RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013–2016)

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Four years of growth of the internal medicine units of the Spanish National Health System (2013–2016)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "171" "paginaFinal" => "176" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Zapatero-Gaviria, R. Gomez-Huelgas, J. Diez-Manglano, R. Barba-Martín, J. Carretero-Gomez, A. Maestre-Peiró, J.L. Bernal-Sobrino, J. Marco-Martinez, C. Fernandez-Perez, F.J. Elola-Somoza" "autores" => array:10 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Zapatero-Gaviria" "email" => array:1 [ 0 => "antonio.zapatero@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Gomez-Huelgas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." 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"apellidos" => "Elola-Somoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] ] "afiliaciones" => array:9 [ 0 => array:3 [ "entidad" => "Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Miguel Servet, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Hospital de Zafra, Zafra, Badajoz, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital Universitario de Vinalopó, Elche, Alicante, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Hospital Universitario Clínico San Carlos, Madrid, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 922 "Ancho" => 1528 "Tamanyo" => 81538 ] ] "descripcion" => array:1 [ "en" => "Correlation between the number of discharges by internal medicine units recorded using the survey (RECALMIN) and minimum basic data set. Abbreviation: MBDS, minimum basic data set." ] ] ] "textoCompleto" => "BackgroundIn 2008, the Spanish Society of Internal Medicine (SEMI) conducted a survey on the healthcare offerings of internal medicine units (IMUs).<a class="elsevierStyleCrossRef" href="#bib0130">1</a> In 2009, SEMI analyzed the IMU activity of hospitals in the Spanish National Health System (SNHS).<a class="elsevierStyleCrossRef" href="#bib0135">2</a> The first RECALMIN survey conducted in 2014 with data from 139 hospitals corresponding to 2013 showed a marked variability in the indicators of structure, activity and management, as well as significant gaps in patient management and in adopting good practices recommendations in clinical management.<a class="elsevierStyleCrossRef" href="#bib0140">3</a>Subsequent studies on the RECALMIN project found associations between resources, especially the burden of care per nurse, and the health outcomes of patients hospitalized in IMUs,<a class="elsevierStyleCrossRef" href="#bib0145">4</a> as well as a marked increase in patient age and complexity.<a class="elsevierStyleCrossRef" href="#bib0150">5</a>The objectives of this article are to show the results of comparing the 2014 and 2017 RECALMIN surveys, referring to 2013 and 2016, respectively, and to analyze the 2016 data on the structure, resources and activity of IMUs based on the type of hospital to which they belong.Materials and methodsThe RECALMIN surveys considered the IMUs of general acute care hospitals with 50 or more installed beds in 2014 and 100 or more in 2017. Except for those regarding discharges and mean stays, the data obtained from the minimum basic data set (MBDS) of the SNHS were collected using an ad hoc questionnaire, requesting confirmation from the head of the IMU when out-of-range values were encountered.The units were classified according to the hospital type<a class="elsevierStyleCrossRef" href="#bib0155">6</a>: type 1: <200; type 2: 200–499; type 3: 500–999; and type 4: ≥1000 beds. We calculated the Internal Medicine Weighted Activity Index, an approximation of IMU productivity, based on the estimated workloads for the various clinical activities for medical internists.<a class="elsevierStyleCrossRef" href="#bib0160">7</a> We multiplied the activity in each care modality recorded in the survey for the estimated workload (Table 1 of citation 7), adjusting the mean stay by the complexity-adjusted mean stay index and the number of successive consultations, limiting it to the mean ratio of successive consultations to first consultations. We divided the total burden of care calculated in this manner by the number of medical internists multiplied by the time available per year minus 20% for dedication to continuing education and research activities.Statistical analysisThe qualitative variables are presented as numbers and percentages, and the quantitative variables are presented as mean, median and standard deviation. For the comparisons between quantitative variables, after a homogeneity of variance study, we employed Student's t-test and analysis of variance (ANOVA) with Bonferroni correction, as needed. In all cases, we rejected the null hypothesis with an alpha error <0.05. The statistical analyses were performed with the STATA program version 13.0.ResultsThe number of responses was similar in 2014 and 2017 (139 vs. 138, respectively). Their distribution was 27% vs. 26% for type 1, 29% vs. 37% for type 2, 33% vs. 26% for type 3 and 11% vs. 10% for type 4.StructureThe main structural variables of the IMU (installed beds, reference population, average number of internists and rate of internists per 100,000 inhabitants remained without statistically significant differences (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>ActivityWe found a very high correlation between the number of discharges by IMUs recorded using the survey (2016) and using the MBDS (2015) (r=0.92; p<.001) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The mean number of discharges, attendance by 100,000 inhabitants, interconsultations and first consultations increased in absolute terms (10.7%, 9.4%, 18% and 16%, respectively), although the differences were not statistically significant. The ratio of successive and first consultations decreased approximately 3%, but the differences were also not significant (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Ninety-four percent of the IMUs had implemented an interconsultation unit in 2016, with a median of 1 physician dedicated to this activity, with wide variations among IMUs in the dedication of internists to this activity (mean, 1.6±1.7). The mean number of interconsultations in the IMUs with an implemented unit was 400, with 3.1 visits per patient. Seventy-seven percent of the IMUs stated that they had implemented shared care with the trauma department, 58% had done so with the general surgery department, and 53% had done so with the urology department.Efficiency and productivityThe mean stay decreased 10% (p=.0014), and the mean number of discharges per internist and the Internal Medicine Weighted Activity Index increased in