Strengthening care for noncommunicable diseases in the Americas

Noncommunicable diseases (NCDs), such as cardiovascular diseases, cancer, respiratory diseases and diabetes, account for 81% of lives lost in the Americas. An estimated 240 million adults in the Region live with at least one NCD, requiring access to continuous support, delivered through Primary Health Care. Successful implementation of NCD policies and interventions can result in significant cost savings, alleviating the economic burden on healthcare systems, individuals, and society, while effective NCD management at the Primary Health Care level reduces premature deaths and disabilities. Strengthening integration of NCDs into Primary Health Care represents a key milestone in a country’s health system response to the Sustainable Development Agenda, with the aim of leaving no-one behind.

Comorbidities and use of health services in people with diabetes mellitus according to risk levels by adjusted morbidity groups.

BACKGROUND: People with diabetes mellitus frequently have other comorbidities and involve greater use of primary and hospital care services. The aim of this study was to describe the comorbidities and use of primary and hospital care services of people with diabetes according to their risk level by adjusted morbidity groups (AMG) and to analyse the factors associated with the utilisation of these services. METHODS: Cross-sectional study. People with diabetes were identified within the population of patients with chronic conditions of an urban health care centre by the AMG stratification tool integrated into the primary health care electronic clinical record of the Community of Madrid. Sociodemographic, functional, clinical characteristics and annual health care services utilisation variables were collected. Univariate, bivariate and Poisson regression analyses were performed. RESULTS: A total of 1,063 people with diabetes were identified, representing 10.8% of patients with chronic conditions within the health centre. A total of 51.4% were female, the mean age was 70 years, 94.4% had multimorbidity. According to their risk level, 17.8% were high-risk, 40.6% were medium-risk and 41.6% were low-risk. The most prevalent comorbidities were hypertension (70%), dyslipidaemia (67%) and obesity (32.4%). Almost 50% were polymedicated. Regarding health services utilisation, 94% were users of primary care, and 59.3% were users of hospital care. Among the main factors associated with the utilisation of both primary and hospital care services were AMG risk level and complexity index. In primary care, utilisation was also associated with the need for primary caregivers, palliative care and comorbidities such as chronic heart failure and polymedication, while in hospital care, utilisation was also associated with comorbidities such as cancer, chronic obstructive pulmonary disease or depression. CONCLUSIONS: People with diabetes were older, with important needs for care, many associated comorbidities and polypharmacy that increased in parallel with the patient's risk level and complexity. The utilisation of primary and hospital care services was very high, being more frequent in primary care. Health services utilization were principally associated with functional factors related to the need of care and with clinical factors such as AMG medium and high-risk level, more complexity index, some serious comorbidities and polymedication.

Analysis of the performance of health services in a group of vulnerable municipalities. / Análise do desempenho dos serviços de saúde em um grupo de municípios vulneráveis.

This work was a descriptive study that analyzed the performance of health services in 112 municipalities (g100) characterized by more than 80,000 inhabitants, low public revenue, and socioeconomic vulnerability. Based on the Projeto de Avaliação de Desempenho do Sistema de Saúde, 31 indicators of funding, resources, access, effectiveness, acceptability, and appropriateness were selected for the period of 2017-2020, and were compared to the variations of each year's indicators year on year. In 2020, an increase in funding, especially SUS transfers (31.6%), was observed. The availability of hospital beds had been decreasing between 2017 and 2019, but began to increase again in 2020; likewise, the availability of health professionals also showed a slight increase. A decline was observed in cervical and breast cancer screening exams of nearly 40% (2020), as well as a decrease in surgical procedures, such as cataracts and angioplasties. The hospitalizations due to conditions manageable by primary care were 15.8% in 2020, 14.1% lower than in 2019. A 55.8% increase in mortality due to diabetes and greater tuberculosis treatment non-adherence was also observed. The pandemic context calls for caution when interpreting results, which highlight access barriers and postponements of proper health care.

