Ética en investigación: Nuevos desafíos, ¿viejos dilemas? / Research Ethics: New challenges, old dilemmas?

Memoria de las ponencias del 1er Congreso de Ética en Investigación, realizado en la Ciudad de Buenos Aires en septiembre de 2022, y organizado por el Comité Central de Ética en Investigación del Ministerio de Salud de esta ciudad. Los dos ejes del Congreso fueron: Desafíos éticos en la investigación durante la pandemia y post-pandemia; y Aporte de las nuevas tecnologías para los procesos de investigación. Se presentan las ponencias del congreso, organizadas en los capítulos: El trabajo de los Comités de Ética en Investigación durante la pandemia; El rol de las comunidades en la investigación; Aporte de las nuevas tecnologías para los procesos de investigación; y Desafíos modernos para la investigación en salud.

Dissemination of public health research to prevent non-communicable diseases: a scoping review.

BACKGROUND: Dissemination is a critical element of the knowledge translation pathway, and a necessary step to ensure research evidence is adopted and implemented by key end users in order to improve health outcomes. However, evidence-based guidance to inform dissemination activities in research is limited. This scoping review aimed to identify and describe the scientific literature examining strategies to disseminate public health evidence related to the prevention of non-communicable diseases. METHODS: Medline, PsycInfo and EBSCO Search Ultimate were searched in May 2021 for studies published between January 2000 and the search date that reported on the dissemination of evidence to end users of public health evidence, within the context of the prevention of non-communicable diseases. Studies were synthesised according to the four components of Brownson and colleagues' Model for Dissemination of Research (source, message, channel and audience), as well as by study design. RESULTS: Of the 107 included studies, only 14% (n = 15) directly tested dissemination strategies using experimental designs. The remainder primarily reported on dissemination preferences of different populations, or outcomes such as awareness, knowledge and intentions to adopt following evidence dissemination. Evidence related to diet, physical activity and/or obesity prevention was the most disseminated topic. Researchers were the source of disseminated evidence in over half the studies, and study findings/knowledge summaries were more frequently disseminated as the message compared to guidelines or an evidence-based program/intervention. A broad range of dissemination channels were utilised, although peer-reviewed publications/conferences and presentations/workshops predominated. Practitioners were the most commonly reported target audience. CONCLUSIONS: There is a significant gap in the peer reviewed literature, with few experimental studies published that analyse and evaluate the effect of different sources, messages and target audiences on the determinants of uptake of public health evidence for prevention. Such studies are important as they can help inform and improve the effectiveness of current and future dissemination practices in public health contexts.

Implementation costs of telephone nurse triage service.

Telephone nurse triage services are becoming increasingly common in healthcare systems worldwide. Florianópolis (Santa Catarina State, Brazil) is the first municipality in the country to provide this service in its public health system. This study adopted a quantitative, descriptive, and analytical methodology to evaluate the impact of this program on overall costs of the public health system. The research examined all 33,869 calls received by the telephone triage service from March 16 to October 31 in 2020, and calculated the program costs during the period. Avoided cost were calculated by the difference between estimated consultation costs considering patient-stated first alternative and the program recommendation after triage. Analyzing only the costs for the municipality of Florianópolis, the program's costs exceeded avoided costs by almost BRL 2.5 million during the period. By expanding the analysis to include costs of emergency department consultation - not administered by the municipality - based on data from previous research, we found that the program spares BRL 34.59 per call, a 21% cost reduction for the health system. Considering the preliminary results of the study and its limitations, it is understood that the service of telephone nurse triage can reduce costs in the healthcare system.

Las Investigaciones en Servicios y Sistemas de Salud, instrumento de gestión en la atención sanitaria / Research in Health Services and Systems, a management tool in health care

Mejorar los procesos de atención en los servicios sanitarios es una prioridad del Ministerio de Salud Pública en Cuba y la Investigación en Servicios y Sistemas de Salud. Las proyecciones en este campo pueden estar dirigidas a la descripción de problemas de salud y de los servicios, la evaluación de intervenciones en salud (promoción, prevención, curación y rehabilitación) y las enfocadas en determinar situaciones problemáticas surgidas en la aplicación de actividades sanitarias con el objetivo de analizar las causas posibles y encontrar soluciones. Las investigaciones en servicios y sistemas de salud facilitan la planificación, organización, evaluación y control de los servicios y aportan evidencias para la dirección científica del sistema de Salud, por lo que el objetivo del artículo es analizar los aspectos metodológicos y organizacionales de las Investigaciones en Servicios y Sistemas de Salud y posibilitar la participación de los profesionales y directivos de múltiples disciplinas que propician la intersectorialidad.

