[Cost-effectiveness of two hospital care schemes for psychiatric disorders]. / Costo-efectividad de dos esquemas de atención hospitalaria psiquiátrica.

BACKGROUND: In Mexico, six of every twenty Mexicans suffer psychiatric disorders at some time in their lives. This disease ranks fifth in the country. The objective was to determine and compare the cost-effectiveness of two models for hospital care (partial and traditional) at a psychiatric hospital of Instituto Mexicano del Seguro Social (IMSS). METHODS: a multicenter study with a prospective cohort of 374 patients was performed. We made a cost-effectiveness analysis from an institutional viewpoint with a six-month follow-up. Direct medical costs were analyzed, with quality of life gains as outcome measurement. A decision tree and a probabilistic sensitivity analysis were used. RESULTS: patient care in the partial model had a cost 50 % lower than the traditional one, with similar results in quality of life. The cost per successful unit in partial hospitalization was 3359 Mexican pesos while in the traditional it increased to 5470 Mexican pesos. CONCLUSIONS: treating patients in the partial hospitalization model is a cost-effective alternative compared with the traditional model. Therefore, the IMSS should promote the infrastructure that delivers the psychiatric services to the patient attending to who requires it.

Introducción: en México, seis de cada veinte mexicanos presentan trastornos psiquiátricos alguna vez en la vida. Está enfermedad ocupa el quinto lugar en nuestro país. El objetivo de este estudio fue determinar y comparar el costo-efectividad de los dos modelos de atención médica hospitalaria (parcial y tradicional) del IMSS. Métodos: estudio multicéntrico, con cohorte prospectiva de 374 pacientes y análisis de costo-efectividad con perspectiva institucional y seguimiento de seis meses. Se analizaron los costos médicos directos, con la ganancia en calidad de vida como medida de resultados. Se empleó un árbol de decisiones y un análisis probabilístico de sensibilidad. Resultados: la atención de pacientes del modelo de hospitalización parcial implicó un costo 50 % menor al tradicional, con resultados similares en calidad de vida. El costo por unidad de éxito en hospitalización parcial fue de 3359, mientras que en tradicional se incrementó a 5470 (ambas cantidades en pesos mexicanos). Conclusiones: tratar a los pacientes en el modelo de hospitalización parcial es una alternativa costo-efectiva con respecto a la tradicional; el IMSS debe considerar la promoción de la infraestructura que permita ofrecer este servicio a los pacientes que lo requieran.

Socioeconomic factors associated with drug consumption in prison population in Mexico.

BACKGROUND: Consumption of illegal drugs is a public health problem in Mexico, and the prison population is a vulnerable group with higher rates of prevalence than in the general population. The objective of this study was to determine the main socioeconomic variables associated with drug consumption in the prison population. METHODS: Utilizing data from the Second Incarcerated Population Survey carried out by the Centre of Research and Teaching of Economics (CIDE) in Mexico, a logistic model in two stages was developed. The first stage analyzed the determinants of habitual drug consumption by prisoners (prior to admittance into prisons), while the second stage of the model addressed drug consumption within prisons. RESULTS: Prevalence of drug consumption previous to incarceration was 28.5%, although once people were imprisoned this figure dropped to 7.4%. The characteristics that most heavily influenced against the possibility of habitual drug consumption prior to admittance to prison were: preparatory school or higher, being employed and having children; while the variables associated negatively were: male gender, childhood home shared with adults who consumed illegal drugs; abandoning childhood home; and having previous prison sentences. Once in prison, the negative conditions in there are associated with drug consumption. CONCLUSIONS: Work and study during incarceration, in addition to being instruments for rehabilitation, seem to exert an important positive association against drug consumption. However, this correlation seems to be minimized in the face of negative conditions of the penal institution; thus, public policies are necessary to improve the prisoner's environment.

Survey on physicians' knowledge and attitudes towards clinical practice guidelines at the Mexican Institute of Social Security.

