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Introduction One of the missions of the Spanish Society of Rheumatology is to provide the necessary tools for excellence in health care. Currently, there is no reference point to quantify medical actions in this specialty, and this is imperative. Material and method A list of actions was drawn up and a hierarchical classification system was established by developing a complexity index, calculated based on the completion time and difficulty level of each action. Results The results of the Delphi method tended to the consensus opinion within a group (mean σ2 − σ1 = 0 .75–1.43 = −0.68, mean IQR2–IQR1 = 0.8–1.9 = −1.1). The values of the complexity index ranged between 48 and 465 points. Among consultation actions, those reaching the highest scores were the first inpatient visit (366) and visits to the patient's home (369). Among diagnostic techniques, biopsies were prominent, those with the highest score were: bone biopsy (465), sural nerve biopsy (416) and synovial biopsy (380). Ultrasound scan scored 204, capillaroscopy 113 and densitometry 112. Among therapeutic techniques, infiltration/arthrocentesis/articular injection in children reached the highest difficulty (388). The score for ultrasound-guided articular injection was 163. The score for clinical report on disability was 323 and expert report 370. Conclusions A nomenclature of 54 actions in Rheumatology was compiled. Biopsies (bone, sural nerve, synovial), inpatient visits, visits to the patient's home, infiltrations in children, and the preparation of the expert report were identified as the most complex actions. Musculoskeletal ultrasound is twice as complex as subsequent visits, capillaroscopy or bone densitometry.

espanolIntroduccion Una mision de la Sociedad Espanola de Reumatologia es aportar las herramientas necesarias para alcanzar la excelencia asistencial. En la actualidad no existe una referencia que cuantifique la complejidad de los actos medicos de esta especialidad. Material y metodo Se elaboro una relacion de los actos propios del reumatologo y se establecio un sistema de clasificacion jerarquica a partir de la construccion de un indice de complejidad, calculado mediante el tiempo de realizacion y el grado de dificultad de cada acto. Resultados Los resultados del metodo Delphi tendieron a una opinion grupal consensuada (media σ2 - σ1 = 0,75-1,43 = -0,68, media IQR2 - IQR1 = 0,8-1,9 = -1,1). El rango de valores del indice de complejidad oscilo de 48 a 465 puntos. Entre las consultas, las que alcanzaron mayor gradacion fueron la primera visita al paciente hospitalizado (366) y la visita a domicilio (369). Entre las tecnicas diagnosticas, destacaron las biopsias. Las que puntuaron mas alto fueron: biopsia osea (465), de nervio sural (416) y sinovial (380). La ecografia tuvo una puntuacion de 204, la capilaroscopia de 113 y la densitometria de 112. Entre las tecnicas terapeuticas, la maxima dificultad (388), la alcanzo la infiltracion/artrocentesis/ inyeccion articular infantil. La puntuacion de la inyeccion articular con control ecografico fue de 163. El informe clinico de minusvalia, 323 y el informe pericial, 370. Conclusiones Este trabajo ha permitido elaborar un nomenclator de 54 actos en reumatologia donde se identifican como actos mas complejos la realizacion de biopsias (osea, nervio sural, sinovial), la visita a paciente hospitalizado, la visita a domicilio, la infiltracion infantil bajo sedacion y la elaboracion de un informe pericial. La ecografia osteomuscular es considerada el doble de compleja de una visita sucesiva, la capilaroscopia o la densitometria osea. EnglishIntroduction One of the missions of the Spanish Society of Rheumatology is to provide the necessary tools for excellence in health care. Currently, there is no reference point to quantify medical actions in this specialty, and this is imperative. Material and method A list of actions was drawn up and a hierarchical classification system was established by developing a complexity index, calculated based on the completion time and difficulty level of each action. Results The results of the Delphi method tended to the consensus opinion within a group (mean σ2 - σ1 = 0.75-1.43 = -0.68, mean IQR2 - IQR1 = 0.8-1.9 = -1.1). The values of the complexity index ranged between 48 and 465 points. Among consultation actions, those reaching the highest scores were the first inpatient visit (366) and visits to the patient's home (369). Among diagnostic techniques, biopsies were prominent, those with the highest score were: bone biopsy (465), sural nerve biopsy (416) and synovial biopsy (380). Ultrasound scan scored 204, capillaroscopy 113 and densitometry 112. Among therapeutic techniques, infiltration/ arthrocentesis/articular injection in children reached the highest difficulty (388). The score for ultrasound-guided articular injection was 163. The score for clinical report on disability was 323 and expert report 370. Conclusions A nomenclature of 54 actions in Rheumatology was compiled. Biopsies (bone, sural nerve, synovial), inpatient visits, visits to the patient's home, infiltrations in children, and the preparation of the expert report were identified as the most complex actions. Musculoskeletal ultrasound is twice as complex as subsequent visits, capillaroscopy or bone densitometry.

