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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of standardized PAH rates by age and sex in PCA from 2013 to 2015&#46; The violin shape shows the density of the standardized rates by age and sex per 10&#44;000 residents &#40;a&#41; and the density of normalized standardized rates &#40;b&#41; to facilitate the comparison of variations among conditions with very different prevalences&#46; The white circles show the median&#44; the boxes the interquartile range&#44; and the spikes the 5th and 95th percentiles for each of the conditions&#46; ACD&#58; acute complications of diabetes&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; congestive heart failure&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Potentially avoidable hospitalizations &#40;PAH&#41; are defined as admissions caused by health problems in which outpatient care that is appropriate in terms of the type of care&#44; location&#44; intensity&#44; accessibility&#44; and effectiveness could help decrease the risk of hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the case of PAH due to chronic conditions&#44; it is assumed that if the conditions that cause them were treated in the outpatient setting in an effective manner&#44; a worsening of the patient&#8217;s condition and&#44; thus&#44; their hospitalization could be avoided&#46; In terms of quality management and improvement&#44; high rates of this type of admission could be indicative of insufficient quality care and an inefficient use of healthcare resources&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Numerous works on the incidence of these hospitalizations in Spain&#8217;s National Health System &#40;SNS&#44; for its initials in Spanish&#41; can be found in the literature&#46; At AtlasVPM group&#44; numerous studies have been conducted on its variability&#44; evolution&#44; and underlying factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In terms of the latter&#44; the factors that explain avoidable hospitalizations depend on the healthcare system analyzed&#46; In the original studies conducted in the United States of America&#44; these admissions are considered sensitive to effective access to primary care&#44; thus explaining their name&#58; ambulatory care-sensitive conditions &#40;ACSC&#41;&#46; In these first works&#44; patients&#8217; income level&#44; education level&#44; and lifestyle were of particular relevance as explanatory factors of PAH&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Later works&#44; which were conducted in healthcare systems in which primary care plays a different role&#44; have postulated that in addition to effective access to quality primary care&#44; the fragmentation of care&#44; lack of connection between levels of care&#44; differences in hospital care availability&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> differences in patient admission criteria&#44; and hospitals&#8217; varying propensities towards hospitalizing their reference populations<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> are factors strongly associated with PAH&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">With the objective of conducting a detailed analysis of PAH&#44; the AtlasVPM group has created the Atlas of Potentially Avoidable Hospitalisations for Chronic Conditions<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> &#40;<a href="https://www.atlasvpm.org/atlas/hpe-zbs/">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlas&#47;hpe-zbs&#47;</a>&#41;&#46; This work analyses PAH which occurred in the SNS from 2013 to 2015&#46; It uses two units of analysis that are relevant in the study of this type of hospitalization&#58; primary care areas &#40;PCA&#41; as a primary care service providing unit that is the main provider of care to chronic patients&#44; and the healthcare area&#44; representing the comprehensive provision of primary&#44; specialized&#44; and hospital healthcare services in the context of the Spanish SNS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This work is an observational ecological study on administrative data that analyzed unjustified variations in PAH in six chronic conditions during the period from 2013 to 2015&#58; chronic obstructive pulmonary disease &#40;COPD&#41;&#44; asthma&#44; acute complications of diabetes &#40;ACD&#41;&#44; congestive heart failure &#40;CHF&#41;&#44; nonprimary angina without an associated procedure&#44; and dehydration&#46; These indicators have their origin in the proposals by the US Agency for Healthcare Research and Quality &#40;AHRQ-PQI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> but with definitions that have been adapted and validated in the Spanish context&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Data source</span><p id="par0035" class="elsevierStylePara elsevierViewall">The discharges analyzed corresponded to publicly funded hospital activity and were identified from diagnoses recorded in the Minimum Basic Data Set on Hospital Discharges &#40;CMBD&#44; for its initials in Spanish&#41; of Spain&#8217;s 17 autonomous communities from 2013 to 2015&#46; Once identified&#44; each episode was assigned to a place of residence according to the Atlas VPM methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In regard to the denominator used to determine the rates&#44; or the population at risk of suffering a PAH&#44; the resident population of the PCA and healthcare areas were used&#46; These data were obtained from the municipal population registries of the National Institute of Statistics&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Units of analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">The indicators for the 2455 PCA and 203 healthcare areas that constitute the SNS &#40;excluding Ceuta and Melilla&#44; which are run directly by the Ministry of Health through INGESA&#41; were analyzed and represented&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Standardized rates of PAH that occurred in the period from 2013 to 2015 were calculated according to age and sex &#40;direct method&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The standardized rates per 10&#44;000 residents over 40 years of age were calculated for all indicators except for discharges due to dehydration&#44; in which the cutoff age was 65 years&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The standardized hospitalization ratio was estimated using the Besag-York-Mollie Bayesian method&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> In order to represent the data on a map&#44; the probability the standardized hospitalization ratio would exceed a value of 1 &#40;greater risk of PAH than expected&#41; or would be a value statistically inferior than 1 &#40;lesser risk of PAH than expected&#41; was shown&#46; Two cutoff points were used&#58; a high probability &#40;between 0&#46;8 and 0&#46;9&#41; that the risk of PAH was higher &#40;or lower&#41; than what