A Systematic Review of Economic Aspects of Service Interventions to Increase Anticoagulation Use in Atrial Fibrillation.

OBJECTIVE: To systematically identify and appraise existing evidence surrounding economic aspects of anticoagulation service interventions for patients with atrial fibrillation. METHODS: We searched the published and grey literature up to October 2019 to identify relevant economic evidence in any health care setting. A narrative-synthesis approach was taken to summarise evidence by economic design and type of service intervention, with costs expressed in pound sterling and valued at 2017 to 2018 prices. RESULTS: A total of 13 studies met our inclusion criteria from 1,168 papers originally identified. Categories of interventions included anticoagulation clinics (n = 4), complex interventions (n = 4), decision support tools (n = 3) and patient-centred approaches (n = 2). Anticoagulation clinics were cost-saving compared with usual care (range for mean cost difference: £188-£691 per-patient per-year) with equivalent health outcomes. Only one economic evaluation of a complex intervention was conducted; case management was more expensive than usual care (mean cost difference: £255 per-patient per-year) and the probability of its cost-effectiveness did not exceed 70%. There was limited economic evidence surrounding decision support tools or patient-centred approaches. Targeting service interventions at high-risk groups and those with suboptimal treatment was most likely to result in cost savings. CONCLUSION: This review revealed some evidence to support the cost-effectiveness of anticoagulation clinics. However, summative conclusions are constrained by a paucity of economic evidence, a lack of direct comparisons between interventions, and study heterogeneity in terms of intervention, comparator and study year. Further research is urgently needed to inform commissioning and service development. Data from this review can inform future economic evaluations of anticoagulation service interventions.

Respiratory Tract Infection Management and Antibiotic Prescription in Children: A Unique Study Comparing Three Levels of Healthcare in The Netherlands.

BACKGROUND: Respiratory tract infections (RTIs) are common in children with febrile illness visiting the general practitioner (GP) or emergency department. We studied the management of children with fever and RTI at 3 different levels of healthcare in The Netherlands, focusing on antibiotic prescription. METHODS: This prospective observational study is part of the Management and Outcome of Febrile children in Europe study. Data were used from face-to-face patient contacts of children with febrile illness in three healthcare settings in Nijmegen, The Netherlands during 2017. These settings were primary (GP), secondary (general hospital) and tertiary care (university hospital). RESULTS: Of 892 cases with RTI without complex comorbidities, overall antibiotic prescription rates were 29% with no differences between the 3 levels of healthcare, leading to an absolute number of 5031 prescriptions per 100,000 children per year in primary care compared with 146 in secondary and tertiary care combined. The prescription rate in otitis media was similar in all levels: 60%. In cases with lower RTI who received nebulizations prescription rates varied between 19% and 55%. CONCLUSIONS: Antibiotic prescription rates for RTIs in children were comparable between the 3 levels of healthcare, thus leading to a majority of antibiotics being prescribed in primary care. Relatively high prescription rates for all foci of RTIs were found, which was not in agreement with the national guidelines. Antibiotic stewardship needs improvement at all 3 levels of healthcare. Guidelines to prescribe small spectrum antibiotics for RTIs need to be better implemented in hospital care settings.

PEGuilação do peptídeo Lunatina-1 visando novo candidato à fármaco antimicrobiano / PEGylation of the peptide Lunatin-1 aiming at novel candidate for antimicrobial drug