Resumen Objetivo El proyecto AR Excellence evalua la atencion clinica a los pacientes con artritis reumatoide (AR) en Espana. El objetivo del presente estudio es analizar la utilizacion de metotrexato (MTX) en AR Excellence y compararla con las recomendaciones vigentes. Pacientes y metodos Se reviso a pacientes con AR que habian iniciado tratamiento con MTX, recogiendo datos demograficos, dosificacion, vias de administracion, combinaciones con otros farmacos antirreumaticos modificadores de enfermedad (FAME), tiempo hasta combinacion con otro FAME (convencional o biologico) y efectos adversos. Resultados Se incluyo a 625 pacientes con AR (edad media de 55,1 anos; 70,6% mujeres), con una duracion media de la AR de 21,3 meses. El 90% inicio tratamiento con MTX. La dosis media de inicio fue de 11 mg semanales; en el 58% de los casos se incremento la dosis. El tiempo medio hasta alcanzar la dosis plena de MTX (20 mg semanales) fue de 6,67 meses. El tiempo hasta la combinacion de MTX con otro FAME sintetico o biologico fue de 3 meses. El 67,4% de los pacientes recibieron el MTX por via oral y el 18,6%, subcutaneo. En el 12% de los casos se cambio la via de administracion, transcurrida una media de tiempo de 6 meses. En 544 pacientes se asociaron suplementos de folato. El 17,3% de los sujetos presentaron acontecimientos adversos por MTX. Conclusion El MTX es el farmaco sobre el que pivota el tratamiento de la AR. El subanalisis del proyecto AR Excellence nos informa de que la escalada a sus dosis plenas no se realiza con la rapidez adecuada. La via subcutanea se utiliza en pocos pacientes.

Resumen Objetivo Identificar las barreras y los facilitadores en la implantacion de estandares de calidad en las unidades de hospital de dia (UHdD) reumatologicas. Material y metodos Se analizaron las valoraciones sobre UHdD clasificadas en torno a estandares de estructura, procesos y resultados. La aproximacion cualitativa se llevo a cabo mediante 13 grupos de discusion (GD) formados por profesionales de Reumatologia (7), de Enfermeria (4) y pacientes (2) de UHdD. La captacion de informantes se realizo mediante muestreo intencionado atendiendo a variables que configuran las percepciones de las UHdD. El analisis de los datos se realizo siguiendo una perspectiva descriptiva-interpretativa. Resultados La especializacion de las UHdD monovalentes y la formacion especifica en Reumatologia para Enfermeria se perciben como los principales facilitadores para la implantacion de estandares. Por el contrario, la demora en la disponibilidad de los farmacos en las UHdD se identifica como una barrera que prolonga la estancia de pacientes y desaprovecha recursos. Las diferencias en regulaciones locales se perciben como una posible barrera para el acceso equitativo a farmacos. El elemento mejor valorado por los pacientes fue la atencion recibida, por encima de las variables estructurales o de proceso. Conclusiones Los hallazgos de este estudio sugieren que las mejoras para la implantacion de estandares de calidad en las UHdD pueden incluir 3 niveles de actuacion: la propia UHdD, el centro hospitalario, y un tercero relacionado con regulaciones locales de acceso a farmacos.

Objective To identify barriers and facilitators in the implementation of quality standards in hospital day care units (HDCU) in rheumatology. Materials and methods We analyzed appraisals of HDCU in terms of standards for structure, processes and results. The qualitative approach was conducted through 13 discussion groups created by rheumatology health professionals (7), nursing professionals (4) and HDCU patients (2). The recruitment of informants was done through purposive sampling, attending to variables that form the perceptions of the HDCU. Data analysis was performed using a descriptive-interpretive method. Results The specialization of the HDCU and specific training in rheumatology for nursing are perceived as the main facilitator for the implementation of standards. Conversely, the delay in the availability of medicines at the HDCU is identified as a barrier that prolongs patient stay and wastes resources. Differences in local regulations are perceived as a potential barrier to equitable access to medicines. The patients gave higher ratings to the care received than to structural variables or those related to process. Conclusions The findings of this study suggest that improvements in the implementation of quality standards in HDCU may include three levels of action: the HDCU, the hospital and a third related to local regulations to access to medicines.

