Catalan Healthcare System Research Articles

A plan to transform primary and community care at Catalonia based on a process improvement methodology

Abstract Aim: This article outlines the implementation and deployment strategy defined by the Catalan healthcare system which sought to promote a plan to strengthen and transform primary care in order to provide high-quality healthcare services whilst making an optimal use of resources across the Catalan region. Background: Following the COVID-19 pandemic, the Catalan healthcare system initiated a plan to enhance primary care services. The Lean methodology has been used extensively in other sectors for process improvement. More recently, it has been adopted in large hospitals, showing good results, so Lean was selected as the most appropriate method to achieve this project’s goal. The Process Office of the Catalan Health System, which is made up of experts in Lean methodology, has been involved in defining and deploying the strategy to all 374 Primary Care Teams (PCTs) within the Catalan healthcare system. Methods: The deployment strategy was executed in four phases (each consisting of a number of sessions): (1) explaining the project’s goals and training the professionals in the methodology; (2) assessing the current status regarding the processes with the various PCTs; (3) identifying and implementing improvement projects; and (4) defining key performance indicators to monitor the impact of the projects. Findings: As a conclusion, this project has allowed to successfully define and implement a standard at a strategic and deployment level of a project for primary care improvement that may be replicated in other regions. The key elements to ensure success have been the following: leadership, implementation of an improvement methodology, standardization of sessions, and involvement and training of front-line professionals.

Mortality in Catalonia during the summer of 2022 and its relation with high temperatures and COVID-19 cases.

To analyse the association between the mortality during the summer 2022 and either high temperatures or the COVID-19 wave with data from the Catalan Health Care System (7.8 million people). We performed a retrospective study using publicly available data of meteorological variables, influenza-like illness (ILI) cases (including COVID-19) and deaths. The study comprises the summer months of the years 2021 and 2022. To compare the curves of mortality, ILI and temperature we calculated the z-score of each series. We assessed the observed lag between curves using the cross-correlation function. Finally, we calculated the correlation between the z-scores using the Pearson correlation coefficient (R2). During the study period, 33,967 deaths were reported in Catalonia (16,416 in the summer of 2021 and 17,551 in the summer of 2022). In 2022, the observed lag and the correlation between the z-scores of temperature and all-cause deaths was 3 days and R2 = 0.86, while between ILI and all-cause deaths was 22 days and R2 = 0.21. This high correlation between temperature and deaths increased up to 0.91 when we excluded those deaths reported as COVID-19 deaths, while the correlation between ILI and non-COVID-19 deaths decreased to -0.19. No correlation was observed between non-COVID deaths and temperature or ILI cases in 2021. Our study suggests that the main cause of the increase in deaths during summer 2022 in Catalonia was the high temperatures and its duration. The contribution of the COVID-19 seems to be limited.

Transmissibility, hospitalization, and intensive care admissions due to omicron compared to delta variants of SARS-CoV-2 in Catalonia: A cohort study and ecological analysis.

PurposeWe aim to compare the severity of infections between omicron and delta variants in 609,352 SARS-CoV-2 positive cases using local hospitalization, vaccination, and variants data from the Catalan Health Care System (which covers around 7. 8 million people).MethodsWe performed a substitution model to establish the increase in transmissibility of omicron using variant screening data from primary care practices (PCP) and hospital admissions. In addition, we used this data from PCP to establish the two periods when delta and omicron were, respectively, dominant (above 95% of cases). After that, we performed a population-based cohort analysis to calculate the rates of hospital and intensive care unit (ICU) admissions for both periods and to estimate reduction in severity. Rate ratios (RR) and 95% confidence intervals (95% CI) were calculated and stratified by age and vaccination status. In a second analysis, the differential substitution model in primary care vs. hospitals allowed us to obtain a population-level average change in severity.ResultsWe have included 48,874 cases during the delta period and 560,658 during the omicron period. During the delta period, on average, 3.8% of the detected cases required hospitalization for COVID-19. This percentage dropped to 0.9% with omicron [RR of 0.46 (95% CI: 0.43 to 0.49)]. For ICU admissions, it dropped from 0.8 to 0.1% [RR 0.25 (95% CI: 0.21 to 0.28)]. The proportion of cases hospitalized or admitted to ICU was lower in the vaccinated groups, independently of the variant. Omicron was associated with a reduction in risk of admission to hospital and ICU in all age and vaccination status strata. The differential substitution models showed an average RR between 0.19 and 0.50.ConclusionBoth independent methods consistently show an important decrease in severity for omicron relative to delta. The systematic reduction happens regardless of age. The severity is also reduced for non-vaccinated and vaccinated groups, but it remains always higher in the non-vaccinated population. This suggests an overall reduction in severity, which could be intrinsic to the omicron variant. The fact is that the RR in ICU admission is systematically smaller than in hospitalization points in the same direction.