Estudo descritivo que analisou o desempenho dos serviços de saúde de um grupo de 112 municípios denominado g100 caracterizado por mais de 80 mil habitantes, baixa receita pública e vulnerabilidade socioeconômica. Do Projeto de Avaliação de Desempenho do Sistema de Saúde, foram selecionados 31 indicadores de financiamento, recursos, acesso, efetividade, aceitabilidade e adequação, para o período 2017-2020, e comparadas variações de cada ano em relação ao anterior. Em 2020, houve aumento no aporte financeiro, especialmente por transferências SUS (31,6%). A disponibilidade de leitos vinha decaindo entre 2017 e 2019, aumentou em 2020 e a oferta de profissionais de saúde apresentou leve aumento. Houve redução nos exames de rastreamento de câncer de colo do útero e mama de quase 40% (2020), e reduções de internações cirúrgicas, como cataratas e angioplastias. O percentual de internações por condições sensíveis à atenção primária foi 15,8% em 2020, 14,1% menor do que em 2019. Houve aumento de 55,8% na mortalidade por diabetes e maior abandono do tratamento de tuberculose. O contexto pandêmico exige cautela na interpretação de resultados, que apontam para barreiras de acesso e postergação na prestação de cuidados.

Aportes y desafíos en el proceso de reforma del sector salud con énfasis en territorios prioritarios: Colombia 2022

En coherencia con los planes del Gobierno nacional, la Asociación Colombiana de Salud Pública, con apoyo de la Alianza Académica Nacional Presente y Futuro de la Salud Pública y su grupo especializado en Atención Primaria de la Salud, por solicitud y en coordinación con la Organización Panamericana de la Salud (OPS) en Colombia desarrollan una propuesta que contribuye al mejoramiento de la salud de la población colombiana en los departamentos con mayores desigualdades de acceso a los servicios de salud. La transición democrática que vive Colombia es una oportunidad para presentar iniciativas de este tipo que permitan reforzar y transformar las condiciones de acceso a servicios de salud y el desarrollo de programas integrales e integrados de salud pública en los departamentos prioritarios y con mayores desigualdades, tales como Nariño, Amazonas, Vichada y Caquetá. La Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS), en acuerdo con las autoridades nacionales y territoriales, establecerá los criterios para seleccionar los departamentos e implementar la propuesta según factibilidad y viabilidad técnica financiera. Este libro busca contribuir con elementos analíticos y propuestas prácticas y se orienta a: fortalecer la autoridad sanitaria y la gobernanza de la salud pública; mejorar la capacidad resolutiva del sistema en relación a los determinantes sociales, la prevención, el cuidado y la atención primaria de los problemas y necesidades de la salud; seleccionar y capacitar a los equipos interdisciplinarios de salud garantizando su contratación y estabilidad laboral y generando una red de universidades e institutos tecnológicos dispuestos y con capacidad de dar soporte a la transformación del sistema de salud en los territorios más vulnerables de Colombia. Cada uno de los capítulos de este libro desarrolla una serie de pasos a seguir para lograr un cambio a escala que acelere intervenciones participativas con el propósito de cerrar la brecha de acceso a los servicios de salud y brindar soluciones a necesidades y problemas estructurales que condicionan los modos de producción y de vida en cada territorio. Para dar viabilidad al desarrollo e implementación del nuevo modelo de salud en Colombia, se hace necesaria una propuesta de soporte técnico financiero. Este contenido se pone a disposición del Ministerio de Salud y Protección Social con la expectativa de que pueda integrarse en sus consideraciones para enfrentar el desafío de la reforma de la salud propuesta y como base para establecer una relación sinérgica que viabilice el alcance de las grandes metas de acceso universal a la salud para la población colombiana.

