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National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

Resumen Una de las propuestas para conseguir mejorar la practica clinica es la incorporacion de sistemas informatizados de apoyo a las decisiones (SADC) y su integracion con los registros clinicos electronicos. El objetivo de este trabajo es revisar de forma sistematica la evidencia sobre la eficacia de los SADC en el manejo de la depresion. Para ello se realizo una busqueda bibliografica en Medline, EMBASE y PsycInfo. La calidad de los estudios cuantitativos se evaluo mediante el metodo SIGN y los estudios cualitativos mediante el checklist de CASPe. Se identificaron 7 estudios (3 ensayos clinicos aleatorizados, 3 ensayos no aleatorizados y un estudio cualitativo). Los SADC evaluados incorporaron contenidos derivados de guias u otros productos basados en la evidencia. En lineas generales, los SADC mostraron un impacto positivo sobre diferentes aspectos como el cribado y diagnostico, tratamiento, mejora de sintomas depresivos y calidad de vida y derivacion de pacientes a asistencia especializada. El empleo de SADC podria optimizar la atencion de la depresion en diversos escenarios mediante la provision de recomendaciones basadas en la mejor evidencia disponible y la facilitacion de la toma de decisiones de los profesionales en la practica clinica.

Resumen Objetivo: El presente trabajo surge con el propósito de desarrollar una metodología explícita para la selección de prioridades sanitarias que apoye la toma de decisiones sobre las tecnologías a evaluar de cara a su inclusión en la cartera de servicios del Sistema Nacional de Salud. El objetivo principal es identificar y analizar los criterios, procesos y marcos conceptuales empleados para la priorización de intervenciones sanitarias en el ámbito nacional e internacional. Método: Se ha llevado a cabo una revisión exhaustiva de la literatura. Para ello, se ha buscado en las principales bases de datos biomédicas y se han revisado las páginas web de las principales agencias de evaluación, entre otras fuentes. Resultados: En términos generales, se encontró que no existen criterios universales ni procedimientos estándar para la asignación de prioridades, aunque se han identificado algunos acuerdos y tendencias comunes respecto a aspectos fundamentales (criterios, modelos y estrategias, actores clave, etc.). Globalmente se identificaron ocho dominios críticos: 1) necesidad de la intervención; 2) resultados en salud; 3) tipo de beneficio de la intervención; 4) consecuencias económicas; 5) conocimiento existente sobre la intervención/calidad e incertidumbre de la evidencia; 6) implementación y complejidad de la intervención/factibilidad; 7) prioridad, justicia y ética; y 8) contexto global. Conclusiones: La revisión proporciona un análisis detallado de los aspectos relevantes y ofrece recomendaciones clave para el desarrollo de un marco de priorización nacional. Se plantea que esta información podría ser útil para diferentes organizaciones públicas que pretendan establecer prioridades sanitarias.

Desarrollado con los objetivos de aportar una metodología consensuada para elaborar GPC basadas en la evidencia científica así como para homogeneizar el proceso de elaboración de guías. Está organizado conforme a la secuencia de las diferentes etapas en el desarrollo de una guía y consta de diferentes apartados concebidos como unidades de uso independiente. Como novedad metodológica, desarrolla con detalle el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE).

This study was carried out to develop an explicit health priority setting methodology to support decision-making regarding the technologies to be assessed for inclusion in the National Health Service service portfolio. The primary objective is to identify and analyse the criteria, approaches and conceptual frameworks used for national/international priority setting.An exhaustive review of the literature was carried out. For this purpose, a search of the main biomedical databases was performed and assessment agency websites were reviewed, among other sources.In general terms, it was found that there are no standardised criteria for priority setting, although some consensus and common trends have been identified regarding key elements (criteria, models and strategies, key actors, etc.). Globally, 8 key domains were identified: 1) need for intervention; 2) health outcomes; 3) type of benefit of the intervention; 4) economic consequences; 5) existing knowledge on the intervention/quality of and uncertainties regarding the evidence; 6) implementation and complexity of the intervention/feasibility; 7) priority, justice and ethics; and 8) overall context.The review provides a thorough analysis of the relevant issues and offers key recommendations regarding considerations for developing a national prioritisation framework. Findings are envisioned to be useful for different public organisations that are aiming to establish healthcare priorities.

