[Political will and governance: keys to Implementing HEARTS in PeruVontade política e governança, chaves na Implementação da iniciativa HEARTS no Peru]. / La voluntad política y la gobernanza: claves en la implementación de HEARTS en el Perú.

The objective of this article is to describe how governance and political will have influenced the implementation of the HEARTS Initiative for the prevention and control of hypertension in the Peruvian health system.The governance process is described and a secondary data analysis compares baseline levels at the start of HEARTS phase 1 with observed levels after the first six months of follow-up in 34 health facilities.HEARTS implementation was planned and organized at the national level through the Directorate of Noncommunicable Diseases, with political support from senior management of the Ministry of Health and technical support from the Pan American Health Organization. Governance was structured at three levels: national, regional, and local; implementation was supported by key actors from academia, scientific societies, regional health directorates, and integrated networks.Results after the initial months of follow-up showed an increase in the coverage and control of hypertension in most of the participating facilities. Analysis of the key factors related to political will and governance in the implementation of the HEARTS Initiative for the prevention and control of hypertension showed that the functions of senior management-in terms of aligning public policies and prioritizing noncommunicable diseases, in close and permanent coordination between policymakers and the Minister of Health-had a positive effect on the implementation of the HEARTS Initiative in Peru.

O objetivo do artigo é descrever como a governança e a vontade política influenciaram a implementação da Iniciativa HEARTS para a prevenção e o controle da hipertensão arterial no sistema de saúde peruano.O processo de governança é descrito e uma análise de dados secundários é realizada comparando os níveis basais no início da fase 1 do HEARTS com os primeiros 6 meses de acompanhamento em 34 estabelecimentos de saúde.O planejamento e a organização da implementação do HEARTS foi realizado no nível nacional por meio da Diretoria de Doenças Não Transmissíveis, contando com a vontade política da alta direção do Ministério da Saúde e o apoio técnico da Organização Pan-Americana da Saúde. A governança foi estruturada em três níveis ­ nacional, regional e local ­ e a implementação contou com o apoio de atores importantes do meio acadêmico, das sociedades científicas, das diretorias regionais de saúde e das redes integradas.Os resultados encontrados após os primeiros meses de acompanhamento mostraram um aumento da cobertura e do controle da hipertensão arterial na maioria dos estabelecimentos nos quais a intervenção foi implementada. A análise dos principais fatores relacionados à vontade política e à governança na implementação da Iniciativa HEARTS para a prevenção e o controle da hipertensão arterial mostrou que a atuação da alta direção para alinhar as políticas públicas e priorizar as doenças não transmissíveis, em estreita e permanente articulação entre os formuladores de políticas e o Ministério da Saúde, teve um efeito positivo na implementação da Iniciativa HEARTS no Peru.

Comorbidity of dementia: a cross-sectional study of primary care older patients.

BACKGROUND: The epidemiologic study of comorbidities of an index health problem represents a methodological challenge. This study cross-sectionally describes and analyzes the comorbidities associated with dementia in older patients and reviews the existing similarities and differences between identified comorbid diseases using the statistical methods most frequently applied in current research. METHODS: Cross-sectional study of 72,815 patients over 64 seen in 19 Spanish primary care centers during 2008. Chronic diseases were extracted from electronic health records and grouped into Expanded Diagnostic Clusters®. Three different statistical methods were applied (i.e., analysis of prevalence data, multiple regression and factor analysis), stratifying by sex. RESULTS: The two most frequent comorbidities both for men and women with dementia were hypertension and diabetes. Yet, logistic regression and factor analysis demonstrated that the comorbidities significantly associated with dementia were Parkinson's disease, congestive heart failure, cerebrovascular disease, anemia, cardiac arrhythmia, chronic skin ulcers, osteoporosis, thyroid disease, retinal disorders, prostatic hypertrophy, insomnia and anxiety and neurosis. CONCLUSIONS: The analysis of the comorbidities associated with an index disease (e.g., dementia) must not be exclusively based on prevalence rates, but rather on methodologies that allow the discovery of non-random associations between diseases. A deep and reliable knowledge about how different diseases are grouped and associated around an index disease such as dementia may orient future longitudinal studies aimed at unraveling causal associations.

Priorities to reduce the burden of stroke in Latin American countries.

The large and increasing burden of stroke in Latin American countries, and the need to meet the UN and WHO requirements for reducing the burden from non-communicable disorders (including stroke), brought together stroke experts and representatives of the Ministries of Health of 13 Latin American countries for the 1st Latin American Stroke Ministerial meeting in Gramado, Brazil, to discuss the problem and identify ways of cooperating to reduce the burden of stroke in the region. Discussions were focused on the regional and country-specific activities associated with stroke prevention and treatment, including public stroke awareness, prevention strategies, delivery and organisation of care, clinical practice gaps, and unmet needs. The meeting culminated with the adoption of the special Gramado Declaration, signed by all Ministerial officials who attended the meeting. With agreed priorities for stroke prevention, treatment, and research, an opportunity now exists to translate this Declaration into an action plan to reduce the burden of stroke.

