Buscar en
Neurología (English Edition)
Toda la web
Inicio Neurología (English Edition) Study of outpatient neurological care in the Region of Madrid: The impact of imp...
Journal Information
Vol. 30. Issue 8.
Pages 479-487 (October 2015)
Visits
2780
Vol. 30. Issue 8.
Pages 479-487 (October 2015)
Original article
Full text access
Study of outpatient neurological care in the Region of Madrid: The impact of implementing free choice of hospital
Estudio de la asistencia neurológica ambulatoria en la Comunidad de Madrid: impacto del modelo de libre elección de hospital
Visits
2780
J.A. Matías-Guiua,
Corresponding author
, D. García-Azorína, R. García-Ramosa, E. Basocob, C. Elvirab, J. Matías-Guiua
a Servicio de Neurología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria “San Carlos”, Universidad Complutense, Madrid, Spain
b Servicio de Admisión, Hospital Clínico San Carlos, Madrid, Spain
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (5)
Show moreShow less
Tables (4)
Table 1. Diagnostic categories in the sample.
Table 2. Demographic and care-related factors for in-district vs. out-of-district patients.
Table 3. Demographic and care-related factors and reason for choosing our district.
Table 4. Comparison of studies conducted in Spain.
Show moreShow less
Abstract
Introduction

A new model permitting free choice of hospital has been introduced in the Region of Madrid. This may result in changes in how outpatient neurological care is provided and managed. The purpose of this study is to analyse initial visits to a general neurology department in the Region of Madrid and record the health district corresponding to each patient's residence.

Methods

Observational and prospective study of a cohort of patients making initial outpatient visits to a neurology department between 16 September 2013 and 16 January 2014.

Results

The study included 1109 patients (63.8% women, mean age 55.2±20.5). The most frequent diagnostic groups were periodic headache, cognitive disorders, and neuromuscular diseases. Non-neurological diseases were diagnosed in 1.1% of the cases. The mean time of delay was 7.2±5.1 days. Residents within the hospital's health district made up 73.8% of the total, while 26.2% chose a hospital outside of the health district corresponding to their residences. In the latter group, 59.5% made the choice based on the level of care offered, while 39.7% changed hospitals due to shorter times to consultation. The patients who came from another health district were younger (50.7 vs. 57.3, P<.0001) and had a lower rate of discharges on the first visit (16.4% vs. 30.1%, P<.0001).

Conclusion

The model of free choice of hospital delivers significant changes in healthcare management and organisation. Reasons given for choosing another hospital are more ample experience and shorter delays with respect to the home district hospital. Management of patients from outside the health district is associated with greater complexity.

Keywords:
Outpatient neurological care
Healthcare management
Epidemiology
Resumen
Introducción

En la Comunidad de Madrid se ha desarrollado un nuevo sistema de libertad de elección de área sanitaria, que puede suponer un cambio en la asistencia sanitaria neurológica y su gestión. El objetivo de este estudio fue analizar las primeras visitas de Neurología general atendidas en un área sanitaria de Madrid, teniendo en cuenta el área sanitaria de procedencia del paciente.

Métodos

Estudio observacional, prospectivo, de una cohorte de primeras visitas de neurología ambulatoria realizadas entre el 16 de septiembre del 2013 y el 16 de enero del 2014.

Resultados

Se incluyó a 1.109 pacientes (63,8% mujeres, edad media 55,2±20,5 años). Las categorías diagnósticas más frecuentes fueron cefalea periódica, trastornos cognitivos y patología neuromuscular. El 1,1% se consideró patología no neurológica. El tiempo medio de demora fue de 7,2 ± 5,1 días. El 73,8% perteneció a la propia área sanitaria del hospital, mientras que el 26,2% procedió de otra área por libertad de elección. De estos, el 59,5% acudió por excelencia, mientras que el 39,7% por una menor demora. Los pacientes que acudieron por libre elección tuvieron una edad media menor (50,7 vs. 57,3 años; p<0,0001) y una menor tasa de altas en la primera visita (16,4% vs. 30,1%; p<0,0001).

Conclusión

El modelo de libre elección de la asistencia neurológica implica un cambio relevante en la gestión sanitaria. La búsqueda de centros a los que se atribuye mayor excelencia y con menor demora son motivos para la libertad de elección, asociándose los pacientes de otra área a una mayor complejidad.

