Spanish Public Hospitals Research Articles

Evaluation of consent forms for clinical practice in Spanish Public Hospitals

ObjectiveTo evaluate the access, development, and quality of consents forms for clinical practice within the Spanish Public Hospitals. MethodA cross-sectional study was conducted in a two-stage process (January 2018–September 2021). In stage 1, A nationwide survey was undertaken across all public general hospitals (n=223) in the Spanish Healthcare System. In stage 2, Data was taken from the regional health services websites and Spanish regulations. Health Regional Departments were contacted to verify the accuracy of the findings. Data was analyzed using a descriptive and inferential statistics (frequencies, percentages, Chi-square & Fisher's exact tests). ResultsThe response rate was 123 (55.16%) of Spanish Public Hospitals. The results revealed a range of hospital departments involved in the development of consent documents and the absence of a standardized approach to consent forms nationally. Consent audits are undertaken in 43.09% hospitals and translation of written consents into other languages is limited to a minority of hospitals (35.77%). The validation process of consent documentation is not in evidence in 13% of Spanish Hospitals. Regional Informed Consent Committees are not place in the majority (70.7%) of hospitals. Citizens can freely access to consent documents through the regional websites of Andalusia and Valencia only. ConclusionVariability is found on access, development and quality of written consent across the Spanish Public Hospitals. This points to the need for a national informed consent strategy to establish policy, standards and an effective quality control system. National audits at regular intervals are necessary to improve the consistency and compliance of consent practice.

Understanding the Effect of Research on Hospitals Performance: The Complementary Role with HIT

Hospitals are knowledge-centered organizations where technology and research are factors of central importance in their operations and performance. In this study, we propose that research in hospitals is pivotal, first, to improve hospitals' performance in terms of reductions in readmission and mortality rates, as well as in their overall risks measured through the Malpractice Insurance Premium (MIP). Second, research complements technology to improve hospital outcomes. We provide evidence supporting these results using a panel data set comprising 189 Spanish public hospitals with 1,120 observations for the period from 2001 to 2009. Our findings add new evidence on how research may contribute to a more sustainable and affordable healthcare system by highlighting its key role not only in improving hospitals’ performance but also in making health technology more efficient. These results constitute a helpful piece of evidence for advising policymakers and hospitals’ managers.

Estudio poblacional de casuística y morbimortalidad de la prostatectomía radical en España

IntroductionThere is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention.Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation. Material and methodsWe designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD).We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables. ResultsBetween 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9 ± 3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with < 500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year. ConclusionsIn national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.

Comorbidities in Patients with Autoimmune Bullous Disorders: Hospital-Based Registry Study.

The incidence of autoimmune bullous disorders has increased over the years, especially in elderly patients with multiple comorbidities, which has stimulated research into their association with other diseases. We performed a retrospective observational study used the Minimum Basic Data Set of hospital discharges to review records of patients admitted to Spanish public hospitals between 2016 and 2019 with a diagnosis of any autoimmune bullous disorder. The objectives were to describe the comorbidity profile and the clinical-epidemiological characteristics of patients with pemphigus and pemphigoid, and analyze the evolution of the incidence of these diseases. The study included 1950 patients with pemphigus and 5424 patients with pemphigoid. Incidence increased from 2016 to 2019. The main comorbidities were hypertension (40.19%) and diabetes mellitus (28.57%). Compared to patients with pemphigoid, those with pemphigus had a higher prevalence of neoplasms, osteoporosis, solid metastases and malignant lymphoma, while the prevalence of hypertension, kidney disease, diabetes, heart failure, dementia, chronic obstructive pulmonary disease and Parkinson’s disease was higher in the pemphigoid group (p < 0.05). Therefore, since autoimmune bullous disorders are associated with diverse comorbidities and their incidence has risen in recent years, the establishment of strategies to prevent the main comorbidities in these patients is justified.

