This study has provided insights into the strengths and limitations of two new eHealth services for use across countries within the European Union, and has provided indications of how those services could be improved.

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INTRODUCCIÓNLos CP han demostrado su eficacia a la hora de aumentar la calidad de vida de los pacientes oncológicos en SCET y son plenamente aceptados y valorados positivamente tanto por ellos como por sus familias (1). Sin embargo está demostrado que los pacientes con enfermedades crónicas no oncológicas en fase terminal presentan un grado de distress sintomático [0212-7199 (2008) (Madrid) 2008; 25: 187-191. RESUMENEn la actualidad la Medicina Paliativa (MP) está cambiando desde una visión específica dirigida a los pacientes con cáncer avanzado hacia otra más genérica que abarca también a los pacientes con enfermedades avanzadas no malignas. También está cada vez más arraigado que los cuidados al final de la vida constituyen un derecho fundamental de la sociedad. Pero en realidad estos pacientes no oncológicos excepcionalmente entran en programas de Cuidados Paliativos (CP). Se sabe que es por la dificultad en diagnosticar la situación clínica de enfermedad terminal (SCET). En el presente artículo comentaremos la justificación y limitación de los CP en los pacientes no oncológicos así como la situación paradójica que tiene lugar a pesar del incremento paulatino de los programas de cuidados paliativos. Pero sobre todo proponemos una manera práctica de poder determinar cuando un paciente con enfermedad avanzada de órgano no maligna puede ser subsidiario de unos adecuados CP. Para ello tenemos que conocer el diagnóstico y los factores pronósticos relacionados con la SCET de las patologías crónicas avanzadas de órga-no más frecuentes (enfermedad pulmonar crónica avanzada, insuficiencia cardiaca crónica avanzada, cirrosis hepática avanzada, insuficiencia renal crónica avanzada y demencias muy evolucionadas), establecer una adecuada toma de decisiones teniendo en cuenta las preferencias o deseos del paciente y familia, documentar y registrar en la historia clínica todos estos parámetros y ofrecer al paciente el tratamiento más adecuado con el fin de conseguir una muerte digna y considerando unos estándares clínicos, culturales y éticos.Se destaca la necesidad de llevar a cabo estudios prospectivos que ayuden a establecer unos criterios de inclusión en programas de CP a pacientes con enfermedades avanzadas de órgano no malignas.

Background: most studies that analyze the influence of structure factors on clinical outcomes are retrospective, based on clinical-administrative databases, and mainly focusing on surgical volume.Objective: to study variations in the process and outcomes of oncologic surgery for esophagus, stomach, pancreas, liver metastases and rectum cancers in Catalonia, as well as the factors associated with these variations.Patients and method: a retrospective (2002) and prospective (2003-05) multicenter cohort study. Data forms were designed to collect patient, process, and care outcome characteristics before surgery, at hospital discharge, and at 3 and 6 months after discharge. Main outcome measures were hospital and followup mortality, complications, re-interventions, and relapse rates.Results: 49 hospitals (80%) participated in the retrospective phase, 44 of which (90%) also participated in the prospective phase: 3,038 patients (98%) were included. No differences were observed in the profile of operated patients according to hospital level of complexity, but clinical-pathological staging and other functional status variables could not be assessed because of over 20% of missing values. There was significant variability in the volume of interventions as well as in certain aspects of the healthcare process depending on type of cancer and center complexity. High rates of esophageal cancer mortality (18.2% at discharge, 27.3% at 6 months) and of complications and re-interventions for all cancers assessed, especially rectal cancer (18.4% re-interventions at 6 months), were identified.Conclusions: the study of the variability identified will require adequate risk-adjustment and should take into account different structure factors. It is necessary that information included in medical records be improved.Key words: Digestive cancer. Surgery. Medical practice variations. Structure, process, and outcomes of care. INTRODUCTIONOne of the aspects that is most debated in oncologic surgery and other fields (both surgical and medical procedures) is the relationship between the volume of patients having undergone surgery and clinical outcomes. It has been 30 years since the relationship between increased volume and improved outcomes was described (1). However, this relationship is not always observed, and the reasons why it occurs remain unknown. Several hypotheses, especially relating to surgeon-related technical factors (2-6), have been considered. However, if better outcomes are obtained in several different procedures or pathologies, healthcare organization and coordination factors should also be sought. This may be especially useful in the case of oncology, where it is necessary for professionals from different specialties to work together in tackling with diagnosis and treatment: surgery, oncology, as well as the site's central and general services.Most studies that have analyzed the influence of these physician-/center-related factors, particularly volume, on the variability of the process and outcome of cancer surgery are retrosp...