[Impact in the quality of health care and cost-effectiveness analysis of the reform of an emergency medicine service]. / Evaluación del impacto en la calidad asistencial y análisis coste-efectividad de la reforma de un servicio de urgencias de medicina.

BACKGROUND: To determine the effects that the reform of an emergency department (ED) have on efficacy, health care quality and efficiency. MATERIAL AND METHOD: Reforms consisted of 50% and 34% increases in structural and human resources, respectively. Roles of each ED member were redetermined, new assistance pathways were implemented, and the relationship between ED and the remaining hospital departments was reassessed. As efficacy markers, we determined the number of patients waiting to be attended (Pesp), the waiting time of patients to receive medical assistance (T(esp)),and the total waiting time of patients staying in the ED (T(total)). As health-care quality markers, we determined the percentage of patients leaving ED without having been visited by a physician(IPNV), the percentage of patients who were visited again (IPR),and the percentage of mortality (IPF). We also quantified the number of visits to the ED. All these data were obtained daily over 3 weeks, before (February 1999) and after (February 2000)the reforms. Effectiveness was estimated from the ratio P(total)/T(esp)(E1) and P(total)/P(esp) (E2). Costs were recorded for both periods and a cost-effectiveness analysis was performed to study the efficiency. RESULTS: In 2000, the number of visits increased by +12% (CI 95%: 2% to 22%). Despite this increase, we observed an improvement of most efficacy and health-care quality markers after the ED reforms. E1 increased by 996% (CI 95%: 335% to 1,658%) and E2 increased by 186% (CI 95%: -23%to 395%). Cost-effectiveness analysis showed 70% (CI 95%: 33%to 107%) and 56% (CI 95%: 18% to 94%) increases regarding E1 and E2, respectively, after the reforms. CONCLUSIONS: Providing ED with the necessary resources leads to an objective improvement of its efficacy and health-care quality and, consequently, the service and quality perceived by users improve. Despite the total cost increase after the ED reforms, efficiency also improves.

Clinical assessment and arteriography for patients with penetrating extremity injuries: a review of 500 cases with the Veterans Affairs West Side Medical Center.

For patients suspected of having arterial injuries form penetrating trauma to the extremities, the decision to perform arteriography should be based on clinical criteria rather than "proximity" alone. In order to demonstrate the increased yield of arteriography resulting from appropriate patient selection, we reviewed the results of 500 arteriograms performed at the West Side Veterans Affairs Medical Center to exclude arterial injuries in symptomatic patients following penetrating trauma to their extremities. According to their clinical presentation, the patients were grouped into three different screening categories A, B, and C, which correspond respectively to "mild," "soft," and "hard" clinical signs and symptoms suggestive of arterial injury. All symptomatic patients injured by shotgun were included in category C due to the weapon's destructive power. The majority (318/500, 63.6%) of the 500 arteriograms were positive, and 102 of the positive studies identified major injuries that required surgical intervention. The remaining 216 identified injuries were minor or self-limiting. Increasing incidence of major injuries was found when comparing patients with mild (1.22%), soft (27.8%), and hard (60.0%) clinical signs and symptoms of arterial injury. These result suggest that arteriography, when combined with appropriate patient selection based on clinical examination, would be most effective in finding significant arterial injuries.

[Women and work. Panorama in Latin America 1960-1990]. / Mujer y trabajo. Panorama en America Latina 1960-1990.

PIP: Significant increases have occurred over the past 40 years in the labor force participation of Latin American women. The changes have been caused primarily by transformations in the economic system, but also in part by changes of attitude regarding the role of women in economic development and household survival. Average female labor force participation rates are difficult to compare over time and between countries because of differing cultural patterns concerning work, use of differing concepts of productive work and labor force, and different time periods of coverage. Some common trends can be observed in labor force participation despite the data limitations. A decline occurred in overall participation rates, at least until 1980, while female participation rates increased continually over the entire period. Several factors have been suggested to explain the overall decline, among them longer school attendance by young people. The Latin American Economic Commission classified Latin American countries into four groups according to their level of economic and social modernization. The role of women in the labor market and in domestic work is associated with the level of modernization. In all four groups, female activity rates have systematically increased in all countries. The distribution of women in the different productive sectors varied in the four groups. The two most developed groups concentrate a large part of the urban population, and in these groups the increase in female economic participation has been most pronounced. Establishment of maquiladora industries has been particularly associated with growth of female labor force participation in the past 15 years. The work of maquiladoras is associated with such problems of the informal sector as poor hygiene and exploitation. The informal sector is known to have grown considerably and to have permitted survival of many families during the economic crisis of the 1980s, but sufficient data is not yet available to gauge its true size.^ieng