Economic Evaluation of a Mobile Stroke Unit Service in Germany.

BACKGROUND: Lower global disability and higher quality of life among ischemic stroke patients was found to be associated with the dispatch of mobile stroke units (MSUs) among patients eligible for recanalizing treatments in the Berlin_Prehospital Or Usual Delivery of stroke care (B_PROUD) study. The current study assessed the cost-utility and cost-effectiveness of additional MSU dispatch using data from this prospective, controlled, intervention study. METHODS: Outcomes considered in the economic evaluation included quality-adjusted life years (QALYs) derived from the 3-level version of EQ-5D (EQ-5D-3L) and modified Rankin Scale (mRS) scores for functional outcomes 3-months after stroke. Costs were prospectively collected during the study by the MSU provider (Berlin Fire Brigade) and the B_PROUD research team. We focus our results on the societal perspective. As we aimed to determine the economic consequences of the intervention beyond the study's follow-up period, both care costs and QALYs were extrapolated over 5 years. RESULTS: The additional MSU dispatch resulted in an incremental €40,984 per QALY. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €24,470.76 and €61,690.88 per QALY. In the cost-effectiveness analysis, MSU dispatch resulted in incremental costs of €81,491 per survival without disability. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €44,455.30 and €116,491.15 per survival without disability. INTERPRETATION: Among patients eligible for recanalizing treatments in ischemic stroke, MSU dispatch was associated with both higher QALYs and higher costs and is cost-effective when considering internationally accepted thresholds ranging from an additional €40,000 to €80,000 per QALY. ANN NEUROL 2023;93:942-951.

Mapping Studies to Estimate Health-State Utilities From Nonpreference-Based Outcome Measures: A Systematic Review on How Repeated Measurements are Taken Into Account.

OBJECTIVES: Mapping algorithms are developed using data sets containing patient responses to a preference-based questionnaire and another health-related quality-of-life questionnaire. When data sets include repeated measurements from the same individuals over time, the assumption of observations' independence, required by standard models, is violated, and standard errors are underestimated. This review aimed to identify how studies deal with methodological challenges of repeated measurements, provide an overview of practice to date, and potential implications for future work. METHODS: We conducted a systematic literature search of MEDLINE, Cumulative Index to Nursing and Allied Health Literature, specialized databases, and previous systematic reviews. A data template was used to extract, among others, start and target instruments if the data set(s) used for estimation and validation had repeated measurements per patient, used regression techniques, and which (if any) adjustments were made for repeated measurements. RESULTS: We identified 278 publications developing at least 1 mapping algorithm. Of the 278 publications, 121 used a data set with repeated measurements, among which 92 used multiple time points for estimation, and 39 selected specific time points to have 1 observation per participant. A total of 36 studies did not account for repeated measurements. An adjustment was conducted using cluster-robust standard errors (21), random-effects models (30), generalized estimating equations (7), and other methods (7). CONCLUSIONS: The inconsistent use of methods to account for interdependent observations in the literature indicates that mapping guidelines should include recommendations on how to deal with repeated measurements, and journals should update their guidelines accordingly.

Study Design and Protocol of a Randomized Controlled Trial of the Efficacy of a Smartphone-Based Therapy of Migraine (SMARTGEM).

Background: Digitalization and electronic health (eHealth) offer new treatment approaches for patients with migraine. Current smartphone applications (apps) for migraine patients include a wide spectrum of functions ranging from digital headache diaries to app-based headache treatment by, among others, analysis of the possible triggers, behavioral therapy approaches and prophylactic non-drug treatment methods with relaxation therapy or endurance sport. Additional possibilities arise through the use of modern, location-independent communication methods, such as online consultations. However, there is currently insufficient evidence regarding the benefits and/or risks of these electronic tools for patients. To date, only few randomized controlled trials have assessed eHealth applications. Methods: SMARTGEM is a randomized controlled trial assessing whether the provision of a new digital integrated form of care consisting of the migraine app M-sense in combination with a communication platform (with online consultations and medically moderated patient forum) leads to a reduction in headache frequency in migraine patients, improving quality of life, reducing medical costs and work absenteeism (DRKS-ID: DRKS00016328). Discussion: SMARTGEM constitutes a new integrated approach for migraine treatment, which aims to offer an effective, location-independent, time-saving and cost-saving treatment. The design of the study is an example of how to gather high quality evidence in eHealth. Results are expected to provide insightful information on the efficacy of the use of electronic health technology in improving the quality of life in patients suffering from migraine and reducing resource consumption.

