conTemporary reflectiOns regarding heart failure manaGEmenT - How to ovERcome the PorTuguese barriers (TOGETHER-PT)

INTRODUCTION AND OBJECTIVES

Heart failure (HF) is a complex clinical syndrome that is a significant burden in hospitalisations, morbidity, and mortality. Although a significant effort has been made to better understand its consequences and current barriers in its management, there are still several gaps to address. The present work aimed to identify the views of a multidisciplinary group of health care professionals on HF awareness and literacy, diagnosis, treatment and organization of care, identifying current challenges and providing insights into the future.

METHODS

A steering committee was established, including members of the Heart Failure Study Group of the Portuguese Society of Cardiology (GEIC-SPC), the Heart Failure Study Group of the Portuguese Society of Internal Medicine (NEIC-SPMI) and the Cardiovascular Study Group (GEsDCard) of the Portuguese Association of General and Family Medicine (APMGF). This steering committee produced a 16-statement questionnaire regarding different HF domains that was answered to by a diversified group of 152 cardiologists, internists, general practitioners, and nurses with an interest or dedicated to HF using a five-level Likert scale. Full agreement was defined as ≥80% of level 5 (fully agree) responses.

RESULTS

Globally, consensus was achieved in all but one of the 16 statements. Full agreement was registered in seven statements, namely 3 of 4 statements for patient education and HF awareness and 2 in 4 statements of both HF diagnosis and healthcare organization, with proportions of fully agree responses ranging from 82.9% to 96.7%. None of the HF treatment statements registered full agreement but 3 of 4 achieved ≥80% of level 4 (agree) responses.

CONCLUSION

This document aims to be a call-to-action to improve HF patients' quality of life and prognosis, by promoting a change in HF care in Portugal.

Bibliometric analysis of the official journals of internal medicine societies in Europe

INTRODUCTION

Bibliometrics evaluates the quality of biomedical journals. The aim of this study has been to compare the main bibliometric indexes of the official journals of scientific societies of Internal Medicine in Europe.

MATERIAL AND METHODS

Bibliometric information was obtained from the Web of Science (WoS) and Scopus databases. Both impact metrics (Journal Impact Factor [JIF], CiteScore) and normalized metrics (Journal Citation Indicator [JCI], Normalized Eigenfactor, Source Normalized Impact per Paper [SNIP] and SCImago Journal Rank [SJR]) of the journals for the year 2022 were analyzed, and their evolution over the last decade was described.

RESULTS

Twenty-three official journals from 33 scientific societies were evaluated. Eight journals were included in WoS and 11 in Scopus. The best positioned journals in 2022 were: 1) European Journal of Internal Medicine, which ranked in the first quartile (Q1) for JIF, CiteScore and JCI metrics, exceeding values of 1 in Normalized Eigenfactor and SNIP metrics; 2) Internal and Emergency Medicine, with Q1 for CiteScore and JCI metrics, and with values >1 in Normalized EigenFactor and SNIP metrics; 3) Polish Archives of Internal Medicine, with Q1 for JCI metrics; 4) Revista Clínica Española, with Q2 for JIF, CiteScore and JCI metrics; and 5) Acta Medica Belgica, with Q2 for CiteScore and JCI metrics. These journals increased their impact metrics in the last 3 years, in parallel with the COVID pandemic.

CONCLUSIONS

Five official journals of European Internal Medicine societies, including Revista Clínica Española, meet high quality standards.

Executive summary of the consensus document for the training and development of clinical ultrasound in Internal Medicine: Recommendations from the Clinical Ultrasound Working Group of the Spanish Society of Internal Medicine (GTECO-SEMI)

INTRODUCTION

Given the increasing adoption of clinical ultrasound in medicine, it is essential to standardize its application, training, and research.

OBJECTIVES AND METHODS

The purpose of this document is to provide consensus recommendations to address questions about the practice and operation of clinical ultrasound units. Nineteen experts and leaders from advanced clinical ultrasound units participated. A modified Delphi consensus method was used.

RESULTS

A total of 137 consensus statements, based on evidence and expert opinion, were considered. The statements were distributed across 10 areas, and 99 recommendations achieved consensus.

