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The clinical value of transanal total mesorectal excision is debated.This study aimed to compare short- and medium-term effects of transanal versus anterior total mesorectal excision for rectal cancer.This was a multicenter retrospective cohort study.The study included all Catalonian public hospitals.All patients receiving transanal or anterior total mesorectal excision (open or laparoscopic) for nonmetastatic primary rectal cancer in 2015 to 2016 were included.Data on vital status were collected to March 2019. Between-group differences were minimized by applying propensity score matching to baseline patient characteristics. Competing risk models were used to assess systemic and local recurrence along with death at 2 years, and multivariable Cox regression was used to assess 2-year disease-free survival. Results are expressed with their 95% CIs.The final subsample was 537 patients receiving total mesorectal excision (transanal approach: n = 145; anterior approach: n = 392). Median follow-up was 39.2 months (interquartile range, 33.0-45.8). Accounting for death as a competing event, there was no association between transanal total mesorectal excision and local recurrence (matched subhazard ratio 1.28, 95% CI 0.55-2.96). There were no statistical differences in the comparative rate of local recurrence (transanal: 1.77 per 100 person-years, 95% CI 0.76-3.34; anterior: 1.37 per 100 person-years, 95% CI 0.8-2.15) or mortality (transanal: 3.98 per 100 person-years, 95% CI 2.36-6.16; anterior: 2.99 per 100 person-years, 95% CI 2.1-4.07). Groups presented similar 2-year cumulative incidence of local recurrence (4.83% versus 3.57%) and disease-free survival (HR, 1.33; 95% CI 0.92-1.92).We used data only from the public system, the study is retrospective, and data on individual surgeons are not reported.These population-based results support the use of either the transanal, open, or laparoscopic approach for rectal cancer in Catalonia. See Video Abstract at http://links.lww.com/DCR/B744.ESCISIÓN MESORRECTAL TOTAL TRANSANAL VERSUS ESCISIÓN MESORRECTAL TOTAL ANTERIOR PARA EL CÁNCER DE RECTO: UN ESTUDIO POBLACIONAL CON EMPAREJAMIENTO DE PUNTAJE DE PROPENSIÓN EN CATALUÑA, ESPAÑA.Se debate el valor clínico de la escisión mesorrectal total transanal.Comparar los efectos a corto y mediano plazo de la escisión mesorrectal total transanal versus anterior para el cáncer de recto.Este fue un estudio de cohorte retrospectivo multicéntrico.El estudio incluyó a todos los hospitales públicos de Cataluña.Todos los pacientes no metastásicos que recibieron escisión mesorrectal total anterior o transanal (abierta o laparoscópica) por cáncer de recto primario en 2015-16.Los datos sobre el estado vital se recopilaron hasta marzo de 2019. Las diferencias entre los grupos se minimizaron aplicando el emparejamiento de puntajes de propensión a las características iniciales del paciente. Se utilizaron modelos de riesgo competitivo para evaluar la recurrencia sistémica y local junto con la muerte a los dos años, y la regresión de Cox multivariable para evaluar la supervivencia libre de enfermedad a dos años. Los resultados se expresan con sus intervalos de confianza del 95%.La submuestra final fue de 537 pacientes que recibieron escisión mesorrectal total (abordaje transanal: n = 145; abordaje anterior: n = 392). La mediana de seguimiento fue de 39,2 meses (rango intercuartílico 33,0-45,8). Teniendo en cuenta la muerte como un evento competitivo, no hubo asociación entre la escisión mesorrectal total transanal y la recurrencia local (cociente de subriesgo apareado 1,28, 0,55-2,96). No hubo diferencias estadísticas en la tasa comparativa de recurrencia local (transanal: 1,77 por 100 personas-año, 0,76-3,34; anterior: 1,37 por 100 personas-año, 0,8-2,15) o mortalidad (transanal: 3,98 por 100 personas-año, 2,36-6,16; anterior: 2,99 por 100 personas-año, 2,1-4,07). Los grupos presentaron una incidencia acumulada de dos años similar de recidiva local (4,83% frente a 3,57%, respectivamente) y supervivencia libre de enfermedad (índice de riesgo 1,33, 0,92-1,92).Utilizamos datos solo del sistema público, el estudio es retrospectivo y no se informan datos sobre cirujanos individuales.Estos resultados poblacionales apoyan el uso del abordaje transanal, abierto o laparoscópico para el cáncer de recto en Cataluña. Consulte. Video Resumen en http://links.lww.com/DCR/B744. (Traducción- Dr. Francisco M. Abarca-Rendon).

