Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia.

PURPOSE: Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system. MATERIALS AND METHODS: A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model. RESULTS: A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26). CONCLUSION: Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.

Pulsión de muerte: una lectura desde el contexto carcelario

Resumen El presente artículo es resultado de la investigación "Pulsión de muerte y actos delictivos en un grupo de internos del INPEC - Pasto". El objetivo de la inves­tigación fue comprender la pulsión de muerte en los actos violentos presentes en un grupo de internos de la Cárcel Judicial de Pasto, que permitiera el diseño de una propuesta de intervención con la población seleccionada. Se realizó la reflexión de tres catego­rías: acontecimientos, la repetición y la rectifica­ción subjetiva; desde un paradigma cualitativo, con enfoque hermenéutico y método etnográfico acu­diendo como instrumentos de recolección: entrevis­ta semi-estructurada, historia de vida y grupo focal. El estudio permite afirmar que, a pesar que en la mayoría de internos, no se presentan niveles altos de conducta antisocial, los porcentajes de internos que si presentan estos niveles no deben ser despreciados, puesto que esto implica una tendencia a la comisión de estas conductas durante su ciclo vital.

Abstract This paper is the result of the research "Death drive and criminal acts in a group of inmates of INPEC - Pasto", completed in 2017, with the collaboration of the Mariana University and the inma­tes and officials of the National Penitentiary Institute and INPEC Prison - Pasto. The investigation was guided by the general objective of understanding the death drive in violent acts of a group of inmates of the Pasto Prison, which allowed for the design of an intervention proposal with the selected population. The specific objectives of the study were directed towards exhaustive re­flection on three important categories: events, the unconscious mechanism of repetition and the process of subjective rectification; from a qualitative paradigm, with a hermeneutical approach and an ethnographic method as collecting instruments: the semi-structured interview, the life his­tory, and the focus group. The study allows to affirm that, although in most inmates there are no high levels of antisocial behavior, the percentages of inmates who do present these levels should not be disregarded, since this implies a tendency to commit these behaviors during its life cycle.