Basque Public Health Research Articles

Chronic Pain Management in The Basque Health Service: Starting from The Strategy

Introduction: Pain is defined by the International Association for the Study of Pain (IASP) as an "unpleasant, unpleasant, and unpleasant sensory and emotional experience of pain. (IASP) as an "unpleasant sensory and emotional experience, associated with or similar to that associated with actual or potential tissue damage". In Spain, it is estimated that 1 in 6 Spaniards (17%) suffers from chronic pain and that this disease represents the second cause of consultation in primary care (PC) and more than 50% of these interventions are related to it. Of the 10 most prevalent pathologies, half of them are related to pain, with a notably higher impact on women.
 Aims And Objectives:
 - To know the approach to pain, with special emphasis on chronic pain, in the Basque public health system.
 - To carry out an analysis of the results obtained in the survey and in the interviews with key clinical and management professionals.
 - Design and implement a pain strategy in Osakidetza.
 Material And Method: Design of an online survey with the different key areas of a strategy for pain management in a healthcare organization. 31 questions in 8 blocks.
 1.Pain management strategy or plan
 2.Resources allocated by the organization
 3.Assessment tools
 4.Pain management
 5.Training activities for professionals
 6.Information/sensitization and empowerment of the patients and families
 7.Coordination and continuity of care
 8.Evaluation indicators
 Results:
 All organizations have strategies or plans.
 67% of the Integrated care Organisation (ICO) have a Pain commission
 100% of the ICO has a Pain Unit.
 25% have specific resources for primary care.
 100% has medical protocols for referrals and 75% in infirmary.
 100% of ICO use the analog visual scale (AVS), among others.
 83% of the ICOs have drug management reconciliation activities and safety criteria in drug management, and 75% refer to non-pharmacological approach methodologies, mainly related to the neurosciences.
 58% of the OSIs consider that there are activities such as specific courses on pain and in 75% of them encourage an interdisciplinary approach with specific pain care plans such as musculoskeletal pain.
 67% believe that it promotes empowerment interventions, such as community interventions, patient empowerment, group approaches, and health education for both patients and caregivers.
 regarding continuity of care 75% have face-to-face activities and 100% have non-face-to-face activities.
 Realted to evaluation 60% uses AVS instrument and there is a high use of opioids
 Conclussion: Although there are a multitude of interventions and many agents involved in pain management, the truth is that there is great heterogeneity in the availability of the same resources in the different ICO. Pprimary care still has a residual role in the management of these patients as well as non-pharmacological treatments. the lack of psychological care for these patients is striking. Also noteworthy is the almost non-existent difference in care according to the patient's gender.
 Implications For Applicability And Limitations: A strategic plan is therefore necessary for the corporation

Coping strategies during pregnancy and their relationship with anxiety and depression

ABSTRACT How individuals perceive and cope with stressful situations may determine their level of anxiety or depression. The identification of coping strategies (CS) in pregnancy could help prevent depression and anxiety (D&A), and their consequent effects on the health of the mother and the baby. A cross-sectional descriptive correlational study was conducted to identify the CS most commonly used by pregnant women in a Spanish population and to evaluate the association of these CS with D&A. A consecutive sample of 282 pregnant women over 18 years of age were recruited when attended midwife consultations and through snowball sampling between December 2019 and January 2021 in the Basque public health system. CS were measured using the RevisedPrenatal Coping Inventory (NuPCI) questionnaire, assigning the score to an avoidant, preparatory or spiritual scale. Cutoff points were established to categorize anxiety and depressive symptomatology, using the STAI-S and EPDS scales. Multivariate logistic regression models were constructed to analyze the association between CS and D&A. The results show that the higher the score on the avoidance subscale, the higher the likelihood of having an anxiety disorder (OR: 8.88 (95 percent Confidence Interval [CI] 4.26–20.1), and depressive symptoms (OR: 8.29 (95 percent CI 4.24–17.4). Multiparous women are more likely to have anxiety (OR: 3.41 (95 percent CI 1.58–7.5) or depressive symptomatology (OR: 4.1 (95 percent CI 2.04–8.53) during pregnancy. These results highlight the need to consider the evaluation of CS used during pregnancy to tailor the care provided, but further studies on the implementation and effectiveness of interventions are needed.

