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Aida Ribera,1–3 Sònia Abilleira,1,3 Gaietà Permanyer-Miralda,2,3 Ricard Tresserras,4 Joan MV Pons,1,3 Miquel Gallofré3,4 1Stroke Program, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain; 2Cardiovascular Epidemiology Unit, Hospital Vall d'Hebron, Barcelona, Spain; 3CIBER Epidemiología y Salud Pública, Madrid, Spain; 4Stroke Program, Department of Health, Autonomous Government of Catalonia, Barcelona, Spain Background: Development of process-based quality measures has been of increasing interest. We aimed to construct a composite quality measure for acute stroke care and to evaluate its performance at the hospital level. Methods: We used data from the Stroke Audit 2007, based on retrospective review of medical charts linked to the Mortality Register 2007–2008 (Catalonia, Spain). Eight quality measures were selected on the basis of clinical relevance, scientific evidence, and relationship to mortality: screening of dysphagia, initiation of antiplatelets at less than 48 hours (if ischemic stroke), early mobilization, assessment of rehabilitation, management of hypertension, management of dyslipidemia, anticoagulation in case of atrial fibrillation (if ischemic stroke), and antithrombotics on discharge (ischemic strokes only). We constructed an opportunity-based composite quality measure of eight individual measures and correlated noncompliance with the individual and composite quality measures with risk-standardized 30-day mortality at the hospital level. Noncompliance with the opportunity-based composite measure was calculated as the sum of the total instances that a required individual measure was not performed or not documented. Multilevel linear regression analyses were conducted to assess the variability of noncompliance at the hospital level and to what extent variability could be explained by differences in hospital characteristics. Results: We analyzed data from 1,686 patients (representing 9,334 opportunities for compliance with the composite quality measure) admitted to 47 acute hospitals. Noncompliance with the composite was 32.7% (95% confidence interval [CI], 31.5%–33.9%), and the correlation with hospital risk-adjusted 30-day mortality was 0.24 (P=0.1). Using multilevel logistic modeling, hospitals with an intermediate number of annual stroke admissions (150–350 versus

Background: This article reports on the impact assessment experience of a funding program of non-commercial clinical and health services research. The aim was to assess the level of implementation of results from a subgroup of research projects (on respiratory diseases), and to detect barriers (or facilitators) in the translation of new knowledge to informed decision-making. Methods: A qualitative study was performed. The sample consisted of six projects on respiratory diseases funded by the Agency for Health Quality and Assessment of Catalonia between 1996 and 2004. Semi-structured interviews to key informants including researchers and healthcare decision-makers were carried out. Interviews were recorded, transcribed verbatim and analysed on an individual (key informant) and group (project) basis. In addition, the differences between achieved and expected impacts were described. Results: Twenty-three semi-structured interviews were conducted. Most participants indicated changes in health services or clinical practice had resulted from research. The channels used to transfer new knowledge were mainly conventional ones, but also in less explicit ways, such as with the involvement of local scientific societies, or via debates and discussions with colleagues and local leaders. The barriers and facilitators identified were mostly organizational (in research management, and clinical and healthcare practice), although there were also some related to the nature of the research as well as personal factors. Both the expected and achieved impacts enabled the identification of the gaps between what is expected and what is truly achieved. Conclusions: In this study and according to key informants, the impact of these research projects on decisionmaking can be direct (the application of a finding or innovation) or indirect, contributing to a more complex change in clinical practice and healthcare organization, both having other contextual factors. The channels used to transfer this new knowledge to clinical practice are complex. Local scientific societies and the relationships between researchers and decision-makers can play a very important role. Specifically, the relationships between managers and research teams and the mutual knowledge of their activity have shown to be effective in applying research funding to practice and decision-making. Finally the facilitating factors and barriers identified by the respondents are closely related to the idiosyncrasy of the human relations between the different stakeholders involved.