Innovation and entrepreneurship in Catalan private laboratories: origins and rise of Grifols Lab (1880-1955)

Studying the evolution of private medical clinics is extremely useful in understanding the history of the Catalan healthcare system where, from the 19th century onwards, a Marshallian atmosphere of flows of knowledge, people and technology has resulted in close connections between the public and private practice of modern medicine. The history of the Grifols Laboratories, from 1880 to the 1950s, is a relevant case study in this context, as it highlights patterns that were repeated in other medical laboratories in Catalonia a century ago. But Grifols is also particularly interesting both because of its survival and evolution to this day, and for its curation of its own historical archive.This article aims to understand how a small laboratory in the healthcare district of Barcelona built its scientific foundations on laboratory medicine during the early 20th century, and finally changed its business strategy because of the Spanish Civil War, becoming a family pharmaceutical company. The sources are documents from the Grifols archive and interviews with managers at the company. The findings highlight the importance of interdisciplinary analysis, suggesting that both scientific and business adaptations by successive generations are equally important in explaining the success of Grifols Laboratories. Science-based family firms that endure over time not only acquire specialised knowledge to compete in the market, but also knowledge about transferring entrepreneurship in the long term. In Grifols case, knowledge from younger generations was crucial to adapting their activity, first to a changing scientific paradigm and then to a precarious national market.

The Catalonia Suicide Risk Code: A secondary prevention program for individuals at risk of suicide

BackgroundSuicide prevention is an emerging priority for public health systems. Here, we present the Catalonia Suicide Risk Code (CSRC), a secondary suicide prevention program that provides a systematic approach to follow-up care for patients at risk. We describe the care pathway of the CSRC and characteristics of the patients enrolled in the program. MethodsObservational study based on data extracted from the Catalan health care system between the years 2014 and 2019. The following patient-related data were obtained: sociodemographic and clinical characteristics, characteristics of suicidal behaviour, and pathway of care. ResultsA total of 12,596 individuals (64.1% women) were screened for suicide risk and 8,403 (66.7%) were subsequently enrolled in the CSRC. Adherence data show that most patients (81.9%) attended a face-to-face appointment and most (67.1%) were successfully contacted by telephone afterwards. Most face-to-face appointments were performed within 10 days of enrolment for adults and 72 h for minors. Psychiatric disorders were significant risk factors for both men and women. Females were significantly more likely to report stressful life events, while males were more likely to report social problems. Compared to men, women were more likely to use poisoning. LimitationsAdherence to the CSRC care pathway might reflect obstacles to its implementation. Due to the observational study design, it is not possible to determine the effectiveness of the CSRC to reduce suicide re-attempts. ConclusionsAlthough the CSRC successfully provided follow-up care for many individuals at high risk of suicide, greater adherence to the CSRC care pathway is needed.

1628O - Consistency of ESMO-MCBS scores with drug access recommendations in Catalonia