ResumenLas guías de práctica clínica pretenden servir de puente entre los niveles de decisión y las fuentes de conocimiento, ofreciendo a los decisores la mejor síntesis de la evidencia científica y un análisis del contexto, para proporcionar elementos de juicio y poder trasladar el conocimiento científico a la práctica clínica. Sin embargo, su impacto real en la asistencia sanitaria es variable y la efectividad a la hora de cambiar la práctica médica moderada. Estudios cualitativos y cuantitativos nos muestran que para la mayoría de los médicos de atención primaria las guías son una valiosa fuente de asesoramiento y formación, y creen que mejoran la calidad de la atención sanitaria. No obstante, subrayan su rigidez, la dificultad para aplicar a pacientes individuales y que su objetivo es reducir costes sanitarios. En España existen diversas experiencias en la elaboración de guías de práctica clínica, muchas de ellas dirigidas específicamente a atención primaria, siendo destacable el papel que en este sentido está jugando GuíaSalud. Pero la adecuada implementación de una guía de práctica clínica incluye no solamente la calidad y la rigurosidad de las evidencias utilizadas para desarrollarla, sino también la credibilidad de los profesionales y las organizaciones que la elaboran y otros factores contextuales, como características de los pacientes, de los proveedores y de las organizaciones o sistemas. Un importante paso en la investigación futura será desarrollar una mejor comprensión teórica sobre el cambio organizativo que se requiere para que los sistemas de gestión y los profesionales den la orientación adecuada a la implementación de las guías de práctica clínica.AbstractClinical practice guidelines are intended to serve as a bridge between the decision levels and the sources of knowledge, giving decision makers the best synthesis of scientific evidence and an analysis of context, to provide elements of judgement and to transfer scientific knowledge into clinical practice. However, the actual impact on health care is variable and effectiveness in changing medical practice, moderate. Qualitative and quantitative studies show that most primary care physicians consider that the guides are a valuable source of advice and training and a kind of improving the quality of healthcare. However, they underline its rigidity, the difficulty to apply to individual patients and that their main goal is to reduce healthcare costs. In Spain, there are several experiences as GuíaSalud in developing clinical practice guidelines aimed specifically at primary care. However, the proper implementation of a clinical practice guideline includes not only the quality and thoroughness of the evidence, but the credibility of professionals and organizations and other contextual factors such as characteristics of patients, providers and organizations or systems. An important step in future research is to develop a better theoretical understanding of organizational change that is required for management and professionals to give appropriate guidance to the implementation of the clinical practice guidelines.

INTRODUCTION:There is an increasing interest in divesting activities, giving rise to several initiatives both academic and governmental to identify and address one of the problems of health systems. In 2013 the Spanish Atlas of Variability in Clinical Practice (VPM) in collaboration with the Spanish Network of Health Technology Assessment (HTA) Agencies started a project with the purpose of providing elements to support a national strategy aimed at minimizing the use of doubtful procedures in the Spanish National Health System (1).METHODS:The identification, selection and definition of low added value procedures and the determination of the most cost-effective alternatives were carried out jointly between the AtlasVPM group and the HTA agencies of Andalusia (AETSA), Catalonia (AQUAS), Galicia (Avalia-t), Basque Country (Osteba), Madrid (UETS) and Aragon (IACS). The process consisted of the following phases: (i) Literature review; (ii) Preliminary list of procedures of dubious value; (iii) Analysis of feasibility and construction of the indicators (variability); and (iv) Empirical validation of the defined indicators. Different lists and sources of evidence were used to identify the procedures and evidence that support their low-value.RESULTS:The synthesis of the evidence gave rise to an initial list of fifty-nine procedures of doubtful value that could be classified as: obsolete or outdated procedures in comparison to more effective / cost-effective alternatives (n = 31), procedures of doubtful value when used outside their main indication (n = 17) and procedures for which the evidence around effectiveness was still insufficient (n = 11). With the advice of clinical experts and coders, the original list was reduced to seventeen procedures and after some adjustments to thirteen.CONCLUSIONS:Identifying procedures of low-added value is a complex task and is context dependent. Literature could be useful to identify a preliminary list but the analysis of the clinical practice, its variability and reasons that justify it are required to determine which procedures are good candidates for disinvestment.

