Validation of the Portuguese version of the supportive care needs survey short-form questionnaire (SCNS-SF34-Pt) and the breast cancer supplementary module (SCNS-BR8-Pt)

OBJECTIVE

This study aimed to test the psychometric properties of the Portuguese Supportive Care Needs Survey-Short Form-34 (SCNS-SF34-Pt) and its breast cancer-specific complementary module (SCNS-BR8-Pt). A further aim was to characterize Portuguese Breast Cancer Survivors' (BCS) unmet supportive care needs, using these measures.

METHODS

A convenient sample of BCS was recruited from five hospitals in Portugal and invited to complete SCNS-SF34-Pt and SCNS-BR8-Pt, EORTCQLQC30 and QLQBR23, the Generalized Anxiety Disorder, and the Patient Health-Questionnaire. The validity (i.e. convergent, discriminant and convergent validity) and reliability of SCNS-SF34-Pt and SCNS-BR8-Pt were statistically evaluated. BCS' unmet supportive care needs were descriptively assessed.

FINDINGS

336 BCS participated in the study. A four-factor solution was produced for SCNS-SF34-Pt. This solution included the Physical and daily living needs, Psychological needs, Sexuality needs, and Health system, information, and patient support needs dimensions (73% of the total variance; Cronbach's alpha=.82 to .97). SCNS-SF34-Pt demonstrated good convergent validity. It could also discriminate between known-groups regarding age, disease staging, treatment performed, and ECOG performance status. SCNS-BR8-Pt revealed a single-factor structure (62% of the total variance; Cronbach's alpha=.91).Portuguese BCS' most prevalent unmet supportive care needs were associated with the Psychological, and Physical and daily living domains. Fear of cancer spreading, the inability to do things as usual, and lack of energy/tiredness were perceived as issues requiring further supportive care.

CONCLUSIONS

SCNS-SF34-Pt and the SCNS-BR8-Pt are valid and reliable tools to assess Portuguese BCS' unmet supportive care needs. Fear of cancer spreading and lack of energy/tiredness concerns should be a target of supportive care services.

Application of the time-driven activity-based costing methodology to a complex patient case management program in Portugal

BACKGROUND

The number of people with chronic diseases has increased globally, as has the number of chronic diseases per person. Faced with this reality, the term "complex patient" is current and actual. The healthcare costs associated with these patients are high and are expected to increase since most healthcare systems are not yet ready to provide integrated long-term care. In Portugal, several health institutions have made efforts to provide integrated care: case management models have been implemented to complex patients follow-up. However, studies related to cost of these programs are still limited. Therefore, a qualitative investigation was conducted, approaching the design criteria of a case study research, to design a case management program for complex patients and determine its direct costs, following the Time-Driven Activity-Based Costing methodology, in Local Health Unit setting.

METHOD

The direct costs of providing care to a complex patient involved in a case management program were determined, using the Time-Driven Activity-Based Costing methodology. A map of the complex patient was drawn, considering a standard flow in the program. Times and costs were allocated to the activities on the map, following Portuguese and international practices of case management models.

RESULTS

A total of 684,45€/year is spent for each new patient in the case management program, of which 452,65€ corresponds to cost of remuneration of professionals involved; and 663,85€/year, for each patient who is in the case management program (over 1 year), where 432,05€ corresponds to cost of the remuneration of the professionals involved. Follow-up is the most costly phase (80.82%) and where more time is spent (85.62%).

CONCLUSION

The time spent by professionals and resources involved and the costs associated with each patient were obtained. The economic impact of the analysed activities was not studied, however, according to international authors, when well applied and selected, integrated care models lead to cost reduction and improved health outcomes.

Breast Cancer Survivors' Attitudes toward eMental Health: A Cross-Sectional Study

BACKGROUND

Breast cancer survivors' (BCS) attitudes toward eMental Health (eMH) are largely unknown, and adoption predictors and their interrelationships remain unclear. This study aimed to explore BCS' attitudes toward eMH and investigate associated variables.

METHODS

A cross-sectional study involving 336 Portuguese BCS was conducted. Attitudes toward eMH, depression and anxiety symptoms, health-related quality of life, and sociodemographic, clinical, and internet-related variables were assessed using validated questionnaires. Spearman-ranked correlations, χ2, and multiple regression analyses were computed to explore associations between attitudes and collected variables.

RESULTS

BCS held a neutral stance toward eMH. In models adjusted for age and education, positive attitudes were statistically significantly associated with increased depressive symptoms and worse emotional, cognitive, and body image functioning. Social network use, online health information and mental healthcare seeking, higher self-reported knowledge of eMH, and previous use of remote healthcare were positively associated with better attitudes toward eMH.

CONCLUSIONS

eMH programs targeting BCS seem to be a promising strategy for providing supportive psychosocial care to BCS. However, increasing awareness about eMH efficacy and security may be necessary to improve its acceptance and use among BCS. Additional research is necessary to understand how BCS' unmet care needs, and specifically their psychological distress severity, may impact BCS' acceptance and use of eMH.

Effect of the COVID-19 pandemic on the frequency of emergency department visits in Portugal: An interrupted time series analysis until July 2021

Objectives

This study aims to evaluate the effect of the COVID-19 pandemic on the frequency of emergency department (ED) visits in Portugal between March 2020 and July 2021.

Methods

We used data on the monthly number of visits for all public hospitals' EDs from mainland Portugal between January 2017 and July 2021. We studied the impact of the pandemic overall, by type of ED (general, pediatric, and obstetric) and by Manchester Triage System color (red, orange, yellow, green, and blue) using an interrupted time series analysis. The prepandemic period corresponded to the months from January 2017 to February 2020 and the pandemic period to the months from March 2020 to July 2021.

Results

We observed over 26 million ED visits, the majority in general EDs (74.0%) and triaged yellow (48.4%) or green (38.4%). During the pandemic period, ED visits decreased 45.7% (95% confidence interval [CI]: -39.8% to -51.2%) and pediatric ED visits decreased by 72.4% (95% CI: -64.6% to -78.6%). A decrease was observed for all colors but tended to be progressively smaller as the priority increased. There was an increase in ED visits during the pandemic period (2.3%; 95% CI: 1.4% to 3.2%), eventually returning to prepandemic values.

Conclusion

Our data indicate a considerable and long-lasting effect of the COVID-19 pandemic affecting mainly pediatric and milder cases, which were returning toward prepandemic values as the pandemic progressed. In a country with frequent use of EDs, the health system may need to be prepared to respond to prepandemic baseline ED demand, together with additional demand because of long-term sequels of COVID-19 cases and delayed care for chronic and acute conditions.