Environmental health competence in Basque health workers. Analyzing the soil before sowing the seed

BACKGROUND AND AIM Modifiable environmental factors account for the 23% and 22% of mortality and morbidity respectively. However, it is unclear whether health practitioners – especially those in primary care – are sufficiently aware of the connections between environmental exposures and health and able to intervene in this domain. The objective of this study was to assess environmental health (EH) literacy and competences among health professionals working in the Basque Public Health System. METHODS We recruited a sample of 366 (85% females) including nurses, family doctors, paediatric doctors, gynaecological doctors and advanced university students of nursery and medicine. The online questionnaire measured 1) general and specific EH competences, 2) use of exposure clinical history, 3) perceived competence to deliver medical advice on several exposures, and, 4) perceptions of Basque Public Health Services. Data were analysed with descriptive statistics, chi-squared tests and ANOVA with post-hoc comparisons. RESULTS Overall, we found low to moderate general and specific EH competence and found that nurses and nursery students reported higher perceived general and specific competences than the rest of the profiles at the p < .001. These differences were small to large in size according to the Hedges’ g statistic. The sample was scarcely educated in the use of exposure clinical history and only 6 participants confirmed its use. The EH topics that more frequently appeared in the consultation room (e.g. passive smoke exposure or sun protection) were the ones for which the professionals reported a higher competence level and vice versa (least frequent topics were biomarkers and industrial emissions). Finally, even though Basque Public Health Services were highly regarded, participants rarely contacted them. CONCLUSIONS Interventions addressing environmental health knowledge and competences among health professionals in the Basque Health System are needed to improve population’s health. KEYWORDS: Environmental health competence, Health practitioners, Public health

Knowledge about COVID-19 and vaccine acceptability among priority groups defined for vaccination: A cross-sectional study in Araba/Alava, Spain, before the vaccination against SARS-CoV-2

BackgroundThe acceptability of COVID-19 vaccine varies depending on the time, place, type of vaccine and information available at the time. Knowledge of attitudes and practices towards COVID-19 among the population at high risk of developing the disease would help to tailor the strategy to improve adherence to vaccination recommendations. AimTo analyze the willingness, knowledge and risk perception of patients and health care workers (HCW) to get the vaccines against SARS-CoV-2. MethodsCross-sectional survey in Araba/Álava province (Spain). Subjects who met the criteria for the influenza vaccination in 2019 and HCWS from the Basque Public Health Service were included. The participants answered a questionnaire on the knowledge, attitudes and practices towards COVID-19 before starting vaccination against SARS-CoV-2. The intention to vaccinate was compared using the chi-squared test. Results316 HCWs and 389 patients responded to the survey. Around 90% of the patients and 80% of HCW would accept vaccination in all scenarios according to the questionnaire (p < 0.001). Only 3–12% hesitated about the COVID-19 vaccines. Compared to 40–70% of patients, 60–80% of HCWs perceived a high risk of COVID-19 (p < 0.001). Statistically significant differences were found in 10 of the 17 questions regarding the mechanism of transmission and symptoms. ConclusionHCWs had a better knowledge and risk perception of COVID-19 than the surveyed patients. They had a higher proportion of hesitancy to get COVID-19 vaccine, probably related to doubts about the effectiveness of the new vaccines and the scientific evidence.

Development, validation and transfer to clinical practice of a mobile application for the treatment of smoking

ObjectiveThe main objective is to transfer to clinical practice a new smoking cessation application (“Vive sin Tabaco” a) in all health centers of the public Basque Health Service. DesignAn implementation study of a smoking cessation program previously validated. After implementation, a retrospective study has been carried out to evaluate its use under normal conditions. SiteThe process of transfer to clinical practice has been held in several phases; first a pilotage in four health centers of Alava and subsequently, when all reported incidents were resolved, it was extended to all health centers of the Basque Health Service. Intervention and main measurementDevelopment of “Vive sin Tabaco”; a corporate tool for smoking cessation, and its transfer to clinical practice. All interested health care workers received training on how to use the application. User manuals for both patients and professionals were developed. Smoking cessation rates at 12 months during implementation were also collected. ResultsThe percentage of patients of post pilot phase who quit smoking at 12 months was 14.1%. ConclusionsThe conception of “Vive sin tabaco” as a corporate tool for smoking cessation, available in all health centers of Basque Health Service, has been long and arduous, and has required the participation of health professionals and patients as end-users in order to obtain a tool that adapts to their expectations and guarantees greater usability and satisfaction. This application is being effective as an adjuvant tool to health advice.