Translated article] Dermatology Care in Spanish Public Hospitals: A Mapping Study of Health Care Resources and Medical and Surgical Activity in Dermatology Departments in 2019

Background and objectiveNo recent data on health care resources and medical and surgical activity in Spanish dermatology departments are available in the literature. The aim of this study was to compile this information for 2019. Material and methodsCross-sectional study based on an online survey sent to the heads of dermatology departments at public hospitals in Spain. ResultsOf the 162 department heads contacted, 59 answered the survey (participation rate, 36.4%). General findings included a shortage of staff, especially dermatologists, in hospitals of low and medium complexity. The main reason given for the shortage of dermatologists was a lack of interested applicants. Large hospital complexes had more infrastructure and equipment. Over 50% of the departments surveyed used a combination of in-person and virtual visits. Psoriasis units were the most common specialized care units. Approximately 75% of the hospitals had operating rooms with an anesthetist. More complex procedures such as sentinel lymph node biopsy and Mohs micrographic surgery were performed more often in large hospital complexes. Hospitalization and the presence of dermatology residents working call shifts were also more common in these hospitals. Teaching and research activity differed according to hospital complexity. ConclusionsWe have mapped health care resource availability and medical and surgical activity in Spanish dermatology departments prior to the COVID-19 pandemic. Our findings could be useful for improving clinical management and defining future actions and areas for improvement.

Increasing Incidence of mucormycosis in Spanish inpatients from 1997 to 2018.

Mucormycosis is a worldwide angio-invasive fungal infection that is associated with high morbidity and mortality. A few European studies have focused on the epidemiology. A retrospective longitudinal descriptive study was performed with inpatients diagnosed with mucormycosis (ICD-9-CM, code 117.7, cases 1997-2015; and ICD-10, code B46, cases 2016-2018; along with length of hospital stay) in Spanish public hospitals between 1 January 1997 and 31 December 2018. Data were obtained from the Minimum Basic Data Set (CMBD in Spanish). A total of 962 patients were recorded; 665 were men. The mean age (±SD) was 55±18.8years. The annual incidence rate increased from 0.74 to 1.24 cases per million person-years. The lethality rate was 31.3%. Renal failure (41.6%) and haematological malignancy (36.3%) were the main factors involved. Mucormycosis is a rare infectious disease in Spain, but it has had a significantly increased incidence in the last two decades. Being an adult male and having diabetes, neoplasm or renal failure are the main factors associated. High mortality is usually associated mainly with haematological malignancy and renal failure. CMBD studies could be an efficient tool for assessing changes in the epidemiology of mucormycosis.

Suicidal ideation: Prevalence and risk factors during pregnancy

Introduction: Although suicide is the main cause of maternal death during pregnancy in industrialized countries, there are few research regarding the prevalence and risk factors of suicidal ideation during pregnancy, especially in Spain. Method: In a multicenter study, the sample included 1,524 pregnant women recruited from an obstetrics setting from two Spanish tertiary-care public hospitals. The prevalence of prenatal suicidal ideation was estimated by analyzing their responses to item 9 on the Patient Health Questionnaire (PHQ-9). The risk factors (which increases the probability of having suicidal ideation) included sociodemographic and biomedical variables, and the stress subscale from the revised prenatal version of the Postpartum Depression Predictors Inventory (PDPI-R). Results: A total of 2.6% of pregnant women reported suicidal ideation. Risk factors of suicidal ideation during pregnancy include sociodemographic, such as prior history of depression (β = 0.120, p < .05), unemployment (β = 0.149, p < .05), and being an immigrant (β = 0.140, p < .01), and biomedical variables, such as previous abortion (β =0.169, p < .01) and assisted reproduction (β = -0.100, p < .05). Discussion: Given that the prevalence of suicidal ideation is higher than expected, the results of the study suggest the critical need for screening and designing preventive interventions adapted to pregnant women to decrease risk of associated suicidal behavior. In protocols carried out by midwives, specific risk factors should be included in health screenings during pregnancy.