Background: : Despite the efficacy of biological agents, surgery is still required for a large percentage of patients with inflammatory bowel disease (IBD). Aims: To assess the postoperative mortality rates and associated risk factors in IBD patients in a population-based setting in the era of biological agents. Methods: This is a population-based longitudinal study including all patients diagnosed with IBD in Catalonia who underwent intestinal resection or colectomy between 2007 and 2016, identified from the Catalan Health Surveillance System database. Logistic regression was used to calculate the adjusted odds ratio for postoperative in-hospital and 30-day mortality. Data for Crohn's disease (CD) and ulcerative colitis (UC) were analysed separately. Results: A total of 1,660 interventions for CD (69%) and 738 for UC (31%) were performed at 55 centres. In-hospital and 30-day postoperative mortality rates were 2.1% and 2.5% for CD, and 5.4% and 6.4% for UC, respectively. In the multivariate logistic regression analysis, comorbidity was associated with in-hospital and 30-day postoperative mortality in CD and UC, whereas age was only associated with mortality in CD and a non-laparoscopic surgical approach with UC. Conclusions: In the era of biologicals, the postoperative mortality rate for IBD depends mostly on comorbidities and age. (C) 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Resumen: Introducción: Los grupos de morbilidad ajustados (GMA) y los clinical risk groups (CRG) son herramientas de estratificación poblacional basada en la morbilidad que permiten clasificar a los pacientes en categorías mutuamente excluyentes. Objetivo: Comparar la estratificación, según niveles de complejidad, proporcionada por los GMA con la de los CRG y con la realizada ad-hoc por los evaluadores. Diseño: Muestra aleatoria por estratos de riesgo de morbilidad. Emplazamiento: Cataluña. Participantes: Cuarenta médicos de atención primaria emparejados 2 a 2. Intervenciones: Cada pareja de evaluadores tuvo que validar 25 historias. Mediciones principales: Se evaluó la concordancia entre evaluadores, y entre los evaluadores y los resultados obtenidos por los 2 agrupadores de morbilidad con el índice kappa, la sensibilidad, la especificidad, el valor predictivo positivo y el negativo. Resultados: La concordancia entre evaluadores se situó alrededor del valor kappa 0,75 (valor medio = 0,67), entre los GMA y los evaluadores fue similar (valor medio = 0,63), y más elevada que para los CRG (valor medio = 0,35). Los profesionales otorgaron una puntuación de 7,5 a la bondad de ambos agrupadores, aunque para los estratos de mayor complejidad, según asignación de los profesionales, los GMA obtuvieron mejores puntuaciones que los CRG. Los profesionales prefirieron mayoritariamente los GMA frente a los CRG. Estas diferencias se incrementaron con el aumento de la complejidad de los pacientes según el criterio clínico.Globalmente, se encontró menos de un 2% de errores graves de clasificación proporcionada por ambos agrupadores. Conclusión: Los profesionales consideraron que ambos agrupadores clasificaban adecuadamente a la población, aunque los GMA tienen un mejor comportamiento en los estratos que los profesionales identifican como de mayor complejidad. Además, en la mayoría de los casos, los evaluadores clínicos prefirieron los GMA. Abstract: Introduction: Adjusted Morbidity Groups (GMAs) and the Clinical Risk Groups (CRGs) are population morbidity based stratification tools which classify patients into mutually exclusive categories. Objetive: To compare the stratification provided by the GMAs, CRGs and that carried out by the evaluators according to the levels of complexity. Design: Random sample stratified by morbidity risk. Location: Catalonia. Participants: Forty paired general practitioners in the primary care, matched pairs. Interventions: Each pair of evaluators had to review 25 clinical records. Main outputs: The concordance by evaluators, and between the evaluators and the results obtained by the 2 morbidity tools were evaluated according to the kappa index, sensitivity, specificity, and positive and negative predicted values. Results: The concordance between general practitioners pairs was around the kappa value 0.75 (mean value = 0.67), between the GMA and the evaluators was similar (mean value = 0.63), and higher than for the CRG (mean value = 0.35). The general practitioners gave a score of 7.5 over 10 to both tools, although for the most complex strata, according to the professionals’ assignment, the GMA obtained better scores than the CRGs. The professionals preferred the GMAs over the CRGs. These differences increased with the complexity level of the patients according to clinical criteria.Overall, less than 2% of serious classification errors were found by both groupers. Conclusion: The evaluators considered that both grouping systems classified the studied population satisfactorily, although the GMAs showed a better performance for more complex strata. In addition, the clinical raters preferred the GMAs in most cases. Palabras clave: Agrupador de morbilidad, Multimorbilidad, Validación clínica, Keywords: Morbidity grouper, Multimorbidity, Clinical Validation