The Pandemic-Related Factors Associated with Emergency Department Visits in Portugal throughout Two Years of the Pandemic: A Retrospective Population-Based Study

The COVID-19 pandemic has affected the use of emergency departments (ED) worldwide. This study identifies the pandemic-related factors associated with the number of ED visits in mainland Portugal and each of its regions. We collected data on ED visits from March 2020 to March 2022. Data on incidence, vaccination, mobility, containment index, and Google search volume were retrieved from open online sources at different time points. We fitted a quasi-Poisson generalized linear regression model, and each variable was modeled separately and adjusted for time and month. There was a positive ED trend throughout the two years of the pandemic in mainland Portugal and each of its regions. In the mainland, during months with high workplace mobility, there were 10.5% more ED visits compared to months with average mobility. ED visits decreased in months with low mobility for retail and recreation, groceries and pharmacies, and transit compared to months of medium mobility. Portugal saw a reduction in ED utilization during the pandemic period, but with a positive trend from March 2020 to March 2022. The change in the population's behavior of seeking the ED throughout the pandemic might be associated with mobility, incidence, and pandemic fatigue.

Cross-sectional study investigating the prevalence and causes of vision impairment in Northwest Portugal using capture-recapture

OBJECTIVES

The aim of this study was to estimate the prevalence and causes of vision impairment (VI) in Portugal.

SETTING

Information about people with VI was obtained from primary care centres, blind association (ACAPO) and from hospitals (the PCVIP study) in the Northwest of Portugal during a period spanning years 2014-2015. Causes of VI were obtained from hospitals.

PARTICIPANTS

Administrative and medical records of people with visual acuity in the better seeing eye of 0.5 decimal (0.30logMAR) or worse and/or visual field less than 20° were investigated. Capture-recapture with log-linear models was applied to estimate the number of individuals missing from lists of cases obtained from available sources.

PRIMARY AND SECONDARY OUTCOME MEASURES

Log-linear models were used to estimate the crude prevalence and the category specific prevalence of VI.

RESULTS

Crude prevalence of VI was 1.97% (95% CI 1.56% to 2.54%), and standardised prevalence was 1% (95% CI 0.78% to 1.27%). The age-specific prevalence was 3.27% (95% CI 2.36% to 4.90%), older than 64 years, 0.64% (95% CI 0.49% to 0.88%), aged 25-64 years, and 0.07% (95% CI 0.045% to 0.13%), aged less than 25 years. The female-to-male ratio was 1.3, that is, higher prevalence among females. The five leading causes of VI were diabetic retinopathy, cataract, age-related macular degeneration, glaucoma and disorders of the globe.

CONCLUSIONS

The prevalence of VI in Portugal was within the expected range and in line with other European countries. A significant number of cases of VI might be due to preventable cases and, therefore, a reduction of the prevalence of VI in Portugal seems possible. Women and old people were more likely to have VI and, therefore, these groups require extra attention. Future studies are necessary to characterise temporal changes in prevalence of VI in Portugal.

Understanding Mental Health Professionals' Perspectives and Practices Regarding the Implementation of Digital Mental Health: Qualitative Study

BACKGROUND

Despite the potential of digital mental health to provide cost-effective mental health care, its adoption in clinical settings is limited, and little is known about the perspectives and practices of mental health professionals regarding its implementation or the factors influencing these perspectives and practices.

OBJECTIVE

This study aims to characterize in depth the perspectives and practices of mental health professionals regarding the implementation of digital mental health and explore the factors affecting such perspectives and practices.

METHODS

A qualitative study using in-depth semistructured interviews with Portuguese mental health professionals (N=13)-psychologists and psychiatrists-was conducted. The transcribed interviews were thematically analyzed.

RESULTS

Mental health professionals deemed important or engaged in the following practices during the implementation of digital mental health: indication evaluation, therapeutic contract negotiation, digital psychological assessment, technology setup and management, and intervention delivery and follow-up. Low-threshold accessibility and professionals' perceived duty to provide support to their clients facilitated the implementation of digital mental health. Conversely, the lack of structured intervention frameworks; the unavailability of usable, validated, and affordable technology; and the absence of structured training programs inhibited digital mental health implementation by mental health professionals.

CONCLUSIONS

The publication of practice frameworks, development of evidence-based technology, and delivery of structured training seem key to expediting implementation and encouraging the sustained adoption of digital mental health by mental health professionals.

Trends, geographical variation and factors associated with the use of anti-VEGF intravitreal injections in Portugal (2013-2018): a retrospective analysis of administrative data

AIMS

The arrival of anti-vascular endothelial growth factor (anti-VEGF) therapies represented a treatment shift for several ophthalmological disorders and led to an increasing number of patients undergoing intravitreal injections. The aims of this observational study were to assess the expansion of anti-VEGF intravitreal injections in the Portuguese National Health System (NHS) and to identify factors correlated with geographical variations in episode rates.

METHODS

Administrative database on discharge from Portuguese NHS hospitals was analysed for annual values and rates of intravitreal anti-VEGF injections at a national and regional level, between 2013 and 2018.

RESULTS

The number of episodes of anti-VEGF treatment and patients treated increased 16% and 9% per year, respectively, between 2013 and 2018. During the study period around 72% of patients were treated in the Metropolitan areas of Lisbon and Porto and in the Central region. Intravitreal anti-VEGF treatment rates in 2018 were 560 per 100 000 population and presented high variability between municipalities. Higher anti-VEGF treatment rates at the municipality level were associated with shorter distances between their residence and the hospital. At the hospital level, higher ratio of ophthalmologists and higher organisational level were associated with higher anti-VEGF treatment rates.

CONCLUSION

The number of episodes and patients treated with anti-VEGF injections has been growing in recent years. Proximity to healthcare, more access to ophthalmologists and hospitals with higher organisational levels are associated with higher anti-VEGF treatment rates. Improving access is crucial to reduce regional discrepancies and ensure optimal treatment frequency, which may improve health outcomes.

Direct Costs of COVID-19 Inpatient Admissions in a Portuguese Tertiary Care University Centre

Background

The COVID-19 pandemic has posed greater financial pressure on health systems and institutions that had to respond to the specific needs of COVID-19 patients while ensuring the safety of the diagnosis and treatment of all patients and healthcare professionals. To assess the financial impact of COVID-19 patients admitted to hospitals, we have characterized the cost of COVID-19 admissions, using inpatient data from a Portuguese Tertiary Care University Centre.

Methods

We analysed inpatient data from adult patients diagnosed with COVID-19 who were admitted between March 1, 2020 and May 31, 2020. Admissions were eligible if the ICD-10-CM principal diagnosis was coded U07.1. We excluded admissions from patients under 18 years old, admissions with incomplete records, admissions from patients who had been transferred to or from other hospitals or those whose inpatient stay was under 24 h. Pregnancy, childbirth, and puerperium admissions were also excluded, as well as admissions from patients who had undergone surgery.

Results

We identified 223 admissions of patients diagnosed with COVID-19. Most were men (64.1%) and aged 45-64 years (30.5%). Around 13.0% of patients were admitted to intensive care units and 9.9% died in hospital. The average length of hospital stay was 12.7 days (SD = 10.2) and the average estimated cost per admission was EUR 8,177 (SD = 11,534), which represents more than triple the inpatient base price (EUR 2,386). Human resources accounted for the highest proportion of the total costs per admission (50.8%). About 92.4% of the admissions were assigned to Diagnosis Related Group (DRG) 723, whose inpatient price is lower than COVID-19 inpatient costs for all degrees of severity.