The digital transformation in nursing education and practice

Digital health refers to “the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including healthcare services, health surveillance, health literature, and health education, knowledge and research.” The adoption of digital health solutions has been accelerated by the COVID-19 pandemic, proving they are key for the delivery of care at all levels of the public health system: the patient, the community, the care team, the healthcare institution, and the political and economic environment. Digital health is an integral part of health priorities and can be beneficial when used in an ethical, equitable, and sustainable way. The comprehensive benefits of digital health include facilitating the assessment, diagnosis, and management of health problems in a safe and effective manner, thereby fostering greater equity in access to timely medical care; addressing unmet health needs; and strengthening the capacity of the whole sector to access the information needed to understand complex scenarios and make decisions, among others. This publication presents the possibilities of incorporating and using technologies in the education and practices of nurses in their various contexts of activity and proposes a digital transformation of nursing as part of the increased technological advance in health care. It also contemplates regulatory and normative aspects in digital health. This digital transformation depends on a range of aspects, such as investment, infrastructure, professional recognition, cultural change, educational update, new skills, and competencies. It positions the nurse as a health agent capable of transforming nursing processes for a future setting where patients will be more digitally empowered and more knowledgeable on their own health status.

The value of health service-based research to health service organisations: a qualitative study with senior health service executives.

BACKGROUND: Research evidence has demonstrably improved health care practices and patient outcomes. However, systemic translation of evidence into practice is far from optimal. The reasons are complex, but often because research is not well aligned with health service priorities. The aim of this study was to explore the experiences and perspectives of senior health service executives on two issues: (1) the alignment between local research activity and the needs and priorities of their health services, and (2) the extent to which research is or can be integrated as part of usual health care practice. METHODS: In this qualitative study, semi-structured interviews were conducted with senior health leaders from four large health service organisations that are members of Sydney Health Partners (SHP), one of Australia's nationally accredited research translation centres committed to accelerating the translation of research findings into evidence-based health care. The interviews were conducted between November 2022 and January 2023, and were either audio-recorded and transcribed verbatim or recorded in the interviewer field notes. A thematic analysis of the interview data was conducted by two researchers, using the framework method to identify common themes. RESULTS: Seventeen health executives were interviewed, including chief executives, directors of medical services, nursing, allied health, research, and others in executive leadership roles. Responses to issue (1) included themes on re-balancing curiosity- and priority-driven research; providing more support for research activity within health organisations; and helping health professionals and researchers discuss researchable priorities. Responses to issue (2) included identification of elements considered essential for embedding research in health care; and the need to break down silos between research and health care, as well as within health organisations. CONCLUSIONS: Health service leaders value research but want more research that aligns with their needs and priorities. Discussions with researchers about those priorities may need some facilitation. Making research a more integrated part of health care will require strong and broad executive leadership, resources and infrastructure, and investing in capacity- and capability-building across health clinicians, managers and executive staff.

Clinical, economic, and societal burden of cystic fibrosis and the impact of the CFTR modulator, lumacaftor/ivacaftor: an assessment using linked registry data in Sweden.

AIMS: We aimed to describe the clinical, economic, and societal burdens of cystic fibrosis (CF) and impact of CF transmembrane conductance regulator modulator (CFTRm) treatment on people with CF, caregivers, and healthcare systems. MATERIAL AND METHODS: This retrospective study used linked real-world data from Swedish national population-based registries and the Swedish CF Quality Registry to assess clinical, economic, and societal burden and CFTR impact in CF. Records from people with CF and a ten-fold control population without CF matched by sex, birth year, and location were compared during 2019. Outcomes for a subset aged >6 years initiating lumacaftor/ivacaftor (LUM/IVA) in 2018 were compared 12 months pre- and post-treatment initiation. RESULTS: People with CF (n = 743) had >10 times more inpatient and outpatient specialist visits annually vs controls (n = 7406). Those aged >18 had an additional 77·7 (95% CI: 70·3, 85·1) days of work absence, at a societal cost of €11,563 (95% CI: 10,463, 12,662), while caregivers of those aged <18 missed an additional 6.1 (5.0, 7.2) workdays. With LUM/IVA treatment, people with CF (n = 100) had significantly increased lung function (mean change in ppFEV1 [3·8 points; 95% CI: 1·1, 6·6]), on average 0·5 (95% CI: -0·8, -0·2) fewer pulmonary exacerbations and 45·2 (95% CI: 13·3, 77·2) fewer days of antibiotics. Days of work lost by caregivers of people with CF aged <18 decreased by 5·4 days (95% CI: 2·9, 7·9). CONCLUSION: CF is associated with a high clinical economic and societal burden in Sweden. Improvements in clinical status observed in people with CF treated with LUM/IVA were reflected in reduced caregiver and societal burden.