To assess the plasma apolipoprotein B/apolipoprotein A1 ratio and its potential association with cardiovascular events (CVE) in patients with rheumatoid arthritis (RA).A baseline analysis was made of the CARdiovascular in rheuMAtology Project (CARMA), a 10-year prospective study evaluating the presence of at least one CVE in 775 Spanish patients with RA. Of them, 29 had already experienced CVE prior to the inclusion in the study. We assessed the association between the elevation of the apoB/apoA1 ratio with the presence of CVE according to a logistic regression model for possible confounding factors. We also analysed the main parameters of activity of RA and parameters related to lipid metabolism. RA patients were classified according to treatment: patients treated with disease-modifying anti-rheumatic drugs without biologics and those undergoing biologic therapy (anti-TNF-α, anti-IL-6 receptor, and other biologic agents).The apoB/apoA1 ratio of patients who had experienced CVE was higher than that of patients without previous CVE (0.65 vs. 0.60). However, the difference between both subgroups did not reach statistical significance (p=0.197). It was also the case after the multivariate analysis [OR: 1.48 (95% CI: 0.15-14.4); p=0.735]. RA patients from the group with CVE were more commonly receiving lipid-lowering treatment with statins than those without CVE history (41.4% vs. 20%, p=0.005). High HAQ and high atherogenic index were significantly associated with the presence of CVE. There was no statistical association between the type of biologic therapy used in RA and the presence of CVE.No association between ApoB/apoA1 ratio and CVE was found at the baseline visit of patients with RA from the CARMA study.

Objective To describe the variability of the day care hospital units (DCHUs) of Rheumatology in Spain, in terms of structural resources and operating processes. Material and methods Multicenter descriptive study with data from a self-completed questionnaire of DCHUs self-assessment based on DCHUs quality standards of the Spanish Society of Rheumatology. Structural resources and operating processes were analyzed and stratified by hospital complexity (regional, general, major and complex). Variability was determined using the coefficient of variation (CV) of the variable with clinical relevance that presented statistically significant differences when was compared by centers. Results A total of 89 hospitals (16 autonomous regions and Melilla) were included in the analysis. 11.2% of hospitals are regional, 22.5% general, 27% major and 39.3% complex. A total of 92% of DCHUs were polyvalent. The number of treatments applied, the coordination between DCHUs and hospital pharmacy and the post graduate training process were the variables that showed statistically significant differences depending on the complexity of hospital. The highest rate of rheumatologic treatments was found in complex hospitals (2.97 per 1000 population), and the lowest in general hospitals (2.01 per 1000 population). The CV was 0.88 in major hospitals; 0.86 in regional; 0.76 in general, and 0.72 in the complex. Conclusions There was variability in the number of treatments delivered in DCHUs, being greater in major hospitals and then in regional centers. Nonetheless, the variability in terms of structure and function does not seem due to differences in center complexity.

Resumen Objetivos Describir la variabilidad de las unidades de hospitalizacion de dia (UHdD) de Reumatologia en Espana, en terminos de recursos estructurales y procesos de funcionamiento. Material y metodos Estudio descriptivo, multicentrico, con evaluacion de las UHdD mediante cuestionario autocumplimentado a partir de estandares de calidad de la Sociedad Espanola de Reumatologia. Se analizaron recursos estructurales y procesos de las UHdD estratificados por complejidad del hospital (comarcal, general, mayor y complejo), y se determino la variabilidad mediante el coeficiente de variacion (CV) de la variable con relevancia clinica que presentara diferencias estadisticamente significativas al comparar por centros. Resultados Un total de 89 centros (16 comunidades autonomas y Melilla) se incluyeron en el analisis. El 11,2% de los hospitales son comarcales; el 22,5%, generales; el 27%, mayores, y el 39,3%, complejos. El 92% de las UHdD son polivalentes. El numero de tratamientos aplicados, la coordinacion entre las UHdD y farmacia hospitalaria y la presencia de formacion posgrado fueron las variables de proceso que presentaron diferencias estadisticamente significativas en funcion del nivel de complejidad del hospital. La tasa de tratamientos mas alta se hallo en hospitales complejos (2,97 por 1.000 habitantes), y la mas baja, en hospitales generales (2,01 por 1.000 habitantes). El CV fue de 0,88 en hospitales mayores, de 0,86 en comarcales, de 0,76 en generales y de 0,72 en los complejos. Conclusiones Existe una mayor variabilidad en el numero de tratamientos de UHdD en los hospitales mayores, seguido de los comarcales. Sin embargo, la variabilidad en estructura y funcionamiento no parece deberse a diferencias de complejidad de los centros.