Palabras clave:
Asistencia neurológica ambulatoria
Gestión sanitaria
Epidemiología
Full Text
Introduction

The last few years have witnessed significant improvements in outpatient and non-hospital neurological care.1–4 The rising frequency of neurological diseases, their growing social and care-related repercussions, and deeper knowledge of the diseases themselves all contribute to the higher demand for neurological consultations.5 In Spain, the General Law on Healthcare of 1986 established creating health care districts to serve as the basic building blocks of the healthcare system, whether for primary care or specialist care.6 Since then, several studies have examined outpatient neurological care in different regions of our country.7–22 These studies were conducted as a means to improving health planning and care.23,24

In 2010, the Region of Madrid implemented a system in which patients may freely choose their doctors and hospitals, including specialists; this change resulted in the unified health district of the Region of Madrid.25–27 This system differed greatly from the previous one that had been established by the General Law on Healthcare. Within the new framework, the patient may freely consult with specialists or a department from another health district, and this may mean major changes in health planning. These changes in turn may affect outpatient neurological care, which is a relevant consideration for healthcare management.

The purpose of this study was to analyse the first neurological consultations in one health district in Madrid to obtain demographic, diagnostic, and care-related data. We noted whether patients resided in the same health district in which the study was carried out, or if they had specifically chosen to seek care in that district.

Material and methods

Specialist neurological care in the Region of Madrid is provided in 27 zones that are geographically equivalent to the health districts established by the previous system. Each health district is headed by a hospital, and care is provided in that hospital or in its corresponding specialist care centres.

Outpatient neurological care in District 7 is headed by Hospital Clínico San Carlos. Care is provided in that hospital's facilities, at the Modesto Lafuente specialist care centre, or at the Avenida de Portugal specialist care centre. Throughout 2013, care was provided to 38,214 patients; 6311 were seen by general neurologists for the first time following a referral from primary care doctors, and 1063 of them had opted to use our healthcare centres. The rest of the patients received care from more specific units within the neurology department.

This observational prospective study examined a cohort of patients receiving outpatient general neurology care for the first time. Patients seen between 16 September 2013 and 16 January 2014 were recruited consecutively. Our team recorded demographic and clinical variables (age, sex, diagnostic category) for all patients examined during this time period in the consulting rooms of 3 neurologists at either Hospital Clínico San Carlos (JAM, JM) or at the Modesto Lafuente specialist care centre (JAM, RG). Diagnostic categories included the following: periodic headache; acute headache; cognitive disorder; parkinsonism; tremor (excluding parkinsonism); other movement disorders, seizure, syncope, and epilepsy; stroke and other cerebrovascular diseases; multiple sclerosis; neuro-ophthalmic disease; neuropathic pain; lumbar and disc disorders; neuromuscular disease; dizziness, instability, and vertigo; brain tumours; phakomatoses, malformations, and genetic concerns; non-specific neurological symptoms; psychiatric disorders; administrative referrals; and non-neurological disease.

We also recorded the following care-related variables:

  • Delay to care, defined as the time in days between the patient's referral and the date of his or her appointment with the neurologist, including non-working days. This entry reported the date on which the patient was evaluated by the referring primary care doctor or specialist, as well as the date of discharge from the emergency department or the hospital.

  • The patient's referral route: primary care, specialist care, hospitalisation, or emergency department care.

  • The patient's health district of residence. Patients who specifically chose our centre and those residing in the district served by Hospital Clínico. Patients who had opted for our district were asked whether their choice was based on the centre's reputation, greater delays elsewhere, or both reasons.

  • Which patients were being monitored by the neurology department.

  • Patients who had been referred for a second opinion following an examination of the same condition by primary care doctors.

  • The patient's management outcome, recorded as one of the following options: referral to a specific unit within the neurology department, referral to the emergency department, ordering tests, referral to a different specialty, or discharge.

Results were analysed with IBM® SPSS® statistical software, version 20.0 for Mac. Data are given as means±standard deviation and as frequencies (percentages). Qualitative variables were compared using the chi-square test for qualitative variables. The t test for independent samples was used to compare both qualitative and quantitative variables.

Results

We included 1109 patients with a mean age of 55.2±20.5 years; 707 were women (63.8%). The mean age of men was 55.6±20.6 years, whereas the mean age of women was 55.1±20.5 years (P=.689). Fig. 1 shows the distribution of the sample by age groups. Ninety patients (8.1%) did not show up for their appointments.