Cystic fibrosis (CF) is a disease caused by a single faulty gene called CFTR, which affects the lungs, pancreas, and other organs. Medications known as CFTR modulators help improve the function of this faulty gene and have shown benefits for people with CF. In Sweden, two such medicines, lumacaftor and ivacaftor (LUM/IVA), have been available since July 2018 for treating CF. This study looks at the impact of CF on patients, caregivers, and the healthcare system, as well as the benefits of CFTR modulators. Using data from Swedish national healthcare and social insurance registries, the study compared 743 people with CF in 2019 to about 7400 people without CF, matched by sex, birth year, and location. The findings show that people with CF had 24 times higher direct healthcare costs, including outpatient visits, hospitalizations, and CF-related medications, totaling 23,233 Euros. Indirect costs, such as work absences for those over 18 with CF anssd caregivers' absences to care for sick children, were 9,629 Euros, which is five times higher than the general population. Those over 6 years old treated with LUM/IVA showed improved lung health, reduced hospitalizations (though not significantly), and needed fewer antibiotics. Caregivers' work absences decreased, but there was no change in work absences for adults with CF. Overall, treatment with LUM/IVA improved clinical outcomes and reduced the burden on caregivers and society.

The impact of decentralization of health services at the municipal level on health outcomes: evidence from China.

Objectives: Under the system of health decentralization, there are differences in the level of expenditure decentralization at different levels of government, and their impact on residents' health may also be different. This paper is one of the first to evaluate the effect of decentralization of health services at the municipal level from a multi-dimensional health perspective. Data and methods: This paper uses the data of expenditure decentralization of health services at the municipal level to match the panel data from the China Household Panel Survey (CFPS) from 2010 to 2018, and uses the logit model, ordered logit model and two-way fixed effects model to empirically analyze the impact of health decentralization at the municipal level on health outcomes. Results: Based on the perspective of multi-dimensional health, from the three aspects of physical health, depression status and cognitive ability, the six sub-indicators of self-rated health, BMI standards, depression scores (summation method), depression scores (factor method), phrase test scores and mathematics test scores are discussed separately. The results show that the decentralization of health services at the municipal level has a significant promotion effect on the multi-dimensional health of residents. Conclusion: The decentralization of health services at the municipal level has important theoretical significance for promoting the reasonable division of medical and health powers and expenditure responsibilities between provincial and municipal governments, improving the efficiency of health expenditure funds, and establishing a fiscal system that matches financial resources.

Dynamic evolution of utilization efficiency of medical and health services in China.

In order to optimize the Chinese medical and health system and improve people's health level, the SFA Malmquist model, the spatial econometric model, and the standard deviation ellipse method were used to measure the efficiency of medical and health services in China's 31 provinces between 2010 and 2020. Study results indicated that the average efficiency value of the 31 provinces generally exceeded 0.8. Specifically, the average efficiency values in the eastern and central regions increased from 0.852 to 0.875 and from 0.858 to 0.88, respectively. In the western and northeastern regions, these values rose from 0.804 to 0.835 and from 0.827 to 0.854, respectively. From the perspective of spatial distribution, there were high-high and low-low clusters in most provinces with significant spatial dependence among them. This analysis reveals that medical and health services efficiency in China demonstrates a spatial pattern extending from northeast to southwest.