Comparing randomized controlled trials of outpatient family-based or inpatient multimodal treatment followed by outpatient care in youth with anorexia nervosa: Differences in populations, metrics, and outcomes.

OBJECTIVE: Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT. METHOD: Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT. RESULTS: Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented. DISCUSSION: An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

HIT-6 and EQ-5D-5L in patients with migraine: assessment of common latent constructs and development of a mapping algorithm.

OBJECTIVE: The aims of this study were to assess whether there is a conceptual overlap between the questionnaires HIT-6 and EQ-5D and to develop a mapping algorithm allowing the conversion of HIT-6 to EQ-5D utility scores for Germany. METHODS: This study used data from an ongoing randomised controlled trial for patients suffering from migraine. We assessed the conceptual overlap between the two instruments with correlation matrices and exploratory factor analysis. Linear regression, tobit, mixture, and two-part models were used for mapping, accounting for repeated measurements, tenfold cross-validation was conducted to validate the models. RESULTS: We included 1010 observations from 410 patients. The EQ-5D showed a substantial ceiling effect (47.3% had the highest score) but no floor effect, while the HIT-6 showed a very small ceiling effect (0.5%). The correlation between the instruments' total scores was moderate (- 0.30), and low to moderate among each domain (0.021-0.227). The exploratory factor analysis showed insufficient conceptual overlap between the instruments, as they load on different factors. Thus, there is reason to believe that the instruments' domains do not capture the same latent constructs. To facilitate future mapping, we provide coefficients and a variance-covariance matrix for the preferred model, a two-part model with the total HIT-6 score as the explanatory variable. CONCLUSION: This study showed that the German EQ-5D and the HIT-6 lack the conceptual overlap needed for appropriate mapping. Thus, the estimated mapping algorithms should only be used as a last resort for estimating utilities to be employed in economic evaluations.

"How Come You Don't Call Me?" Smartphone Communication App Usage as an Indicator of Loneliness and Social Well-Being across the Adult Lifespan during the COVID-19 Pandemic.

Loneliness and lack of social well-being are associated with adverse health outcomes and have increased during the COVID-19 pandemic. Smartphone communication data have been suggested to help monitor loneliness, but this requires further evidence. We investigated the informative value of smartphone communication app data for predicting subjective loneliness and social well-being in a sample of 364 participants ranging from 18 to 78 years of age (52.2% female; mean age = 42.54, SD = 13.22) derived from the CORONA HEALTH APP study from July to December 2020 in Germany. The participants experienced relatively high levels of loneliness and low social well-being during the time period characterized by the COVID-19 pandemic. Apart from positive associations with phone call use times, smartphone communication app use was associated with social well-being and loneliness only when considering the age of participants. Younger participants with higher use times tended to report less social well-being and higher loneliness, while the opposite association was found for older adults. Thus, the informative value of smartphone communication use time was rather small and became evident only in consideration of age. The results highlight the need for further investigations and the need to address several limitations in order to draw conclusions at the population level.

Determining the Evolution of Headache Among Regular Users of a Daily Electronic Diary via a Smartphone App: Observational Study.