Figure 1.

Patient total broken down by age groups.

(0.08MB).

Among patients who did attend, the most common diagnostic categories were periodic headache (197; 19.3%); cognitive disorder (148; 14.5%); neuromuscular disease (115; 11.3%); dizziness, instability, or vertigo (93; 9.1%); seizures, syncope, and epilepsy (83; 8.1%); and acute headache (64; 6.3%). Other reasons for consultation are given in Table 1. A non-neurological disorder was diagnosed in 12 cases (1.1%). There was an association between diagnostic categories and patients’ ages, as can be observed in Fig. 2.

Table 1.

Diagnostic categories in the sample.

Periodic headache  197 (19.3%) 
Cognitive disorder  148 (14.5%) 
Neuromuscular  115 (11.3%) 
Dizziness, instability, vertigo  93 (9.1%) 
Epilepsy, seizures, syncope  83 (8.1%) 
Acute headache  64 (6.3%) 
Cerebrovascular disease  43 (4.2%) 
Non-parkinsonian tremor  39 (3.8%) 
Lumbar sciatic pain; radicular or disc disease  34 (3.3%) 
Parkinson's disease  33 (3.2%) 
Non-specific neurological symptoms  32 (3.1%) 
Neuro-ophthalmic disease  27 (2.6%) 
Multiple sclerosis  22 (2.2%) 
Other movement disorders  19 (1.9%) 
Sleep disorders  19 (1.9%) 
Neuropathic pain  14 (1.4%) 
Psychiatric disorders  14 (1.4%) 
Non-neurological disorders  12 (1.2%) 
Administrative referrals  4 (0.4%) 
Neurogenetic concerns, malformations, phakomatoses  4 (0.4%) 
Nervous system tumours  3 (0.3%) 
Figure 2.

Most common diagnoses by age group (0-35, 36-50, 51-65, 66-80, ≥81).

(0.14MB).

Mean delay to care was 7.2±5.1 days. Primary care was responsible for referring 880 patients (86.4%); 92 (9.0%) were referred by specialists, 42 (4.1%) by the emergency department, and 5 (0.5%) by a different hospital ward. Thirty patients (2.9%) requested a second opinion after having consulted with a private doctor. Ninety patients (8.1%) did not attend the appointment, while 58 (5.2%) were already being monitored by our department. Regarding outcomes of the patients we examined, 271 were discharged (26.6%), 709 required an examination or consultation in a specific unit in the neurology department (69.5%), 32 were referred to another specialty (3.1%), and 7 were referred to the emergency department (0.7%). Additional tests were ordered for 313 cases (30.7%).

Broken down by health district, 818 of the total resided in the zone corresponding to the hospital (73.8%); 291 resided in another zone (26.2%). Of the patients who attended their appointments 262 specifically opted for our facilities (25.7%). Compared to patients residing in our zone, those who opted for our facilities were younger (mean age 50.7±20.2 out-of-district vs. 57.3±20.3 in-district; P=.0001). Out-of-district patients also showed a lower percentage of women (59.7% out-of-district vs. 65.5% in-district; P=.082). More patients in the out-of-district group had been referred by specialists and emergency departments than in the other group (80.5% referred by primary care for out-of-district vs. 88.4% in-district; 13.7% by specialists for out-of-district vs. 7.4% in-district; 5.0% by emergency departments for out-of-district vs. 3.8% in-district. P=.011). The percentage of no-shows was similar between out-of-district (10%) and in-district patients (7.5%), P=.178 (Table 2). The two groups showed statistically significant differences with regard to both diagnostic category and management outcome (Table 2).

Table 2.

Demographic and care-related factors for in-district vs. out-of-district patients.