CONCLUSIONS

This consensus defines the most important aspects of clinical ultrasound in the field of Internal Medicine, with the aim of standardizing and promoting this healthcare advancement in its various aspects. The document has been prepared by the Clinical Ultrasound Working Group and endorsed by the Spanish Society of Internal Medicine.

Characteristics and treatment of nonagenarian patients with vascular disease admitted to internal medicine services. NONAVASC-2 registry

INTRODUCTION

Vascular disease (VD) is the most frequent cause of morbidity and mortality and its prevalence increases with age. Old patients are not included in studies on VD, their characteristics and treatments being unknown.

OBJECTIVE

Know the clinical characteristics of nonagenarian patients hospitalized in Internal Medicine services with a diagnosis of established VD and the adequacy of their pharmacological management.

MATERIAL AND METHODS

The NONAVASC-2 registry is an observational, prospective, multicentre study. Hospitalized patients for any cause were included. Data collection was carried out through an anonymous online database with sociodemographic, clinical, analytical, therapeutic and evolutionary parameters.

RESULTS

One thousand forty-nine patients with a mean age of 93.14 years (57.8% women) were included. The prevalence of risk factors and VD was high: hypertension (84.9%), dyslipidemia (50.9%) and diabetes mellitus (29.4%). 33.4% presented severe-total dependency. 82.9% received antithrombotic treatment (53.7% antiplatelets, 25.4% anticoagulation and 3.8% double therapy). Only 38.2% received statins. The percentage of severe dependence (39.2% vs 24.1%; p = 0.00) and severe cognitive impairment (30.8% vs 13.8%; p = 0.00) was significantly higher among patients who did not receive them. 19% died during admission.

CONCLUSIONS

Nonagenarian patients with VD present high comorbidity, dependence and mortality. Despite being in secondary prevention, 17% did not receive antithrombotics and only 38% received statins. The underprescription is conditioned, among other factors, by the functional status. More studies are necessary to determine the impact of this issue on their prognosis.

RECALMIN IV. Evolution in the activity of internal medicine units of the National Health System (2008-2021)

AIMS

This work aims to analyze the structure, activity, and outcomes of internal medicine units and departments (IMU) of the Spanish National Health System (SNHS) and to analyze the challenges for the specialty and propose policies for improvement. It also aims to compare the results from the 2021 RECALMIN survey with IMU surveys from previous years (2008, 2015, 2017, 2019).

METHODS

This work is a cross-sectional, descriptive study of IMUs in acute care general hospitals of the SNHS that compares data from 2020 with previous studies. The study variables were collected through an ad hoc questionnaire.

RESULTS

Between 2014 and 2020, hospital occupancy and discharges by IMU increased (annual mean of 4% and 3.8%, respectively), as did hospital cross-consultation and initial consultation rates (2.1% in both cases). E-consultations increased notably in 2020. Risk-adjusted mortality and length of hospital stay did not show significant changes from 2013-2020. Progress in the implementation of good practices and systematic care for complex chronic patients was limited. A consistent finding in RECALMIN surveys was the variability among IMUs in terms of resources and activity, though no statistically significant differences were found in regard to outcomes.

CONCLUSIONS

There is considerable room for improvement in the operation of IMUs. The reduction in unjustified variability in clinical practice and inequities in health outcomes are a challenge for IMU managers and the Spanish Society of Internal Medicine.

Predicting the response to methylprednisolone pulses in patients with SARS-COV-2 infection

INTRODUCTION

Treating systemic inflammation caused by SARS-COV 2 (COVID-19) has become a challenge for the clinician. Corticosteroids have been the turning point in the treatment of this disease. Preliminary data from Recovery clinical trial raises hope by showing that treatment with dexamethasone at doses of 6mg/day shows a reduction on morbidity in patients requiring added oxygen therapy. However, both the start day or what kind of corticosteroid, are still questions to be clarified. Since the pandemic beginning, we have observed large differences in the type of corticosteroid, dose and initiation of treatment. Our objective is to assess the predictive capacity of the characteristics of patients treated with methylprednisolone pulses to predict hospital discharge.

MATERIALS AND METHODS

We presented a one-center observational study of a retrospective cohort. We included all patients admitted between 03/06/2020 and 05/15/2020 because of COVID-19. We have a total number of 1469 patients, of whom 322 received pulses of methylprednisolone. Previous analytical, radiographic, previous disease data were analyzed on these patients. The univariant analysis was performed using Chi-squared and the T test of Student according to the qualitative or quantitative nature of the variables respectively. For multivariate analysis, we have used binary logistic regression and ROC curves.