Objective The AR Excellence project evaluates clinical monitoring in patients with rheumatoid arthritis (RA) in Spain. The aim of the study was to analyse the use of methotrexate (MTX) in the AR Excellence cohort and to compare it with current recommendations. Patients and methods We collected data from RA patients who initiated treatment with MTX. They included demographics, dose and routes of administration, switching among them, highest dose in each route, combinations with other disease-modifying antirheumatic drugs (DMARDs), time to combination with another DMARD (either conventional or biological) and adverse events. Results Six hundred twenty-five patients with RA (mean age 55 years; 70.6% women) were included, with an average disease duration of 21 months. Ninety percent of the patients initiated treatment with MTX. Therapy was begun with a mean dose of 11 mg per week; this initial dose was increased in 58% of the individuals. The average time to reach the full dose of MTX (20 mg a week) was 6.67 months. Time to combination of MTX with another DMARD, either synthetic or biological, was 3 months. In all, 67.4% of the patients received oral MTX and the route was subcutaneous in 18.6%. In 12% of the cases, there was a change in the route of administration after a period of 6 months. In 544 patients, folate supplements were added to MTX; MTX-related adverse events were detected in 17.3% of the patients. Conclusion MTX is currently the pivotal treatment in RA. The subanalysis of the AR Excellence project demonstrates that MTX escalation to its full doses is not done with adequate speed. The subcutaneous route is used in a small proportion of patients.

To establish a set of recommendations for the management of patients diagnosed with rheumatoid arthritis (RA) who cannot be treated with methotrexate (MTX) due to contraindications, drug toxicity or lack of adherence, and to establish therapeutic strategies more effective and safer in these RA patients. A qualitative analysis of the scientific evidence available to June 2015. The 2-round Delphi technique of consensus was used to collect and establish expert opinion based on the participants' clinical experience when only low quality evidence was available. A total of eighteen recommendations were developed for the management of this patient profile. Fourteen of these recommendations were related to drug safety aspects. Recommendations on contraindication and toxicity of MTX have been updated. The experts recommend the use of biological monotherapy, a preferred treatment option, in patients whose profiles reveal a contraindication, intolerance or circumstances that prevent us against the use of MTX. There is some high-quality scientific evidence that supports contraindication and establishes certain conditions of MTX use in RA patients with specific clinical profiles.

ResumenObjetivoIdentificar factores asociados a reingreso hospitalario en personas de edad avanzada.DiseñoEstudio observacional descriptivo.EmplazamientoÁrea sanitaria 3 de Madrid.ParticipantesPacientes mayores de 74 años que han ingresado en el Hospital Universitario Príncipe de Asturias en 2006. Se han excluido aquellos con ingreso en los 6 meses previos. Participaron 1.051 pacientes.Mediciones principalesSe utilizaron el conjunto mínimo básico de datos al alta hospitalaria y el sistema de información de atención primaria para desarrollar modelos de regresión logística. La variable dependiente fue reingreso en seis meses y las variables independientes fueron sociodemográficas, de estado de salud del paciente, y de la actividad asistencial.ResultadosEl 22,6% reingresaron en los seis primeros meses. Las variables que se asocian con mayor fuerza al reingreso fueron la estancia hospitalaria (estancias superiores a 15 días presentan un OR: 1,73; IC del 95%: 1,17–2,54), el total de fármacos prescritos al paciente (OR: 1,05; IC del 95%: 1,01–1,09), padecer hipertensión (OR:1,56; IC del 95%: 1,11–2,18), insuficiencia cardiaca (OR: 1,56; IC del 95%: 1,00–2,44) o cardiopatía isquémica (OR: 1,51; IC del 95%: 1,00–2,26), y la presión asistencial media de enfermería (OR: 0,93; IC del 95%: 0,87–0,98). El modelo que identifica mayor número de factores asociados al reingreso es el que integra información de ambos sistemas.ConclusionesLos reingresos hospitalarios se han asociado a condiciones propias del paciente y a factores derivados de la asistencia sanitaria recibida. Integrar información de bases de datos clínico-administrativas de atención primaria y hospitalaria mejora la capacidad para identificar factores asociados con un mayor riesgo de reingreso que podrían servir para plantear estrategias.AbstractObjectiveTo identify factors associated with hospital readmissions in the elderly.DesignObservational descriptive study.SettingHealth area 3 of Madrid.ParticipantsPatients 74 years-old and over with a hospital admission to Hospital Universitario Príncipe de Asturias in 2006. Those with a hospital admission in the previous 6 months were excluded. A total of 1051 patients were identified.Main MeasuresHospital Discharge Minimum Basic Data Set and primary care information system were used to develop logistical regression models. The dependent variable was the hospital readmission in a 6 month period. Independent variables were socio-demographics, health status and health care activity.ResultsThere were 22.6% readmissions in the first 6 months. Variables associated with higher risk of readmission were, hospital stay (hospital stay greater than 15 days had an OR: 1.73 (95% CI:1.17–2.54), the total number of medicines prescribed to the patient (OR: 1.05; 95% CI:1.01–1.09), having hypertension (OR:1.56; 95% CI:1.11–2.18), heart failure (OR: 1.56; 95% CI:1.00–2.44) or ischemic heart disease (OR: 1.51; 95% CI:1.00–2.26), and the primary care nursing mean attendance pressure (OR: 0.93; 95% CI:0.87–0.98). The model that integrates information from both systems explains a higher number of factors associated with readmission.ConclusionsHospital readmissions have been associated to patient medical condition and to factors related to the health care received. Integrating information from hospital and primary care administrative data bases improves the capacity to identify factors associated with a higher readmission risk.