Determinants of participation in a post-hospitalization physical exercise program for older adults

BackgroundOlder patients often experience a decline in physical function and cognitive status after hospitalization. Although interventions involving physical exercise are effective in improving functional performance, participation in physical exercise interventions among older individuals is low. We aimed to identify factors that contribute to exercise refusal among post-hospitalized older patients.MethodsA cross-sectional study of recruitment data from a randomized controlled trial was conducted involving 495 hospitalized people ≥70 years old. Sociodemographic and clinical data were obtained from the Basque Public Health System database. We determined physical function with the Short Physical Performance Battery (SPPB), nutritional status with the Mini-Nutritional Assessment, frailty according to the Fried phenotype criteria, and cognitive function with the Short Portable Mental Status Questionnaire (SPMSQ). Student’s t, Mann-Whitney U, or chi-squared tests were applied for bivariate analysis. Parameters significantly associated with participation were introduced in a logistic multivariate regression model.ResultsAmong the analyzed patients, 88.8% declined participation in the physical exercise program. Multivariate regression revealed that older age (OR: 1.13; 95% CI: 1.07–1.19), poor nutritional status (OR: 0.81; 95% CI: 0.69–0.95), and reduced home accessibility (OR: 0.27; 95% CI: 0.08–0.94) were predictors of participation refusal. Moreover, patients who declined participation had worse performance on the SPPB (P < 0.05) and its tests of balance, leg strength, and walking speed (P < 0.05). No differences were found between groups in other variables.ConclusionsThis study confirms low participation of older adults in a post-hospitalization physical exercise program. Non-participation was associated with increased age, poor nutritional status, and reduced home accessibility. Our findings support the need for intervention design that accounts for these factors to increase older patient participation in beneficial exercise programs.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12619000093189, (date: January 22, 2019, retrospectively registered).

Accesibilidad de las mujeres sordas al sistema público sanitario del País Vasco

ObjectiveTo explore what are the perceptions and experiences of deaf women in relation to accessibility to the Basque Public Health System (Osakidetza). As a secondary objective, explore the experience of these women about gender violence. MethodA qualitative study with exploratory design is developed. The selection of the informants was carried out through intentional sampling. Deaf women were invited to participate through the Federation of Deaf People of the Basque Country. Four discussion groups were developed between October 2013 and July 2014, with duration of 90-120minutes. The discussion groups were recorded in video for their later literal transcription in which the service of interpreters of sign language of Euskadi participated. Thematic analyses carried out. ResultsThree main categories arise: 1) feelings of discrimination and limitation of the principle of autonomy; 2) barriers and facilitators in the accessibility to the health system; and 3) vulnerability of deaf women as a result of the lack of communication. ConclusionsNowadays, deaf women continue having difficulties in accessing to the health system in our context. The results of this study can be the starting point for the development of health policies and institutional protocols.

Analysis of a scoreboard of quantitative indicators to assess the performance on integrated care in the Basque Health System

Introduction: The public Basque Health System is undergoing a transformation process towards more integrated care. A cornerstone of this process was the creation of 13 integrated healthcare organizations (IHOs), starting in 2010. In order to assess changes in performance on integrated care, a scoreboard of quantitative indicators was selected and analysed. Methods: For the selection of indicators, the following steps were taken: - An international literature review on most commonly used indicators. - Interviews with 19 key informants on the integration process in the public Basque Health System. - Available data sources were identified. - A team of 13 regional experts was consulted on the list of indicators in the scoreboard. Based on the Donabedian model, the following categories of indicators were selected: structure, process, and (intermediary and final) results. Control variables were also identified. Trends in indicators over the 2010-2017 period were analysed, both at IHO and at whole system level. Results: A list of 49 indicators was identified and analysed. Most structural indicators showed improvement along the integration process, providing evidence of efforts made in areas such as the development of new coordination roles, and electronic information and communication tools. Process indicators showed increased efforts in improving the continuity of care for pluripathological patients and access to care at home, as well as on the assessment of functional dependency among older patients and the registration and follow-up of end-of-life patients. Some improvements were also found in the adequacy of prescription. Improvements in GP access to some diagnostics tests (eg: colonoscopies) was found. Generalised evidence of reduction in visits to especialised outpatient care could not be found. Regarding indicators of intermediary results, positive trends were found in several indicators for pluripathological patients, as well as on the reduction in potentially avoidable hospitalizations for people over 39. In most IHOs no reduction in 30-day emergency hospital readmissions was found. Regarding population health results, trends are difficult to link to integration initiatives, given their multifactorial nature. Positive developments were found in the control of diabetic patients, while only in a few IHOs diminishing trends in amenable mortality could be identified. Professionals’ perception of interprofessional collaboration between care levels was measured with a questionnaire validated elsewhere(1). While the chronic patient experience was measured using the IEXPAC Scale. Conclusions: In those groups of patients where integration initiatives have particularly focused, such as pluripathological patients, positive trends can already be identified in process and intermediary results’ indicators. Improvements in comprehensive indicators are more difficult to identify in most organisations. Lessons learned: It is useful to combine indicators more closely related to implemented interventions and targeted patients’ groups, with more comprehensive indicators that allow assessing their relative impact at system-level. Limitations: In most cases, identified trends cannot be unequivocally assigned to progress on integrated care. Trends were not statistically analysed. Nuno-Solinis R, Berraondo Zabalegui I, Sauto Arce R, San Martin Rodriguez L, Toro Polanco N. Development of a questionnaire to assess interprofessional collaboration between two different care levels.