is expected and a very high probability &#40;greater than 0&#46;9&#41; that the risk of PAH was higher &#40;or lower&#41; than what is expected&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The variability of PAH among PCA was determined by the ratio of variation between the standardized rates of the zones in the 5th and 95th percentiles &#40;RV<span class="elsevierStyleInf">5&#8722;95</span>&#41;&#44; as a measurement of the extreme variation range&#44; and between the rates in zones in the 25th and 75th percentiles &#40;RV<span class="elsevierStyleInf">25&#8722;75</span>&#41;&#44; as a measurement of the variation among areas in the interquartile interval&#46; In addition&#44; the systematic component of the variation &#40;SCV&#41; was calculated as an estimate of nonrandom variation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">For the analysis of PAH in specific subgroups of the population&#44; Bayesian shared-component modeling was used&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The difference in risk of PAH between people older than 80 years of age and people between 65 and 79 years of age &#40;or vice versa&#41; and the difference in risk of PAH between women and men &#40;or vice versa&#41; beyond the baseline differences related to age&#44; sex&#44; or the epidemiological burden that may exist between subgroups were calculated&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To determine a healthcare area&#8217;s contribution to the variation of rates beyond what was observed among PCA&#44; generalized multilevel models were estimated in which the PCA was the first level of the model and the healthcare area was the second&#46; Estimation of the area&#39;s effect was carried out by calculating Spearman&#8217;s Rho&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The analyses were performed using the statistical programs Stata 13 and R 3&#46;5&#46;1&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Between 2013 and 2015&#44; 439&#44;878 PAH admissions were recorded in SNS hospitals&#44; which indicates that one out of every 161 residents over 40 years of age had a potentially avoidable hospitalization due to any of the conditions analyzed&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Of the total number of PAH&#44; 183&#44;960 admissions &#40;42&#37;&#41; were due to COPD&#44; 16&#44;543 &#40;4&#37;&#41; due to asthma&#44; 164&#44;509 &#40;37&#37;&#41; due to CHF&#44; 44&#44;057 &#40;10&#37;&#41; due to angina&#44; 21&#44;464 &#40;5&#37;&#41; due to dehydration&#44; and 7057 &#40;2&#37;&#41; due to ACD &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The most extreme variations in PAH rates found among the PCA were differences of up to four-fold&#44; although differences varied depending on the condition analyzed &#40;for greater detail&#44; see <a href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_variacion_ZBS-AREA_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;variacion&#95;ZBS-AREA&#95;2013-2015&#47;atlas&#46;html</a>&#41;&#46; The conditions with greater variability among zones were asthma&#44; angina&#44; ACD&#44; and dehydration&#44; with interquartile ratio of variation &#40;RV<span class="elsevierStyleInf">25&#8722;75</span>&#41; of six for ACD&#44; four for asthma&#44; and three for angina and dehydration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The systematic variation &#40;variation with respect to what is expected according to chance&#41; of the totality of PAH was moderate&#8212;22&#37; &#40;variation is considered low if it is less than 10&#37;&#41;&#8212;and remained fairly stable with respect to the previous period of 2010&#8211;2012 &#40;23&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">According to clinical conditions&#44; a considerable increase in systematic variation was observed in admissions due to angina&#58; they went from 67&#37; to 79&#37; above what is expected&#46; The systematic variations of admissions due to asthma and dehydration were also very high &#40;72&#37; and 50&#37; above what is expected&#41;&#46; Moderate-high values of systematic variation among the rest of conditions &#40;ACD&#44; COPD&#44; CHF&#41; were maintained&#44; with a slight decrease with respect to the period from 2010 to 2012 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In regard to the analyses by population subgroups&#44; the PAH rate for the set of clinical conditions was greater in men than in women &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In 380 PCA &#40;16&#37; of the total&#41;&#44; men had a greater risk of experiencing a PAH than women&#46; They had a very high probability beyond the epidemiological differences between sexes &#40;for greater detail&#44; see <a href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_H_M_ZBS_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;H&#95;M&#95;ZBS&#95;2013-2015&#47;atlas&#46;html</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">According to clinical conditions&#44; admissions due to asthma&#44; CHF&#44; dehydration&#44; and ACD were more frequent in women than in men&#46; The greatest differences were found in asthma&#44; with a rate that was 3&#46;5 times higher in women than in men&#46; For CHF&#44; dehydration&#44; and ACD&#44; the rates were 71&#37;&#44; 57&#37;&#44; and 14&#37; higher in women than in men&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In 592 &#40;24&#37;&#41;&#44; 316 &#40;13&#37;&#41;&#44; 322 &#40;13&#37;&#41;&#44; and 321 &#40;13&#37;&#41; PCA&#44; women had a greater risk &#40;with a very high probability&#41; that PAH for CHF&#44; asthma&#44; ACD&#44; and dehydration were greater than that of men&#44; beyond the epidemiological differences attributable to sex&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">On the contrary&#44; PAH due to COPD and angina were more frequent in men&#46; The rate of PAH due to COPD was nearly four times higher in men than in women whereas the rate due to angina was 61&#37; higher &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In 481 PCA &#40;20&#37;&#41;&#44; men presented with greater risk&#8212;with a very high probability&#8212;of PAH due to COPD whereas in 242 PCA &#40;10&#37;&#41;&#44; the risk of hospitalizations due to angina was greater in men compared to women&#44; beyond the epidemiological differences attributable to sex&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In regard to age subgroups&#44; as is expected&#44; the PAH rate in people older than 80 years of age was up to three times higher than the rate for people between 65 and 79 years of age &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Beyond the expected differences due to differences in age&#44; in 442 PCA &#40;18&#37;&#41;&#44; people older than 80 years of age had a very high probability of having a preventable admission with respect to people between 65 and 79 years of age &#40;for greater detail&#44; see <a