RESULTS

The analysis resulted statistically significant in dyspnea, high blood pressure, dyslipidemia, stroke, ischemic heart disease, cognitive impairment, solid tumor, C-reactive protein (CRP), lymphopenia and d-dimer within 5 days of admission. Radiological progression and FIO₂ input are factors that are associated with a worst prognosis in COVID-19 that receive pulses of methylprednisolone. Multivariate analysis shows that age, dyspnea and C-reactive protein are markers of hospital discharge with an area below the curve of 0.816.

CONCLUSIONS

In patients with methylprednisolone pulses, the capacity of the predictive model for hospital discharge including variables collected at 5 days was (area under the curve) 0.816.

Obesity is a chronic disease. Positioning statement of the Diabetes, Obesity and Nutrition Workgroup of the Spanish Society of Internal Medicine (SEMI) for an approach centred on individuals with obesity

BACKGROUND

Obesity is a chronic, complex and multifactorial metabolic disease involved in the development of chronic noncommunicable diseases such as type 2 diabetes mellitus, cardiovascular disease and cancer. The care of individuals with obesity is an essential part of the holistic approach provided by internal medicine to patients.

MATERIAL AND METHODS

Between September 2019 and January 2020, we distributed an online survey to the members of the Spanish Society of Internal Medicine. We prepared a Strengths, Weaknesses, Opportunities, and Threats analysis using the responses and, using the nominal group technique, developed the recommendations.

RESULTS

We obtained 599 responses. The respondents mean age was 44.4 ± 11 years, and 52.1% were women. Some 91.8% of the internists evaluate their patients to rule out the comorbidities associated with obesity, mainly type 2 diabetes mellitus (96.2%), cardiovascular disease (88.9%) and obesity-associated hypoventilation syndrome (73%), among others. Some 79.9% provided indications on lifestyle changes. Some 64.1% and 74.9% of the respondents knew the indications for the drugs and bariatric surgery, respectively. Some 93.8% and 83% of the respondents considered obesity and excess weight a chronic disease, and 88.7% considered it a disease of specific interest to internists, who should take an active and leading role in its treatment (85.3%).

CONCLUSIONS

The objective of the present document is to determine the degree of understanding and sensitivity of internists regarding the management of obesity and to develop a consensus of recommendations for the Spanish Society of Internal Medicine based on the scientific evidence and the opinion of its members.

Relationship between internal medicine journals' activity on social networks and the citations they receive

BACKGROUND AND OBJECTIVES

Social networks are a means for disseminating scientific information. Alternative metrics assessing the impact of scientific publications on social networks have been created. Our study aims to assess the correlation between the activity of internal medicine journals on social networks and traditional metrics based on citations.

METHODS

Internal medicine journals were identified in the SCImago-Scopus database and information on traditional impact metrics was extracted. In addition, alternative metrics of activity were determined for Facebook, Twitter, YouTube, and Instagram. The correlation was assessed through Spearman's correlation coefficient.

RESULTS

Of 134 Internal Medicine journals, 17 had a presence on the social networks evaluated. The SJR index was higher in journals with a presence on social networks vs. those without (59 vs. 18, p < .0001). The overall correlation between the SJR index and the number of followers/year was very strong for Facebook (Spearman's correlation coefficient 0.95, p < .05) and strong for Twitter (Spearman's correlation coefficient 0.54 p < .05).

CONCLUSIONS

Our study suggests that there is a very strong correlation between social network activity metrics (mainly Facebook and Twitter) compared to traditional metrics based on the number of citations of internal medicine journals.

Recommendations on the comprehensive, multidimensional assessment of hospitalized elderly people. Position of the Spanish Society of Internal Medicine

This position paper describes the most relevant and essential aspects of a comprehensive, multidimensional assessment of hospitalized elderly people. The change in demographic patterns and the epidemiological profiles of diseases makes it necessary for internal medicine departments to adapt in order to take into account the vulnerabilities of the elderly in this context. A comprehensive, multidimensional assessment and the multidisciplinary development of a care plan during hospitalization can have an impact in terms of preventing mortality, disability, and institutionalization at discharge. It is necessary for all internists to acquire skills to improve the hospitalization experience in the elderly and obtain better health outcomes in our patients. This document has been developed by the Focus Group on Aging and the Polypathological and Advanced Age Working Group and endorsed by the Spanish Society of Internal Medicine.