Effectiveness of randomized controlled trial of a mobile app to promote healthy lifestyle in obese and overweight patients.

Health advice is useful for establishing behavioural changes, but such changes tend not to last. It would therefore be good to identify mechanisms for reinforcing advice and one option is the use of information and communication technologies. Given the limited evidence on the effectiveness of such technologies, we decided to conduct a clinical trial to assess the efficacy of a mobile application (app) for supporting the provision health advice for weight loss. A randomized clinical trial with 110 obese and overweight patients from the Basque public health care network (Araba). Patients were randomly allocated to the control (health advice) or intervention (health advice + app) groups. Primary (weight) and secondary (blood cholesterol level, blood pressure, haemoglobin A1c (HbA1c) and adherence to dietary and exercise recommendations) outcome variables were assessed at 1, 3 and 6 months after the end of the intervention. There were no significant differences in weight (0.357 kg; P = 0.7), blood cholesterol (2.6 mg/dl; P = 0.617), blood pressure (2.3 mmHg; P = 0.369) or adherence to recommendations on diet (84.6% in control and 92.9% the intervention group, P = 0.413) or physical activity (56% in controls and 75% the intervention group, P = 0.145). On the other hand, there were significant differences in HbA1c in favour of the control group (-0.095%; %; P = 0.046). The use of AKTIDIET® to support health advice for weight loss cannot be recommended. More high quality studies are needed, and patients should be involved in the design of apps to increase their efficacy and usability. NCT02308176.

HOBE+ case study, how a virtual community of practice to support innovation in primary care becomes a corporate innovation tool in Osakidetza (Basque Public Health Service)

&lt;p&gt;A virtual professional community of practice (VCoP), HOBE+, was set up in 2011 to foster and facilitate innovation . It was aimed at all primary care professionals of the Basque Public Health Service (Osakidetza) in the provinces of Biscay and Araba. HOBE+ incorporated a innovation management process from the generation of ideas to their implementation.&lt;/p&gt;&lt;p&gt;In 2015, based on its success, HOBE+ became a corporate tool in Osakidetza extending its radio of action to all employees and settings (primary and Hospital care).&lt;/p&gt;&lt;p class="h2"&gt;This manuscript objective is to assess, via a case study method, the process of developing and implementing a VCoP open to all primary care professionals in Osakidetza, including the take-up, participation and use of this VCoP in the first 15 months after its launch in October 2011. The usefulness of the VCoP was also assessed through a survey gathering the opinions of the professionals involved.&lt;/p&gt;&lt;p&gt;The experience shows that it is possible to create a virtual CoP for innovation in primary care where professionals from different professional categories propose ideas for innovation that are ultimately implemented; a experience that had been later on refined and extended to all Osakidetza.&lt;/p&gt;