absolute terms (9.1% and 16.6%, respectively), although the differences were not statistically significant. The ratio of patients to morning shift nurse on weekdays in hospital rooms decreased slightly (3%), although the differences were also not significant (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Good practicesThe percentage of the population covered by systematic care programs for complex chronic patients increased 9% up to 33%. Fifty-six percent of the IMUs had implemented a heart failure care protocol in 2016, compared with 45% in 2013. The difference in the implementation of multidisciplinary rounds was 2%, reaching 35% in 2016. In terms of the system for follow-up and activation in case of deterioration (in 2013, 21% of the IMUs responded that they had implemented this system), the 2016 survey asked about the implementation of the National Institute for Health and Care Excellence guidelines,<a class="elsevierStyleCrossRef" href="#bib0165">8</a> with 8% of the IMUs responding in the affirmative. In both surveys, 60% of the IMUs responded that they conducted early planning for the discharge.Comparison of internal medicine units by hospital sizeThe reference population and number of internists per IMU increased with the hospital size, as did all indicators of activity. The patient workload per nurse on weekdays was lower in the type 4 IMUs than in the other IMUs (p=.2), while the number of discharges per internist was lower in the type 4 IMUs (p=.04) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The mean stay was notably longer in the IMUs of type 3 and 4 hospitals (p<.001), as was the ratio between successive and first consultations (p=.02). Research work, according to the number of publications and their factor of impact, was greater the larger the hospital (p<.001 and p=.05, respectively) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).DiscussionOur study's main conclusion is that, faced with the increased burden of care, especially during hospitalization, the IMUs responded by decreasing the mean stay and increasing in absolute terms the mean number of discharges per internist and increasing the Internal Medicine Weighted Activity Index. There was slow progress in implementing good practices, and the variability in its structure, resources and activity remained, which probably indicates significant opportunities for improvement.The increase in the burden of hospitalization is a trend that was sustained from 2005, the year in which the MBDS began to reflect the discharge service.<a class="elsevierStyleCrossRefs" href="#bib0135">2,5</a> The trend was accompanied by a greater age and comorbidity of hospitalized patients.<a class="elsevierStyleCrossRef" href="#bib0150">5</a> According to our findings, the IMUs responded to this trend by improving their efficiency and increasing productivity in absolute terms. Although there was a slight increase in resources between 2013 and 2016, this can barely compensate for the increased burden of care resulting from the increased complexity of hospitalized patients.There are, however, significant differences according to hospital type, with IMUs located in centers with fewer than 500 beds being significantly more productive in caring for hospitalized patients. The mean patient burden per morning shift nurse is high compared with that of other countries.<a class="elsevierStyleCrossRefs" href="#bib0170">9,10</a> Within IMUs of the SNHS, an association has been found between greater nursing burden and poorer results,<a class="elsevierStyleCrossRef" href="#bib0145">4</a> a problem that needs addressing.The mean stay decreased significantly compared with 2013, with marked differences between IMUs in hospitals with more or fewer than 500 beds, the latter of which had significantly shorter stays.The data from 2017 still show an appreciable gap between the clinical management of patients and the recommendations of the Ministry of Health,<a class="elsevierStyleCrossRef" href="#bib0180">11</a> especially in implementing the recommendations regarding the management of critical and acute patients.<a class="elsevierStyleCrossRefs" href="#bib0165">8,12,13</a> Progress in the multidisciplinary rounds<a class="elsevierStyleCrossRefs" href="#bib0195">14–16</a> or the early planning of discharges<a class="elsevierStyleCrossRefs" href="#bib0210">17–21</a> has been practically nonexistent. The population coverage of systematic care programs for complex chronic patient is still low, although it increased slightly from 2013. There is a considerable gap in terms of the recommendations for units for polypathological patients<a class="elsevierStyleCrossRef" href="#bib0235">22</a> and the strategy for approaching chronicity in the SNHS.<a class="elsevierStyleCrossRef" href="#bib0240">23</a>The mean number of interconsultations by IMUs and the number of interconsultation units has increased; however, not all have implemented shared care with the departments they support, which are generally surgical. Seventy-seven percent of the units reported sharing care with trauma and orthopedic departments, a slightly higher percentage than that found by Marco-Martínez et al. in a survey with data from 2014 (65%).<a class="elsevierStyleCrossRef" href="#bib0245">24</a> The Spanish Society of Internal Medicine should more precisely define the criteria that determine the presence of shared interconsultation units.<a class="elsevierStyleCrossRef" href="#bib0250">25</a>The increase in first consultations by IMU and the decrease in successive consultations, in absolute terms, points to timid progress in managing the demand, which is probably insufficient while no progress is made in implementing systematic care models for complex chronic patients. The significantly greater proportion of successive consultations over first consultations in the IMUs of hospitals with 200 or more installed beds could be related to poor management of the demand, to an increased presence of more complex patients and to the increased burden of specialized clinics.As in RECALMIN 2014, the 2017 survey showed that research activities in the IMUs are linked to the hospital's complexity. The number of publications and their impact factor in type 4 IMUs was 10 times greater than that in type 1 IMUs.The correlation between the number of hospital discharges recorded in the survey and that recorded in the MBDS leads us to think that the reliability of the responses given by the heads of the IMU is high. Although 61% of the units responded to the RECALMIN survey, the sample can be considered representative of the whole of the SNHS, with notable stability in the structural data, despite the changes in the IMUs that filled out the survey and their distribution by complexity. Nevertheless, increasing the number of IMUs that respond to the RECALMIN survey remains a challenge for the Spanish Society of Internal Medicine.ConclusionsIMUs approach the increased demand for care by improving their efficiency. In contrast, advances have been scarce in implementing good practices, including the systematic care of complex chronic patients. It is unlikely that the improvement can compensate for the increased patient complexity and demand for care if healthcare models are not in place for the systematic management of complex chronic patients.FundingThe RECALMIN study benefited from an unconditional grant from Laboratorios Menarini S.A.