  In-district  Out-of-district  P-value 
Age (years)  57.3  50.7  <.0001 
Sex (women) (%)  496 (65.5%)  156 (59.5%)  .082 
Referred by
Primary care  669 (88.4%)  211 (80.5%)  <.0001 
Specialist care  56 (7.4%)  36 (13.7%)   
Emergency dept.  29 (3.8%)  13 (5.0%)   
Hospital ward  3 (0.4%)  2 (0.8%)   
Follow-up by neurology department  46 (6.1%)  10 (3.8%)  .167 
Second opinion for private diagnosis  20 (2.7%)  10 (3.8%)  .334 
Care delay (days)  7.0±4.7  7.8±6.3  .053 
Management outcome
Discharge  228 (30.1%)  43 (16.4%)  <.0001 
Follow-up  505 (66.3%)  262 (79.0%)   
Referral to another specialty  23 (3.0%)  9 (3.4%)   
Referral to emergency department  4 (0.5%)  3 (1.1%)   
Requests for additional tests  241 (31.8%)  73 (27.9%)  .230 
No-shows  61 (7.5%)  29 (10%)  .178 

Of the out-of-district group, 156 patients (59.5%) stated that they had chosen the medical centre based on its reputation, whereas 104 patients (39.7%) indicated that delays were longer in their home health districts. Two patients (0.8%) stated that they had chosen neurological care in our district due to both reasons. In successive analyses comparing the group citing reputation and the one citing delay times, we excluded the 2 patients pointing to both motives. Results from comparing these groups are shown in Table 3 and Fig. 3. Diagnostic categories also differed between the in-district and out-of-district groups (Fig. 4).

Table 3.

Demographic and care-related factors and reason for choosing our district.

  Reputation (n=156)  Delay (n=104)  P-value 
Age (years)  51.4±19.6  49.8±21.3  .555 
Sex (women) (%)  90 (57.7%)  65 (62.5%)  .439 
Referred by
Primary care  114 (73.1%)  95 (91.3%)  .002 
Specialist care  29 (18.6%)  7 (6.7%)   
Emergency dept.  11 (7.1%)  2 (1.9%)   
Hospital ward  2 (1.3%)  0 (0%)   
Follow-up by neurology department  7 (4.5%)  3 (2.9%)  .503 
Second opinion for private diagnosis  8 (5.2%)  2 (1.9%)  .165 
Care delay (days)  7.78  7.72  .932 
Management outcome
Discharge  23 (14.7%)  20 (19.2%)  .550 
Case review  124 (79.5%)  81 (77.9%)   
Referral to another specialty  7 (4.5%)  2 (1.9%)   
Referral to emergency department  2 (1.3%)  1 (1.0%)   
Requests for additional tests  35 (22.4%)  38 (36.5%)  .013 
Figure 3.

Diagnostic categories in patients choosing our district broken down by motive (reputation or delays elsewhere).

(0.29MB).
Figure 4.

Diagnostic categories broken down by patients’ district of residence (in-district, out-of-district).

(0.17MB).
Discussion

The demand for healthcare may fluctuate over time, and it responds to a series of sociodemographic, care-related, use-related and economic factors.24 These factors must be understood to foster good healthcare planning.28 Different studies carried out in Spain have examined activity within outpatient neurology clinics and recorded relevant demographic, clinical, and care-related factors. Mean age in our study is similar to that reported by other comparable studies performed in the past few years. These data suggest that mean patient age has risen with respect to studies performed in the late 1980s and early 1990s, but also that mean age has remained stable since the late 1990s and early 2000s. The percentage of women underwent a similar change and has also stabilised at 60%-63% according to the most recent studies (Table 4).

Table 4.

Comparison of studies conducted in Spain.