Recommendations on the comprehensive, multidimensional assessment of hospitalized elderly people. Position of the Spanish Society of Internal Medicine

This position paper describes the most relevant and essential aspects of a comprehensive, multidimensional assessment of hospitalized elderly people. The change in demographic patterns and the epidemiological profiles of diseases makes it necessary for internal medicine departments to adapt in order to take into account the vulnerabilities of the elderly in this context. A comprehensive, multidimensional assessment and the multidisciplinary development of a care plan during hospitalization can have an impact in terms of preventing mortality, disability, and institutionalization at discharge. It is necessary for all internists to acquire skills to improve the hospitalization experience in the elderly and obtain better health outcomes in our patients. This document has been developed by the Focus Group on Aging and the Polypathological and Advanced Age Working Group and endorsed by the Spanish Society of Internal Medicine.

Multidisciplinary care and units for uveitis in the internal medicine departments in Spain: Survey of the Systemic Autoimmune Diseases Group

OBJECTIVE

To identify the multidisciplinary uveitis units in which internal medicine departments participate in collaboration with ophthalmology departments in Spain.

MATERIAL AND METHODS

We conducted a multicentre, observational cross-sectional study that collected information using a structured survey sent by email to 1015 partners of the Systemic Autoimmune Diseases Workgroup of the Spanish Society of Internal Medicine (GEAS-SEMI) from the 1st to the 31st of March 2017.

RESULTS

We identified a total of 21 support units/consultations for the ophthalmology departments. Seventeen (81%) of the units were specific internal medicine-ophthalmology consultations, and 5 (24%) units had been created in the past 5 years. A median of 460 patients were assessed per unit by the end of the year.

CONCLUSIONS

This study shows, for the first time in Spain, the important and close collaboration between ophthalmologists and internists, especially in highly specialised national reference institutions.

Profile of patients who consult with internists for an osteoporosis assessment: The OSTEOMED registry

BACKGROUND AND OBJECTIVES

Osteoporosis is considered a generalised skeletal disorder in which there is impaired bone resistance, which predisposes the individual to a greater risk of fracture. The aim of this cross-sectional study was to collect and present data on the main clinical characteristics of patients who consult medical internists in Spain. Understanding these characteristics can help in implementing action plans to improve these patients' care more effectively and efficiently.

MATERIAL AND METHODS

Through an analysis of the Osteoporosis in Internal Medicine (OSTEOMED) registry, this study presents the main clinical characteristics of patients with osteoporosis who attended internal medicine consultations in 23 Spanish hospital centres between 2012 and 2017. We analysed the reasons for the consultations, the densitometric values, the presence of comorbidities, the prescribed treatment and other lifestyle-related factors.

RESULTS

In total, 2024 patients with osteoporosis were assessed (89.87% women, 10.13% men). The patients' mean age was 64.1±12.1 years (women, 64.7±11.5 years; men, 61.2±14.2 years). There was no significant difference between the sexes in their history of recent falls (9.1% and 6.7%); however, there were significant differences in the daily intake of calcium from milk products (553.8±332.6mg for women vs. 450.2±303.3mg for men; p<.001) and in the secondary causes of osteoporosis (13% of men vs. 6.5% of women; p<.001). In the sample, there were 404 fractures (20%), with a notable number of confirmed vertebral fractures (17.2%, 35.6% in men vs. 15.2% in women; p<.001). A large portion of the patients did not undergo the indicated treatment and presented low levels of physical activity and sun exposure. A significant percentage of the patients presented associated comorbidities, the most common of which were hypertension (32%) and dyslipidaemia (28%).

CONCLUSIONS

These results define the profile of patients with osteoporosis who attend internal medicine consultations in Spain. The results also show the multisystemic character of this condition, which, along with its high prevalence, determine that the specific internal medicine consultations dedicated to managing the condition are the appropriate place for caring for these patients.

