Evaluación de la calidad de los servicios de cuidados paliativos domiciliarios: revisión de la literatura / Assessing the Quality of Home-based Palliative Care Services: A Literature Review / Avaliação da qualidade dos serviços de cuidados paliativos domiciliares: revisão de literatura

Introducción: La calidad de los servicios de salud se mide con indicadores que permiten encontrar oportunidades de mejora, datos clínicos y no clínicos de relevancia, información epidemiológica y calidad percibida del servicio brindado. Los cuidados paliativos pueden ofrecerse en distintas modalidades, siendo los cuidados domiciliarios una ruta novedosa que permite el cuidado del paciente lejos del intervencionismo hospitalario; los indicadores que evalúan la calidad de esta modalidad varían respecto a los servicios intramurales. Objetivo: describir los indicadores de calidad en salud utilizados para evaluar los servicios de cuidados paliativos domiciliarios según la literatura consultada. Método: revisión sistemática de la literatura científica disponible sobre los indicadores de calidad en salud para los cuidados paliativos domiciliarios. Para valorar la calidad metodológica se usó la lista CASPe. Resultados:se encontraron 47 indicadores que evalúan la calidad de los servicios de atención domiciliaria paliativa, siendo los indicadores de resultados los que tuvieron mayor presencia. Dentro de los indicadores se midieron diversos aspectos de los cuidados paliativos como manejo de síntomas, visitas domiciliarias por personal especializado, lugar de muerte elegido, eventos relacionados con la seguridad del paciente y disponibilidad de medicamentos. Conclusiones: La medición del lugar de fallecimiento y la presencia de síntomas aun con un tratamiento farmacológico establecido fueron dos de los indicadores más encontrados. Se observó una medición al personal médico y enfermero superior al resto de profesionales que conforman el equipo multidisciplinario de cuidados paliativos, se encontraron algunos indicadores específicos para pacientes con patologías oncológicas

Introduction: Quality of health services is measured by indicators that make it possible to find improvement opportunities, relevant clinical and non-clinical data, epidemiological information, and perceived quality of the provided service. Palliative care can be offered in different forms; home-based care is a novel path that enables patients to be cared for far from hospital interventionism; the quality indicators that assess this form of care vary from those that assess intramural services. Objective: To describe quality indicators for health care used to assess home-based palliative care services, according to the literature consulted. Method: Systematic review of the available scientific literature on quality indicators for home-based palliative care. The CASPe list was used to assess methodological quality. Results: 47 indicators for quality assessment of home-based palliative care services were found; outcome indicators had the greatest presence. Among the indicators, different aspects of palliative care were measured, such as symptom management, home visits by specialized personnel, chosen place of death, events related to patient safety, and medication availability. Conclusions: Measurements for the place of death and presence of symptoms, even with a determined pharmacological treatment, were the two most frequently found indicators. A measurement of medical and nursing personnel higher than the rest of the professionals that make up the palliative multidisciplinary team was observed, some specific indicators were found for patients with oncological pathologies

Introdução: A qualidade dos serviços de saúde é medida com indicadores que permitem encontrar oportunidades de melhoria, dados clínicos e não clínicos de relevância, informação epidemiológica e qualidade percebida do serviço prestado. Os cuidados paliativos podem ser oferecidos em diferentes modalidades, sendo o atendimento domiciliar uma rota inovadora que permite o atendimento ao paciente longe do intervencionismo hospitalar; os indicadores que avaliam a qualidade dessa modalidade variam no que diz respeito aos serviços intramuros. Objetivo: descrever os indicadores de qualidade de saúde utilizados para avaliar os serviços de cuidados paliativos domiciliares segundo a literatura consultada. Método: revisão sistemática da literatura científica disponível sobre indicadores de qualidade em saúde em cuidados paliativos domiciliares. Para avaliar a qualidade metodológica foi utilizada a guia CASPe. Resultados: foram encontrados 47 indicadores que avaliam a qualidade dos serviços de atenção paliativa domiciliar, sendo os indicadores de resultado os que tiveram maior presença. Dentro dos indicadores mediram-se vários aspectos dos cuidados paliativos, como manejo dos sintomas, visitas domiciliares pelo pessoal especializado, local de preferência para o óbito, eventos relacionados com a segurança do paciente e disponibilidade de medicamentos. Conclusões: A medição do local do óbito e a presença de sintomas, mesmo com o tratamento farmacológico estabelecido, foram dois dos indicadores mais encontrados. Observou-se uma medição à equipe médica e de enfermagem superior ao restante dos profissionais que compõem a equipe multiprofissional de cuidados paliativos. Acharam-se alguns indicadores específicos para pacientes com patologias oncológicas

New Long-Term Care Policies in Latin America: The National System of Care in Uruguay.

BACKGROUND: Uruguay is the Latin American country with the largest share of elderly population and it has the greatest pressure for formal long-term care services in the region. For this reason, last year the government approved a law creating a National System of Care. OBJECTIVE: This article describes and analyzes the long-term care policy in the recently created National System of Care of Uruguay. METHOD: The Director of the National System of Care was asked to complete a questionnaire with a description and management of long-term care programs. This information was completed with official information and peer-reviewed articles of long-term care in Uruguay. RESULTS: The National System of Care includes long-term care services. The main services are carried out through a cash-for-care system for home-based services, but in the future the benefits will expand to day centers and residential and nursing homes. CONCLUSION: The system follows international trends in terms of universality, services, and regulations dealing with care. However, the current and future financing is low, and this condition could undermine its development capacity.

Building Long-Term Care Policies in Latin America: New Programs in Chile.

BACKGROUND: Little is known about long-term care policies in developing regions. Latin America is one of those regions. In less than 20 years, it will surpass Europe's elderly population. At that point, Chile will be the country with the largest share of elderly population in the region. For that reason, long-term care pilot programs have been implemented in recent years. OBJECTIVE: This article describes the long-term care policy in Chile, analyzed according to the international experience. METHOD: National directors of these programs were asked to complete questionnaires with a description of each, and the results of the past year. This information was compared with interviews to experts and official information available online. RESULTS: Programs follow the international trends, although they are underfinanced and lack the necessary mechanisms to control service quality. CONCLUSION: It is suggested that budgets should be increased, and there should be higher requirements for caregiver training. Also, mechanisms for quality control should be established, and policies should be evaluated for formal direct hiring through a cash-for-care system.

Comparación de costos y resultados sanitarios de usuarios con neumonia adquirida en comunidad atendidos en domicilio o en hospitalización tradicional: estudio exploratorio de 40 casos.

INTRODUCTION: Economic evaluations of health technologies and health interventions are considered in many countries as the fourth barrier for adopting new services or drugs; followed by safety, efficacy and quality. The validity and reliability of the results will depend on the perspective of the study, timeframe of the analysis, discount rate, the model used and the costs involved. OBJECTIVES: This study aims to assess the cost effectiveness of home care treatment in users with diagnosis of uncomplicated community acquired pneumonia compared with traditional hospitalization at inpatient wards. The hypothesis is that home based care would be more cost effective compared to traditional hospitalization. METHODS: The study perspective was from the health provider. Microcosting was used to determine the costs of both treatment modalities in a sample of 20 users treated with each modality during 2013 at main Hospitals of Coquimbo Region, Chile. RESULTS: The main outcome of effectiveness was the number of inpatient care days saved. Additionally, number of infections associated to health care (IAHC) and type of discharge were measured. CONCLUSIONS: The study concludes that there is a better cost effectiveness relationship for the home care modality, with fewer days of treatment, at lower costs and without risk of IAHC. However, further studies are needed in order to achieve accurate results.

Assessment of the effectiveness of a home-based care program for patients coinfected with tuberculosis and human immunodeficiency virus after discharge from a reference hospital in South-Eastern Brazil

The effectiveness of tuberculosis treatment delivered by a home-based care program to patients coinfected with HIV was compared with that of a service provided by outpatient departments. A retrospective study was made of a cohort of coinfected patients discharged from hospital between January 1998 and December 2002 who had been followed-up for one year within one of these programs. Two-hundred-and-forty-three patients who met the inclusion criteria were grouped according to their treatment program (group 1 received home-based care; group 2 attended outpatient departments) and then paired one-to-one across the groups by gender, age and level of education. Only 48 patients from each group could be paired. Apart from the duration of HIV infection, there were no statistically significant differences (P < 0.05) between patients in the two groups with respect to social-demographic status and clinical or laboratory characteristics. In group 1, 75.0 percent of patients attained successful tuberculosis treatment compared with 72.9 percent of those in group 2 (P = 0.816). Treatment was abandoned by 22.9 percent of patients in group 1 and by 54.2 percent of those in group 2 (P = 0.008). The death rate within one year after discharge was 20.8 percent for group 1 compared with 6.3 percent for group 2 (P = 0.334). Although both programs achieved a similar success rate in the treatment of tuberculosis, patients receiving outpatient care were three to eight-times more likely to abandon the program. The importance of assigning patients at-risk of abandoning treatment to a home-based care program after discharge from hospital is emphasized.