href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_65-79_80_ZBS_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;65-79&#95;80&#95;ZBS&#95;2013-2015&#47;atlas&#46;html</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">In all the chronic conditions studied&#44; the older population had a greater frequency of hospitalization&#46; However&#44; in the case of admissions due to dehydration&#44; contrary to what is expected according to the baseline differences between age groups&#44; in 310 PCA &#40;13&#37;&#41;&#44; people between 65 and 79 years of age had a greater risk of this type of admission compared to those older than 80 years of age&#44; with a very high probability&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Lastly&#44; the contribution of the comprehensive healthcare services provider &#40;healthcare area&#41; in the explanation of the variation observed among PCA was estimated&#46; For all PAH&#44; the healthcare area explained 33&#37; of the variability that was not explained by the PCA&#46; According to clinical condition&#44; in admissions due to angina&#44; asthma&#44; COPD&#44; and CHF&#44; the healthcare area explained a large proportion of the variability not explained by the PCA&#58; -55&#37;&#44; 36&#37;&#44; 29&#37;&#44; and 28&#37;&#44; respectively&#46; In ACD and dehydration&#44; the contribution of the healthcare area in the explanation of the variation was modest&#58; 15&#37;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this Atlas&#44; the enormous variability in PAH rates in chronic patients among PCA is demonstrated&#46; This variability is more marked in some clinical conditions than in others&#46; It also shows that variability can depend on a person&#39;s age and sex&#46; Lastly&#44; in addition to the variation observed among PCA&#44; there are latent factors that are characteristic of the healthcare area &#40;care plans or strategies that affect all centers&#44; distribution of specialized resources&#44; or the degree of coordination among levels&#41; that are highly relevant &#40;although unequal depending to the conditions observed&#41; in explaining the variability&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">There is agreement on the notion that the existence of PAH could reflect a problem in healthcare quality &#40;for example&#44; in the intensity of care in primary care&#44; which is unequal according to patients&#8217; age or sex&#41; and of inefficiencies in the healthcare system due to an inadequate use of resources &#40;for example&#44; patients treated in a hospital who could be treated as outpatients&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Tools such as the Atlas of Variations in Medical Practice&#44; which allow for detecting PAH magnitude and analysing the factors that cause them&#44; can help guide plans and measures for reducing them&#46; Indeed&#44; the Atlas of Potentially Avoidable Hospitalisations has allowed for the identification of PCA or areas in which providers consistently report low rates&#44; which are ideally those in which the comprehensive care of chronic patients prevents hospitalizations&#46; With the appropriate cautions&#44; these PCA could be used as examples of good practices&#46; On the contrary&#44; areas or zones with higher rates could warrant a more in-depth analysis to determine if what was observed is due to problems related to the management of chronic patients&#44; both in primary care and throughout the healthcare continuum&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">For example&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a shows the performance profile of the Alhaur&#237;n el Grande PCA&#44; in Andalusia&#44; whose PAH rates are below the target national threshold&#44; established in this case in the 25th percentile&#44; with the exception of the rate of dehydration among elderly patients&#44; which did not statistically differ from it&#46; If the healthcare area this zone belongs to&#44; Valle del Guadalhorce&#44; is analyzed&#44; a similar result is found &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#46; In light of the low rates of PAH observed in these settings&#44; which are below the national targets&#44; the management of chronic patients in both could serve as inspiration to providers who are similar but which have higher PAH rates&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0160" class="elsevierStylePara elsevierViewall">PAH due to chronic conditions could reflect problems in healthcare quality and an inefficient use of resources&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In the Atlas of Potentially Avoidable Hospitalisations for Chronic Conditions&#44; the wide variability in rates of these hospitalizations among the PCA and healthcare areas of the SNS are shown&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The analysis of data and their representation in the form of an atlas facilitates identifying PCA and healthcare areas with better results &#40;therefore&#44; potential management models for other providers&#41; and those with worse results &#40;areas that merit a more in-depth analysis and priority intervention&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">This work was funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">European Social Fund through the Carlos III Institute of Health through the REDISSEC</span> grants <span class="elsevierStyleGrantNumber" refid="gs0005">&#40;&#35;RD16&#47;0001&#47;0007</span>&#41; and the <span class="elsevierStyleGrantSponsor" id="gs0010">FIS Project</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs0010">PI1400786</span>&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest in regard to this article&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Potentially avoidable hospitalisations &#40;PAHs&#41; due to chronic conditions are a healthcare problem that could reflect healthcare of insufficient quality&#46; This study reports the systematic variations in PAHs for the collection of providers of the Spanish National Health System&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">We conducted an ecological study on government data&#44; analysing the systematic variation in PAHs for 6 chronic conditions during 2013&#8211;2015&#46; To determine the variation&#44; we performed a small area analysis using Bayesian methodology&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Between 2013 and 2015&#44; 439&#44;878 admissions for PAHs were recorded in the Spanish National Health System&#46; There was an up to 4-fold difference in PAH rates between certain basic health areas &#40;BHA&#41;&#44; with highly variable differences depending on the analyzed condition&#46; Forty percent of the BHAs showed a greater than expected risk of PAH&#46; Beyond the systematic variation observed between BHAs&#44; the healthcare areas of the patients&#8217; residence explained 33&#37; of the variation in PAHs&#46; We observed specific differences in these general results according to clinical condition&#44; age and