BackgroundThe Catalan Healthcare System (CatSalut) runs a specific program for drug evaluation (PHF) aimed to guarantee equity in the access to innovative medications. PHF recommendations determine the degree of priority and mechanism for drug invoicing: clinical criteria with direct invoicing; individualised criteria requiring approval by an ad-hoc committee, and exceptional use with no budget allocation. In 2017, the program incorporated an EVIDEM based matrix for Multiple Criteria Decision Analysis a standard procedure. In 2018, the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) was included in the matrix for oncological drugs. This study retrospectively checked the consistency of recommendations issued by the PHF for oncological drugs with the ESMO-MCBS score. MethodsThe recommendations of the PHF between 2011 and 2018 for oncological drugs were retrieved from reports and meeting minutes. Pivotal studies were scored using ESMO-MCBS version 1.1 for each drug. Matchings and discrepancies were summarised, and the debate reflected in the minutes of the committees was retrieved. ResultsThroughout the period 2011 to 2018 a total of 47 decisions were made on 57 oncology drugs evaluated. All PHF recommendations for drugs with ESMO-MCBS scores ≥ 4 were positive. Discrepancies were seen for 2 drugs in the curative setting (A score and exceptional use), 8 drugs in the non-curative (1-2 score and clinical criteria) and 1 in the curative setting (C and clinical criteria). The main criteria supporting the PHF decisions for these products are summarised in the table. Table: 1628OTable: 1628OCurativeTrial qualityMifamurtideSafety concernsIpilimumabManaged agreementPembrolizumabNon curativeConsolidated useBevacizumab AfliberceptSubgroupsNintedanib EribulineManaged agreementEverolimus CabazitaxelNoneTrastuzumab Abiraterone ConclusionsFactors explaining discrepancies between PHF recommendations and ESMO-MCBS were mostly related to the context of the appraisal. ESMO-MCBS standardises efficacy but does not consider quality of trials, added value to other drugs or other factors. It may not be a single formula to reach decisions, but may be useful to ensure that the size of effect is systematically approached in appraisals, and to complement a multiple criteria based system. Legal entity responsible for the studyCatSalut. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Hospitalizations due to exacerbations of COPD: A big data perspective.

Patients with Chronic Obstructive Pulmonary Disease (COPD) may suffer episodes of exacerbation (ECOPD) that require hospitalization and worsen their health status, and prognosis. We hypothesized that a detailed interrogation of health-care "big data" databases can provide valuable information to better understand the risk factors and outcomes of these episodes. We interrogated four databases of the Catalan health-care system (>8,000,000 registries) to identify patients hospitalized because of ECOPD for the first time (index event) between 2010 and 2012. Analysis was carried forward since the index event until the end of 2014 or the death of the patient. The two years that preceded the index event were also investigated. We identified 17,555 patients, (≥50 years of age) hospitalized because of ECOPD (ICD9 v.9 codes at discharge) for the first time between 2010 and 2012. In this population we observed that: (1) 23% of patients die within a year after being discharged from their first ECOPD hospitalization; (2) in the remaining patients, all-cause mortality was related to the number of re-hospitalizations, particularly with early (<30 days) readmissions; (3) despite this being a 'respiratory' cohort, prescription and dispensation of drugs for cardiovascular diseases was higher than for obstructive airway diseases; and, finally, (4) lower winter ambient temperatures are associated with hospital admissions for ECOPD particularly in early re-admitters. Overall these results indicate under appreciation of the burden of COPD in patients hospitalized for the first time because ECOPD.

Development and assessment of an active strategy for the implementation of a collaborative care approach for depression in primary care (the INDI\xb7i project)

BackgroundPrimary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice.MethodsObjective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care.Design: A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system.Participants: The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia).Intervention: The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework.Measures: Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact.DiscussionThis project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society.Trial registrationClinicalTrials.gov identifier: NCT03285659; Registered 12th September, 2017.

The “Results Centre” of the Catalan healthcare system: A tool for integrated care