Strategies for involving patients and the public in scaling initiatives in health and social services: A scoping review.

BACKGROUND: Scaling in health and social services (HSS) aims to increase the intended impact of proven effective interventions. Patient and public involvement (PPI) is critical for ensuring that scaling beneficiaries' interests are served. We aimed to identify PPI strategies and their characteristics in the science and practice of scaling in HSS. METHODS: In this scoping review, we included any scaling initiative in HSS that used PPI strategies and reported PPI methods and outcomes. We searched electronic databases (e.g., Medline) from inception to 5 February 2024, and grey literature (e.g., Google). Paired reviewers independently selected and extracted eligible reports. A narrative synthesis was performed and we used the PRISMA for Scoping Reviews and the Guidance for Reporting Involvement of Patients and the Public (GRIPP2). FINDINGS: We included 110 unique reports out of 24,579 records. In the past 5 years, the evidence on PPI in scaling has increased faster than in any previous period. We found 236 mutually nonexclusive PPI strategies among 120 scaling initiatives. Twenty-four initiatives did not target a specific country; but most of those that did so (n = 96) occurred in higher-income countries (n = 51). Community-based primary health care was the most frequent level of care (n = 103). Mostly, patients and the public were involved throughout all scaling phases (n = 46) and throughout the continuum of collaboration (n = 45); the most frequently reported ethical lens regarding the rationale for PPI was consequentialist-utilitarian (n = 96). Few papers reported PPI recruitment processes (n = 31) or incentives used (n = 18). PPI strategies occurred mostly in direct care (n = 88). Patient and public education was the PPI strategy most reported (n = 31), followed by population consultations (n = 30). CONCLUSIONS: PPI in scaling is increasing in HSS. Further investigation is needed to better document the PPI experience in scaling and ensure that it occurs in a meaningful and equitable way. PATIENT AND PUBLIC CONTRIBUTION: Two patients were involved in this review. They shared decisions on review questions, data collection instruments, protocol design, and findings dissemination. REVIEW REGISTRATION: Open Science Framework on 19 August 2020 (https://osf.io/zqpx7/).

Estructura, composición y dinámica de la fuerza de trabajo en salud en Costa Rica, en el contexto de la COVID-19

En este documento se exponen los resultados del estudio titulado Análisis de la estructura, dinámica y composición de la fuerza de trabajo en salud en Costa Rica, en el contexto de la pandemia de COVID-19. A finales de la década de los noventa e inicios de la primera década del presente siglo, se llevaron a cabo estudios similares que permitieron contar con un panorama claro de la situación de los recursos humanos en el país e identificar las principales tendencias y desafíos. Desde entonces, no se había hecho una investigación similar, por lo cual, el área de Sistemas y Servicios de Salud de la Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS) en Costa Rica, en coordinación con la Dirección de Servicios de Salud del Ministerio de Salud, acordaron llevar a cabo la presente investigación. El propósito de etse etsudio es contribuir al conocimiento y debate sobre la situación de la fuerza de trabajo en salud en Costa Rica, los desafíos que enfrenta el país en este campo y avanzar en la formulación de una política y planificación de Recursos Humanos en Salud (RHUS) en el ámbito sectorial. Este tipo de análisis se volvió particularmente relevante en el contexto de la pandemia de COVID-19, que produjo un incremento inesperado en la demanda de profesionales de la salud (especialmente enfermeras, médicos generales y especialistas, entre otros); también, porque permite apoyar la contención de la emergencia y sus secuelas, así como los aspectos relacionados con la salud y seguridad de la fuerza de trabajo en salud. Esto último hace evidente, una vez más, la urgente necesidad de conocer mejor la situación de la fuerza de trabajo en salud y los desafíos para el corto y mediano plazo. La investigación se llevó a cabo en cuatro etapas: conceptualización, caracterización. recolección y sistematización de datos estadísticos. A partir de los datos proporcionados, se hizo una caracterización y análisis de la fuerza de trabajo en salud en el sector público, en relación con aspectos como estructura y composición, dinámica y formación.

Health financing and access to medicines in the Caribbean

For millions of people, including those in the Caribbean region, accessing affordable and high-quality medicines poses significant challenges. These include affordability issues, concerns over the quality and safety of medicines, and inadequate financing for health care, as well as the inappropriate use of essential medicines, weak or limited regulatory systems, and complex procurement and supply chain management processes. The Caribbean region also faces a unique set of challenges, including high levels of public debt and significant informal economies. These factors constrain the capacity of governments to invest in social programs and agendas, including the provision of universal health coverage. At present, public spending on health care in the region is only 3.9% of gross domestic product, well below the 6% target. Consequently, many people must rely on out-of-pocket payments for health care, including medicines. This financial burden creates barriers to accessing health care and can lead to the irrational use of prescription drugs and other medicines. This report offers an initial and concise evaluation of certain health financing aspects that are crucial for accessing medicines in the Caribbean. It also provides a preliminary set of recommendations to guide national and regional efforts to improve the region’s current organization, financing, and provision of medicines. These recommendations aim to tackle the significant challenges highlighted in the report, including those related to system financing, barriers to access, and the financial burden of out-of-pocket costs. Envisioned as an integral part of a broader series of initiatives, this study aims to promote equitable, affordable, and sustainable access to medicines and health technologies by strengthening regulatory frameworks and production capacities, as well as by promoting the rational use of medicines. The publication also aims to be a useful resource for policymakers, health professionals, and other stakeholders in the region and beyond, as they work toward ensuring that everyone in the Caribbean has access to the medicines they need to lead healthy and productive lives, and that the region can achieve sustainable and equitable health financing.

Laboratório de Inovação em Saúde: Práticas Integrativas e Complementares em Saúde (PICS)

Seis experiências exitosas em Práticas Integrativas e Complementares em Saúde (PICS) no Sistema Único de Saúde (SUS) participaram do Laboratório de Inovação em Saúde, que teve o desafio de compreender a complexidade e o alcance das PICS no SUS e, a partir da sistematização delas, aqui apresentadas, fomentar o intercâmbio de conhecimento entre os profissionais de saúde e gestores do SUS. A iniciativa foi lançada em outubro de 2021, pela Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS) no Brasil e pela Secretaria de Atenção Primária à Saúde do Ministério da Saúde, por meio da Coordenação Nacional de Práticas Integrativas e Complementares em Saúde, em comemoração aos 15 anos da Política Nacional de Práticas Integrativas e Complementares em Saúde no SUS (PNPIC). As PICS vêm se demonstrando como estratégias de cuidados inovadoras, baseadas em conhecimentos tradicionais, e que há mais de uma década está ganhando protagonismo nos serviços de saúde, em todos os níveis de atenção, da primária à média e alta complexidade. Atualmente, 29 práticas são oferecidas pelo SUS: apiterapia, aromaterapia, arteterapia, ayurveda, biodança, bioenergética, constelação familiar, cromoterapia, dança circular, geoterapia, hipnoterapia, homeopatia, imposição de mãos, medicina antroposófica, medicina tradicional chinesa/acupuntura, meditação, musicoterapia, naturopatia, osteopatia, ozonioterapia, plantas medicinais e fitoterápicos, quiropraxia, reflexoterapia, reiki, shantala, terapia comunitária integrativa, terapia de florais, termalismo social/crenoterapia e yoga. No campo acadêmico, registra-se que, apesar de muito ter se avançado na busca de evidências científicas que demonstrem a eficácia das PICS para a saúde, é necessário avançar com metodologias de pesquisa cada vez mais robustas, com a ampliação do campo de pesquisa clínico. Com o objetivo de reduzir as lacunas do conhecimento sobre o tema, o Laboratório de Inovação em Saúde sistematizou práticas consolidadas no SUS para contribuir para a promoção e recomendação das PICS de forma segura e oportuna, para o bem comum das populações, ampliando o acesso aos cuidados de saúde.

Tackling the non-communicable disease epidemic: a framework for policy action in low- and middle-income countries.

Health policy frameworks for the prevention and control of non-communicable diseases have largely been developed for application in high-income countries. Limited attention has been given to the policy exigencies in lower- and middle-income countries where the impacts of these conditions have been most severe, and further clarification of the policy requirements for effective prevention is needed. This paper presents a policy approach to prevention that, although relevant to high-income countries, recognizes the peculiar situation of low-and middle-income countries. Rather than a narrow emphasis on the implementation of piecemeal interventions, this paper encourages policymakers to utilize a framework of four embedded policy levels, namely health services, risk factors, environmental, and global policies. For a better understanding of the non-communicable disease challenge from a policy standpoint, it is proposed that a policy framework that recognizes responsible health services, addresses key risk factors, tackles underlying health determinants, and implements global non-communicable disease conventions, offers the best leverage for prevention.

Association of frailty with the use of health services in older adults: a secondary analysis of the Mexican Health and Aging Study.

BACKGROUND: Frailty has been related to adverse outcomes, but evidence on its association with the use of health services is still scarce. OBJECTIVE: The purpose of this work was to determine the association of frailty with the use of health services in Mexican adults older than 60 years. MATERIAL AND METHODS: Analysis of the Mexican Health and Aging Study for the years 2015 (baseline) and 2018 (follow-up). Frailty was defined with the frailty index. The following outcomes were included: hospitalization, medical visits, major surgery, minor surgical procedures, and dental visits. Competing risk and count analyses (negative binomial regression) were performed. RESULTS: A total of 8,526 individuals were included, whose average age was 70.8%; 55.8% corresponded to the female gender. According to the results, hospitalization days and the number of minor procedures were associated with frailty. CONCLUSIONS: Frailty could be useful in the planning of health services for older adults. On the other hand, its evaluation would allow prioritizing care for those who are at higher risk of adverse outcomes.

ANTECEDENTES: La fragilidad se ha relacionado con desenlaces adversos, pero aún es escasa la evidencia sobre su asociación con el uso de servicios de salud. OBJETIVO: Evidenciar la asociación de la fragilidad con el uso de servicios de salud en adultos mexicanos mayores de 60 años. MATERIAL Y MÉTODOS: Análisis del Estudio Nacional sobre Salud y Envejecimiento en México para 2015 (basal) y 2018 (seguimiento). La fragilidad se definió con el índice de fragilidad. Fueron incluidos los siguientes desenlaces: hospitalización, visitas médicas, cirugía mayor, procedimientos quirúrgicos menores y visitas al dentista. Se utilizaron modelos de riesgos competitivos y de número de eventos (regresión negativa binomial). RESULTADOS: Se incluyeron 8526 individuos, cuya edad promedio fue de 70.8 %; 55.8 % correspondió al sexo femenino. De acuerdo con los resultados, los días de hospitalización y el número de procedimientos menores se asociaron a fragilidad. CONCLUSIONES: La fragilidad podría ser un parámetro útil en la planeación de los servicios de salud para los adultos mayores. Por otro lado, su evaluación permitiría priorizar la atención a quienes presenten mayor riesgo de desenlaces adversos.

The coupling coordination between health service supply and regional economy in China: spatio-temporal evolution and convergence.