sex&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The wide systematic variation in PAHs suggests a problem of quality in the care provided to chronically ill patients by the providers of healthcare areas in Spain&#46; Identifying and analysing these areas and other healthcare areas with better results could provide a reference for improving the care of other suppliers with poorer performance&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Las hospitalizaciones potencialmente evitables &#40;HPE&#41; por condiciones cr&#243;nicas constituyen un problema sanitario que puede ser reflejo de una atenci&#243;n sanitaria de insuficiente calidad&#46; En este trabajo se describen las variaciones sistem&#225;ticas en HPE para el conjunto de proveedores del Sistema Nacional de Salud&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Estudio ecol&#243;gico sobre datos administrativos en el que se analiza la variaci&#243;n sistem&#225;tica en las HPE por 6 condiciones cr&#243;nicas en el per&#237;odo 2013&#8722;2015&#46; Para la estimaci&#243;n de la variaci&#243;n se realiza an&#225;lisis de &#225;rea peque&#241;a utilizando metodolog&#237;a Bayesiana&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Entre 2013 y 2015 se registraron 439&#46;878 ingresos por HPE en el Sistema Nacional de Salud&#46; La variaci&#243;n de tasas de HPE entre zonas b&#225;sicas de salud &#40;ZBS&#41; extremas fue de hasta 4 veces&#44; con diferencias muy variables dependiendo de la condici&#243;n analizada El 40&#37; de las ZBS present&#243; un riesgo de HPE por encima de la esperado&#46; M&#225;s all&#225; de la variaci&#243;n sistem&#225;tica observada entre ZBS&#44; las &#225;reas sanitarias de residencia de los pacientes explicaron un 33&#37; de la variaci&#243;n en las HPE&#46; Sobre estos resultados generales&#44; se observaron diferencias espec&#237;ficas en funci&#243;n de la condici&#243;n cl&#237;nica&#44; edad y sexo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La amplia variaci&#243;n sistem&#225;tica en HPE sugiere la existencia de un problema de calidad en la atenci&#243;n prestada a pacientes cr&#243;nicos por el conjunto de proveedores de las &#225;reas sanitarias&#46; La identificaci&#243;n y an&#225;lisis de aquellas zonas y &#225;reas sanitarias con mejores resultados podr&#237;a servir de referencia para la mejora de los cuidados en otros proveedores con peor desempe&#241;o&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of standardized PAH rates by age and sex in PCA from 2013 to 2015&#46; The violin shape shows the density of the standardized rates by age and sex per 10&#44;000 residents &#40;a&#41; and the density of normalized standardized rates &#40;b&#41; to facilitate the comparison of variations among conditions with very different prevalences&#46; The white circles show the median&#44; the boxes the interquartile range&#44; and the spikes the 5th and 95th percentiles for each of the conditions&#46; ACD&#58; acute complications of diabetes&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; congestive heart failure&#46;</p>"
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        "etiqueta" => "Figure 2"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Performance profile of the Alhaur&#237;n el Grande &#40;a&#41; and the healthcare area it belongs to&#44; Valle del Guadalhorce &#40;b&#41; for the period from 2013 to 2015&#46; Results of the PAH indicators and comparison with the national p25 &#40;a&#41; and p10 &#40;b&#41;&#46; Circles representing the standardized rate of each indicator are located on a bar limited by the minimum and maximum rate&#46; If the rate of the zone or area analyzed is significantly lower than the p25 or p10 value&#44; respectively &#40;represented by a vertical line&#41;&#44; the color of the circle is light gray&#46; If the value is not significantly different&#44; it is dark gray&#46; Modified based on <span class="elsevierStyleInterRef" id="intr0005" href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_perfil_ZBS_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;perfil&#95;ZBS&#95;2013-2015&#47;atlas&#46;html</span>&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ACD&#58; acute complications of diabetes&#59; SVC&#58; systematic variation component&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; congestive heart failure&#59; nc&#58; not calculable&#59; RV<span class="elsevierStyleInf">5&#8722;95</span>&#58; ratio of variation between the 5 and 95 percentile&#59; RV<span class="elsevierStyleInf">25&#8722;75</span>&#58; ratio of variation between the 25 and 75 percentile&#59; SR&#58; standardized rate&#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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ACD</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">COPD</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CHF</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Angina</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Asthma</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dehydration</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;493&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">184&#44;639&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">183&#44;960&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">160&#44;329&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">164&#44;509&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#44;644&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;667&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;543&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;329&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;464&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">435&#44;955&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">439&#44;878&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Min SR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cases&#44; rates&#44; and variation statistics of PAH for the six conditions separately and the aggregate total in the periods from 2010 to 2012 and 2013 to 2015&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ACD&#58; acute complications of diabetes&#59; SVC&#58; systematic variation component&#59; DH&#58; dehydration&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; congestive heart failure&#59; CR&#58; crude rate&#59; SR&#58; standardized rate&#46;</p>"
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">3222&nbsp;\t\t\t\t\t\t\n
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Original article
Wide systematic variations in potentially avoidable hospitalizations of chronically ill patients: Ecological study of primary care areas and healthcare areas
Amplias variaciones sistemáticas en hospitalizaciones potencialmente evitables en pacientes crónicos: estudio ecológico sobre zonas básicas de salud y áreas sanitarias
E. Angulo-Pueyoa,b,c, N. Martínez-Lizagaa,b,c, E. Bernal-Delgadoa,
Corresponding author
ebernal.iacs@aragon.es

Corresponding author.
