analyzer at the beginning and end of the day are automated processes. The throughput for the HA-8160 analyzer was 20 samples/h, and 100 samples/h for the Cobas 6000 analyzer. The HPLC method also included a time-consuming manual analysis of each chromatogram. Conclusions. An excellent correlation was observed between the HPLC and immunoturbidimetric methods. The advantages of the immunoturbidimetric method are optimization of processing time of HbA1c tests and a reduction in the unit cost per test (AU)

Sex ratio at birth is associated with first-trimester maternal thyrotropin in women receiving levothyroxine.

BACKGROUND: The sex ratio at birth (male out of total alive newborns) is historically established at 0.515 and is influenced by numerous factors. It is not known, however, whether it is influenced by maternal thyroid conditions. Our aim was to analyze its association with maternal thyroid autoimmunity and first-trimester thyrotropin (TSH). METHODS: We performed a retrospective cohort study at a tertiary care center. We studied 167 women who had received pregestational treatment with levothyroxine for hypothyroidism or differentiated thyroid carcinoma and gave birth to live infants. Women with secondary/tertiary hypothyroidism, pregestational diabetes mellitus, or multiple pregnancies were excluded. Autoimmunity was defined as present/absent, and mean first-trimester TSH was tested both as a quantitative variable and using six predefined categories. The outcome measure was sex ratio at birth. RESULTS: The sex ratio at birth was 0.485, not significantly different from expected. Maternal characteristics were similar in mothers of female and male newborns with the exception of mean first-trimester TSH, which was higher in pregnancies of female fetuses (3.27 vs. 2.52 mUI/L, p<0.025). Newborn sex differed across predefined TSH categories (p<0.021, with a sex ratio of 0.200 [95% confidence interval 0.00-0.402] for TSH ≥10 mUI/L). A multiple logistic regression analysis to predict newborn male sex confirmed maternal mean first-trimester TSH as the single predictor (odds ratio 0.900 [95% confidence interval 0.823-0.984], p<0.020). CONCLUSIONS: In women under pregestational treatment with levothyroxine, mean maternal first-trimester TSH is negatively associated with sex ratio at birth. This association has not been previously described.

Differences in the therapeutic approach to colorectal cancer in young and elderly patients.

PURPOSE: To analyze differences in the therapeutic approach to and tumor-related mortality of young and elderly colorectal cancer (CRC) patients. PATIENTS AND METHODS: This was a descriptive study of a retrospective cohort, based on administrative databases, of all patients with CRC diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, type of treatment received, survival time, and cause of death. We compared differences between a young group (YG) (age <75 years) and an older group (OG) (age ≥75 years) and assessed the variables associated with receiving different therapeutic options (multivariate analysis) and with survival time (Cox proportional hazards models). RESULTS: The study included 503 patients (YG, 320; OG, 183), with mean ages of 63.1 years in the YG and 81.8 years in the OG. No differences were observed between the groups in degree of differentiation, extension, tumor stage, or comorbidity. After adjustment for gender, comorbidity, and tumor localization and extension, YG patients were more likely than OG patients to receive surgery, radiotherapy, and chemotherapy and less likely to receive palliative care. After a median follow-up of 36.5 months, YG patients had a longer tumor-specific survival time than OG patients (36.41 months vs 26.05 months). After further adjustment, the YG had a lower tumor-specific mortality risk (hazard ratio, 0.66) than the OG. CONCLUSION: In comparison with younger patients, elderly CRC patients are undertreated, mainly because of their age and not because of their tumor type or comorbidity. Elderly patients have a significantly shorter tumor-specific survival time, partially because of this undertreatment.

Glycemic control and pregnancy outcomes in women with type 1 diabetes mellitus using lispro versus regular insulin: a systematic review and meta-analysis.

AIMS: This study performed a systematic review and meta-analysis on glycemic control and pregnancy outcomes in women with type 1 diabetes mellitus (T1DM) treated with lispro (LP) versus regular insulin (RI) since before pregnancy. METHODS: We performed a MEDLINE and EMBASE search. Abstracts (and full articles when appropriate) were reviewed by two independent researchers. Inclusion criteria were patients with T1DM, data on women treated with RI and LP since before pregnancy until delivery in the same article, at least five pregnancies in each group, and information on at least one pregnancy outcome. Quality assessment was performed using the Newcastle-Ottawa Quality Assessment Scale for cohort studies. RESULTS: Outcome data were summarized with Revman version 5.0 (ims.cochrane.org/revman/download [The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark]), applying a random effects model. Two hundred sixty-seven abstracts were identified, and four full articles fulfilled inclusion criteria, all of them corresponding to observational studies. Baseline characteristics were similar in women treated with LP or RI. Regarding outcome data, no differences between LP and RI groups were observed in hemoglobin A1c, gestational age at birth, birth weight, and rate of diabetic ketoacidosis, pregnancy-induced hypertension, pre-eclampsia, spontaneous miscarriages, interruptions, total abortions, cesarean section, preterm birth, macrosomia, small-for gestational-age newborns, stillbirth, neonatal and perinatal mortality, neonatal hypoglycemia, and major malformations. The rate of large-for-gestational age newborns was higher in the LP group (relative risk 1.38; 95% confidence interval 1.14-1.68). CONCLUSIONS: In relation to women with T1DM treated with RI, those treated with LP display similar baseline characteristics and no differences in metabolic control or perinatal outcome with the exception of a higher rate of large-for-gestational-age newborns.

Por su investigación desarrollada en embarazo y diabetes mellitus / For her research done in diabetes and pregnancy

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Hipotiroidismo central y dislipemia mixta secundarios a tratamiento con bexaroteno / Bexarotene-induced central hypothyroidism and mixed dyslipidemia

El bexaroteno es un análogo de retinoide sintético caracterizado por unirse selectivamente a un tipo de receptores retinoides (receptores X) que fue diseñado para el tratamiento, entre otros, de estadios avanzados de linfoma cutáneo de células T resistentes a tratamientos convencionales. Se ha descrito que hasta el 40% de los pacientes que reciben bexaroteno pueden desarrollar hipotiroidismo secundario y hasta el 70%, hiperlipemia mixta grave, efecto común a otros retinoides. Presentamos a 3 pacientes que desarrollaron hipotiroidismo central y dislipemia tras el inicio de tratamiento con bexaroteno; en uno de ellos pudimos observar que estas alteraciones remitían tras la supresión del tratamiento (AU)

Bexarotene is a synthetic retinoid analogue that joints selectively to retinoid X receptor and has been designed for treatment of advanced stages of cutaneous T- cell lymphoma. Up to a 40% of patients treated with bexarotene develop central hypothyroidism while severe mixed dyslipidemia may be present in up to 70%. We report 3 patients that developed central hypothyroidism and dyslipidemia after bexarotene treatment was initiated. In one of them, we observed normalization of the thyroid function when bexarotene treatment was stopped (AU)

Endocrinología y Nutrición: en buen camino y en buenas manos / Endocrinology and Nutrition: on the right road and in good hands

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Apetencia por la madera: forma excepcional de pica por celulosa en la anemia ferropénica / Wood craving: an unusual form of cellulose pica in ferropenic anaemia

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