Letter to the Editor
Introducing a neurology department at a local hospital
Introducción de Neurología en un hospital comarcal
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Gros Bañeres, A. Herrer Castejón, C. Ascaso Martorell, V. Bertol Alegre" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Gros Bañeres" "email" => array:1 [ 0 => "mbgros@salud.aragon.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Herrer Castejón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Ascaso Martorell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "V." "apellidos" => "Bertol Alegre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Introducción de Neurología en un hospital comarcal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It was with great interest that we read the article by Martínez Fernández et al. titled “Impact of introducing neurology into a local hospital in Andalusia”.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">As described in the article, the main purpose of Spain's stroke care plan is to create an organised stroke care system to respond to each patient's needs and optimise the use of healthcare resources so as to guarantee an equal care for all stroke patients. The stroke care strategy adopted by Spain's National Health System (SNS), and those of each autonomous community, are responsible for implementing this plan.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> The main purpose of these programmes and their ‘process-based management’ is to offer comprehensive and interdisciplinary patient-focused care. The aim is to draft guidelines and protocols unifying healthcare practices so that patients receive the same quality of care regardless of the location and the attending medical personnel. Equal care is achieved in this way since not every patient can be cared for by the most qualified specialist in each specific illness anywhere in Spain and at any point during the process.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a> However, both the design and the conclusions from this study warrant comment. In an evaluation of care for stroke patients, doctors did not assess NIHSS scores, course of stroke, or patient comorbidity; the latter is a fundamental factor in the decision of whether to refer patients to the internal medicine or the neurology department, and comorbidity also plays a crucial role in all study parameters (mean stay, mortality, dependence, and institutionalisation).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Results show that patients not referred to the neurology department were a mean of 10 years older than the other group, which is indicative of higher comorbidity. Although the isolated effect of age was assessed when the variable was included in the multivariate analysis, this was not the case for intercurrent diseases, which were not studied.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is surprising that relative risk of death would be 8 times higher in patients <span class="elsevierStyleItalic">not</span> attended by neurologists; if this were really true, it would point to a severe problem for stroke care in the hospital in question.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Confounding or interaction factors were not assessed for any variables, referring to both study variables and the comorbidities omitted by the study. However, both age and comorbidities can act as confounding or interaction factors and may consequently modify odds ratios in both directions, and especially the OR of the main factor in this study, neurological care. By this logic, neurological care may improve outcomes in patients without comorbidities but not those with comorbidities, or vice versa.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition, it is surprising that the factor ‘neurological care’ was coded to yield an OR<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1; interpreting OR magnitude for a protective factor is difficult, and therefore using its inverse and temporarily recoding the variable is recommendable.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Odds ratios for mortality and dependency with neurological care are 0.04 and 0.14, respectively; the OR for mean stay is not mentioned and the variable has no significant effect on institutionalisation. These are minimum values that may be negligible for practical purposes, mainly because Nagelkerke's <span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span> value is not included in the results.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our opinion, despite this being a very interesting study that required painstaking data collection, its conclusions may be spurious because the data mentioned above were not assessed.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gros Bañeres B, Herrer Castejón A, Ascaso Martorell C, Bertol Alegre V. Introducción de Neurología en un hospital comarcal. Neurología. 2014;29:184–185.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Repercusión de la introducción de neurología en un hospital comarcal de Andalucía" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Martínez Fernández" 1 => "G. Sanz Fernández" 2 => "A. 