, on behalf of the Atlas VPM Group
a Grupo de Investigación en Servicios y Políticas Sanitarias. Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain
b Instituto de Investigación Sanitaria Aragón (IIS Aragón), Spain
c Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Potentially avoidable hospitalizations &#40;PAH&#41; are defined as admissions caused by health problems in which outpatient care that is appropriate in terms of the type of care&#44; location&#44; intensity&#44; accessibility&#44; and effectiveness could help decrease the risk of hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the case of PAH due to chronic conditions&#44; it is assumed that if the conditions that cause them were treated in the outpatient setting in an effective manner&#44; a worsening of the patient&#8217;s condition and&#44; thus&#44; their hospitalization could be avoided&#46; In terms of quality management and improvement&#44; high rates of this type of admission could be indicative of insufficient quality care and an inefficient use of healthcare resources&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Numerous works on the incidence of these hospitalizations in Spain&#8217;s National Health System &#40;SNS&#44; for its initials in Spanish&#41; can be found in the literature&#46; At AtlasVPM group&#44; numerous studies have been conducted on its variability&#44; evolution&#44; and underlying factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In terms of the latter&#44; the factors that explain avoidable hospitalizations depend on the healthcare system analyzed&#46; In the original studies conducted in the United States of America&#44; these admissions are considered sensitive to effective access to primary care&#44; thus explaining their name&#58; ambulatory care-sensitive conditions &#40;ACSC&#41;&#46; In these first works&#44; patients&#8217; income level&#44; education level&#44; and lifestyle were of particular relevance as explanatory factors of PAH&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Later works&#44; which were conducted in healthcare systems in which primary care plays a different role&#44; have postulated that in addition to effective access to quality primary care&#44; the fragmentation of care&#44; lack of connection between levels of care&#44; differences in hospital care availability&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> differences in patient admission criteria&#44; and hospitals&#8217; varying propensities towards hospitalizing their reference populations<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> are factors strongly associated with PAH&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">With the objective of conducting a detailed analysis of PAH&#44; the AtlasVPM group has created the Atlas of Potentially Avoidable Hospitalisations for Chronic Conditions<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> &#40;<a href="https://www.atlasvpm.org/atlas/hpe-zbs/">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlas&#47;hpe-zbs&#47;</a>&#41;&#46; This work analyses PAH which occurred in the SNS from 2013 to 2015&#46; It uses two units of analysis that are relevant in the study of this type of hospitalization&#58; primary care areas &#40;PCA&#41; as a primary care service providing unit that is the main provider of care to chronic patients&#44; and the healthcare area&#44; representing the comprehensive provision of primary&#44; specialized&#44; and hospital healthcare services in the context of the Spanish SNS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This work is an observational ecological study on administrative data that analyzed unjustified variations in PAH in six chronic conditions during the period from 2013 to 2015&#58; chronic obstructive pulmonary disease &#40;COPD&#41;&#44; asthma&#44; acute complications of diabetes &#40;ACD&#41;&#44; congestive heart failure &#40;CHF&#41;&#44; nonprimary angina without an associated procedure&#44; and dehydration&#46; These indicators have their origin in the proposals by the US Agency for Healthcare Research and Quality &#40;AHRQ-PQI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> but with definitions that have been adapted and validated in the Spanish context&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Data source</span><p id="par0035" class="elsevierStylePara elsevierViewall">The discharges analyzed corresponded to publicly funded hospital activity and were identified from diagnoses recorded in the Minimum Basic Data Set on Hospital Discharges &#40;CMBD&#44; for its initials in Spanish&#41; of Spain&#8217;s 17 autonomous communities from 2013 to 2015&#46; Once identified&#44; each episode was assigned to a place of residence according to the Atlas VPM methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In regard to the denominator used to determine the rates&#44; or the population at risk of suffering a PAH&#44; the resident population of the PCA and healthcare areas were used&#46; These data were obtained from the municipal population registries of the National Institute of Statistics&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Units of analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">The indicators for the 2455 PCA and 203 healthcare areas that constitute the SNS &#40;excluding Ceuta and Melilla&#44; which are run directly by the Ministry of Health through INGESA&#41; were analyzed and represented&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Standardized rates of PAH that occurred in the period from 2013 to 2015 were calculated according to age and sex &#40;direct method&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The standardized rates per 10&#44;000 residents over 40 years of age were calculated for all indicators except for discharges due to dehydration&#44; in which the cutoff age was 65 years&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The standardized hospitalization ratio was estimated using the Besag-York-Mollie Bayesian method&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> In order to represent the data on a map&#44; the probability the standardized hospitalization ratio would exceed a value of 1 &#40;greater risk of PAH than expected&#41; or would be a value statistically inferior than 1 &#40;lesser risk of PAH than expected&#41; was shown&#46; Two cutoff points were used&#58; a high probability &#40;between 0&#46;8 and 0&#46;9&#41; that the risk of PAH was higher &#40;or lower&#41; than what is expected and a very high probability &#40;greater than 0&#46;9&#41; that the risk of PAH was higher &#40;or lower&#41; than what is expected&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The variability of PAH among PCA was determined by the ratio of variation between the standardized rates of the zones in the 5th and 95th percentiles &#40;RV<span