Profile of patients who visit medical internists for an osteoporosis assessment: The OSTEOMED registry

BACKGROUND AND OBJECTIVES

Osteoporosis is considered a generalised skeletal disorder in which there is impaired bone resistance, which predisposes the individual to a greater risk of fracture. The aim of this cross-sectional study was to collect and present data on the main clinical characteristics of patients who consult medical internists in Spain. Understanding these characteristics can help in implementing action plans to improve these patients' care more effectively and efficiently.

MATERIAL AND METHODS

Through an analysis of the Osteoporosis in Internal Medicine (OSTEOMED) registry, this study presents the main clinical characteristics of patients with osteoporosis who attended internal medicine consultations in 23 Spanish hospital centres between 2012 and 2017. We analysed the reasons for the consultations, the densitometric values, the presence of comorbidities, the prescribed treatment and other lifestyle-related factors.

RESULTS

In total, 2024 patients with osteoporosis were assessed (89.87% women, 10.13% men). The patients' mean age was 64.1±12.1 years (women, 64.7±11.5 years; men, 61.2±14.2 years). There was no significant difference between the sexes in their history of recent falls (9.1% and 6.7%); however, there were significant differences in the daily intake of calcium from milk products (553.8±332.6mg for women vs. 450.2±303.3mg for men; P<.001) and in the secondary causes of osteoporosis (13% of men vs. 6.5% of women; P<.001). In the sample, there were 404 fractures (20%), with a notable number of confirmed vertebral fractures (17.2%, 35.6% in men vs. 15.2% in women; P<.001). A large portion of the patients did not undergo the indicated treatment and presented low levels of physical activity and sun exposure. A significant percentage of the patients presented associated comorbidities, the most common of which were hypertension (32%) and dyslipidaemia (28%).

CONCLUSIONS

These results define the profile of patients with osteoporosis who attend internal medicine consultations in Spain. The results also show the multisystemic character of this condition, which, along with its high prevalence, determine that the specific internal medicine consultations dedicated to managing the condition are the appropriate place for caring for these patients.

Characteristics of adults with Down syndrome hospitalised in Spanish internal medicine departments during 2005-2014

INTRODUCTION AND OBJECTIVES

The clinical problems of adults with Down syndrome seem to differ from those of the general population. To better understand these differences, we list the demographic and clinical characteristics of adults with Down syndrome admitted to Spanish internal medicine departments during 2005-2014.

PATIENTS AND METHODS

We conducted an observational retrospective study using data collected from the minimum basic data set on hospitalisation episodes of adults with Down syndrome in the internal medicine departments of Spain's National Health System from 2005 to 2014. We analysed the patients' epidemiological, clinical and societal data.

RESULTS

A total of 7548 hospitalisation episodes from 3786 patients were recorded. Some 56.6% of the patients were male with a mean age (±SD) of 47±13 years, and 715 of the patients died (18.9%). The age-adjusted mortality was 26.6%, and the mean stay was 9.6±12 days. The hospitalisation was for respiratory disease in 3684 episodes (48.8%) and for cardiac origin in 760 (10%). The most common comorbidities were hypothyroidism (27.1%, 2043 episodes), epilepsy (24.1%, 1819 episodes) and dementia (15.4%, 1162 episodes).

CONCLUSIONS

The hospitalisation of adults with Down syndrome in internal medicine departments has increased in the past decade. Although the reasons for hospitalisation, mean stay and cost per episode for this population are similar to those of the general population treated by internal medicine departments, the age-adjusted hospital mortality was significantly greater.

Which surgical patients require shared care?

Most hospitalized surgical patients have significant medical comorbidity and are treated with a considerable number of drugs and/or experience significant complications. Shared care (SC) is the shared responsibility and authority in managing hospitalized patients. In this article, we discuss whether patients should be selected for SC or not. The various selection criteria are not an exact science nor are they easy to apply. Furthermore, they may leave out many patients who may be good candidates for SC. Perioperative management is essential for preventing postoperative mortality. Failure to rescue (in-hospital mortality secondary to postoperative complications) is the main factor linked to in-hospital surgical mortality and can affect any patient regardless of age, comorbidity, or type of surgery. The component that most reduces failure to rescue is the presence of internists in surgical wards. We believe that all patients hospitalized in surgery departments should receive SC.