Clinical characteristics and management of type 1 diabetes in Spain. The SED1 study

ObjectivesTo determine the sociodemographic and clinical profile of a representative sample of people with type 1 diabetes mellitus (DM1) in Spain and identify factors associated with glycemic control. Material and methodsA cross-sectional observational study was carried out in adults and children with DM1 treated in 75 Spanish public hospitals, geographically distributed in order to be representative of the Spanish population. Within each center, the patients were included on a consecutive basis as they visited the clinic. They were interviewed, and their clinical histories were reviewed. A descriptive statistical analysis was made, and factors associated with HbA1c were analysed using multivariate linear regression analysis. ResultsA total of 647 patients were included: 55.3% females, aged 36.6 ± 14.4 years, 97.2% Caucasians, BMI 24.7 ± 4.4 kg/m2 (12.1% ≥ 30 kg/m2), and 74.0% had secondary / university education. A total of 20.2% were active smokers. The mean time from the diagnosis of DM1 was 17.9 ± 12.0 years. A total of 48.7% presented comorbidities: 19.3% retinopathy and 16.4% hypothyroidism. As regards treatment for DM1, 76.5% received basal-bolus insulin therapy and 20.7% continuous subcutaneous insulin infusion (CSII); 51.0% of the patients used an insulin/carbohydrate ratio (ICR), with 4.6 ± 1.6 self-monitored capillary blood glucose (SMCBG) measurements a day, and 24.8% used continuous glucose monitoring (CGM). The mean HbA1c value was 7.6 ± 1.1% (30% below 7%). Metabolic control improved (lower HbA1c) with more daily SMCBG (B = −0.053; p = 0.009), a higher educational level (B = 0.461; P < 0.001), greater number of hypoglycemia episodes (B = −0.253; P = 0.018) and carbohydrate counting (B = −0.190; P = 0.048), and worsened the longer the duration of the disease (B = 0.010; P = 0.010), higher total dose of insulin (B = 0.010; P < 0.0001), poorer adherence to diet (B = 0.650; P < 0.0001) and a family history of DM (B = −0.233; P = 0.007). ConclusionsThe management of patients with DM1 in Spain, as well as the treatment they receive, is similar to that seen in other Western countries. Blood glucose control is associated with educational level, disease duration, and the characteristics of treatment and self-care.

Building resilience and performance in turbulent times: The influence of shared leadership and passion at work across levels

The COVID-19 pandemic has tested health care professionals to the extreme. This study investigated the re-enchanting effect of shared leadership and passion at work in the context of public health care. This study advances on the Self-Determination Theory to suggest that shared leadership has a positive effect on resilience and performance through passion at work at different levels of analysis. A sample of 518 physicians working in Spanish public hospitals was used. The results showed that shared leadership was associated with team and individual outcomes via passion at work at team level, while no significant mediating effect was found for passion at work at the individual level. The theoretical and practical implications of the findings are discussed, limitations are considered, and future research directions are suggested.JEL CLASSIFICATION: M12, M54

Características clínicas y manejo de la diabetes tipo 1 en España. Estudio SED1

ObjectivesTo determine the sociodemographic and clinical profile of a representative sample of people with type 1 diabetes mellitus (DM1) in Spain and identify factors associated with glycemic control. Material and methodsA cross-sectional observational study was carried out in adults and children with DM1 treated in 75 Spanish public hospitals, geographically distributed in order to be representative of the Spanish population. Within each center, the patients were included on a consecutive basis as they visited the clinic. They were interviewed, and their clinical histories were reviewed. A descriptive statistical analysis was made, and factors associated with HbA1c were analyzed using multivariate linear regression analysis. ResultsA total of 647 patients were included: 55.3% females, aged 36.6±14.4 years, 97.2% Caucasians, BMI 24.7±4.4kg/m2 (12.1% ≥30kg/m2), and 74.0% had secondary / university education. A total of 20.2% were active smokers. The mean time from the diagnosis of DM1 was 17.9±12.0 years. A total of 48.7% presented comorbidities: 19.3% retinopathy and 16.4% hypothyroidism. As regards treatment for DM1, 76.5% received basal-bolus insulin therapy and 20.7% continuous subcutaneous insulin infusion (CSII); 51.0% of the patients used an insulin/carbohydrate ratio (ICR), with 4.6±1.6 self-monitored capillary blood glucose (SMCBG) measurements a day, and 24.8% used continuous glucose monitoring (CGM). The mean HbA1c value was 7.6±1.1% (30% below 7%). Metabolic control improved (lower HbA1c) with more daily SMCBG (B=−0.053; p=0.009), a higher educational level (B=0.461; P<0.001), greater number of hypoglycemia episodes (B=−0.253; P=0.018) and carbohydrate counting (B=−0.190; P=0.048), and worsened the longer the duration of the disease (B=0.010; P=0.010), higher total dose of insulin (B=0.010; P<0.0001), poorer adherence to diet (B=0.650; P<0.0001) and a family history of DM (B=−0.233; P=0.007). ConclusionsThe management of patients with DM1 in Spain, as well as the treatment they receive, is similar to that seen in other Western countries. Blood glucose control is associated with educational level, disease duration, and the characteristics of treatment and self-care.

