Medical deserts in Spain-Insights from an international project

INTRODUCTION

Medical deserts are a growing phenomenon across many European countries. They are usually defined as (i) rural areas, (ii) underserved areas or (iii) by applying a measure of distance/time to a facility or a combination of the three characteristics. The objective was to define medical deserts in Spain as well as map their driving factors and approaches to mitigate them.

METHODS

A mixed methods approach was applied following the project "A Roadmap out of medical deserts into supportive health workforce initiatives and policies" work plan. It included the following elements: (i) a scoping literature review; (ii) a questionnaire survey; (iii) national stakeholders' workshop; (iv) a descriptive case study on medical deserts in Spain.

RESULTS

Medical deserts in Spain exist in the form of mostly rural areas with limited access to health care. The main challenge in their identification and monitoring is local data availability. Diversity of both factors contributing to medical deserts and solutions applied to eliminate or mitigate them can be identified in Spain. They can be related to demand for or supply of health care services. More national data, analyses and/or initiatives seem to be focused on the health care supply dimension.

CONCLUSIONS

Addressing medical deserts in Spain requires a comprehensive and multidimensional approach. Effective policies are needed to address both the medical staff education and planning system, working conditions, as well as more intersectoral approach to the population health management.

Social Prescribing Schemes in Primary Care in Spain (EvalRA Project): a mixed-method study protocol to build an evaluation model

BACKGROUND

Social Prescribing is a Primary Health Care service that provides people with non-clinical care alternatives that may have an impact on their health. Social Prescribing can be more or less formal and structured. Social Prescribing Schemes are formal Social Prescribing of health assets by Primary Health Care teams in coordination and follow-up of patients with providers. The emerging evidence suggests that this service can improve people's health and well-being, create value and provide sustainability for the healthcare system. However, some evaluations note that the current evidence regarding social prescribing is insufficient and needs further investigation. The EvaLRA project aims to elaborate an evaluation model of Social Prescribing Schemes in Primary Health Care based on a set of structure, process, and outcomes indicators.

METHODS

In the region of Aragon, the Community Health Care Strategy aims to promote the development of social prescription schemes in Primary Health Care teams. This study is divided into two stages. Stage 1: identification of primary health care teams that implement social prescribing schemes and establish a first set of indicators to evaluate social prescribing using qualitative consensus techniques with experts. Stage 2 evaluation of the relevance, feasibility and sensitivity of selected indicators after 6 and 12 months in primary health care teams. The results will provide a set of indicators considering structure, process and outcomes for social prescribing schemes.

DISCUSSION

Current evaluations of the application of social prescribing schemes use different criteria and indicators. A set of agreed indicators and its piloting in primary health care teams will provide a tool to evaluate the implementation of social prescription schemes. In addition, the scorecard created could be of interest to other health systems in order to assess the service and improve its information system, deployment and safety.

Epidemiological study on gender bias and low-value practices in primary care: a study protocol

INTRODUCTION

Evidence shows that gender has a substantial impact on health behaviours, access to and use of health systems and health system responses. This study aims to assess gender bias in patients subjected to low-value practices in the primary care setting and to develop recommendations for reducing adverse events that women experience for this reason.

METHODS AND ANALYSIS

A Delphi study will be performed to reach a consensus on the 'Do Not Do' recommendations with a possible gender bias. A retrospective cohort study in a random selection of medical records will then be carried out to identify the frequency of adverse events that occur when the selected 'Do Not Do' recommendations are ignored. Qualitative research techniques (consensus conference and nominal group) will be carried out to develop recommendations to address any gender bias detected, considering barriers and facilitators in clinical practice.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of San Juan de Alicante Hospital (San Juan de Alicante, Spain) Reference N. 21/061. We will disseminate the research findings via peer-reviewed articles, presentations at national and international scientific forums and webinars.

TRIAL REGISTRATION NUMBER

The study was registered at ClinicalTrials.gov (NCT05233852) on 10 February 2022.