Resumen Objetivo Evaluar el porcentaje de deteccion del ganglio centinela en el cancer de vulva, su sensibilidad y su valor predictivo negativo. Determinar las complicaciones de la tecnica y las recidivas a largo plazo. Material y metodos Revision sistematica de la literatura con posterior extraccion de datos y sintesis de la evidencia. Resultados Se incluyeron 19 estudios de caracter observacional. El Tc99-coloide asociado o no al colorante detecto el 98% de los ganglios centinelas. Los falsos negativos fueron menores del 2%, la sensibilidad y el valor predictivo negativo superiores al 95% y las recidivas ganglionares del 3%. Conclusiones La tecnica de ganglio centinela parece una alternativa razonable a la linfadenectomia inguinal en pacientes con cancer de vulva de estadios iniciales. A la hora de su implementacion, se deberian tener en cuenta factores relativos al equipo de trabajo, la seleccion de pacientes, la tecnica de deteccion, la tecnica quirurgica y anatomopatologica y la curva de aprendizaje.

Resumen Objetivo Describir las variaciones existentes en las tasas de utilizacion de los diversos procedimientos relacionados con el parto, en las diferentes comunidades autonomas espanolas, provincias y tipos de hospital. Sujetos y metodos Estudio transversal; la unidad de analisis fueron los partos realizados en Espana (2001-2006) y la fuente de informacion, el CMBD al alta hospitalaria. Se realizo una agregacion de los datos y un analisis descriptivo en funcion de las variables de estudio. Resultados El numero de partos se incremento en Espana a un ritmo de 10.000-15.000 partos al ano. El porcentaje de partos no instrumentados fue del 62,7%, el de partos instrumentados del 15,1% y el de cesareas del 22,2%. Se observo una gran variabilidad en todos los procedimientos estudiados, tanto entre provincias, como CCAA o tipos de hospitales. Conclusiones Los resultados obtenidos muestran la gran variabilidad existente en la asistencia al parto, tanto desde el punto de vista temporal, geografico, y de la practica clinica.

Resumen Objetivo Evaluar la eficacia y la seguridad de los sistemas de soporte hepatico extracorporeo Molecular Adsorbent Recirculating System (MARS®) y Prometheus® en el tratamiento de la insuficiencia hepatica. Diseno Revision sistematica de la literatura medica desde enero de 1999 hasta junio de 2009 en las bases de datos Medline, Embase, HTA, DARE, NHSEED, Cochrane Library Plus, Clinical Trials Registry y Health Services Research Projects in Progress. La seleccion de estudios se realizo mediante una serie de criterios de inclusion previamente establecidos, relativos al diseno del estudio, a la poblacion, al tipo de intervencion, al idioma y a las variables de resultado. Pacientes e intervenciones Pacientes con insuficiencia hepatica aguda o insuficiencia hepatica cronica agudizada en tratamiento con los sistemas MARS® o Prometheus®. Variables de resultado: datos relativos a la seguridad, a la supervivencia a largo plazo, a los efectos clinicos y a las variables bioquimicas y hemodinamicas. Resultados Se seleccionaron 22 estudios que evaluaban la eficacia y la seguridad de los sistemas MARS® y Prometheus®. Se observo la existencia de heterogeneidad y limitaciones metodologicas que dificulto la correcta evaluacion de estas tecnicas. Conclusiones Los sistemas de soporte hepatico extracorporeo son capaces de depurar tanto sustancias hidrosolubles como sustancias unidas a proteinas. Sin embargo, los datos actuales muestran que solo el sistema MARS® reduce la mortalidad en la insuficiencia hepatica aguda y en la insuficiencia hepatica cronica agudizada, aunque de forma no significativa. Estas tecnicas pueden considerarse seguras, con efectos adversos similares a los del grupo control. Su principal indicacion seria en la insuficiencia hepatica grave de forma limitada en el tiempo, mientras se recupera el organo o se produce su trasplante.

