Design of the PROstate cancer follow-up care in Secondary and Primary hEalth Care study (PROSPEC): a randomized controlled trial to evaluate the effectiveness of primary care-based follow-up of localized prostate cancer survivors.

BACKGROUND: In its 2006 report, From cancer patient to cancer survivor: lost in transition, the U.S. Institute of Medicine raised the need for a more coordinated and comprehensive care model for cancer survivors. Given the ever increasing number of cancer survivors, in general, and prostate cancer survivors, in particular, there is a need for a more sustainable model of follow-up care. Currently, patients who have completed primary treatment for localized prostate cancer are often included in a specialist-based follow-up care program. General practitioners already play a key role in providing continuous and comprehensive health care. Studies in breast and colorectal cancer suggest that general practitioners could also consider to provide survivorship care in prostate cancer. However, empirical data are needed to determine whether follow-up care of localized prostate cancer survivors by the general practitioner is a feasible alternative. METHODS: This multicenter, randomized, non-inferiority study will compare specialist-based (usual care) versus general practitioner-based (intervention) follow-up care of prostate cancer survivors who have completed primary treatment (prostatectomy or radiotherapy) for localized prostate cancer. Patients are being recruited from hospitals in the Netherlands, and randomly (1:1) allocated to specialist-based (N = 195) or general practitioner-based (N = 195) follow-up care. This trial will evaluate the effectiveness of primary care-based follow-up, in comparison to usual care, in terms of adherence to the prostate cancer surveillance guideline for the timing and frequency of prostate-specific antigen assessments, the time from a biochemical recurrence to retreatment decision-making, the management of treatment-related side effects, health-related quality of life, prostate cancer-related anxiety, continuity of care, and cost-effectiveness. The outcome measures will be assessed at randomization (≤6 months after treatment), and 12, 18, and 24 months after treatment. DISCUSSION: This multicenter, prospective, randomized study will provide empirical evidence regarding the (cost-) effectiveness of specialist-based follow-up care compared to general practitioner-based follow-up care for localized prostate cancer survivors. TRIAL REGISTRATION: Netherlands Trial Registry, Trial NL7068 (NTR7266). Prospectively registered on 11 June 2018.

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district.

BACKGROUND: With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. METHODS: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. RESULTS: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. CONCLUSION: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.

The Organization of Secondary Outpatient Care at SHS-DF. / A organização da atenção ambulatorial secundária na SESDF.

Secondary Outpatient Care (SOC) is a subject seldom studied in the literature, but of great importance for the strengthening of Primary Health Care (PHC) and the structuring of the Health Care Network. After the increase of PHC coverage following the Family Health Strategy (FHS) model, through the "CONVERTE APS" project, the State Health Secretariat of the Federal District (SHS-DF) identified the need to organize this level of care throughout the Federal District. SHS-DF has, as its Health Care Planning basis, the knowledge experienced in one of its regions, in addition to the theoretical framework produced and systematized by the National Council of Health Secretariats (CONASS) in recent years, as well as successful experiences in other regions of Brazil and countries with public health systems. The strategies to be used include the following: diagnosis and organization of facility structures, creation of a regional managerial level for Secondary Care, personnel sizing, development of the legal framework for level of care regulation, creation of technical milestones, regulation of medical and non-medical consultations in health regions and matrix support as an education strategy, but also of connection between levels of care.

A Atenção Ambulatorial Secundária (AASE) é um tema pouco estudado na literatura, porém de grande importância no fortalecimento da APS e na estruturação da Rede de Atenção à Saúde. Após a ampliação de cobertura da APS no modelo de eSF, por meio do CONVERTE APS, a SESDF, identificou-se a necessidade de organização deste nível de atenção em todo o Distrito Federal. Assim, tem como laboratório a experiência de Planificação da Atenção à Saúde vivenciada em uma de suas regiões, além de todo arcabouço teórico produzido e sistematizado pelo CONASS nos últimos anos, assim como experiências positivas em outras regiões do Brasil e de países com sistemas públicos de saúde. Para isso tem-se como estratégias o diagnóstico e a organização das estruturas físicas, criação de nível gestor regional da Atenção Secundária, dimensionamento de pessoal, desenvolvimento de marco legal para regulamentação do nível de atenção, criação de marcos técnicos, regulação das consultas médicas e não médicas nas regiões de saúde e o matriciamento como estratégia educação, mas também de vinculação entre os níveis de atenção.