Resumen Los cambios que se estan produciendo en los paises occidentales obligan a los sistemas sanitarios a adaptarse a las nuevas necesidades y expectativas de la poblacion. En Cataluna se esta produciendo una profunda transformacion del modelo asistencial, con el fin de poder dar una respuesta adecuada a esta nueva situacion y a la vez garantizar la sostenibilidad del sistema en un contexto de crisis economica. Esta transformacion se basa en convertir el actual modelo asistencial centrado en la enfermedad y fraccionado por niveles en otro centrado en la persona, integrado y de base territorial, que promueva el trabajo compartido en red de los diferentes profesionales, dispositivos y niveles asistenciales, estableciendo objetivos comunes explicitados en acuerdos y pactos territoriales. Los cambios que ha llevado a cabo el Servei Catala de la Salut (CatSalut) pasan principalmente por incrementar la capacidad de resolucion de la atencion primaria, reducir la variabilidad de la practica clinica, evolucionar hacia hospitales mas quirurgicos, potenciar las alternativas a la hospitalizacion convencional, desarrollar modalidades de atencion no presencial, concentrar y sectorizar territorialmente la atencion de alta complejidad y disenar codigos sanitarios especificos, como respuesta a situaciones de emergencia. La finalidad de estas actuaciones es mejorar la efectividad, la calidad, la seguridad y la eficiencia del sistema asegurando la equidad de acceso de la poblacion y el equilibrio territorial. Entre los instrumentos que deben facilitar y promover estos cambios cabe destacar la historia clinica compartida, el nuevo modelo de contratacion y pago por resultados, los pactos territoriales, las alianzas entre centros, el aprovechamiento de las potencialidades de las tecnologias de la informacion y la comunicacion, y la evaluacion de resultados.

Uno de los retos mas importantes de los sistemas sanitarios es decidir que prestaciones se han de concentrar, ateniendonos a su baja frecuencia, complejidad, riesgo, experiencia acumulada y costes, entre otros factores. La concentracion ha de permitir garantizar la calidad de la prestacion y los mejores resultados posibles. En este articulo se describen los elementos conceptuales, los criterios de referencia, el impacto en los centros y las condiciones necesarias que han de reunir los dispositivos, y que se han tenido en cuenta en la reordenacion de la alta complejidad en Cataluna. Tambien se exponen algunos de los temas que se han tratado en el proceso de reordenacion, como la cardiologia terciaria, tanto en el apartado de la cirugia cardiaca como en el de la angioplastia coronaria terapeutica, y la oncologia, en el apartado de las cirugias oncologicas poco frecuentes. Tambien se abordan el trasplante renal, la atencion al politraumatismo grave y el despliegue de la tomografia por emision de positrones.