Conclusion

COVID-19 admissions represent a substantial financial burden for the Portuguese NHS. For each COVID-19 hospitalized patient it would have been possible to treat three other hospitalized patients. Also, the price set for DRG 723 is not adjusted to the cost of COVID-19 patients. These findings highlight the need for additional financial resources for the health system and, in particular, for hospitals that have treated high volumes of hospitalized patients diagnosed with COVID-19.

Development and Evaluation of the Usefulness, Usability, and Feasibility of iNNOV Breast Cancer: Mixed Methods Study

BACKGROUND

Despite the efficacy of psychosocial interventions in minimizing psychosocial morbidity in breast cancer survivors (BCSs), intervention delivery across survivorship is limited by physical, organizational, and attitudinal barriers, which contribute to a mental health care treatment gap in cancer settings.

OBJECTIVE

The aim of this study is to develop iNNOV Breast Cancer (iNNOVBC), a guided, internet-delivered, individually tailored, acceptance and commitment therapy-influenced cognitive behavioral intervention program aiming to treat mild to moderate anxiety and depression in BCSs as well as to improve fatigue, insomnia, sexual dysfunction, and health-related quality of life in this group. This study also aims to evaluate the usefulness, usability, and preliminary feasibility of iNNOVBC.

METHODS

iNNOVBC was developed using a user-centered design approach involving its primary and secondary end users, that is, BCSs (11/24, 46%) and mental health professionals (13/24, 54%). We used mixed methods, namely in-depth semistructured interviews, laboratory-based usability tests, short-term field trials, and surveys, to assess iNNOVBC's usefulness, usability, and preliminary feasibility among these target users. Descriptive statistics were used to characterize the study sample, evaluate performance data, and assess survey responses. Qualitative data were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Overall, participants considered iNNOVBC highly useful, with most participants reporting on the pertinence of its scope, the digital format, the relevant content, and the appropriate features. However, various usability issues were identified, and participants suggested that the program should be refined by simplifying navigation paths, using a more dynamic color scheme, including more icons and images, displaying information in different formats and versions, and developing smartphone and tablet versions. In addition, participants suggested that tables should be converted into plain textboxes and data visualization dashboards should be included to facilitate the tracking of progress. The possibility of using iNNOVBC in a flexible manner, tailoring it according to BCSs' changing needs and along the cancer care continuum, was another suggestion that was identified.

CONCLUSIONS

The study results suggest that iNNOVBC is considered useful by both BCSs and mental health professionals, configuring a promising point-of-need solution to bridge the psychological supportive care gap experienced by BCSs across the survivorship trajectory. We believe that our results may be applicable to other similar programs. However, to fulfill their full supportive role, such programs should be comprehensive, highly usable, and tailorable and must adopt a flexible yet integrated structure capable of evolving in accordance with survivors' changing needs and the cancer continuum.

Hospitalization for ambulatory care sensitive conditions: What conditions make inter-country comparisons possible?

Hospitalizations for ambulatory care sensitive conditions have been extensively used in health services research to assess access, quality and performance of primary health care. Inter-country comparisons can assist policy-makers in pursuing better health outcomes by contrasting policy design, implementation and evaluation. The objective of this study is to identify the conceptual, methodological, contextual and policy dimensions and factors that need to be accounted for when comparing these types of hospitalizations across countries. A conceptual framework for inter-country comparisons was drawn based on a review of 18 studies with inter-country comparison of ambulatory care sensitive conditions hospitalizations. The dimensions include methodological choices; population's demographic, epidemiologic and socio-economic profiles and features of the health services and system. Main factors include access and quality of primary health care, availability of health workforce and health facilities, health interventions and inequalities. The proposed framework can assist in designing studies and interpreting findings of inter-country comparisons of ambulatory care sensitive conditions hospitalizations, accelerating learning and progress towards universal health coverage.

Mapping mental healthcare professionals’ journey towards digital mental health adoption: A qualitative study

Introduction

Digital Mental Health holds strategic potential in fulfilling populations’ mental healthcare unmet needs, enabling convenient and equitable access to mental healthcare. However, despite strong evidence of efficacy, uptake by mental healthcare providers remains low and little is known about factors influencing adoption and its interrelationship throughout the Digital Mental Health adoption process.

Objectives

This study aimed at gaining in-depth understanding of factors influencing adoption and mapping its interrelationship along different stages of the Digital Mental Health adoption process.

Methods

This work adopted a qualitative approach consisting of in-depth semi-structured interviews with 13 mental healthcare professionals, including both psychologists and psychiatrists. The interviews were transcribed and analysed thematically, following Braun and Clarke’s method.

Results

In this communication, we will describe how digital technology is currently used by clinicians to deliver mental healthcare. We identify potential factors influencing Digital Mental Health adoption and characterize the different identified stages inherent to this appropriation process: i) Pondering appropriate use; ii) Contractualizing the therapeutic relationship; iii) Performing online psychological assessment; iv) Adapting and/or developing interventions; v) Delivering Digital Mental Health interventions; and vi) Identifying training unmet needs. A discussion on how different factors and its interrelationship impact the adoption process will also be performed.

Conclusions

By characterizing mental healthcare providers journey throughout the Digital Mental Health adoption process, we intend to inform ecosystem stakeholders, such as researchers, policy makers, societies and industry, on key factors influencing adoption, so policies, programs and interventions are developed in compliance with this knowledge and technology is more easily integrated in clinical practice.

Economic and financial crisis based on Troika's intervention and potentially avoidable hospitalizations: an ecological study in Portugal

BACKGROUND

Hospitalisations for Ambulatory Care Sensitive Conditions (ACSC) cause harm to users and to health systems, as these events are potentially avoidable. In 2009, Portugal was hit by an economic and financial crisis and in 2011 it resorted to foreign assistance ("Memorandum of Understanding" (2011-2014)). The aim of this study was to analyse the association between the Troika intervention and hospitalisations for ACSC.

METHODS

We analysed inpatient data of all public NHS hospitals of mainland Portugal from 2007 to 2016, and identified hospitalisations for ACSC (pneumonia, chronic obstructive pulmonary disease, hearth failure, hypertensive heart disease, urinary tract infections, diabetes), according to the AHRQ methodology. Rates of hospitalisations for ACSC, the rate of enrollment in the employment center and average monthly earnings were compared among the pre-crisis, crisis and post-crisis periods to see if there were differences. A Spearman's correlation between socioeconomic variables and hospitalisations was performed.

RESULTS

Among 8,160,762 admissions, 892,759 (10.94%) were classified as ACSC hospitalizations, for which 40% corresponded to pneumonia. The rates of total hospitalisations and hospitalisations for ACSC increased between 2007 and 2016, with the central and northern regions of the country presenting the highest rates. No correlations between socioeconomic variables and hospitalisation rates were found.

CONCLUSIONS

During the period of economic and financial crisis based on Troika's intervention, there was an increase in potentially preventable hospitalisations in Portugal, with disparities between the municipalities. The high use of resources from ACSC hospitalisations and the consequences of the measures taken during the crisis are factors that health management must take into account.

Evolution of inequalities in the coronavirus pandemics in Portugal: an ecological study

Background

Previous literature shows systematic differences in health according to socioeconomic status (SES). However, there is no clear evidence that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection might be different across SES in Portugal. This work identifies the coronavirus disease 2019 (COVID-19) worst-affected municipalities at four different time points in Portugal measured by prevalence of cases, and seeks to determine if these worst-affected areas are associated with SES.