A organização da atenção ambulatorial secundária na SESDF / The Organization of Secondary Outpatient Care at SHS-DF

Resumo A Atenção Ambulatorial Secundária (AASE) é um tema pouco estudado na literatura, porém de grande importância no fortalecimento da APS e na estruturação da Rede de Atenção à Saúde. Após a ampliação de cobertura da APS no modelo de eSF, por meio do CONVERTE APS, a SESDF, identificou-se a necessidade de organização deste nível de atenção em todo o Distrito Federal. Assim, tem como laboratório a experiência de Planificação da Atenção à Saúde vivenciada em uma de suas regiões, além de todo arcabouço teórico produzido e sistematizado pelo CONASS nos últimos anos, assim como experiências positivas em outras regiões do Brasil e de países com sistemas públicos de saúde. Para isso tem-se como estratégias o diagnóstico e a organização das estruturas físicas, criação de nível gestor regional da Atenção Secundária, dimensionamento de pessoal, desenvolvimento de marco legal para regulamentação do nível de atenção, criação de marcos técnicos, regulação das consultas médicas e não médicas nas regiões de saúde e o matriciamento como estratégia educação, mas também de vinculação entre os níveis de atenção.

Abstract Secondary Outpatient Care (SOC) is a subject seldom studied in the literature, but of great importance for the strengthening of Primary Health Care (PHC) and the structuring of the Health Care Network. After the increase of PHC coverage following the Family Health Strategy (FHS) model, through the "CONVERTE APS" project, the State Health Secretariat of the Federal District (SHS-DF) identified the need to organize this level of care throughout the Federal District. SHS-DF has, as its Health Care Planning basis, the knowledge experienced in one of its regions, in addition to the theoretical framework produced and systematized by the National Council of Health Secretariats (CONASS) in recent years, as well as successful experiences in other regions of Brazil and countries with public health systems. The strategies to be used include the following: diagnosis and organization of facility structures, creation of a regional managerial level for Secondary Care, personnel sizing, development of the legal framework for level of care regulation, creation of technical milestones, regulation of medical and non-medical consultations in health regions and matrix support as an education strategy, but also of connection between levels of care.

Doctors' opinions on clinical coordination between primary and secondary care in the Catalan healthcare system.

OBJECTIVE: To analyse doctors' opinions on clinical coordination between primary and secondary care in different healthcare networks and on the factors influencing it. METHODS: A qualitative descriptive-interpretative study was conducted, based on semi-structured interviews. A two-stage theoretical sample was designed: 1) healthcare networks with different management models; 2) primary care and secondary care doctors in each network. Final sample size (n = 50) was reached by saturation. A thematic content analysis was conducted. RESULTS: In all networks doctors perceived that primary and secondary care given to patients was coordinated in terms of information transfer, consistency and accessibility to SC following a referral. However, some problems emerged, related to difficulties in acceding non-urgent secondary care changes in prescriptions and the inadequacy of some referrals across care levels. Doctors identified the following factors: 1) organizational influencing factors: coordination is facilitated by mechanisms that facilitate information transfer, communication, rapid access and physical proximity that fosters positive attitudes towards collaboration; coordination is hindered by the insufficient time to use mechanisms, unshared incentives in prescription and, in two networks, the change in the organizational model; 2) professional factors: clinical skills and attitudes towards coordination. CONCLUSIONS: Although doctors perceive that primary and secondary care is coordinated, they also highlighted problems. Identified factors offer valuable insights on where to direct organizational efforts to improve coordination.

The effects of integrated care: a systematic review of UK and international evidence.

BACKGROUND: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS: The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS: One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION: Prospero registration number: 42016037725 .

Implementation of dental specialty centers: a descriptive analysis of the current status in the Brazilian territory

ABSTRACT This study aimed to assess the current implementation status of Dental Specialty Centers (Centros de Especialidades Odontológicas - CEO) in Brazil. The sample included CEOs implemented up to November 2015 in the 27 Brazilian federative units. Data were obtained directly from the database of the Informatics Department of the Brazilian Unified Health System, according to the National Registry of Health Facilities (NRHF) of Dental Specialty Centers of all Brazilian regions. Primary care data were also collected from the cities with implemented CEOs, including coverage status of the Family Health Strategy (FHS) and number of Oral Health Teams (OHT) I and II, at 2 collection periods (January 2006 and November 2015). There were 1019 CEOs implemented in Brazil, which were unequally distributed among the Brazilian states, with prevalence of implementation of CEOs type II (n=503, 49.4%). The statistical analysis showed significant difference between the three types of CEO (I, II, and III) and the variables of coverage rate (FHS) and number of teams (OHT I, OHT II) at both data collection periods. Although presenting an evolutionary aspect in the implementation of CEOs, the implementation of medium-complexity care in Brazil is disorganized.