Introduction: Improving the quality and transparency of the healthcare government has an impact on the health of the population through policies, management of organizations, and clinical practice. Moreover, the comparison between healthcare centres or territories on a population basis, and the transparent and open feedback of results to policy makers, managers, professionals and citizens contributes directly to improve results. Description of policy context and objective: The Results Centre of the Catalan healthcare system measures and disseminates the results achieved by the different healthcare centres in order to facilitate a co-responsible decision making process, to improve the quality of healthcare provided to the population of Catalonia. It favours the benchmarking between defined geographical local areas and healthcare centres and share best practices in a transparent way. As a result of the development of a chronic care and an integrated health and social care strategy in Catalonia, there is an increasing need to introduce a population based shared outcome framework with objectives and indicators which could act as drivers for integration with an increasing “triple aim” orientation Targeted population: For citizens, the Results Center promotes a wider and better understanding of the field of health, and allows them to interact with the healthcare system and participate in decisions that affect their health. For healthcare centres, it allows them to compare the results achieved, identify and share best practices, and look for opportunities for improvement and cooperation between institutions. For the health administration, the Results Centre respond to the demand for transparency in health policy decisions, as well as for accountability in the use of resources. Highlights: Since 2012, an annual report has been produced for hospitals, primary care, long-term care, mental healthcare, public health activities, and territory with population based indicators. For each topic, around 60 quality indicators are measured, identifying the provider and the territory. Some of the indicators are especially relevant for integrated care such as prevalence of people with complex healthcare needs or in advanced chronic disease condition, rate of avoidable emergency admissions related to a range of selected chronic conditions, readmission rates related to selected chronic conditions, and others. The experiences of centres with better results, and the opinion of experts are incorporated, and a version for citizens is published. The “territory report” offers a picture of population-based health, and a tool to monitor changes due to integrated care policies. All detailed results are available in tables, together with technical definitions (http://observatorisalut.gencat.cat), and in open data format. Comments on transferability: This project is possible due to the high level of development of health information systems in Catalonia, and to the maturity and compromise of the healthcare sector. The Chronic care Program and Integrated Health and Social care Plan is working in partnership with the Results Centre to continuously improve the project, incorporating new indicators significant for the evaluation of integrated care (i.e. “high needs, high cost”-) and spread this vision of integrated care with a population based orientation. Conclusions: Engaging healthcare professionals is essential to move towards better clinical practice by identifying and sharing best practices. These reports are used among managers and clinical and other professional leaders as a tool for benchmarking, and among commissioners to facilitate better understanding of the territorial performance. This is a pioneering initiative in Spain, and is aligned with the most advanced countries in terms of policies of transparency and accountability.

Doctors’ opinions on clinical coordination between primary and secondary care in the Catalan healthcare system

ObjectiveTo analyse doctors’ opinions on clinical coordination between primary and secondary care in different healthcare networks and on the factors influencing it. MethodsA qualitative descriptive-interpretative study was conducted, based on semi-structured interviews. A two-stage theoretical sample was designed: 1) healthcare networks with different management models; 2) primary care and secondary care doctors in each network. Final sample size (n = 50) was reached by saturation. A thematic content analysis was conducted. ResultsIn all networks doctors perceived that primary and secondary care given to patients was coordinated in terms of information transfer, consistency and accessibility to SC following a referral. However, some problems emerged, related to difficulties in acceding non-urgent secondary care changes in prescriptions and the inadequacy of some referrals across care levels. Doctors identified the following factors: 1) organizational influencing factors: coordination is facilitated by mechanisms that facilitate information transfer, communication, rapid access and physical proximity that fosters positive attitudes towards collaboration; coordination is hindered by the insufficient time to use mechanisms, unshared incentives in prescription and, in two networks, the change in the organizational model; 2) professional factors: clinical skills and attitudes towards coordination. ConclusionsAlthough doctors perceive that primary and secondary care is coordinated, they also highlighted problems. Identified factors offer valuable insights on where to direct organizational efforts to improve coordination.

Execution of Preventive Healthcare and Health Promotion Activities in the Paediatric Age Group Led by Primary Care Nurses

Introduction: The constant pursuit of improvement in the quality of healthcare received by citizens is palpable throughout the Catalan healthcare system. In this context, professional roles must be redefined, fostering the redistribution of skills and optimising the autonomy of every practitioner. Therefore, in response to the request put forward by many bodies that are part of the Catalan Healthcare and Social Services Consortium (CSC), in June 2013, we organised a seminar focussed on advanced nursing skills, in which different experiences undertaken in Catalonia were presented and in which advanced skills were already tangible.Main Objective: In order to lend continuity to this seminar, it was agreed to put together a series of documents outlining recommendations to help all those bodies that considered implementing one of the experiences presented. Preventive healthcare and health promotion activities in the paediatric age group in primary care, led by nursing practitioners, were unanimously chosen as one of the first skills to be nurtured and developed.Description: This document was drawn up by a working group comprising experts with different health professional roles (paediatricians, paediatric nurses, community nurses, centre directors, etc.), in the field of primary care throughout Catalonia.The key points for implementing nurse-led preventive healthcare and health promotion activities are as follows:1) It must be a consensus decision reached by management and the professionals involved;2) Implementation may be commenced by the more motivated and expert professionals;3) The ultimate goal is to apply the initiative across the whole centre;4) There must be a high level of mutual trust between paediatricians and nurses;5) Dynamic teams of paediatricians-nurses must be created;6) The initiative must be coordinated and managed by professionals who believe in the model;7) Spaces must be accessible between the nurse’s consulting room and that of the paediatrician;8) Nurses must be trained and experienced in this field;9) Various duly trained nurses are required;10) Protocols for action must be agreed upon;11) Information systems must be shared between the paediatrician and the nurse;12) The family must be informed about the model.Discussion: In practice, it is a model that promotes nurse autonomy in paediatrics and families’ accessibility to healthcare, making the nurse a reference point for these families. This system helps create a climate of trust and closer relations for all those involved. It also allows paediatricians to dedicate more time to the pathologies that most need it, freeing up agendas.As suggestions for improvement in the present day, impetus must be given to training nurses both internally and externally, as well as to increasing the number of trained nurses to lead the child healthcare programme.Conclusions: This model seeks to foster the skills of paediatricians and nurses, supporting nursing leadership and the provision of more appropriate care by paediatricians to care for children in need of it on account of their pathology, fostering preventive healthcare and the promotion of health coupled with family empowerment and better resource distribution.

