RECALSEEN analyses the structure, activity and results of the Endocrinology and Nutrition Services and Units (S-U_EyN) of the Spanish National Health System (SNHS). This article presents data collected from the 2024 survey, as well as activity and outcome indicators from the SNHS Minimum Basic Data Set (CMBD) for 2007–2022.
Material and methodsDescriptive cross-sectional study of S-U_EyN in general acute care hospitals of the SNHS. Data obtained through an ad hoc survey referring to data from 2023 and discharges from S-U_EyN recorded in the CMBD (2022) were used.
ResultsA total of 116 responses were obtained from S-U_EyN of 160 general acute care hospitals in the SNHS (72%). Fifty-six per cent of the S-U_EyN respondents were services or clinical management units. The average number of endocrinologists per S-U_EyN department was 8.4 (5.4), with an estimated rate of 2.9 endocrinologists per 100,000 inhabitants. In 74% of hospitals there is a Clinical Nutrition Unit (dependent on the S-U_EyN in 93% of cases) and 39% of S-U_EyNs have a day hospital. The portfolio of services offered by S-U_EyN is closely related to the complexity of the hospital. There is a significant trend to decline in hospitalisations for endocrine and nutritional diseases. Notable differences were found in resources, activity and outcomes between hospitals and autonomous communities. In relation to quality management and the implementation of good practices, there was still considerable room for improvement. The trend to worsening of short- and long-term complication indicators for diabetes mellitus in the period 2016–2022 should be analysed.
ConclusionsRECALSEEN provides relevant information on S-U_EyN and the evolution of endocrinology and nutrition care in the SNHS.
RECALSEEN analiza la estructura, actividad y resultados de los Servicios y Unidades de Endocrinología y Nutrición (S-U_EyN) del Sistema Nacional de Salud español (SNS). En este artículo se presentan los datos recogidos de la encuesta de 2024 así como los indicadores de actividad y resultados procedentes del Conjunto Mínimo Básico de Datos (CMBD) del SNS de 2007–2022.
Material y métodosEstudio descriptivo transversal de los S-U_EyN realizado en hospitales generales de agudos del SNS. Se han utilizado datos obtenidos mediante una encuesta “ad hoc” referida a datos de 2023 y de las altas dadas por los S-U_EyN registradas en el conjunto mínimo de datos (CMBD) del SNS (2022).
ResultadosSe obtuvieron 116 respuestas de S-U_EyN sobre un total de 160 hospitales generales de agudos del SNS (72%). El 56% de los S-U_EyN que respondieron eran servicios o unidades de gestión clínica. El promedio de endocrinólogos por S-U_EyN fue de 8,4 (5,4), siendo la tasa estimada de endocrinólogos por cada 100.000 habitantes de 2,9. En el 74% de los hospitales existe una Unidad de Nutrición Clínica (dependiente del S-U_EyN en el 93% de los casos) y un 39% de los S-U_EyN disponen de hospital de día. La cartera de servicios de los S-U_EyN está estrechamente relacionada con la complejidad del hospital. Se observa una significativa tendencia de disminución de las hospitalizaciones por enfermedades endocrinas y nutricionales. Se encontraron notables diferencias en recursos, actividad y resultados entre hospitales y Comunidades Autónomas. En relación con la gestión de la calidad e implantación de buenas prácticas seguía existiendo un amplio margen de mejora. Debe analizarse el cambio de tendencia al empeoramiento, en el período 2016–2022, de los indicadores de complicaciones a corto y largo plazo de la diabetes mellitus.
ConclusionesRECALSEEN suministra una información relevante sobre los S-U_EyN y la evolución de la asistencia en endocrinología y nutrición en el SNS.
RECALSEEN is a project of the Spanish Society of Endocrinology and Nutrition (SEEN) launched in 2017 in a context anticipating major challenges derived from population aging, the increasing prevalence of specialty-related diseases such as diabetes, obesity, and malnutrition, and the progressive technification of diagnostic and therapeutic processes.1–3 The need to obtain information on the resources, activity, and quality of Endocrinology and Nutrition Services and Units (E-N S/U) to formulate data-driven health policy proposals has become even more evident as a consequence of the impact of the SARS-CoV-2 pandemic on health care services, including the need for transformation and the acceleration of health care “digitalization.”4 The RECALSEEN project, developed by SEEN in collaboration with the IMAS Foundation, aims to gather information on the structure, organization, and functioning of E-N S/U, as well as on the care provided for endocrine and nutritional diseases within the Spanish National Health System (NHS) to develop proposals to improve quality and efficiency based on available data. The RECALSEEN project has 2 main data sources: the RECALSEEN survey and the National Health System’s Minimum Basic Data Set (MBDS). The project was conducted in 2017, 2021, and 2024.1,5–7 The objective of this article is to present the most relevant results obtained in 2024. The full report is available on the SEEN website.8
Material and methodsWe conducted a cross-sectional descriptive study conducted among E-N S/U within the Spanish NHS. The study universe included E-N S/U located in general acute-care hospitals with 200 or more installed beds; information from E-N S/U in hospitals with <200 installed beds that responded to the survey was also incorporated. The questionnaire used for data collection is presented in Appendix B (Supplementary data). A preconfigured Excel® form was sent to the heads of the E-N S/U. The management and validation of the questionnaire have been described elsewhere.1,6 Survey data correspond to the year 2023. The survey was open from July 15th, 2024, to January 31st, 2025. MBDS data correspond to the period 2007–2022.
Statistical analysisQualitative variables are described using frequency distributions (number of cases and percentages), and quantitative variables using mean, median, standard deviation (SD), and interquartile range (IQR). The chi-square test was used to compare qualitative variables, while the Student t-test was used for quantitative variables. Trend analyses were performed using Poisson regression. Risk adjustments were performed using multilevel logistic regression models,9 with age, sex, and the Charlson index as adjustment variables,10 in the absence of a specific adjustment model; hospital or autonomous community was included as the second level, as appropriate. To distinguish between high- and low-volume centers (based on the number of episodes managed), a k-means clustering algorithm was used.
In all tests, the null hypothesis was rejected at an alpha error of less than 0.05. Statistical analyses were performed using STATA version 17.0.
ResultsSurveyA total of 116 E-N S/U responded to the RECALSEEN survey, 115 of them from NHS hospitals, out of a total of 160 general acute-care NHS hospitals (72%). Fourteen hospitals had <200 installed beds; 47 had between 200 and 500 beds; 42 had between 500 and 1000 beds; and 12 E-N S/U were located in hospitals with >1000 beds. The mean number of installed beds in hospitals hosting E-N S/U was 584 (353). All responding E-N S/U were included in the analyses. The distribution of responses by autonomous community is shown in Appendix B, Table 1 (Supplementary data). The estimated population within the catchment areas of responding E-N S/U represented 72% of the total Spanish population as of July 1st, 2023 (INE). The sample obtained represents >50% of the total hospitals, installed beds, and population served in all autonomous communities except Castile-La Mancha, the Region of Murcia, and Extremadura. The reliability of region-specific indicators depends on the sample size relative to the total population, with greater reliability as it approaches 100%.