class="elsevierStyleInf">5&#8722;95</span>&#41;&#44; as a measurement of the extreme variation range&#44; and between the rates in zones in the 25th and 75th percentiles &#40;RV<span class="elsevierStyleInf">25&#8722;75</span>&#41;&#44; as a measurement of the variation among areas in the interquartile interval&#46; In addition&#44; the systematic component of the variation &#40;SCV&#41; was calculated as an estimate of nonrandom variation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">For the analysis of PAH in specific subgroups of the population&#44; Bayesian shared-component modeling was used&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The difference in risk of PAH between people older than 80 years of age and people between 65 and 79 years of age &#40;or vice versa&#41; and the difference in risk of PAH between women and men &#40;or vice versa&#41; beyond the baseline differences related to age&#44; sex&#44; or the epidemiological burden that may exist between subgroups were calculated&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To determine a healthcare area&#8217;s contribution to the variation of rates beyond what was observed among PCA&#44; generalized multilevel models were estimated in which the PCA was the first level of the model and the healthcare area was the second&#46; Estimation of the area&#39;s effect was carried out by calculating Spearman&#8217;s Rho&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The analyses were performed using the statistical programs Stata 13 and R 3&#46;5&#46;1&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Between 2013 and 2015&#44; 439&#44;878 PAH admissions were recorded in SNS hospitals&#44; which indicates that one out of every 161 residents over 40 years of age had a potentially avoidable hospitalization due to any of the conditions analyzed&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Of the total number of PAH&#44; 183&#44;960 admissions &#40;42&#37;&#41; were due to COPD&#44; 16&#44;543 &#40;4&#37;&#41; due to asthma&#44; 164&#44;509 &#40;37&#37;&#41; due to CHF&#44; 44&#44;057 &#40;10&#37;&#41; due to angina&#44; 21&#44;464 &#40;5&#37;&#41; due to dehydration&#44; and 7057 &#40;2&#37;&#41; due to ACD &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The most extreme variations in PAH rates found among the PCA were differences of up to four-fold&#44; although differences varied depending on the condition analyzed &#40;for greater detail&#44; see <a href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_variacion_ZBS-AREA_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;variacion&#95;ZBS-AREA&#95;2013-2015&#47;atlas&#46;html</a>&#41;&#46; The conditions with greater variability among zones were asthma&#44; angina&#44; ACD&#44; and dehydration&#44; with interquartile ratio of variation &#40;RV<span class="elsevierStyleInf">25&#8722;75</span>&#41; of six for ACD&#44; four for asthma&#44; and three for angina and dehydration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The systematic variation &#40;variation with respect to what is expected according to chance&#41; of the totality of PAH was moderate&#8212;22&#37; &#40;variation is considered low if it is less than 10&#37;&#41;&#8212;and remained fairly stable with respect to the previous period of 2010&#8211;2012 &#40;23&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">According to clinical conditions&#44; a considerable increase in systematic variation was observed in admissions due to angina&#58; they went from 67&#37; to 79&#37; above what is expected&#46; The systematic variations of admissions due to asthma and dehydration were also very high &#40;72&#37; and 50&#37; above what is expected&#41;&#46; Moderate-high values of systematic variation among the rest of conditions &#40;ACD&#44; COPD&#44; CHF&#41; were maintained&#44; with a slight decrease with respect to the period from 2010 to 2012 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In regard to the analyses by population subgroups&#44; the PAH rate for the set of clinical conditions was greater in men than in women &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In 380 PCA &#40;16&#37; of the total&#41;&#44; men had a greater risk of experiencing a PAH than women&#46; They had a very high probability beyond the epidemiological differences between sexes &#40;for greater detail&#44; see <a href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_H_M_ZBS_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;H&#95;M&#95;ZBS&#95;2013-2015&#47;atlas&#46;html</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">According to clinical conditions&#44; admissions due to asthma&#44; CHF&#44; dehydration&#44; and ACD were more frequent in women than in men&#46; The greatest differences were found in asthma&#44; with a rate that was 3&#46;5 times higher in women than in men&#46; For CHF&#44; dehydration&#44; and ACD&#44; the rates were 71&#37;&#44; 57&#37;&#44; and 14&#37; higher in women than in men&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In 592 &#40;24&#37;&#41;&#44; 316 &#40;13&#37;&#41;&#44; 322 &#40;13&#37;&#41;&#44; and 321 &#40;13&#37;&#41; PCA&#44; women had a greater risk &#40;with a very high probability&#41; that PAH for CHF&#44; asthma&#44; ACD&#44; and dehydration were greater than that of men&#44; beyond the epidemiological differences attributable to sex&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">On the contrary&#44; PAH due to COPD and angina were more frequent in men&#46; The rate of PAH due to COPD was nearly four times higher in men than in women whereas the rate due to angina was 61&#37; higher &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In 481 PCA &#40;20&#37;&#41;&#44; men presented with greater risk&#8212;with a very high probability&#8212;of PAH due to COPD whereas in 242 PCA &#40;10&#37;&#41;&#44; the risk of hospitalizations due to angina was greater in men compared to women&#44; beyond the epidemiological differences attributable to sex&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In regard to age subgroups&#44; as is expected&#44; the PAH rate in people older than 80 years of age was up to three times higher than the rate for people between 65 and 79 years of age &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Beyond the expected differences due to differences in age&#44; in 442 PCA &#40;18&#37;&#41;&#44; people older than 80 years of age had a very high probability of having a preventable admission with respect to people between 65 and 79 years of age &#40;for greater detail&#44; see <a href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_65-79_80_ZBS_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;65-79&#95;80&#95;ZBS&#95;2013-2015&#47;atlas&#46;html</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">In all the chronic conditions studied&#44; the