Multidisciplinary care and units for uveitis in the internal medicine departments in Spain: Survey of the Systemic Autoimmune Diseases Group

OBJECTIVE

To identify the multidisciplinary uveitis units in which internal medicine departments participate in collaboration with ophthalmology departments in Spain.

MATERIAL AND METHODS

We conducted a multicentre, observational cross-sectional study that collected information using a structured survey sent by email to 1015 partners of the Systemic Autoimmune Diseases Workgroup of the Spanish Society of Internal Medicine (GEAS-SEMI) from the 1st to the 31st of March 2017.

RESULTS

We identified a total of 21 support units/consultations for the ophthalmology departments. Seventeen (81%) of the units were specific internal medicine-ophthalmology consultations, and 5 (24%) units had been created in the past 5 years. A median of 460 patients were assessed per unit by the end of the year.

CONCLUSIONS

This study shows, for the first time in Spain, the important and close collaboration between ophthalmologists and internists, especially in highly specialized national reference institutions.

Valoración preoperatoria en cirugía no cardiaca: un abordaje por pasos

Preoperative assessment in non-cardiac surgery is essential to reducing the rate of in-hospital complications. Its purpose is to identify patients with higher levels of risk. Preoperative assessment should not be restricted to cardiovascular aspects, but it should focus on all organs and systems and include medication reconciliation. The purpose of this article is to approach the performance of a preoperative assessment in non-cardiac surgery from the perspective of the internist, with the purpose to help prevent adverse events and improve the overall outcome.

Analysis of patients shared in consultations of internal medicine and other medical specialties

BACKGROUND AND OBJECTIVE

The aging population is resulting in an increasing number of patients with multiple diseases that require treatment by various specialties. We examined the evolution of consultations and of the percentage of patients treated by several medical specialties.

METHODS

We analysed internal medicine (IM) consultations and those of other medical specialties in a hospital during 1997, 2007 and 2017 for the general population and for those older than 65 years.

RESULTS

Over the course of 20 years, the rate of first IM consultations per 1000 inhabitants increased 44%, and that of other medical specialties increased 137%. The percentage of patients seen by more than one specialty went from 13.8% in 1997 to 32.6% in 2017 and reached 45.5% for those older than 65 years.

CONCLUSIONS

The care for populations with growing comorbidity has a major impact on health systems and requires organisational changes for their care.

Left bundle branch block as equivalent of ST-segment elevation myocardial infarction: when yes, when not?

A new or presumably new left bundle branch block along with ischemic symptoms has traditionally been considered an electrocardiographic equivalent of ST-segment elevation myocardial infarction, which should be brought to emergent reperfusion. However, several criteria have been proposed for its definition, but none has reached out an optimal diagnostic yield. Below we detail these criteria, their main problems and the advantages they have shown.

Analysis of the activity of interconsultations conducted by the departments of internal medicine. REINA-SEMI study: Registry of Interconsultations and Shared Care of the Spanish Society of Internal Medicine

OBJECTIVE

To analyse the activity of interconsultations conducted by internal medicine (IM) departments, their formal aspects and the profile of clinical care required and to quantify the workload they represent.

MATERIAL AND METHOD

A multicentre, observational prospective study was conducted with consecutive hospitalised patients treated by IM departments using interconsultations between May 15 and June 15, 2016. We estimated the workload related to this activity (1time unit [TU]=10min).

RESULTS

We recorded 1,141 interconsultations from 43 hospitals. The mean age of the patients involved was 69.4 years (SD: 16.2), and 51.2% were men. The mean Charlson index was 2.3 (SD: 2.2). The most common reasons for the consultations were general assessments (27.4%), fever (18.1%), dyspnoea (13.6%), metabolic disorder (9.6%), arterial hypertension (6.3%) and delirium (5.3%). The duration of the first visit was 4 TUs (SD: 5.9) and 7.3 (SD: 21.5) for the sum of all subsequent visits. The surgical patients were older (70.6 [SD, 15.9] vs. 64.4 [SD, 16.3] years; P=.0001) and required more follow-up time (5 [SD, 7.3] vs. 3.5 [SD, 4.2] days; P=.009). The following issues were more common in the interconsultation format performed by medical services: number of regular interconsultations (response >24h), specification of the reason for the interconsultation, minimal data regarding the medical history and agreement on the appropriateness of the time spent with the consultant.

