Reinversión en sanidad: fundamentos,aclaraciones, experiencias y perspectivas

During the economic crisis, the pressure to reduce health services expenditure as an isolated measure is greater than measures intended to increase the efficiency of these services. Information, methods and experiences to improve health outcomes with limited resources are available and a number of countries have been applying measures to achieve this goal. One of these measures is disinvestment. Given that this tactic is necessary but also intricate, allergenic and confusing, this article tries to clarify its meaning, place it in its correct context, and describe the methods and criteria used to identify and prioritize candidate medical technologies for disinvestment. The experiences of Spain, New Zealand, Australia, Canada, the United Kingdom and Italy in this endeavor are reviewed, as well as the obstacles faced by these countries when disinvesting and their mid-term perspectives. Ignorance does not excuse its application, regardless of whether there is a crisis or not. Efforts to improve social efficiency are a permanent obligation of the national health system.     

La comunicación y la satisfacción de las primíparas en un servicio público de salud

Objective

To analyze first-time mothers communication with health professionals, and to explore satisfaction, needs and expectation towards healthcare services.

Method

Qualitative design using in-deep interviews and phenomenology was used. First-time mothers from Huercal-Overa (Almería) were intentionally selected in 2010 and were included in the study. A hermeneutic analysis was performed.

Results

Six meta-categories were obtained. Saturation of information was found with nine interviews. The meta-categories were the following: 1) Health professionals; 2) Pregnancy, partum and postpartum; 3) Communication; 4) Child nutrition; 5) Feelings; 6) Others. The mothers perceived as exciting this new experience and expressed feelings of fear, anguish and high sensitiveness. These feelings are increased by the information received from the family circle and the professionals which is referred low and contradictory. All professionals were positively considered, specially the midwife. The following negative experiences were identified: contractions, dilation and delivery. The end of the stay at the hospital was considered early and the time for consultation was short for the mothers. There is a demand about more information on breast feeding. Mothers wish health professionals to respect their decisions.

Conclusions

The study found some areas for improvement in the communication between firs-time mothers and health professionals which could be taken into account in satisfaction promotion plans in regards to healthcare services.     

Potencial sesgo de selección en las encuestas telefónicas: teléfonos fijos y móviles

The increasing use of mobile phones in the last decade has decreased landline telephone coverage in Spanish households. This study aimed to analyze sociodemographic characteristics and health indicators by type of telephone service (mobile phone vs. landline or landline and mobile phone). Two telephone surveys were conducted in Spanish samples (February 2010 and February 2011). Multivariate logistic regression analyses were performed to analyze differences in the main sociodemographic characteristics and health indicators according to the type of telephone service available in Spanish households. We obtained 2027 valid responses (1627 landline telephones and 400 mobile phones). Persons contacted through a mobile phone were more likely to be a foreigner, to belong to the manual social class, to have a lower educational level, and to be a smoker than those contacted through a landline telephone. The profile of the population that has only a mobile phone differs from that with a landline telephone. Therefore, telephone surveys that exclude mobile phones could show a selection bias.     

Derivación a las consultas de gastroenterología desde atención primaria: evaluación de dos programas

Objectives

To analyze the effect of implementing a high-resolution clinic (HRC) and an increasing resolution capacity program in primary care (IRCPPC) for referrals to a gastroenterology outpatient clinic from primary care and the resources used.

Methods

A retrospective and observational study based on a review of referral sheets and databases was performed. We analyzed the number and reason for referrals, delay times and resource consumption in two periods: before (first 4 months of 2007) and after (first 4 months of 2009) the launch of the IRCPPC and HRC.

Results

In the first and second periods, 881 and 1076 patients, respectively, referred from primary health care were evaluated in the gastroenterology clinic, with a decrease in the delay time in the second period (80.8 ± 64.34 days vs 36.1 ± 29.12 days, p < 0.001). The most frequent reasons for referral were dyspepsia (27.7%), high-risk of colorectal cancer (17.1%), disturbance of bowel rhythm (18.2%), abdominal pain (16%), and gastroesophageal reflux (11.2%), with no differences between the two periods. Although delay times until the first visit (10.8 ± 9.03 days vs 42.8 ± 28.67 days, p < 0.001) and until discharge (39.6 ± 80.65 days vs 128.6 ± 135.34 days, p < 0.001) were lower in referrals to the HRC, the number of visits (3.6 ± 2.20 vs 3.2 ± 1.95, p = 0.015) and the cost of referrals (592.7 ± 421.50 € vs 486.0 ± 309.66 €, p < 0.001) was higher.

