Assessment of the learning curve of peribulbar blocks using the Learning-Curve Cumulative Sum Method (LC-CUSUM): an observational study.

INTRODUCTION: This study aimed to assess the learning curves of peribulbar anesthesia and estimate the number of blocks needed to attain proficiency. METHODS: Anonymized records of sequential peribulbar blocks performed by first-year anesthesia residents were analyzed. The block sequential number and the outcomes were extracted from each record. Success was defined as a complete sensory and motor block of the eye, and failure was defined as an incomplete block requiring supplemental local anesthetic injections or general anesthesia. Learning curves using the LC-CUSUM method were constructed, aiming for acceptable and unacceptable failure rates of 10% and 20%, and 10% probability of type I and II errors. Simulations were used to determine the proficiency limit h0. Residents whose curves reached h0 were considered proficient. The Sequential Probability Ratio Test Cumulative Sum Method (SPRT-CUSUM) was used for follow-up. RESULTS: Thirty-nine residents performed 2076 blocks (median = 52 blocks per resident; Interquartile Range (IQR) [range] = 27-78 [4-132]). Thirty residents (77%) achieved proficiency after a median of 13 blocks (13-24 [13-24]). CONCLUSIONS: The LC-CUSUM is a robust method for detecting resident proficiency at peribulbar anesthesia, defined as success rates exceeding 90%. Accordingly, 13 to 24 supervised double-injection peribulbar blocks are needed to attain competence at peribulbar anesthesia.

Systems science methods in public health: what can they contribute to our understanding of and response to the cost-of-living crisis?

BACKGROUND: Many complex public health evidence gaps cannot be fully resolved using only conventional public health methods. We aim to familiarise public health researchers with selected systems science methods that may contribute to a better understanding of complex phenomena and lead to more impactful interventions. As a case study, we choose the current cost-of-living crisis, which affects disposable income as a key structural determinant of health. METHODS: We first outline the potential role of systems science methods for public health research more generally, then provide an overview of the complexity of the cost-of-living crisis as a specific case study. We propose how four systems science methods (soft systems, microsimulation, agent-based and system dynamics models) could be applied to provide more in-depth understanding. For each method, we illustrate its unique knowledge contributions, and set out one or more options for studies that could help inform policy and practice responses. RESULTS: Due to its fundamental impact on the determinants of health, while limiting resources for population-level interventions, the cost-of-living crisis presents a complex public health challenge. When confronted with complexity, non-linearity, feedback loops and adaptation processes, systems methods allow a deeper understanding and forecasting of the interactions and spill-over effects common with real-world interventions and policies. CONCLUSIONS: Systems science methods provide a rich methodological toolbox that complements our traditional public health methods. This toolbox may be particularly useful in early stages of the current cost-of-living crisis: for understanding the situation, developing solutions and sandboxing potential responses to improve population health.

Avaliação da visita domiciliar em programas na primeira infância: contribuições para a realidade brasileira / Evaluación de la visita domiciliaria en programas de primera infancia: contribuciones a la realidad brasileña / House call assessment in early childhood programs: contributions to the brazilian reality

RESUMO Introdução: este estudo consiste numa reflexão sobre a avaliação da visita domiciliar em programas na primeira infância. Objetivo: discutir as dimensões envolvidas em um modelo de avaliação para a realidade brasileira, além da percepção dos autores a respeito do tema. Método: essa reflexão foi estruturada nos seguintes tópicos: dimensões envolvidas na avaliação da visita domiciliar e o processo avaliativo nos programas brasileiros. Considerando a centralidade e relevância da visita domiciliar nos programas brasileiros com foco na Primeira Infância e a tendência de consolidação dessa tecnologia como forma de intervenção adequada a programas dessa natureza, propõe-se organizar quatro dimensões para a avaliação das visitas domiciliares: dosagem, conteúdo, relacionamento e responsividade do participante. Resultado: avaliar a tecnologia de intervenção dos programas voltados para a primeira infância, no caso a visita domiciliar, permite investigar os processos que ocorrem durante a entrega das visitas domiciliares e abrir a "caixa preta" da intervenção, sendo possível elucidar problemas operacionais e propor recomendações para corrigi-las. Conclusão: o modelo proposto possibilita aos supervisores e tomadores de decisão acompanhar de forma sistemática e ajustar as dimensões que impactam nos resultados dos programas de visita domiciliar voltados para a Primeira Infância.

RESUMEN Introducción: este estudio consiste en una reflexión sobre la evaluación de la visita domiciliaria en programas en la primera infancia. Objetivo: discutir las dimensiones involucradas en un modelo de evaluación para la realidad brasileña, además de la percepción de los autores acerca del tema. Método: esta reflexión fue estructurada en los siguientes tópicos: dimensiones involucradas en la evaluación de la visita domiciliaria y el proceso evaluativo en los programas brasileños. Considerando la centralidad y relevancia de la visita domiciliaria en los programas brasileños con foco en la Primera Infancia y la tendencia de consolidación de esta tecnología como forma de intervención adecuada a programas de esa naturaleza, se propone organizar cuatro dimensiones para la evaluación de las visitas domiciliarias: dosificación, contenido, relación y respuesta del participante. Resultado: evaluar la tecnología de intervención de los programas dirigidos a la primera infancia, en el caso la visita domiciliaria, permite investigar los procesos que ocurren durante la entrega de las visitas domiciliarias y abrir la "caja negra" de la intervención, siendo posible aclarar problemas operativos y proponer recomendaciones para corregirlos. Conclusión: el modelo propuesto posibilita a los supervisores y tomadores de decisiones acompañar de forma sistemática y ajustar las dimensiones que impactan en los resultados de los programas de visita domiciliariadirigidos para la Primera Infancia.