Background: The coordination of health service supply and regional economy is an integral path to promote China's prosperity. Methods: Based on the coupling mechanism of health service supply and regional economy, we sampled the data from 30 provinces in China from 2009 to 2021 in this study and constructed the evaluation index system. Additionally, we calculated the coupling coordination degree (HED) of the two through the coupling coordination degree model. We further used the kernel density estimation, Moran's I index, and spatial ß convergence model to assess the dynamic evolution trends, spatial aggregation effect, and spatial convergence characteristics of coupling coordination. Conclusion: (1) HED in China showed a rising trend during the study period but with large regional differences, forming a gradient distribution pattern of "high in the east and low in the west." (2) The results of Kernel density estimation show that HED has formed a gradient differentiation phenomenon within each region in China. (3) HED has modeled spatial clustering characteristics during the study period, with high-value clusters mainly appearing in the eastern region and low-value clusters appearing in the northwestern region. (4) There are absolute ß-convergence and conditional ß-convergence trends in HED in China and the three major regions during the study period, but there is an obvious regional heterogeneity in the control factors. The research provides a reference for accurately implementing policies according to different levels of health service supply and economic development, in addition to narrowing the regional differences of the coupling coordination between the regional economy and health service supply.

Actitud de los fisioterapeutas acerca del acceso directo y su implementación a través de un cambio en la política pública en Puerto Rico / Attitude of physiotherapists about direct access and its implementation through a change in public policy in Puerto Rico

Objetivos: Explorar las actitudes de los fisioterapeutas de Puerto Rico: 1) hacia el acceso directo (AD), 2) las implicaciones para la profesión, la práctica y los servicios de salud, y 3) la implementación del AD a través de un cambio en política pública. Métodos: El diseño fue exploratorio transversal, no experimental y con un enfoque cuantitativo. Los participantes eran fisioterapeutas con licencia vigente, mayores de 21 años de edad, con cualquier grado académico en fisioterapia y que actualmente ejercen la práctica en Puerto Rico. Fueron excluidos fisioterapeutas sin experiencia clínica, que estaban completando un grado doctoral transicional o con experiencia ejerciendo con AD. Para abordar los objetivos de investigación, se construyó un cuestionario, cuyo contenido fue validado por 4 fisioterapeutas expertos utilizando el modelo de Lawshe modificado por Tristán. Resultados: Participaron de este estudio 100 fisioterapeutas. El 96% de los participantes estuvo de acuerdo con la implementación del AD en Puerto Rico. El 83% indicó estar preparado para ejercer la profesión por AD. El 55% entienden que fisioterapeutas con grado doctoral están más preparados para ejercer por AD. El 59% indicó que el AD debe estar restringido por nivel educativo y/o experiencia. Conclusión: La actitud de los fisioterapeutas en Puerto Rico respecto al AD resultó ser favorable, independientemente del grado académico, ya que están a favor con incorporar el AD a la fisioterapia, se sienten preparados para ejercer por AD y consideran el AD beneficioso para los pacientes, la práctica y la profesión. (AU)

Objectives: To explore the attitudes of physiotherapists in Puerto Rico: (1) towards direct access (DA), (2) the implications for the profession, practice, and health services, and (3) the implementation of DA through a change in public policy. Methods: The design was cross-sectional exploratory, non-experimental, and quantitative in nature. Participants were licensed physiotherapists, over 21 years old, with any academic degree in physiotherapy, currently practicing in Puerto Rico. Physiotherapists without clinical experience, those completing a transitional doctoral degree, or with experience practicing with DA were excluded. To address the research objectives, a questionnaire was constructed, whose content was validated by 4 expert physiotherapists using the Lawshe model modified by Tristán. Results: One hundred physiotherapists participated in this study. 96% of participants agreed with the implementation of DA in Puerto Rico. However, only 83% indicated being prepared to practice the profession through DA. 55% understood that physiotherapists with doctoral degrees were better prepared to practice through DA. 59% indicated that DA should be restricted based on educational level and/or experience. Conclusion: The attitude of physiotherapists in Puerto Rico towards DA was favorable regardless of academic degree. They are in favor of incorporating DA into physiotherapy, feel prepared to practice through DA, and consider it beneficial for patients, practice, and the profession. (AU)