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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Hospitals of the 2009 &#8220;Statistics on Healthcare Establishments Providing Inpatient Care&#8221; included in the study&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Background</span><p id="par0025" class="elsevierStylePara elsevierViewall">Emergency departments &#40;EDs&#41; in Spain treat more than 26 million episodes annually&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Only a small percentage of these episodes &#40;lower than 0&#46;2&#37;&#41; end in the patient&#39;s death&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The majority of deaths that occur in Spanish EDs are of elderly patients&#44; patients with poor functional states and patients with significant associated comorbidity&#46; These deaths are often &#40;62&#8211;98&#37;&#41; predictable on hospital arrival due to the patients&#8217; poor medical condition&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> However&#44; it seems preferable that these deaths occur in a hospital ward or at the patients&#8217; home when the prior medical condition is terminal&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7</span></a> Many studies provide the percentage of emergencies treated that result in death&#59; however&#44; there are few data on the relationship between deaths that occur in the ED and those that occur in conventional hospital wards &#40;percentage of hospital deaths prior to admission &#91;PHDPA&#93;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a> In Spain&#44; there is a progressive increase in the percentage of deaths that occur in hospitals versus total mortality &#40;44&#37; in 1997&#44; 48&#37; in 2003&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> 57&#37; in 2009<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a>&#41;&#46; However&#44; the PHDPA seems to follow a slight downward trend&#44; given that a previous study measured PHDPA at 12&#46;9&#37; in 1997<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and 11&#46;1&#37; in 2003&#46; Global data from the <span class="elsevierStyleItalic">Estad&#237;stica de Establecimientos Sanitarios con R&#233;gimen de Internado</span> &#40;Statistics on Health Establishments Providing Inpatient Care&#44; EESRI&#41; of 2009 puts the figure at 10&#46;8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The hypothesis of this study is that there may be significant variability in PHDPA at the national level and that this variability may reflect the different characteristics of hospital centers or the healthcare activities they perform&#46; We also considered whether it would be feasible&#44; given the volume of hospital stays generated&#44; to propose that many of the deaths that occur in the ED could instead occur in the ward&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We established the following objectives for this study&#58; &#40;a&#41; to specify the PHDPA for the entire country and for the various autonomous communities &#40;ACs&#41;&#59; &#40;b&#41; to explore the relationship between PHDPA&#44; on the one hand&#44; and on the other hand&#44; the centers&#8217; characteristics and a number of variables that measure the pressure on EDs and the availability of beds in the hospitals&#59; and &#40;c&#41; to estimate the possible impact on hospitalization of admitting the majority of patients who died in the ED&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Materials and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">This was an ecological study of data collected from the 2009 EESRI&#44; prepared annually by the Ministry of Health&#46; Participation in this survey is mandatory for all public and private Spanish hospitals that declare their healthcare activity&#44; endowments and human resources&#46; The hospitals&#8217; microdata are available anonymously&#44; in terms of hospital and province&#44; on the corresponding website for the entire country&#44; with the exception of Ceuta and Melilla&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The study unit was the hospital&#46; We excluded from the study centers that were exclusively surgical&#44; psychiatric or long-stay&#44; as well as private for-profit hospitals and those with a minimum of activity &#40;less than 1000 hospital discharges or 10&#44;000 emergencies annually&#41; or less than 5 deaths per year in either the ED or wards&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The dependent variable was the PHDPA &#40;&#91;number of ED deaths&#93;&#47;&#91;number of ED deaths<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>number of ward deaths&#93;&#41;&#44; and the independent variables were ownership &#40;public or private&#41;&#44; the number of beds and the autonomous community of each hospital&#46; We also studied&#44; as independent variables&#44; the following measures of activity&#58; annual emergencies&#44; emergencies by ED physician &#40;&#91;number of emergencies treated&#93;&#47;&#91;number of ED physicians&#93;&#44; counting part-time physicians as 0&#46;5&#41;&#44; ward bed occupancy rate &#40;&#91;occupied beds&#93;&#47;&#91;available beds&#93;&#41; and pressure from the ED &#40;percentage of ward admissions that originate from the