Lead author  Pondal Sordo  Baquero  Villagra  Gracia-Naya  Gracia-Naya  Batalla  Morera-Guitart  Huerta-Villanueva  González Menacho  Sempere 
Year performed  1986-1987  1992-1993  1992  1993  1995  1996  1996  1997  1999  1999-2000 
City  Parla, Madrid  Valencia  Gran Canaria  Zaragoza  Aragon  Baix Llobregat  Marina Alta, Alicante  Tortosa, Tarragona  Baix Camp, Tarragona  Vega Baja, Alicante 
Study period (months)  18  12  12  12  12  24 
Consultations  1715  5480  3000  552  3489  592  2919  718  1278  2227 
Initial visits  1715  2213  1300  552  3489  592  1067  718  1278  2227 
Mean age±SD (years)  38.4  49  –  45.1  51.5  45.1  55.5  40.4  48.7  51.6 
% Women  60%  57.5%  –  57.6%  57%  57.7%  56%  52%  61.8%  60% 
No-shows  –  –  –      –  –  16.8%  –  – 
Referred by primary care  83.3%  –  –  84.7%  79.3%  89%  44.4%  52.0%  –  – 
Care delay (days)    –  –  12.4  12/19  35.6  122.9  –  – 
Discharges  41.3%  –  80.5%  62%  –  74%  –  22.8%  –  – 
Transfer to emergency dept.  –    –  1.2%  –  3.3%  –  –  –  – 
Tests  –  31.9%  –  56%  48.9%  51%  –  –  29.3%  – 
Lead author  Morera-Guitart  Pérez-Carmona  Fragoso  Huerta-Villanueva  López-Domínguez  López-Hernández  López-Pousa  Casado Menéndez  Martín  Present study 
Year performed  2001  2003-2004  2004-2005  2003-2004  2005-2006  2005-2006  2006-2007  2006-2008  2008  2013-2014 
City/Province  Marina Alta, Alicante  Marina Baixa, Alicante  Rubí, Barcelona  Tortosa, Tarragona  Huelva  Elche, Alicante  Girona  Gijón  Burgos  Madrid 
Study period (months)  12  12  12  24  18  12 
Consultations  3301  1000  1460  1004  500  3937  1078  1000  1341  1109 
Initial visits  1494  265  496  1004  500  3937  1078  1000  1341  1109 
Mean age (years)  60.4  55.0  –  56.7  51  56.8  60.6  62.04  56.2  55.2 
% Women  57%  52.8%  –  62%  63.4%  62%  61.4%  59.8%  60.9%  63.8 
No-shows  –  9.8%  23.79%  20.8%  –  18%  –  16%  12%  8.1% 
Referred by primary care  51.6%  –  –  69.3%  –  93.9%  –  61.5%  76%  86.4% 
Care delay (days)  43.8  –  –  165.4  –  30.6  –  –  –  7.2 
Discharges  –  17.7%  9.2%  21.1%  40.2%  42%  –  50.4%  59%  26.6 
Transfer to emergency dept.  –  –  –    –  1%  –  –  –  0.7% 
Tests  –  –  –    55%  34%  –  –  –  30.7% 

In our cohort, headaches were the most common motive for consultation, followed by cognitive disorders. Most of the similar studies performed in recent years also cite cognitive disorders as the second most common concern. The increased presence of cognitive disorders in neurology clinics has also been highlighted by studies performed in the same health district during 2 different time periods.5,17Fig. 5 displays a comparison of the most frequent diagnostic categories reported by different studies.

Figure 5.

Diagnostic categories in different studies conducted in Spain.

(0.35MB).

One of the most interesting results from our study was the low percentage of non-neurological diagnoses. In fact, this rate was far lower than those observed in other earlier studies,9,11,12,14,15,18,19,21,22,29 which is indicative of better selection of the neurological cases referred to us. Despite the above, we cannot rule out the possibility of discrepancies in the definition of ‘non-neurological disease’ between these very different studies. For example, other studies have included syncope or subjective memory loss within the non-neurological category14,18; nevertheless, these symptoms may require assessment by a neurologist in order to rule out neurological disease in differential diagnosis, so we have not classified them as non-neurological. In any case, this lower percentage of non-neurological disease may be responsible for the lower rate of re-referral after the initial consultation compared to some earlier studies (here, the rate reached 60% or even 80%). This suggests greater awareness of the criteria for referral to a neurologist.30

Another key aspect is the percentage of no-shows, which was also lower than in earlier studies providing these figures.31,32 As demonstrated in prior studies,32 fewer no-shows might be the result of shorter waiting times, which would decrease the number of patients forgetting appointments and finding alternative care providers.

In our study, 26.2% of the patient total resided out of our health district. This percentage is rather high and indicates that many patients take advantage of the option of choosing their medical centre. The 2 main motives given by patients opting for out-of-district care are the hospital's reputation, cited by 59.5%, and the waiting times in the case of the remaining 39.7%. Patients who chose the health district based on its reputation may also do so for a variety of motives. Examples include prior direct or indirect experience with the department or hospital, geographical convenience, the primary care doctor's recommendation, and the care delay compared to other centres, since there are several neurology departments operating in the Region of Madrid.

On the other hand, the out-of-district patients who choose our hospital have a lower rate of re-referrals on the first visit, but more referrals to specialised units and higher rates of follow-up within the same department. This tendency remains when we analyse only those patients opting for our district because of care delays elsewhere. This indicates that patients who decide to use another healthcare district, even those citing different motives, constitute a subgroup whose cases are more complex and may consequently require more resources.