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1183857" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1104275" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1183856" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1104276" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Structure" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Activity" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Efficiency and productivity" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Good practices" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Comparison of internal medicine units by hospital size" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-24" "fechaAceptado" => "2018-11-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1104275" "palabras" => array:3 [ 0 => "Internal medicine" 1 => "RECALMIN" 2 => "Indicator" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1104276" "palabras" => array:3 [ 0 => "Medicina Interna" 1 => "RECALMIN" 2 => "Indicador" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyze the differences between IMUs in 2016 by hospital size. Material and methodsWe conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). ResultsBetween 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; p=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; p=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. ConclusionsIMUs responded to the increased burden of care they supported during 2013–2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosComparar la estructura, recursos y actividad de las Unidades de Medicina Interna (UMI) del Sistema Nacional de Salud (SNS) en 2013 y 2016. Analizar las diferencias entre UMI en 2016 por tamaño de hospital. Material y métodosComparativa de 2 estudios descriptivos transversales de UMI en hospitales generales de agudos del Sistema Nacional de Salud con datos referidos a 2013 y a 2016. Las variables fueron recogidas mediante un cuestionario «ad hoc» (encuesta RECALMIN). ResultadosEntre 2013 y 2016 aumentó notablemente la demanda asistencial (con un promedio anual del 11% en altas de hospitalización y del 16% en primeras consultas) y ligeramente la comorbilidad (2%). En el mismo período, aumentó un 16,7% la productividad media de las UMI (0,6±0,3 vs. 0,7±0,3; p=0,09) y la estancia media disminuyó un 10% (9±2,2 vs. 8,1±2,1 días; p=0,001). Los progresos en la implantación de buenas prácticas y de una atención sistemática al paciente crónico complejo fueron escasos. La variabilidad entre UMI y las notables diferencias entre UMI de hospitales de tamaño distinto fueron hallazgos de ambas encuestas. ConclusionesLas UMI respondieron al aumento de la carga asistencial que soportaron en el período 2013-2016 mejorando su eficiencia y productividad, pero los avances en la implantación de buenas prácticas, incluyendo la atención al paciente crónico complejo, fueron escasos. La importante variabilidad en los indicadores de estructura, actividad y modelos de gestión encontrada en 2013 se mantuvo en 2016." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Zapatero-Gaviria A, Gomez-Huelgas R, Diez-Manglano J, Barba-Martín R, Carretero-Gomez J, Maestre-Peiró A, et al. RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016). Rev Clin Esp. 2019;219:171–176." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 922 "Ancho" => 1528 "Tamanyo" => 81538 ] ] "descripcion" => array:1 [ "en" => "Correlation between the number of discharges by internal medicine units recorded using the survey (RECALMIN) and minimum basic data set. Abbreviation: MBDS, minimum basic data set." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The IMU data correspond to the year prior to the survey (2013 and 2016, respectively)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2017 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2017/2014 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No. of hospitals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">139 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">138 (136+2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Installed beds \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">476±363 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">475±365 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Population setting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">228,660±143,808 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">232,252±140,253 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internists (average IMU) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.2±7.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.8±8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internists per 100,000 inhabitants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.4±3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.7±3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2017956.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Structural characteristics of internal medicine units and hospitals. 2014 and 2017 surveys." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2013 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016/2013 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of hospital discharges \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2866±1791 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3173±1964 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital attendance (discharges per 1000 inhabitants and year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No. of hospital interconsultations (patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">862±912 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1017±1132 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Initial consultations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1916±1343 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2223±1790 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Outpatient attendance rate (discharges per 1000 inhabitants and year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.5±15.