PP284 Volume-Result Relationship Analysis In Digestive Oncological Surgery In Spain By Using Health Data Records

IntroductionIn order to improve patients’ health outcomes, it is important to know the available evidence regarding centralization of surgical interventions for digestive cancer in hospitals with the highest volume of cases. We aim to describe and identify the number of annual interventions recommended by hospitals in order to maximize the health outcomes and efficiency for patients undergoing digestive cancer surgery during 2013–2016 in centers belonging to the Spanish National Health System (SNS).MethodsThe study design was a retrospective cohort study (patients aged ≥18 years). Data from Spanish public hospitals’ basic minimum set of data at hospital discharge for esophagus, stomach, liver, pancreas and rectum cancers was used. Age, sex primary/secondary diagnosis and procedures (Charlson index) were included. Reinterventions, hospital stay and in-hospital mortality were considered as the outcomes and measures of efficiency. Hospitals were grouped as low-/medium-/high-volume according to the number of annual procedures. Descriptive analysis and logistic and Poisson regression models with Stata16 were undertaken.ResultsHigh-volume hospitals performed between 67.4 (rectum) and 88.6 (liver) percent of interventions. The percentage of in-hospital mortality for all cancers was lower in high-volume centers (9.6% esophagus, 6.6% stomach, 7.1% pancreas, 4.2% liver and 2.2% rectum), showing a negative association between center volume and in-hospital mortality, which was statistically significant for esophagus (odds ratio [OR] = 0.48; 95% confidence interval [CI]: 0.28–0.81), stomach (OR = 0.51; 95% CI: 0.39–0.68) and rectum (OR = 0.63; 95% CI: 0.48–0.83) cancers. A non-statistically significant lower in hospital stay was observed in high-volume hospitals.ConclusionsThese results indicate that in Spain there is a negative association between the number of digestive oncological interventions per hospital and in-hospital mortality. This could help to define a threshold or cut-off point for the concentration of digestive cancer surgery in the SNS that might result in an improvement of lower in-hospital mortality and/or hospital stay.

A survey of procedural pain assessment and non-pharmacologic analgesic interventions in neonates in Spanish public maternity units.

To qualify and quantify clinical practices related to pain assessment and non-pharmacologic analgesia (NPA) in newborns in Spanish public maternity hospitals STUDY DESIGN: We surveyed providers online regarding their use of pain assessment scales, NPA interventions in neonates undergoing procedures, as well parents' presence or absence during interventions. The number of painful procedures and the subjective grading of pain from the responding physicians were similar in all hospitals. Only 12.5% of hospitals used pain scales. No NPA was employed in 37.7% of procedures, with less NPA used in the lower complexity hospitals for venous extraction (p < 0.001) and gastric lavage (p = 0.001). Respondents reported parents' absence during 56.1% of procedures. Available pain assessment scales and NPA interventions to mitigate pain are being underused. The presence of the parents during painful interventions is low despite the evidence that this may help to reduce newborns' perception of pain.

Construction, Factor Structure, and Internal Consistency Reliability of the Hospital Physical Therapy Perceived Satisfaction Questionnaire (H-PTPS)

Patient satisfaction is a crucial aspect in the evaluation of the quality of health care provided by health services and units, especially in patients that require physical rehabilitation. This study aims to design and analyze the factor structure and internal consistency reliability of the Hospital Physical Therapy Perceived Satisfaction Questionnaire (H-PTPS) measuring the level of physical therapy patient satisfaction in hospital rehabilitation services. This study has a multicenter cross-sectional survey design. This study used the structural validity and internal consistency domains from COSMIN (consensus-based standards for the selection of health status measurement instruments) guideline. The H-PTPS questionnaire consists of 20 closed questions. A sample of 384 adult patients from physical therapy units from three Spanish public hospitals completed this questionnaire. A factor structure and internal consistency reliability analysis were performed. The factor analysis including the 20 items of the H-PTPS showed an adequacy index of 0.922 according to the Kaiser–Meyer–Olkin measure and the Barlett test allowed us to reject the null hypothesis (p < 0.001). In the rotated component matrix, four specific factors were obtained, explaining 66.75% of the accumulated variance. All factors present satisfactory internal reliability, achieving Cronbach’s alpha indices and Omega coefficients higher than 0.74. The H-PTPS questionnaire has shown a four-factor solution with satisfactory reliability evaluating the satisfaction of Spanish patients treated in physical therapy units in the hospital rehabilitation services.

Práctica actual de la inducción de secuencia rápida en adultos: una encuesta nacional entre anestesiólogos en España

BackgroundRapid sequence induction (RSI) in adults has undergone changes in recent years due to pharmacological and technological advances. The objective of this survey was to evaluate current practice among Spanish anesthesiologists. MethodsA 31-item questionnaire regarding RSI practice was sent to anesthesiologists working in Spanish public hospitals. Differences in responses according to the type of hospital or experience of the respondent were compared for all data using the chi-square and Fisher's exact test. ResultsApproximately 15.89% of Spanish anesthesiologists participated in the survey (1002 questionnaires). The results show considerable heterogeneity in most aspects of RSI. Less than 20% of respondents administer sodium citrate. Sixty-four percent place a nasogastric tube in patients with intestinal obstruction. Gastric residue is assessed by ultrasound in 6% of cases. Only 25% of respondents measure ETO2 to check the effectiveness of preoxygenation, and 22% use nasal oxygen insufflation with nasal prongs or THRIVE. Sixty two percent of respondents apply cricoid pressure, but only 50% release the pressure when encountering intubation difficulty. Up to 40% of respondents reported cases of aspiration despite applying cricoid pressure. Propofol was the most commonly used hypnotic (97.6%), but there was no clear preference in the choice of neuromuscular relaxant (suxamethonium versus rocuronium ratio of approximately 1:1). Only 44% of respondents calculated the dose of sugammadex that would be required for emergency reversal of rocuronium. ConclusionsThe survey showed significant variation in RSI practice, similar to that of other countries. Quality prospective studies are needed to standardize clinical practice.

Influential Variables of Sustainability Disclosures by Spanish Public Hospitals

This paper explores whether the extent of sustainability information disclosed by Spanish public hospitals is affected by internal characteristics of such organizations as well as by political ideology and socioeconomic variables. We used the institutional, stakeholder, and legitimacy theories to explain different levels of sustainability disclosures. To accomplish our goal, we collected data through content analysis of the institutional websites of all Spanish public hospitals registered in the 2016 National Database of Hospitals, corporate annual reports, and sustainability reports published by Spanish hospitals. The results show that the most influential variables associated with the extent of sustainability information disclosed by Spanish public hospitals are the hospitals’ size, political ideology, and reputation as well as the access they have to the Internet. According to the legitimacy theory, the Spanish public hospitals that have revealed more sustainability information are more visible and may be perceived to have greater legitimacy in society. However, the extent of sustainability information disclosed by Spanish public hospitals is far from being adequate. According to the institutional theory, this is explained by the lack of coercive and normative forces.

Statin consumption and risk of post-endoscopic retrograde cholangiopancreatography pancreatitis

BackgroundThe most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP acute pancreatitis (PEP). Statin consumption seems to lower the incidence of acute pancreatitis. We aimed to investigate the relationship between the use of statins and the incidence of PEP. Methodsmulticenter (4 Spanish tertiary-level public hospitals) retrospective cohort study. Adult patients undergoing an ERCP were included in the study. We excluded patients with chronic pancreatitis, with ongoing acute pancreatitis and those who developed other complications after ERCP. Patients were classified into 2 groups: those under statin treatment (group S) and controls (group C). A multivariate analysis was performed (binary logistic regression) including age, center, female gender, previous pancreatitis, suspected sphincter of Oddi dysfunction, difficult cannulation (>10 min), >1 pancreatic guidewire passages, pancreatic injection, pancreatic stenting and presence of choledocholitiasis. Resultsseven hundred and two patients were included, median age 74 (62–82 years), 330 (47%) females, 223 (32%) in group S. Thirty-five (5%) patients developed PEP, 6 (3%) in group S and 29 (6%) in group C. Statin use was not associated with a lower frequency of PEP in univariate analysis, OR 0.429 (95% confidence interval 0.176–1.05, p = 0.06) or in multivariate analysis, adjusted OR 0.5 (0.19–1.32), p = 0.16. Statin use had no effect on severity of PEP, being mild in 50% vs 78.6% in non-statin users, p = 0.306. Conclusionsthe chronic use of statins was not associated with a decreased risk of PEP or a milder course of disease in our sample of patients.

Murine typhus. How does it affect us in the 21st century? The epidemiology of inpatients in Spain (1997–2015)

ObjectiveThe aim of this study was to analyze the epidemiological impact of murine typhus in patients who required hospitalization in the National Health System (SNS) in Spain between 1997 and 2015. BackgroundMurine typhus (MT) is a zoonosis caused by Rickettsia typhi. MT is transmitted from rats, cats, dogs, and opossums to humans by their fleas. The clinical picture is characterized by headache, fever, rash, and liver function alteration. The prevalence of MT is considered underestimated since most cases are mild and self-limited. However, up to 10% of patients develop serious complications such as pneumonia or acute kidney injury and may even need admission to intensive care units. MethodsThis was a retrospective longitudinal descriptive study of inpatients diagnosed with Rickettsia typhi infection (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], 081.0) in Spanish public hospitals between January 1, 1997, and December 31, 2015. Data were obtained from the Minimum Basic Data Set (MBDS, CMBD in Spanish), which includes information about inpatients admitted to the National Health System (NHS) hospitals provided by the Health Information Institute of the Ministry of Health and Equality. ResultsNinety-nine inpatients were included. The incidence rate of MT was 0.12 (95% CI, 0.09-0.14) cases per one million person-years. Cases were irregularly distributed throughout the period of study, with a slight upward trend between 2013 and 2015. The Canary Islands had the highest incidence rate: 2.17 (95% CI, 1.69–2.64) cases per one million person-years (80 cases). Most patients were men (63.6%). The mean age (±SD) was 46.4 years (±19). Five patients were under 15 years old. Approximately 85.9% of cases required urgent hospital admissions. The average hospital stay was 11 days (±9.9). Only 1 patient died. ConclusionsAlthough considered uncommon, the incidence of MT seems to be increasing slowly. Most cases occurred in middle-aged men between late summer and early autumn in Spain. The Canary Islands and Andalusia registered the highest number of cases. The MBDS is an appropriate approach to study MT hospital management.

Sustainability endeavors and sustainable development in Spanish public hospitals

Purpose The research aims to describe the foundation of healthcare organizations’ past and present sustainability endeavors; describe the direction of a health-care organizations’ sustainable development; reveal and characterize what determines the foundation and direction in a public health-care sector; and provide some insights into social marketing for sustainability endeavors. Design/methodology/approach Based on a semi-inductive approach, judgmental sampling was applied to select relevant health-care organizations. Informants were identified according to their knowledge of their organizations’ sustainability initiatives. Findings Offer insights into the foundation of sustainability endeavors and the direction of sustainable development for upstream social marketing in the studied public sector. The social marketing perspective is a common factor of relevance for the studied public hospitals. Research limitations/implications The foundations of sustainability endeavors undertaken across the studied health-care organizations have not so far been homogenous. The direction of sustainable development has also varied across the studied public healthcare organizations and there is a need to move beyond individuals and shift from a micro to a macro/structural environment of sustainable development, so as to observe the effectiveness of any social marketing intervention. Practical implications This study highlights the importance of applying an upstream social marketing approach and programs, as part of a social marketing strategy, to promote and stimulate sustainable change in health-care organizations. Social implications Contrary to the common sense predominating in many societies nowadays regarding sustainability endeavors and sustainable development, we conclude that neither the foundation of such endeavors nor the direction of sustainable development has progressed adequately in the studied public healthcare sector. As social marketing is intended to benefit society and foster social change, the macro level of intervention of the upstream approach clearly reveals its usefulness in the public health area. Originality/value Reveals two axes based on a social marketing approach. One is of micro and macro determinants characterizing the direction of sustainable development in a public sector. Another is of homogeneous and heterogeneous foundations of sustainability endeavors.

Self-efficacy and organizational commitment among Spanish nurses: the role of work engagement.

The objective of this study was to verify the mediating role of work engagement between self-efficacy and affective organizational commitment on the basis of the Job Demands-Resources Model in a sample of Spanish nursing staff. Affective organizational commitment is a key element, both for the permanence of nursing staff and for the provision of an excellent quality of care of health organizations. However, the relationships between self-efficacy, work engagement and affective commitment to the organization have been little explored within the nursing context. A total of 527 nursing professionals from Spanish public hospitals in Andalusia were surveyed, obtaining a convenience sample of 324 participants (52.96% nurses, 47.04% nursing assistants). The mediating role of work engagement was examined using structural equationmodelling and the bootstrapping method. The results showed that affective organizational commitment was positively predicted by self-efficacy and work engagement. Work engagement had a direct effect on affective organizational commitment, while the effect of self-efficacy on affective commitment was totally mediated by work engagement. The results give empirical support to the Job Demands-Resources Model, which raises the mediating role of work engagement between self-efficacy (personal resource) and affective organizational commitment (organizational result). Health organizations should be aware that a greater perception of efficacy beliefs and work engagement strengthens the affective bond with the organization, thus improving the corporate image of the health institution. Policy changes are necessary to create work environments that enhance the self-efficacy of nursing staff and generate high levels of work engagement, such as flexible training plans and informal support groups.

Differences between patient-driven adherence to vitamin K antagonists and direct oral anticoagulants. Do few missed doses matter? ACO-MEMS Study

IntroductionLack of INR controls might affect the adherence to direct oral anticoagulants (DOAC). The vast majority of studies that addresses adherence to anticoagulants are retrospective and based on pharmacy refill data. Our aim was to compare the adherence between vitamin K antagonists (VKA) and DOAC and to analyze the clinical relevance of non-adherence. Materials and methodsA prospective two-arm observational cohort study was performed in two Spanish public hospitals. Adherence was assessed by Medication Event Monitoring System. Relationship between adherence and events during follow-up and time in therapeutic range (TTR) in the VKA group were analyzed. Results257 patients were included (132 DOAC and 125 VKA). Monitoring time was 120 days (101−133). Patients in VKA group showed higher taking adherence (97.9% vs. 95.8%) and less non-adherent patients of >5% and >10% of the doses, without differences in >20% of the doses. Taking adherence was strongly associated with TTR (AUC: 0.89, CI 95%: 0.81–0.97 of TTR for detection of non-adherent patients of >10% of doses). During a follow-up of 1.8 years (1.6–2) non-adherent patients of >5% of doses presented more thromboembolic events (HR 6.1, CI95% 1.3–28.1). ConclusionsAlthough adherence to oral anticoagulant therapy was excellent, it was higher to VKA than to DOAC. Time in therapeutic range was highly sensitive to few missed doses of AVK. Non-adherence of >5% of prescribed doses had high clinical relevance.