Gender analysis of Spanish National Questionnaire on behaviours and attitudes of doctors towards their own illness (CAMAPE)

INTRODUCTION AND OBJECTIVES

Physicians' health is a key element for quality healthcare. Medical professionals have difficulty accepting their role as patients and it might be different among sexes. The aim was to describe behaviours and attitudes of doctors towards their own illness.

MATERIALS AND METHODS

An online survey was launched through the General Council of Medical Associations webpage for all Spanish registered doctors. A bivariate analysis by sex was performed for all the questionnaire variables using parametric and non-parametric tests. The significance level was p<0.05 (95% confidence interval).

RESULTS

A total of 4,308 registered doctors (1,858 men and 2,450 women) answered. Women were younger, single, and worked mainly in non-surgical specialities in the public sector. Men were older, married, and worked more frequently in public-private practice. Women had less chronic conditions, except for anxiety disorders (11.52% vs 15.18%). Both sexes, especially women, primarily self-treated (94.29% vs 95.02%), went to work while ill (88.16% vs 90.29%), visited their GP (56% vs 70%), and half of them underwent annual occupational health checks (40% vs 48%). Women self-prescribed more analgesics (93.43% vs 95.63%), more presenteeism (88% vs 90%) and felt more insecure when treating sick fellows (9.96% vs 20.12%) and requested training for it. More women agreed to make deontological recommendations about doctors' health (91.55% vs 96.16%) and considered revalidation may contribute to improve doctors' health (65.29% vs 66.16%).

CONCLUSIONS

Male and female doctors show illness-health behaviours and attitudes at work to improve. There are differences among male and female doctors. Regarding, medical feminization, ethical recommendations may be of benefit regarding doctors' health-illness issues and considering gender perspective.

Behaviour and attitudes of Spanish physicians towards their own process of falling ill: Study protocol and validation of CAMAPE questionnaire

Physicians have not learned their role as patients. Health programmes for doctors are focused on mental health. Nevertheless, anomalous behaviours of ill doctors exist independently of health problems. We present a study to describe behaviour and attitudes of doctors towards their own illness (CAMAPE) including the analysis of questionnaire validation.

MATERIAL AND METHODS

A mix methodology study based on semi-structured interviews to ill physicians and focus groups with members of medical colleges, occupational medicine services and doctors of ill doctors was performed. A survey was designed. Survey validation process included content and face validity, construct validity through exploratory and confirmatory factor analysis and reliability by Cronbach's Alpha Index.

RESULTS

A total of 27 interviews to ill doctors and 4 focus group were performed. Content and feasibility assessment was made by experts. Psychometric validation was performed with a sample of 4308 answers (2450 women, 56.87%). A 5-factor (F) model explained 78.08% variance. First factor (F1) "The work might worsen health". Second (F2) "Mental issues, toxic habits and the impact of a bad health on work performance"; Third (F3) presenteeism and sick leaves; Fourth (F4) the handling of an ill colleague and the role of medical colleges. Fifth (F5) the healthcare pathway and potential value of revalidation in medical profession.

CONCLUSIONS

A comprehensive mixed study on the process of physicians becoming ill has been launched with a reliable questionnaire in a large sample of registered doctors. The analysis will help to formulate gender-sensitive policy and ethical recommendations in relation to sick doctors given the progressive feminisation of the medical profession.

[Diagnostic error and overdiagnosis in Primary Care. Proposals for the improvement of clinical practice family medicine]

Family doctors see a wide range of patients, with a wide range of complexity, in a short time and with few diagnostic resources. This situation makes primary care professionals more vulnerable to diagnostic errors. For this reason, an adequate clinical reasoning process is the most powerful tool family doctors have to safely guide the patient care process. Considering these errors as missed opportunities for a correct diagnosis, which may cause harm to the patient, leads us as professionals to review how to improve this process. The review includes, among other aspects, identifying cognitive biases, analysing the ways in which work is organised in primary care teams, and situations in the care context that may contribute to such errors. In this article we describe the most frequent diagnostic errors and their causal factors in primary care, the impact of cognitive process failures, situations of overdiagnosis and the diagnostic and therapeutic cascades associated with them. Finally, we propose a set of tools to improve decision-making in the diagnostic process in primary care.