OBJECTIVE: A survey was organized to determine the general level of knowledge and attitudes of medical personnel towards clinical practice guidelines (CPG). METHODS: A questionnaire modified from two validated instruments was used. Multi-stratified sampling was applied, and 1782 questionnaires were completed. RESULTS: A total of 80.4% of physicians had regular employment contract, 8.6% managerial post and 9.3% temporary work contract. Average age and working time were 43.7 and 15 years respectively; 64.3% were male. It was reported that 47.9% participated in academic activities, 70.8% belonged to a medical association, 40.3% identified CPG as steps towards arriving at a diagnosis and/or treatment and 14.9% thought that CPG were norms. A total of 10.7% of the physicians believed that guidelines are based on scientific evidence, 10% perceived them as supporting tools, 10.8% had no knowledge of them, 65% said that they used them, 76.7% thought that personal experience was as important as CPG recommendations and 57.4% thought that CPG were necessary for good medical practice. Physicians preferred that CPG be produced by personnel from outside the Mexican Institute of Social Security, or who had followed validity criteria. CONCLUSIONS: The majority of physicians considered CPG to be useful tools. It was evident that few knew where to acquire CPG, and this would lead to their limited use. Findings from this study enabled procuring a broader idea of the level of knowledge and attitudes of Mexican Institute of Social Security physicians towards CPG. This information is relevant when planning strategies for the purpose of sharing and implementing CPG.

[Cost-effectiveness of anxiolytics in anxiety disorders]. / Costo-efectividad de ansiolíticos en los trastornos de ansiedad.

BACKGROUND: adequate treatment of anxiety disorders reduces the economic impact, improves functionality in daily life activities and quality of life. Pharmacologic treatment depends on patient's characteristics and doctor's experience. The aim of this study was to determine the use of resources in anxiety disorder and to analyze its cost-effectiveness. METHODS: use of resources related to chronic treatment of anxiety disorders and cost-effectiveness of drugs were determined, as well as patients' out-of-pocket expenses and productivity loss. A one-year time horizon and decision tree with benzodiazepines, selective inhibitor of serotonin re-intake (SISR) and tricyclic antidepressant drugs were included. RESULTS: benzodiazepines were the treatment that had the lowest total cost ($147,587 MXP), followed by SISR (incremental cost of $2,182 MXP), and the highest cost was tricyclic antidepressant drugs ($155,903 MXP). CONCLUSIONS: benzodiazepines are good alternative for anxiety disorder because of their high effectiveness to control symptoms and because they reduce hospital costs.

[The clinical guidelines as a potential tool to improving health care quality]. / El potencial de las guías de práctica clínica para mejorar la calidad de la atención.

There is an increasing demand to ensure quality in the providing and receiving health care. Health care services face different challenges, such as: a growing aging population, increasing care costs, variations in clinical practice, and a fasting increase in the generation of information on diagnostic methods and therapies. In this context, a wave of development and use of clinical guidelines (CGL) based on scientific evidence has emerged worldwide, with the aim to creating tools to promote clinical excellence in practice. Our country and the Instituto Mexicano del Seguro Social (IMSS), with its experience in developing CGL has joined this trend as a main project. It is beneficial for IMSS health professionals and their patients. The aim of this paper is to present general information on definitions, structure, quality standards, development proceedings, updating, and potential advantages and disadvantages by using CGL. To achieve the expectations of a positive impact on quality and the health care budget distribution, health care personnel must be open to and receptive to the CGL recommendations and be flexible in changing their clinical practice.

[Knowledge of medical doctors about health economics]. / Conocimientos de los médicos sobre economía de la salud.

OBJECTIVE: To identify the level of knowledge about health economics of physicians with different academic degree, working place and medical activities. MATERIAL AND METHODS: A questionnaire with 24 items about commonly used health economics concepts was applied. Face validity, content, construct, and consistency of the questionnaire were assessed. 523 Mexican physicians from public and private health institutions in Sinaloa and Distrito Federal were interviewed. RESULTS: The average general score was 4.1 +/- 2.1 (0 to 10 scale), for physicians at the IMSS was 4.1 +/- 2.1, SSA 4.3 +/- 2.5, ISSSTE 3.3 +/- 2; SEDENA 3.9 +/- 2.3 and in private medical services 4.4 +/- 2.2 (p = 0.001). Interns scored 3.7 +/- 2.1; physicians with specialties different from family medicine 4.3 +/- 2.2 and family physicians 4 +/- 2 (p = 0.05). The question that got the most correct answers was the definition of direct costs (82%) and the one with fewest was the percentage of the gross national product recommended by the World Health Organization for the health sector (11%). CONCLUSIONS: Interviewed physicians had poor knowledge about health economics. Academic degree and institutional work were factors related to that knowledge.

[Cost-effectiveness of the treatment of acute and chronic rhinosinusitis at the IMSS]. / Costo-efectividad del tratamiento de rinosinusitis aguda y crónica en el IMSS.