ResumenObjetivoEl Cuestionario SF-36 es uno de los instrumentos de Calidad de Vida Relacionada con la Salud (CVRS) más utilizados y evaluados. Tras una década de uso este artículo revisa críticamente el contenido, propiedades métricas y nuevos desarrollos de la versión española.MétodosRevisión de los artículos indizados en Medline (Pub-Med) y en las bases de datos IBECS e IME que han utilizado la versión española del cuestionario. Se seleccionaron los artículos con información sobre modelo de medida, fiabilidad, validez y sensibilidad al cambio del instrumento.ResultadosSe encontraron 79 artículos, 17 de los cuales describían características métricas del cuestionario. En el 96% las escalas superaron el estándar propuesto de fiabilidad (α de Cronbach) de 0,7. Las estimaciones agrupadas obtenidas por metaanálisis fueron superiores a 0,7 en todos los casos. El SF-36 mostró buena discriminación entre grupos de gravedad, correlación moderada con indicadores clínicos y alta con otros instrumentos de CVRS. El SF-36 predijo mortalidad y detectó mejoría tras la angioplastia coronaria, la cirugía de hipertrofia prostática benigna o la ventilación domiciliaria no invasiva. Los nuevos desarrollos descritos (puntuaciones basadas en normas, la versión 2, el SF-12 y el SF-8) mejoraron sus propiedades métricas y su interpretación.ConclusionesEl SF-36, conjuntamente con las nuevas versiones desarrolladas, es un instrumento muy adecuado para su uso en investigación y en la práctica clínica.AbstractObjectiveThe Short Form-36 Health Survey (SF-36) is one of the most widely used and evaluated generic health-related quality of life (HRQL) questionnaires. After almost a decade of use in Spain, the present article critically reviews the content and metric properties of the Spanish version, as well as its new developments.MethodsA review of indexed articles that used the Spanish version of the SF-36 was performed in Medline (PubMed), the Spanish bibliographic databases IBECS and IME. Articles that provided information on the measurement model, reliability, validity, and responsiveness to change of the instrument were selected.ResultsSeventy-nine articles were found, of which 17 evaluated the metric characteristics of the questionnaire. The reliability of the SF-36 scales was higher than the suggested standard (Cronbach's alpha) of 0.7 in 96% of the evaluations. Grouped evaluations obtained by meta-analysis were higher than 0.7 in all cases. The SF-36 showed good discrimination among severity groups, moderate correlations with clinical indicators, and high correlations with other HRQL instruments. Moreover, questionnaire scores predicted mortality and were able to detect improvement due to therapeutic interventions such as coronary angioplasty, benign prostatic hyperplasia surgery, and non-invasive positive pressure home ventilation. The new developments (normbased scoring, version 2, the SF-12 and SF-8) improved both the metric properties and interpretation of the questionnaire.ConclusionsThe Spanish version of the SF-36 and its recently developed versions is a suitable instrument for use in medical research, as well as in clinical practice.

ObjectivesThe goal of this study was to assess the risk associated with double antiplatelet therapy (DAT) discontinuation, and specifically, temporary discontinuation, during the first year after drug-eluting stent (DES) implantation.BackgroundDoubts remain about the risk of temporary DAT discontinuation within 1 year after DES implantation.MethodsA total of 1,622 consecutive patients undergoing DES implantation at 29 hospitals were followed up at 3, 6, 9, and 12 months to record the 1-year antiplatelet therapy discontinuation (ATD) rate, the number of days without DAT, and the rate of 1-year major cardiac events. Cox regression was used to analyze the association between ATD considered as a time-dependent covariate and 1-year cardiac events.ResultsOne hundred seventy-two (10.6%) patients interrupted at least 1 antiplatelet drug during the first year after DES implantation, although only 1 during the first month. Most (n = 111, 64.5%) interrupted DAT temporarily (median: 7 days; range: 5 to 8.5): 79 clopidogrel (31 temporarily), 38 aspirin (27 temporarily), and 55 both drugs (53 temporarily). Discontinuation was followed by acute coronary syndrome in 7 (4.1%; 95% confidence interval [CI]: 1.7 to 8.2), a similar rate of major cardiac events to that in patients without ATD (n = 80; 5.5%; 95% CI: 4.4 to 6.8; p = 0.23). ATD was not independently associated with 1-year major cardiac events (hazard ratio: 1.32 [95% CI: 0.56 to 3.12]).ConclusionsATD within the first year and beyond the first month after DES is not exceptional, is usually temporary, and does not appear to have a large impact on risk.