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Álvarez Sabín" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Inv Clin Farm" "fecha" => "2004" "volumen" => "1" "paginaInicial" => "39" "paginaFinal" => "46" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ministerio de Sanidad y Política Social" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Estrategia en ictus del Sistema Nacional de Salud" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2008" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Regresión logística binaria, multinomial, de Poisson y binomial negativa" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.M. Doménech Massons" 1 => "J.B. Navarro Pastor" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "isbn" => "8480495103" "fecha" => "2007" "paginaInicial" => "275" "editorial" => "Barcelona, Signo" "editorialLocalizacion" => "Metodología de la investigación en ciencias de la salud" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735808/0000002900000003/v1_201404040032/S2173580814000212/v1_201404040032/en/main.assets" "Apartado" => array:4 [ "identificador" => "17109" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "CO1" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735808/0000002900000003/v1_201404040032/S2173580814000212/v1_201404040032/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580814000212?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 10 | 7 | 17 |
| 2024 September | 8 | 6 | 14 |
| 2024 August | 11 | 1 | 12 |
| 2024 July | 15 | 4 | 19 |
| 2024 June | 23 | 4 | 27 |
| 2024 May | 32 | 3 | 35 |
| 2024 April | 40 | 2 | 42 |
| 2024 March | 38 | 9 | 47 |
| 2024 February | 41 | 8 | 49 |
| 2024 January | 25 | 5 | 30 |
| 2023 December | 18 | 3 | 21 |
| 2023 November | 16 | 11 | 27 |
| 2023 October | 14 | 13 | 27 |
| 2023 September | 11 | 4 | 15 |
| 2023 August | 12 | 6 | 18 |
| 2023 July | 15 | 7 | 22 |
| 2023 June | 22 | 5 | 27 |
| 2023 May | 19 | 2 | 21 |
| 2023 April | 19 | 0 | 19 |
| 2023 March | 17 | 7 | 24 |
| 2023 February | 11 | 1 | 12 |
| 2023 January | 8 | 7 | 15 |
| 2022 December | 13 | 4 | 17 |
| 2022 November | 15 | 9 | 24 |
| 2022 October | 9 | 6 | 15 |
| 2022 September | 15 | 9 | 24 |
| 2022 August | 13 | 11 | 24 |
| 2022 July | 15 | 17 | 32 |
| 2022 June | 17 | 3 | 20 |
| 2022 May | 11 | 8 | 19 |
| 2022 April | 6 | 6 | 12 |
| 2022 March | 13 | 5 | 18 |
| 2022 February | 9 | 4 | 13 |
| 2022 January | 12 | 6 | 18 |
| 2021 December | 11 | 10 | 21 |
| 2021 November | 11 | 8 | 19 |
| 2021 October | 12 | 5 | 17 |
| 2021 September | 13 | 8 | 21 |
| 2021 August | 10 | 10 | 20 |
| 2021 July | 12 | 7 | 19 |
| 2021 June | 11 | 11 | 22 |
| 2021 May | 15 | 6 | 21 |
| 2021 April | 30 | 25 | 55 |
| 2021 March | 13 | 12 | 25 |
| 2021 February | 9 | 6 | 15 |
| 2021 January | 9 | 11 | 20 |
| 2020 December | 11 | 8 | 19 |
| 2020 November | 9 | 2 | 11 |
| 2020 October | 5 | 4 | 9 |
| 2020 September | 13 | 5 | 18 |
| 2020 August | 11 | 9 | 20 |
| 2020 July | 5 | 12 | 17 |
| 2020 June | 6 | 7 | 13 |
| 2020 May | 7 | 11 | 18 |
| 2020 April | 7 | 3 | 10 |
| 2020 March | 5 | 0 | 5 |
| 2020 February | 8 | 5 | 13 |
| 2020 January | 5 | 13 | 18 |
| 2019 December | 12 | 3 | 15 |
| 2019 November | 8 | 6 | 14 |
| 2019 October | 1 | 4 | 5 |
| 2019 September | 7 | 1 | 8 |
| 2019 August | 5 | 3 | 8 |
| 2019 July | 16 | 8 | 24 |
| 2019 June | 22 | 26 | 48 |
| 2019 May | 48 | 72 | 120 |
| 2019 April | 6 | 8 | 14 |
| 2019 March | 3 | 5 | 8 |
| 2019 February | 9 | 6 | 15 |
| 2019 January | 6 | 11 | 17 |
| 2018 December | 3 | 5 | 8 |
| 2018 November | 7 | 5 | 12 |
| 2018 October | 10 | 5 | 15 |
| 2018 September | 7 | 2 | 9 |
| 2018 August | 9 | 10 | 19 |
| 2018 July | 3 | 1 | 4 |
| 2018 June | 0 | 0 | 0 |
| 2018 May | 6 | 1 | 7 |
| 2018 April | 4 | 1 | 5 |
| 2018 March | 4 | 0 | 4 |
| 2018 February | 0 | 2 | 2 |
| 2018 January | 6 | 2 | 8 |
| 2017 December | 3 | 0 | 3 |
| 2017 November | 2 | 1 | 3 |
| 2017 October | 8 | 2 | 10 |
| 2017 September | 4 | 0 | 4 |
| 2017 August | 12 | 1 | 13 |
| 2017 July | 7 | 2 | 9 |
| 2017 June | 6 | 2 | 8 |
| 2017 May | 11 | 2 | 13 |
| 2017 April | 6 | 2 | 8 |
| 2017 March | 4 | 1 | 5 |
| 2017 February | 9 | 1 | 10 |
| 2017 January | 5 | 2 | 7 |
| 2016 December | 8 | 3 | 11 |
| 2016 November | 5 | 2 | 7 |
| 2016 October | 8 | 3 | 11 |
| 2016 September | 10 | 5 | 15 |
| 2016 August | 4 | 1 | 5 |
| 2016 July | 7 | 1 | 8 |
| 2016 June | 15 | 4 | 19 |
| 2016 May | 9 | 7 | 16 |
| 2016 April | 13 | 7 | 20 |
| 2016 March | 19 | 16 | 35 |
| 2016 February | 14 | 11 | 25 |
| 2016 January | 5 | 2 | 7 |
| 2015 December | 13 | 5 | 18 |
| 2015 November | 18 | 4 | 22 |
| 2015 October | 15 | 7 | 22 |
| 2015 September | 9 | 6 | 15 |
| 2015 August | 11 | 1 | 12 |
| 2015 July | 10 | 5 | 15 |
| 2015 June | 1 | 1 | 2 |
| 2015 May | 13 | 1 | 14 |
| 2015 April | 12 | 3 | 15 |
| 2015 March | 15 | 9 | 24 |
| 2015 February | 11 | 3 | 14 |
| 2015 January | 34 | 7 | 41 |
| 2014 December | 29 | 9 | 38 |
| 2014 November | 12 | 3 | 15 |
| 2014 October | 21 | 6 | 27 |
| 2014 September | 28 | 7 | 35 |
| 2014 August | 25 | 7 | 32 |
| 2014 July | 26 | 8 | 34 |
| 2014 June | 21 | 6 | 27 |
| 2014 May | 27 | 10 | 37 |
| 2014 April | 31 | 14 | 45 |
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