BACKGROUND: Smartphone-based apps represent a major development in health care management. Specifically in headache care, the use of electronic headache diaries via apps has become increasingly popular. In contrast to the soaring volume of available data, scientific use of these data resources is sparse. OBJECTIVE: In this analysis, we aimed to assess changes in headache and migraine frequency, headache and migraine intensity, and use of acute medication among people who showed daily use of the headache diary as implemented in the freely available basic version of the German commercial app, M-sense. METHODS: The basic version of M-sense comprises an electronic headache diary, documentation of lifestyle factors with a possible impact on headaches, and evaluation of headache patterns. This analysis included all M-sense users who had entered data into the app on a daily basis for at least 7 months. RESULTS: We analyzed data from 1545 users. Mean MHD decreased from 9.42 (SD 5.81) at baseline to 6.39 (SD 5.09) after 6 months (P<.001; 95% CI 2.80-3.25). MMD, AMD, and migraine intensity were also significantly reduced. Similar results were found in 985 users with episodic migraine and in 126 users with chronic migraine. CONCLUSIONS: Among regular users of an electronic headache diary, headache and migraine frequency, in addition to other headache characteristics, improved over time. The use of an electronic headache diary may support standard headache care.

Primary headaches during the COVID-19 lockdown in Germany: analysis of data from 2325 patients using an electronic headache diary.

BACKGROUND: Lockdown measures due to the COVID-19 pandemic have led to lifestyle changes, which in turn may have an impact on the course of headache disorders. We aimed to assess changes in primary headache characteristics and lifestyle factors during the COVID-19 lockdown in Germany using digital documentation in the mobile application (app) M-sense. MAIN BODY: We analyzed data of smartphone users, who entered daily data in the app in the 28-day period before lockdown (baseline) and in the first 28 days of lockdown (observation period). This analysis included the change of monthly headache days (MHD) in the observation period compared to baseline. We also assessed changes in monthly migraine days (MMD), the use of acute medication, and pain intensity. In addition, we looked into the changes in sleep duration, sleep quality, energy level, mood, stress, and activity level. Outcomes were compared using paired t-tests. The analysis included data from 2325 app users. They reported 7.01 ± SD 5.64 MHD during baseline and 6.89 ± 5.47 MHD during lockdown without significant changes (p > 0.999). MMD, headache and migraine intensity neither showed any significant changes. Days with acute medication use were reduced from 4.50 ± 3.88 in the baseline to 4.27 ± 3.81 in the observation period (p < 0.001). The app users reported reduced stress levels, longer sleep duration, reduced activity levels, along with a better mood, and an improved energy level during the first lockdown month (p ≤ 0.001). In an extension analysis of users who continued to use M-sense every day for 3 months after initiation of lockdown, we compared the baseline and the subsequent months using repeated-measures ANOVA. In these 539 users, headache frequency did not change significantly neither (6.11 ± 5.10 MHD before lockdown vs. 6.07 ± 5.17 MHD in the third lockdown month, p = 0.688 in the ANOVA). Migraine frequency, headache and migraine intensity, and acute medication use were also not different during the entire observation period. CONCLUSION: Despite slight changes in factors that contribute to the generation of headache, COVID-19-related lockdown measures did not seem to be associated with primary headache frequency and intensity over the course of 3 months.

Improvement in the anti-inflammatory profile with lifelong physical exercise is related to clock genes expression in effector-memory CD4+ T cells in master athletes.