INTRODUCTION: Rhinosinusitis is one of the more common diseases encountered in outpatient visits to health care. The objective of this study was to determine the most cost-effective antibiotic treatment for patients with acute (RSA) and chronic rhinosinusitis (RSC) that is available at the Mexican Institute of Social Security (IMSS). METHODS: Cost-effectiveness analysis of RSA and RSC treatment from an institutional perspective. Effectiveness outcome was defined as the percentage of cure. A decision tree with a Bayesian approach included the following therapeutic alternatives: ciprofloxacin, gatifloxacin, trimetoprim/sulfametoxazol (TMP/SMX), amoxicilin/clavulanic acid (AAC) and clindamicin. RESULTS: Treatment for RSA with AAC showed a mean cost per cured patient of $ 878 pesos. The remaining antibiotics had a higher cost per unit of success, and therefore the results showed that AAC was the best alternative considering this criterion. The therapy that showed a larger percentage of cured patients in RSC was clindamicin; however, the therapeutic alternative with the lowest cost per successful unit was the one based on ciprofloxacin, which dominates gatifloxacin and AAC. CONCLUSIONS: The most cost-effective alternative in the antibiotic treatment of patients with RSA was ACC while for RSC it was ciprofloxacin; sensitivity analysis showed the strength of the base study results.

[Causes for failure of the medical appointment program in a family medicine clinic]. / Incumplimiento de la cita previa en el primer nivel. Motivos relacionados.

The objective of this study was to identify, for both patients and health services, the probable causes for non-attendance at medical appointments in a family medicine clinic located in Mexico City. The three top reasons of visit, type 2 diabetes, hypertension and antenatal care were analyzed. Four hundred and thirty-nine patients who missed their appointment during May 2004 answered an interview. Patient's variables were age, gender, schooling, employment status, workday, employer support to attend to the appointment, physical conditions, family support, affordability of the travel expenses to attend to the clinic, place of residence, forgetting the appointment and hospitalization. Health services variables were conflict between the dates of the appointment with the family doctor and with the laboratory, mistakes in the agenda, re-scheduling or cancellation of the appointment, entitlement to receive medical care, absence of the family doctor, and patient's decision to leave the clinic before the appointment. Data were analyzed by using descriptive statistics. 45.8% of patients forgot their appointment and 44% had administrative problems that impaired their receive medical care; 76.4% of pregnant women had administrative problems as well. Addressing these two possible causes is essential to the success of the medical appointment program.

[Prescription of temporal disability certificates in workers attending to IMSS from the perspective of health economy]. / Prescripción de certificados de incapacidad temporal en el IMSS. Perspectiva desde la economía de la salud.

The repercussion of health-disease state on social life or individual includes his/her work performance. In many countries, social security is one of the options for diffusing and buffering the impact of the disease. This paper is focused on the analysis of the unjustified prescription of temporary sick leave certificates (CITT), which combines the social security medical components and economic benefits (subsidies). The objective is to analyze the mechanism of prescription of CITT from the perspective of health economics and health care services. The detailed flow of CITT at the Mexican Institute of Social Security is described, as are some concepts of the health economics perspective that contribute to explain the prescription of CITT. Statistical data of sick leaves due to work-related and non-work-related diseases are presented from the institutional perspective. Finally, it is emphasized that although CITT are a medical prescription, it is advisable to take into account the economic perspective and its concepts in order to achieve an efficient use of resources.

Health and working conditions of pregnant women working inside and outside the home in Mexico City.

BACKGROUND: To explore differences related to health and working conditions by comparing socio-demographic parameters, reproductive and prenatal care characteristics and working conditions among pregnant women who are employed outside the home (extra-domestic) while still performing a domestic workload versus those who perform exclusively domestic work in the home (intra-domestic). METHODS: A cross-sectional study was carried out at Family Medicine Unit N 31 of the Mexican Institute of Social Security (IMSS) in Mexico City between April and July 2003. Interviews were conducted with 537 pregnant women engaged in either extra-domestic work plus intra-domestic tasks, or those performing strictly intra-domestic work. Information was obtained regarding their demographic status, prenatal care, reproductive, work characteristics, and health during pregnancy. RESULTS: One hundred ninety-six (36.5%) of the interviewed women had paid jobs outside the home in addition to domestic tasks, while three hundred forty-one (63.5 %) engaged in exclusively intra-domestic occupations. Of the women with paid jobs, 78.6% worked as clerks. Among domestic tasks, we found that the greatest workload was associated with washing of clothes, and our micro-ergonomic analysis revealed that women who worked strictly inside the home had a higher domestic workload versus employed women (69.2 vs. 44.9%). When we analyzed the effect of work on health during pregnancy, we observed that women who worked strictly inside the home were at a higher risk for musculoskeletal and genitourinary symptoms than those employed outside the home. CONCLUSION: These findings suggest that the effect of intra-domestic work should not be ignored when considering women's health during pregnancy, and that greater attention should be paid to women's working conditions during intra and extra-domestic work.

