The appearance of biologics has been a major therapeutic advance and a remarkable improvement in the prognosis of inflammatory rheumatic diseases such as rheumatoid arthritis (RA), psoriatic arthritis and spondyloarthropathies, as well as an improvement in the quality of life of patients who have these diseases.1 These drugs have a clinical efficacy that has surpassed traditional treatments and, in the case of RA, have allowed a delay in structural2 damage. The drugs come in subcutaneous and intravenous presentations, and some of them cannot be administered on an outpatient basis.

It is understood that “Day Hospital” (DH) accounts for hospital care lasting a few hours, either for diagnostic, clinical or multiple tests or treatments that cannot be performed as an outpatient or justify hospitaizationl.3,4 Thus, the patient receives treatment with biological drugs and receives the same service as if hospitalized, but without being so, thereby reducing the associated risks and costs.4 For this reason, in recent years there has been an increase in the number of day hospitals in Spain, some of which are dedicated to a single specialty or some of which are polyvalent, i.e., jointly attending patients of different specilties.3,4 Also, Rheumatology Day Hospital (RDH) may allow for other tasks, such as informing and educating the patient, giving psychosocial support or running clínical4 trials, thus favoring the scientific production of Rheumatology.

The Ministry of Health, through the Task Force for the preparation of “Standards and Recommendations of Day Hospitals”, published in 2009 standards and recommendations for the DH.3 These are not normative, but rather seek to make available to the government, managers and caregivers, common criteria for such units to improve safety and the quality of their practice. These recommendations include issues relating to the rights and guarantees of the patient, their safety, organization and management of the Day Hospital, its structure, material and human resources, as well as the quality of care provided.

As other publications have manifiested,3,4 there are few studies analyzing the situation of Day Hospitals in Spain. Some have described the situation in certain Autonomous Communities5 RDH, with interesting results that could serve as a point of comparison for other regions. Further analysis is therefore needed to help plan strategies to optimize the use of RDH in our country.

The objective of the DH-Reumatolex project is to evaluate the current status of various Spanish RDH's from a strategic, training, management and quality of care perspective, in order to design action plans that focus on the RDH and the rheumatologist's role within it.

The HD-Reumatolex project was carried out between 2008 and 2009 and involved the design of a “model of excellence in HDR” which served as a basis for anonymous comparative analysis and benchmarking among the 21 Spanish Rheumatology departments listed in Table 1. These 21 centers with a RDH were available and agreed to join the initiative, with 8 corresponding to autonomous regions. In the case of participating hospitals, 86% (n=18) were large hospitals (>601 beds) and 43% (n=9) counted over 10 rheumatologists in their departments. Most of the RDH (66%, n=14) presented a polyvalent model of DH, 29% (n=6) responded to an Rheumatology model and 5% (n=1) to a model limited to the administration of biologic therapies. Each participant was randomly assigned a number to perform a comparative analysis anonymously.

The project consisted of the following phases: (1) design of a “model of excellence in RDH” self-assessment questionnaire. This is not based on any previous model. Its definition was elaborated by three rheumatologists and subsequently validated by another 18 other rheumatologists using an IDEFO process methodology, (2) commitment to the initiative and elaboration of the questionnaire, and (3) analysis of the benchmarking results. The self-assessment questionnaire, based on a map process is detailed in Fig. 1, was completed by participants RDH to know in detail their situation in that context.

Fig. 1.

Process map used to elaborate the questionnaire for the DH-Reumatolex project self-evaluation.

(0.27MB).

In order to define the basis of the project and the questionnaires, previously there was a meeting with three expert clinical rheumatologists who preliminarily evaluated biological management in RDH.

The Day Hospital as a healthcare modality has seen considerable development in recent years and has significantly increased the efficiency of patient care. In 2004 there were about 1500000 DH sessions in Spain, with 1.1 sessions of this type for every 10 conventional hospital stays.3 Studies have confirmed the advantages of the DH in terms of pressure decrease in the hospitalization area, reduced hospital spending, minimizing the social and family isolation associated with hospitalization, and compatibility with the patient's4 working life. These benefits apply equally to the context of RDH.

The main conclusion of the DH-Reumatolex project is that the best scores were obtained in the “Key Processes” category, reflecting a good general state in 21 RDH adhered to the initiative. Although 11 of the 19 criteria were analyzed in the RDH bottom group in the total results, none of them appeared in this group, mainly because good scores in the “Key Processes” category offset the shortcomings of other criteria or categories.

Moreover, no RDH got the highest total, or category level or total results score. This means that there are opportunities for improvement for all participants. Even the RDH that played a leading role (RDH15) could be improved a notch to achieve the excellence category. For all others, and according to their scores, there are opportunities for improvement.

For comparison between the different RDH analyzed, the DH-Reumatolex project can conclude that in “Strategic Process” category there existed two clear leaders of excellence (RDH's 15 and 19) that set the benchmark in the 4 criteria. RDH 1 also positioned itself as a strong leader, benchmarking in 3 of the 4 criteria in this category. Moreover, in “Key Processes” category, the undisputed leader of excellence was the RDH 15, which marked the benchmark in 8 of the 9 criteria in this category. The HDR HDR 1 and 7 also positioned themselves as strong leaders, setting the benchmark in 7 of the 9 criteria. Finally, in the “Support processes” category, we identified two clear leaders of excellence, RDH's 1 and 15, who set the benchmark in 5 of the 6 criteria in this category.

Those areas where there were greater opportunities for improvement (i.e., those with lower average scores) were lacking clinical practice guidelines/recommendations, the existence of a quality plan (Strategic processes), criteria for RDH staff training and knowledge management (support processes), and patient admission and registration procedures (key processes). Several have been described previously as areas for improvement,4,6 in particular, it has recommended that, in the RDH, multidisciplinary working groups for the creation, dissemination, review and updating of protocols be formed.6 With regard to the accessibility of the patient to treatment, we identified factors that could negatively influence it, such as the scarcity or part-time resources available (personnel), often in Spanish RDH. It has also been proposed the RDH itself perform additional tests, excluding analytical, in order to optimize the assistance process.6 Finally, the preparation and submission of discharge and satisfaction and quality of life surveys have been described as measures that could improve patient care as well as telephone follow-up to address health education.6

In the training field, we identified gaps and observations that confirm those published.4,6 Thus, previous studies have included the recommendations of expertise in Rheumatology Nursing or the increase in the number of clinical sessions, both multidisciplinary and specifically regarding biologics, in which the RDH staff participate. In addition, the Ministry is proposing a plan to implement the recommendations and the establishment of indicators to assess the introduced improvements.3

Notably, this study had two major limitations. First, although the selected RDH corresponded to 8 autonomous regions, they were not necessarily representative of all Spanish centers. Moreover, in each RDH it was the physician's own department which evaluated the questionnaire, which could lead to a bias in the scoring of the different items.

In conclusion, the proposed DH-Reumatolex project provides a panoramic analysis of Spanish RDH from a strategic, training, management and quality of care perspective. The data obtained allow us to establish improvement processes that become examples of excellence through specific action plans that focus on the RDH (in the areas of quality, processes, patients, knowledge management, resources and structures) and the role of the rheumatologist in them.

The DH-Reumatolex project was performed through a financial collaboration between Bristol-Myers Squibb and Antares Consulting (project code “BMS España, Implantación del Modelo de Excelencia en Hospital de Día Reumatológico, 08-50-00073-P”). An editorial agency provided assistance, financed by Bristol-Myers Squibb.

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of Data. The authors declare that no patient data appears in this article.

Right to privacy and informed consent. The authors declare that no patient data appears in this article.