In conclusion, having the option of choosing one's public provider of neurological care in the Region of Madrid implies major changes for healthcare management, since many patients do explore their care options out-of-district. Although care delays may affect the patient's decision, patients will also seek out centres said to have greater experience or better results in specific areas. As a result, out-of-district patients present more complex cases than do in-district patients. A comparison with similar published studies shows that our results indicate a higher rate of consultations for cognitive disorders and a lower rate of patients with non-neurological disease. The rate of no-shows was also lower, indicating that the patients seen in general neurological consultations must value this level of care.

Conflict of interest

The authors have no conflicts of interest to declare.

References
[1]
J. Matías-Guiu.
Neurología de distrito: un cambio conceptual.
Rev Neurol, 22 (1994), pp. 357
[2]
M.R. Martín-González.
Necesidades de asistencia especializada en Neurología.
Rev Neurol, 29 (1999), pp. 670-672
[3]
F. Bermejo-Pareja.
Demanda neurológica en España. Datos para un futuro más exigente.
Rev Neurol, 29 (1999), pp. 673-677
[4]
J. Morera-Guitart.
Asistencia neurológica ambulatoria en España. Pasado, presente, ¿futuro?.
Rev Neurol, 41 (2005), pp. 65-67
[5]
J. Morera-Guitart, M.J. Pedro Cano.
Variación en la patología atendida en las consultas de Neurología: un futuro demencial.
Neurología, 18 (2003), pp. 417-424
[6]
Ley 14/1986. Boletín Oficial del Estado número 102 de 29 de abril de 1986.
[7]
M. Pondal Sordo, F. Bermejo Pareja, T. del Ser Quijano.
La asistencia neurológica ambulatoria extrahospitalaria. Análisis de la demanda registrada durante 18 meses en una consulta jerarquizada de neurología.
Neurología, 4 (1989), pp. 123-131
[8]
M. Baquero, F.J. Domínguez, J.J. Vílchez, T. Sevilla, B. Casanova.
La asistencia médica en Neurología: perspectiva desde los datos iniciales de una consulta extrahospitalaria.
Rev Neurol, 22 (1994), pp. 427-431
[9]
P. Villagra, A. Cubero.
Estudio de la demanda asistencial en una consulta jerarquizada de Neurología correspondiente al área Norte de las Palmas de Gran Canaria.
Rev Neurol, 25 (1997), pp. 1544-1546
[10]
M. Gracia-Naya, E. Marta, M. Usón, J. Carod.
Estudio epidemiológico descriptivo de una consulta externa de Neurología.
Rev Neurol, 24 (1996), pp. 633-637
[11]
M. Gracia-Naya, M.M. Usón-Martín, Grupo de Estudio de Neurólogos Aragoneses.
Estudio transversal multicéntrico de las consultas externas de Neurología de la Seguridad Social en Aragón. Resultados globales.
Rev Neurol, 25 (1997), pp. 194-199
[12]
X. Batalla.
Neurología extrahospitalaria. Análisis descriptivo de una consulta en el Baix Llobregat.
Rev Neurol, 25 (1997), pp. 1546-1550
[13]
J. González Menacho, J.M. Olivé Plana.
Epidemiología de la patología neurológica ambulatoria en el Baix Camp (Tarragona) durante 1999.
Neurología, 16 (2001), pp. 154-162
[14]
A.P. Sempere, S. Mola, V. Medrano, T. Esguevillas, C. Costa, V. Salazar, et al.
Epidemiología descriptiva de la asistencia neurológica ambulatoria en el área Vega Baja (Alicante).
Rev Neurol, 35 (2002), pp. 822-826
[15]
N. Pérez-Carmona, R.M. Sánchez-Pérez, I. Abellán-Miralles, C. Díaz-Marín.
Asistencia neurológica ambulatoria en el área de la Marina Baixa, Alicante.
Rev Neurol, 39 (2004), pp. 607-613
[16]
M. Fragoso, M. Aguilar-Barberà.
Análisis de una consulta de Neurología ambulatoria en el área de Rubí, Barcelona.
Rev Neurol, 42 (2006), pp. 58-59
[17]
M. Huerta-Villanueva, J.J. Baiges-Octavio, G. Martín-Ozaeta, E. Muñoz-Farjas, F. Rubio-Borrego.