As infecções relacionadas à assistência à saúde (IRAS) podem ser causadas por bactérias, vírus e fungos, sendo de extrema importância para o sistema de tratamento e pacientes. Com o alarmante avanço no surgimento de bactérias resistentes, tem havido uma preocupação crescente com as IRAS de origem bacteriana. Nesse sentido, várias pesquisas buscam alternativas para os fármacos antimicrobianos convencionais, sendo que os peptídeos antimicrobianos (AMPs), como a lunatina-1, aparecem como moléculas promissoras. No entanto, os AMPs geralmente apresentam rápida degradação proteolítica no trato gastrointestinal e meia-vida curta na corrente sanguínea, principais fatores limitantes para sua aplicação no tratamento de IRAS. Entre as estratégias empregadas para superar esses inconvenientes, a PEGuilação apresenta-se como alternativa eficaz que aumenta o tempo de circulação in vivo dos AMPs, resultando na melhora farmacocinética e, em alguns casos, também farmacodinâmica. A PEGuilação consiste na ligação covalente de cadeias de polietileno glicol (PEG) ao peptídeo, que pode ser efetuada por meio de uma reação aleatória ou sítio-específica. Neste trabalho, desenvolveu-se uma PEGuilação sítio-específica no N-terminal da lunatina-1 empregando-se mPEG-NHS de 2 kDa em tampão fosfato 100 mM, visando o aumento da solibilidade deste peptídeo, bem como para avaliar sua ação antimicrobiana. Com relação à reação de PEGuilação, avaliou-se a influência da razão molar PEG:peptídeo (10:1 ou 15:1) a pH 8,5. Foi obtido um rendimento de PEGuilação de 92%, através da análise por RP-HPLC quantitativo. Quanto à purificação da lunatina-1 PEGuilada, foi empregada a técnica semi-preparativa de RP-HPLC utilizando a coluna C18. A caracterização da lunatina-1 PEGuilada, incluindo determinação do grau de PEGuilação, foi realizada por MALDI-TOF Autoflex Speed (Bruker), mostrando que a molécula foi monoPEGuilada na região N-terminal. A atividade antimicrobiana de lunatina-1 livre e bioconjugada frente a diferentes cepas bacterianas, sendo duas Gram-negativas (ATCC 25922 de Escherichia coli e ATCC 9027 de Pseudomonas aeruginosa) e uma Gram-positiva (CECT 239 de Staphylococcus aureus), foi estudada por determinação da concentração inibitória mínima (CIM) em microplaca, sendo que foram obtidos valores de CIM de 86 e 140 µM para o peptídeo liver e PEGuilado, respetivamente. O potencial hemolítico também foi estudado, sendo que a forma PEGuilada mostrou significativa redução da atividade hemolítica em comparação à forma livre. Em suma, a PEGuilação da lunatina-1, aumenta a sua solubilidade e reduz a atividade hemolítica. Porém, para viabilizar esta estratégia a PEGuilação deve ser reversível, pois a conjugação ao polímero reduz atividade antimicrobiana

Health care-related infections (HAIs) caused by bacteria, viruses and fungi are extremely important for patients and health systems. With the alarming advance in the emergence of resistant bacteria, a growing concern with HAIs of bacterial origin is observed. In this sense, several studies investigate alternatives to conventional antimicrobial drugs and antimicrobial peptides (AMPs), such as lunatin-1, appear as promising molecules. However, AMPs generally show rapid proteolytic degradation in the gastrointestinal tract and short half-life in the bloodstream, the main limiting factors for their therapeutic application to treat HAIs. Among the strategies used to overcome these drawbacks, PEGylation presents itself as an effective alternative that increases the in vivo circulation time of AMPs, resulting in improved pharmacokinetics and, in some cases, also pharmacodynamics. PEGylation consists on the covalent attachment of polyethylene glycol (PEG) chains to the peptide, which can be carried out by means of a random or site-specific reaction. In this work, a site-specific PEGylation was developed at the N-terminus of lunatin-1 using 2 kDa mPEG-NHS to increase the solubility of this peptide, as well as to evaluate its antimicrobial activity. Regarding the PEGylation reaction, the influence of the molar ratio PEG: peptide (10: 1 or 15: 1) at pH 8.5 was evaluated and a PEGylation yield of 92% was obtained, based on quantitative RP-HPLC analysis. As for the purification of PEGylated lunatin-1, semi-preparative RP-HPLC was used. The characterization of PEGylated lunatin-1, including determination of the degree of PEGylation, was performed by MALDI-TOF Autoflex Speed (Bruker), showing that the peptide was monoPEGylated in the N-terminal region. The antimicrobial activity of free and bioconjugated lunatin-1 against different bacterial strains, two Gram-negative (ATCC 25922 from Escherichia coli and ATCC 9027 from Pseudomonas aeruginosa), and one Gram positive (CECT 239 from Staphylococcus aureus), was studied by determining the minimum inhibitory concentration (MIC) in a microplate, resulting in MIC values of 86 and 140 µM for the free and PEGylated peptide, respectively. The hemolytic potential was also studied and the PEGylated form showed a significant reduction in hemolytic activity compared to the free form. In short, the PEGylation of lunatin-1 increases its solubility and reduces hemolytic activity. However, to make this strategy feasible, PEGylation must be reversible, since the conjugation to the polymer reduces antimicrobial activity

Healthcare professionals' opinions, barriers and facilitators towards low-value clinical practices in the hospital setting / Opiniones, barreras y facilitadores de los profesionales de la salud hacia las prácticas clínicas de poco valor en el ámbito hospitalario

OBJECTIVE: To explore healthcare professionals' opinions about low-value practices, identify practices of this kind possibly present in the hospital and barriers and facilitators to reduce them. Low-value practices include those with little or no clinical benefit that may harm patients or lead to a waste of resources. METHOD: Using a mixed methodology, we carried out a survey and two focus groups in a tertiary hospital. In the survey, we assessed doctors' agreement, subjective adherence and perception of usefulness of 134 recommendations to reduce low-value practices from local and international initiatives. We also identified low-value practices possibly present in the hospital. In the focus groups with professionals from surgical and medical fields, using a phenomenological approach, we identified additional low-value practices, barriers and facilitators to reduce them. RESULTS: 169 doctors of 25 specialties participated (response rate: 7%-100%). Overall agreement with recommendations, subjective adherence and usefulness were 83%, 90% and 70%, respectively. Low-value practices form 22 recommendations (16%) were considered as possibly present in the hospital. In the focus groups, the professionals identified seven more. Defensive medicine and scepticism due to contradictory evidence were the main barriers. Facilitators included good leadership and coordination between professionals. CONCLUSIONS: High agreement with recommendations to reduce low-value practices and high perception of usefulness reflect great awareness of low-value care in the hospital. However, there are several barriers to reduce them. Interventions to reduce low-value practices should foster confidence in decision-making processes between professionals and patients and provide trusted evidence

OBJETIVO: Explorar las opiniones de profesionales sanitarios sobre las prácticas de poco valor, identificar aquellas posiblemente presentes en el hospital y las barreras y los facilitadores para reducirlas. Las prácticas de poco valor incluyen aquellas con poco beneficio clínico que pueden perjudicar a los pacientes o desperdiciar recursos. MÉTODO: Usando una metodología mixta se llevaron a cabo una encuesta y varios grupos focales en un hospital terciario. En la encuesta se evaluó el grado de acuerdo, la adherencia subjetiva y la percepción de utilidad de 134 recomendaciones para reducir las prácticas de poco valor de iniciativas locales e internacionales, y se identificaron aquellas que podrían estar realizándose en el hospital. En dos grupos focales con profesionales de campos médicos y quirúrgicos, utilizando un enfoque fenomenológico, se identificaron prácticas de poco valor adicionales, barreras y facilitadores para reducirlas. RESULTADOS: En la encuesta participaron 169 médicos de 25 especialidades (tasa de respuesta: 7-100%). El acuerdo con las recomendaciones, la adherencia subjetiva y la utilidad fueron del 83%, el 90% y el 70%, respectivamente. Se identificaron prácticas de poco valor de 22 recomendaciones (16%) posiblemente presentes en el hospital. En los grupos focales se identificaron siete prácticas de poco valor adicionales; la medicina defensiva y el escepticismo debido a evidencia contradictoria como principales barreras; y un buen liderazgo y la coordinación entre profesionales como facilitadores. CONCLUSIONES: El alto grado de acuerdo con las recomendaciones para reducir las prácticas de poco valor y la alta percepción de utilidad reflejan una gran concienciación sobre este problema en el hospital. Sin embargo, existen numerosas barreras para eliminarlas. Las intervenciones para reducirlas deberían fomentar la confianza en la toma de decisiones entre profesionales y pacientes, y proporcionar una evidencia confiable

What we talk about when we talk about care management.

To support effective care management programs in the context of value-based care, we propose a framework categorizing care management as disease management, utilization management, and care navigation interventions.

Integration vs separation in the provision of health care: 24 OECD countries compared.