Conclusions

In the study period the number of referrals increased, while the delay time decreased. Although the HRC reduces delay times, it is associated with an increase in health resource use.     

Necesidades de información y uso de Internet en pacientes con cáncer de mama en España

Objective

To analyze information needs and search strategies among women with breast cancer in Spain. An additional aim was to explore how the internet, as a source of health information, influences the autonomy and active management of this disease among patients. The research was conducted in 2010 and 2011.

Method

This study forms part of a broader qualitative study that focuses on describing patients’ experiences of breast cancer and the trajectory of the disease, with the aim of creating a platform of integrated information resources for patients, relatives and healthcare professionals (PyDEsalud: http://www.pydesalud.com). We carried out 41 in-depth, semi-structured interviews with breast cancer patients in different stage of the disease, who were aged between 32 and 69 years. The interviewees’ were selected by intentional sampling, which included 15 Spanish regions. The field work was carried out from June to August, 2010. The interviews were recorded on videotape or audio. Based on patients’ narratives of their disease, a thematic-inductive analysis was performed of the information gathered.

Results

The findings show the importance of the internet as a source of health information. Moreover, the internet is a resource that is able to promote the empowerment process among patients and, consequently, to aid improvement in disease management.

Conclusions

Users need access to web sites with high quality health information, adapted to their needs and objectives.     

Experiencia de colaboración entre atención primaria y salud mental en el Departamento de Salud La Ribera, 7 años después

Despite the high prevalence of mental health problems among patients attending primary care, diagnosis and treatment of these disorders remain inadequate. Sound training of primary care physicians in how to manage mental health problems is needed to reduce the health, economic and social impact associated with these disorders. Among other elements, there is a need for cooperation between primary care physicians and mental health services. Distinct models are available for such collaboration. In 2006, our health department started a collaboration between these two levels of heath care, using a liaison model. Delays until the first specialist visit were reduced and satisfaction among health professionals increased, although these results should be interpreted with caution. Evidence has recently accumulated on the usefulness of the collaborative model, but evaluation of this model and extrapolation of its results are complex. We intend to evaluate our model more thoroughly, similar to other projects in our environment.     

Transparencia y buen gobierno en sanidad. También para salir de la crisis

Countries thrive on an economic foundation capable of facilitating the fulfillment of human potential in a society that does not renounce major achievements such as the welfare state. A necessary condition is that the “rules of the game”, formal and informal institutions, make what is socially desirable individually attractive. Improving health governance, including its dimension of controlling corruption, and helping Spain out of the current economic crisis are two sides of the same coin. Characterization of health system governance in Spain and analysis of the impact of this governance on health policy, management of healthcare organizations and clinical practice allows an ambitious and feasible agenda to be drawn up of the remaining tasks that health professionals -broadly defined- and social actors should undertake with the support of citizens.     

Gestión de coberturas de personal en atención primaria. Automatización del cálculo

The Santa Coloma de Gramenet Primary Care Service has designed a new tool to standardize and automate the process of planning the number of needed health care workers. The tool is divided in two parts: a calculator, which gives guidance on the foreseeable risk depending on the activity and the health care workers’ workload, and sentinel indicators; the main is the “welfare basic level”, that is the percentage structure of visited patients and their delay at 2, 3 and 7 calendar days, assessing the impact on the care of the population. The results of its use in the summer of 2010 have demonstrated its efficiency by lowering the needed workers with respect to 2009, achieving a better distribution according to the workload and improving the economic management. Given that the necessary data are accessible through computerized databases and its simple use, we believe it to be exportable to other fields.     

Entorno de práctica de los profesionales de enfermería y competencia para la incorporación de la evidencia a las decisiones: situación en las Islas Baleares

Objectives

To determine the factors that nursing professionals perceive as facilitating evidence-based clinical practice (EBCP) in the Balearic Islands Health Service (Spain) by identifying possible differences according to nurses’ characteristics and their occupational settings.