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.9±8.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ratio of successive to first visits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.5±2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.4±1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.9% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2017957.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of activity indicators of internal medicine units 2013 and 2016." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviation: IMWAI Aj, Weighted Activity Index in Internal Medicine (adjusted by length of stay and successive/first consultation ratio)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2017 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016/2013 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9±2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.1±2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.0014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−10.0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No. of discharges per internist and year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">219±110 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">239±107 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IMWAI Aj \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient per morning shift nurse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.9±2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.6±2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">-3.0% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2017958.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Efficiency and productivity of internal medicine units 2013 and 2016." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviation: IMWAI, Weighted Activity Index in Internal Medicine." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of hospital</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Population setting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95,995±51,387 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">197,357±78,897 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">333,717±116,601 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">431,352±105,243 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.9±2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.8±4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19.3±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29.8±9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ratio of patients to morning shift nurse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.4±2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.1±2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5±1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.7±2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.163 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Discharges \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1956±1165 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3296±1712 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3849±2417 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4785±2402 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Discharges per internist and year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">248±116 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">264±114 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">213±83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">172±62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.037 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.5±1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.5±1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.1±1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.7±3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital Interconsultations (patients) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">380±214 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">960±1122 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1204±1754 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2066±1913 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ratio of successive to first visits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.018 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">At least 1 member of the department/unit has participated in publications in journals with impact factor (JCR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total impact factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">108.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.047 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IMWAI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.6±0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.8±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.7±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.6±0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">037 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2017959.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of internal medicine units by hospital type. 2016." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Encuesta SEMI sobre la oferta asistencial de los internistas en los hospitales del Sistema Público de Salud" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.E. Losa" 1 => "A. Zapatero" 2 => "R. Barba" 3 => "J. Marco" 4 => "S. Plaza" 5 => "J. Canora" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2011.01.002" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2011" "volumen" => "211" "paginaInicial" => "223" "paginaFinal" => "232" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21496798" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0135" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis de 2 años de actividad de Medicina Interna en los hospitales del Sistema Nacional de Salud" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Barba Martín" 1 => "J. Marco Martínez" 2 => "J. Emilio Losa" 3 => "J. Canora Lebrato" 4 => "S. Plaza Canteli" 5 => "A. Zapatero Gaviria" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2009" "volumen" => "209" "paginaInicial" => "459" "paginaFinal" => "466" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19889315" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0140" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "RECALMIN. La atención al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Zapatero Gaviria" 1 => "R. Barba Martín" 2 => "P. Román Sánchez" 3 => "E. Casariego Vales" 4 => "J. Diez Manglano" 5 => "M. 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RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013–2016)

RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016)

A. Zapatero-Gaviriaa,

Corresponding author

antonio.zapatero@salud.madrid.org

Corresponding author.

, R. Gomez-Huelgasb, J. Diez-Manglanoc, R. Barba-Martínd, J. Carretero-Gomeze, A. Maestre-Peiróf, J.L. Bernal-Sobrinog,h, J. Marco-Martinezi, C. Fernandez-Perezh,i, F.J. Elola-Somozah

a Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain

b Hospital Regional Universitario de Málaga, Málaga, Spain

c Hospital Miguel Servet, Zaragoza, Spain

d Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain

e Hospital de Zafra, Zafra, Badajoz, Spain

f Hospital Universitario de Vinalopó, Elche, Alicante, Spain

g Hospital Universitario 12 de Octubre, Madrid, Spain

h Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain

i Hospital Universitario Clínico San Carlos, Madrid, Spain

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Except for those regarding discharges and mean stays&#44; the data obtained from the minimum basic data set &#40;MBDS&#41; of the SNHS were collected using an ad hoc questionnaire&#44; requesting confirmation from the head of the IMU when out-of-range values were encountered&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The units were classified according to the hospital type<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a>&#58; type 1&#58; &#60;200&#59; type 2&#58; 200&#8211;499&#59; type 3&#58; 500&#8211;999&#59; and type 4&#58; &#8805;1000 beds&#46; We calculated the Internal Medicine Weighted Activity Index&#44; an approximation of IMU productivity&#44; based on the estimated workloads for the various clinical activities for medical internists&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> We multiplied the activity in each care modality recorded in the survey for the estimated workload &#40;Table 1 of citation 7&#41;&#44; adjusting the mean stay by the complexity-adjusted mean stay index and the number of successive consultations&#44; limiting it to the mean ratio of successive consultations to first consultations&#46; We divided the total burden of care calculated in this manner by the number of medical internists multiplied by the time available per year minus 20&#37; for dedication to continuing education and research activities&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">The qualitative variables are presented as numbers and percentages&#44; and the quantitative variables are presented as mean&#44; median and standard deviation&#46; For the comparisons between quantitative variables&#44; after a homogeneity of variance study&#44; we employed Student&#39;s <span class="elsevierStyleItalic">t</span>-test and analysis of variance &#40;ANOVA&#41; with Bonferroni correction&#44; as needed&#46; In all cases&#44; we rejected the null hypothesis with an alpha error &#60;0&#46;05&#46; The statistical analyses were performed with the STATA program version 13&#46;0&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">The number of responses was similar in 2014 and 2017 &#40;139 vs&#46; 138&#44; respectively&#41;&#46; Their distribution was 27&#37; vs&#46; 26&#37; for type 1&#44; 29&#37; vs&#46; 37&#37; for type 2&#44; 33&#37; vs&#46; 26&#37; for type 3 and 11&#37; vs&#46; 10&#37; for type 4&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Structure</span><p id="par0040" class="elsevierStylePara elsevierViewall">The main structural variables of the IMU &#40;installed beds&#44; reference population&#44; average number of internists and rate of internists per 100&#44;000 inhabitants remained without statistically significant differences &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Activity</span><p id="par0045" class="elsevierStylePara elsevierViewall">We found a very high correlation between the number of discharges by IMUs recorded using the survey &#40;2016&#41; and using the MBDS &#40;2015&#41; &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;92&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The mean number of discharges&#44; attendance by 100&#44;000 inhabitants&#44; interconsultations and first consultations increased in absolute terms &#40;10&#46;7&#37;&#44; 9&#46;4&#37;&#44; 18&#37; and 16&#37;&#44; respectively&#41;&#44; although the differences were not statistically significant&#46; The ratio of successive and first consultations decreased approximately 3&#37;&#44; but the differences were also not significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Ninety-four percent of the IMUs had implemented an interconsultation unit in 2016&#44; with a median of 1 physician dedicated to this activity&#44; with wide variations among IMUs in the dedication of internists to this activity &#40;mean&#44; 1&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7&#41;&#46; The mean number of interconsultations in the IMUs with an implemented unit was 400&#44; with 3&#46;1 visits per patient&#46; Seventy-seven percent of the IMUs stated that they had implemented shared care with the trauma department&#44; 58&#37; had done so with the general surgery department&#44; and 53&#37; had done so with the urology department&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Efficiency and productivity</span><p id="par0055" class="elsevierStylePara elsevierViewall">The mean stay decreased 10&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0014&#41;&#44; and the mean number of discharges per internist and the Internal Medicine Weighted Activity Index increased in absolute terms &#40;9&#46;1&#37; and 16&#46;6&#37;&#44; respectively&#41;&#44; although the differences were not statistically significant&#46; The ratio of patients to morning shift nurse on weekdays in hospital rooms decreased slightly &#40;3&#37;&#41;&#44; although the differences were also not significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Good practices</span><p id="par0060" class="elsevierStylePara elsevierViewall">The percentage of the population covered by systematic care programs for complex chronic patients increased 9&#37; up to 33&#37;&#46; Fifty-six percent of the IMUs had implemented a heart failure care protocol in 2016&#44; compared with 45&#37; in 2013&#46; The difference in the implementation of multidisciplinary rounds was 2&#37;&#44; reaching 35&#37; in 2016&#46; In terms of the system for follow-up and activation in case