OBJECTIVE: To find out, from the health professionals’ point of view, how different immigrant groups access and use the health services. DESIGN: Qualitative, descriptive and phenomenological study carried out in Barcelona between September and December of 2007. SETTING: The study was carried out in the 6 Basic Health Areas of Barcelona, where there is a higher percentage of immigrant population, and in 3 public hospitals. PARTICIPANTS: A total of 73 hospital and primary health care professionals. Theoretical sampling was carried out on respondents who defined 4 professional profiles: directors or coordinators, physicians, nurses, and cultural mediators. METHODS: There were 7 debate groups and 12 partly-structured interviews. Both the interviews and groups were analysed by a narrative analysis of the content. RESULTS: The outcomes indicate that, according to the professionals, the immigrant patients do not find barriers that can make their access to health services more difficult. The perception that the emergency service is their main access gate for them is unanimous, as well as that most of the immigrant patients have less continuity of care. Finally, professionals detect differences in the access and use of health services depending on their origin and the level of social integration of the immigrant group. CONCLUSIONS: Professionals attribute a higher use of emergencies, late access to the health services, and less continuity of care, to a series of factors related to economic precariousness and to aspects related to the social inclusion. There is the room for social inclusion policies to reduce these inequalities.

One of the principal challenges in healthcare systems is deciding which services have to be concentrated, taking into account, among other things, their low-frequency, complexity, risk, accumulated experience and costs., Concentration must make it possible to guarantee the quality of the service and the best results possible. This article describes, the conceptual elements, the benchmark criteria, the impact on the centres and the minimum conditions that the mechanisms must meet, which have been taken into account in the reorganisation of high-complexity services in Catalonia. Some of those issues that have been dealt with in the restructuring process are also considered, such as tertiary cardiology, in both the cardiac surgery and therapeutic coronary angioplasty sections, and oncology in the section of infrequent oncological surgery. Renal transplants, serious multiple-trauma care and the use of positron emission tomography are also dealt with.

Performance assessment of healthcare services is receiving greater attention due to increasing health care expenditures, greater expectations among the population, and the need to obtain results from the invested resources. Taking advantage of the existing experience of the Agència de Salut Pública de Barcelona and the Consorci Sanitari de Barcelona, which compared the healthcare services of Barcelona and Montreal, a grant from the Agència d'Avaluació de Tecnologia i Recerca Mèdiques, and the health planning interest of the Departament de Salut, the performance assessment of the Catalan healthcare service project was started in Catalonia in 2005. This article aims to present the development of the project, to provide some examples that illustrate the kind of numerical and graphical information that could be obtained and the kind of analysis that could be performed, to provide possible explanations for the results shown, and to discuss some limitations and implications. Currently, the added value of this project is that it identifies the extent to which the healthcare system is achieving its objectives, establishes a set of homogeneous indicators that could be used in the future, and is a key tool in the development of the Central de Resultats del Departament de Salut de la Generalitat de Catalunya.

The objective of this paper is to apply a framework for country-level performance assessment to the cities of Montreal, Canada, and Barcelona, Spain, and to use this framework to explore and understand the differences in their health systems. The UK National Health Service Performance Assessment Framework was chosen. Its indicators went through a process of selection, adaptation and prioritisation. Most of them were calculated for the period 2001-3, with data obtained from epidemiological, activity and economic registries. Montreal has a higher number of old people living alone and with limitations on performing one or more activities of daily life, as well as longer hospital stays for several conditions, especially in the case of elderly patients. This highlights a lack of mid-term, long-term and home care services. Diabetes-avoidable hospitalisation rates are also significant in Montreal, and are likely to improve following reforms in primary care. Efficient health policies such as generic drug prescription and major ambulatory surgery are lower in Barcelona. Rates of caesarean deliveries are higher in Barcelona, owing to demographics and clinical practice. Waiting times for knee arthroplasty are longer in Barcelona, which has triggered a plan to reduce them. In both cities, avoidable mortality and the prevalence of smoking have been identified as areas for improvement through preventive services. In conclusion, performance assessment fits perfectly in an urban context, as it has been shown to be a useful tool in designing and monitoring the accomplishment of programmes in both cities, to assess the performance of the services delivered, and for use in policy development.