Methods

We performed a multicenter, cross-sectional, observational study of 3,129 staff nurses in the Balearic Islands Health Service in 2009, who were surveyed using the Evidence-Based Practice Questionnaire (EBPQ) and the Nursing Work Index (PES-NWI). The strategy for the analysis encompassed an exploratory analysis, bivariate analysis with parametric and non-parametric tests according to the nature of the distributions (correlation, ANOVA, Kruskall-Wallis, chi square) and multivariate analysis of the main study variables and factors on the PES-NWI and EBPQ questionnaires. The analyses had a confidence level of 95%.

Results

A total of 1,753 questionnaires were received, corresponding to a participation rate of 56.02%. The results established significant differences between the two questionnaires in the analysis of the hospital setting and primary care (p < 0.001). These differences remained significant when the questionnaires were compared according to professional category and experience.

Conclusions

This study compared nursing practice environments with different characteristics. Of the factors included in the questionnaires, that with the greatest influence on EBP was the support of nursing managers. This study also found that the two validated instruments are plausible tools for assessing EBCP and help to establish areas for improvement both at the individual and organizational level.     

Desarrollo de IEMAC,un Instrumento para la Evaluación de Modelos de Atención ante la Cronicidad

Objective

To present the context, aim and process of designing the Instrument for the Assessment of Chronic Care Models (Instrumento de Evaluación de Modelos de Atención ante la Cronicidad [IEMAC]), which was developed to make the conceptual framework of the chronic care model operational in the Spanish national health system.

Methods

The IEMAC was developed by a series of national experts with distinct profiles of expertise using qualitative research techniques. A matrix was built with the dimensions selected as basic for the new model. In each dimension, actions were identified and categorized, creating a taxonomy of components and interventions. The clarity and appropriateness of each intervention, and the degree of evidence to support it, were assessed. The resulting questionnaire was validated by other experts from diverse disciplines and settings. Finally, the IEMAC 1.0 was piloted at macro, meso and micro levels.

Results

The IEMAC is a tool to be self-administered by health organizations at macro, meso and micro levels. This instrument is composed of six dimensions, 27 components and 80 interventions, whose implementation is assessed with the aid of a scale that combines deployment, systematic evaluation, and orientation improvement. The IEMAC uses a systemic, population-based approach and integrates promotion, prevention, and coordination with social services.

Conclusions

The IEMAC contains a set of interventions that can be used as a road map by decision makers, managers and clinicians interested in building a state-of-the-art chronic care model. At the same time, the IEMAC allows healthcare organizations to identify their baseline score and the progress achieved after improvement interventions.     

Barreras para la normalización de la telemedicina en un sistema de salud basado en la concertación de servicios

Objective

Despite the clear political will to promote telemedicine and the large number of initiatives, the incorporation of this modality in clinical practice remains limited. The objective of this study was to identify the barriers perceived by key professionals who actively participate in the design and implementation of telemedicine in a healthcare system model based on purchasing of healthcare services using providers’ contracts.

Methods

We performed a qualitative study based on data from semi-structured interviews with 17 key informants belonging to distinct Catalan health organizations.

Results

The barriers identified were grouped in four areas: technological, organizational, human and economic. The main barriers identified were changes in the healthcare model caused by telemedicine, problems with strategic alignment, resistance to change in the (re)definition of roles, responsibilities and new skills, and lack of a business model that incorporates telemedicine in the services portfolio to ensure its sustainability.

Conclusions

In addition to suitable management of change and of the necessary strategic alignment, the definitive normalization of telemedicine in a mixed healthcare model based on purchasing of healthcare services using providers’ contracts requires a clear and stable business model that incorporates this modality in the services portfolio and allows healthcare organizations to obtain reimbursement from the payer.     

Nuevo diseño de la Encuesta de Salud de Cataluña (2010-2014): un paso adelante en planificación y evaluación sanitaria

This article presents the genesis of the Health Survey of Catalonia (Spain, 2010-2014) with its semiannual subsamples and explains the basic characteristics of its multistage sampling design. In comparison with previous surveys, the organizational advantages of this new statistical operation include rapid data availability and the ability to continuously monitor the population. The main benefits are timeliness in the production of indicators and the possibility of introducing new topics through the supplemental questionnaire as a function of needs. Limitations consist of the complexity of the sample design and the lack of longitudinal follow-up of the sample. Suitable sampling weights for each specific subsample are necessary for any statistical analysis of micro-data. Accuracy in the analysis of territorial disaggregation or population subgroups increases if annual samples are accumulated.     

Impacto de la Ley 28/2005 de medidas sanitarias frente al tabaquismo en la prevalencia de la exposición al humo ambiental del tabaco en Barcelona

Objective

To assess the impact of the 28/2005 Spanish smoking law on exposure to second-hand smoke (SHS) in Barcelona.

Methods

We performed a pre-post evaluation study. Two cross-sectional surveys were compared. Data were obtained from the Barcelona Health Surveys of 2000 and 2006. The prevalence of SHS exposure among non-smoking adults was analyzed by setting (home, workplace and leisure time) and sociodemographic variables.

Results

SHS exposure in non-smokers significantly decreased between 2000 and 2006 (p <0.01). Odds ratios adjusted by sex, age and social class were 0.7 (95% CI: 0.6-0.8) for home and 0.2 (95% CI: 0.2-0.3) for workplace exposure in 2006 compared with 2000. In both settings, the decrease in exposure was greater in the higher social classes. After the implementation of the law, almost 50% of the population remained exposed to SHS during leisure time, younger people being the most exposed (83.5%).

Conclusion

After the implementation of the law, the prevalence of SHS exposure in non-smokers in Barcelona decreased significantly in workplaces and in the home. Nevertheless, nearly half of the population remained exposed to SHS during leisure time.     

Evaluación de la efectividad de un programa de mindfulness en profesionales de atención primaria

Objectives

To determine the long-term effects of a mindfulness program on burnout, mood states, empathy, and mindfulness in primary care professionals.

Methods

A repeated measures before-after study was performed in 87 participants working in primary care. The variables evaluated were scores of the Burnout Inventory (Maslach), mood states (Profile of Mood States [POMS]), empathy (Jefferson Scale of Physician Empathy [JSPE]) and mindfulness (Five Facet Mindfulness Questionnaire [FFMQ]), adherence to the intervention, and changes in attitudes. Evaluations were performed at baseline, at 8 weeks, and at 6 and 12 months. The intervention lasted for 1 year and consisted of two training phases, an intensive first phase lasting 28 hours, spread over 8 weeks, and a second, maintenance phase of 25 hours spread over 10 months. The effect of the intervention was assessed through observed change, standardized response mean (SRM), and linear mixed-effects models on repeated measures.

Results

The scores of all the scales improved significantly during the follow-up compared with baseline scores. The greatest differences were obtained at 12 months, especially in the the FFMQ (SRM: 1.4), followed by the POMS (SRM: 0,8). The greatest improvement in the maintenance phase was found in the difference between consecutive scores. The only scale that showed major changes in all phases was the FFMQ scale. At the end of the intervention, 89% of participants practiced the exercises of the program on their own and 94% reported improvements in self-care and greater professionalism.

Conclusions

A psychoeducational program based on mindfulness reduces burnout and improves mood states, empathy, and mindfulness, while encouraging better self-care.     

La voz de las mujeres sometidas a mutilación genital femenina en la Región de Murcia

Objective

To explore the perceptions of a group of women who underwent female genital mutilation on the impact of this practice on their sexual and reproductive health.

Methods

We performed a phenomenological qualitative study in a sample of 9 sub-Saharan Africa women, whose mean age was 30 years old and who had lived in Spain for 1 to 14 years. These women underwent genital mutilation in their countries of origin. Data was collected using a socio-demographic survey and an in-depth, structured personal interview. Subsequently, we performed a thematic discourse analysis.

Results

The discourses were grouped into four categories related to participants’ perceptions of female genital mutilation. These categories were intimate relationships, pregnancy, childbirth, and social impact.

Conclusions

The practice of female genital mutilation is maintained due to social and family pressure, transmitted from generation to generation and silenced by women themselves. This practice affects their sexual and reproductive health, as demonstrated by anorgasmia and dyspareunia. The women were satisfied with the healthcare received during pregnancy and childbirth. Nevertheless, most of them were not satisfied with family planning.