of deterioration &#40;in 2013&#44; 21&#37; of the IMUs responded that they had implemented this system&#41;&#44; the 2016 survey asked about the implementation of the National Institute for Health and Care Excellence guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> with 8&#37; of the IMUs responding in the affirmative&#46; In both surveys&#44; 60&#37; of the IMUs responded that they conducted early planning for the discharge&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Comparison of internal medicine units by hospital size</span><p id="par0065" class="elsevierStylePara elsevierViewall">The reference population and number of internists per IMU increased with the hospital size&#44; as did all indicators of activity&#46; The patient workload per nurse on weekdays was lower in the type 4 IMUs than in the other IMUs &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;2&#41;&#44; while the number of discharges per internist was lower in the type 4 IMUs &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The mean stay was notably longer in the IMUs of type 3 and 4 hospitals &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; as was the ratio between successive and first consultations &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; Research work&#44; according to the number of publications and their factor of impact&#44; was greater the larger the hospital &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;05&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Our study&#39;s main conclusion is that&#44; faced with the increased burden of care&#44; especially during hospitalization&#44; the IMUs responded by decreasing the mean stay and increasing in absolute terms the mean number of discharges per internist and increasing the Internal Medicine Weighted Activity Index&#46; There was slow progress in implementing good practices&#44; and the variability in its structure&#44; resources and activity remained&#44; which probably indicates significant opportunities for improvement&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The increase in the burden of hospitalization is a trend that was sustained from 2005&#44; the year in which the MBDS began to reflect the discharge service&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;5</span></a> The trend was accompanied by a greater age and comorbidity of hospitalized patients&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> According to our findings&#44; the IMUs responded to this trend by improving their efficiency and increasing productivity in absolute terms&#46; Although there was a slight increase in resources between 2013 and 2016&#44; this can barely compensate for the increased burden of care resulting from the increased complexity of hospitalized patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">There are&#44; however&#44; significant differences according to hospital type&#44; with IMUs located in centers with fewer than 500 beds being significantly more productive in caring for hospitalized patients&#46; The mean patient burden per morning shift nurse is high compared with that of other countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">9&#44;10</span></a> Within IMUs of the SNHS&#44; an association has been found between greater nursing burden and poorer results&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> a problem that needs addressing&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The mean stay decreased significantly compared with 2013&#44; with marked differences between IMUs in hospitals with more or fewer than 500 beds&#44; the latter of which had significantly shorter stays&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The data from 2017 still show an appreciable gap between the clinical management of patients and the recommendations of the Ministry of Health&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> especially in implementing the recommendations regarding the management of critical and acute patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">8&#44;12&#44;13</span></a> Progress in the multidisciplinary rounds<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">14&#8211;16</span></a> or the early planning of discharges<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">17&#8211;21</span></a> has been practically nonexistent&#46; The population coverage of systematic care programs for complex chronic patient is still low&#44; although it increased slightly from 2013&#46; There is a considerable gap in terms of the recommendations for units for polypathological patients<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> and the strategy for approaching chronicity in the SNHS&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The mean number of interconsultations by IMUs and the number of interconsultation units has increased&#59; however&#44; not all have implemented shared care with the departments they support&#44; which are generally surgical&#46; Seventy-seven percent of the units reported sharing care with trauma and orthopedic departments&#44; a slightly higher percentage than that found by Marco-Mart&#237;nez et al&#46; in a survey with data from 2014 &#40;65&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> The Spanish Society of Internal Medicine should more precisely define the criteria that determine the presence of shared interconsultation units&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The increase in first consultations by IMU and the decrease in successive consultations&#44; in absolute terms&#44; points to timid progress in managing the demand&#44; which is probably insufficient while no progress is made in implementing systematic care models for complex chronic patients&#46; The significantly greater proportion of successive consultations over first consultations in the IMUs of hospitals with 200 or more installed beds could be related to poor management of the demand&#44; to an increased presence of more complex patients and to the increased burden of specialized clinics&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">As in RECALMIN 2014&#44; the 2017 survey showed that research activities in the IMUs are linked to the hospital&#39;s complexity&#46; The number of publications and their impact factor in type 4 IMUs was 10 times greater