Improving care processes in health services is a priority of the Ministry of Public Health in Cuba and Research in Health Services and Systems. The projections in this field can be aimed at the description of health problems and services, the evaluation of health interventions (promotion, prevention, cure, and rehabilitation) and those focused on determining problematic situations that arise in the application of health activities with the objective of analyzing the possible causes and finding solutions. Research in health services and systems facilitate the planning, organization, evaluation, and control of services and provide evidence for the scientific direction of the health system, so the objective of the article is to analyze the methodological and organizational aspects of Research in Health Services and Systems and enable the participation of professionals and managers from multiple disciplines that foster intersectoriality.

Entrevista com Ana Paula Cupertino / Interview with Ana Paula Cupertino

Resumo Nesta entrevista à revista Saúde e Sociedade, a Dra. Cupertino faz um relato do seu engajamento para alcançar pessoas em situações desafiadoras como a pandemia de covid-19. O diálogo buscou conhecer experiências exitosas capazes de interromper ou reduzir a perpetuação das disparidades em saúde. Em sua trajetória profissional, perpassou pelo Instituto de Câncer de Wilmot (WIC), onde atua no momento, sempre apoiada em referências brasileiras importantes como Paulo Freire. No seu trabalho, percebe-se a utilização de estratégias que ultrapassam questões acadêmicas e trazem a comunidade para o protagonismo da pesquisa, permitindo que o processo de translação ocorra apropriadamente. Por fim, define as parcerias com países da América Latina como fundamentais para o desenvolvimento de ações de saúde direcionadas a imigrantes que vivem nos Estados Unidos, uma vez que a variável relações sociais é determinante para a saúde de uma comunidade. A fala da Dra. Cupertino revela, assim, um olhar distinto sobre realidades distantes, mas que podem contribuir para reflexões importantes em um mundo globalizado, no qual intercâmbios são cada vez mais frequentes.

Abstract In this interview with the journal Saúde e Sociedade, Dr. Cupertino talks about her actions to reach people under challenging situations, such as the COVID-19 pandemic. The dialogue aimed to learn about successful experiences capable of erasing or reducing the perpetuation of health disparities. In her professional career, she worked at the Wilmot Cancer Institute (WIC), her current employer, always supported by important Brazilian references such as Paulo Freire. Her research work uses strategies that go beyond academic issues and bring the community to the forefront, enabling an accurate translation process. Finally, she considers the partnerships with Latin American countries as fundamental for developing health actions towards immigrants living in the United States, since the social relations variable is crucial for community health. Dr. Cupertino's testimony thus reveals a distinct look at distant realities, which can contribute to important reflections in a globalized world where exchanges are increasingly frequent.

The Roles of Regional Organisations in Strengthening Health Research Systems in Africa: Activities, Gaps, and Future Perspectives.

BACKGROUND: Regional cooperation on health in Africa is not new. The institutional landscape of regional cooperation for health and health research, however, has seen important changes. Recent health emergencies have focussed regional bodies' attention on supporting aspects of national health preparedness and response. The state of national health research systems is a key element of capacity to plan and respond to health needs - raising questions about the roles African regional bodies can or should play in strengthening health research systems. METHODS: We mapped regional organisations involved in health research across Africa and conducted 18 interviews with informants from 15 regional organisations. We investigated the roles, challenges, and opportunities of these bodies in strengthening health research. We deductively coded interview data using themes from established pillars of health research systems - governance, creating resources, research production and use, and financing. We analysed organisations' relevant activities in these areas, how they do this work, and where they perceive impact. RESULTS: Regional organisations with technical foci on health or higher education (versus economic or political remits) were involved in all four areas. Most organisations reported activities in governance and research use. Involvement in governance centred mainly around agenda-setting and policy harmonisation. For organisations involved in creating resources, activities focused on strengthening human resources, but few reported developing research institutions, networks, or infrastructure. Organisations reported more involvement in disseminating than producing research. Generally, few have directly contributed to financing health research. Informants reported gaps in research coordination, infrastructure, and advocacy at regional level. Finally, we found regional bodies' mandates, authority, and collaborations influence their activities in supporting national health research systems. CONCLUSION: Continued strengthening of health research on the African continent requires strategic thinking about the roles, comparative advantages, and capability of regional organisations to facilitate capacity and growth of health research systems.

Reflections from the COVID-19 pandemic on inequalities and patient and public involvement and engagement (PPIE) in social care, health and public health research.

Patient and public involvement and engagement (PPIE) has evolved to become widely established practice in social care, health and public health research in the UK. The COVID-19 pandemic has caused rapid change in practice in PPIE, notably in moving from face-to-face meetings to virtual ones. This has opened a space for reflecting on established PPIE practice, but there is a risk this is conducted too narrowly, such as only weighing our preferences and the relative pros and cons with regard to in-person versus virtual meetings. The pandemic has also demonstrated the wide inequalities in society, and hence, we argue that an inequalities lens ought to guide a deeper and wider reflection on PPIE practice. We do not seek to criticize practice pre- or during the pandemic, but to encourage using the inequalities lens as a means of encouraging debate and focusing energy on a more rigorous review of PPIE practice to widen involvement in social care, health and public health research.

Epidemiological Analysis of 37,424 Carotid Artery Stenosis Intervention Procedures During 11 Years in the Public Health System in Brazil: Stenting has Been More Common Than Endarterectomy.

BACKGROUND: Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10-20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large-scale results of carotid bifurcation surgery in Brazil. METHODS: This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases. RESULTS: Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008). CONCLUSIONS: In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS.

Operationalizing the Ethical Review of Global Health Policy and Systems Research: A Proposed Checklist.

There has been growing consensus to develop relevant guidance to improve the ethical review of global health policy and systems research (HPSR) and address the current absence of formal ethics guidance.

Real-World Health-Economic Considerations Around Aortic-Valve Replacement in a Publicly Funded Health System.

Herein, we describe the unique interplay among biomedical ethics, principles of distributive justice, and economic theory to highlight the role of health technology assessments to compare therapeutic options for aortic valve replacement. From the perspective of the Canadian health care system, transcatheter aortic-valve implantation is associated with higher costs but also higher incremental health benefits compared with surgical aortic-valve replacement. At current willingness to pay thresholds, transcatheter aortic-valve replacement is likely cost effective across the spectrum of risk, from inoperable patients to those at low surgical risk. However, we highlight the nuances within each subgroup of surgical risk that merit careful consideration by the heart team. Moreover, incorporation of patients and their preferences in decision-making is key. In particular, in young, low-risk patients, there remains uncertainty regarding the optimal treatment, with unique concerns around valve durability, selection of valve prosthesis, and consideration for special procedures such as the Ross procedure. Nonetheless, current research suggests that, universally, patients prefer a less invasive approach compared with a more invasive approach. Finally, we highlight that there remain critical issues around timeliness of access to care and unacceptable geographic inequities across Canada. Further research into alternative funding mechanisms and integrated cross-sector care pathways is necessary to address these issues.

Lower Limb Revascularization for Peripheral Arterial Disease in 10,951 Procedures over 11 years in a Public Health System: A Descriptive Analysis of the Largest Brazilian City.

BACKGROUND: Worldwide, peripheral arterial disease (PAD) is a disease with high morbidity, affecting more than 200 million people. Our objective was to analyze the surgical treatment for PAD performed in the Unified Health System of the city of São Paulo during the last 11 years based on publicly available data. METHODS: The study was conducted with data analysis available on the TabNet platform, belonging to the DATASUS. Public data (government health system) from procedures performed in São Paulo between 2008 and 2018 were extracted. Sex, age, municipality of residence, operative technique, number of surgeries (total and per hospital), mortality during hospitalization, mean length of stay in the intensive care unit and amount paid by the government system were analyzed. RESULTS: A total of 10,951 procedures were analyzed (either for claudicants or critical ischemia-proportion unknown); 55.4% of the procedures were performed on males, and in 50.60%, the patient was older than 65 years. Approximately two-thirds of the patients undergoing these procedures had residential addresses in São Paulo. There were 363 in-hospital deaths (mortality of 3.31%). The hospital with the highest number of surgeries (n = 2,777) had lower in-hospital mortality (1.51%) than the other hospitals. A total of $20,655,272.70 was paid for all revascularizations. CONCLUSIONS: Revascularization for PAD treatment has cost the government system more than $20 million over 11 years. Endovascular surgeries were performed more often than open surgeries and resulted in shorter hospital stays and lower perioperative mortality rates.

Impact of Non-Weighting in the Analysis of Data Obtained from Complex Samples

Abstract Objective: To compare the estimates obtained, considering or not the weighting data. Material and Methods: Secondary data from the Oral Health Survey of the State of São Paulo (SBSP2015) was used for calculation of mean estimates, standard errors of the mean and confidence intervals (CI) for the DMFT index and components (decayed, lost and filled), in the age group of 35-44 years. Multiple logistic regression models were estimated, considering or not the weighting from the sampling plan (p<0.05). Results: It was observed that the estimates of the DMFT index and the carious component did not vary much when the design was considered or not (1.1% and 2.0%, respectively). However, the data referring to the lost and filled component showed greater differences between the values of the means. The averages fluctuated up and down by up to 6.7% for weighted versus unweighted analyses. The standard error was underestimated in the unweighted analysis and the confidence interval showed variations. Differences between the regression models obtained by the weighted and unweighted analysis of the data were detected. Conclusion: Although weighted and unweighted models presented differences of less than 10% in estimates of the mean, confidence intervals, as well as statistical inferences, were different. Thus, weighting should be applied in the population base data analysis collected by sampling with complex designs.

Disparities in surgical management of endometrial cancers in a public healthcare system: A question of equity.

OBJECTIVE: Timely surgery has been shown to impact outcome in endometrial cancer patients. Social determinants of health (SDH) are associated with adverse cancer outcomes. We sought to evaluate the association of SDH with surgical treatment indicators in endometrial cancer patients in a public healthcare system. METHODS: Endometrial cancer patients in Ontario, Canada, diagnosed between 2009 and 2017 were identified, and clinical, social and demographic variables were extracted from administrative databases. Validated community marginalization scores that include material deprivation, residential instability and ethnic concentration were used for stratification. Surgical treatment features were compared across marginalization quintiles using chi-square, Fischer exact or Wilcoxon rank sum tests as appropriate. Predictors of timely surgical treatment were evaluated with logistic regression. RESULTS: 20228 patients were identified of whom 14,423 had primary hysterectomy for a preoperative diagnosis of endometrial cancer. Fewer patients in marginalized communities received surgery (89% vs. 93%, p < 0.001). Surgical delay was longer among marginalized patients and 78% had surgery within 12 weeks compared to 84% of those least marginalized (p < 0.0001). Other quality indicators of surgical treatment were not negatively associated with marginalization. On multivariable analysis adjusted for patient and disease factors, marginalization was independently associated with increased odds of delayed surgery (OR = 0.94/quintile, CI 0.91-0.97, p < 0.001). CONCLUSIONS: Social marginalization is associated with decreased likelihood of having surgery and with delayed surgery among endometrial cancer patients in Ontario. This may be mediated by delayed presentation and real or perceived barriers to access. Reducing surgical wait times among marginalized cancer patients is an important deliverable in public healthcare.

Envisioning the future of clinical analytics: a modified Delphi process in New South Wales, Australia.

BACKGROUND: Clinical analytics is a rapidly developing area of informatics and knowledge mobilisation which has huge potential to improve healthcare in the future. It is widely acknowledged to be a powerful mediator of clinical decision making, patient-centred care and organisational learning. As a result, healthcare systems require a strategic foundation for clinical analytics that is sufficiently directional to support meaningful change while flexible enough to allow for iteration and responsiveness to context as change occurs. METHODS: In New South Wales, the most populous state in Australia, the Clinical Analytics Working Group was charged with developing a five-year vision for the public health system. A modified Delphi process was undertaken to elicit expert views and to reach a consensus. The process included a combination of face-to-face workshops, traditional Delphi voting via email, and innovative, real-time iteration between text re-formulation and voting until consensus was reached. The six stage process engaged 35 experts - practising clinicians, patients and consumers, managers, policymakers, data scientists and academics. RESULTS: The process resulted in the production of 135 ideas that were subsequently synthesised into 23 agreed statements and encapsulated in a single page (456 word) narrative. CONCLUSION: The visioning process highlighted three key perspectives (clinicians, patients and managers) and the need for synchronous (during the clinical encounter) and asynchronous (outside the clinical encounter) clinical decision support and reflective practice tools; the use of new and multiple data sources and communication formats; and the role of research and education.

State of the eye health system in the Pacific: is medical technology available and used by mid-level eye care workers?

INTRODUCTION: The aim of this study is to describe the availability, use and comfort with ophthalmic equipment and medications by mid-level eye care workers in Papua New Guinea and Pacific Island countries and territories as indicators of the state of eye care in the Pacific. METHODS: Health information system data, from a workforce support program to Pacific mid-level eye care workers, were analysed for availability and comfort with use of ophthalmic equipment and topical medications. RESULTS: For refraction equipment, access was excellent (98% for retinoscopes and trial lenses) 'very frequent use' range was 42-74% and 'high comfort of use' range was 54-86%. Equipment for ocular health assessment is widely available (slit lamps 67%), with high comfort levels (78-100% 'very comfortable'). Over 70% of respondents have access to topical diagnostic medications, 98% have access to at least one type of antibiotic drops and 63% have access to at least one topical corticosteroid. CONCLUSION: Overall, trained mid-level eye care workers in the Pacific seem well equipped for ocular health and refractive assessments. Comfort levels are encouraging, but also highlight areas for continuing professional development. Access to ophthalmic medications appears acceptable in the region for low morbidity anterior segment conditions.