To determine the dilution titles at antinuclear antibodies (ANA) by indirect immunofluorescence observed in cell substrate HEp-2 and its association with the diagnosis of systemic connective tissue disease in ANA test requested by a Rheumatology Unit.Samples of patients attended for the first time in the rheumatology unit, without prior ANA test, between January 2010 and December 2012 were selected. The dilution titers, immunofluorescence patterns and antigen specificity were recorded. In January 2015 the diagnosis of the patients were evaluated and classified in systemic disease connective tissue (systemic lupus erythematosus, Sjögren's syndrome, systemic sclerosis, undifferentiated connective, antiphospholipid syndrome, mixed connective tissue and inflammatory myophaty) or not systemic disease connective tissue.A total of 1282 ANA tests requested by the Rheumatology Unit in subjects without previous study, 293 were positive, predominance of women (81.9%). Patients with systemic connective tissue disease were recorded 105, and 188 without systemic connective tissue disease. For 1/640 dilutions the positive predictive value in the connective was 73.3% compared to 26.6% of non-connective, and for values ≥1/1,280 85% versus 15% respectively. When performing the multivariate analysis we observed a positive association between 1/320 dilution OR 3.069 (95% CI: 1.237-7.614; P=.016), 1/640 OR 12.570 (95% CI: 3.659-43.187; P=.000) and ≥1/1,280 OR 42.136 (95% CI: 8.604-206.345; P=.000).These results show association titles dilution ≥1/320 in ANA's first test requested by a Rheumatology Unit with patients with systemic connective tissue disease. The VPP in these patients was higher than previous studies requested by other medical specialties. This may indicate the importance of application of the test in a targeted way.

Resumen Fundamento La mediastinitis posquirurgica es una de las complicaciones mas graves de la cirugia cardiaca. Se han descrito diversos factores de riesgo y estrategias para disminuir su incidencia. El objetivo de este estudio es determinar la incidencia y los factores de riesgo de mediastinitis en enfermos sometidos a cirugia cardiaca en el Hospital Universitario La Paz y establecer propuestas de mejora del proceso asistencial. Material y metodos Estudio de casos y controles, seleccionando 2 controles por cada caso de mediastinitis diagnosticado durante los anos 2002 y 2003 y el primer cuatrimestre de 2004. Recogida de informacion mediante revision de historias clinicas. Analisis estadistico: descriptivo (media, mediana, desviacion tipica y distribucion de frecuencias) y analitico (χ 2 de Pearson y U de Mann-Whitney). Resultados Incidencia, 3,5%. Principales factores identificados como susceptibles de mejora: control glucemico de los enfermos, identificacion a priori de los enfermos con mayor riesgo de mediastinitis, para lo que se construyo un indice que evalua 8 items, y actuacion temprana ante la agrupacion de 2 o mas casos. Conclusiones A partir de los resultados, se han propuesto cambios en el proceso asistencial que pueden contribuir a disminuir la incidencia de mediastinitis en enfermos intervenidos de cirugia cardiaca en el Hospital La Paz.