IEXPAC, a tool to assess patient experience

Introduction: Knowing about LTC long term conditions patients´ experience with the care they receive is vital to advance towards a better and more patient centred integrated care. Although the latter is a core element of the theoretical framework of integrated care, there are few tools that measure the mentioned experience. The Basque Health Service already uses other tools IEMAC, and so on to self- assess the level of care integration of the Service Organizations SO, including Integrated Care Organizations, Mental Health Networks and Medium and Long Term Care Hospitals. Description of practice change implemented: the design of a 12 item scale IEXPAC, Chronic Patient´s Experience Assessment Tool, to be used by OS in a homogeneous way, that measures LTC patients´ care experience. The use of this tool by SO is included in the Contract-Programme CP, the centralized mechanism in the Basque Public Health System to assess and fund OS´ performance and activity. This scale will be used as a complement to other existing surveying tools. Aim: to Foster the assessment by the OS of the patient´s experience in order to improve the care provided. Targeted populations: LTC population user of the SO care. The CP has required a minimum number between 25 and 125 of surveyed LTC patients single pathology, pluripathology depending on the population attended by the SO. Timeline: the use of the scale has been rolled out along 2016 pilots and 2017 mainly in almost 16 out of 17 all the SO of the Basque Health Service. This implementation will be assessed in late2017 and 2018 within each SO´s CP general assessment. Highlights innovation, impact and outcomes: almost all the SO have surveyed, at least, the minimum number of patients requested. The total surveyed patients number is nearly 2,100 data analysis on 1,173 patients so far. There is a phone survey version, besides the face to face one, and the questionnaire is offered in the two official languages in the Basque Country. Sustainability and Transferability: There is an ongoing analysis of the possibility of adapting the survey to other patients groups children, rare diseases, frail elderly and other communication channels of the Health Service Health Folder, Health Advise, website, and so on, and of creating a specific one for caregivers. Conclusions, Discussion and lessons learnt: The survey use rate by the SO has been very high. There is an assessment currently being carried on to reflect on the usefulness of the tool for the care improvement in the SO. The preliminary outcomes note that IEXPAC is a valid tool for the general evaluation as a complement of other existing tools satisfaction surveys, IEMAC. Some SO have launched improvement actions as a result of their self-assessment e.g. the use of digital resources to get information and access services of the Health System. The use of internet resources and the digital access to the clinical record are, in fact, the items with the lowest frequency among the surveyed patients.

Inequalities in Health Services Usage in a National Health System Scheme

Health services can reduce inequalities caused by other determinants of health or increase them due to the effect of the inverse care law-the principle that the availability of good quality care tends to vary inversely with the need for it in the population served. The purpose of the research was to describe inequalities in the use of nursing services, medical services in primary care, specialist care, and services not fully covered by the Basque public health system in Spain. A cross-sectional study of adults aged at least 25 years who completed the 2013 Basque Health Survey (N = 10,454) was conducted. Age-standardized prevalence and prevalence ratios for use of services that are covered and noncovered in the health system were computed. The association of health services usage with socioeconomic variables was estimated using a Poisson regression model with robust variance. The relative index of inequality (RII) was used to measure the magnitude of socioeconomic status inequalities in health service use. All analyses were carried out separately for men and women. Individuals with lower socioeconomic status were more likely to use primary care (RII = 0.87, 95% CI [0.79, 0.97]) and less likely to use specialist services (RII = 0.82, 95% CI [0.75, 0.89]). Across noncovered health services, inequalities between the highest and lowest social groups were significant in all cases and especially marked in men's use of physiotherapists (RII = 0.46, 95% CI [0.35, 0.61]) and podiatrists (RII = 0.24, 95%CI [0.15, 0.38]). There are significant inequalities in primary and specialist health service use based on individual socioeconomic status, particularly for services that are not provided free of charge within the existing health system. This suggests that health service systems that are not explicitly designed to provide universal access may actually amplify preexisting social and health inequalities within their target populations.