Avoidable Adverse Events Related to Ignoring the Do-Not-Do Recommendations: A Retrospective Cohort Study Conducted in the Spanish Primary Care Setting

OBJECTIVE

This study aimed to measure the frequency and severity of avoidable adverse events (AAEs) related to ignoring do-not-do recommendations (DNDs) in primary care.

METHODS

A retrospective cohort study analyzing the frequency and severity of AAEs related to ignoring DNDs (7 from family medicine and 3 from pediatrics) was conducted in Spain. Data were randomly extracted from computerized electronic medical records by a total of 20 general practitioners and 5 pediatricians acting as reviewers; data between February 2018 and September 2019 were analyzed.

RESULTS

A total of 2557 records of adult and pediatric patients were reviewed. There were 1859 (72.7%) of 2557 (95% confidence interval [CI], 71.0%-74.4%) DNDs actions in 1307 patients (1507 were performed by general practitioners and 352 by pediatricians). Do-not-do recommendations were ignored more often in female patients (P < 0.0001). Sixty-nine AAEs were linked to ignoring DNDs (69/1307 [5.3%]; 95% CI, 4.1%-6.5%). Of those, 54 (5.1%) of 1062 were in adult patients (95% CI, 3.8%-6.4%) and 15 (6.1%) of 245 in pediatric patients (95% CI, 3.1%-9.1%). In adult patients, the majority of AAEs (51/901 [5.7%]; 95% CI, 4.2%-7.2%) occurred in patients 65 years or older. Most AAEs were characterized by temporary minor harm both in adult patients (28/54 [51.9%]; 95% CI, 38.5%-65.2%) and pediatric patients (15/15 [100%]).

CONCLUSIONS

These findings provide a new perspective about the consequences of low-value practices for the patients and the health care systems. Ignoring DNDs could place patients at risk, and their safety might be unnecessarily compromised.

TRIAL REGISTRATION NUMBER

NCT03482232.

Addressing Acute Stress among Professionals Caring for COVID-19 Patients: Lessons Learned during the First Outbreak in Spain (March-April 2020)

Objectives: To describe lessons learned during the first COVID-19 outbreak in developing urgent interventions to strengthen healthcare workers' capacity to cope with acute stress caused by health care pressure, concern about becoming infected, despair of witnessing patients' suffering, and critical decision-making requirements of the SARS-CoV-2 pandemic during the first outbreak in Spain. Methods: A task force integrated by healthcare professionals and academics was activated following the first observations of acute stress reactions starting to compromise the professionals' capacity for caring COVID-19 patients. Literature review and qualitative approach (consensus techniques) were applied. The target population included health professionals in primary care, hospitals, emergencies, and nursing homes. Interventions designed for addressing acute stress were agreed and disseminated. Findings: There are similarities in stressors to previous outbreaks, and the solutions devised then may work now. A set of issues, interventions to cope with, and their levels of evidence were defined. Issues and interventions were classified as: adequate communication initiative to strengthen work morale (avoiding information blackouts, uniformity of criteria, access to updated information, mentoring new professionals); resilience and recovery from physical and mental fatigue (briefings, protecting the family, regulated recovery time during the day, psychological first aid, humanizing care); reinforce leadership of intermediate commands (informative leadership, transparency, realism, and positive messages, the current state of emergency has not allowed for an empirical analysis of the effectiveness of proposed interventions. Sharing information to gauge expectations, listening to what professionals need, feeling protected from threats, organizational flexibility, encouraging teamwork, and leadership that promotes psychological safety have led to more positive responses. Attention to the needs of individuals must be combined with caring for the teams responsible for patient care. Conclusions: Although the COVID-19 pandemic has a more devastating effect than other recent outbreaks, there are common stressors and lessons learned in all of them that we must draw on to increase our capacity to respond to future healthcare crises.

[What regulations have launched autonomous communities to going forward on patient safety culture in healthcare organizations?]