Implementation of dental specialty centers: a descriptive analysis of the current status in the Brazilian territory.

This study aimed to assess the current implementation status of Dental Specialty Centers (Centros de Especialidades Odontológicas - CEO) in Brazil. The sample included CEOs implemented up to November 2015 in the 27 Brazilian federative units. Data were obtained directly from the database of the Informatics Department of the Brazilian Unified Health System, according to the National Registry of Health Facilities (NRHF) of Dental Specialty Centers of all Brazilian regions. Primary care data were also collected from the cities with implemented CEOs, including coverage status of the Family Health Strategy (FHS) and number of Oral Health Teams (OHT) I and II, at 2 collection periods (January 2006 and November 2015). There were 1019 CEOs implemented in Brazil, which were unequally distributed among the Brazilian states, with prevalence of implementation of CEOs type II (n=503, 49.4%). The statistical analysis showed significant difference between the three types of CEO (I, II, and III) and the variables of coverage rate (FHS) and number of teams (OHT I, OHT II) at both data collection periods. Although presenting an evolutionary aspect in the implementation of CEOs, the implementation of medium-complexity care in Brazil is disorganized.

[The interface between primary and secondary care in dentistry in the Unified Health System (SUS): an integrative systematic review]. / Interface entre a Atenção Primária e a Secundária em odontologia no Sistema Único de Saúde: uma revisão sistemática integrativa.

Secondary care in dentistry in Brazil has scarce and broadly underutilized resources. The challenge is to organize the interface between primary health care (PHC) and secondary care in order to consolidate the population's access to specialist dental care in the Unified Health System (SUS). This article seeks to analyze national publications in Portuguese and English on the interface between secondary health care and primary health care in dentistry from the perspective of comprehensive care in the SUS. It is an integrative review, considering the publications of the following databases: SciELO (Scientific Electronic Library Online), LILACS (Latin American and Caribbean Literature) WEB OF SCIENCE, SCOPUS, PubMed (International Literature on Health Sciences) and GOOGLE SCHOLAR. The search located 966 articles, of which 12 were used in full. Coverage of the oral health teams (ESB) in the family health strategy (ESF), primary health care implementation in a structured way, access to secondary health care, counter-referral to PHC, development of indicators and socioeconomic conditions and inequalities in the distribution of dental specialist centers (CEO) are factors that influence the integrity of oral health care in the SUS.

Interface entre a Atenção Primária e a Secundária em odontologia no Sistema Único de Saúde: uma revisão sistemática integrativa / The interface between primary and secondary care in dentistry in the Unified Health System (SUS): an integrative systematic review

Resumo A atenção secundária em odontologia no Brasil apresenta recursos escassos e em grande parte subutilizados. O desafio consiste em realizar a interface entre a atenção primária à saúde (APS) e a atenção secundária de forma a consolidar o acesso da população à atenção odontológica especializada no Sistema Único de Saúde (SUS). O objetivo deste artigo é analisar publicações nacionais em língua portuguesa e inglesa sobre a interface entre a atenção secundária e a APS em odontologia na perspectiva da integralidade do cuidado no âmbito do SUS. Revisão integrativa considerando as publicações dos seguintes bancos de dados: SciELO (Scientific Eletronic Library Online), Lilacs (Literatura Latino-Americana e do Caribe), Web of Science, Scopus, PubMed (Literatura Internacional em Ciências da Saúde) e Google Acadêmico. Foram encontrados 966 artigos, dos quais 12 foram utilizados na integra. A cobertura das equipes de saúde bucal (ESB) nas estratégias de saúde da família (ESF), a implantação da APS de forma estruturada, o acesso a atenção secundária, o contrarreferenciamento para APS, os indicadores de desenvolvimento e as condições socioeconômicas e desigualdades na distribuição dos CEO's são fatores que influenciam a integralidade do cuidado em saúde bucal no SUS.

Abstract Secondary care in dentistry in Brazil has scarce and broadly underutilized resources. The challenge is to organize the interface between primary health care (PHC) and secondary care in order to consolidate the population's access to specialist dental care in the Unified Health System (SUS). This article seeks to analyze national publications in Portuguese and English on the interface between secondary health care and primary health care in dentistry from the perspective of comprehensive care in the SUS. It is an integrative review, considering the publications of the following databases: SciELO (Scientific Electronic Library Online), LILACS (Latin American and Caribbean Literature) WEB OF SCIENCE, SCOPUS, PubMed (International Literature on Health Sciences) and GOOGLE SCHOLAR. The search located 966 articles, of which 12 were used in full. Coverage of the oral health teams (ESB) in the family health strategy (ESF), primary health care implementation in a structured way, access to secondary health care, counter-referral to PHC, development of indicators and socioeconomic conditions and inequalities in the distribution of dental specialist centers (CEO) are factors that influence the integrity of oral health care in the SUS.

Improving the appropriateness of prescribing in older patients: a systematic review and meta-analysis of pharmacists' interventions in secondary care.

INTRODUCTION: potentially inappropriate prescribing (PIP) in older hospitalised patients, and in particular those with dementia, is associated with poorer health outcomes. PIP reduction is therefore essential in this population. METHODS: a comprehensive electronic literature search was conducted using 12 databases from inception up to and including September 2014. Inclusion criteria were controlled trials (randomised or non-randomised) of interventions involving pharmacists conducted in hospitals, with an objective of the study being PIP reduction in patients 65 years or older or patients with dementia of any age, using any validated PIP tool as an outcome measure. Risk of bias assessments were conducted utilising the Cochrane Collaboration's tool. RESULTS: a total of 1,752 records were found after duplicates were removed. Four trials (n = 1,164 patients; two randomised, two non-randomised) from three countries were included in the quantitative analysis. All studies were at moderate risk of bias. No study focused specifically on dementia patients. Three trials reported statistically significant reductions in the Medication Appropriateness Index score in the intervention group (mean difference from admission to discharge = -7.45, 95% CI: -11.14, -3.76) and other PIP tools such as Beers Criteria. One trial reported reduced drug-related readmissions and another reported increased adverse drug reactions. CONCLUSION: multi-disciplinary teams involving pharmacists may improve prescribing appropriateness in older inpatients, though the clinical significance of observed reductions is unclear. More research is required into the effectiveness of pharmacists' interventions in reducing PIP in dementia patients. Additionally, easily assessed and clinically relevant measures of PIP need to be developed.

Integrating primary and secondary care for children and young people: sharing practice.

OBJECTIVE: To share innovative practice with enough detail to be useful for paediatricians involved in planning services. DESIGN: A review of practice, adopting a realist approach. SETTING: We collected detailed information about five initiatives which were presented at two meetings in July and October 2014 and telephone interviews between July and November 2014 with key informants, updating information again in February 2015. RESULTS: The five case studies involved three clinical commissioning groups (CCGs): Islington CCG and Southwark and Lambeth CCG in London and Taunton CCG in the Southwest. All five initiatives involved acute paediatric units. We heard about four distinct types of services designed to bring paediatric expertise into primary care and/or improve joint working between paediatricians and primary care professionals: telephone multidisciplinary team, hospital at home, general practitioner (GP) outreach clinics, and advice and guidance. We defined four common ways that initiatives might work: promoting shared responsibility; upskilling GPs; establishing relationships between paediatricians and primary healthcare professionals; and by taking specialist care to the patient. CONCLUSIONS: We derived common aims and mechanisms and generated programme (mid-level) theory for each integrated care initiative about how they might work. These descriptions of what is being done can inform debate about which interventions should be prioritised for wider implementation. There is an urgent need for evaluation of these interventions and more indepth research into how mechanisms and their effectiveness could be assessed.

Continuity of care: what matters to women when they are referred from primary to secondary care during labour? a qualitative interview study in the Netherlands.

BACKGROUND: Continuity of care during labour is important for women. Women with an intrapartum referral from primary to secondary care look back more negatively on their birh experience compared to those who are not referred. It is not clear which aspects of care contribute to this negative birth experience. This study aimed to explore in-depth the experiences of women who were referred during labour from primary to secondary care with regard to the different aspects of continuity of care. METHODS: A qualitative interview study was conducted in the Netherlands among women who were in primary care at the onset of labour and were referred to secondary care before the baby was born. Through purposive sampling 27 women were selected. Of these, nine women planned their birth at home, two in an alongside midwifery unit and 16 in hospital. Thematic analysis was used. RESULTS: Continuity of care was a very important issue for women because it contributed to their feeling of safety during labour. Important details were sometimes not handed over between professionals within and between primary and secondary care, in particular about women's personal preferences. In case of referral of care from primary to secondary care, it was important for women that midwives handed over the care in person and stayed until they felt safe with the hospital team. Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected.Fear of transportion during or after labour was a reason for women to choose hospital birth but also to opt for home birth. Choice of place of birth emerged as a fluid concept; most women planned their place of birth during pregnancy and were aware that they would spend some time at home and possibly some time in hospital. CONCLUSIONS: In case of referral from primary to secondary care during labour, midwives should hand over their care in person and preferrably stay with women throughout labour. Planned place of birth should be regarded as a fluid concept rather than a dichotomous choice.