Costos directos del ingreso en el hogar en Cuba / Direct costs of home-based care in Cuba

Introducción El ingreso en el hogar es una alternativa asistencial de la atención primaria cuyos objetivos principales son mejorar la atención del paciente y lograr una utilización más eficiente de los recursos. En Cuba han sido pocos los estudios sobre esta modalidad que aborden diferentes entornos geográficos. Objetivos Estimar y caracterizar el costo directo del ingreso en el hogar para diferentes áreas geográficas en Cuba. Métodos Se desarrolló un estudio parcial, descriptivo, de costos entre 2001 y 2002 en cuatro áreas geográficas del país. Se consideraron aquellos costos asumidos por el Sistema Nacional de Salud y parte de los asumidos por las familias. Las partidas empleadas fueron: recursos humanos, material gastable, medios diagnósticos y tratamiento farmacológico. Se estimó el costo por paciente y por causa de ingreso. EL total de pacientes ingresados fue de 837. Resultados El costo por paciente osciló entre los casi 10,00 y 20,00 pesos. El área rural mostró el mayor costo en este aspecto. Las partidas de mayor aporte fueron el salario y el tratamiento farmacológico. La diferencia entre el costo por paciente del área rural y el resto estuvo determinada por el tratamiento. El ingreso en el hogar representó un gasto de familia promedio, por compra de medicamentos, que osciló entre los 7,00 y los 18,00 pesos por paciente. Conclusiones El ingreso en el hogar generó costos medios similares en las áreas urbanas y rurales. Las enfermedades respiratorias fueron las de mayores costos asociados y el aporte de las diferentes partidas fue similar independientemente del área geográfica y del motivo que causó el ingreso. A medida que la gravedad del paciente aumentó, se observó diferencias en los costos entre las áreas, y los incrementos se produjeron a expensas fundamentalmente de la partida "tratamiento".

Introduction Home-based care is a primary health care option mainly aimed at improving the patient care and at using available economic resources more effectively. There have been few studies on this care modality that included different geographical settings in Cuba. Objectives To estimate and to characterize the direct cost of home care in the various geographical areas of the island. Methods A partial cost study was conducted from 2001 to 2002 in four Cuban geographical areas. Those costs afforded by the national healthcare system and part of those paid by the families were analyzed. The considered items were human resources, waste materials, diagnostic means and drug therapy. Cost per patient and per cause of home care was estimated. The total number of patients cared at home was 837. Results The cost per patient ranged from nearly 10,00 to 20,00 pesos. The rural setting showed the highest cost in this regard. Items that contributed the most were salary and drug therapy. The difference between cost per patient in a rural area and in the other areas was determined by the kind of treatment. Home-based care accounted for an average family cost, in terms of purchase of drugs, from 7,00 to 18,00 pesos per patient. Conclusions Home care generated comparable average costs in both rural and urban areas. Respiratory diseases were the most costly and the contribution by the various items was similar regardless of the geographical area and of the cause of home care. As the condition of the patients became more critical, differences in terms of costs between urban and rural areas were observed, and cost increases mainly occurred at the expense of the item "treatment."

Cuidado domiciliar intensivo: uma possível realidade do Sistema Único de Saúde? / Intensive home-based care: is it a possible reality for the public health system? / ¿Cuidado domiciliar intensivo: una posible realidad del Sistema Único de Salud?

Investigação de abordagem qualitativa que se enquadra como um estudo exploratório de caso individual. Cuja questão norteadora configurou-se em indagar como o Sistema Único de Saúde (SUS) disponibiliza o cuidado domiciliar intensivo. Os objetivos do estudo foram: analisar como é disponibilizado este suporte de saúde: qual o tipo de assistência prestada e como é a manutenção e garantia dos equipamentos; visibilizar como o sujeito deste estudo obteve este serviço: como o mesmo chegou até ele e quanto tempo demora. Os resultados revelam que os caminhos para se obter um suporte à vida são cercados de obstáculos e que este trajeto percorrido em busca de uma assistência domiciliar pela dinâmica do SUS envolve burocracia, profissionais e equipamentos que em muitas situações dificultam o acesso da população.

A qualitative investigation characterized as an exploratory study of individual case. The guiding point was inquiring into how the Public Health System (SUS) provides intensive home-based care. The study was aimed at analyzing how this health support is made available - that is, what kind of assistance is given and what is the equipment maintenance and warranty like - and at examining how the subject of this study obtained this service, that is, how the service reached him/her and how long it usually takes to do so. The results show that the paths to get life support are full of obstacles and that this path in search of home-based care through the SUS dynamics involves bureaucracy, professionals, and equipment that often make it difficult for the population to have access to public health services.

Investigación de abordaje cualitativa que se encuadra como un estudio exploratorio de caso individual. Cuya cuestión norteadora se configuró en indagar cómo el Sistema Único de Salud (SUS) pone a disposición el cuidado domiciliar intensivo. Los objetivos del estudio fueron: analizar como se pone a disposición este soporte de salud: cuál es el tipo de asistencia prestada y cómo es el mantenimiento y la garantía de los equipos; ver cómo el sujeto de este estudio obtuvo este servicio: cómo el mismo llegó hasta él y cuánto tiempo tarda. Los resultados revelan que los caminos para obtenerse un soporte a la vida están cercados de obstáculos y que este trayecto recorrido en búsqueda de una asistencia domiciliar por la dinámica del SUS involucra burocracia, profesionales y equipos que en muchas situaciones dificultan el acceso de la población.