La voluntad política y la gobernanza: claves en la implementación de HEARTS en el Perú / Political will and governance: keys to Implementing HEARTS in Peru / Vontade política e governança, chaves na Implementação da iniciativa HEARTS no Peru

RESUMEN El objetivo del artículo es describir cómo la gobernanza y la voluntad política han influido en la implementación de la Iniciativa HEARTS para la prevención y el control de la hipertensión arterial en el sistema de salud de Perú. Se describe el proceso de gobernanza y se realiza un análisis secundario de datos que compara los niveles basales al inicio de la fase 1 de HEARTS con los primeros seis meses de seguimiento en 34 establecimientos de salud. Se realizó la planificación y organización de la implementación de HEARTS desde el nivel nacional a través de la Dirección de Enfermedades No Transmisibles, contando con la voluntad política de la Alta dirección del Ministerio de Salud y el acompañamiento técnico de la Organización Panamericana de la Salud. La gobernanza se estructuró en 3 niveles: nacional, regional y local; la implementación se apoyó en actores claves de la academia, las sociedades científicas y las Direcciones Regionales de Salud y de las Redes Integrales. Los resultados encontrados tras los primeros meses de seguimiento evidenciaron un incremento de la cobertura y el control de la hipertensión arterial en la mayoría de los establecimientos intervenidos. El análisis de los factores claves relacionados con la voluntad política y la gobernanza en la implementación de la Iniciativa HEARTS para la prevención y el control de la hipertensión arterial demostró que las funciones de la Alta dirección, para alinear las políticas públicas y priorizar las enfermedades no trasmisibles, en coordinación estrecha y permanente entre los formuladores de política y el Ministro de Salud, tuvieron un efecto positivo en la implementación de la Iniciativa HEARTS en el Perú.

ABSTRACT The objective of this article is to describe how governance and political will have influenced the implementation of the HEARTS Initiative for the prevention and control of hypertension in the Peruvian health system. The governance process is described and a secondary data analysis compares baseline levels at the start of HEARTS phase 1 with observed levels after the first six months of follow-up in 34 health facilities. HEARTS implementation was planned and organized at the national level through the Directorate of Noncommunicable Diseases, with political support from senior management of the Ministry of Health and technical support from the Pan American Health Organization. Governance was structured at three levels: national, regional, and local; implementation was supported by key actors from academia, scientific societies, regional health directorates, and integrated networks. Results after the initial months of follow-up showed an increase in the coverage and control of hypertension in most of the participating facilities. Analysis of the key factors related to political will and governance in the implementation of the HEARTS Initiative for the prevention and control of hypertension showed that the functions of senior management—in terms of aligning public policies and prioritizing noncommunicable diseases, in close and permanent coordination between policymakers and the Minister of Health—had a positive effect on the implementation of the HEARTS Initiative in Peru.

RESUMO O objetivo do artigo é descrever como a governança e a vontade política influenciaram a implementação da Iniciativa HEARTS para a prevenção e o controle da hipertensão arterial no sistema de saúde peruano. O processo de governança é descrito e uma análise de dados secundários é realizada comparando os níveis basais no início da fase 1 do HEARTS com os primeiros 6 meses de acompanhamento em 34 estabelecimentos de saúde. O planejamento e a organização da implementação do HEARTS foi realizado no nível nacional por meio da Diretoria de Doenças Não Transmissíveis, contando com a vontade política da alta direção do Ministério da Saúde e o apoio técnico da Organização Pan-Americana da Saúde. A governança foi estruturada em três níveis - nacional, regional e local - e a implementação contou com o apoio de atores importantes do meio acadêmico, das sociedades científicas, das diretorias regionais de saúde e das redes integradas. Os resultados encontrados após os primeiros meses de acompanhamento mostraram um aumento da cobertura e do controle da hipertensão arterial na maioria dos estabelecimentos nos quais a intervenção foi implementada. A análise dos principais fatores relacionados à vontade política e à governança na implementação da Iniciativa HEARTS para a prevenção e o controle da hipertensão arterial mostrou que a atuação da alta direção para alinhar as políticas públicas e priorizar as doenças não transmissíveis, em estreita e permanente articulação entre os formuladores de políticas e o Ministério da Saúde, teve um efeito positivo na implementação da Iniciativa HEARTS no Peru.

Multimorbidity patterns: a systematic review.

OBJECTIVES: The aim of this review was to identify studies on patterns of associative multimorbidity, defined as the nonrandom association between diseases, focusing on the main methodological features of the studies and the similarities among the detected patterns. STUDY DESIGN AND SETTING: Studies were identified through MEDLINE and EMBASE electronic database searches from their inception to June 2012 and bibliographies. RESULTS: The final 14 articles exhibited methodological heterogeneity in terms of the sample size, age and recruitment of study participants, the data source, the number of baseline diseases considered, and the statistical procedure used. A total of 97 patterns composed of two or more diseases were identified. Among these, 63 patterns were composed of three or more diseases. Despite the methodological variability among studies, this review demonstrated relevant similarities for three groups of patterns. The first one comprised a combination of cardiovascular and metabolic diseases, the second one was related with mental health problems, and the third one with musculoskeletal disorders. CONCLUSION: The existence of associations beyond chance among the different diseases that comprise these patterns should be considered with the aim of directing future lines of research that measure their intensity, clarify their nature, and highlight the possible causal underlying mechanisms.