INTRODUCTION

Patient Safety Culture is based on learning from incidents, developing preventive strategies to reduce the likelihood to happen and recognizing and accompanying those who have suffered unnecessary and involuntary harm derived from the health care received. To go ahead on patient safety culture entails facilitating the implementation of these behaviors and attitudes in healthcare professionals. Objective was to describe the regulations of some autonomous communities and national proposals for regulations changes.

MATERIAL AND METHODS

Search of normative changes made in the autonomous communities of Catalonia, Navarra and the Basque Country. Proposals for legislative changes at national level were agreed.

RESULTS

Activities and normative changes made in the autonomous communities of Catalonia, Navarre and the Basque Country are described and proposals for normative changes at the national level at short-term and long-term changes are made. In such a way that it is easier to advance in creating culture of patient safety in the whole National Health System CONCLUSION: Currently there is no global regulation that facilitates to advance in patient safety culture. Changes at the national legislation level are essential. It is at the Inter-territorial Council where the proposed legislative amendment should be defined, promoted by the representatives of the health systems of the autonomous communities.

[Adaptation of the Medical Office Survey on Patient Safety Culture (MOSPSC) tool]

OBJECTIVE

To adapt the Medical Office Survey on Patient Safety Culture (MOSPSC) Excel(®) tool for its use by Primary Care Teams of the Spanish National Public Health System.

METHODS

The process of translation and adaptation of MOSPSC from the Agency for Healthcare and Research in Quality (AHRQ) was performed in five steps: Original version translation, Conceptual equivalence evaluation, Acceptability and viability assessment, Content validity and Questionnaire test and response analysis, and psychometric properties assessment. After confirming MOSPSC as a valid, reliable, consistent and useful tool for assessing patient safety culture in our setting, an Excel(®) worksheet was translated and adapted in the same way. It was decided to develop a tool to analyze the "Spanish survey" and to keep it linked to the "Original version" tool. The "Spanish survey" comparison data are those obtained in a 2011 nationwide Spanish survey, while the "Original version" comparison data are those provided by the AHRQ in 2012.

RESULTS

The translated and adapted tool and the analysis of the results from a 2011 nationwide Spanish survey are available on the website of the Ministry of Health, Social Services and Equality. It allows the questions which are decisive in the different dimensions to be determined, and it provides a comparison of the results with graphical representation.

CONCLUSIONS

Translation and adaptation of this tool enables a patient safety culture in Primary Care in Spain to be more effectively applied.

Atenção Primária à Saúde na Espanha - entrevista com a médica de família e comunidade Maria Pilar Astier-Peña