ABSTRACT Introduction: This study consists of a reflection on house call assessment in early childhood programs, which aimed to discuss the dimensions involved in an assessment model for the Brazilian reality, in addition to the authors' perception of the topic. Method: This reflection was structured around the following topics: dimensions involved in house call assessment and the assessment process in Brazilian programs. Considering the centrality and relevance of house calls in Brazilian programs focused on early childhood and the tendency to consolidate this technology as an intervention strategy suitable for programs of this nature, it is proposed to organize four dimensions for house call assessment: dosage, content, relationship, and participant responsiveness. Results: Assessing the intervention technology of programs aimed at early childhood, in this case house calls, allows us to inquire into the processes that occur during house calls and to open the 'black box' of intervention, making it possible to clarify operational issues and propose recommendations to fix them. Conclusion: The model proposed allows supervisors and decision makers to systematically monitor and adjust the dimensions that impact the results of house call programs aimed at early childhood.

Mapping clinical outcomes to generic preference-based outcome measures: development and comparison of methods.

BACKGROUND: Cost-effectiveness analysis using quality-adjusted life-years as the measure of health benefit is commonly used to aid decision-makers. Clinical studies often do not include preference-based measures that allow the calculation of quality-adjusted life-years, or the data are insufficient. 'Mapping' can bridge this evidence gap; it entails estimating the relationship between outcomes measured in clinical studies and the required preference-based measures using a different data set. However, many methods for mapping yield biased results, distorting cost-effectiveness estimates. OBJECTIVES: Develop existing and new methods for mapping; test their performance in case studies spanning different preference-based measures; and develop methods for mapping between preference-based measures. DATA SOURCES: Fifteen data sets for mapping from non-preference-based measures to preference-based measures for patients with head injury, breast cancer, asthma, heart disease, knee surgery and varicose veins were used. Four preference-based measures were covered: the EuroQoL-5 Dimensions, three-level version (n = 11), EuroQoL-5 Dimensions, five-level version (n = 2), Short Form questionnaire-6 Dimensions (n = 1) and Health Utility Index Mark 3 (n = 1). Sample sizes ranged from 852 to 136,327. For mapping between generic preference-based measures, data from FORWARD, the National Databank for Rheumatic Diseases (which includes the EuroQoL-5 Dimensions, three-level version, and EuroQoL-5 Dimensions, five-level version, in its 2011 wave), were used. MAIN METHODS DEVELOPED: Mixture-model-based approaches for direct mapping, in which the dependent variable is the health utility value, including adaptations of methods developed to model the EuroQoL-5 Dimensions, three-level version, and beta regression mixtures, were developed, as were indirect methods, in which responses to the descriptive systems are modelled, for consistent multidirectional mapping between preference-based measures. A highly flexible approach was designed, using copulas to specify the bivariate distribution of each pair of EuroQoL-5 Dimensions, three-level version, and EuroQoL-5 Dimensions, five-level version, responses. RESULTS: A range of criteria for assessing model performance is proposed. Theoretically, linear regression is inappropriate for mapping. Case studies confirm this. Flexible, direct mapping methods, based on different variants of mixture models with appropriate underlying distributions, perform very well for all preference-based measures. The precise form is important. Case studies show that a minimum of three components are required. Covariates representing disease severity are required as predictors of component membership. Beta-based mixtures perform similarly to the bespoke mixture approaches but necessitate detailed consideration of the number and location of probability masses. The flexible, bi-directional indirect approach performs well for testing differences between preference-based measures. LIMITATIONS: Case studies drew heavily on EuroQoL-5 Dimensions. Indirect methods could not be undertaken for several case studies because of a lack of coverage. These methods will often be unfeasible for preference-based measures with complex descriptive systems. CONCLUSIONS: Mapping requires appropriate methods to yield reliable results. Evidence shows that widely used methods such as linear regression are inappropriate. More flexible methods developed specifically for mapping show that close-fitting results can be achieved. Approaches based on mixture models are appropriate for all preference-based measures. Some features are universally required (such as the minimum number of components) but others must be assessed on a case-by-case basis (such as the location and number of probability mass points). FUTURE RESEARCH PRIORITIES: Further research is recommended on (1) the use of the monotonicity concept, (2) the mismatch of trial and mapping distributions and measurement error and (3) the development of indirect methods drawing on methods developed for mapping between preference-based measures. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 34. See the NIHR Journals Library website for further project information. This project was also funded by a Medical Research Council grant (MR/L022575/1).

