Editorial
Quick Diagnosis Units: Towards the standardization and expansion to the National Health System
Unidades de Diagnóstico Rápido: de la necesidad evidenciada por una crisis económica y una pandemia a su estandarización y extensión
Elisabet Montori-Palacín, Xavier Bosch
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Unitat de Diagnòstic Ràpid, Servei de Medicina Interna, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Even before the economic crisis of 2008, but especially since then, alternatives have been sought to ensure the sustainability of the system. When one studies the items on which most resources are spent, hospitalisation is one of the most important. It is for this reason that, with the prospect of excessive hospital expenditure, alternatives to conventional medicine, which is centred on hospitalisation, have been implemented. A well-established example is major outpatient surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cancer accounts for one in every 5 deaths of adult individuals in developed countries. In Spain, cancer is the second leading cause of overall mortality, being the first in men and the second in women (after death from cardiovascular causes).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Studies suggest that diagnosis in the early stages of the disease is important to improve survival.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> It is for this reason that early detection programmes have been created for the diagnosis of asymptomatic patients (breast cancer, colorectal cancer), as well as initiatives to promote the early identification of the oligosymptomatic patient.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In Catalonia there are diagnostic circuits for patients with certain clinical manifestations of cancer, with quality commitments established by CatSalut, based on diagnostic time and time to initiation of treatment. In this sense, some hospitals have functional units by organ (lung, breast, colon, bladder and prostate cancers) with their own structures and groups of specialists. However, there are also functional units distributed in numerous Catalan hospitals that allow for the prioritisation of the diagnosis of patients with other types of cancer that manifest in the form of specific symptoms of a given origin or in the form of non-specific symptoms. Although they have not yet been accredited by official public bodies, the purpose of these Quick Diagnosis Units is to speed up the diagnosis of patients with symptoms suggestive of potentially serious disease, such as cancer (although not only cancer), prioritising the scheduling of the complementary examinations necessary to reach a final diagnosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The first Quick Diagnosis Unit in Catalonia was created in 1996 at the General Hospital of Granollers. Over the years, this model has spread throughout Catalonia, but there is not much literature on the subject. Where there is extensive literature is in England, where a large number of studies have been conducted that support the importance of rapid diagnosis in patients who come to primary care centres with specific cancer symptoms or <span class="elsevierStyleItalic">red-flag symptoms.</span> At the beginning of the century, the British public health system and, specifically, The National Institute for Health and Care Excellence (NICE), designed the first guidelines with recommendations for patients with symptoms suggestive of cancer assessed by <span class="elsevierStyleItalic">general practitioners.</span> These recommendations are organised not only on the basis of the symptoms experienced by the patient, but also the type of cancer and require referral to hospital within a maximum of 2 weeks when symptoms have a positive predictive value for cancer greater than or equal to 3%,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Since some cancers, e.g. malignant tumours of the central nervous system, pancreatic, gastric and ovarian cancers, and some haematological malignancies, especially multiple myeloma, manifest mostly with non-specific symptoms, the national systems in Denmark and, more recently, England, have introduced devices that allow the necessary diagnostic tests to rule out such an eventuality.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The scientific evidence in our setting regarding the importance of Quick Diagnosis Units in the healthcare model is limited, with most of the studies conducted by our group at Hospital Clínic de Barcelona. The first national publication, which appeared in <span class="elsevierStyleSmallCaps">Medicina Clínica</span> in 2004, was a descriptive article on the model created at the Hospital General de Granollers in 1996.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In a subsequent study, the Quick Diagnosis Unit of the Hospital General de Granollers was compared with the unit of the Hospital Clínic, showing an absence of significant differences in performance through indicators such as diagnostic time.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Another study based on a micro-cost analysis of the Quick Diagnosis Unit of the Hospital de Bellvitge suggested that, for each pathology, the outpatient study was more cost-effective than the inpatient study.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Subsequently, the caseload of the Quick Diagnosis Units of Hospital Clínic and Hospital Plató de Barcelona were compared, again with no significant differences in diagnostic performance indicators.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It was then demonstrated, in a study with real micro-costs, that the differences between the two were due to structural costs (high versus low complexity hospital), with the cost of imaging examinations being the main determinant of the cost per patient.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In Catalonia and elsewhere, there have also been Internal Medicine clinics equivalent to Quick Diagnosis Units, under different names, with the intention of carrying out the diagnostic study of potentially serious illness in the outpatient setting, guaranteeing adequate diagnostic times and with the consequent saving of hospital beds and economic resources,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–17</span></a> although it has not been possible to follow them up in the literature.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It should be noted that Quick Diagnosis Units are not only useful for the early diagnosis of cancer patients. It is well known that there are a significant number of organ diseases that, despite not having a cancer-related cause, require early diagnosis to facilitate treatment and, in some cases, improve prognosis, such as certain types of gastrointestinal diseases (inflammatory bowel disease), infectious diseases (subacute endocarditis, endovascular device infections, encapsulated collections), autoimmune diseases (vasculitis) or neurological diseases (demyelinating diseases). All of these also benefit from the existence of a circuit in which both complementary examinations and their results are expedited, with less delay in referral to the corresponding specialist.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10,12,14–18</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Studies conducted at the Quick Diagnosis Units of Hospital Clínic and Hospital de Bellvitge have also evaluated the patient's perceived experience or satisfaction with the care received, which is a relevant indicator of quality of care. These studies showed that patients with similar diseases evaluated on an outpatient basis in Quick Diagnosis Units as opposed to hospitalisation opted for the outpatient model in the majority of cases. The fact that no hospital admission was required for the diagnostic study was the main reason given by patients for their outpatient setting preference.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Despite all this, there is currently no inter-hospital register of the Quick Diagnosis Units in Catalonia, nor is there any comparative information on the functioning or results of each of them. This has implications in terms of equity in access to resources and speed of diagnosis and, by extension, in the establishment of treatment, especially in patients diagnosed with cancer. It is for this reason that the Catalan-Balearic Society of Internal Medicine has recently created a working group from which we intend to study and centralise the availability and operation of the different units within the territory and thus be able to standardise the resource, with the aim of benchmarking with equivalent facilities in the rest of Europe.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Ethical considerations</span><p id="par0055" class="elsevierStylePara elsevierViewall">Informed consent was not required for this article.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Ethical considerations" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estadística de Gasto Sanitario Público (EGSP)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.C. 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