This article proposes a classification of the different national health care systems based on the way the network of health care providers is organised. To this end, we present two rivalling models: on the one hand, the integrated model and, on the other, the separated model. These two models are defined based on five dimensions: (1) integration of insurer and provider; (2) integration of primary and secondary care; (3) presence of gatekeeping mechanisms; (4) patient's freedom of choice; and (5) solo or group practice of general practitioners. Each of these dimensions is applied to the health care systems of 24 OECD countries. If we combine the five dimensions, we can arrange the 24 national cases along a continuum that has the integrated model and the separated model at the two opposite poles. Portugal, Spain, New Zealand, the UK, Denmark, Ireland and Israel are to be considered highly integrated, while Italy, Norway, Australia, Greece and Sweden have moderately integrated provision systems. At the opposite end, Austria, Belgium, France, Germany, the Republic of Korea, Japan, Switzerland and Turkey have highly separated provision systems. Canada, The Netherlands and the United States can be categorised as moderately separated.

Medication use by adults in greater Manaus: a population-based cross-sectional study, 2015

The use of medicines can be an indicator of healthcare access. Our aim was to evaluate the consumption of medicine and associated factors among adults in Manaus Metropolitan Region, located in the north of Brazil. A cross-sectional population-based study was conducted with adults, ≥18 years old, selected by probabilistic sampling. The outcome was the use of medicine in the previous 15 days. Poisson regression with robust variance was used to calculate the prevalence ratio (PR) of medicine consumption, with 95% confidence interval (CI). Use of medicines was reported by 29% (95% CI: 28-31%) of the participants. People with good (PR: 0.82, 95% CI: 0.72-0.94) and fair (PR: 0.77, 95% CI: 0.65-0.90) health status were shown to use less medication than those with very good health. People with partners (PR: 1.19, 95% CI: 1.08-1.31), and people who had sought healthcare service in the fortnight (PR: 2.16, 95% CI: 1.97-2.37) showed higher medicine consumption. Medical prescription (80.1%) was the main inductor of consumption; purchasing at a drug store (46.4%), and acquiring through the Brazilian Unified Health System (39.6%) were the main ways to obtain medicines. About one-third of adults in the Metropolitan Region of Manaus used medicines regularly, mainly people with very good health, living with partners, and with recent use of a health service.

The last week of life of nursing home residents with advanced dementia: a retrospective study.

BACKGROUND: Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region. METHODS: This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death. RESULTS: Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death. CONCLUSIONS: Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.

Mortalidad por infecciones asociadas a la asistencia sanitaria. Hospital Abel Santa María Cuadrado, 2015 / Mortality due to Infections associated with healthcare. Abel Santa María Cuadrado Hospital, 2015

Objetivo: caracterizar la mortalidad por infecciones asociadas a la asisten-cia sanitaria (IAAS) en el Hospital Abel Santamaría Cuadrado de Pinar del Río durante el año 2015.Metodología: estudio descriptivo de corte transversal. La muestra estuvo constituida por 278 pacientes fallecidos por infecciones asociadas a la asistencia sanitaria con necropsia realizada y datos completos en la historia clínica. Resultados: el 40.6% de pacientes presentó una estadía hospitalaria de 22 días y más. El 66.2% presentó una infección de localización respiratoria, siendo la neumonía nosocomial la principal causa de muerte. El 28.8% de los organismos aislados fueron Enterobacter ssp. El antibiótico más utilizado fue la Ciprofloxacino, con un 54.3% y el procedimiento invasivo más prevalente fue el cateterismo vesical (84.2%). Conclusiones las principales variables asociadas a la mortalidad por IAAS fueron la sobrestadía hospitalaria y el uso de catéter urinario. La infección de localización respiratoria fue la más frecuente con predominio de gérmenes gram negativos. Se evidenció un elevado uso de antibióticos.

Where, when, and how the diagnosis of human visceral leishmaniasis is defined: answers from the Brazilian control program.

BACKGROUND: Timely diagnosis is recommended by the Brazilian Visceral Leishmaniasis (VL) Surveillance and Control Program to reduce case fatality. Attempts at assessing this topic in Brazil are scarce. OBJECTIVE: This study aimed to describe where, when, and how the diagnosis of VL has been performed in a Brazilian endemic setting. METHODS: Data of all autochthonous cases confirmed between 2011 and 2016 (N = 81) were recorded. The care-seeking itinerary until the confirmation of VL diagnosis was assessed among 57 patients. FINDINGS: The majority of VL cases (79.1%) were reported by referral hospitals. The patients mainly sought primary health care centres at the onset of symptoms. However, they had to visit seven health services on average to achieve a confirmed diagnosis. The time from the onset of symptoms to the diagnosis of VL (TD) ranged from 1-212 (median, 25) days. The TD was longer among adult patients. There was a direct correlation between the patient's age and TD (r = 0.22; p = 0.047) and a higher occurrence of deaths due to the disease among older patients (p = 0.002). Almost all the patients (98.9%) underwent laboratory investigation, and the VL diagnosis was mainly confirmed based on clinical-laboratory criteria (92.6%). Positive results for the indirect fluorescence antibody test (22.7%) and parasitological examination plus rk39-based immunochromatographic tests (21.3%) were commonly employed. MAIN CONCLUSIONS: VL diagnosis was predominantly conducted in hospitals with a long TD and wide application of serology. These findings may support measures focused on early diagnosis, including a greater involvement of the primary health care system.

Measuring racial segregation in health system networks using the dissimilarity index.

Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care).

Journey of the Patient With Melanoma: Understanding Resource Use and Bridging the Gap Between Dermatologist, Surgeon, and Oncologist in Different Health Care Systems.

PURPOSE: New scientific evidence has led to modifications in the clinical practice of handling melanoma. In health care systems, there is currently a wide variety of clinical procedures to treat cancer, and the various routes have different effects on the survival of patients with cancer. Thus, this article aimed to evaluate the journey of patients with melanoma in the public and private health care systems in Brazil from the viewpoint of different medical professionals involved in the diagnosis and treatment of the disease. The study also considers the resources used for the complete delivery cycle of health care at different stages of the evolution of melanoma. METHODS: We conducted a behavioral study by applying a questionnaire to a group of medical professionals. A nonprobabilistic sampling method for convenience was used, justified by the heterogeneous national incidence and the limited availability of medical professionals who diagnose and treat melanoma. RESULTS: The questionnaire was answered by 138 doctors, including doctors from the Brazilian states with the highest concentration of medical specialists and regions with a higher melanoma incidence. The results of this study have the potential to enrich our understanding of the reality of Brazilian health care systems and, at the same time, allow us to discuss the multiple ways in which professionals from diverse specialist fields understand and explain decision making in health care. CONCLUSION: Health care decision making is complex and, among other factors, depends on the diversity of available health resources and the knowledge of which treatments provide the greatest benefit to patients and greatest value to the system as a whole. This work can inform debates and reflection that are applicable not only in Brazil, but also in various other countries with similar realities.

Worlds of Healthcare: A Healthcare System Typology of OECD Countries.

In this paper, we present an extended typology of OECD healthcare systems. Our theoretical framework integrates the comparative-institutional perspective of existing classifications with current ideas from the international health policy research debate. We argue that combining these two perspectives provides a more comprehensive picture of modern healthcare systems and takes the past decade's dynamic of reforms into account. Moreover, this approach makes the typology more beneficial in terms of understanding and explaining cross-national variation in population health and health inequalities. Empirically, we combine indicators on supply, public-private mix, and institutional access regulations from earlier typologies with information on primary care orientation and performance management in prevention and quality of care. The results from a series of cluster analyses indicate that at least five distinct types of healthcare systems can be identified. Moreover, we provide quantitative information on the consistency of cluster membership for individual countries via system types.

Are movement-based classification systems more effective than therapeutic exercise or guideline based care in improving outcomes for patients with chronic low back pain? A systematic review.

Objectives: The purpose of this systematic review was to determine if movement-based classification (MBC) systems are more effective than therapeutic exercise or guideline-based care (GBC) in improving outcomes in patients with low back pain (LBP) based upon randomized clinical trials (RCT) with moderate to high methodological quality and low to moderate risk of bias. Methods: The search strategy was developed by a librarian experienced in systematic review methodology and peer reviewed by a second research librarian. The following databases were searched from their inception to May 17, 2018: PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. The identified RCTs with a PEDro score of ≥6 were screened and assessed for risk of bias by two blinded individual reviewers using Covidence. Results: Seven studies were identified that had moderate-to-high methodological quality. One of the studies was identified as having a high risk of bias. Of the six studies that remained, only one study reported finding a statistically significant difference at the immediate follow-up that was not clinically significant. There was no significance at 6 and 12 months. Discussion: There is a paucity of moderate to high methodological quality RCTs with similar methodology that compare MBC to standard of care treatments for patients with LBP. Studies with moderate to high methodological quality that have a low risk of bias do not support MBCs as being superior to general exercise or GBC in the treatment of nonradicular LBP. Level of Evidence: 1a.

A systematic review and novel classification of listing tools to improve medication in older people.

PURPOSE: Suboptimal drugs therapy is a threat to older people, and listing tools providing guidance are developed to address this problem. METHODS: A systematic review was performed to identify and analyze such tools published until February 2018. A novel categorization was developed to separate patient-in-focus listing approaches (PILA) providing disease-related positive and negative guidance from drug-oriented, mostly negative listing approaches (DOLA, DOLA+: with disease specification). RESULTS: In total, 76 tools were identified; only 9 were classified as PILA, 26 as DOLA, and 38 as DOLA+. Three DOLA(+) only address dementia. Most tools were developed in Europe or the USA and address community-dwellers. Thirty-two utilized a Delphi process, and only 10 provide a scoring system. Twenty tools utilize a questionnaire but no structured guidance or answers. Importantly, only 12 interventional clinical trials were identified reporting not only medication quality measures, but also clinical endpoints (e.g. falls, adverse drug reactions, hospitalization). For PILA, 4 trials showed positive, one negative clinical effects of a controlled intervention, for DOLA(+) 1 was positive, 7 negative (Fisher's exact test p < 0.05). DISCUSSION: An abundance of listing tools has been created. DOLAs that may be applied without intricate patient knowledge prevail over PILAs by sevenfold; unfortunately their clinical validation seems to be far less successful than that of patient-initiated approaches. CONCLUSION: Drug therapy in older people has to be tailored to their individual, very divergent needs; tools requiring detailed medical knowledge about the patient as the starting point for medication optimization provide the best support.

Where, when, and how the diagnosis of human visceral leishmaniasis is defined: answers from the Brazilian control program

BACKGROUND Timely diagnosis is recommended by the Brazilian Visceral Leishmaniasis (VL) Surveillance and Control Program to reduce case fatality. Attempts at assessing this topic in Brazil are scarce. OBJECTIVE This study aimed to describe where, when, and how the diagnosis of VL has been performed in a Brazilian endemic setting. METHODS Data of all autochthonous cases confirmed between 2011 and 2016 (N = 81) were recorded. The care-seeking itinerary until the confirmation of VL diagnosis was assessed among 57 patients. FINDINGS The majority of VL cases (79.1%) were reported by referral hospitals. The patients mainly sought primary health care centres at the onset of symptoms. However, they had to visit seven health services on average to achieve a confirmed diagnosis. The time from the onset of symptoms to the diagnosis of VL (TD) ranged from 1-212 (median, 25) days. The TD was longer among adult patients. There was a direct correlation between the patient's age and TD (r = 0.22; p = 0.047) and a higher occurrence of deaths due to the disease among older patients (p = 0.002). Almost all the patients (98.9%) underwent laboratory investigation, and the VL diagnosis was mainly confirmed based on clinical-laboratory criteria (92.6%). Positive results for the indirect fluorescence antibody test (22.7%) and parasitological examination plus rk39-based immunochromatographic tests (21.3%) were commonly employed. MAIN CONCLUSIONS VL diagnosis was predominantly conducted in hospitals with a long TD and wide application of serology. These findings may support measures focused on early diagnosis, including a greater involvement of the primary health care system.