PURPOSE: Ageing is associated with alterations in the immune system as well as with alterations of the circadian rhythm. Immune cells show rhythmicity in execution of their tasks. Chronic inflammation (inflammaging), which is observed in the elderly, is mitigated by lifelong exercise. The aimed this study was to determine the acute effect of a maximal exercise test on clock genes, regulatory proteins and cytokine expression, and evaluate the effect of lifelong exercise on the expression of clock genes in subpopulations of effector-memory (EM) CD4+ and CD8+T cells and the association of these processes with the inflammatory profile. Therefore, this study aimed to investigate the expression of clock genes in subpopulations of effector memory (EM) CD4+ and CD8+ T cells in master athletes and healthy controls and further associate them with systemic inflammatory responses to acute exercise. METHODS: The study population comprised national and international master athletes (n = 18) involved in three sports (athletics, swimming and judo). The control group (n = 8) comprised untrained healthy volunteers who had not participated in any regular and competitive physical exercise in the past 20 years. Anthropometric measurements and blood samples were taken before (Pre), 10 min after (Post) and 1 h after (1 h Post) a maximal cycle ergometer test for the determination of maximum oxygen consumption (VO2 max). The subpopulations of EM CD4+ and CD8+ T cells were purified using fluorescenceactivated cell sorting. RNA extraction of clock genes (CLOCK, BMAL1, PER1, PER2, CRY1, CRY2, REV-ERBα, REV-ERBß, RORa, RORb and RORc) in EM CD4+ and EM CD8+ T cells as well as regulatory proteins (IL-4, IFN-γ, Tbx21, PD-1, Ki67, NF-kB, p53 and p21) in EM CD4+ T cells was performed. The serum concentration of cytokines (IL-8, IL-10, IL-12p70 and IL-17A) was measured. RESULTS: The master athletes showed better physiological parameters than the untrained healthy controls (P < 0.05). The levels of cytokines increased in master athletes at Post compared with those at Pre. The IL-8 level was higher at 1 h Post, whereas the IL-10 and IL-12p70 levels returned to baseline. There was no change in IL-17A levels (P < 0.05). The clock genes were modulated differently in CD4+ T cells after an acute session of exercise in a training status-dependent manner. CONCLUSION: The synchronization of clock genes, immune function and ageing presents new dimensions with interesting challenges. Lifelong athletes showed modified expression patterns of clock genes and cytokine production associated with the physical fitness level. Moreover, the acute bout of exercise altered the clock machinery mainly in CD4+ T cells; however, the clock gene expressions induced by acute exercise were different between the master athletes and control group.

Patients prefer clinical handover at the bedside; nurses do not: Evidence from a discrete choice experiment.

BACKGROUND: Shift-to-shift bedside handover is advocated as a patient-centred approach, yet its enactment is challenging. OBJECTIVES: To describe and compare the preferences of both patients and nurses in the implementation of bedside handover in a Swedish University Hospital. DESIGN: A discrete choice experiment (DCE) survey. SETTINGS: University setting, four medical wards in two hospitals. PARTICIPANTS: Adult medical patients (n = 218) and registered nurses (n = 101) METHODS: The survey was administered by an electronic tablet-assisted face-to-face survey. Respondents made repeated choices between two hypothetical bedside handover alternatives and a third alternative of 'handover away from the bedside'. Handover alternatives were described according to six attributes: invitation to participate, number of nurses present at the handover, family member, carer or trusted friend (of the patient) allowed to be present, level of (patient) involvement, what information related to your (patient) care is discussed. Choice data were analyzed using a mixed logit model. RESULTS: A total of 1308 (patients) and 909 (nurses) choice observations were included in the preference models. Patients showed a strong preference for handover at the bedside compared to nurses. Nurses generally preferred handover away from the bedside. Patients perceived their level of involvement in handover as highly important, being able to speak, hear what was said being the most important characteristic, closely followed by being invited to participate and asked questions as well as being heard. Nurses considered patients being invited to participate most important, followed by level of involvement. Different options for handing over sensitive information were not perceived of importance by patients or nurses. There was substantial variation at the individual level across both patients and nurses for where and how handover is delivered. CONCLUSIONS: In this study, patients strongly preferred handover at the bedside, while the nurses considered patients to be invited to participate to be the most important preference but generally preferred handover to take place away from the bedside, all else equal. When implementing bedside handover in a Swedish context this must be considered, although participation is a prerequisite for bedside handover. Differences between patients and nurses' preferences could jeopardize future introduction of bedside handover in Swedish health care, and might explain why bedside handover is still not very common in hospital wards.

The impact of demographic and clinical characteristics on diabetic painful neuropathy.

INTRODUCTION: Diabetic neuropathy (DN) is one of the most devastating complications of diabetes mellitus; however, in contrast to other countries, there are no scientific studies in Portugal evaluating the impact of demographic and clinical characteristics of this pathological entity. The aim of this study was to evaluate the impact of gender, metabolic control, age of diabetic patients, as well as time of disease progression, the appearance of complaints related to neuropathic pain. MATERIAL AND METHODS: A multicentre study with a non-probabilistic, convenience sample of 359 patients was performed employing the quantitative method, using the Statistical Package for Social Science 24 software. The p-value of p < 0.05 was defined to consider a result statistically significant. The Spearman correlation coefficient (r) was determined to determine the relationship between categorical variables. RESULTS: There was no statistically significant difference in the prevalence of DN between genders (p = 0.633 and r = 0.025). There was a statistically significant relationship between the value of HbA1c and DN, with p = 0.010 and r = 0.136. There is a relationship between age and complaints of neuropathic pain, with p = 0.034 and r = 0.112. The variable, time of disease progression, is also correlated with the appearance of complaints of neuropathic pain with p = 0.020 and r = 0.112. CONCLUSION: The prevalence of neuropathic pain in subjects with diabetes is not negligible and is associated with modifiable risk factors that can be identified, possibly modified and prevented. The correct approach for these patients, which involves screening and early treatment, is decisive improving functionality and quality of life.

Cost-minimisation analysis alongside a pilot study of early Tissue Doppler Evaluation of Diastolic Dysfunction in Emergency Department Non-ST Elevation Acute Coronary Syndromes (TEDDy-NSTEACS).

OBJECTIVE: To estimate the cost implications of early angiography for patients with suspected non-ST elevation acute coronary syndrome (NSTEACS) using tissue Doppler imaging (TDI). DESIGN: A decision tree model was used to synthesise data from the pilot study and literature sources. Sensitivity analyses tested the impact of assumptions incorporated into the analysis. SETTING: Emergency department (ED), Brisbane, Australia. PARTICIPANTS: Patients with suspected NSTEACS. INTERVENTIONS: TDI as a diagnostic tool for triaging patients within 4 hours of presentation in addition to conventional risk stratification, compared with conventional risk stratification alone. DATA SOURCES: Resource used for diagnosis and management were recorded prospectively and costed for 51 adults who had echocardiography within 24 hours of admission. Costs for conventional care were based on observed data. Cost estimates for the TDI intervention assumed patients classified as high risk at TDI (E/e'>14) progressed early to angiography with an associated 1-day reduction in length of stay. PRIMARY OUTCOME MEASURES: Costs until discharge from the Australian healthcare perspective in 2016-2017 prices. RESULTS: Findings suggest that using TDI as a diagnostic tool for triaging patients with suspected NSTEACS is likely to be cost saving by $A1090 (95% credible interval: $A573 to $A1703) per patient compared with conventional care. The results are mainly driven by the assumed reduction in length of stay due to the inclusion of early TDI in clinical decision-making. CONCLUSIONS: This pilot study indicates that compared with conventional risk stratification, triaging patients presenting with suspected NSTEACS with TDI within 4 hours of ED presentation has potential cost savings. Findings assume a reduction in hospital stay is achieved for patients considered to be high risk at TDI. Larger, comparative studies with longer follow-up are needed to confirm the clinical effectiveness of TDI as a diagnostic strategy for NSTEACS, the assumed reduction in hospital stay and any cost saving.

Preferences for the administration of testosterone gel: evidence from a discrete choice experiment.

Objectives: Differences in testosterone replacement therapy (TRT) gel products may affect patient satisfaction, quality-of-life, and treatment response and adherence. This study investigated preferences for TRT gel in terms of formulation and administration. Methods: 525 male adults aged 45 years and over completed a discrete choice experiment. Respondents made repeated choices between two hypothetical testosterone gel treatments described according to four attributes: form, ease of use, impact of use on showering/swimming, and location/dosage of the application. Choice data were analyzed using a latent class model. Results: Three preference classes were identified. Respondents across all classes displayed a preference for the gel being dispensed in smaller units with accurate dosing, waiting shorter times after the gel application before swimming/showering, and using 2.5 gm of gel to be applied to the inner thigh/abdomen as opposed 5 gm to shoulder/abdomen. The importance of these characteristics differed across classes, with preference class membership predicted by age and education level. For instance, younger men (aged 45-64 years) were more likely to belong to a class that prioritized reduced waiting time before being able to undertake activities. Formulation was not an important driver of choice. Conclusions: Preferences demonstrate a predilection for TRT gel dispensed in small units allowing precise dosing, shorter waiting time after application, and application to the inner thigh/abdomen. However, the strength of importance of these characteristics differs between men. This study highlights the attributes of TRT gel considered important to patient subgroups, and which may ultimately affect treatment response, medication adherence, and patient quality-of-life.