ED&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We analyzed PHDPA variability at the national level using statistical variance&#58; the coefficient of variation and ratios of variation between the 5&#8211;95 and 25&#8211;75 percentiles&#46; The normality was checked with the Kolmogorov&#8211;Smirnov test&#46; PHDPA comparisons according to hospital characteristics and AC were performed using the nonparametric Kruskal&#8211;Wallis test&#46; We also studied the relationship between the quantitative variables of activity and PHDPA using the Spearman correlation coefficient&#46; The level of significance for all tests was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46; The database was constructed with dBase IV&#44; and the statistical analysis was performed using SPSS for Windows&#44; version 15&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The 2009 EESRI included information on 770 hospitals with 217&#44;543 discharges due to death&#44; 23&#44;450 of which &#40;10&#46;8&#37;&#41; occurred in the ED&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the study&#39;s hospital inclusion algorithm&#44; which resulted in a final selection of 229 centers in which 166&#44;320 deaths occurred&#44; 21&#44;776 of which took place in the ED &#40;13&#46;1&#37; of the deaths and 13&#46;4&#37; as the mean for the centers studied&#41; and the remainder in wards&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The mean PHDPA was 13&#46;4&#37; &#40;standard deviation 9&#46;0&#37;&#41;&#46; The Kolmogorov&#8211;Smirnov test ruled out the possibility that the distribution of the PHDPA in the included centers was normal &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; The median PHDPA was 11&#46;7&#37; &#40;interquartile range 8&#46;0&#8211;16&#46;8&#37;&#41;&#44; the coefficient of variation was 0&#46;7&#44; the 25&#8211;75 variation ratio was 2&#46;1&#44; and the 5&#8211;95 variation ratio was 6&#46;0&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the PHDPA values according to AC&#44; ownership and the number of beds in each center&#46; The PHDPA values for hospitals in Aragon&#44; Asturias and Castilla y Le&#243;n were approximately 8&#37;&#44; while on the other end&#44; the average PHDPA value for hospitals in the Basque country&#44; Catalonia&#44; Andalusia and the Canary Islands exceeded 16&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; Moreover&#44; the PHDPA was higher in hospitals with less than 100 beds &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#44; and there was no statistically significant relationship with public or private ownership of the center&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the correlation between the PHDPA and several measures of hospital activity&#46; There was a positive relationship with the average rate of annual emergencies per ED physician &#40;Spearman coefficient 0&#46;20&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#44; while the other three variables &#40;number of emergencies&#44; ED pressure and ward bed occupancy&#41; showed no significant correlations&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">This study shows that approximately 13&#37; of hospital deaths in Spain in 2009 occurred in the ED and that this percentage varies considerably&#44; with large differences between ACs and hospitals of different sizes&#46; The operation of the ED is determined by 3 groups of factors&#58; &#8220;on entry&#8221;&#44; &#8220;internal&#8221; and &#8220;on exit&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> An imbalance between these can cause saturation problems in the EDs&#44; and a number of studies have linked these problems with increased mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13&#8211;15</span></a> We believe that the frequency of deaths in the ED may also be conditioned by the same groups of factors&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">&#8220;On entry&#8221; factors&#58; The influx of patients to the ED may lead to saturation of these services&#44; with the resulting reduction in their effectiveness&#59; however&#44; the literature gives this factor less importance than organizational aspects&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;16</span></a> In this regard&#44; considerable geographical variability has been reported in Spain in the use of EDs&#44; which seems to be due basically to their differential use for minor problems&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;17</span></a> We must also consider here the influence of the patient&#39;s or family&#39;s preference as to the where the death occurs and the decision to go to the hospital with terminal conditions&#44; which is conditioned in turn by sociocultural factors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">&#8220;Internal&#8221; ED factors that determine their &#8220;response capacity&#8221;&#58; We estimate that the variance in the effectiveness of ED care should be the least quantitatively important factor&#44; except in cases of critical patients whose survival may directly depend on their care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">&#8220;On exit&#8221; factors&#58; These are the factors that have been most closely linked to the phenomenon of ED saturation&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It