CONCLUSION

The patients treated through interconsultations by the IM departments represented a significant workload. The interconsultations from the medical departments were more in line with the request format.

[RECALMIN. Patient care in the internal medicine units of the Spanish national health system]

OBJECTIVES

To perform a situation analysis of the care provided by internal medicine units (IMUs) in Spain and to develop, based on this analysis, proposals for improving the quality of care in these units.

MATERIAL AND METHODS

A descriptive, cross-sectional study of the IMUs of general acute care hospitals of the Spanish National Health System (SNHS), with data referring to 2013. The study variables were collected via an ad hoc questionnaire.

RESULTS

Of the total 260hospitals identified in the SNHS, 142responses were obtained from 139hospitals throughout Spain, which represents 53.5% of the IMUs in the SNHS. The mean number of internists per IMU was 14±8, with a mean rate of 7.2±3.3 internists per 100,000 inhabitants. In 2013, the average number of hospital discharges from the IMU was 2,987±2,066, and those discharged by internists was 232±107. Sixty-one percent of the IMUs had implemented an interconsultation unit, and 41% had implemented a systematic care program for complex chronic patients. Thirty-three percent of the IMUs conducted multidisciplinary rounds, and 60% of these IMUs planned the discharge.

CONCLUSIONS

The 2013 RECALMIN survey revealed a number of important aspects of the organisation, structure and management of IMUs. The remarkable variability in the indicators of structure, activity and management probably reflect significant differences in efficiency and productivity, which therefore provide significant room for improvement.

[Spanish short-stay-units: results according to department designated to manage the unit]

OBJECTIVES

To compare the efficiency of short-stay units (SSUs) managed by different departments within hospitals.

MATERIAL AND METHODS

Cross-sectional study in 40 hospitals with SSUs. From June 1 to December 31, 2012,we gathered data on clinical caseloads and management. Variables directly related to efficiency were mean length of stay, bed rotation index, and weekend discharge rate.

RESULTS

Forty SSUs were studied; 25 (62.5%) were managed by the hospital's emergency department (ED), 9 (22.5%) were managed by the internal medicine department (IMD), 5 (12.5%) were independent, and 1 was jointly managed by the hospital's ED and the IMD. A total of 45 140 patients were discharged from the SSUs. The most common diagnoses were exacerbation of chronic heart or respiratory disease, urinary tract infection, and respiratory infection. Age was the only variable that was related to the hospital department designated to manage these SSUs. The mean ages by management type were as follows: independent SSUs (75.6 years) vs ED-managed SSUs (67.2 years) vs IMD-managed SSUs (57.8 years) (P=.02). Group-by-group comparisons showed that the mean length of stay was shorter in ED-managed SSUs than in IMD-managed units (2.65 vs 3.73 respectively; P=.047), and overall mortality was lower in IMD-managed SSUs than in ED-managed SSUs (0.64% vs 3%; P=.033). However, unforeseen mortality (after excluding patients under palliative care or judged to be in the final hours of life) did not differ significantly between groups.

CONCLUSION

We did not detect important differences between SSUs managed by different departments in the hospitals in this series. However, mean length of stay was found to be shorter in ED-managed SSUs than in IMD-managed units.

The management of pneumonia in internal medicine

Pneumonia generates a high workload for internal medicine departments. Management of this disease is challenging, because patients are usually elderly and have multiple comorbid conditions. Furthermore, the interpretation and adherence to guidelines are far from clear in this setting. We report the opinion of 43 internists especially interested in infectious diseases that were questioned at the 2011 XXXII National Conference of Spanish Society of Internal Medicine about the main issues involved in the management of pneumonia in the internal medicine departments, namely, classification, admission criteria, microbiological workup, therapeutic management, discharge policy, and prevention of future episodes. Participants were asked to choose between 2 options for each statement by 4 investigators. Consensus could not be reached in many cases. The most controversial issues concerned recognition and management of healthcare-associated pneumonia (HCAP). Most participants were aware of the differences in terms of underlying diseases, etiological distribution, and outcome of HCAP compared with community-acquired pneumonia, but only a minority agreed to manage HCAP as hospital-acquired pneumonia, as suggested by some guidelines. A clinical patient-to-patient approach proved to be the option preferred by internists in the management of HCAP.