Methods

The worst-affected areas were defined using the spatial scan statistic for the cumulative number of cases per municipality. The likelihood of being in a worst-affected area was then modelled using logistic regressions, as a function of area-based SES and health services supply. The analyses were repeated at four different time points of the COVID-19 pandemic: 1 April, 1 May, 1 June, and 1 July, corresponding to two moments before and during the confinement period and two moments thereafter.

Results

Twenty municipalities were identified as worst-affected areas in all four time points, most in the coastal area in the Northern part of the country. The areas of lower unemployment were less likely to be a worst-affected area on the 1 April [adjusted odds ratio (AOR) = 0.36 (0.14–0.91)], 1 May [AOR = 0.03 (0.00–0.41)] and 1 July [AOR = 0.40 (0.16–1.05)].

Conclusion

This study shows a relationship between being in a worst-affected area and unemployment. Governments and public health authorities should formulate measures and be prepared to protect the most vulnerable groups.

Inpatient Hospitalizations during the First Wave of COVID-19 in Portugal

The objective of this study was to analyze the impact of the pandemic on inpatient hospital admissions during the first wave in Portugal. Data from hospital admissions in mainland Portugal from 2008 to 2017 were used to forecast inpatient hospital admissions for March to May 2020. The observed number of hospitalizations and their characteristics were compared to forecasted values. Variations were compared by hospital and region. Statistical analysis was used to investigate whether patterns of variations existed according to hospital characteristics. There were 119,315 fewer hospitalizations than expected during March to May 2020 in Portugal, which represented a 57% reduction. Non-COVID-19 hospitalizations had a higher mean length of stay and proportion of inpatient deaths than forecasted values. Differences between observed and forecasted values varied greatly among regions and hospitals. These variations were not associated with COVID-19 hospital admissions, region, forecasted number of hospitalizations, type of hospital, or occupation rate. The impact on inpatient hospital admissions for each hospital was not consistent or proportional to the expected use across Portugal, as indicated by variations between forecasted and observed values. The appropriate planning of future responses may contribute to improving the necessary balance between the level of hospital admissions for usual health needs of the population and the response to COVID-19 patients.

Mitigating COVID-19 Impact on the Portuguese Population Mental Health: The Opportunity That Lies in Digital Mental Health

COVID-19 mitigation measures present unprecedented challenges in mental healthcare delivery, posing high risk to the mental health of at-risk populations, namely patients diagnosed with COVID-19, frontline healthcare providers, and those submitted to quarantine or isolation measures, as well as the general population. Ensuring safe and equitable access to mental healthcare by these groups entails resorting to innovative psychosocial intervention strategies, such as digital mental health. In this perspective piece, we describe the impact of COVID-19 on the Portuguese population's mental health, present an overview on initiatives developed to address the challenges currently faced by the Portuguese mental healthcare system, and discuss how the timely implementation of a comprehensive digital mental health strategy, coupling research, education, implementation, and quality assessment initiatives, might buffer COVID-19's impact on the Portuguese society.

Defining ambulatory care sensitive conditions for adults in Portugal

Background

Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal.

Methods

A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions.

Results

After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus.

Conclusions

New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.

A Review of Capture-recapture Methods and Its Possibilities in Ophthalmology and Vision Sciences

Epidemiological information is expected to be used to develop key aspects of eye care such as to control and minimise the impact of diseases, to allocate resources, to monitor public health actions, to determine the best treatment options and to forecast the consequence of diseases in populations. Epidemiological studies are expected to provide information about the prevalence and/or incidence of eye diseases or conditions. To determine prevalence is necessary to perform a cross-sectional screening of the population at risk to ascertain the number of cases. The aim of this review is to describe and evaluate capture-recapture methods (or models) to ascertaining the number of individuals with a disease (e.g. diabetic retinopathy) or condition (e.g. vision impairment) in the population. The review covers the fundamental aspects of capture-recapture methods that would enable non-experts in epidemiology to use it in ophthalmic studies. The review provides information about theoretical aspects of the method with examples of studies in ophthalmology in which it has been used. We also provide a problem/solution approach for limitations arising from the lists obtained from registers or other reliable sources. We concluded that capture-recapture models can be considered reliable to estimate the total number of cases with eye conditions using incomplete information from registers. Accordingly, the method may be used to maintain updated epidemiological information about eye conditions helping to tackle the lack of surveillance information in many regions of the globe.

Portuguese Psychologists' Attitudes Toward Internet Interventions: Exploratory Cross-Sectional Study

BACKGROUND

Despite the significant body of evidence on the efficacy and cost-effectiveness of internet interventions, the implementation of such programs in Portugal is virtually non-existent. In addition, Portuguese psychologists' use and their attitudes towards such interventions is largely unknown.

OBJECTIVE

The aim of this study was to explore Portuguese psychologists' knowledge, training, use and attitudes towards internet interventions; to investigate perceived advantages and limitations of such interventions; identify potential drivers and barriers impacting implementation; and study potential factors associated to previous use and attitudes towards internet interventions.

METHODS

An online cross-sectional survey was developed by the authors and disseminated by the Portuguese Psychologists Association to its members.

RESULTS

A total of 1077 members of the Portuguese Psychologists Association responded to the questionnaire between November 2018 and February 2019. Of these, 37.2% (N=363) were familiar with internet interventions and 19.2% (N=188) considered having the necessary training to work within the field. 29.6% (N=319) of participants reported to have used some form of digital technology to deliver care in the past. Telephone (23.8%; N=256), e-mail (16.2%; N=175) and SMS (16.1%; N=173) services were among the most adopted forms of digital technology, while guided (1.3%; N=14) and unguided (1.5%; N=16) internet interventions were rarely used. Accessibility (79.9%; N=860), convenience (45.7%; N=492) and cost-effectiveness (45.5%; N=490) were considered the most important advantages of internet interventions. Conversely, ethical concerns (40.7%; N=438), client's ICT illiteracy (43.2%; N=465) and negative attitudes towards internet interventions (37%; N=398) were identified as the main limitations. An assessment of participants attitudes towards internet interventions revealed a slightly negative/neutral stance (Median=46.21; SD=15.06) and revealed greater acceptability towards blended treatment interventions (62.9%; N=615) when compared to standalone internet interventions (18.6%; N=181). Significant associations were found between knowledge (χ24=90.4; P<.001), training (χ24=94.6; P<.001), attitudes (χ23=38.4; P<.001) and previous use of internet interventions and between knowledge (χ212=109.7; P<.001), training (χ212=64.7; P<.001) and attitudes towards such interventions, with psychologists reporting to be ignorant and not having adequate training in the field, being more likely to present more negative attitudes towards these interventions and not having prior experience in its implementation.

CONCLUSIONS

This study revealed that most Portuguese psychologists are not familiar with and have no training or prior experience using internet interventions and had a slightly negative/neutral attitude towards such interventions. There was greater acceptability towards blended treatment interventions compared to standalone internet interventions. Lack of knowledge and training were identified as the main barriers to overcome, underlining the need of promoting awareness and training initiatives to ensure internet interventions successful implementation.