Coherent decisions about which health services and treatments to provide rely on economic analysis to weigh potential health benefits against costs. For decisions to be consistent across the whole health service, benefits need to be counted in the same way for patients with different health problems. This is accomplished by using a unit of measurement for treatment outcomes called the quality-adjusted life-year. The best way to calculate quality-adjusted life-years is to ask patients taking part in clinical studies to fill in specially designed questionnaires to describe their health in a simple, standardised way. However, clinical trials often record patient outcomes in different ways, leaving economic analysts without the necessary information to calculate quality-adjusted life-years. A way to overcome this problem (known as 'statistical mapping') is to use the available clinical data to predict the responses that would have been made by trial participants to the standard questionnaire. This requires analysis of data from an additional study in which patients have provided both types of outcome data to construct a statistical 'mapping model'. Mapping is widely used in practice, but it is often based on simple mapping models that in some circumstances systematically mispredict and may consequently give a false picture of the real health benefits of treatments. This is important because it influences decisions about which treatments are available in the NHS; it has real effects on patients, clinicians, industry and the general public. Our objectives are to develop promising new statistical mapping models specifically designed for different clinical contexts and to compare them using patient data in different disease areas. We have also developed an approach for judging the outcome of a mapping study. We find that the new methods work better than existing methods in terms of their ability to fit the data and avoid systematic bias.

Considerações sobre a discussão da revisão do esquema da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) / Thoughts on the discussion about the revision of the International Classification of Functioning, Disability and Health (ICF) scheme

A Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) apresenta uma abordagem inovadora ao funcionamento: o modelo biopsicossocial. Desde então, a estrutura da CIF e seu esquema explicativo têm sido utilizados em muitos contextos, incluindo saúde, previdência social e educação. Recentemente, surgiram algumas críticas e surgiram propostas a respeito de suas revisões. Objetivos: Este artigo discute propostas anteriores de revisões do esquema da CIF e apresenta sugestões de uma nova. Métodos: Descrevemos algumas das sugestões de esquemas de funcionamento alternativo da CIF e apresentamos algumas de suas características. Resultados: Também propomos nosso próprio esquema, destacando suas vantagens sobre os antecessores. Em nossa proposta, os componentes atuais do esquema são mantidos e dispostos equidistantemente ao longo de uma estrutura tridimensional de "casco de bola" conectada por setas de duas pontas. Nosso esquema é inovador, pois não apresenta nenhum componente como central, permitindo que o esquema seja mais adaptável à realidade de cada perfil funcional. Também é dinâmico, girando em 3 eixos, possibilitando o posicionamento central do componente mais importante. As esferas para cada componente podem ser ampliadas, demonstrando a magnitude de cada componente. Conclusão: Esperamos contribuir para a discussão atual sobre o esquema da CIF e sua revisão.

The International Classification of Functioning, Disability and Health (ICF) presents an innovative approach to functioning: the biopsychosocial model. Since then, the ICF framework and its explanatory scheme has been used in many settings, including health, social security, and education. Recently, some criticism has arisen and proposals have ensued regarding its revisions. Objective: This paper discusses previous proposals for revisions to the ICF scheme and present suggestions of a new one. Methods: We outline some of the suggestions of ICF alternative functioning schemes, and present some of their features. Results: We also propose our own scheme, highlighting its advantages over predecessors. In our proposal, current scheme components are kept and arranged equidistantly along a three dimension 'ball shell' structure connected by double-headed arrows. Our scheme is innovative in that it does not present any component as central, allowing the scheme to be more adaptable to the reality of each functioning profile. It is also dynamic, by rotating on 3 axes, making possible the central positioning of the most important component. The spheres for each component can be enlarged, demonstrating ​​the magnitude of each component. Conclusion: We hope to contribute to the current discussion on ICF scheme and its revision.

Impact of economic recessions on healthcare workers and their crises' responses: study protocol for a systematic review of the qualitative and quantitative evidence for the development of an evidence-based conceptual framework.

INTRODUCTION: During economic recessions, health professionals face reduced income and labour opportunities, hard conditions often exacerbated by governments' policy responses to crises. Growing evidence points to non-negligible effects on national health workforces and health systems-decrease in motivation, burnout, migration-arising from the combination of crisis-related factors. However, no theoretical conceptualisation currently exists framing the impacts recessions have on human resources for health (HRH), or on their reactions. METHODS AND ANALYSIS: This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts' input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970-2019 period-the modern age of global economic recessions-and full texts in English, Spanish, Italian, French, Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A 'best-fit' framework synthesis will be applied to summarise the findings, using an a priori, theoretically driven framework. That preliminary framework was built by the research team to inform the searches, and will be appraised by external experts. ETHICS AND DISSEMINATION: In addition to peer-reviewed publications, the new framework will be presented in global health systems research conferences and inform regional policy dialogue workshops in Latin America on economic recessions and health systems. PROSPERO REGISTRATION NUMBER: CRD42019134165.

How Equity-Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy.