is essentially a problem of bed availability for patients indicated for ward admission&#44; which leads to patients spending more time in the ED than desirable&#44; with the majority of deaths in the ED occurring among these patients&#46; Studies have described the relationship between hospital bed availability and ED saturation&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> as well as between healthcare overload and mortality in this area&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">This study confirms significant variability in PHDPA among the various hospitals and the presence of overall patterns of behavior by AC&#46; In terms of factors that explain this variability&#44; we estimated that there may be at least 5 components&#58; &#40;1&#41; Variability in the percentage of deaths in hospitals or at home&#46; In fact&#44; the community with the highest proportion of hospital deaths &#40;the Canary Islands &#91;72&#37;&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> was also one of the communities with the highest PHDPA in our study &#40;16&#46;3&#37;&#41;&#46; &#40;2&#41; The variable degree of aging in the various ACs&#44; which may lead to differences in the proportion of expected deaths on arrival at the hospital&#46; &#40;3&#41; The availability of medium-stay or long-stay centers to which to refer patients from the EDs of acute care hospitals&#44; patients who are critically ill but who require fairly uncomplicated treatments&#46; &#40;4&#41; The saturation of certain EDs&#44; an explanation that is supported by the positive correlation found in the EESRI data between PHDPA and the average annual number of emergencies per ED physician&#46; &#40;5&#41; Cultural factors that&#44; in certain centers&#44; result in the general consensus among their physicians that if a patient in the ED is in the final hours of his&#47;her life then it is not necessary to transfer them to a ward&#44; thereby avoiding the use of a limited resource&#58; hospital beds&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study did not show a correlation between PHDPA and the percentage of hospital occupancy&#46; However&#44; we believe that the annual average occupancy is not a good reflection of the isolated circumstances of saturation that may occur over the course of a year and that may be correlated with PHDPA&#46; The same could be said regarding the lack of a correlation with emergency pressure&#44; which would reflect isolated problems of bed availability for hospitalization&#46; However&#44; the finding of an association between PHDPA and the average number of emergencies per physician may point to a relationship with healthcare overload&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The considerable variability in PHDPA detected in this study brings into question the validity of hospital mortality assessments in terms of the healthcare quality of systems implemented more than a decade ago in Spain<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and earlier in other countries&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> These assessments are based exclusively on an analysis of the minimum basic data set &#40;MBDS&#41; on hospitalization&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;21</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">One of the limitations of this study is inherent in ecological studies as a result of their methodology&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> among them the so-called &#8220;ecological fallacy&#46;&#8221; It is impossible to confirm that the relationships between the variables observed in the study are cause-and-effect&#59; for example&#44; that the greater burden of emergencies treated by physicians is the cause of the increased PHDPA&#46; Moreover&#44; we should mention the limitations that result from the reliability of the EESRI&#59; however&#44; the agreement between the EESRI data and the Hospital Morbidity Survey data &#40;prepared by the National Statistics Institute&#41;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> support the reliability of the EESRI data&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We can reflect&#44; however&#44; on the <span class="elsevierStyleItalic">best</span> circumstances for the death of a terminal patient&#44; which is likely to be at home&#44; in a peaceful environment surrounded by loved ones&#46; In marked contrast&#44; EDs tend to be stressful places that regularly limit the company of family members&#46; Various studies conducted in Spain have reported that death was expected in a substantial number of deaths in the ED<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> and that a significant portion of the patients died alone&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> From both a medical and humane standpoint&#44; we believe it desirable to keep reducing&#44; as much as possible&#44; the percentage of deaths in the ED&#44; which currently is approximately 13&#37; of hospital deaths&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Solutions to this problem are not easy to find&#59; the progressive aging of the population and the medicalization of the death process suggests a predictable increase in this trend&#46; In the medium to long term&#44; this situation could be alleviated by the development of palliative hospital and home care&#44; the availability of quality healthcare resources in sufficient quantitites<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and the education of chronically ill patients &#40;when clinically stable&#41; and their families about the patient&#39;s prognosis&#44; with the aim of avoiding especially aggressive treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> In the short term&#44; it seems desirable to adapt ED facilities to provide specific bays for caring for patients in end-stage conditions&#44; so that the patient can remain accompanied<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or proceed to ward hospitalization of these patients&#46; To assess the feasibility of the proposal of hospitalizing the majority of patients who die in the ED&#44; we performed the following estimate&#58; Considering that the 229 hospitals analyzed treated more than 28 million stays during the study year&#44; if 80&#37; of the patients who died in the ED had been admitted to a ward and had died there after the same period of time &#40;estimated at 1 day&#41;&#44; there would have been an increase in hospital stays of less than 0&#46;1&#37;&#46; We can therefore conclude that the impact of this change on hospital resources would be minimal&#46;</p></span></span>"
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          "identificador" => "xres166139"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Background"
            2 => "Patients and methods"
            3 => "Results"
            4 => "Conclusions"
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        1 => array:2 [
          "identificador" => "xpalclavsec154349"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres166138"
          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Fundamento"
            2 => "Pacientes y m&#233;todos"
            3 => "Resultados"
            4 => "Conclusiones"
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          "identificador" => "xpalclavsec154347"
          "titulo" => "Palabras clave"
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        4 => array:2 [
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          "titulo" => "Background"
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        5 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Materials and methods"
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        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Results"
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        7 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "xack44376"
          "titulo" => "Acknowledgments"
        ]
        9 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2012-08-31"
    "fechaAceptado" => "2012-11-13"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec154349"
          "palabras" => array:3 [
            0 => "Mortality"
            1 => "In-hospital mortality"
            2 => "Emergency department mortality"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec154347"
          "palabras" => array:3 [
            0 => "Mortalidad"
            1 => "Mortalidad hospitalaria"
            2 => "Mortalidad en servicios de urgencias"
          ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0015">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Deaths in emergency departments &#40;ED&#41; should only occur in rare cases&#46; The aim of the study was to describe the distribution of deaths in Spanish hospitals in two locations&#58; the ED or pre-admission and in-hospital or post-admission&#44; and their geographical distribution and possible conditioning factors&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study was ecological&#46; The percentage of hospital deaths prior to admission &#40;PHDPA&#41; compared to total hospital deaths for each center was calculated&#46; The information was obtained from the &#8220;2009 Survey of Health Care Establishments with In-Patient facilities&#8221;&#46; This survey included information for all the Spanish hospitals&#46; It analyzed geographical variability and its relation to the characteristics of the centers and various indicators of health care activity using non-parametric tests&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The PHDPA was 13&#46;4&#37;&#44; with wide variability between regions&#58; from 7&#46;4&#37; to 16&#46;4&#37;&#46; PHDPA was higher in hospitals with fewer than 100 beds and those with a higher average of emergencies per ED physician&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our study reveals the important variability in PHDPA&#46; We estimate that if 80&#37; of those patients who had died in the ED had died in the hospital ward&#44; hospital stays would only have been increased by less than 0&#46;1&#37;&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Fundamento</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las muertes en los servicios de urgencias hospitalarios &#40;SUH&#41; deber&#237;an ocurrir solo en casos muy puntuales&#46; El objetivo del estudio fue describir la distribuci&#243;n de las muertes en hospitales espa&#241;oles en los SUH &#40;previas al ingreso&#41; y en las unidades de hospitalizaci&#243;n &#40;posteriores al