Deploying eHealth: a new approach to face depression in the basque country

Introduction/context : Depression is one of the most frequent mental health diseases worldwide, with approximately 350 million of individuals affected. Antidepressants are still the mainstay of treatment for depression in healthcare settings. In the Basque Country, about 400.000 people suffer from depression; 10% of them with mild or moderate symptoms. cCBT has proven to be effective to fight depression, enabling the patient to change destructive patterns. This type of cCBT can be self-administrated at any time and place; this is why it contributes to improve accessibility to treatment. Also, it enables the delivery of care at the natural environment, minimizing the negative effect of mental health stigma, and contributing to the acceptance of the one's own condition. Description/aim : The Basque Country, within the European project Mastermind, has deployed a Computerized Cognitive Behavioral Therapy (cCBT) service. The Mastermind project started in March 2014 and finishes in Febrary 2017. During the implementation phase, barriers and facilitators related to both clinical and organizational areas have been identified and analyzed. The cCBT platform enables a two-way patient-professional communication, a close patient´s follow-up, while providing the patient with tools to manage its own condition and prevent future episodes. Methods : The practice being implemented in the Basque Country comprises three main work areas: 1. Develop a cCBT platform, called “Supera tu depresion” together with other 3 Spanish partners of the project, taking into account the needs for patient-professional interaction and fluid communication, integration within information systems and therapeutic content that nurtures the platform. The piloting in the Basque Country started in January 2016 and finishes in Febrary 2017, due to the finalisation of the project. 2. Deploy a protocol for comprehensive care that includes key professionals (primary care, mental health and emergency) adapted to the context of the Basque Country. 3. Put into practice an integrated care intervention targeting individuals over 18 years old, diagnosed of low or mid depression. 4. Pre-post assessment of quantitative and qualitative aspects (by focus groups to clinicians and semi structured interviews to managers) according to the MAST model. Results/discussion/lessons learned : The results are to be measured according to the MAST model in terms of health problems, application features, safety, clinical effectiveness, patient and professional perspective and economic, organizational, socio-cultural, ethical and legal aspects. The following data is being analyzed in the Basque Country and the results will be published in the first quarter of 2017. Out of the 182 patients took part in the project, 23 have finalized the therapy and 89 are drop outs. Nowadays, 70 patients still continue in the therapy, and their data will be analyzed after the finalization of the project (Febrary 2017). Although the overall quantitative analysis is ongoing, some conclusions can be highlighted from the qualitative perspective: The patients who complete the therapy are very satisfied with it, although the technical difficulties and lack of time of the professionals have been important barriers. The simplicity of the software and its robustness has been identified as critical success factors, both for patients and professionals. This project will raise awareness about the key issues underpinning online cCBT integration within regular care, generating the knowledge and expertise needed for the extension of this type of care. Transferability : The inclusion of the therapy in the day-to-day practice is being raised in the Basque public Health Provider, Osakidetza. The final decision will depend on the results of the analysis that are being performed during the last months of 2016. If positive, the possibility to provide the cCBT service using existing corporative tools will be assessed.

Frailty and Related Factors Based On A Multidimensional Assessment In People 70 Years Old Or Over

1.1 Introduction: The Healthcare Plan for the Elderly (PAM) of the Basque Public Health Service (Osakidetza) determines different typologies of people ≥ 70 years of age based on a multidimensional assessment. The objective is to learn about the prevalence of frailty and its relationship with other variables of the assessment. 1.2 Material and methods: Cross-sectional study with a sample of 666 people (569 with a certain typology determined) ≥70 years of age from 7 healthcare centres, selected by random sampling. Different typologies were determined based on functionality (Instrumental Activities of Daily Living - IADL, Lawton-Brody Index; Basic Activities of Daily Living - BADL, Barthel Index), existence of chronic diseases, and life expectancy 59, life expectancy > 6 months), ‘dependent’, and ‘at the end of life’. 1.3 Results: The 19.2% (95% CI 16.1-22.6%) were frail. Frailty was significantly related (p 80 years old versus 27.2% non-frail), physical inactivity (57.1 versus 15.4%), previous falls (58.4% versus 34.2%) and number of chronic medications (median 13 versus 8). It was also related to certain pathologies (cardiovascular, osteoarticular) and visual deficit. Detection through the assessment of IADL is closely related to the Timed Up and Go Test (p < 0.001). 1.4 Conclusions: In order to detect frailty, it is important to consider older age, physical inactivity, certain comorbidity (cardiovascular, osteoarticular, sensory) and polypharmacy. IADL and performance-based tests show very good correlation.

The Cost of Colorectal Cancer According to the TNM Stage

IntroductionThe aim of this study was to measure the cost of treatment of colorectal cancer in the Basque public health system according to the clinical stage. MethodsWe retrospectively collected demographic data, clinical data and resource use of a sample of 529 patients. For stages I to III the initial and follow-up costs were measured. The calculation of cost for stage IV combined generalized linear models to relate the cost to the duration of follow-up based on parametric survival analysis. Unit costs were obtained from the analytical accounting system of the Basque Health Service. ResultsThe sample included 110 patients with stage I, 171 with stage II, 158 with stage III and 90 with stage IV colorectal cancer. The initial total cost per patient was 8644 € for stage I, 12675 € for stage II and 13034 € for stage III. The main component was hospitalization cost. Calculated by extrapolation for stage IV mean survival was 1.27years. Its average annual cost was 22403 €, and 24509 € to death. The total annual cost for colorectal cancer extrapolated to the whole Spanish health system was 623.9 million €. ConclusionsThe economic burden of colorectal cancer is important and should be taken into account in decision-making. The combination of generalized linear models and survival analysis allows estimation of the cost of metastatic stage.