than that in type 1 IMUs&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The correlation between the number of hospital discharges recorded in the survey and that recorded in the MBDS leads us to think that the reliability of the responses given by the heads of the IMU is high&#46; Although 61&#37; of the units responded to the RECALMIN survey&#44; the sample can be considered representative of the whole of the SNHS&#44; with notable stability in the structural data&#44; despite the changes in the IMUs that filled out the survey and their distribution by complexity&#46; Nevertheless&#44; increasing the number of IMUs that respond to the RECALMIN survey remains a challenge for the Spanish Society of Internal Medicine&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">IMUs approach the increased demand for care by improving their efficiency&#46; In contrast&#44; advances have been scarce in implementing good practices&#44; including the systematic care of complex chronic patients&#46; It is unlikely that the improvement can compensate for the increased patient complexity and demand for care if healthcare models are not in place for the systematic management of complex chronic patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">The RECALMIN study benefited from an unconditional grant from <span class="elsevierStyleGrantSponsor" id="gs1">Laboratorios Menarini S&#46;A&#46;</span></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To compare the structure&#44; resources and activity of the internal medicine units &#40;IMUs&#41; of the Spanish National Health System &#40;SNHS&#41; in 2013 and 2016&#46; To analyze the differences between IMUs in 2016 by hospital size&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System&#44; with data referring to 2013 and 2016&#46; The variables were collected via an ad hoc questionnaire &#40;RECALMIN survey&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Between 2013 and 2016&#44; the demand for care increased dramatically &#40;with an annual average of 11&#37; in hospital discharges and 16&#37; in first consultations&#41;&#44; and comorbidity slightly increased &#40;2&#37;&#41;&#46; During this period&#44; the mean productivity of IMUs increased 16&#46;7&#37; &#40;0&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3 vs&#46; 0&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;09&#41;&#44; and the mean stay decreased 10&#37; &#40;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;2 vs&#46; 8&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;1 days&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Progress in implementing good practices and systematic care for complex chronic patients was scarce&#46; Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">IMUs responded to the increased burden of care they supported during 2013&#8211;2016 by improving their efficiency and productivity&#59; however&#44; advances in implementing good practices&#44; including care for chronic complex patients&#44; were scare&#46; The significant variability in the indicators of structure&#44; activity and management models found in 2013 remained in 2016&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparar la estructura&#44; recursos y actividad de las Unidades de Medicina Interna &#40;UMI&#41; del Sistema Nacional de Salud &#40;SNS&#41; en 2013 y 2016&#46; Analizar las diferencias entre UMI en 2016 por tama&#241;o de hospital&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Comparativa de 2 estudios descriptivos transversales de UMI en hospitales generales de agudos del Sistema Nacional de Salud con datos referidos a 2013 y a 2016&#46; Las variables fueron recogidas mediante un cuestionario &#171;ad hoc&#187; &#40;encuesta RECALMIN&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Entre 2013 y 2016 aument&#243; notablemente la demanda asistencial &#40;con un promedio anual del 11&#37; en altas de hospitalizaci&#243;n y del 16&#37; en primeras consultas&#41; y ligeramente la comorbilidad &#40;2&#37;&#41;&#46; En el mismo per&#237;odo&#44; aument&#243; un 16&#44;7&#37; la productividad media de las UMI &#40;0&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;3 vs&#46; 0&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;3&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;09&#41; y la estancia media disminuy&#243; un 10&#37; &#40;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;2 vs&#46; 8&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;1 d&#237;as&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Los progresos en la implantaci&#243;n de buenas pr&#225;cticas y de una atenci&#243;n sistem&#225;tica al paciente cr&#243;nico complejo fueron escasos&#46; La variabilidad entre UMI y las notables diferencias entre UMI de hospitales de tama&#241;o distinto fueron hallazgos de ambas encuestas&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las UMI respondieron al aumento de la carga asistencial que soportaron en el per&#237;odo 2013-2016 mejorando su eficiencia y productividad&#44; pero los avances en la implantaci&#243;n de buenas pr&#225;cticas&#44; incluyendo la atenci&#243;n al paciente cr&#243;nico complejo&#44; fueron escasos&#46; La importante variabilidad en los indicadores de estructura&#44; actividad y modelos de gesti&#243;n encontrada en 2013 se mantuvo en 2016&#46;</p></span>"
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            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Zapatero-Gaviria A&#44; Gomez-Huelgas R&#44; Diez-Manglano J&#44; Barba-Mart&#237;n R&#44; Carretero-Gomez J&#44; Maestre-Peir&#243; A&#44; et al&#46; RECALMIN&#46; Cuatro a&#241;os de evoluci&#243;n de las Unidades de Medicina Interna del Sistema Nacional de Salud &#40;2013-2016&#41;&#46; Rev Clin Esp&#46; 2019&#59;219&#58;171&#8211;176&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Correlation between the number of discharges by internal medicine units recorded using the survey &#40;RECALMIN&#41; and minimum basic data set&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>&#58; MBDS&#44; minimum basic data set&#46;</p>"
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      1 => array:8 [