Policy Points A consensus regarding the need to orient health systems to address inequities is emerging, with much of this discussion targeting population health interventions and indicators. We know less about applying these approaches to primary health care. This study empirically demonstrates that providing more equity-oriented health care (EOHC) in primary health care, including trauma- and violence-informed, culturally safe, and contextually tailored care, predicts improved health outcomes across time for people living in marginalizing conditions. This is achieved by enhancing patients' comfort and confidence in their care and their own confidence in preventing and managing health problems. This promising new evidence suggests that equity-oriented interventions at the point of care can begin to shift inequities in health outcomes for those with the greatest need. CONTEXT: Significant attention has been directed toward addressing health inequities at the population health and systems levels, yet little progress has been made in identifying approaches to reduce health inequities through clinical care, particularly in a primary health care context. Although the provision of equity-oriented health care (EOHC) is widely assumed to lead to improvements in patients' health outcomes, little empirical evidence supports this claim. To remedy this, we tested whether more EOHC predicts more positive patient health outcomes and identified selected mediators of this relationship. METHODS: Our analysis uses longitudinal data from 395 patients recruited from 4 primary health care clinics serving people living in marginalizing conditions. The participants completed 4 structured interviews composed of self-report measures and survey questions over a 2-year period. Using path analysis techniques, we tested a hypothesized model of the process through which patients' perceptions of EOHC led to improvements in self-reported health outcomes (quality of life, chronic pain disability, and posttraumatic stress [PTSD] and depressive symptoms), including particular covariates of health outcomes (age, gender, financial strain, experiences of discrimination). FINDINGS: Over a 24-month period, higher levels of EOHC predicted greater patient comfort and confidence in the health care patients received, leading to increased confidence to prevent and manage their health problems, which, in turn, improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life). In addition, financial strain and experiences of discrimination had significant negative effects on all health outcomes. CONCLUSIONS: This study is among the first to demonstrate empirically that providing more EOHC predicts better patient health outcomes over time. At a policy level, this research supports investments in equity-focused organizational and provider-level processes in primary health care as a means of improving patients' health, particularly for those living in marginalizing conditions. Whether these results are robust in different patient groups and across a broader range of health care contexts requires further study.

[Application of occupational hazard risk index model in occupational health risk assessment in a decorative coating manufacturing enterprises].

Objective: To evaluate the occupational health risk of decorative coating manufacturing enterprises and to explore the applicability of occupational hazard risk index model in the health risk assessment, so as to provide basis for the health management of enterprises. Methods: A decorative coating manufacturing enterprise in Hebei Province was chosen as research object, following the types of occupational hazards and contact patterns, the occupational hazard risk index model was used to evaluate occupational health risk factors of occupational hazards in the key positions of the decorative coating manufacturing enterprise, and measured with workplace test results and occupational health examination. Results: The positions of oily painters, water-borne painters, filling workers and packers who contacted noise were moderate harm. And positions of color workers who contacted chromic acid salts, oily painters who contacted butyl acetate were mild harm. Other positions were harmless. The abnormal rate of contacting noise in physical examination results was 6.25%, and the abnormality was not checked by other risk factors. Conclusion: The occupational hazard risk index model can be used in the occupational health risk assessment of decorative coating manufacturing enterprises, and noise was the key harzard among occupational harzards in this enterprise.

The prevalence of COPD in England: An ontological approach to case detection in primary care.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality in England, however estimates of its prevalence vary considerably. Routinely collected and coded primary care data can be used to monitor disease prevalence, however reliance upon diagnostic codes alone is likely to miss cases. METHODS: We devised an ontological approach to COPD case detection and implemented it in a large primary care database to identify definite and probable cases of COPD. We used this to estimate the prevalence of COPD in England. RESULTS: Use of this approach to detect definite COPD cases yielded a prevalence of 2.57% (95% CI 2.55-2.60) in the total population, 4.56% (95%CI 4.52-4.61) in those aged ≥ 35 and 5.41% (95% CI 5.36-5.47) in ex or current smokers. The ontological approach identified an additional 10,543 definite cases compared with using diagnostic codes alone. Prevalence estimates were higher than the 1.9% prevalence currently reported by the UK primary care pay for performance (P4P) disease register. COPD prevalence when definite and probable cases were combined was 3.02% (95% CI 3.0-3.05) in the total population, 5.38% (95% CI 5.33-5.42) in those aged ≥ 35 and 6.46% (95% CI 6.46-6.40-6.56) in ex or current smokers. CONCLUSIONS: We demonstrate a robust reproducible method for COPD case detection in routinely collected primary care data. Our calculated prevalence differed significantly from current estimates based upon P4P data, suggesting that the burden of COPD in England is greater than currently predicted.

Modeling of Food and Nutrition Surveillance in Primary Health Care / Modelização da Vigilância Alimentar e Nutricional na Atenção Primária em Saúde

ABSTRACT Objective: To describe the modeling stages of food and nutrition surveillance in the Primary Health Care of the Unified Health Care System, considering its activities, objectives, and goals Methods: Document analysis and semi-structured interviews were used for identifying the components, describe the intervention, and identify potential assessment users. Results: The results include identification of the objectives and goals of the intervention, the required inputs, activities, and expected effects. The intervention was then modeled based on these data. The use of the theoretical logic model optimizes times, resources, definition of the indicators that require monitoring, and the aspects that require assessment, identifying more clearly the contribution of the intervention to the results Conclusion: Modeling enabled the description of food and nutrition surveillance based on its components and may guide the development of viable plans to monitor food and nutrition surveillance actions so that modeling can be established as a local intersectoral planning instrument.