Direct and lost productivity costs associated with avoidable hospital admissions

Background

Hospitalizations for ambulatory care sensitive conditions are commonly used to evaluate primary health care performance, as the hospital admission could be avoided if care was timely and adequate. Previous evidence indicates that avoidable hospitalizations carry a substantial direct financial burden in some countries. However, no attention has been given to the economic burden on society they represent. The aim of this study is to estimate the direct and lost productivity costs of avoidable hospital admissions in Portugal.

Methods

Hospitalizations occurring in Portugal in 2015 were analyzed. Avoidable hospitalizations were defined and their associated costs and years of potential life lost were calculated. Direct costs were obtained using official hospitalization prices. For lost productivity, there were estimated costs for absenteeism and premature death. Costs were analyzed by components, by conditions and by variations on estimation parameters.

Results

The total estimated cost associated with avoidable hospital admissions was €250 million (€2515 per hospitalization), corresponding to 6% of the total budget of public hospitals in Portugal. These hospitalizations led to 109,641 years of potential life lost. Bacterial pneumonia, congestive heart failure and urinary tract infection accounted for 77% of the overall costs. Nearly 82% of avoidable hospitalizations were in patients aged 65 years or older, therefore did not account for the lost productivity costs. Nearly 84% of the total cost comes from the direct cost of the hospitalization. Lost productivity costs are estimated to be around €40 million.

Conclusion

The age distribution of avoidable hospitalizations had a significant effect on costs components. Not only did hospital admissions have a substantial direct economic impact, they also imposed a considerable economic burden on society. Substantial financial resources could potentially be saved if the country reduced avoidable hospitalizations.

Cost-effectiveness of basic vision rehabilitation (The basic VRS-effect study): study protocol for a randomised controlled trial

PURPOSE

To investigate the cost-effectiveness of a basic vision rehabilitation service (basic-VRS) in Portugal. We designed a parallel group, randomised controlled trial whose aim is to compare the effects and costs of 'usual low vision care' with a 'basic-VRS intervention' on self-reported visual ability and other psychosocial and health-related quality-of-life outcomes.

METHODS

The trial will recruit participants that meet the following inclusion criteria: (1) visual acuity between 0.4-1.0 logMAR in the better-seeing eye, (2) cause of vision loss is diabetic retinopathy or age-related macular degeneration, (3) 18 years or older and iv) live in the community (not in nursing homes or other type of institution). Participants will be randomised to one of the study arms consisting of immediate intervention and delayed intervention. The delayed intervention group will receive 'usual care' or no intervention in the first 12 weeks. Visual acuity, contrast sensitivity and retinal structure will be assessed during the study.

RESULTS

The primary outcome measure is visual ability, which will be evaluated with the Massof Activity Inventory, we expect that the intervention will raise the overall person measure or visual ability. Reading, health-related quality-of-life, anxiety and depression and social support will be also assessed. The analysis will be undertaken on an intention-to-treat basis. A cost-effectiveness analysis will be performed to provide information about the cost per unit of utility. To evaluate the cost-effectiveness of the intervention we will adopt the perspective of the healthcare system.

CONCLUSION

This study will provide additional evidence about the effects of basic-VRS on self-reported visual ability. Findings from this study should also contribute to better planning of low vision provision and, consequently, may contribute to reduce barriers to basic-VRS.

The impact of diabetes on multiple avoidable admissions: a cross-sectional study

BACKGROUND

Multiple admissions for ambulatory care sensitive conditions (ACSC) are responsible for an important proportion of health care expenditures. Diabetes is one of the conditions consensually classified as an ACSC being considered a major public health concern. The aim of this study was to analyse the impact of diabetes on the occurrence of multiple admissions for ACSC.

METHODS

We analysed inpatient data of all public Portuguese NHS hospitals from 2013 to 2015 on multiple admissions for ACSC among adults aged 18 or older. Multiple ACSC users were identified if they had two or more admissions for any ACSC during the period of analysis. Two logistic regression models were computed. A baseline model where a logistic regression was performed to assess the association between multiple admissions and the presence of diabetes, adjusting for age and sex. A full model to test if diabetes had no constant association with multiple admissions by any ACSC across age groups.

RESULTS

Among 301,334 ACSC admissions, 144,209 (47.9%) were classified as multiple admissions and from those, 59,436 had diabetes diagnosis, which corresponded to 23,692 patients. Patients with diabetes were 1.49 times (p < 0,001) more likely to be admitted multiple times for any ACSC than patients without diabetes. Younger adults with diabetes (18-39 years old) were more likely to become multiple users.

CONCLUSION

Diabetes increases the risk of multiple admissions for ACSC, especially in younger adults. Diabetes presence is associated with a higher resource utilization, which highlights the need for the implementation of adequate management of chronic diseases policies.

One-year rehospitalisations for congestive heart failure in Portuguese NHS hospitals: a multilevel approach on patterns of use and contributing factors

OBJECTIVES

Identification of rehospitalisations for heart failure and contributing factors flags health policy intervention opportunities designed to deliver care at a most effective and efficient level. Recognising that heart failure is a condition for which timely and appropriate outpatient care can potentially prevent the use of inpatient services, we aimed to determine to what extent comorbidities and material deprivation were predictive of 1 year heart failure specific rehospitalisation.

SETTING

All Portuguese mainland National Health Service (NHS) hospitals.

PARTICIPANTS

A total of 68 565 hospitalisations for heart failure principal cause of admission, from 2011 to 2015, associated to 45 882 distinct patients aged 18 years old or over.

OUTCOME MEASURES

We defined 1 year specific heart failure rehospitalisation and time to rehospitalisation as outcome measures.

RESULTS

Heart failure principal diagnosis admissions accounted for 1.6% of total hospital NHS budget, and over 40% of this burden is associated to patients rehospitalised at least once in the 365-day follow-up period. 22.1% of the patients hospitalised for a principal diagnosis of heart failure were rehospitalised for the same cause at least once within 365 days after previous discharge. Nearly 55% of rehospitalised patients were readmitted within 3 months. Results suggest a mediation effect between material deprivation and the chance of 1 year rehospitalisation through the effect that material deprivation has on the prevalence of comorbidities. Heart failure combined with chronic kidney disease or chronic obstructive pulmonary disease increases by 2.8 and 2.2 times, respectively, the chance of the patient becoming a frequent user of inpatient services for heart failure principal cause of admission.

CONCLUSIONS

One-fifth of patients admitted for heart failure are rehospitalised due to heart failure exacerbation. While the role of material deprivation remained unclear, comorbidities considered increased the chance of 1 year heart failure specific rehospitalisation, in particular, chronic kidney disease and chronic obstructive pulmonary disease.

A guided internet-delivered individually-tailored ACT-influenced cognitive behavioural intervention to improve psychosocial outcomes in breast cancer survivors (iNNOVBC): Study protocol

BACKGROUND

Internet-delivered interventions can provide remarkable opportunities in addressing breast cancer survivors' unmet support care needs, as they present an effective strategy to improve care coordination and provide access to efficacious, cost-efficient and convenient survivorship care. Nevertheless, research focusing on improving survivors' psychosocial needs using internet-based tools is scarce and its practical implementation is limited.