older population had a greater frequency of hospitalization&#46; However&#44; in the case of admissions due to dehydration&#44; contrary to what is expected according to the baseline differences between age groups&#44; in 310 PCA &#40;13&#37;&#41;&#44; people between 65 and 79 years of age had a greater risk of this type of admission compared to those older than 80 years of age&#44; with a very high probability&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Lastly&#44; the contribution of the comprehensive healthcare services provider &#40;healthcare area&#41; in the explanation of the variation observed among PCA was estimated&#46; For all PAH&#44; the healthcare area explained 33&#37; of the variability that was not explained by the PCA&#46; According to clinical condition&#44; in admissions due to angina&#44; asthma&#44; COPD&#44; and CHF&#44; the healthcare area explained a large proportion of the variability not explained by the PCA&#58; -55&#37;&#44; 36&#37;&#44; 29&#37;&#44; and 28&#37;&#44; respectively&#46; In ACD and dehydration&#44; the contribution of the healthcare area in the explanation of the variation was modest&#58; 15&#37;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this Atlas&#44; the enormous variability in PAH rates in chronic patients among PCA is demonstrated&#46; This variability is more marked in some clinical conditions than in others&#46; It also shows that variability can depend on a person&#39;s age and sex&#46; Lastly&#44; in addition to the variation observed among PCA&#44; there are latent factors that are characteristic of the healthcare area &#40;care plans or strategies that affect all centers&#44; distribution of specialized resources&#44; or the degree of coordination among levels&#41; that are highly relevant &#40;although unequal depending to the conditions observed&#41; in explaining the variability&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">There is agreement on the notion that the existence of PAH could reflect a problem in healthcare quality &#40;for example&#44; in the intensity of care in primary care&#44; which is unequal according to patients&#8217; age or sex&#41; and of inefficiencies in the healthcare system due to an inadequate use of resources &#40;for example&#44; patients treated in a hospital who could be treated as outpatients&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Tools such as the Atlas of Variations in Medical Practice&#44; which allow for detecting PAH magnitude and analysing the factors that cause them&#44; can help guide plans and measures for reducing them&#46; Indeed&#44; the Atlas of Potentially Avoidable Hospitalisations has allowed for the identification of PCA or areas in which providers consistently report low rates&#44; which are ideally those in which the comprehensive care of chronic patients prevents hospitalizations&#46; With the appropriate cautions&#44; these PCA could be used as examples of good practices&#46; On the contrary&#44; areas or zones with higher rates could warrant a more in-depth analysis to determine if what was observed is due to problems related to the management of chronic patients&#44; both in primary care and throughout the healthcare continuum&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">For example&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a shows the performance profile of the Alhaur&#237;n el Grande PCA&#44; in Andalusia&#44; whose PAH rates are below the target national threshold&#44; established in this case in the 25th percentile&#44; with the exception of the rate of dehydration among elderly patients&#44; which did not statistically differ from it&#46; If the healthcare area this zone belongs to&#44; Valle del Guadalhorce&#44; is analyzed&#44; a similar result is found &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#46; In light of the low rates of PAH observed in these settings&#44; which are below the national targets&#44; the management of chronic patients in both could serve as inspiration to providers who are similar but which have higher PAH rates&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0160" class="elsevierStylePara elsevierViewall">PAH due to chronic conditions could reflect problems in healthcare quality and an inefficient use of resources&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In the Atlas of Potentially Avoidable Hospitalisations for Chronic Conditions&#44; the wide variability in rates of these hospitalizations among the PCA and healthcare areas of the SNS are shown&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The analysis of data and their representation in the form of an atlas facilitates identifying PCA and healthcare areas with better results &#40;therefore&#44; potential management models for other providers&#41; and those with worse results &#40;areas that merit a more in-depth analysis and priority intervention&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">This work was funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">European Social Fund through the Carlos III Institute of Health through the REDISSEC</span> grants <span class="elsevierStyleGrantNumber" refid="gs0005">&#40;&#35;RD16&#47;0001&#47;0007</span>&#41; and the <span class="elsevierStyleGrantSponsor" id="gs0010">FIS Project</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs0010">PI1400786</span>&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest in regard to this article&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Potentially avoidable hospitalisations &#40;PAHs&#41; due to chronic conditions are a healthcare problem that could reflect healthcare of insufficient quality&#46; This study reports the systematic variations in PAHs for the collection of providers of the Spanish National Health System&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">We conducted an ecological study on government data&#44; analysing the systematic variation in PAHs for 6 chronic conditions during 2013&#8211;2015&#46; To determine the variation&#44; we performed a small area analysis using Bayesian methodology&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Between 2013 and 2015&#44; 439&#44;878 admissions for PAHs were recorded in the Spanish National Health System&#46; There was an up to 4-fold difference in PAH rates between certain basic health areas &#40;BHA&#41;&#44; with highly variable differences depending on the analyzed condition&#46; Forty percent of the BHAs showed a greater than expected risk of PAH&#46; Beyond the systematic variation observed between BHAs&#44; the healthcare areas of the patients&#8217; residence explained 33&#37; of the variation in PAHs&#46; We observed specific differences in these general results according to clinical condition&#44; age and sex&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The wide systematic