A governance model for integrated primary/secondary care for the health-reforming first world - results of a systematic review.

BACKGROUND: Internationally, key health care reform elements rely on improved integration of care between the primary and secondary sectors. The objective of this systematic review is to synthesise the existing published literature on elements of current integrated primary/secondary health care. These elements and how they have supported integrated healthcare governance are presented. METHODS: A systematic review of peer-reviewed literature from PubMed, MEDLINE, CINAHL, the Cochrane Library, Informit Health Collection, the Primary Health Care Research and Information Service, the Canadian Health Services Research Foundation, European Foundation for Primary Care, European Forum for Primary Care, and Europa Sinapse was undertaken for the years 2006-2012. Relevant websites were also searched for grey literature. Papers were assessed by two assessors according to agreed inclusion criteria which were published in English, between 2006-2012, studies describing an integrated primary/secondary care model, and had reported outcomes in care quality, efficiency and/or satisfaction. RESULTS: Twenty-one studies met the inclusion criteria. All studies evaluated the process of integrated governance and service delivery structures, rather than the effectiveness of services. They included case reports and qualitative data analyses addressing policy change, business issues and issues of clinical integration. A thematic synthesis approach organising data according to themes identified ten elements needed for integrated primary/secondary health care governance across a regional setting including: joint planning; integrated information communication technology; change management; shared clinical priorities; incentives; population focus; measurement - using data as a quality improvement tool; continuing professional development supporting joint working; patient/community engagement; and, innovation. CONCLUSIONS: All examples of successful primary/secondary care integration reported in the literature have focused on a combination of some, if not all, of the ten elements described in this paper, and there appears to be agreement that multiple elements are required to ensure successful and sustained integration efforts. Whilst no one model fits all systems these elements provide a focus for setting up integration initiatives which need to be flexible for adapting to local conditions and settings.

Factors associated to experienced continuity of care between primary and outpatient secondary care in the Catalan public healthcare system.

OBJECTIVE: To analyze patient's reported elements of relational, informational and managerial (dis)continuity between primary and outpatient secondary care and to identify associated factors. METHODS: Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care for the same condition. The study settings consisted of three health areas of the Catalan health system. Data were collected in 2010 using the CCAENA questionnaire, which identifies patients' experiences of continuity of care. Descriptive analyses and multivariable logistic regression models were carried out. RESULTS: Elements of continuity of care were experienced by most patients. However, elements of discontinuity were also identified: 20% and 15% were seen by more than one primary or secondary care physician, respectively. Their secondary care physician or both professionals were identified as responsible for their care by 40% and 45% of users, respectively. Approximately 20% reported a lack of information transfer. Finally, 72% of secondary care consultations were due to primary care referral, whilst only 36% reported a referral back to primary care. Associated factors were healthcare setting, age, sex, perceived health status and disease duration. CONCLUSION: Users generally reported continuity of care, although elements of discontinuity were also identified, which can be partially explained by the healthcare setting and some individual factors. Elements of discontinuity should be addressed to better adapt care to patients' needs.

La eficiencia del programa integral de salud mental: perspectivas asistenciales, docentes y de investigación / The efficiency of the Integral Program of Mental Health: Assistencial, Teaching and Research Perspectives

Se define el modelo integral de programas de Salud mental, que combina la eficiencia de la medicina popular con la eficacia de la medicina científica, en una estructura piramidal de delegación de funciones. En el nivel primario de atención, se discute la eficiencia del programa aplicada a alcoholismo, neurosis, privación sensorial y psicosis, por niveles de delegación. El nivel D5, población expuesta, aprende a reconocer estos cuadros y nociones de prevención. El nivel D4, ex-pacientes entrenados como líderes, resuelven casos simples y educan a D5.El nivel D3, técnicos o lideres formales, resuelven problemas más complejos. Los niveles D2 y D1, profesionales, resuelven los casos de mayor complejidad y dirigen el programa. Se presentan datos del área sur de Santiago que muestran que el Programa Integral resuelve con eficiencia los dilemas: 1) Nivel de cobertura de las acciones vs. complejidad de ellas. 2) Calidad de las técnicas vs. costo de ellas. 3) Eficacia de las técnicas vs. reacciones adversas de ellas. Se enfatiza la eficiencia del Programa Integral en el aspecto docente, en los 5 niveles de delegación, así como en las investigación operativa orientada a evaluarlo en una comunidad. Se recomienda iniciar, para este último propósito, un Area Experimental, de 100 a 200,000 habitantes, en cada país latinoamericano