ingreso&#41;&#44; as&#237; como su distribuci&#243;n geogr&#225;fica y sus posibles condicionantes&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El estudio fue ecol&#243;gico&#46; Se calcul&#243; el porcentaje de muertes hospitalarias previas al ingreso &#40;PMHPI&#41; respecto al total de muertes hospitalarias para cada centro a partir de la &#171;Encuesta de Establecimientos Sanitarios con R&#233;gimen de Internado de 2009&#187;&#44; que incluye informaci&#243;n de todos los hospitales espa&#241;oles&#46; Se analiz&#243; su variabilidad geogr&#225;fica y su relaci&#243;n con las caracter&#237;sticas de los centros y diversos indicadores de actividad asistencial mediante pruebas no param&#233;tricas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El PMHPI se situ&#243; en el 13&#44;4&#37;&#44; con una amplia variabilidad entre comunidades aut&#243;nomas &#40;rango 7&#44;4&#8211;16&#44;4&#37;&#41;&#46; El PMHPI fue mayor en los hospitales de menos de 100 camas y en aquellos con mayor promedio de urgencias anuales por facultativo del SUH&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestro estudio desvela la importante variabilidad del PMHPI&#46; Estimamos que si el 80&#37; de los pacientes fallecidos en SUH lo hubieran hecho en planta&#44; las estancias hospitalarias se hubieran incrementado en menos del 0&#44;1&#37;&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Jim&#233;nez-Puente A&#44; et al&#46; Variabilidad en la mortalidad hospitalaria previa al ingreso en Espa&#241;a&#46; Rev Clin Esp&#46; 2013&#46; <span class="elsevierStyleInterRef" id="intr0005" href="http://dx.doi.org/10.1016/j.rce.2012.11.012">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;rce&#46;2012&#46;11&#46;012</span>&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Hospitals of the 2009 &#8220;Statistics on Healthcare Establishments Providing Inpatient Care&#8221; included in the study&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Data taken from the 2009 &#8220;Statistics on Healthcare Establishments Providing Inpatient Care&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; of hospitals&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Standard deviation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Autonomous Regions</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#46;0001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#46;50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aragon&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asturias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;66&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Balearic Islands&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Castilla la Mancha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Castilla y Le&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Catalonia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Valencia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Extremadura&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Galicia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Madrid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Murcia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Navarra&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Basque Country&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>La Rioja&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Ownership of hospital</span>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Correlation between the percentage of hospital deaths prior to admission and various indicators of activity&#46;</p>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">What we know</span><p id="par0010" class="elsevierStylePara elsevierViewall">The majority of deaths that occur in Spanish emergency departments are predictable upon hospital arrival due to the patients&#8217; poor medical condition&#46; It seems preferable that these deaths occur under conventional hospitalization or at the patients&#8217; home if the prior medical condition was terminal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">What this article provides</span><p id="par0015" class="elsevierStylePara elsevierViewall">In Spain&#44; the percentage of hospital deaths that occurred in emergency departments in 2009 was 13&#46;4&#37; and varied considerably based on geographical location&#44; hospital size and the number of emergencies treated by each physician&#46; If 80&#37; of these deaths had taken place under conventional hospitalization&#44; the mean hospital stay would not have changed significantly&#46;<span class="elsevierStyleVsp" style="height:0.5px"></span>The Editors</p></span></span>"
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Brief original
Variability in hospital mortality prior to admission in Spanish hospitals
Variabilidad en la mortalidad hospitalaria previa al ingreso en España
A. Jiménez-Puentea,d,
Corresponding author
ajpuente@hcs.es

Corresponding author.
, F. Rivas-Ruízb,d, J. Agulló-Garcíac
a Unidad de Evaluación, Hospital Costa del Sol, Marbella, Málaga, Spain
b Unidad de Apoyo a la Investigación, Hospital Costa del Sol, Marbella, Málaga, Spain
c Unidad de Urgencias, Hospital Costa del Sol, Marbella, Málaga, Spain
d Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain

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