What are factors influencing coordination and continuity across care levels in the Catalan national health care system?

Introduction: The identification of factors influencing care coordination can offer valuable insights to healthcare managers and professionals on where to direct their efforts to improve health care service towards the provision of a smooth patient trajectory. Nevertheless, literature that comprehensively analyse influencing factors from the physician’s and patient’s perspective is scarce. Care coordination is the harmonious connection of the different services needed to provide care to a patient throughout the care continuum in order to achieve a common objective without producing conflicts. Continuity of care, in turn, is how patients experience care coordination. The objective is to explore factors influencing care coordination and continuity across care levels in different areas of the Catalan healthcare system (Spain) from the physician’s and patients’ perspective.Methods: Descriptive-interpretative qualitative study. A three-stage theoretical sample was selected: (i) study contexts: healthcare areas in Catalonia with different services management models (selecting Baix Empordà, Girona and Ciutat Vella in Barcelona); (ii) GP and specialists (including different specialities providing outpatient, inpatient and emergency care) having been employed in the study areas for at least 1.5 years; (iii) users ≥ 18 years of age who were attended to at both care levels for the same condition. Data were collected by means of individual semi-structured interviews with GPs (26), specialists (24) and patients (49). Interviews were recorded and transcribed. Data were segmented by informant and study area. A thematic content analysis was carried out with a mixed generation of categories and triangulation of analysts.Results: Physicians and patients of all study areas generally perceive the existence of coordination and continuity across care levels, especially referring to information transfer and consistency of treatments and tests. Only a few deficiencies in all the areas were perceived. Its (non-)existence was explained by a variety of influencing factors, of which only some related to organizations varied across the areas. 1) System-related factors: Physicians identified the rapid diagnostic circuit and the integrated electronic prescription system to be system-developed mechanisms that promoted timely access to secondary care and consistency across levels in treatment, respectively. However, lack of shared criteria and incentives for prescriptions emerged as barriers favouring frequent changes in treatments. In the patients’ discourse emerged the ‘clear distribution of roles’ between physicians, which was considered to favour consistency of care and accessibility across levels. 2) Organization-related factors: Different care coordination mechanisms were identified. The shared medical record system was identified by physicians and patients to be the main facilitator of information transfer. Physicians and to a lesser degree patients also identified mechanisms for informal communication (telephone and e-mail) and the expert system (joint meetings to discuss clinical cases in Girona and Baix Empordà, and e-consultations Baix Empordà and Ciutat Vella) which was used for rapidly solving doubts and facilitating access to secondary care. Physicians further mentioned the proximity of professionals (co-location in Ciutat Vella, small organization size in Baix Empordà and proximity in Girona and Baix Empordà) to promote mutual knowledge, which favours direct communication. Moreover, lack of time and insufficient resources were reported by both groups to be main barriers to achieve care coordination/continuity, leading to the insufficient use of mechanisms and an increase in waiting times to secondary care. Finally, GPs in Ciutat Vella and Girona reported that the change in the organization model, which perceived aim was to reduce secondary care activities, has resulted, in some cases, in a lack of provision of necessary secondary care. 3) Physician-related factors: Some specialists identified the limited training of GPs as a factor hindering adequate referrals to secondary care. On the contrary, patients highlighted that the GPs’ technical competence favoured referrals to the right care level when necessary. The attitude to collaborate and commitment to patient care, the latter only mentioned by patients, further emerged as enabling factors of consistency of care in all areas.Discussion: Physicians and patients linked (dis)continuity to certain factors related to the system, organization and physicians. Some factors were identified commonly by both informant groups, such as a variety of coordination mechanisms, insufficient available resources, and the physician’s attitude towards collaboration. Other factors were specific to the information group: whilst physicians referred to a greater variety of coordination mechanisms and factors promoting personal proximity, patients identified the clear distribution of roles and the commitment to the patient care.Conclusion: Physicians and users identify various factors that influence coordination and continuity across care levels which could be addressed when aiming to achieve integrated care delivery.