[Study of primary care health needs through family health diagnosis]. / Estudio de las necesidades de salud en atención primaria mediante el diagnóstico de salud de la familia.

OBJECTIVE: To assess the health needs of the eligible public population of the Mexican Institute of Social Security (IMSS). DESIGN: Observational, descriptive, transversal study. SETTING: Family Medicine Unit number 8 of the IMSS, in the city of Tlaxcala, Mexico. PARTICIPANTS: A sample of 1200 families using multi-stage sampling, between October 1999 and March 2000. MAIN MEASUREMENTS: The designed and validated questionnaire on "Family health diagnosis" was used. RESULTS: A 19.2% of the families had a very low socio-economic level, and 14.9% of subjects were not entitled to Social Security. Functional illiteracy in at least one member was found in 12.6% of the families. According to the family Apgar, 93% of families were functional and two-thirds of the families were classified as nuclear. About 51.1% and 36.9% of women used programs for detection of cervical/uterine and breast cancer, respectively. Only 25% of the adult population underwent the detection tests for diabetes mellitus and hypertension and 10.9% had a chronic disease. 56.4% of families considered the quality of health care good, and only 18.13% were satisfied with the care received. CONCLUSIONS: Identification of health needs through diagnosis of family health is useful as a basis for establishing a hierarchy of problems as well as for developing health programs that may facilitate greater equity in attention.

Estudio de las necesidades de salud en atención primaria mediante el diagnóstico de salud de la familia / Study of primary care health needs through family health diagnosis

Objetivo. Analizar las necesidades de salud en la población adscrita al Instituto Mexicano del Seguro Social (IMSS). Diseño. Estudio observacional, descriptivo y transversal. Emplazamiento. La Unidad de Medicina Familiar número 8 del IMSS en la ciudad de Tlaxcala, México. Participantes. Muestra de 1.200 familias por muestreo polietápico. El estudio se realizó entre octubre de 1999 y marzo de 2000. Mediciones principales. Se ha aplicado el cuestionario «Diagnóstico de salud de la familia», previamente elaborado y validado. Resultados. El 19,2% de las familias tenía un nivel socioeconómico muy bajo y un 14,9% de los sujetos no tuvo derecho a la Seguridad Social. El 12,6% de las familias tenía al menos un miembro analfabeto. De acuerdo con el resultado del test de Apgar familiar, el 93% de las familias era funcional y los dos tercios de las familias se clasificaron como nucleares. La cobertura de los programas de detección de cáncer cervicouterino y de mama en las mujeres fue del 51,1 y el 36,9%, respectivamente. Sólo en el 25% de la población adulta se realizaron pruebas de detección de diabetes mellitus e hipertensión arterial. El 10,9% de la población refirió tener alguna enfermedad crónica. El 56,4% de las familias consideró que la calidad de la atención fue buena y sólo el 18,13% estuvo satisfecho con la atención recibida. Conclusiones. El diagnóstico de salud familiar es importante en el proceso de evaluación de las necesidades de salud en la población para la jerarquización de problemas, así como para el desarrollo de los programas de salud que permitirán una mayor equidad en la atención

Objective. To assess the health needs of the eligible public population of the Mexican Institute of Social Security (IMSS). Design. Observational, descriptive, transversal study. Setting. Family Medicine Unit number 8 of the IMSS, in the city of Tlaxcala, Mexico. Participants. A sample of 1200 families using multi-stage sampling, between October 1999 and March 2000. Main measurements. The designed and validated questionnaire on "Family health diagnosis" was used. Results. A 19.2% of the families had a very low socio-economic level, and 14.9% of subjects were not entitled to Social Security. Functional illiteracy in at least one member was found in 12.6% of the families. According to the family Apgar, 93% of families were functional and two-thirds of the families were classified as nuclear. About 51.1% and 36.9% of women used programs for detection of cervical/uterine and breast cancer, respectively. Only 25% of the adult population underwent the detection tests for diabetes mellitus and hypertension and 10.9% had a chronic disease. 56.4% of families considered the quality of health care good, and only 18.13% were satisfied with the care received. Conclusions. Identification of health needs through diagnosis of family health is useful as a basis for establishing a hierarchy of problems as well as for developing health programs that may facilitate greater equity in attention

Cost-effectiveness of chronic hepatitis C treatment with thymosin alpha-1.