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        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The IMU data correspond to the year prior to the survey &#40;2013 and 2016&#44; respectively&#41;&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2017&#47;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#46; of hospitals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">138 &#40;136<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Installed beds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">476<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>363&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">475<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>365&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Population setting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">228&#44;660<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>143&#44;808&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">232&#44;252<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>140&#44;253&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internists &#40;average IMU&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internists per 100&#44;000 inhabitants&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2013&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of hospital discharges&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2866<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1791&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3173<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1964&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital attendance &#40;discharges per 1000 inhabitants and year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#46; of hospital interconsultations &#40;patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">862<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>912&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1017<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1132&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Initial consultations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1916<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1343&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2223<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1790&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Outpatient attendance rate &#40;discharges per 1000 inhabitants and year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ratio of successive to first visits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparison of activity indicators of internal medicine units 2013 and 2016&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>&#58; IMWAI Aj&#44; Weighted Activity Index in Internal Medicine &#40;adjusted by length of stay and successive&#47;first consultation ratio&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;10&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#46; of discharges per internist and year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">239<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IMWAI Aj&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient per morning shift nurse&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Efficiency and productivity of internal medicine units 2013 and 2016&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital Interconsultations &#40;patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">960<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1122&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2066<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1913&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;018&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">108&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;047&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison of internal medicine units by hospital type&#46; 2016&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "Encuesta SEMI sobre la oferta asistencial de los internistas en los hospitales del Sistema P&#250;blico de Salud"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "J&#46;E&#46; Losa"
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                            2 => "R&#46; Barba"
                            3 => "J&#46; Marco"
                            4 => "S&#46; Plaza"
                            5 => "J&#46; Canora"
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                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2011.01.002"
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                        "volumen" => "211"
                        "paginaInicial" => "223"
                        "paginaFinal" => "232"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21496798"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "An&#225;lisis de 2 a&#241;os de actividad de Medicina Interna en los hospitales del Sistema Nacional de Salud"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Barba Mart&#237;n"
                            1 => "J&#46; Marco Mart&#237;nez"
                            2 => "J&#46; Emilio Losa"
                            3 => "J&#46; Canora Lebrato"
                            4 => "S&#46; Plaza Canteli"
                            5 => "A&#46; Zapatero Gaviria"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                      "titulo" => "RECALMIN&#46; La atenci&#243;n al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud"
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                            2 => "P&#46; Rom&#225;n S&#225;nchez"
                            3 => "E&#46; Casariego Vales"
                            4 => "J&#46; Diez Manglano"
                            5 => "M&#46; Garc&#237;a Cors"
                          ]
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                      ]
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                            2 => "E&#46; Casariego Vales"
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                            5 => "J&#46;L&#46; Bernal"
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                      "doi" => "10.1093/intqhc/mzx055"
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                        "tituloSerie" => "Int J Qual Health Care"
                        "fecha" => "2017"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2019.03.004

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