La transparencia en la toma de decisiones de salud pública

Improving the quality and transparency of governmental healthcare decision-making has an impact on the health of the population through policies, organisational management and clinical practice. Moreover, the comparison between healthcare centres and the transparent feedback of results to professionals and to the wider public contribute directly to improved results. The “Results Centre” of the Catalan healthcare system measures and disseminates the results achieved by the different healthcare centres in order to facilitate a shared decision-making process, thereby enhancing the quality of healthcare provided to the population of Catalonia (Spain). This is a pioneering initiative in Spain and is aligned with the most advanced countries in terms of policies of transparency and accountability.

El Consejo Consultivo de Pacientes de Cataluña: la voz directa del paciente en las políticas de salud en Cataluña

The transition from a more paternalistic model of care focused on the disease and on the medical professional's authority towards a more participatory model cantered on the rights and duties of informed patients represents a significant change in public health policy. One of the most widespread methods of social participation in Catalonia today is the tendency to form associations around a particular disease. This kind of organizational participation is a pioneering tool in the debate around public health policy. The Government of the Generalitat de Catalunya undertook to promote the Strategic Plan of patient participation within the public health system. The Department of Health created the Patient Advisory Council of Catalonia (CCPC, as per the acronym in Catalan). This initiative constitutes a permanent consultative and participatory body for patient representatives in the Catalan healthcare system. The CCPC was set up with a solid determination to place the patient at the centre of the healthcare system, including them in the decision-making processes which directly affect them. This patient participation plan has defined and developed 8 different lines approved by the government, with consensus approval between regional government and the organisations. The CCPC has proven itself to be an effective tool for fostering active patient participation in health policy and its relationship with the system has evolved from that of a monologue to becoming the mechanism for dialogue it is today.

Factors influencing coordination and continuity across care levels in the Catalan Health Care System

Background Care coordination is the harmonious connection of the different services needed to provide care to a patient throughout the care continuum in order to achieve a common objective without producing conflicts. Continuity of care is related to how patients experience the coordination of services. The objective is to identify factors influencing care coordination and continuity across care levels …

A tool for assessing continuity of care across care levels: an extended psychometric validation of the CCAENA questionnaire

The CCAENA questionnaire was developed to assess care continuity across levels from the patients' perspective. The aim is to provide additional evidence on the psychometric properties of the scales of this questionnaire. Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care in three health care areas of the Catalan health care system. Data were collected in 2010 using the CCAENA questionnaire. To assess psychometric properties, an exploratory factor analysis was performed (construct validity) and the item-rest correlations and Cronbach's alpha were calculated (internal consistency). Spearman correlation coefficients were calculated (multidimensionality) and the ability to discriminate between groups was tested. The factor analysis resulted in 21 items grouped into three factors: patient-primary care provider relationship, patient-secondary care provider relationship and continuity across care levels. Cronbach's alpha indicated good internal consistency (0.97, 0.93, 0.80) and the correlation coefficients indicated that dimensions can be interpreted as separated scales. Scales discriminated patients according to health care area, age and educational level. The CCAENA questionnaire has proved to be a valid and reliable tool for measuring patients' perceptions of continuity. Providers and researchers could apply the questionnaire to identify areas for health care improvement.

How do healthcare users experience continuity of care across care levels in different settings in the Catalan healthcare system?

Background Achieving continuity of care across care levels has become a priority in many health care systems that experience specialization and fragmentation of care; since continuity should contribute to the delivery of high quality care and the adequate use of resources. Continuity of care is defined as one patient experiencing the provision of care over time as coherent and interlinked. Three types can be distinguished: informational, managerial and relational continuity. The objective is to explore …

A First Approach to Differences in Continuity of Care Perceived by Immigrants and Natives in the Catalan Public Healthcare System

Objective: To compare immigrants’ and natives’ perceptions of relational, managerial and informational continuity of care and to explore the influence of the length of stay on immigrants’ perceptions of continuity. Methods: Cross-sectional study based on a survey of a random sample of 1,500 patients, of which 22% (331) were immigrants. The study area was made up by three healthcare areas of the Catalan healthcare system. To collect data, the CCAENA questionnaire was applied. Multivariate logistic regression models were conducted. Results: Like natives, immigrants perceive high levels of managerial continuity (88.5%) and relational continuity with primary and secondary care physicians (86.7 and 81.8%), and lower levels of informational continuity (59.1%). There were no statistically significant differences in managerial and informational continuity between immigrants and natives. However, immigrants perceive a worse relational continuity with primary care physicians in terms of trust, communication and clinical responsibility. Conversely, immigrants perceive higher relational continuity with secondary care physicians in terms of effective communication and clinical responsibility. Discussion: Similar managerial and informational continuity perceptions seem to point towards a similar treatment of patients, regardless of their immigrant status. However, differences in relational continuity highlight the need for improvements in professionals’ skills in treating immigrants’ patients.

Catalonia WHO Palliative Care Demonstration Project at 15 Years (2005)

Since 1990, a wide range of palliative care services has been implemented throughout the Catalan Health Care System. In 2005, 21,400 patients received palliative care; 59% had cancer (79.4% of all cancer patients) and 41% had other noncancer diagnoses (25.0%–56.5% of all noncancer patients). Today, more than 95% of Catalonia is covered by palliative care services. Fourteen districts have comprehensive palliative care networks. A total of 140 full-time physicians work in 183 specialty programs, including 63 palliative care units (with a total of 552 beds), 34 hospital consult teams, 70 home care teams, 16 outpatient clinics, and specialized pediatric and HIV/AIDS consult teams. Opioid consumption increased from 3.5 mg per capita in 1989 to 21 mg per capita population in 2004. The cost of the specialist palliative care network is more than 40 million Euros annually. However, the cost efficiency is striking. Due to the radical change in the use of acute and emergency beds, the project saves the Catalan Health Care System an estimated 48 million Euros annually, a net savings of 8 million Euros annually. Additional preliminary data suggest that symptom control and patient/family satisfaction are both improved by these services.

Evaluation of Risk-Adjusted Hospital Mortality After Coronary Artery Bypass Graft Surgery in the Catalan Public Healthcare System. Influence of Hospital Management Type (ARCA Study)

Previous studies suggest that the effectiveness of coronary surgery is influenced by the type of management at the healthcare centre where the intervention is performed. The present study assessed the risk-adjusted hospital mortality of coronary surgery in the Catalan healthcare system in hospitals under either private or public management. We carried out a prospective study of all consecutive patients receiving a first coronary artery bypass graft, with public financial support, in a period of 2 years at 5 hospitals under either public or private management. Preoperative risk was assessed using the EuroSCORE and Catalan Agency for Health Technology Assessment (CAHTA) predictive models. Overall, 1605 patients underwent interventions, 21% of which were at private hospitals. The percentage of patients undergoing non-elective surgery was higher at private hospitals (64% vs 50%), as was the percentage needing intravenous nitrates (17% vs 11%) and the percentage in functional class IV (20% vs 11%). The odds ratio for in-hospital mortality in private compared with public hospitals was 0.56 (95% CI, 0.29-1.06) when adjusted for EuroSCORE, 0.56 (95% CI, 0.29-1.07) when adjusted for CAHTA score, and 0.43 (95% CI, 0.21-0.87) when adjusted for patient characteristics. The mortality observed, 4.8% (95% CI 3.8-5.6), was not significantly higher than that predicted. a) Hospital mortality was equivalent to or lower than that expected after adjustment for the 2 risk scores; b) after adjustment for baseline patient characteristics, the results favored privately managed centers; and c) comparison with previous results suggests that coronary surgery effectiveness has improved in recent years.