Anna García-Altés, Head of the Catalan Health System Observatory
This report presents the results of all public hospitals network (SISCAT) for 2014. The structure of this year’s report is slightly different from previous years. It deals with fewer topics but in a more concrete, in depth manner. A special effort has been made to include indicators of nursing care evaluations, an area little discussed up until now in the reports of the Results Centre, and other new indicators from records that so far have not been analyzed in the reports. Some examples of such indicators are: mortality in low mortality DRG’s, mortality in patients who have developed complications, bedsores, or indicators relating to donation and transplants registration and the A&E MBDS. However, the tables with the values of all indicators centre by centre -the distinguishing feature of the Results Centre- remain. As in previous years, all reports include innovative experiences that provide good care results, included in the Health Care Innovation Observatory in Catalonia (OIGS) as well as the experts’ opinion and specific results indicators of a monographic hospital, this year the Hospital Maternoinfantil de Vall d’Hebron.
After the 2011’ descent, the hospital activity has been steadily increased, starting from 2012 when demanding objectives related to increased surgical activity and reducing surgical waiting lists have been established. This evolution has gone from 796,362 hospitalizations per year in 2013 to 811,851 in 2014. This increase is attributable to increased surgical activity to the detriment of medical (non surgical) activity. This shift in the type of hospitals’ activity has been accompanied by a significant increase in the number of major ambulatory surgery interventions: currently, 6 out of 10 interventions are performed with outpatient surgery. This increase is visible in all susceptible procedures and particularly some of them, such as varicose veins of the lower extremities, 8 out of 10 are performed with outpatient surgery.
On the other hand, also regarding the centres’ efficiency, the length of stay in conventional hospital has stabilized in recent years with values around 6.1 days; however, under specific conditions such as congestive heart failure or femoral neck fracture, there has been a downward trend, possibly the result of improved continuity of care for these patients.
As it has become a classic view, the favourable users’ perception of health services is very high. In particular, and for specialized outpatient care, the level of overall satisfaction achieved an average score of 7.8 out of 10, and fidelity is 82.9%. The personal attention of the physician is the best reviewed, with an average of 92.3, all hospitals in Catalonia being located at the level of excellence of care aspect. The time between the detection of the need to visit a specialist and the day of the visit is the worst valued aspect, with 65.5% positive rating.
Furthermore, the results of SISCAT hospitals in 2014 maintained and even improved compared to 2013. This is the case of indicators closely linked to medical practice, such as high mortality in patients with acute myocardial infarction with elevation of the ST segment, congestive heart failure, stroke, or femoral neck fracture, that carry on showing a steady improvement despite the aging of population. There is a new feature this year related the femoral neck fracture: the analysis of the care process. A set of indicators reflecting the risk factors of patients, the results of hospital care (mortality) and pre and post fracture resource consumption (primary care and pharmacy) have been selected. The results have been measured by the total in Catalonia and nominally for each hospital and primary care team.
Most indicators that refer to the adequacy of care remain unchanged, except for the percentage of pneumonia without complications following a downward trend since 2009; related to this, there is a recommendation of the Essencial project (http://essencialsalut.gencat.cat) to decrease revenue related with this condition. Another exception is the needle holding time in thrombolytic IV or in ischemic stroke, which went from 51 minutes in 2013 to 48 minutes in 2014.
Moving on to safety indicators, the rates of venous catheter bacteremia are on a downward trend, reaching 0.19 per 1,000 days of stay in 2014. In the case of central venous catheter bacteremia rate we can also notice a decline; in this particular case, the cost savings resulting from the decline of this rate between 2008 and 2013 is nearly 10 million euros. Following safety indicators and advancing to those related to nursing care, mortality in low mortality DRG remains stable at around 0.07%. However, mortality in patients who have developed complications follow a downward trend since 2009, and has fallen from 27.3% to 25.3% in 2014. Pressure ulcers go along a more irregular trend.
The austerity and rationalization measures that have been necessarily implemented from the beginning of the economic crisis in SISCAT hospitals have allowed a reduction in expenses and have generated an operating loss that, despite the decline in revenue, show some results indicators that in 2013 are similar to those of 2009, the year before to the start of the adjustment measures implementation. Thus, indicators of the SISCAT hospitals’ Balance Centre for 2013 relating to the profitability, the positive generated resources and incomes per unit of output have worsened, but generated a lower loss than the corroborated negative economic impacts that have occurred in 2013 (tariffs reduction, VAT rate increases and the rise in social security contributions), while the cost per unit of output and productivity improved compared with 2012. The solvency, liquidity and debt values are fairly stable over the fiscal year of 2012.
As for the SISCAT hospitals’ training, the average scores of the first 3 resident doctors chosen by a Catalan hospital is 7; in the case of resident nurses is 96. Finally, as to the indicators of IT use in health, the results show slightly lower, although positive, values than last year, as is the digitization and use of the electronic medical records in 75% of centres, or the use of remote consultations and remote diagnosis in 44.1% and respectively 50.0% of centres,.
The fact that the first nominal data report includes data from the previous two years, enables us today to have a series of six years (2009-2014). This has made it possible to select a set of indicators which appear in all the reports and analyze the trend in values, in order to see the impact of health policies and the improvement actions carried out in recent years. This assessment represents a further step to strengthen the Results Centre as a tool to monitor, evaluate and compare the evolution of health care and centres’ management outcomes, as well as to reinforce the objectives of transparency and accountability. This is the case of:
- The focus on the patient, and the fundamental role of PLAENSA in knowing the users’ ratings;
- Hospitalizations, especially the increase in surgical ones, and the outpatient surgery potentiating, as well as important elements for improving the efficiency of care;
- Mortality at discharge and 30 days after, very sensitive to the progressive knowledge of the associated factors, and the clinical leadership needed to implement measures of improvement;
- Caesarean sections, in which the elements always present in hospitals that do less, have been identified;
- Emergency admissions and emergencies admitted, closely related to the adequacy of admission criteria and the use of alternatives to conventional hospitalization;
- Venous catheter and central venous catheter bacteremia, where we noticed a significant decline, and where VINCat, Bacteremia Zero and Cat-VINCat programs played a paramount role.
As in previous years, the analysis of the results of this report can be deepened through the Results Centre’s applicative and the dynamic calculation sheets available on the Observatory’s website (http: //observatorisalut.gencat.cat), as well as through open data files that, while meeting W3C international standards, are available to all on the Generalitat de Catalunya website (http://dadesobertes.gencat.cat/ca). As a novelty, for ease accessing the results, this year indicators for hospitals (the “hospitals’ files”) are included in the printed report tables, which last year were available on the website. Also, a sheet featuring graphical representation of a selection of indicators for each of the hospitals, has been designed with the objective of being a helping tool in the clinical management of the centres. Finally, similarly to last year, a summary of the results in the form of an info-graphic has been published.
This report, and all the presented data, can be found on the Observatory website: http://observatorisalut.gencat.cat