OBJECTIVES

To study the acceptability, feasibility, efficacy and cost-effectiveness of iNNOVBC, a 10 weeks guided internet-delivered individually-tailored Acceptance and Commitment Therapy (ACT)-influenced cognitive behavioural (CBT) intervention developed to improve mild to moderate anxiety and depression in Breast cancer survivors when compared to treatment as usual (TAU) in a waiting list control group (WLC).

METHODS

A two-arm, parallel, open label, multicentre, waiting list randomized controlled trial will be conducted to investigate the efficacy and cost-effectiveness of INNOVBC. The primary outcomes in this research will be anxiety and depression. Secondary outcomes will include psychological flexibility, fatigue, insomnia, sexual dysfunction and Health Related Quality of Life (HRQoL).

ETHICAL APPROVAL

This study has been reviewed and approved by Comissão Nacional de Proteção de Dados; Instituto Português de Oncologia do Porto Francisco Gentil; Unidade Local de Saúde de Matosinhos, EPE; Centro Hospitalar de São João and Ordem dos Psicólogos ethical committees.

EXPECTED RESULTS

It is anticipated that iNNOVBC will show to be an efficacious and cost-effective program in improving the outcomes of interest in this study, as opposed to a WLC under TAU. The results of this research will be published in accordance with CONSORT-EHEALTH guidelines.

CONCLUSIONS

This study will inform on the acceptability, feasibility, efficacy and cost-effectiveness of iNNOVBC, in improving psychosocial outcomes in breast cancer survivors when compared to TAU in a WLC. Its conclusions will contribute to understand the idiosyncrasies of designing and implementing internet-delivered interventions in breast cancer survivors.Trial Registration code: INNOVBC (NCT03275727).

Comparative research aspects on hospitalizations for ambulatory care sensitive conditions: the case of Brazil and Portugal

Hospitalizations for ambulatory care sensitive conditions have been used to measure access, quality and performance of the primary health care delivery system, as timely and adequate care could potentially avoid the need of hospitalization. Comparative research provides the opportunity for cross-country learning process. Brazil and Portugal have reformed their primary health care services in the last years, with similar organizational characteristics. We used hospitalization data of Brazil and Portugal for the year 2015 to compare hospitalizations for ambulatory care sensitive conditions between the two countries, and discussed conceptual and methodological aspects to be taken into consideration in the comparative approach. Brazil and Portugal presented similarities in causes and standardized rates of hospitalizations for ambulatory care sensitive conditions. There was great sensitivity on rates according to the methodology employed to define conditions. Hospitalizations for ambulatory care sensitive conditions are important sources of pressure for both Brazil and Portugal, and there are conceptual and methodological aspects that are critical to render the country-comparison approach useful.

Avoidable hospitalizations in Brazil and Portugal: Identifying and comparing critical areas through spatial analysis

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions have been used to assess the performance of primary health care. Few studies have compared geographic variation in rates of avoidable hospitalizations and characteristics of high-risk areas within and between countries. The aim of this study was to identify and compare critical areas of avoidable hospitalizations in Brazil and Portugal, because these countries have reformed their primary health care systems in recent years and have similar organizational characteristics.

METHODS

An ecological study on hospitalizations for ambulatory care sensitive conditions produced in Brazil and Portugal in 2015 was used. Geographic variation of rates were analyzed and compared at the municipal level. A spatial scan statistic was employed to identify clusters with higher risk of hospitalizations for acute and chronic conditions in each country separately. Socioeconomic and primary health care characteristics of critical areas were compared to non-critical areas.

RESULTS

There were high variations in rates of avoidable hospitalizations within and between Brazil and Portugal, with higher variations found in Brazil. A more evident pattern of rates was found in Portugal. Rates and cluster distribution of acute and chronic conditions had significant agreement for both countries. The differences in primary health care and socioeconomic characteristics between areas identified as high risk clusters and non-clusters varied between category of conditions and between countries.

CONCLUSION

Brazil and Portugal presented expressive regional differences with respect to rates of avoidable hospitalizations, indicating that there is room to improve by reducing such events in both countries. Different areas presented distinct interactions between primary health care, socioeconomic characteristics, and avoidable hospitalizations. Results indicate that the primary health care reforms, with similar organizational characteristics in different contexts, did not produce similar results either between or within countries. Possible actions to reduce these events should be defined at a local level.

Productivity Losses and Their Explanatory Factors Amongst People with Impaired Vision

Purpose: To estimate productivity losses amongst people with impaired vision in Portugal and to investigate explanatory factors associated with non-participation in the labour market.Methods: A total of 546 visually impaired individuals participated in face-to-face interviews. Participants were asked about their workforce participation to determine productivity (employment status questionnaire), their health-related quality of life - HRQoL (EQ-5D) and their visual acuity and visual ability (Activity Inventory). Productivity losses included absenteeism and reduction in workforce participation. Logistic regression was used to determine independent factors associated with participation in the labour market.Results: From the 546 participants, 50% were retired, 47% were of working age and 3% were students. The employment rate was 28%, and the unemployment rate was 21% for the working age sample. For those of working age, productivity losses were estimated at €1.51 million per year, mean of €5496 per participant. The largest contributor to productivity losses was reduced workforce participation, estimated from 159 early retired or unemployed participants. After controlling for visual acuity and ability, younger individuals, with more years of education, without comorbidities and high HRQoL had a higher probability of being employed.Conclusions: Our findings show a high unemployment rate and high productivity losses amongst people with impaired vision. The probability of being employed was associated with education, HRQoL and comorbidities. We speculate that promoting education and health through effective visual rehabilitation programs may help to increase participation in the labour market. These findings can inform decisions to intervene to reduce the burden of vision loss.

Synthetic polymeric barrier membrane associated with blood coagulum, human allograft, or bovine bone substitute for ridge preservation: a randomized, controlled, clinical and histological trial

During the normal healing process, an extraction site may lose significant bone volume, making implant placement problematic. Quantitative evaluations of the amount of bone maintained by socket preservation with various materials are limited. The objective of this study was to evaluate, both clinically and histologically, the extent of alveolar bone preservation by blood coagulum (BC) and the potential additional benefits of bone allograft material (AL) versus the state-of-the-art bovine bone mineral (BB), covered by a polyethylene glycol (PEG) barrier, in extraction socket grafting procedures. Adult patients (n=32) with single-rooted teeth indicated for extraction were treated (45 sites). After atraumatic extraction, the sockets were filled with BC, AL, or BB and covered with a synthetic PEG barrier membrane. Changes in bone height and width were measured clinically and the amount of bone formed and residual graft particles were measured histologically after 6 months. Changes in ridge width at 6 months were -1.5mm for AL versus -2.5mm for BB and -2.3mm for BC. New bone formation amounted to 47.8%, 33.3%, and 28.2% at BC-, AL-, and BB-treated sites, respectively. Using AL with the PEG barrier preserved the ridge width at 6 months better than BB or BC and resulted in similar amounts of bone histologically to BB.

Predicting participation of people with impaired vision in epidemiological studies

Background

The characteristics of the target group and the design of an epidemiologic study, in particular the recruiting methods, can influence participation. People with vision impairment have unique characteristics because those invited are often elderly and totally or partially dependent on help to complete daily activities such as travelling to study sites. Therefore, participation of people with impaired vision in studies is less predictable than predicting participation for the general population.

Methods

Participants were recruited in the context of a study of prevalence and costs of visual impairment in Portugal (PCVIP-study). Participants were recruited from 4 Portuguese public hospitals. Inclusion criteria were: acuity in the better eye from 0.5 decimal (0.30logMAR) or worse and/or visual field of less than 20 degrees. Recruitment involved sending invitation letters and follow-up phone calls. A multiple logistic regression model was used to assess determinants of participation. The J48 classifier, chi-square and Fisher’s exact tests were applied to investigate the possible differences between subjects in our sample.

Results

Individual cases were divided into 3 groups: immediate, late and non-participants. A participation rate of 20% was obtained (15% immediate, 5% late). Factors positively associated with participation included years of education, annual hospital attendance, and intermediate visual acuity. Females and greater distance to the hospital were inversely associated with participation.

Conclusion

In our study, a letter followed by a phone call was efficient to recruit a significant number of participants from a larger group of people with impaired vision. However, the improvement in participation observed after the phone call might not be cost-effective. People with low levels of education and women were more difficult to recruit. These findings need to be considered to avoid studies whose results are biased by gender or socio-economic inequalities of their participants. Young subjects and those at intermediate stages of vision impairment, or equivalent conditions, may need more persuasion than other profiles.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0889-9) contains supplementary material, which is available to authorized users.

Visual and health outcomes, measured with the activity inventory and the EQ-5D, in visual impairment

PURPOSE

Generic instruments to assess health utilities can be used to express the burden of health problems in widely used indexes. That is in contrast with what can be obtained with condition-specific instruments, outcomes are very specific and difficult to compare across conditions. The purpose of this study was to assess health and visual outcomes and its determinants in patients with visual impairment (VI) using the EQ-5D-3L and the Activity Inventory (AI).

METHODS

Participants were recruited in different hospitals during the PCVIP-study. A total of 134 patients with acuity 0.30 logMAR or less in the better eye were interviewed. The AI includes 46 goals split between three objectives: social functioning, recreation and daily living, and was used to measure visual ability. The EQ-5D consists of five questions covering one domain each and was used to provide a measure of health states. Responses to each domain were combined to produce a single individual index.

RESULTS

The AI and the EQ-5D-3L showed enough discriminatory power between VI levels (p < 0.001), and their results were strongly correlated r(134) = 0.825, (p < 0.001). Explanatory factors for visual ability were level of VI in better eye, age and gender, R²  = 0.43, (p < 0.001). Explanatory factors for the EQ-5D-3L were level of VI in the better eye, comorbidities and gender, R²  = 0.36, (p < 0.001).

CONCLUSION

Our results showed that the EQ-5D-3L is useful when characterizing the burden of VI and to compute, when necessary, quality-adjusted-life-years (QALY) changes due to VI. However, it is important to consider that the EQ-5D-3L uses a coarse response scale, assesses a limited spectrum of domains and is influenced by comorbidities. This might limit its responsiveness to small changes in visual ability.

A Influência das Características dos Prestadores e dos Utentes no Consumo de Recursos em Unidades de Cuidados Continuados

<b><i>Introdução:</i></b> O envelhecimento populacional, o aumento da prevalência de doenças crónicas e de multipatologia, são fenómenos que encontraram novas respostas com a criação da Rede Nacional de Cuidados Continuados Integrados (RNCCI) em Portugal, a partir de 2006. É esperado que esta estrutura adicional de oferta de cuidados permita contribuir para a criação de valor aos seus utentes. <b><i>Objetivo:</i></b> O presente estudo teve como objetivos estimar o consumo de recursos medido através da duração de internamento em unidades de internamento em cuidados continuados (UICC) em Portugal e analisar a associação com as características dos utentes e dos prestadores de cuidados. <b><i>Método:</i></b> Foi realizado um estudo transversal e retrospetivo, que utilizou informação da atividade das unidades da RNCCI entre 2010 e 2012. Recorreu-se a modelos de regressão lineares múlti­plos, utilizando a duração de internamento como variável dependente e, como preditores, variáveis representativas das características individuais dos utentes e dos prestadores. <b><i>Resultados:</i></b> Para os 30.090 episódios incluídos, a duração média de internamento foi de 34,2 dias nas unidades de convalescença, 84,1 dias nas unidades de média duração e reabilitação e 106 dias nas unidades de longa duração e manutenção. A dispersão da duração de internamento foi elevada em todas as tipologias e regiões. Isoladamente, as variáveis associadas às características dos utentes apresentaram capacidade preditiva muito reduzida. A inclusão das variáveis associadas à organização da oferta de cuidados aumentou a capacidade do modelo explicar a variabilidade do tempo de internamento dos utentes. <b><i>Conclusão:</i></b> Os resultados do modelo de regressão linear múltipla sugerem que são as características associadas à oferta de cuidados que apresentam maior relevância para explicar a variabilidade da duração de internamento em cuidados continuados. Sugere-se que futuros desenvolvimentos incluam melhorias nas práticas de registo e a implementação de um sistema de classificação de utentes específico, internacionalmente validado para a estratificação do risco em cuidados continuados.

The impact of multiple chronic diseases on hospitalizations for ambulatory care sensitive conditions

BACKGROUND

The high financial burden of avoidable hospitalizations has led to an increase of the study of hospitalizations for ambulatory care sensitive conditions (ACSC). There is limited information on the impact of secondary diagnoses on these hospitalizations, although patients' social and demographic characteristics, as well as the coexistence of multiple diseases are often identified in the literature as risk factors for avoidable hospitalizations. This study explores the impact of chronic conditions on the likelihood of hospitalizations for ACSC.

METHODS

Data were extracted from the Portuguese hospital discharge database. Avoidable hospitalizations were identified according to the Canadian Institute for Healthcare Information, and chronic conditions were identified according to criteria set by the Agency for Healthcare Research and Quality. A retrospective study analysing all patients hospitalized for an ACSC and all patients hospitalized for non-ACSC was made, using multiple logistic regression models to identify the impact of chronic conditions on the risk of admission.

RESULTS

The risk of an avoidable hospitalization increases by a factor of 1.35 (95 % CI [1.34;1.35]) for each additional chronic condition, and 1.55 (95 % CI [1.55;1.56]) for each additional body system affected. The respiratory and circulatory systems have the most impact on the risk of ACSC, increasing the risk by 8.72 (95 % CI [8.58;8.86]) and 3.01 (95 % CI [2.95;3.06]), respectively.

CONCLUSIONS

The number of chronic conditions and the body systems affected increase the risk of hospital admissions for ACSC.

Diffusion of anti-VEGF injections in the Portuguese National Health System

OBJECTIVES

To analyse the temporal and geographical diffusion of antivascular endothelial growth factor (anti-VEGF) interventions, and its determinants in a National Health System (NHS).

SETTING

NHS Portuguese hospitals.

PARTICIPANTS

All inpatient and day cases related to eye diseases at all Portuguese public hospitals for the period 2002-2012 were selected on the basis of four International Classification of Diseases 9th revision, Clinical Modification (ICD-9-CM) codes for procedures: 1474, 1475, 1479 and 149.

PRIMARY AND SECONDARY OUTCOME MEASURES

We measured anti-VEGF treatment rates by year and county. The determinants of the geographical diffusion were investigated using generalised linear modelling.

RESULTS

We analysed all hospital discharges from all NHS hospitals in Portugal (98,408 hospital discharges corresponding to 57,984 patients). National rates of hospitals episodes for the codes for procedures used were low before anti-VEGF approval in 2007 (less than 12% of hospital discharges). Between 2007 and 2012, the rates of hospital episodes related to the introduction of anti-VEGF injections increased by 27% per year. Patients from areas without ophthalmology departments received fewer treatments than those from areas with ophthalmology departments. The availability of an ophthalmology department in the county increased the rates of hospital episodes by 243%, and a 100-persons greater density per km(2) raised the rates by 11%.

CONCLUSIONS

Our study shows a large but unequal diffusion of anti-VEGF treatments despite the universal coverage and very low copayments. The technological innovation in ophthalmology may thus produce unexpected inequalities related to financial constraints unless the implementation of innovative techniques is planned and regulated.

Caracterização e Evolução dos Internamentos Evitáveis em Portugal: Impacto de Duas Abordagens Metodológicas

<strong>Introduction:</strong> The aim of this study is to evaluate the health systems performance through the avoidable hospital admissions, once these have gained international relevance. We used two different methods to identify the admissions for Ambulatory Care Sensitive Conditions, describing the Portuguese reality and evolution.<br /><strong>Material and Methods:</strong> Over 12 million hospitalizations were analyzed between 2000 and 2012 using the national hospital discharge databases. We used two different methodologies to identify the hospitalizations for Ambulatory Care Sensitive Conditions, determining their concordance. We also estimated potential improvement scenarios.<br /><strong>Results: </strong>In 2012, 4.4% and 32.4% of the hospitalizations for medical causes were avoidable according to the Canadian and Spanish methodologies respectively. The hospitalizations are more frequent in children and the elderly. The most frequent causes vary according to the age group and methodology. During the analyzed period the rate of admissions has dropped 20% according to the Canadian methodology and increased 16% according to the Spanish methodology. There are regional clusters of performance under and above the national average. The concordance between methodologies is low. The improvement scenarios estimated possible reductions between 20.3% and 53.5% of the hospitalizations.<br /><strong>Discussion:</strong> The avoidable admissions assume a relevant volume in Portugal. Although in theory they are avoidable their complete elimination is a practical impossibility. Their study, however, allows the evaluation and results motorization enabling to establish intervention priorities.<br /><strong>Conclusion:</strong> To have a precise characterization of the avoidable admissions in Portugal it is necessary to achieve consensus on the identification methodology.

[Characterization and Evolution of Avoidable Admissions in Portugal: The Impact of Two Methodologic Approaches]

INTRODUCTION

The aim of this study is to evaluate the health systems performance through the avoidable hospital admissions, once these have gained international relevance. We used two different methods to identify the admissions for Ambulatory Care Sensitive Conditions, describing the Portuguese reality and evolution.

MATERIAL AND METHODS

Over 12 million hospitalizations were analyzed between 2000 and 2012 using the national hospital discharge databases. We used two different methodologies to identify the hospitalizations for Ambulatory Care Sensitive Conditions, determining their concordance. We also estimated potential improvement scenarios.

RESULTS

In 2012, 4.4% and 32.4% of the hospitalizations for medical causes were avoidable according to the Canadian and Spanish methodologies respectively. The hospitalizations are more frequent in children and the elderly. The most frequent causes vary according to the age group and methodology. During the analyzed period the rate of admissions has dropped 20% according to the Canadian methodology and increased 16% according to the Spanish methodology. There are regional clusters of performance under and above the national average. The concordance between methodologies is low. The improvement scenarios estimated possible reductions between 20.3% and 53.5% of the hospitalizations.

DISCUSSION

The avoidable admissions assume a relevant volume in Portugal. Although in theory they are avoidable their complete elimination is a practical impossibility. Their study, however, allows the evaluation and results motorization enabling to establish intervention priorities.

CONCLUSION

To have a precise characterization of the avoidable admissions in Portugal it is necessary to achieve consensus on the identification methodology.

The Great Recession in Portugal: impact on hospital care use

The Great Recession started in Portugal in 2009, coupled with severe austerity. This study examines its impact on hospital care utilization, interpreted as caused by demand-side effects (related to variations in population income and health) and supply-side effects (related to hospitals' tighter budgets and reduced capacity). The database included all in-patient stays at all Portuguese NHS hospitals over the 2001-2012 period (n=17.7 millions). We analyzed changes in discharge rates, casemix index, and length of stay (LOS), using a before-after methodology. We additionally measured the association of health care indicators to unemployment. A 3.2% higher rate of discharges was observed after 2009. Urgent stays increased by 2.5%, while elective in-patient stays decreased by 1.4% after 2011. The LOS was 2.8% shorter after the crisis onset, essentially driven by the 4.5% decrease among non-elective stays. A one percentage point increase in unemployment rate was associated to a 0.4% increase in total volume, a 2.3% decrease in day cases, and a 0.1% decrease in LOS. The increase in total and urgent cases may reflect delayed out-patient care and health deterioration; the reduced volume of elective stays possibly signal a reduced capacity; finally, the shorter stays may indicate either efficiency-enhancing measures or reduced quality.

Switching to sirolimus in renal transplant recipients with hepatitis C virus: a safe option

INTRODUCTION

The presence of hepatitis C virus (HCV) in renal transplant recipients is an independent risk factor for death and graft failure. Chronic allograft nephropathy (CAN) favored by the use of calcineurin inhibitors (CNI) is one of the main causes of graft loss, whereas sirolimus (SRL) has proven to maintain better graft function with lower rates of CAN.

OBJECTIVES AND METHODS

We developed a protocol to evaluate the safety of SRL in transplant recipients with respect to HCV. We studied 5 patients (3 men) of mean age 52 +/- 9.2 years with HCV who had not received antiviral treatment. The viral genotypes were 1b in 4 cases and 2a/2c in 1 case. Basic immunosuppression was mycophenolate mofetil (MMF) and corticosteroids in all patients, cyclosporine (CsA) in 4 cases, and tacrolimus (Tac) in 1 case. Before the switch, a renal biopsy was performed and viral replication and cryoglobulins determined.

RESULTS

Biopsy provided a diagnosis of CAN in 1 case, CNI toxicity-associated CAN in 2 cases, CNI toxicity in 1 case, and no renal damage in the remaining case. We observed a nonsignificant decrease in the number (log) of viral copies with a stabilization of renal function but with a slight to moderate increase in proteinuria.

CONCLUSIONS

The switch seemed to be safe with no increase in viral copies. Graft renal function remained stable with increased proteinuria that must be supervised, even though it did not reach statistical significance.