Background: The treatment of choice for acute ischaemic stroke is the intravenous administration of recombinant tissue plasminogen activator within 3-4.5 h of symptom onset. However, the use of a thrombolytic would be limited by its narrow therapeutic window and contraindications. As a result, in recent years, techniques such as mechanical thrombectomy have emerged, which employ thrombus retrieval devices, such as stent retrievers (Solitaire™, Trevo® or Revive™), whose safety and efficacy in the endovascular treatment of acute ischaemic stroke is analysed in this article. Methods: A systematic literature search was undertaken until March 2015. The quality of evidence was assessed according to the GRADE methodology. A meta-analysis of the results of randomised controlled trials (RCTs) was performed, and the weighted average for the case series' sample size was calculated (Review Manager v5.2 and SPSS v19). Results: Seventeen primary studies (2 RCTs, Solitaire™ and Trevo® vs. Merci®, and 15 case series) were selected. The RCT results show that stent retrievers have a safety profile similar to the Merci® device. However, both Solitaire™ and Trevo® achieved a higher recanalisation success rate (OR, 4.56; 95% CI, 2.63-7.90; p < 0.00001) and appropriate clinical outcome at 90 days (OR, 2.54; 95% CI, 1.52-4.25; p < 0.0004), although the 90-day mortality rate was similar in both groups (OR, 0.75; 95% CI, 0.17-3.37; p = 0.70). Conclusions: Stent retrievers appear to be safe and effective devices, achieving high recanalisation rates and good clinical outcomes in the endovascular treatment of patients with acute ischaemic stroke due to the occlusion of intracranial arteries in comparison with the clot retriever Merci®.

One of the proposals for improving clinical practice is to introduce computerised decision support systems (CDSS) and integrate these with electronic medical records. Accordingly, this study sought to systematically review evidence on the effectiveness of CDSS in the management of depression. A search was performed in Medline, EMBASE and PsycInfo, in order to do this. The quality of quantitative studies was assessed using the SIGN method, and qualitative studies using the CASPe checklist. Seven studies were identified (3 randomised clinical trials, 3 non-randomised trials, and one qualitative study). The CDSS assessed incorporated content drawn from guidelines and other evidence-based products. In general, the CDSS had a positive impact on different aspects, such as the screening and diagnosis, treatment, improvement in depressive symptoms and quality of life, and referral of patients. The use of CDSS could thus serve to optimise care of depression in various scenarios by providing recommendations based on the best evidence available and facilitating decision-making in clinical practice.

Este manual tiene como objetivo aportar herramientas, métodos y estrategias que faciliten a los profesionales sanitarios y no sanitarios la incorporación y la participación de pacientes en el desarrollo de una GPC. Los destinatarios de este manual son los grupos de trabajo elaboradores de una GPC que deseen incorporar la visión y perspectiva de los pacientes o trabajar con ellos en el desarrollo de la GPC.

Clinical practice guidelines are intended to serve as a bridge between the decision levels and the sources of knowledge, giving decision makers the best synthesis of scientific evidence and an analysis of context, to provide elements of judgement and to transfer scientific knowledge into clinical practice. However, the actual impact on health care is variable and effectiveness in changing medical practice, moderate. Qualitative and quantitative studies show that most primary care physicians consider that the guides are a valuable source of advice and training and a kind of improving the quality of healthcare. However, they underline its rigidity, the difficulty to apply to individual patients and that their main goal is to reduce healthcare costs. In Spain, there are several experiences as GuíaSalud in developing clinical practice guidelines aimed specifically at primary care. However, the proper implementation of a clinical practice guideline includes not only the quality and thoroughness of the evidence, but the credibility of professionals and organizations and other contextual factors such as characteristics of patients, providers and organizations or systems. An important step in future research is to develop a better theoretical understanding of organizational change that is required for management and professionals to give appropriate guidance to the implementation of the clinical practice guidelines.