variation in PAHs suggests a problem of quality in the care provided to chronically ill patients by the providers of healthcare areas in Spain&#46; Identifying and analysing these areas and other healthcare areas with better results could provide a reference for improving the care of other suppliers with poorer performance&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Las hospitalizaciones potencialmente evitables &#40;HPE&#41; por condiciones cr&#243;nicas constituyen un problema sanitario que puede ser reflejo de una atenci&#243;n sanitaria de insuficiente calidad&#46; En este trabajo se describen las variaciones sistem&#225;ticas en HPE para el conjunto de proveedores del Sistema Nacional de Salud&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Estudio ecol&#243;gico sobre datos administrativos en el que se analiza la variaci&#243;n sistem&#225;tica en las HPE por 6 condiciones cr&#243;nicas en el per&#237;odo 2013&#8722;2015&#46; Para la estimaci&#243;n de la variaci&#243;n se realiza an&#225;lisis de &#225;rea peque&#241;a utilizando metodolog&#237;a Bayesiana&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Entre 2013 y 2015 se registraron 439&#46;878 ingresos por HPE en el Sistema Nacional de Salud&#46; La variaci&#243;n de tasas de HPE entre zonas b&#225;sicas de salud &#40;ZBS&#41; extremas fue de hasta 4 veces&#44; con diferencias muy variables dependiendo de la condici&#243;n analizada El 40&#37; de las ZBS present&#243; un riesgo de HPE por encima de la esperado&#46; M&#225;s all&#225; de la variaci&#243;n sistem&#225;tica observada entre ZBS&#44; las &#225;reas sanitarias de residencia de los pacientes explicaron un 33&#37; de la variaci&#243;n en las HPE&#46; Sobre estos resultados generales&#44; se observaron diferencias espec&#237;ficas en funci&#243;n de la condici&#243;n cl&#237;nica&#44; edad y sexo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La amplia variaci&#243;n sistem&#225;tica en HPE sugiere la existencia de un problema de calidad en la atenci&#243;n prestada a pacientes cr&#243;nicos por el conjunto de proveedores de las &#225;reas sanitarias&#46; La identificaci&#243;n y an&#225;lisis de aquellas zonas y &#225;reas sanitarias con mejores resultados podr&#237;a servir de referencia para la mejora de los cuidados en otros proveedores con peor desempe&#241;o&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes y objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiales y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Angulo-Pueyo E&#44; Mart&#237;nez-Lizaga N&#44; Bernal-Delgado E&#46; Amplias variaciones sistem&#225;ticas en hospitalizaciones potencialmente evitables en pacientes cr&#243;nicos&#58; estudio ecol&#243;gico sobre zonas b&#225;sicas de salud y &#225;reas sanitarias&#46; Rev Clin Esp&#46; 2021&#59;221&#58;69&#8211;75&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of standardized PAH rates by age and sex in PCA from 2013 to 2015&#46; The violin shape shows the density of the standardized rates by age and sex per 10&#44;000 residents &#40;a&#41; and the density of normalized standardized rates &#40;b&#41; to facilitate the comparison of variations among conditions with very different prevalences&#46; The white circles show the median&#44; the boxes the interquartile range&#44; and the spikes the 5th and 95th percentiles for each of the conditions&#46; ACD&#58; acute complications of diabetes&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; congestive heart failure&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Performance profile of the Alhaur&#237;n el Grande &#40;a&#41; and the healthcare area it belongs to&#44; Valle del Guadalhorce &#40;b&#41; for the period from 2013 to 2015&#46; Results of the PAH indicators and comparison with the national p25 &#40;a&#41; and p10 &#40;b&#41;&#46; Circles representing the standardized rate of each indicator are located on a bar limited by the minimum and maximum rate&#46; If the rate of the zone or area analyzed is significantly lower than the p25 or p10 value&#44; respectively &#40;represented by a vertical line&#41;&#44; the color of the circle is light gray&#46; If the value is not significantly different&#44; it is dark gray&#46; Modified based on <span class="elsevierStyleInterRef" id="intr0005" href="https://www.atlasvpm.org/atlasvpm/hpe_zbs/hpe-zbs_perfil_ZBS_2013-2015/atlas.html">https&#58;&#47;&#47;www&#46;atlasvpm&#46;org&#47;atlasvpm&#47;hpe&#95;zbs&#47;hpe-zbs&#95;perfil&#95;ZBS&#95;2013-2015&#47;atlas&#46;html</span>&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ACD&#58; acute complications of diabetes&#59; SVC&#58; systematic variation component&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CHF&#58; congestive heart failure&#59; nc&#58; not calculable&#59; RV<span class="elsevierStyleInf">5&#8722;95</span>&#58; ratio of variation between the 5 and 95 percentile&#59; RV<span class="elsevierStyleInf">25&#8722;75</span>&#58; ratio of variation between the 25 and 75 percentile&#59; SR&#58; standardized rate&#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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ACD</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">COPD</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CHF</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Angina</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Asthma</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dehydration</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&#8722;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&#8722;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;493&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">184&#44;639&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">183&#44;960&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">160&#44;329&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">164&#44;509&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#44;644&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;057&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;667&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;543&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;329&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;464&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">435&#44;955&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">439&#44;878&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0185" class="elsevierStylePara elsevierViewall">The authors would like to express their gratitude to the Atlas VPM group &#40;atlasvpm&#46;org&#41; and the healthcare authorities of the national health system for providing the data for conducting this work&#46;</p>"
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Article information
ISSN: 22548874
Original language: English
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