Saúde do Trabalhador e da Trabalhadora / Worker's health and of the worker

Este Caderno busca contribuir para a qualificação do cuidado à saúde desenvolvido pelas equipes de atenção básica / equipes de saúde da família (eAB/eSF), considerando as relações entre o trabalho e as condições de saúde e doença dos(as) usuários(as) trabalhadores(as) na população sob sua responsabilidade. Apresenta aspectos conceituais, ferramentas para o manejo clínico e estratégias de intervenções terapêuticas e de promoção e vigilância dos agravos à saúde relacionados ao trabalho, organizados a partir do processo de trabalho das equipes. A proximidade das Unidades Básicas de Saúde (UBS) dos domicílios das pessoas e dos seus ambientes de trabalho, o alto grau de descentralização e capilaridade da Atenção Básica (AB) no Brasil, em articulação com a Rede Nacional de Atenção Integral à Saúde do(a) Trabalhador(a) (Renast) e as demais Redes de Atenção à Saúde (RAS), favorecem a garantia de acesso a uma atenção à saúde de qualidade para a população trabalhadora. Portanto, a AB desempenha um papel central na implementação da Política Nacional de Saúde do Trabalhador e da Trabalhadora (PNSTT). Considera-se que o desenvolvimento das ações de ST não representam algo novo, a ser agregado à agenda das equipes, mas busca incorporar competências ­ conhecimentos, habilidades e atitudes ­ relativas ao cuidado à saúde desse grupo da população, nas práticas cotidianas. A rigor, as equipes de eAB/eSF lidam com o contexto da vida das pessoas sob sua responsabilidade e no dia a dia deparam-se com formas de adoecimento, por vezes maldefinidas, para as quais a contribuição do trabalho ou mesmo a ausência dele desempenha papel importante. Também, é comum que as pessoas se definam enquanto indivíduos e cidadãos pela posição que ocupam nos Ministério da Saúde | Secretaria de Atenção à Saúde | Secretaria de Vigilância em Saúde processos produtivos. A pergunta ­ quem é você? com frequência é respondida com a menção ao trabalho ou ocupação. Desse modo, o trabalho está presente e permeia as práticas de saúde, de modo especial na Atenção Básica. Porém, esse é um processo em construção e um dos objetivos deste Caderno é dar visibilidade às práticas e às intervenções já realizadas pelos profissionais da AB, considerando o papel do trabalho na determinação das condições de vida e de saúde e doença dos(as) trabalhadores(as).

Essential strategies in HAI prevention and control: performance assessment through the implementation of the HAI-CoSIP tool of the GISIO-SItI group. A pilot study in a sample of Italian Organizations.

BACKGROUND: Healthcare-Associated Infections are a great concern for worldwide healthcare systems and represent a considerable threat to patient safety, leading to adverse clinical outcomes. A defined panel of indicators represents a key element to guide Healthcare Organizations towards identification of main gaps, implementation of effective actions and continuous improvements on Healthcare-Associated Infections prevention and control activities. A review on accreditation systems conducted by the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene Preventive Medicine and Public Health revealed a substantial heterogeneity of implemented standards and led to the development of a core set of indicators and requirements for Healthcare-Associated Infections' prevention and control within the hospital setting. The main aim of the study was to test the feasibility of the Healthcare-Associated Infections' prevention and control within the hospital setting tool to calculate performance scores on a sample of Italian Healthcare Organizations and to identify major critical issues. The potential benefits of the possibility of future implementation of the tool within Institutional Accreditation Programs is discussed. STUDY DESIGN: Cross sectional pilot survey. METHODS: The Healthcare-Associated Infections' prevention and control within the hospital setting included 96 criteria and 20 key areas including an area for outcomes indicators. For applicable criteria, standards fulfilment was evaluated according to a 4 point Likert scale. A composite score was calculated for each Healthcare Organization and five performance levels were identified. Data were further analysed by computing performance scores at the level of each area and requirement. RESULTS: 20 Healthcare Organizations agreed to take part in this pilot study including two rehabilitative Healthcare Organizations. Among the whole sample a mean of 12.20% of requirements resulted not fulfilled, leaving space for further improvements. Critical areas were easily identified and the instrument was able to capture substantial differences between Healthcare Organizations. Only a few number of standards resulted "Not Applicable" (Mean = 4.71%) and most of them regarded Rehabilitative Healthcare Organizations. Mean composite performance index resulted 74.06% (SD = 16.96, range 36.30 - 94.27%); area of outcome indicators obtained a mean score of 56.17. CONCLUSION: The Healthcare-Associated Infections' prevention and control within the hospital setting resulted an useful tool to assess Healthcare Organizations' performance in the field of Healthcare-Associated Infections prevention and control and to identify necessary actions for further improvements. The distribution of total scores by Healthcare Organizations showed a high heterogeneity. Implementation of the Healthcare-Associated Infections' prevention and control within the hospital setting tool as an institutional accreditation tool may help to drive the required harmonization at a national level of Healthcare-Associated Infections management and control strategies and overcome current substantial regional differences.

Niveles de complejidad asistencial en pacientes con códigos diagnósticos de insuficiencia cardiaca en una población / Complexity levels in patients with heart failure diagnostic codes in a population

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