ResumenObjetivoExplorar la percepción de utilización de la evaluación de tecnologías sanitarias en el sistema sanitario público de Galicia, obtener valoraciones sobre la utilidad de los diferentes servicios y productos desarrollados por la Agencia de Evaluación de Tecnologías Sanitarias de Galicia (avalia-t), e identificar barreras y facilitadores a la transferencia de resultados a la práctica clínica.MétodoEstudio cualitativo basado en 20 entrevistas en profundidad semiestructuradas realizadas a expertos seleccionados mediante muestreo intencional (diez del ámbito clínico y diez de gestión). Las entrevistas fueron grabadas y se realizó un análisis temático inductivo de la información.ResultadosSe evidenció un alto grado de interés por la evaluación de tecnologías sanitarias, aunque la gran mayoría de los entrevistados aludieron a su infrautilización como herramienta de decisión en la práctica asistencial. Se identificaron una serie de factores clave para garantizar el éxito de la evaluación: el aumento de las actividades de difusión y disponibilidad de los resultados, el fomento de la comunicación e implicación de los profesionales sanitarios en la selección y priorización de temas a evaluar, la contextualización y adaptación de los estudios al contexto, el aumento del respaldo organizativo y el mayor apoyo económico.ConclusionesEl presente estudio permite contrastar con los usuarios finales la valoración/utilidad de los diferentes productos/servicios ofertados por las agencias para poder adecuar la actividad a sus necesidades y expectativas. La colaboración de los profesionales se plantea como uno de los principales ejes de acción para las agencias de evaluación, participación que hay que reforzar en la vertiente del contacto personal, al tiempo que debe fortalecerse la retroalimentación en los procesos de colaboración.AbstractObjectiveTo explore perceptions of the use of health technology assessment (HTA) in the Galician public health system, identify opinions on the usefulness of the products and services developed by the Galician Health Technology Assessment Agency (avalia-t), and determine the barriers and facilitators to the transfer of results to clinical practice.MethodWe performed a qualitative study based on in-depth semi-structured interviews of 20 intentionally selected experts (10 health care professionals and 10 hospital decision makers). The interviews were tape recorded and transcribed for inductive thematic analysis.ResultsInterest in HTA activities was high, but most informants considered these activities to be underused as a tool to aid decision making in clinical practice. A series of key factors was identified to guarantee HTA use: greater dissemination of HTA activities and availability of the results, increased involvement and communication among health care professionals in the selection and prioritization of relevant research, contextualization and adaptation of results to the local context, increased organizational support and greater financial resources.ConclusionsThe present study allows end-userś opinions on the utility of the various products/services offered by HTA agencies to be contrasted in order to adapt HTA activity to their needs and requirements. The involvement of health care professionals in all HTA fields is perceived as one of the main lines of action for HTA agencies. Such involvement could be achieved by reinforcing personal contact and increasing feedback to collaborators.

To explore perceptions of the use of health technology assessment (HTA) in the Galician public health system, identify opinions on the usefulness of the products and services developed by the Galician Health Technology Assessment Agency (avalia-t), and determine the barriers and facilitators to the transfer of results to clinical practice.We performed a qualitative study based on in-depth semi-structured interviews of 20 intentionally selected experts (10 health care professionals and 10 hospital decision makers). The interviews were tape recorded and transcribed for inductive thematic analysis.Interest in HTA activities was high, but most informants considered these activities to be underused as a tool to aid decision making in clinical practice. A series of key factors was identified to guarantee HTA use: greater dissemination of HTA activities and availability of the results, increased involvement and communication among health care professionals in the selection and prioritization of relevant research, contextualization and adaptation of results to the local context, increased organizational support and greater financial resources.The present study allows end-userś opinions on the utility of the various products/services offered by HTA agencies to be contrasted in order to adapt HTA activity to their needs and requirements. The involvement of health care professionals in all HTA fields is perceived as one of the main lines of action for HTA agencies. Such involvement could be achieved by reinforcing personal contact and increasing feedback to collaborators.

To evaluate the safety and efficacy of the MARS and Prometheus extracorporeal liver support systems in the treatment of liver failure.We performed a systematic review of the literature from January 1999 to June 2009 in the Medline, Embase, HTA, DARE, NHSEED, Cochrane Library Plus, Clinical Trials Registry and HSRPROJ databases. Study selection was based on a series of previously established inclusion criteria related to the study design, population, type of intervention, language, and outcome measures.Patients with acute liver failure or acute exacerbations of chronic liver failure treated with the MARS or Prometheus systems.Data on safety, long-term survival, clinical effects and biochemical and hemodynamic variables.We selected 22 studies evaluating the safety and efficacy of the MARS and Prometheus systems. Adequate evaluation of these techniques was hampered by the heterogeneity of the studies and their methodological limitations.Extracorporeal liver support systems are able to purify both hydrosoluble and protein-bound substances. However, current data show that only the MARS system reduces mortality in acute liver failure and in acute exacerbations of chronic liver failure, although this reduction is non-significant. These techniques can be considered safe, with adverse effects similar to those of the control group. Their main indication is severe liver failure, for short periods while the liver recovers or a liver transplant becomes available.