RESUMO Objetivo: Descrever as etapas de modelização da vigilância alimentar e nutricional na Atenção Primária em Saúde no Sistema Único de Saúde, considerando suas atividades, objetivos e metas. Métodos: Foram utilizadas as técnicas de análise documental e entrevistas semi-estruturadas para identificar os componentes, descrever a intervenção e identificar os potenciais usuários da avaliação. Resultados: Foram identificados os objetivos e metas da intervenção, os insumos necessários, as atividades e os efeitos esperados. A partir dessas informações, a intervenção foi modelizada. A utilização do modelo lógico teórico otimiza tempo, recursos, definição de indicadores a serem monitorados e aspectos a serem avaliados, identificando com mais clareza qual a contribuição da intervenção para o alcance dos resultados. Conclusão: A modelização possibilitou descrever a vigilância alimentar e nutricional a partir de seus componentes e poderá orientar a elaboração de planos viáveis de monitoramento das ações da vigilância alimentar e nutricional para sua efetivação como um instrumento de planejamento intersetorial em nível local.

[Incorporating health equity into implementation research: review of conceptual modelsIncorporação da igualdade em saúde na pesquisa de implementação: revisão de modelos conceituais]. / Incorporación de equidad en salud en la investigación sobre implementación: revisión de los modelos conceptuales.

OBJECTIVE: Search for conceptual frameworks or models that incorporate aspects of health equity into implementation research and prepare a systematic synthesis of them. METHODS: A systematic search was done of MEDLINE-PubMed, Embase, and LILACS (1965-2016), and Scopus (1998-2016) databases, employing, in addition, a snowball strategy and gray literature search. Article type was assessed, along with elements that were included on implementation research, the science of implementation, and health equity. RESULTS: A total of 701 articles were found, of which 100 were included for review of relevance. Of these, 19 articles related to conceptual frameworks: 12 were general, five were on ethnic or racial disparities, and two related to child health. The most frequent categories were financing, infrastructure, advocacy, quality, internal barriers, and coverage. The least frequent were other sectors, outpatient needs, health status, and equity impact assessment. CONCLUSIONS: In order to reduce health gaps and with them health inequities, it becomes necessary to have a consolidated implementation research framework that includes aspects of health equity. This framework would facilitate improving implementation processes for interventions, services, and health programs.

OBJETIVO: Fazer uma busca e revisão sistemática dos marcos ou modelos conceituais que abrangem aspectos de igualdade em saúde em pesquisa de implementação. MÉTODOS: Busca sistemática nas bases de dados MEDLINE-PubMed, Embase e LILACS (1965­2016) e Scopus (1998­2016) com o uso de estratégia de amostragem em bola de neve e busca da literatura cinzenta. Foram avaliados o tipo de artigo e os elementos contidos sobre pesquisa de implementação (implementation research, IR), ciência de implementação e igualdade em saúde. RESULTADOS: Foram identificados 701 artigos, dos quais 100 foram incluídos na revisão. Destes, 19 artigos estavam relacionados aos marcos conceituais: 12 gerais, cinco sobre disparidades étnicas ou raciais e dois relacionados com saúde infantil. As categorias mais frequentes dos marcos conceituais foram: financiamento, infraestrutura, defesa da causa, qualidade, barreiras internas e cobertura. As menos frequentes foram: outros setores, necessidades dos pacientes ambulatoriais, estado de saúde e avaliação do impacto na equidade. CONCLUSÕES: Para reduzir as lacunas em saúde e as desigualdades em saúde, faz-se necessário dispor de um modelo consolidado de pesquisa de implementação no qual sejam incluídos os aspectos de igualdade em saúde. Este modelo contribuiria para melhorar os processos de implementação das intervenções, serviços e programas de saúde.

Incorporación de equidad en salud en la investigación sobre implementación: revisión de los modelos conceptuales / Incorporating health equity into implementation research: review of conceptual models / Incorporação da igualdade em saúde na pesquisa de implementação: revisão de modelos conceituais

Objetivo Buscar y elaborar una síntesis sistemática de los marcos o modelos conceptuales que incorporan aspectos de equidad en salud en implementación de la investigación. Métodos Búsqueda sistemática en Medline-Pubmed, Embase y Lilacs (1965-2016) y Scopus (1998-2016). Además, se utilizó una estrategia en bola de nieve y búsqueda de la literatura gris. Se evaluó el tipo de artículo y los elementos que se incluyeron sobre investigación de la implementación (IR, por sus siglas en inglés), la ciencia de la implementación y equidad en salud. Resultados Se encontraron 701 artículos, de los cuales 100 se incluyeron para revisión de relevancia. De estos, quedaron 19 artículos relacionados con marcos conceptuales: 12 fueron generales, cinco sobre disparidades étnicas o raciales y dos relacionados con salud infantil. Las categorías más frecuentes fueron: financiación, infraestructura, abogacía, calidad, barreras internas y cobertura. Las menos frecuentes fueron: otros sectores, las necesidades de los pacientes externos, el estado de salud y la evaluación del impacto sobre la equidad. Conclusiones Para disminuir las brechas en salud y con ellas las inequidades en salud, se hace necesario contar con un marco consolidado de IR en el que se incluyan los aspectos de equidad en salud. Este marco facilitaría mejorar los procesos de implementación de las intervenciones, los servicios y los programas de salud.