Evolución de la demanda de asistencia neurológica ambulatoria y patología atendida en la consulta de neurología de la región sanitaria de Tortosa, Tarragona.
Rev Neurol, 41 (2005), pp. 68-74
[18]
N. López-Hernández, J. Espinosa-Martínez.
Análisis descriptivo de la asistencia neurológica ambulatoria en Elche, Alicante.
Rev Neurol, 45 (2007), pp. 219-223
[19]
J.M. López-Domínguez, I. Rojas-Marcos, G. Sanz-Fernández, A. Blanco-Ollero, A. Robledo-Strauss, C. Díaz-Espejo.
Análisis descriptivo de la demanda de asistencia neurológica en un área sanitaria de Huelva.
Rev Neurol, 44 (2007), pp. 527-530
[20]
S. López-Pousa, S. Monserrat-Vila, O. Turró-Garriga, M. Aguilar-Barberà, C. Caja-López, J. Vilalta-Franch, et al.
Análisis de la demanda asistencial neurológica generada por la atención primaria en un área geográfica de las comarcas de Girona.
Rev Neurol, 49 (2009), pp. 288-294
[21]
I. Casado Martínez.
Análisis de los motivos de consulta en una consulta de Neurología de área en Asturias.
Neurología, 24 (2009), pp. 309-314
[22]
M.A. Martín Santidrian, M. Jimenez, G. Trejo, J.M. Galán.
Análisis descriptivo de la demanda asistencial neurológica ambulatoria en el área sanitaria de Burgos.
Neurología, 26 (2011), pp. 39-44
[23]
J. Matías-Guiu, J.J. Vílchez, R. Martín, A. Lago, J. Catalá, J. Morera.
por la Comisión de Análisis de la Calidad de la Sociedad Valenciana de Neurología.
Rev Neurol, 25 (1997), pp. 257-261
[24]
Gestión sanitaria y asistencia neurológica,
[25]
Ley 6/2009, de 16 de noviembre, de Libertad de Elección en la Sanidad de la Comunidad de Madrid. Boletín Oficial de la Comunidad de Madrid, número 274 de 18 de noviembre de 2009.
[26]
Decreto 51/2010, de 29 de julio, por el que se regula el ejercicio de la libertad de elección de médico de familia, pediatra y enfermero en Atención Primaria, y de hospital y médico en Atención Especializada en el Sistema Sanitario Público de la Comunidad de Madrid. Boletín Oficial de la Comunidad de Madrid, número 189 de 9 de agosto del 2010.
[27]
Decreto 52/2010, de 29 de julio, por el que se establecen las estructuras básicas sanitarias y directivas de Atención Primaria del Área Única de Salud de la Comunidad de Madrid. Boletín Oficial de la Comunidad de Madrid, número 189 de 9 de agosto del 2010.
[28]
R. Pineault, C. Daveluy.
La planificación sanitaria. Conceptos, métodos, estrategias.
Ed. Masson, (1989),
[29]
J. Escudero, M. Cano, I. Martínez Moreno.
Estudio comparativo entre la asistencia neurológica extrahospitalaria con el resto de especialidades médicas en el distrito sanitario de Xátiva.
Rev Neurol, 22 (1994), pp. 432-434
[30]
R. Martín, J.M. Delgado, R. Gómez, M.T. Puigcerver, J. Matías-Guiu.
La formación en neurología del médico general. Resultados de una encuesta realizada a 196 médicos de atención primaria.
Rev Neurol, 23 (1995), pp. 39-42
[31]
J. Morera-Guitart, M.A. Mas Servé, G. Mas Sesé.
Análisis de los pacientes no presentados a la consulta de neurología de La Marina Alta.
Rev Neurol, 34 (2002), pp. 701-705
[32]
C. Íñiguez-Martínez, P. Larrodé-Pellicer, J.A. Mauri-Llerda, S. Santos, C. Tejero-Juste, E. López-García, et al.
Evaluación de los pacientes no presentados a las consultas de neurología.
Rev Neurol, 37 (2003), pp. 1104-1106

Please cite this article as: Matías-Guiu JA, García-Azorín D, García-Ramos R, Basoco E, Elvira C, Matías-Guiu J. Estudio de la asistencia neurológica ambulatoria en la Comunidad de Madrid: impacto del modelo de libre elección de hospital. Neurología. 2015;30:479–487.

Copyright © 2014. Sociedad Española de Neurología
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos