Evaluación de la práctica clínica en cirugía de cataratas: resultados de una encuesta a oftalmólogos de la provincia de Barcelona

Variabilidad en la asistencia hospitalaria. El caso de la cirugía nasosinusal en España

OBJECTIVES

To describe variations in the management of nasosinus disorders among the Autonomous Communities and hospitals of Spain.

METHODS

We analyzed the Minimum Basic Data Set of the public health system from 1998-2000 for the diagnoses of nasosinus polyps and chronic sinusitis. We studied the distribution by regions of the rate of hospitalizations and of 4 indicators of quality of care and efficiency: mean length of stay, percentage of discharges without surgery, percentage of functional endoscopic sinus surgery and surgical complications. A cluster analysis was performed to classify hospitals according to the values of these indicators.

RESULTS

We analyzed 13061 discharges from 263 hospitals. Marked differences were found in age-adjusted hospitalization rates by regions. Cluster analysis classified the centers with more than 10 annual discharges in 3 categories: a) 32 hospitals in which the 4 quality indicators were above average; b) 35 hospitals in which 3 of the indicators were below average, and c) 74 hospitals in which 2 indicators were above average and 2 indicators were below average.

CONCLUSIONS

Marked interregional variations were found in hospitalization rates, as well as in the characteristics of management of nasosinus disorders in Spanish hospitals. The centers examined could be grouped into three clearly defined patterns according to indicators of quality of care and efficiency.

[Variation in medical practice. Apropos of the use of CAT and NMR in INSALUD]

OBJECTIVE

In this study the variability on the utilization of nuclear magnetic resonance (NMR) and computerized tomography (CT) scan among hospitals and provinces in the INSALUD (Spanish National Health System) is evaluated as well as the role of the availability of resources in the variability.

METHOD

Data on availability of resources, its use and the reference population for each hospital were obtained from the Specialized Care Information System (SIAE) for the years 1996-1997. The units of analysis were the hospitals and the provinces in the INSALUD territory. The independent variables were the ratio of technologies and professional per inhabitant. Also the waiting list and the economical level of the province were used. Data analysis included the extremal quotient and multiple linear regression.

RESULTS

The ratio of the highest to lowest rate of CT and NMR use is 15 and 27 among hospitals and 3 and 4 among provinces, respectively. The number of neurosurgeons, number of CT apparatus, waiting list for CT and rate of NMR use, all standardized per population, explains 61% of CT variability among hospitals. Among provinces, the number of CT apparatus explains 31% of all variability. For NMR use among hospitals, the number of neurosurgeons, number of orthopedic surgeons and CT use, all variables standardized per population, explains 42% of variability. The amount of equipment is not associated with NMR rate among provinces.

CONCLUSIONS

The variation found in the INSALUD territory for the two procedures is high and ecologically associated to the availability of resources. It would be convenient to perform an observational study to confirm the findings and evaluate the possible contribution of inappropriate use to the variation.

Effectiveness of cataract surgery in Barcelona, Spain site results of an international study. Barcelona I-PORT investigators. International Patient Outcomes Research Team

OBJECTIVES

To describe the impact of cataract surgery on visual function and health status in terms of clinical indicators as well as perceived health and functional capacity, and to identify patient characteristics and differences in clinical management that might affect outcomes.

SUBJECTS AND METHODS

Observational longitudinal study of a cohort of 218 patients aged 50 or older undergoing first eye cataract surgery. Patients were evaluated pre- and postoperatively by clinical examinations (visual acuity [VA], ocular and medical comorbidity) and standardized telephone interviews. Main outcome measures included: the VF-14 Visual Function Index, the Cataract Symptom Score (CSS), the Sickness Impact Profile (SIP), and global measures of patients' trouble and satisfaction with vision.

RESULTS

Significant improvement in all outcomes measures were observed at 4 months postoperatively (P < 0.001). However, the proportion of improved patients varied according to the outcome considered: VA (87%), CSS (72%), VF-14 (62%), and SIP (38%). Patient characteristics associated with higher a level of improvement were: worse preoperative visual function (VA, CSS, VF-14) (P < 0.001), less ocular comorbidity (P < 0.05), less postoperative complications (P < 0.05) and better preoperative general health status (SIP) (P < 0.01). The differences in clinical management were not associated with the outcomes (effectiveness) of surgery.

CONCLUSIONS

A large proportion of patients benefit from cataract surgery, the greatest gain corresponding to visual function rather than to general health status. Since effectiveness of surgery is unrelated to operative procedures, less costly practices (i.e., day case surgery and loco-regional anesthesia) should be promoted.