Objective Search for conceptual frameworks or models that incorporate aspects of health equity into implementation research and prepare a systematic synthesis of them. Methods A systematic search was done of MEDLINE-PubMed, Embase, and LILACS (1965-2016), and Scopus (1998-2016) databases, employing, in addition, a snowball strategy and gray literature search. Article type was assessed, along with elements that were included on implementation research, the science of implementation, and health equity. Results A total of 701 articles were found, of which 100 were included for review of relevance. Of these, 19 articles related to conceptual frameworks: 12 were general, five were on ethnic or racial disparities, and two related to child health. The most frequent categories were financing, infrastructure, advocacy, quality, internal barriers, and coverage. The least frequent were other sectors, outpatient needs, health status, and equity impact assessment. Conclusions In order to reduce health gaps and with them health inequities, it becomes necessary to have a consolidated implementation research framework that includes aspects of health equity. This framework would facilitate improving implementation processes for interventions, services, and health programs.

Objetivo Fazer uma busca e revisão sistemática dos marcos ou modelos conceituais que abrangem aspectos de igualdade em saúde em pesquisa de implementação. Métodos Busca sistemática nas bases de dados MEDLINE-PubMed, Embase e LILACS (1965-2016) e Scopus (1998-2016) com o uso de estratégia de amostragem em bola de neve e busca da literatura cinzenta. Foram avaliados o tipo de artigo e os elementos contidos sobre pesquisa de implementação (implementation research, IR), ciência de implementação e igualdade em saúde. Resultados Foram identificados 701 artigos, dos quais 100 foram incluídos na revisão. Destes, 19 artigos estavam relacionados aos marcos conceituais: 12 gerais, cinco sobre disparidades étnicas ou raciais e dois relacionados com saúde infantil. As categorias mais frequentes dos marcos conceituais foram: financiamento, infraestrutura, defesa da causa, qualidade, barreiras internas e cobertura. As menos frequentes foram: outros setores, necessidades dos pacientes ambulatoriais, estado de saúde e avaliação do impacto na equidade. Conclusões Para reduzir as lacunas em saúde e as desigualdades em saúde, faz-se necessário dispor de um modelo consolidado de pesquisa de implementação no qual sejam incluídos os aspectos de igualdade em saúde. Este modelo contribuiria para melhorar os processos de implementação das intervenções, serviços e programas de saúde.

Concepto carga en los modelos teóricos sobre enfermedad crónica: revisión sistemática / Charging concept theoretical models diseasechronic: a systematic review

RESUMEN Objetivo Describir el abordaje de carga que tienen los modelos teóricos sobre enfermedad crónica no trasmisible (ECNT) Metodología La búsqueda de los estudios se realizó definiendo la ventana de observación bajo criterios establecidos para los descriptores modelos teóricos, enfermedad crónica y costo de la enfermedad, en 14 bases de datos como Scielo, Medline, Science direct, Infotrac Health Reference Center Academic, teniendo en cuenta publicaciones arbitradas e incluyendo publicaciones cuantitativas, cualitativas y de revisión, tiempo e idioma de las publicaciones y tipo de estdio tal como se presentan a contiuación. Resultados Las 20 publicaciones registradas van desde el 2005 al 2012. Dentro de ellas aparecen tres grupos para el abordaje de la carga que incluyen el que se basa en un paradigma de cuidado, el que la entiende como un paradigma económico conjunto de la enfermedad y su impacto financiero y los paradigmas eclécticos que admiten la suma de miradas de algunos matices económicos junto con otros propios de la experiencia de vivir o cuidar en situaciones de ECNT. Conclusiones Los modelos teóricos sobre enfermedad crónica evidenciados indican que el concepto se agrupa en tres: la carga vista desde el abordaje del cuidado; el abordaje económico centrado en la enfermedad y su impacto financiero y el abordaje mixto que retoma parcialmente aspectos de los dos anteriores. La comparación de estos hallazgos con la literatura ratifica los grupos encontrados y sugiere la necesidad de hacer explícito el concepto de carga de la ECNT desde el paradigma empleado.(AU)

ABSTRACT Objective To describe the approach of cost of illness within the theoretical models of chronic non communicable disease (NCD) Methodology A systematic literature review was carried by defining observational parameters guided by the key words "theoretical, models" , "chronic disease" and "cost of illness" in 14 databases as Scielo, Medline, Science direct, Infotrac Health Reference Center Academic, including indexed publications of quantitative, qualitative, analysis and review articles, their publication language with an open time definition. Results 20 registered publications were found ranging from 2005 to 2012. Within these publications three groups emerged in the way they approach the burden or illness cost. They include: a group based on a caring paradigm, a group based on an economic paradigm understood as a set of the disease appear and their financial impact and a third group that with an eclectic approach that combined some of the economic aspects as well as some of the experiences of living and caring in situations of NCDs. Conclusions The theoretical models of chronic disease evidenced by this systematic search indicates that the concept of cost of illness is grouped into three: the view from the approach of burden of care; the economic approach focused on the disease and its financial impact and the mixed approach that takes aspects of the previous two. Comparing these findings with the literature confirms the groups founded and suggested the need to make explicit the utilized paradigm within in the conceptualization of the cost of illness while approaching NCDs.(AU)

Risk-Taking Attitudes of Patients who Seek Health Care: An Exploratory Approach through Lottery Games. / La valoración de la actitud ante el riesgo en personas que demandan cuidados en salud: una aproximación mediante juegos de loterías utilizando generalized estimating equations.