Maria Pilar Astier-Peña é licenciada e doutora em Medicina e Cirurgia pela Universidad de Zaragoza, Espanha. Possui Mestrado em Saúde Pública e Administração Sanitária pela Universidad de Valencia e Mestrado em Economia da Saúde e Gestão Sanitária pelas Universidades Central de Barcelona e Pompeu Fabra. Atualmente Pilar é médica de família e comunidade e coordenadora médica do Centro de Saúde de Caspe (Zaragoza) do Serviço Aragonês de Saúde e realiza, também, pesquisa sobre sistemas de informação e projetos de melhoria da qualidade assistencial no âmbito hospitalar. Em agosto deste ano, esteve no Brasil, ocasião em que visitou Clínicas da Família no Rio de Janeiro e ministrou oficinas para os residentes e preceptores do Programa de Residência em Medicina de Família e Comunidade da Secretaria Municipal de Saúde do Rio de Janeiro. RBMFC: Qual é a situação atual da atenção primária na Espanha e qual é o papel do médico de família e comunidade?Pilar Astier: O sistema nacional de saúde na Espanha está atualmente organizado em 17 serviços regionais de saúde, que, em seu conjunto, possuem 3.600 centros de saúde e 10.116 consultórios locais em pequenos vilarejos, onde os profissionais de saúde trabalham para dar conta de uma população de 47.213.000 habitantes.Em cada centro de saúde trabalha uma equipe de atenção primária composta por médicos de família e comunidade, pediatras, profissionais de enfermagem, uma enfermeira obstetra e, em algumas equipes, também um odontólogo. Essa equipe conta com o apoio de profissionais administrativos. Cada equipe é responsável por uma população específica chamada de “zona básica de saúde”, e cada médico de família e comunidade tem sob sua responsabilidade entre 1500 e 2000 habitantes.Cada zona básica tem um hospital de referência com serviço de emergência, internação e atenção especializada ambulatorial, para que os médicos de família e comunidade possam encaminhar os pacientes para avaliação especializada.Os médicos do centro de saúde oferecem consultas médicas em função da demanda do paciente, bem como consultas programadas com o objetivo de fazer um acompanhamento dos processos crônicos. Eles realizam visitas domiciliares para pacientes com dificuldades de se deslocar à unidade de saúde, tanto de forma programada como por solicitação do próprio paciente.Os médicos têm o apoio de profissionais de enfermagem para as atividades de promoção da saúde, acompanhamento de pacientes crônicos e de pacientes em cuidados domiciliares, bem como para a coleta de sangue, dispensação de medicamentos e realização de curativos.Cada serviço regional de saúde oferece às suas equipes de atenção primária um prontuário eletrônico comum para toda a região, um sistema de prescrição eletrônica e conexão com o sistema de informação da atenção especializada, que permite ter acesso aos exames radiológicos e aos resultados de exames laboratoriais do hospital de referência, e, em algumas regiões, também aos registros clínicos hospitalares.A maioria dos profissionais de saúde das equipes de atenção primária é assalariada e pertence ao serviço regional de saúde. Os centros de saúde empregam mais de 35.000 médicos (29.000 médicos de família e comunidade e 6.000 pediatras), dos quais 50% aproximadamente são mulheres. Quanto aos profissionais de enfermagem, cerca de 29.000 (8 de cada 10) são mulheres. A razão de médicos de família e comunidade por cada 10.000 habitantes é de 7,6 e, de enfermeiros, 6,3.Nos centros de saúde rurais, os médicos realizam a atenção continuada de 24 horas, para que a população sempre tenha acesso a um médico de família e comunidade de forma programada ou urgente.RBMFC: Quais são os principais problemas que a atenção primária atravessa neste momento?Pilar Astier: Em primeiro lugar, o perfil de nossos pacientes. Com o envelhecimento populacional – 17,4% da população tem idade superior a 65 anos –, os pacientes passaram a apresentar mais comorbidades e, assim, maior uso de polifarmácia. O médico de família e comunidade, portanto, deve estar capacitado para detectar interações medicamentosas, manejar fármacos com janela terapêutica estreita (p.ex., digoxina, anticoagulantes, antiepilépticos e opioides) e para buscar reduzir o risco de eventos adversos relacionados a medicamentos (47% dos eventos adversos na atenção primária da Espanha são relacionados a medicamentos).Por outro lado, com o aumento da prevalência de doenças crônicas, como diabetes, hipertensão, obesidade e artrose, aumentou a carga de cuidados que essa população requer, tornando necessário buscar novas formas de cuidados e empoderar os pacientes para que eles possam conduzir sua própria doença por meio de “programas de pacientes especialistas”.Outra dificuldade é a limitação de acesso aos dados do prontuário eletrônico entre as comunidades autônomas. Os pacientes que se deslocam para outras regiões não têm à sua disposição um conjunto mínimo de informações sobre sua saúde. O paciente deve levar ele mesmo seus relatórios médicos. O mesmo ocorre com a prescrição eletrônica, que somente pode ser usada na região do paciente e não é compartilhada com as outras regiões.Quanto aos profissionais, a situação econômica atual está gerando importantes cortes nos orçamentos da saúde. Na atenção primária, isso afeta diretamente os profissionais, que tiveram a sua carga horária semanal aumentada e os salários diminuídos. Houve também diminuição da contratação de profissionais substitutos para períodos de férias, congressos, etc., e dos investimentos em equipamentos.RBMFC: Na sua recente visita ao Brasil, o que mais lhe chamou a atenção no sistema de saúde brasileiro e, principalmente, no processo de transformação da APS que está sendo implementado no Rio de Janeiro?Pilar Astier: A oportunidade de compartilhar alguns dias com vocês me permitiu conhecer como funcionam as equipes de atenção primária, como se formam os residentes de medicina de família e comunidade e como está sendo planejada a implantação das novas equipes.Dois elementos que me parecem fundamentais são o planejamento do processo e o uso de indicadores para avaliar os resultados sobre a saúde da população, permitindo valorizar adequadamente o trabalho das equipes de atenção