To ascertain why people attend hospital emergency departments (ED) for low complexity health problems.A phenomenological, interactionist, qualitative study was performed. A theoretical sample that selected one urban and one rural area from Catalonia (Spain) was designed. In each setting, persons (n = 36) who had used the ED or a primary care emergency service 1 month before the beginning of the study were chosen. Data were obtained through 8 focus groups. An interpretative content analysis was performed, and emergent categories were constructed through research triangulation.Five categories emerged: symptoms, whether or not self-diagnosis was involved, perception of needs, awareness of the health services available, and the overall context of the person. Symptoms generated feelings of failing health and thus initiated care seeking. Self-diagnosis determined perceived need and the type of care sought. People contrasted their self-perception of need with their own opinion about the health services available. The decision to go to one or other service was made as a result of this contrast, but the individual's family, work, and social situations also played a part. Informants were more familiar with the service provided by the ED than with that provided by primary care. Time consumption also figured heavily in decision making.The presence or absence of self-diagnosis is a determining factor in attendance at EDs. Other factors that influence demand are the level of awareness of the health services available, previous experiences, and the life situation of the individual.

ResumenObjetivoConocer por qué las personas acuden a los servicios de urgencia hospitalarios (SUH) por problemas de salud de baja complejidad.MétodoSe realizó una investigación cualitativa de tipo fenomenológica interaccionista. La muestra teórica pertenecía a un área urbana y otra rural de Cataluña. Se escogieron personas (n = 36) que habían acudido a los SUH o a servicios de urgencia de la atención primaria de salud (SUAP) en el mes previo a su selección. Se recogieron datos en 8 grupos focales. Se realizó un análisis inductivo descriptivo-interpretativo, construyendo categorías emergentes a partir de la triangulación.ResultadosEmergieron 5 categorías: síntomas, elaboración de autodiagnóstico, percepción de necesidad, conocimiento de la oferta y contexto global de la persona. Los síntomas generan la consideración de pérdida de salud y desencadenan la acción. La elaboración del autodiagnóstico determina la necesidad-tipo de atención. Del contraste entre la percepcióntipo de necesidad y el conocimiento de la oferta de los servicios, así como de la situación vital de la persona, surge la decisión de acudir a un servicio u otro y se genera la acción. El conocimiento de la oferta de los SUH es mejor que el de los SUAP. El tiempo parece básico en la toma de decisiones.ConclusionesLa elaboración de un autodiagnóstico es crítica en la determinación de la acción, pero el conocimiento de la oferta de los servicios, las experiencias previas y la situación vital de la persona modulan el tipo de demanda.AbstractObjectiveTo ascertain why people attend hospital emergency departments (ED) for low complexity health problems.MethodA phenomenological, interactionist, qualitative study was performed. A theoretical sample that selected one urban and one rural area from Catalonia (Spain) was designed. In each setting, persons (n=36) who had used the ED or a primary care emergency service 1 month before the beginning of the study were chosen. Data were obtained through 8 focus groups. An interpretative content analysis was performed, and emergent categories were constructed through research triangulation.ResultsFive categories emerged: symptoms, whether or not self-diagnosis was involved, perception of needs, awareness of the health services available, and the overall context of the person. Symptoms generated feelings of failing health and thus initiated care seeking. Self-diagnosis determined perceived need and the type of care sought. People contrasted their selfperception of need with their own opinion about the health services available. The decision to go to one or other service was made as a result of this contrast, but the individual’s family, work, and social situations also played a part. Informants were more familiar with the service provided by the ED than with that provided by primary care. Time consumption also figured heavily in decision making.ConclusionsThe presence or absence of self-diagnosis is a determining factor in attendance at EDs. Other factors that influence demand are the level of awareness of the health services available, previous experiences, and the life situation of the individual.

Background: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective. Methods: A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was 25 assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September- December 2014, with healthcare professionals, managers and experts. Results: From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision 30 (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level. Conclusion: The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to 35 strengthen the centralization strategy.