BACKGROUND: The characterization of the risk-taking attitude of individuals may be useful for planning health care interventions. It has been attempted to study expressions of risk-taking attitude and evaluate characteristics of a standard lottery game in a population that seeks health care to elicit these attitudes. METHODS: Multicentric cross-sectional study. Demographic and socioeconomic characteristics, quality of life (EuroQol-5D), and health risk behaviors were collected from 662 users of 23 health centers selected by random sampling. Risk-taking attitude was evaluated by means of a self-evaluation scale and two lottery games, (L1 and L2; L2 included the possibility of economic losses). Generalized estimating equations (GEE) explicative models were used to evaluate the variability of risk-taking attitude. RESULTS: Nineteen percent out of interviewed people (CI95%: 15.6-22.6%) expressed a high risk appetite, but only 10.0% (CI95% 7.0 to 13.0) were classified as risk-seeking by L2. It was found association between increased risk appetite and having a better perception of health status (0.110, CI95%: 0,007-0,212) or a higher income (0.010, CI95%: 0.017- 0.123) or smoking status (0.059, CI95%: 0.004- 0.114). Being Spanish was associated with lower risk appetite (-0.105, CI95%: -0.005 --0.205), as being over 65 (-0.031, CI95%:- 0.061- -0.001) or a woman (-0.038, CI95%:-0.064- -0.012). The intraclass correlation coefficient for self-evaluation scale was 0.511 (95% CI: 0.372 to 0.629), 0.571 (95% CI: 0.441 to 0.678) for L1 and 0.349 (95% CI: 0.186-0.493) to L2. CONCLUSIONS: People who seek health care express certain inclination to risk, but this feature is attenuated when methodologies involving losses are used. Risk appetite seems greater in young people, males, people with better health, or more income, and in immigrants. Lottery games such as the proposed ones are a simple and useful tool to estimate individuals' inclination to risk.

OBJETIVO: La caracterización de la actitud ante el riesgo puede ser útil en la planificación de las intervenciones sanitarias. El objetivo fue estudiar la actitud ante el riesgo de una población que demanda cuidados de salud y evaluar la capacidad de un juego de loterías para evidenciar dicha actitud. METODOS: Estudio multicéntrico transversal. Se recogieron características demográficas, socioeconómicas, de calidad de vida y conductas de riesgo en salud de 662 personas usuarias de 23 centros de salud seleccionadas mediante muestreo aleatorio. La actitud ante el riesgo se evaluó mediante una escala subjetiva y mediante dos juegos de azar (L1 y L2; L2 incluía la posibilidad de pérdidas económicas). Se realizaron modelos explicativos para valorar la variabilidad de la propensión al riesgo utilizando Generalized Estimating Equations (GEE). RESULTADOS: El 19,1% (IC95%:15,6-22,6%) de los sujetos expresaron una propensión al riesgo alta, el 10,0% (IC95%:7,0-13,0) fueron clasificados como propensos al riesgo con L2. Se encontró asociación entre una mayor propensión al riesgo y tener mejor percepción del estado de salud (0,110; IC95%:0,007- 0,212) o mayor renta (0,010; IC95%: 0,017- 0,123) o ser fumador (0,059; IC95%: 0,004-0,114). Ser español se relacionaba con menor propensión al riesgo (-0,105; IC95%: -0,205- -0,005), al igual que ser mayor de 65 años (-0,031; IC95%:-0,061- -0,001) o ser mujer (-0,038, IC95%:-0,064- -0,012). El coeficiente de correlación intraclase para la escala subjetiva fue 0,511 (IC95%:0,372-0,629), 0,571 (IC95%:0,441-0,678) para L1 y 0,349 (IC95%:0,186-0,493) para L2. CONCLUSIONES: Las personas que demandan cuidados de salud presentan con frecuencia propensión al riesgo, la cual se atenúa cuando se caracteriza mediante metodologías que implican pérdidas. La propensión al riesgo parece mayor en personas jóvenes, varones, con mejor estado de salud, con mayor renta y en inmigrantes.

The EHR-ARCHE project: satisfying clinical information needs in a Shared Electronic Health Record system based on IHE XDS and Archetypes.

PURPOSE: While contributing to an improved continuity of care, Shared Electronic Health Record (EHR) systems may also lead to information overload of healthcare providers. Document-oriented architectures, such as the commonly employed IHE XDS profile, which only support information retrieval at the level of documents, are particularly susceptible for this problem. The objective of the EHR-ARCHE project was to develop a methodology and a prototype to efficiently satisfy healthcare providers' information needs when accessing a patient's Shared EHR during a treatment situation. We especially aimed to investigate whether this objective can be reached by integrating EHR Archetypes into an IHE XDS environment. METHODS: Using methodical triangulation, we first analysed the information needs of healthcare providers, focusing on the treatment of diabetes patients as an exemplary application domain. We then designed ISO/EN 13606 Archetypes covering the identified information needs. To support a content-based search for fine-grained information items within EHR documents, we extended the IHE XDS environment with two additional actors. Finally, we conducted a formative and summative evaluation of our approach within a controlled study. RESULTS: We identified 446 frequently needed diabetes-specific information items, representing typical information needs of healthcare providers. We then created 128 Archetypes and 120 EHR documents for two fictive patients. All seven diabetes experts, who evaluated our approach, preferred the content-based search to a conventional XDS search. Success rates of finding relevant information was higher for the content-based search (100% versus 80%) and the latter was also more time-efficient (8-14min versus 20min or more). CONCLUSIONS: Our results show that for an efficient satisfaction of health care providers' information needs, a content-based search that rests upon the integration of Archetypes into an IHE XDS-based Shared EHR system is superior to a conventional metadata-based XDS search.

Application of the Human Activity Assistive Technology model for occupational therapy research.

BACKGROUND/AIM: Theoretical models provide a framework for describing practice and integrating evidence into systematic research. There are few models that relate specifically to the provision of assistive technology in occupational therapy practice. The Human Activity Assistive Technology model is an enduring example that has continued to develop by integrating a social model of disability, concepts from occupational therapy theory and principles of assistive technology adoption and abandonment. METHODS: This study first describes the core concepts of the Human Activity Assistive Technology model and reviews its development over three successive published versions. A review of the research literature reflects application of the model to clinical practice, study design, outcome measure selection and interpretation of results, particularly among occupational therapists. An evaluative framework is used to critique the adequacy of the Human Activity Assistive Technology model for practice and research, exploring attributes of clarity, simplicity, generality, accessibility and importance. Finally, recommendations are proposed for continued development of the model and research applications. RESULTS: Most of the existing research literature employs the Human Activity Assistive Technology model for background and study design; there is emerging evidence to support the core concepts as predictive factors. Although the concepts are generally simple, clear and applicable to occupational therapy practice and research, evolving terminology and outcomes become more complex with the conflation of integrated theories. CONCLUSIONS AND SIGNIFICANCE: The development of the Human Activity Assistive Technology model offers enhanced access and application for occupational therapists, but poses challenges to clarity among concepts. Suggestions are made for further development and applications of the model.

Evaluating the impact of tuberculosis control: number of deaths prevented by short-course chemotherapy in China.

BACKGROUND: Tuberculosis (TB) is still amongst the most important causes of human morbidity and mortality, killing approximately two million people each year. Standard short-course chemotherapy (SSCC) can rapidly control illness and dramatically reduce the chance of death, but the impact of treatment has rarely been evaluated in these terms. METHOD: We developed a mathematical model that makes use of routinely-collected data to calculate the number of deaths directly prevented by TB treatment (i.e. excluding those due to reduced transmission). The method was applied to the world's largest TB control programme covering over 500 million people in 12 provinces of China. RESULTS: Counties which had been enrolled in the programme since 1991 were, by 1997, preventing at least 46% (37-56%) of the TB deaths that would otherwise have occurred. If replicated across the entire TB control programme area, this would amount to 30 000 (range 26 000-59 000) deaths directly prevented each year. CONCLUSIONS: Short-course chemotherapy has substantially reduced TB mortality in half of China. The analytical method described here could be applied to TB control operations in many other countries, and should help to quantify the true burden of tuberculosis alleviated by SSCC.

Modeling the effects of maternal nutritional status and socioeconomic variables on the anthropometric and psychological indicators of Kenyan infants from age 0-6 months.

This paper presents a comprehensive empirical analysis of the factors affecting growth and psychological development of over 100 infants from birth to age 6 months in the Embu region of Kenya. The analysis was divided into four parts. First, infants' birth weight, and length and head circumference as measured few days after birth, were modeled using multiple regression models. Maternal prepregnancy body mass index (BMI), gestation period, and parity were associated with infants' anthropometric measurements (P < 0.05). Second, the scores on seven clusters of the Brazelton Neonatal Behavioral Assessment Scale were explained by health and socioeconomic indicators. While the models had poor predictive power, the scores were comparable to those reported in the literature for Puerto Rican and African American infants. The third part of the analysis modeled infant growth between 1-6 months by analyzing longitudinal data on length, head circumference, and weight. Dynamic models were postulated for the effects of nutritional, socioeconomic, and environmental factors and morbidity on anthropometric variables. The results showed that infants' calcium intakes were positively associated with length (P < 0.05). Maternal BMI and hemoglobin concentration were positively associated with infant weight (P < 0. 05); infant morbidity was negatively associated with weight (P < 0. 05). Lastly, the infants' scores at 6 months on the Bayley Motor Scale and on eight items from the Bayley Infant Behavior Record were explained using anthropometric, socioeconomic, and psychological variables. The infants' arm circumference and intake of protein were significant predictors of scores on the Bayley Motor Scale. In addition, time spent by the mother talking to the infant was positively associated with the scores on the Bayley Infant Behavior Record. The empirical results have implications for identifying vulnerable children in developing countries.

To cultivate a new model: where de Soysa and Gleditsch fall short.

PIP: In the field of environmental security literature, there is a tendency to criticize the work of Thomas Homer-Dixon. Yet, research efforts that seek to improve upon Homer-Dixon's work have not produced models with more explanatory power or new insights. This paper reviews the article by Indra de Soysa and Nils Petter Gleditsch entitled "To Cultivate Peace: Agriculture in a World of Conflict" and examines its feasibility and similarity with the work of Homer-Dixon. In the article by de Soysa and Gleditsch, they argue that a lack of physical, human, and social capital (poverty) reduces agricultural production, which often leads to violent conflict. Their theory is interesting; however, a careful analysis of the basic causal process reveals that it covers the same territory previously covered by Homer-Dixon. Overall, it is noted that de Soysa and Gleditsch's article has not been a very productive approach to improving the understanding of the complex interaction between environmental scarcities and social systems.^ieng