Valoración del coste económico del cáncer colorrectal según estadio tumoral

IntroductionThe aim of this study was to measure the cost of treatment of colorectal cancer in the Basque public health system according to the clinical stage. MethodsWe retrospectively collected demographic data, clinical data and resource use of a sample of 529 patients. For stagesi toiii the initial and follow-up costs were measured. The calculation of cost for stageiv combined generalized linear models to relate the cost to the duration of follow-up based on parametric survival analysis. Unit costs were obtained from the analytical accounting system of the Basque Health Service. ResultsThe sample included 110 patients with stagei, 171 with stageii, 158 with stageiii and 90 with stageiv colorectal cancer. The initial total cost per patient was 8,644€ for stagei, 12,675€ for stageii and 13,034€ for stageiii. The main component was hospitalization cost. Calculated by extrapolation for stageiv mean survival was 1.27years. Its average annual cost was 22,403€, and 24,509€ to death. The total annual cost for colorectal cancer extrapolated to the whole Spanish health system was 623.9million€. ConclusionsThe economic burden of colorectal cancer is important and should be taken into account in decision-making. The combination of generalized linear models and survival analysis allows estimation of the cost of metastatic stage.

Integrating the community health perspective into the health care provision system: the Basque Country case

Introduction : Integrated care has been recognized as a useful strategy to avoid the existing gaps in health care provision and, consequently, to improve the efficacy of the provided care and to improve patients’ health outcomes, quality of life and satisfaction. Community care is based on the assessment and intervention over the local health determinants, needs and resources. This process, in order to constitute a true community health approach, needs to be performed in a participatory manner by professionals and community stakeholders. Even though integration is being facilitated and promoted though numerous health systems, frequently is focused around care levels (primary care and specialized care) or adjacent health systems (primary care and mental health care), and rarely considers other related aspects as social care or community health. The Basque Country Health Department, since 2013 has been developing an overall strategy aimed to generalize some integrative experiences previously tested. At this point all health care organization at the Basque Health System has functionally integrated primary and secondary care, and several plans are being developed in order to advance towards a comprehensive integration of systems. One of these specific plans is aimed to integrate the community health perspective into the primary care health system and this process and the first results are the subject of this communication. Short description of practice change implemented, aims, target population and key stakeholders involved With the aim of integrating community health perspective into the primary care network, the Public Health Department and Osakidetza (the Public Basque Health System), constituted a work team appointed to lead the necessary process. This group was constituted by health promotion, primary care and research professionals of both institutions. The group proposed a plan based on three main elements: communication of the interest of integrated community care practice; capacitation of professionals; provision of a theoretical framework fitting the Basque Country reality. All these three elements were oriented to promote the integration of health professionals (primary care and health promotion) in local health networks (already existing or newly developed) working in the assessment and intervention over the main local health determinants. The local health network was considered key of the whole process. Key findings : results, outcomes and impact. Regarding the three main elements of the plan, the communication of the interest of integrating community health was based on multilevel plenary sessions attended by the managers of care organizations and primary care units. Also a work cafe was celebrated with the participation of interdisciplinary stakeholders from the health system but also from the local authorities, education, social system and citizenship. Regarding capacitation of professionals, a peer based education process is being developed. Around 70 professionals are taking part on it and at the same time that theoretical contents are being provided, each attendant is putting on place at his/her own local community the lessons learned. Finally a guide for the integration of community health perspective has been composed by some of the members of the team. This guide is based on published evidence and its being used as the base for the education process. It dedicates special attention to the evaluation of the process and the local networks results. Highlights: (discussions, lessons learned from the process of implementation, timeline, contingencies developed) Community care was not a new issue for several health organizations. Abundant experiences were already put in place and, for the professionals already involved, this new plan constitutes a great opportunity to consolidate their advances. It is very important to consider these previous experiences, never neglect them and use that knowledge to improve the new initiative. The process to participate in local health networks is difficult for non-trained professionals. It is necessary to capacitate health professionals in participatory techniques in order to made them feel comfortable with the task and also to enable them to play an active role in the participatory processes. Health care managers need to facilitate the participation of health professionals in local health networks as the key point to integrate community care in the health system. Community stakeholders welcome health professionals to be a part of the existing networks and are willing to promote and work on new ones. Conclusion: (include comments on sustainability and on transferability) Integration of community perspective in the health care provision is a complex task that only can be tackled through the dedication and work of health professionals, the facilitation of the managers and the determination of the whole health system.

The Origin of Variation in Primary Care Process and Outcome Indicators: Patients, Professionals, Centers, and Health Districts.

Healthcare providers are often evaluated by studying variability in their indicators. However, the usefulness of this analysis may be limited if we do not distinguish the variability attributable to health professionals and organizations from that associated with their patients.Our objectives are to describe the main process and outcome indicators of primary healthcare services, analyzing the contribution to variability in these indicators from different levels: individual, health professional, health center, and health district.This is a cross-sectional study that includes all.All the individuals covered by the public Basque Health Service (children [age 0-13], n = 247,493; adults [≥14 years old], n = 1,959,682) over a 12-month period.We calculated the number of visits to primary care doctors, number of referrals, prescription costs, and potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSCs). Using multilevel analysis, we determined the percentage of variance attributable to each level.After adjusting for the characteristics of patients (demographic, socioeconomic, and morbidity), doctors (panel size), health center (size, staff satisfaction, demographic structure of the community), and health district, the variance in the indicators was mainly attributable to differences between patients, independently of the attending health professional, the center, or the healthcare organization, both in children (94.21% for visits to the doctor; 96.66% for referrals; 98.57% for prescription costs; 90.02% for potentially avoidable hospitalizations for ACSCs) and in adults (88.10%; 96.26%; 97.92%; and 93.77%, respectively).The limited contribution of health professionals and organizations to variability in indicators should be taken into account when performing evaluations and planning quality improvement strategies.

Evolución de los procedimientos artroscópicos de cadera en el País Vasco entre 2008 y 2013

ObjectiveTo analyse the evolution of hip arthroscopy as a technique for the treatment of hip pathology. MethodsRetrospective analysis of the data (age, sex, diagnosis, year of intervention, surgical technique performed, and reoperations) from the database of the system Basque Public Health System (Osakidetza) and surgery registers of 2 private centres between 2008 and 2013. ResultsWithin these six years, 542 arthroscopies (530 primary procedures and 12 re-operations) were performed. There was an increase in the number of interventions: from 15 (2.77%) in 2008 to 149 (27.5%) in 2013 (statistically significant difference; p<.001). The mean age was 44.6 (standard deviation, 13.1) years, and 33.8% of cases were women. The most frequent diagnoses were: femoroacetabular impingement (FAI, 430 patients, 81.1%), extra-articular hip pathology (36 patients, 6.79%), and pathology in hip with prosthesis (26 patients, 4.90%). The labrum was refixed in 56.1% of patients intervened by FAI, and the percentage of repairs increased from 28.6% to 70.5% (p<.001). In addition, 23 patients were re-operated by performing a total hip replacement(4.34%), leaving a total of 35 re-operations (6.60%). ConclusionsThe annual number of hip arthroscopies has multiplied between 2008 and 2013. During these years the labral refixation has progressively increased against its resection. Clinical relevanceTo analyze how the hip arthroscopy application has evolved over recent years. Level of evidenceLevel IV, cross-sectional study.

Is organizational progress in the EFQM model related to employee satisfaction?

BackgroundTo determine whether there is greater employee satisfaction in organisations that have made more progress in implementation of the European Foundation for Quality Management (EFQM) model.MethodsA series of cross-sectional studies (one for each assessment cycle) comparing staff satisfaction survey results between groups of healthcare organisations by degree of implementation of the EFQM model (assessed in terms of external recognition of management quality in each organisation). Setting: 30 healthcare organisations including hospitals, primary care and mental health providers in Osakidetza, the Basque public health service. Participants: Employees of 30 Osakidetza organisations. Intervention: Progress in implementation of EFQM model. Main outcome measures: Scores in 9 dimensions of employee satisfaction from questionnaires administered in healthcare organisations in 4 assessment cycles between 2001 and 2010.ResultsComparing satisfaction results in organisations granted Gold or Silver Q Awards and those without this type of external recognition, we found statistically significant differences in the dimensions of training and internal communication. Then, comparing recipients of Gold Q Awards with those with no Q Certification, differences in leadership style and in policy and strategy also emerged as significant.ConclusionsProgress of healthcare organisations in the implementation of the EFQM Excellence Model is associated with increases in their employee satisfaction in dimensions that can be managed at the level of each organisation, while dimensions in which no statistically significant differences were found represent common organisational elements with little scope for self-management.