Structure and resourcesAmong the E-N S/U completing the survey, 56% were clinical management services or units, 29% were sections, and 11% had no independent organizational entity. A total of 74% of hospitals had a Clinical Nutrition and Dietetics Unit (CNDU), and in 93% of these hospitals, the CNDU depended on the E-N S/U. A total of 39% of E-N S/U had a day hospital.
The mean number of endocrinologists assigned to E-N S/U was 8.4 ± 4.5. The estimated rate of endocrinologists was 2.9 per 100,000 inhabitants in the NHS in 2023, below the rate estimated by the Spanish Ministry of Health,3,5 although that estimate includes the private sector.11
A total of 98% of E-N S/U had registered nurses assigned to diabetes education, with a mean of 3.1 ± 1.9 nursing professionals; 65.5% had nurses dedicated to clinical nutrition (mean, 2 ± 1.5); 51% had nurses assigned to obesity education (mean, 1.4 ± 1.1); and 58.6% had dietitians/nutritionists (mean, 2.6 ± 2.6). Significant differences in structure and resources were found according to hospital complexity (Tables 1 and 2). However, no statistically significant differences were observed by hospital size regarding teleconsultation with patients (96% of E-N S/U), remote download and assessment of laboratory and clinical parameters (78%), or collaboration with primary care. A total of 83% of E-N S/U performed triage of consultation requests, with no significant differences by hospital size.
Structural indicators of endocrinology and nutrition services and units.
| E-N S/U structure | Total | <200 beds | 200–499 beds | 500–999 beds | ≥1000 beds | P value |
|---|---|---|---|---|---|---|
| N = 116 | N = 14 | N = 46 | N = 36 | N = 20 | ||
| Installed beds (hospital)a | 584 (353) | 131 (33) | 360 (78) | 715 (150) | 1,179 (138) | < .001 |
| Population in the catchment area of the endocrinology service/unita | 303,463 (175,935) | 119,597 (77,090) | 227,703 (131,233) | 371,433 (132,298) | 480,282 (171,346) | < .001 |
| Total number of endocrinologists assigned to the servicea | 8.4 (5.4) | 2.6 (1.7) | 5.8 (3.9) | 11.3 (4.6) | 13.3 (4.4) | .080 |
| Endocrinologists per 100,000 inhabitantsa | 2.85 (1.46) | 2.38 (0.92) | 2.74 (1.97) | 3.14 (1.07) | 2.89 (0.88) | .375 |
| Endocrinologists per 100 installed beds in the centera | 1.54 (0.77) | 1.96 (1.06) | 1.56 (0.84) | 1.58 (0.62) | 1.12 (0.34) | .014 |
| Nutrition unit | 86 (74.1) | 7 (50) | 27 (58.7) | 33 (91.7) | 19 (95) | < .001 |
| No. of clinic roomsa | 5.6 (4.5) | 2.8 (1.4) | 4.1 (2.6) | 6.8 (3.5) | 8.9 (7.8) | < .001 |
| Day hospital dependent on the E-N S/U | 45 (38.8) | 4 (28.6) | 13 (28.3) | 16 (44.4) | 12 (60) | .071 |
| % E-N S/U with assigned beds | 79 (68.1) | 4 (28.6) | 27 (58.7) | 33 (91.7) | 15 (75) | < .001 |
| No. of ultrasound machines in the E-N S/Ua | 2.2 (1.2) | 1.5 (0.9) | 1.5 (0.8) | 2.3 (0.9) | 3.3 (1.7) | < .001 |
| % of E-N S/U with diabetes nurse educatorsᵇ | 114 (98.3) | 14 (100) | 44 (95.7) | 36 (100) | 20 (100) | .377 |
| No. of diabetes nurse educatorsa,b | 3.1 (1.9) | 1.4 (0.5) | 2.5 (1.4) | 3.8 (1.9) | 4.2 (2.2) | < .001 |
| % of E-N S/U with nurses dedicated to nutritionᵇ | 76 (65.5) | 2 (14.3) | 23 (50) | 33 (91.7) | 18 (90) | < .001 |
| No. of nurses dedicated to nutritiona,b | 2.0 (1.5) | 2.5 (0.7) | 1.3 (0.9) | 1.9 (1.2) | 3.2 (2.0) | .001 |
| % of E-N S/U with nurses providing obesity educationᵇ | 59 (50.9) | 3 (21.4) | 22 (47.8) | 21 (58.3) | 13 (65) | .059 |
| No. of nurses providing obesity educationa,b | 1.4 (1.1) | 1.7 (0.6) | 1.3 (1.4) | 1.5 (1.1) | 1.4 (0.7) | .938 |
| % of E-N S/U with nurses in functional testing | 69 (59.5) | 5 (35.7) | 22 (47.8) | 24 (66.7) | 18 (90) | .002 |
| No. of nurses in functional testinga | 1.0 (0.6) | 1.2 (0.4) | 1.1 (0.6) | 0.9 (0.6) | 1.1 (0.7) | .680 |
| % of E-N S/U with food scientists (bromatologists) | 13 (11.2) | 0 (0) | 0 (0) | 4 (11.1) | 9 (45) | < .001 |
| No. of food scientists (bromatologists)a | 1.2 (0.4) | — (—) | — (—) | 1.3 (0.5) | 1.2 (0.4) | .921 |
| % of E-N S/U with dietitians–nutritionists (university degree) | 68 (58.6) | 7 (50) | 23 (50) | 25 (69.4) | 13 (65) | .271 |
| No. of dietitians–nutritionistsa | 2.6 (2.6) | 0.9 (0.2) | 2.3 (1.7) | 2.7 (2.9) | 4.0 (3.7) | .073 |
| % of E-N S/U with dietetics technicians | 29 (25) | 2 (14.3) | 7 (15.2) | 10 (27.8) | 10 (50) | .018 |
| No. of dietetics techniciansa | 5.2 (3.3) | 3.0 (1.4) | 3.1 (2.5) | 5.8 (2.9) | 6.4 (3.7) | .142 |
No.: number; E-N S/U: endocrinology and nutrition services or units.