primária.Em todos os centros que visitei, constatei a responsabilidade, o profissionalismo e a empolgação de todas as pessoas das equipes que tive o prazer de conhecer.O trabalho docente que está sendo feito pelos preceptores e pela coordenação da unidade docente é crucial para ter uma rede de profissionais médicos qualificados e para apoiar o desenvolvimento de uma atenção primária de qualidade.RBMFC: No Brasil, alguns anos atrás, um debate frequente era se os programas de residência deveriam estar vinculados às universidades. Na Espanha, os programas de residência estão vinculados às universidades?Pilar Astier: Na Espanha, os programas de residência médica não dependem das universidades. O sistema de formação médica especializada, também conhecido como MIR (médico interno residente), é coordenado pelo Ministério da Saúde, que anualmente lança o edital para um exame único de seleção para toda a Espanha e realiza a oferta de vagas nos diferentes hospitais do sistema público de saúde para cada especialidade. Esse sistema começou em 1978.Um conselho nacional de especialistas em ciências da saúde e um comitê específico de cada especialidade são encarregados de elaborar o programa de formação e de certificar as unidades docentes hospitalares e de atenção primária onde se desenvolve a formação. Essas unidades são avaliadas periodicamente para garantir o correto cumprimento do programa.RBMFC: É obrigatório ter o título de especialista para poder trabalhar no sistema público na Espanha?Pilar Astier: O programa MIR é obrigatório atualmente para poder exercer a medicina na Espanha e em qualquer outro país da União Europeia (Portaria 2005/36/CE).RBMFC: Como está a situação da pesquisa na atenção primária? Como é a relação da universidade com o sistema de saúde?Pilar Astier: A situação da pesquisa na atenção primária está melhorando, graças à criação dos institutos de pesquisa dos serviços regionais de saúde. Esses institutos públicos facilitam os trabalhos burocráticos dos pesquisadores com as entidades de financiamento como, por exemplo, em relação às bolsas oferecidas pelas comunidades autônomas, pelo Ministério da Saúde, pelo Conselho da Europa e pela indústria farmacêutica. A tomada de decisão sobre a concessão de bolsas de pesquisa envolve um processo longo e complexo de documentação, como também o posterior gerenciamento dos recursos concedidos, e esses institutos de pesquisa regionais têm facilitado o trabalho dos pesquisadores.De fato, já foram iniciados ensaios clínicos sobre medicamentos na atenção primária, e estamos conseguindo projetos de pesquisa colaborativa com outros países europeus.Também as sociedades científicas de médicos de atenção primária estão apoiando o desenvolvimento de linhas de pesquisa em doenças crônicas, como hipertensão, diabetes, dor crônica, entre outras.Alguns profissionais médicos estabeleceram vínculos formais com as faculdades de Medicina, tornando-se professores associados. Esses professores associados ministram as aulas teóricas nas faculdades e as práticas em seus próprios consultórios, geralmente situados nos serviços regionais de saúde. Na maior parte das faculdades não existe departamento de medicina de família e comunidade. Os médicos de família e comunidade que colaboram como professores associados integram-se em outros departamentos. É por isso que os médicos de família e comunidade não costumam desenvolver projetos de pesquisa em atenção primária vinculados às faculdades.Existem 21 faculdades de medicina públicas e 7 privadas.RBMFC: No Brasil existe uma importante falta de médicos de família e comunidade. Como é a situação na Espanha? Existem médicos de família e comunidade suficientes para dar conta de toda a população?Pilar Astier: Atualmente a Espanha tem um superávit de médicos de família e comunidade. Isso faz com que, em muitas ocasiões, a oferta de vagas melhor pagas e com boas condições de trabalho seja escassa, porque existem muitos profissionais que querem essas vagas.De fato, muitos médicos de família e comunidade estão migrando para a Inglaterra, França, Suécia, Noruega e Alemanha em busca de emprego. Nesses países eles são muito benquistos em função do seu alto nível de qualificação.RBMFC: Qual é a cobertura da atenção primária na Espanha?Pilar Astier: Na Espanha praticamente 99% da população tem cobertura pelo Sistema Nacional de Saúde.Os serviços públicos oferecidos pelas equipes de atenção primária no Sistema Nacional de Saúde espanhol incluem atividades preventivas, diagnósticas, terapêuticas e de reabilitação, bem como de promoção da saúde. A carteira básica de serviços está regulamentada pela Lei 16/2003, que trata sobre a integração e a qualidade do Sistema Nacional de Saúde, e pela Portaria 1030/2006, que estabelece o elenco comum da carteira de serviços e os procedimentos para sua atualização.A “Reforma Sanitária sobre Medidas Urgentes para Garantir a Sustentabilidade do Sistema Nacional de Saúde e Melhorar a Qualidade e a Segurança de seus Serviços” (Real Decreto 16/2012, de 20 abril de 2012) modificou a carteira de serviços. Esse decreto criou uma carteira básica de serviços à qual cada comunidade autônoma poderá acrescentar os serviços que achar pertinentes. Ele restringiu a cobertura de serviços aos cidadãos que tenham contribuído com a Previdência Social e aos seus familiares beneficiários. Os que não contribuíram devem assinar um seguro público mediante pagamento mensal.A atenção às situações de urgência, tanto na atenção primária quanto nos hospitais, é garantida para todas as pessoas.Quando são prescritos fármacos pelo médico de família e comunidade, o paciente tem uma participação no custeio, que é proporcional ao seu nível de renda mensal. As pessoas com rendas muito baixas ficam isentas desse co-pagamento.Texto editado por Michael Schmidt Duncan a partir de entrevista concedida por email por Pilar Astier, com perguntas elaboradas por Lourdes Luzon Oliver e Inaiara Bragante, em parceria entre o Programa de Residência de Medicina de Família e Comunidade da Secretaria Municipal de Saúde do Rio de Janeiro, a Rede de Pesquisa em Atenção Primária da ABRASCO e a Revista Brasileira de Medicina de Família e Comunidade.Tradução: Jacob Pierce

[26th Conference of the Spanish Society of Quality in Healthcare: a good balance between quality, innovation, science and participation]

The experience and learning process of preparing a scientific conference programme, organising and conducting a conference ccompletes the quality circle with the quantitative and qualitative assessment of the process and results. The transmission of this experience and learning process through this paper will improve the performance of committees of future conference venues, partners and participants and collaborators. The method for performing this evaluation is the assessment of the activities of both the scientific and organising committees of the XXVI Conference of the Spanish Society of Quality Healthcare in October 2008 in Zaragoza. The methodology evaluated the observance of the timetable and tasks assigned to the committees in the Congress Manual of the society along with the presentation of final results of the congress concerning scientific participation and overall satisfaction. There were a total of 1211 communications with a rejection rate of 9.1%. Of the total, 577 communications were presented in oral format and 544 in poster format. Aragon was the community of origin of 24% of communications. By subject areas, those of most interest were patient safety, organisational and management processes, and patient perspectives. A total of 83 participants attended 7 of the 11 workshops offered. The average attendance for each workshop was 12 people. The response rate to the assessment of workshops questionnaire was 54.2% with an average score of 4 (scale of 1 to 5). A total of 1131 people attended the conference of which 17% (193) were SECA associates. Out of a total of 1075 overall satisfaction conference questionnaires distributed there was a response rate of 9.30% (100). The scientific content was assessed with an average score of 3.6 and the organization with 3.87, both on a total score of 5 points. According to the number of abstracts received, number of conferences, level of satisfaction with the scientific program and organisation, we can conclude that the XXVI Conference of the Society has been a success, although we are still in our continuous quality improvement circle that will make conferences even better.