BACKGROUND: More than one million individuals in Mexico are infected with hepatitis C virus (HCV), and 80% are at risk for developing a chronic infection that could lead to hepatic cirrhosis and other complications that impact quality of life and institutional costs. The objective of the study was to determine the most cost-effective treatment against HCV among the following: peginterferon, peginterferon plus ribavirin, peginterferon plus ribavirin plus thymosin, and no treatment. METHODS: We carried out cost-effectiveness analysis using the institutional perspective, including a 45-year time frame and a 3% discount rate for costs and effectiveness. We employed a Bayesian-focused decision tree and a Markov model. One- and two-way sensitivity analyses were performed, as well as threshold-oriented and probabilistic analyses, and we obtained acceptability curves and net health benefits. RESULTS: Triple therapy (peginterferon plus ribavirin plus thymosin alpha-1) was dominant with lower cost and higher utility in relationship with peginterferon + ribavirin option, peginterferon alone and no-treatment option. In triple therapy the cost per unit of success was of 1,908 [USD/quality-adjusted life years (QALY)] compared with peginterferon plus ribavirin 2,277/QALY, peginterferon alone 2,929/QALY, and no treatment 4,204/QALY. Sensitivity analyses confirmed the robustness of the base case. CONCLUSIONS: Peginterferon plus ribavirin plus thymosin alpha-1 option was dominant (lowest cost and highest effectiveness). Using no drug was the most expensive and least effective option.

Direct medical costs for partial refractory epilepsy in Mexico.

BACKGROUND: The aim was to determine the direct medical costs in patients with partial refractory epilepsy at the Mexican Institute of Social Security (IMSS) in Mexico. METHODS: We carried out a multicenter, retrospective-cohort partial-economic evaluation study of partial refractory epilepsy (PRE) diagnosed patients and analyzed patient files from four secondary- and tertiary-level hospitals. PRE patients >12 years of age with two or more antiepileptic drugs and follow-up for at least 1 year were included. The perspective was institutional (IMSS). Only direct healthcare costs were considered, and the timeline was 1 year. Cost techniques were microcosting, average per-service cost, and per-day cost, all costs expressed in U.S. dollars (USD, 2004). RESULTS: We reviewed 813 files of PRE patients: 133 had a correct diagnosis, and only 72 met study inclusion criteria. Fifty eight percent were females, 64% were <35 years of age, 47% were students, in 73% maximum academic level achieved was high school, and 53% were single. Fifty one percent of cases experienced simple partial seizures and 94% had more than one monthly seizure. Annual healthcare cost of the 72 patients was 190,486 USD, ambulatory healthcare contributing 76% and hospital healthcare with 24%. CONCLUSIONS: Annual mean healthcare cost per PRE patient was 2,646 USD; time of disease evolution and severity of the patient's illness did not affect costs significantly.

Socioeconomic factors and low birth weight in Mexico.

BACKGROUND: Low birth weight (LBW) is a public health problem linked to lack of equity in populations. Despite efforts to decrease the proportion of newborns with LBW, success has been quite limited. In recent years, studies focused on explaining how social factors influence this problem have shown that populations with greater inequities have a greater proportion of newborns with LBW. METHODS: The objective was to describe socioeconomic factors related to LBW adjusted by demographic, reproductive and health services variables in Mexico City. A case-control study was carried out in three hospitals with gynaecological and obstetrics services in Mexico City during the first half of 1996. During the recruiting period all children with LBW (cases), defined as newborns weighing <2500 grams, were matched with children born on the same day to control for time of birth. Upon arrival at the hospital for delivery, women were interviewed to determine if they met our inclusion criteria. Women with a history of chronic conditions and those with twin or multiple pregnancies were excluded. Variables with clinical and statistical significance were included in a multivariate model (logistic regression). RESULTS: We found that low socioeconomic level was the most important risk factor for LBW and was independent of other factors, including those related to reproduction and nutrition, smoking, morbidity during pregnancy, accessibility to health services and prenatal care (OR 2.68; 95% CI 1.19, 6.03). CONCLUSION: We found that socioeconomic factors are relevant to LBW. However further research should be done in different population groups as well as developing precise ways of measuring socioeconomic factors and their role in reproductive health.