Resource indicators of endocrinology and nutrition services.
| Clinical resources | Total | <200 beds | 200–499 beds | 500–999 beds | ≥1000 beds | P valueb |
|---|---|---|---|---|---|---|
| N = 116 | N = 14 | N = 46 | N = 36 | N = 20 | ||
| Scheduled teleconsultation with patients (%) | 111 (95.7) | 14 (100) | 43 (93.5) | 35 (97.2) | 19 (95) | .705 |
| Real-time telephone visit (%) | 108 (93.1) | 14 (100) | 42 (91.3) | 34 (94.4) | 18 (90) | .644 |
| Real-time video visit (%) | 23 (19.8) | 0 (0) | 9 (19.6) | 8 (22.2) | 6 (30) | .180 |
| Asynchronous visit via email (%) | 48 (41.4) | 4 (28.6) | 14 (30.4) | 18 (50) | 12 (60) | .066 |
| Remote download and review of laboratory and clinical parameters (%) | 91 (78.4) | 10 (71.4) | 34 (73.9) | 30 (83.3) | 17 (85) | .576 |
| Day hospital (%) | 45 (38.8) | 4 (28.6) | 13 (28.3) | 16 (44.4) | 12 (60) | .071 |
| Weekly day-hospital hoursa | 37 (24) | 15 (17) | 34 (14) | 40 (27) | 43 (26) | .187 |
| No. of day-hospital chairs/placesa | 3 (2) | 2 (1) | 3 (2) | 3 (2) | 4 (3) | .208 |
| Endocrinology and nutrition beds (%) | 79 (68.1) | 4 (28.6) | 27 (58.7) | 33 (91.7) | 15 (75) | < .001 |
| No. of endocrinology and nutrition bedsa | 3 (2) | 2 (2) | 2 (2) | 4 (2) | 4 (3) | .006 |
| Ultrasound machines specifically assigned to the unit (%) | 94 (81) | 8 (57.1) | 35 (76.1) | 33 (91.7) | 18 (90) | .022 |
| No. of ultrasound machines in the unita | 2 (1) | 2 (1) | 2 (1) | 2 (1) | 3 (2) | < .001 |
| Any method of coordination with primary care (%) | 106 (91.4) | 12 (85.7) | 43 (93.5) | 33 (91.7) | 18 (90) | .830 |
| Email (%) | 76 (65.5) | 9 (64.3) | 24 (52.2) | 26 (72.2) | 17 (85) | .052 |
| Mobile phone (%) | 61 (52.6) | 7 (50) | 22 (47.8) | 20 (55.6) | 12 (60) | .795 |
| Travel to the health center (%) | 37 (31.9) | 3 (21.4) | 14 (30.4) | 13 (36.1) | 7 (35) | .769 |
| Videoconference (%) | 22 (19) | 2 (14.3) | 9 (19.6) | 6 (16.7) | 5 (25) | .848 |
| Joint referral-criteria protocols (%) | 90 (77.6) | 6 (42.9) | 35 (76.1) | 31 (86.1) | 18 (90) | .005 |
| Screening/triage of consultation requests (%) | 96 (82.8) | 9 (64.3) | 37 (80.4) | 32 (88.9) | 18 (90) | .157 |
| Inpatient consult service for other hospital departments (%) | 87 (75) | 9 (64.3) | 29 (63) | 33 (91.7) | 16 (80) | .019 |
| No. of physicians assigned to the “inpatient consult service” (FTE)a | 2 (1) | 1 (1) | 1 (1) | 2 (1) | 3 (1) | < .001 |
| Endocrinology on-call coverage (%) | 5 (4.3) | 0 (0) | 1 (2.2) | 3 (8.3) | 1 (5) | .462 |
| Availability of urgent 24-h care for endocrine and nutrition diseases (%) | 10 (8.6) | 1 (7.1) | 1 (2.2) | 5 (13.9) | 3 (15) | .190 |
| Extended endocrinology hours (%) | 38 (32.8) | 5 (35.7) | 12 (26.1) | 14 (38.9) | 7 (35) | .649 |
Blank responses were considered “No.” SD, standard deviation; No., number; E-N S/U, endocrinology and nutrition services or units.
Table 3 illustrates the service portfolio in relation to functional units, specialized clinics, and techniques and procedures. In 40% of E-N S/U, the CNDU was formally established as a unit/section, whereas formalization as functional units was lower for diabetes (24%) and general endocrinology (29%). Regarding specialized clinics, >50% of E-N S/U had dedicated diabetes clinics (65.5%), particularly insulin pump therapy and new technologies (63.8%), diabetes and pregnancy (62.1%), morbid obesity/bariatric surgery (58.6%), and nutritional treatment of chronic diseases (52.6%). The most frequently performed procedures (> 70%) were thyroid ultrasound, insulin pump therapy, enteral/parenteral nutrition, bioimpedance, and dynamometry. Higher-volume centers had significantly more functional units, specialized clinics, and procedures. A gap was observed between the “complete” service portfolio proposed by SEEN12 and the resources available in 2023 (Table 2 of the Supplementary data).
Service portfolio of E-N S/U: functional units, specialty clinics, and techniques/procedures.
| Service portfolio | Total | <200 beds | 200–499 beds | 500–999 beds | ≥1000 beds | P valuea |
|---|---|---|---|---|---|---|
| N = 116 | N = 14 | N = 46 | N = 36 | N = 20 | ||
| Units/sections | ||||||
| Clinical nutrition (%) | 46 (39.7) | 2 (14.3) | 8 (17.4) | 20 (55.6) | 16 (80) | < .001 |
| Diabetes (%) | 28 (24.1) | 2 (14.3) | 5 (10.9) | 13 (36.1) | 8 (40) | .013 |
| General endocrinology (%) | 34 (29.3) | 2 (14.3) | 6 (13) | 15 (41.7) | 11 (55) | .001 |
| Other (%) | 20 (17.2) | 1 (7.1) | 4 (8.7) | 9 (25) | 6 (30) | .067 |
| Specialty clinics | ||||||
| Multidisciplinary eating-disorders clinic (%) | 31 (26.7) | 0 (0) | 5 (10.9) | 17 (47.2) | 9 (45) | < .001 |
| Inborn errors of metabolism (%) | 16 (13.8) | 0 (0) | 0 (0) | 9 (25) | 7 (35) | < .001 |
| Diabetic foot (%) | 42 (36.2) | 2 (14.3) | 11 (23.9) | 18 (50) | 11 (55) | .008 |
| Nutritional treatment of chronic diseases (cystic fibrosis, amyotrophic lateral sclerosis, …) (%) | 61 (52.6) | 1 (7.1) | 12 (26.1) | 30 (83.3) | 18 (90) | < .001 |
| Diabetes (%) | 76 (65.5) | 6 (42.9) | 25 (54.3) | 30 (83.3) | 15 (75) | .009 |
| Type 1 diabetes (%) | 63 (54.3) | 6 (42.9) | 20 (43.5) | 22 (61.1) | 15 (75) | .071 |
| CSII and new technologies (%) | 74 (63.8) | 3 (21.4) | 23 (50) | 31 (86.1) | 17 (85) | < .001 |
| Multidisciplinary pituitary disease (%) | 48 (41.4) | 1 (7.1) | 6 (13) | 24 (66.7) | 17 (85) | < .001 |
| Neuroendocrine tumors (%) | 45 (38.8) | 1 (7.1) | 6 (13) | 22 (61.1) | 16 (80) | < .001 |
| Adrenal disease (%) | 35 (30.2) | 1 (7.1) | 5 (10.9) | 19 (52.8) | 10 (50) | < .001 |
| Multidisciplinary morbid obesity/bariatric surgery (%) | 68 (58.6) | 2 (14.3) | 18 (39.1) | 31 (86.1) | 17 (85) | < .001 |
| Multidisciplinary diabetes and pregnancy (%) | 72 (62.1) | 1 (7.1) | 27 (58.7) | 28 (77.8) | 16 (80) | < .001 |
| Bone metabolism (%) | 15 (12.9) | 1 (7.1) | 2 (4.3) | 7 (19.4) | 5 (25) | .061 |
| Multidisciplinary gender identity (%) | 27 (23.3) | 0 (0) | 5 (10.9) | 12 (33.3) | 10 (50) | < .001 |
| Gender identity specialty clinic (%) | 45 (38.8) | 1 (7.1) | 12 (26.1) | 18 (50) | 14 (70) | < .001 |
| Multidisciplinary thyroid cancer (%) | 59 (50.9) | 3 (21.4) | 13 (28.3) | 26 (72.2) | 17 (85) | < .001 |
| Rapid-access thyroid nodule clinic (%) | 66 (56.9) | 4 (28.6) | 18 (39.1) | 29 (80.6) | 15 (75) | < .001 |
| Lipids (%) | 38 (32.8) | 2 (14.3) | 9 (19.6) | 19 (52.8) | 8 (40) | .005 |
| Fertility (%) | 1 (0.9) | 0 (0) | 0 (0) | 0 (0) | 1 (5) | .184 |
| Surgical prehabilitation (%) | 43 (37.1) | 4 (28.6) | 11 (23.9) | 16 (44.4) | 12 (60) | .027 |
| Oropharyngeal dysphagia (%) | 45 (38.8) | 3 (21.4) | 12 (26.1) | 18 (50) | 12 (60) | .014 |
| Pediatric-to-adult transition clinic (%) | 48 (41.4) | 4 (28.6) | 9 (19.6) | 22 (61.1) | 13 (65) | < .001 |
| Diabetes (%) | 47 (40.5) | 5 (35.7) | 8 (17.4) | 21 (58.3) | 13 (65) | < .001 |
| Obesity (%) | 13 (11.2) | 0 (0) | 2 (4.3) | 8 (22.2) | 3 (15) | .035 |
| Inborn errors of metabolism (%) | 12 (10.3) | 0 (0) | 0 (0) | 5 (13.9) | 7 (35) | < .001 |
| Gender identity (%) | 17 (14.7) | 1 (7.1) | 1 (2.2) | 6 (16.7) | 9 (45) | < .001 |
| Other (%) | 15 (12.9) | 1 (7.1) | 2 (4.3) | 5 (13.9) | 7 (35) | .007 |
| Other (%) | 27 (23.3) | 4 (28.6) | 9 (19.6) | 7 (19.4) | 7 (35) | .492 |
| Techniques and procedures | ||||||
| Thyroid/parathyroid ultrasound (%) | 98 (84.5) | 10 (71.4) | 33 (71.7) | 35 (97.2) | 20 (100) | .001 |
| Thyroid fine-needle aspiration | 61 (52.6) | 5 (35.7) | 15 (32.6) | 28 (77.8) | 13 (65) | < .001 |
| Ethanol ablation of thyroid nodules (%) | 32 (27.6) | 2 (14.3) | 11 (23.9) | 12 (33.3) | 7 (35) | .441 |
| Radiofrequency ablation of thyroid nodules (%) | 16 (13.8) | 0 (0) | 4 (8.7) | 8 (22.2) | 4 (20) | .109 |
| Laser ablation of thyroid nodules (%) | 3 (2.6) | 0 (0) | 0 (0) | 2 (5.6) | 1 (5) | .346 |
| Digital retinography (%) | 41 (35.3) | 2 (14.3) | 12 (26.1) | 20 (55.6) | 7 (35) | .012 |
| CSII (%) | 91 (78.4) | 3 (21.4) | 33 (71.7) | 36 (100) | 19 (95) | < .001 |
| Home enteral/parenteral nutrition (%) | 91 (78.4) | 7 (50) | 31 (67.4) | 34 (94.4) | 19 (95) | < .001 |
| Nutritional ultrasound (%) | 76 (65.5) | 6 (42.9) | 25 (54.3) | 27 (75) | 18 (90) | .006 |
| Bioelectrical impedance (%) | 91 (78.4) | 10 (71.4) | 30 (65.2) | 34 (94.4) | 17 (85) | .011 |
| DXA (%) | 30 (25.9) | 2 (14.3) | 7 (15.2) | 11 (30.6) | 10 (50) | .017 |
| CT software (%) | 21 (18.1) | 1 (7.1) | 3 (6.5) | 8 (22.2) | 9 (45) | .001 |
| Handgrip dynamometry and functional tests (%) | 92 (79.3) | 8 (57.1) | 32 (69.6) | 35 (97.2) | 17 (85) | .003 |
| Indirect calorimetry (%) | 18 (15.5) | 1 (7.1) | 3 (6.5) | 7 (19.4) | 7 (35) | .020 |
| Carotid Doppler ultrasound (%) | 33 (28.4) | 1 (7.1) | 7 (15.2) | 16 (44.4) | 9 (45) | .003 |
| Peripheral Doppler ultrasound (%) | 43 (37.1) | 3 (21.4) | 10 (21.7) | 18 (50) | 12 (60) | .004 |
| ABPM (%) | 56 (48.3) | 6 (42.9) | 15 (32.6) | 21 (58.3) | 14 (70) | .019 |
| Neurotester (%) | 14 (12.1) | 1 (7.1) | 0 (0) | 8 (22.2) | 5 (25) | .004 |
| FibroScan (%) | 14 (12.1) | 1 (7.1) | 5 (10.9) | 5 (13.9) | 3 (15) | .883 |
| Other (%) | 16 (13.8) | 4 (28.6) | 4 (8.7) | 6 (16.7) | 2 (10) | .254 |
Blank responses were considered “No.” CSII, continuous subcutaneous insulin infusion; SD, standard deviation; No., number; E-N S/U, endocrinology and nutrition services or units; CT, computed tomography.
Table 4 illustrates clinical activity indicators for E-N S/U in 2023. Considerable variability among E-N S/U was observed across all activity indicators.
Activity of endocrinology and nutrition services. 2023.
| Activity | Total | <200 beds | 200–499 beds | 500–999 beds | ≥1000 beds | P valueb |
|---|---|---|---|---|---|---|
| N = 116 | N = 14 | N = 46 | N = 36 | N = 20 | ||
| Clinical | ||||||
| Discharges/year (conventional hospitalization) a | 90 (70) | 43 (43) | 48 (48) | 106 (65) | 128 (75) | < .001 |
| Mean length of stay (conventional hospitalization) a | 4.7 (2.2) | 3.1 (1.0) | 4.6 (1.9) | 5.0 (2.5) | 5.1 (2.3) | .218 |
| No. of patients/year in day hospitala | 1,889 (2,420) | 1,330 (1,526) | 1,277 (1,641) | 2,001 (2,311) | 2,701 (3,499) | .465 |
| No. of inpatient consults/yeara | 2,875 (3,514) | 2,049 (4,252) | 1,477 (1,848) | 3,625 (3,897) | 4,740 (3,762) | .003 |
| New patient visitsa | 4,271 (3,135) | 1,648 (1,132) | 3,064 (1,753) | 5,403 (3,365) | 6,745 (3,428) | < .001 |
| New inpatient visitsa | 2,685 (2,061) | 1,007 (1,124) | 2,259 (1,792) | 3,529 (2,288) | 3,129 (1,815) | .001 |
| New outpatient visitsa | 2,456 (2,055) | 970 (495) | 1,650 (1,259) | 3,343 (2,555) | 3,339 (1,967) | .001 |
| Mean wait time (days) (as of 12/31/23)a | 52 (67) | 99 (152) | 45 (35) | 43 (35) | 43 (34) | .040 |
| No. of follow-up visits/yeara | 12,826 (9,134) | 4,611 (2,178) | 9,392 (5,719) | 16,824 (10,646) | 19,716 (7,936) | < .001 |
| No. of inpatient follow-up visits/yeara | 9,808 (7,097) | 3,225 (2,695) | 7,437 (7,222) | 11,667 (5,270) | 15,327 (6,813) | < .001 |
| No. of outpatient follow-up visits/yeara | 6,410 (3,874) | 2,800 (2,054) | 6,102 (4,047) | 7,120 (3,841) | 7,913 (3,341) | .054 |
| No. of non–face-to-face visitsa | 3,324 (4,125) | 1,365 (1,102) | 2,314 (2,562) | 3,771 (5,264) | 5,203 (4,289) | .042 |
| Techniques and procedures | ||||||
| No. of thyroid ultrasounds/yeara | 915 (1,275) | 789 (809) | 582 (438) | 947 (986) | 1,452 (2,346) | .174 |
| No. of thyroid FNAs/yeara | 319 (286) | 255 (163) | 210 (161) | 304 (208) | 514 (463) | .028 |
| No. of nodules treated with RFA/lasera | 19 (20) | 3 (—) | 18 (25) | 20 (18) | 22 (23) | .872 |
| No. of nodule ethanol ablations/yeara | 19 (27) | 3 (2) | 13 (14) | 25 (33) | 21 (30) | .538 |
| No. of functional tests/yeara | 480 (653) | 246 (327) | 347 (796) | 573 (600) | 643 (684) | .372 |
| No. of bioelectrical impedance testsa | 1,146 (2,057) | 262 (124) | 675 (662) | 1,040 (1,359) | 2,242 (3,762) | .139 |
| No. of retinographiesa | 618 (788) | 1,300 (990) | 449 (403) | 399 (417) | 987 (1,311) | .203 |
| No. of CSII (patients)a | 157 (134) | 40 (57) | 103 (121) | 193 (143) | 202 (109) | .009 |
| No. of ABPM testsa | 97 (227) | 31 (15) | 66 (61) | 197 (391) | 43 (48) | .374 |
| No. of nutritional ultrasoundsa | 377 (529) | 47 (29) | 235 (387) | 311 (454) | 722 (688) | .034 |
| No. of indirect calorimetry testsa | 167 (252) | — (—) | 102 (172) | 125 (160) | 248 (370) | .691 |
Blank responses were considered “No.” SD, standard deviation; No., number; E-N S/U, endocrinology and nutrition services or units.
Table 5 shows indicators related to research and training activities of E-N S/U. A total of 55% of E-N S/U were accredited for specialist training in endocrinology and nutrition, with a mean of 1.4 ± 0.4 residents per year. Regarding undergraduate teaching, 62.1% had at least one endocrinologist serving as a university lecturer, often as an associate professor. A total of 28% had full-time research-dedicated professionals (mean 0.8 ± 2.3). A total of 69% reported at least 1 scientific publication in the past 2 years, with a mean of 22 ± 28 articles during that period.
Teaching, training, and research indicators of E-N S/U. 2023.
| Total | <200 beds | 200–499 beds | 500–999 beds | ≥1000 beds | P valueb | |
|---|---|---|---|---|---|---|
| N = 14 | N = 46 | N = 36 | N = 20 | |||
| Teaching/training | ||||||
| Accredited for MIR residency training in endocrinology (%) | 64 (55.2) | 1 (7.1) | 16 (34.8) | 29 (80.6) | 18 (90) | < .001 |
| No. of endocrinology residents per yeara | 2.0 (1.6) | 2 (—) | 1.5 (1.1) | 2.3 (1.9) | 2.1 (1.7) | .666 |
| No. of first-year residentsa | 1.4 (0.5) | 2 (—) | 1.1 (0.3) | 1.3 (0.5) | 1.6 (0.6) | .015 |
| No. of second-year residentsa | 1.3 (0.5) | 2 (—) | 1.1 (0.3) | 1.4 (0.5) | 1.5 (0.6) | .089 |
| No. of third-year residentsa | 1.3 (0.5) | 2 (—) | 1.1 (0.3) | 1.3 (0.5) | 1.5 (0.5) | .037 |
| No. of fourth-year residentsa | 1.3 (0.5) | 3 (—) | 1.0 (0) | 1.2 (0.4) | 1.4 (0.5) | < .001 |
| Training for residents from other specialties (%) | 111 (95.7) | 12 (85.7) | 43 (93.5) | 36 (100) | 20 (100) | .092 |
| Training for endocrinology & nutrition residents from other centers (%) | 50 (43.1) | 4 (28.6) | 10 (21.7) | 19 (52.8) | 17 (85) | < .001 |
| Training for dietitians–nutritionists (%) | 65 (56) | 3 (21.4) | 19 (41.3) | 25 (69.4) | 18 (90) | < .001 |
| Service/unit professionals participate in undergraduate teaching (%) | 72 (62.1) | 3 (21.4) | 27 (58.7) | 29 (80.6) | 13 (65) | .002 |
| No. of full professorsa | 0.9 (1.3) | 1 (—) | 0.5 (0.5) | 1.2 (1.8) | 0.5 (0.6) | .710 |
| No. of associate professorsa | 1.1 (1.0) | — (—) | 0.9 (0.7) | 1.3 (1.4) | 0.9 (0.4) | .526 |
| No. of adjunct facultya | 3.0 (2.0) | 1.5 (0.7) | 2.5 (2.5) | 3.0 (1.6) | 3.9 (1.7) | .166 |
| Research | ||||||
| No. of professionals dedicated to research (FTE)a | 0.8 (2.3) | 0.4 (1.2) | 0.2 (0.7) | 1.1 (3.5) | 1.8 (2.0) | .063 |
| Integrated in stable organizational structures (RETIC or CIBER) promoted by Instituto Carlos III (%) | 23 (19.8) | 1 (7.1) | 5 (10.9) | 9 (25) | 8 (40) | .026 |
| Recognized research group in the hospital-associated Research Foundation (%) | 54 (46.6) | 2 (14.3) | 12 (26.1) | 21 (58.3) | 19 (95) | < .001 |
| No. of active publicly funded competitive national/international research projectsa | 1.7 (3.0) | 0.3 (0.8) | 1.0 (1.8) | 2.3 (3.5) | 3.3 (4.1) | .009 |
| No. of active privately funded competitive national/international research projectsa | 1.9 (3.0) | 0.4 (1.2) | 1.0 (1.6) | 2.4 (3.2) | 3.7 (4.1) | .002 |
| No. of active clinical trialsa | 3.6 (6.4) | 0.5 (1.7) | 1.5 (3.2) | 4.4 (5.4) | 8.4 (10.6) | < .001 |
| No. of active non–clinical trials approved by the hospital ethics committeea | 3.2 (3.9) | 0.5 (0.7) | 2.1 (2.9) | 3.5 (3.0) | 6.4 (6.0) | < .001 |
| Publications in journals with impact factor (JCR) (last 2 years)a | 22 (28) | 8 (14) | 9 (12) | 31 (33) | 37 (32) | .001 |
| Total impact factor (last 2 years)a | 165 (273) | 61 (95) | 68 (141) | 180 (338) | 216 (396) | .571 |
| Patent filing or similar (%) | 21 (18.1) | 1 (7.1) | 6 (13) | 8 (22.2) | 6 (30) | .249 |
| Participation in national registries (%) | 55 (47.4) | 3 (21.4) | 15 (32.6) | 25 (69.4) | 12 (60) | .001 |
Blank responses were considered “No.” SD, standard deviation; FTE, full-time equivalents; No., number; E-N S/U, endocrinology and nutrition services or units.
Regarding best practices and quality, there appears to be substantial room for improvement (Table 6). Nutritional screening was performed in 60% of hospitals, although systematic screening of all hospitalized patients occurred in only 23%; implementation was significantly lower in less complex hospitals.
Best-practice indicators of E-N S/U. 2023.
| Best practices | Total | <200 beds | 200–499 beds | 500–999 beds | ≥1000 beds | P valueb |
|---|---|---|---|---|---|---|
| N = 14 | N = 46 | N = 36 | N = 20 | |||
| Nutritional assessment of hospitalized patients (malnutrition screening test) (%) | 70 (60.3) | 6 (42.9) | 21 (45.7) | 27 (75) | 16 (80) | .006 |
| In all admitted patients (%) | 27 (23.3) | 4 (28.6) | 9 (19.6) | 8 (22.2) | 6 (30) | .776 |
| Implemented in some areas (%) | 48 (41.4) | 3 (21.4) | 14 (30.4) | 19 (52.8) | 12 (60) | .017 |
| Multidisciplinary care-team meetings (%) | 105 (90.5) | 9 (64.3) | 41 (89.1) | 35 (97.2) | 20 (100) | .002 |
| Quality lead (%) | 39 (33.6) | 2 (14.3) | 10 (21.7) | 14 (38.9) | 13 (65) | .003 |
| Safety lead (%) | 39 (33.6) | 1 (7.1) | 12 (26.1) | 11 (30.6) | 15 (75) | < .001 |
| Clinical sessions (%) | 99 (85.3) | 8 (57.1) | 36 (78.3) | 35 (97.2) | 20 (100) | < .001 |
| Accredited clinical sessions (%) | 52 (44.8) | 5 (35.7) | 15 (32.6) | 19 (52.8) | 13 (65) | .059 |
| Regular sessions with other hospital departments (%) | 98 (84.5) | 11 (78.6) | 33 (71.7) | 34 (94.4) | 20 (100) | .006 |
| No. of clinical sessions/montha | 5.9 (5.3) | 5.1 (6.1) | 3.8 (3.0) | 6.8 (6.1) | 8.0 (5.8) | .025 |
| Process-based management (%) | 50 (43.1) | 4 (28.6) | 14 (30.4) | 18 (50) | 14 (70) | .013 |
| Process map (%) | 49 (42.2) | 4 (28.6) | 14 (30.4) | 17 (47.2) | 14 (70) | .016 |
| Process-based management implemented for the most relevant processes (%) | 50 (43.1) | 4 (28.6) | 14 (30.4) | 18 (50) | 14 (70) | .013 |
| No. of processes developeda | 4 (2) | 3 (2) | 3 (2) | 4 (2) | 3 (2) | .549 |
| Participation in multidisciplinary committees (%) | 102 (87.9) | 11 (78.6) | 39 (84.8) | 32 (88.9) | 20 (100) | .244 |
| Participation in clinical commissions (%) | 92 (79.3) | 8 (57.1) | 33 (71.7) | 33 (91.7) | 18 (90) | .007 |
| Nutrition (%) | 88 (75.9) | 8 (57.1) | 28 (60.9) | 35 (97.2) | 17 (85) | .001 |
| Obesity (%) | 60 (51.7) | 1 (7.1) | 20 (43.5) | 25 (69.4) | 14 (70) | < .001 |
| Dysphagia (%) | 47 (40.5) | 1 (7.1) | 15 (32.6) | 20 (55.6) | 11 (55) | .005 |
| Thyroid cancer (%) | 74 (63.8) | 4 (28.6) | 23 (50) | 29 (80.6) | 18 (90) | < .001 |
| Other (%) | 44 (37.9) | 4 (28.6) | 14 (30.4) | 17 (47.2) | 9 (45) | .339 |
| No. of professionals participating in hospital quality committeesa | 1.2 (2.1) | 0.7 (1.3) | 0.8 (1.3) | 1.6 (2.7) | 1.6 (2.4) | .279 |
| Unit certified by a recognized system (ISO, EFQM, etc.)? (%) | 25 (21.6) | 1 (7.1) | 3 (6.5) | 10 (27.8) | 11 (55) | < .001 |
| National accreditation as CSUR (%) | 13 (11.2) | 0 (0) | 1 (2.2) | 3 (8.3) | 9 (45) | < .001 |
| Congenital metabolic diseases (%) | 7 (6) | 0 (0) | 0 (0) | 2 (5.6) | 5 (25) | .001 |
| Complex hypothalamic–pituitary disease (children and adults) (%) | 9 (7.8) | 0 (0) | 1 (2.2) | 3 (8.3) | 5 (25) | .007 |
| Mean waiting time for bariatric surgery (days, as of 12/12/23)a | 562 (551) | 831 (590) | 496 (492) | 569 (672) | 532 (371) | .567 |
Blank responses were considered “No.” SD, standard deviation; FTE, full-time equivalents; No., number; E-N S/U, endocrinology and nutrition services or units.
A total of 43% of E-N S/U had implemented process-based management, with a mean of 4 ± 2 processes. A total of 22% had certification from a recognized quality system. Particularly noteworthy was the prolonged waiting time for bariatric surgery (mean, 562 days), with longer delays in hospitals with <200 beds (mean, 831 days).
MBDSThe analysis of the MBDS database and its evolution during the 2007–2022 period is limited to hospital activity, whereas the activity of E-N S/U is predominantly outpatient. Diabetes mellitus (DM) was the most frequent principal discharge diagnosis reported by E-N S/U, accounting for 54% of all discharges from these services during the analyzed period; however, these discharges represented only 22% of all discharges in NHS hospitals (the remaining 78% were issued by other services).
Discharges from E-N S/U progressively decreased during the study period (2007–2022), from 9860 discharges in 2007 to 6821 in 2022. In terms of utilization, this represents a substantial reduction, from 26 discharges per 100,000 inhabitants in 2007 to 17 in 2022 (−53%), suggesting improvements in diagnostic processes and endocrine care that allow a greater proportion of patients to be managed in the outpatient setting. A significant drop in discharges during the period (2007–2022) was observed, particularly in relation to DM (IRR, −3.9%; P < .001). Furthermore, a reduction in median length of stay was noted for discharges from E-N S/U, from 6 days (IQR, 4–8) in 2007 to 4 days (IQR, 3–7) in 2022 (IRR, 0.975; P < .001). The mean hospital stay was 4.7 ± 2.2 days.
A worsening trend was observed between 2016 and 2022 in short- and long-term DM complication indicators developed by the Agency for Healthcare Research and Quality (AHRQ)13 (Table 7). A notable finding was the association between higher care volume and lower mortality (both crude and risk-adjusted) in admissions for DM (Table 3 of the supplementary data). Although no specific risk-adjustment model is available for in-hospital mortality in admissions with a principal diagnosis of DM, the logistic regression model used demonstrated good discrimination (AUROC = 0.796; 95%CI, 0.785–0.808) and calibration (Fig. 1 of the supplementary data).
Evolution of age- and sex-adjusted rates of diabetes mellitus “preventive” indicators. NHS hospitals, 2007–2022.
| Year | Short-term complications | 95%CI | Long-term complications | 95%CI | Admissions for uncontrolled DM | 95%CI | Amputation rate | 95%CI | Composite rate a | 95%CI |
|---|---|---|---|---|---|---|---|---|---|---|
| 2007 a | 16.5 | 16.1–17.0 | 48.1 | 47.3–48.8 | 3.3 | 3.1–3.4 | 67.8 | 66.9–68.7 | ||
| 2008 a | 15.4 | 15.0–15.8 | 45.7 | 45.0–46.4 | 3.1 | 2.9–3.3 | 64.2 | 63.4–65.1 | ||
| 2009 a | 14.6 | 14.2–15.0 | 43.8 | 43.1–44.5 | 3.0 | 2.8–3.2 | 61.4 | 60.5–62.2 | ||
| 2010 a | 13.6 | 13.3–14.0 | 42.1 | 41.4–42.8 | 2.7 | 2.6–2.9 | 58.5 | 57.7–59.3 | ||
| 2011 a | 13.1 | 12.7–13.5 | 38.9 | 38.3–39.6 | 2.2 | 2.0–2.3 | 54.2 | 53.5–55.0 | ||
| 2012 a | 13.1 | 12.7–13.5 | 35.4 | 34.8–36.0 | 1.9 | 1.7–2.0 | 50.3 | 49.6–51.1 | ||
| 2013 a | 12.0 | 11.6–12.3 | 34.2 | 33.6–34.8 | 1.6 | 1.5–1.7 | 47.8 | 47.1–48.4 | ||
| 2014 a | 11.9 | 11.6–12.3 | 32.7 | 32.2–33.3 | 1.4 | 1.3–1.6 | 46.1 | 45.4–46.8 | ||
| 2015a | 12.0 | 11.7–12.4 | 31.1 | 30.5–31.6 | 1.3 | 1.2–1.4 | 44.4 | 43.7–45.0 | ||
| 2016 | 9.1 | 8.8–9.4 | 17.2 | 16.8–17.7 | 11.3 | 11.0–11.7 | 8.8 | 8.8–8.8 | 37.6 | 37.0–38.2 |
| 2017 | 9.5 | 9.2–9.8 | 19.0 | 18.6–19.4 | 11.7 | 11.3–12.0 | 10.2 | 10.1–10.2 | 40.2 | 39.5–40.8 |
| 2018 | 9.2 | 8.9–9.5 | 20.9 | 20.5–21.4 | 13.0 | 12.6–13.3 | 11.5 | 11.5–11.5 | 43.1 | 42.4–43.7 |
| 2019 | 8.9 | 8.6–9.2 | 21.2 | 20.8–21.7 | 13.0 | 12.7–13.4 | 11.9 | 11.9–11.9 | 43.1 | 42.5–43.8 |
| 2020 | 11.3 | 10.9–11.6 | 21.3 | 20.8–21.7 | 11.1 | 10.8–11.4 | 11.8 | 11.8–11.8 | 43.6 | 43.0–44.2 |
| 2021 | 11.8 | 11.5–12.2 | 24.5 | 24.1–25.0 | 11.7 | 11.4–12.1 | 13.0 | 12.9–13.0 | 48.1 | 47.4–48.8 |
| 2022 | 12.1 | 11.8–12.5 | 26.5 | 26.0–27.0 | 11.5 | 11.1–11.8 | 13.7 | 13.7–13.8 | 50.1 | 49.4–50.8 |
| IRR ICD-9 | 0.959 | — | 0.945 | — | 0.883 | — | — | — | 0.946 | — |
| p ICD-9 | < .001 | — | < .001 | — | < .001 | — | — | — | < .001 | — |
| IRR ICD-10 | 1.056 | — | 1.068 | — | 0.996 | — | 1.066 | — | 1.045 | — |
| p ICD-10 | < .001 | — | < .001 | — | 0.661 | — | < .001 | — | < .001 | — |
| IRR | 0.971 | — | 0.940 | — | 1.150 | — | — | — | 0.972 | — |
| P | < .001 | — | < .001 | — | < .001 | — | — | — | <0.001 | — |
DM, diabetes mellitus; 95%CI, 95% confidence interval. Rates adjusted for age and sex per 100,000 inhabitants.
Analysis of both survey and MBDS data reveals significant interterritorial inequalities in resource allocation and activity (Table 4 of the supplementary data). Of note, the reliability of region-specific indicators regarding E-N S/U structure and activity depends on the level of RECALSEEN survey coverage in each territory.
Additionally, terterritorial inequalities were observed in endocrine and nutritional care outcomes within NHS hospitals. Table 8 presents differences in hospital indicators (utilization, length of stay, crude and risk-adjusted mortality) for discharges with DM as the principal diagnosis, as well as AHRQ DM indicators (Table 5 of the supplementary data).
Hospital indicators. Discharges for DM, 2022. Autonomous communities.
| Utilization | Utilization adjusted for age and sex | Median length of stay | CMR (%) | RAMR (%) | |
|---|---|---|---|---|---|
| Andalusia | 45.7 | 48.3 | 8.0 | 6.5 | 6.8 |
| Aragon | 66.1 | 61.8 | 9.0 | 5.5 | 5.2 |
| Principality of Asturias | 75.1 | 65.0 | 6.0 | 4.3 | 4.8 |
| Balearic Islands | 67.2 | 75.1 | 7.0 | 6.1 | 6.3 |
| Canary Islands | 50.6 | 54.2 | 10.0 | 5.2 | 6.2 |
| Cantabria | 94.4 | 86.7 | 8.0 | 5.6 | 5.3 |
| Castile and León | 70.0 | 59.1 | 7.0 | 6.3 | 5.0 |
| Castile–La Mancha | 43.1 | 42.8 | 7.0 | 5.3 | 5.0 |
| Catalonia | 39.7 | 40.3 | 7.0 | 5.2 | 5.2 |
| Valencian Community | 60.3 | 60.6 | 6.0 | 4.4 | 4.7 |
| Extremadura | 51.8 | 50.2 | 6.0 | 8.5 | 6.6 |
| Galicia | 65.8 | 58.6 | 8.0 | 7.1 | 6.1 |
| Madrid | 48.5 | 51.6 | 6.0 | 4.0 | 4.1 |
| Region of Murcia | 80.7 | 87.8 | 6.0 | 4.9 | 5.9 |
| Navarre | 67.9 | 66.4 | 7.0 | 4.3 | 5.3 |
| Basque Country | 72.3 | 66.1 | 6.0 | 4.8 | 4.8 |
| La Rioja | 82.2 | 78.0 | 8.0 | 6.5 | 5.7 |
| Meana | 63.6 | 61.9 | 7.2 | 5.6 | 5.5 |
| Mediana | 66.1 | 60.6 | 7.0 | 5.3 | 5.3 |
| SDa | 15.3 | 13.9 | 1.2 | 1.2 | 0.7 |
| Mina | 39.7 | 40.3 | 6.0 | 4.0 | 4.1 |
| Maxa | 94.4 | 87.8 | 10.0 | 8.5 | 6.8 |
SD, standard deviation; DM, diabetes mellitus; RAMR, risk-adjusted mortality ratio (multilevel); CMR, crude mortality rate.
RECALSEEN 2024 provides relevant information on the structure, resources, and activities of E-N S/U, as well as on the evolution of endocrine and nutritional care in NHS hospitals. The most relevant findings include: 1) Significant interterritorial inequalities in resources, activity, and outcomes in endocrine and nutritional care; 2) The ongoing trend—already identified in RECALSEEN 2017—toward outpatient care and telemedicine expansion; 3) The gap between the service portfolio proposed by SEEN and the current reality of E-N S/U; 4) Opportunities for improvement in the implementation of best practices; and 5) A worsening trend in DM “preventive” indicators since 2016.
As in previous editions of RECALSEEN, substantial differences in resources, activity, and outcomes were observed across hospitals and regions. While differences in resources and activity among hospitals are partly explained by variations in institutional complexity, interterritorial differences should be reduced. For example, the endocrinologist rate is more than twice as high in the autonomous community with the highest staffing vs that with the lowest. Furthermore, marked regional differences were observed in the availability of day hospital positions assigned to E-N S/U. Moreover, outcome disparities were evident, both across hospitals and regions. Regarding crude and risk-adjusted hospital mortality in admissions for DM, the autonomous community with the worst results doubled that of the region with the lowest mortality rate (8.5% crude and 6.6% adjusted vs 4.0% and 4.1%, respectively). Some of these regional differences may be related to health care organization, as an association was found between higher hospital volume and lower mortality in DM admissions—an association previously described for other conditions, such as heart failure, in both international literature14 and NHS hospital analyses.15 Another possible explanation may be unequal regional distribution of health determinants unrelated to health care delivery (eg, educational level, income).16 The causes of these inequalities warrant further investigation.
Although resource differences among E-N S/U are partly linked to hospital complexity, a significant gap remains between the service portfolio proposed by SEEN¹² and current availability, even in hospitals with ≥500 beds. One priority area to reduce this gap may be the systematic implementation of nutritional screening, at least among older patients and other high-risk groups.
The shift toward outpatient care and telemedicine is consistent with the broader concept of “hospital of the future,”4,17 reducing hospital admissions through alternatives such as day hospitals, supported by technological advances (insulin pump therapy) and remote patient monitoring (e-consultation; telemonitoring).
There remains substantial room for improvement in the implementation of best practices within E-N S/U, particularly regarding process-based management (only 43.1% have at least 1 implemented clinical care process). The very long waiting times for bariatric surgery deserve special attention; the significantly longer delays in less complex hospitals may indicate geographic inequity, potentially mitigated by developing care networks between “health area” hospitals and “local” hospitals.
Finally, no evidence-based explanation is currently available for the worsening trend in DM “preventive” indicators. Further investigation is needed, considering not only health care factors but also broader social determinants of health.
LimitationsAs in previous RECALSEEN editions, caution is warranted regarding the reliability of survey-derived indicators, which depend on factors such as sample representativeness within each autonomous community and hospital typology. Nevertheless, given the large sample size, it appears reasonable to consider the findings representative of the current situation of E-N S/U, although the sample cannot be considered statistically representative in a strict sense. No specific risk adjustment is available for discharges with DM as the principal diagnosis.
ConclusionsRECALSEEN 2024 provides relevant information on the resources and activity of E-N S/U, as well as on endocrine and nutritional care outcomes. Interhospital and interregional inequalities represent a challenge for the specialty. The observed worsening trend in “preventive” indicators for hospital admissions due to DM complications also requires further investigation.
FundingThe RECALSEEN 2024 project was funded by Fresenius Kabi and the SEEN Foundation (FSEEN).
None declared.
We thank the Spanish Ministry of Health for the partial provision of the MBDS database.
The following is Supplementary data to this article:
