Objectives To describe the variability of Day Care Hospitals (DH) of Rheumatology in Spain, in terms of resources, organization, management, and quality standardsapplication. To Identify factors associated with avoidable variability and barriers for the implementation of quality standards
Methods A cross-sectional descriptive multicenter study (116 centers with selected DH in 17 Autonomous Communities) conducted in two phases: quantitative and qualitative. Quantitative study collected data through a self-administered questionnaire, previously agreed by a scientific committee and piloted in 3 centers. Variables analyzed include hospital (H), Rheumatology Units (RU) and DH features, to assess the level of compliance with the quality standards on the Structure, Processes and Outcomes domains, previously defined in the Quality of Care Project (ICARO) by the SSR. Data were analyzed with STATA Qualitative study of national scope included 14 Focus group Discussion (8 of rheumatologists, 4 of nurses and 2 of patients).
Results Seventy one rheumatologists and 28 nurses from 89 Hospitals (H) in 16 Regions and Melilla were involved, with a high variability of structural characteristics (levels 1-4) where universitary H predominated (40% of level 4). RU have a median of 4 beds assigned [range IQ 0-6] and 59 [24-130] annual income. 46% had postgraduate and 62% under-graduate training, with a median of 5 [4-8] physicians, 1-4 assigned nurses (76%), and nursing outpatient clinic (52%). Data emphasize the RU research activities (50-100%) notably from public funded sources (range 40-74%). Regarding DH, 92% are multidisciplinary, coordinated by nurses (50%) or rheumatologists (30%), and with a physician assigned to DH in 48%. In 2011, the median of year rheumatology treatments was 667 [300-1250]. More than 70% have digital medical records, electronic citations, administrative support and 69% protocol data collection. Guidelines and protocols are available in 88%, but <50% has standardized operation Procedures. Concerning processes, 63% use an Organization Manual, but only a half have Quality or contingency Plans. Informed consents forms are used by 84%. Nursing processes are well defined, coordination with pharmacy is considered efficient and waiting times acceptable, with integrated visit in 80%. However, only 1/3 DH performs satisfaction surveys and DH contents in training programs are insufficient (25 and 40%). There is no delay in access to 91% DH. Activity and performance evaluation is the rule, that includes costs estimations in 60%. Only 18 DH have a Quality certification. Qualitative study detected barriers for the rheumatologists derived from the setting of supervision biologics committees (at local and regional levels); difficulties on adverse effects managing for nurses; and the fears for withdrawal or down-escalation of therapy for patients
Conclusions There is a substantial variability in features and functioning of Rheumatology DHs, although they share certain homogeneity in structure standards. A polarity is revealed (50/50%, 60/40%) in implementing several process and outcome domain standards. The detection of factors for unjustified variability and barriers helps to identify areas of improvement that should be prioritized for their relevance and feasibility.
Disclosure of Interest None Declared