Adesão à terapia antirretroviral de pacientes portadores de HIV/Aids com lipodistrofia / Adherence to antiretroviral therapy by HIV/AIDS patients with lipodystrophy / Adhesión a la terapia antirretroviral de pacientes VIH / SIDA con lipodistrofia

Objetivo: descrever o perfil de adesão à terapia antirretroviral (TARV) de pacientes com Síndrome Lipodistrófica do Vírus da Imunodeficiência Humana (SLHIV), em uma unidade especializada do Estado do Pará, Brasil. Método: estudo qualiquantitativo, envolvendo questionário e prontuários de 124 pacientes, no período de fevereiro e março de 2013, após aprovação por Comitê de Ética. Na análise, a variância (p<0,05) articulou testes estatísticos, com dados apresentados em tabelas. Resultados: as dificuldades de entender e conhecer o esquema terapêutico, o Diabetes Mellitus e as alterações da lipodistrofia foram significantes na interferência da adesão à TARV. O grupo de adesão irregular está em risco para a eficácia do tratamento. Os demais têm a possibilidade de migração de um grupo para outro a qualquer momento. Conclusão: o perfil de adesão à TARV não é definida por dados socioeconômicos. A participação em grupos de adesão deve ser estimulada como fator de reversão do padrão de abandono. Descritores: HIV; AIDS; lipodistrofia; adesão à medicação.

Objective: to profile adherence to antiretroviral therapy (ART) by patients with human immunodeficiency virus lipodystrophy syndrome (HIVLS) at a specialized unit in Pará, Brazil. Method: this quali-quantitative study, involving a questionnaire and medical records of 124 patients, was conducted from February to March 2013, after research ethics approval. In the analysis, statistical tests were related by variance (p <0.05) and data were presented in table form. Results: the difficulties of understanding and knowing the therapeutic regimen, mellitus diabetes and changes in lipodystrophy were significant in the interference of ART adherence. The irregular adherence group is at risk for treatment efficacy. The others have the possibility of migrating from one group to another at any time. Conclusion: the profile of adherence to ART is not defined by socioeconomic data. Participation in membership groups should be encouraged as a factor in reversing the pattern of abandonment.

Objetivo: describir el perfil de adhesión a la terapia antirretroviral (TARV) de pacientes con síndrome lipodistrófico del virus de la inmunodeficiencia humana (SLHIV), en una unidad especializada del Estado de Pará, Brasil. Método: estudio cualiquantitativo involucrando cuestionario e historias clínicas de 124 pacientes, en el período de febrero y marzo de 2013, después de la aprobación por el Comité de Ética. En el análisis, la varianza (p <0,05) articuló pruebas estadísticas, con datos presentados en tablas. Resultados: las dificultades en entender y conocer el esquema terapéutico, la Diabetes Mellitus y las alteraciones de la lipodistrofia fueron significantes en la interferencia de la adhesión a la TARV. El grupo de adhesión irregular está en riesgo para la eficacia del tratamiento. Los demás tienen la posibilidad de migración de un grupo a otro en cualquier momento. Conclusión: el perfil de adhesión a la TARV no está definido por datos socioeconómicos. La participación en grupos de adhesión debe ser estimulada como factor de reversión del patrón de abandono.

A Systematic Review Comparing the Acceptability, Validity and Concordance of Discrete Choice Experiments and Best-Worst Scaling for Eliciting Preferences in Healthcare.

OBJECTIVE: The aim of this study was to compare the acceptability, validity and concordance of discrete choice experiment (DCE) and best-worst scaling (BWS) stated preference approaches in health. METHODS: A systematic search of EMBASE, Medline, AMED, PubMed, CINAHL, Cochrane Library and EconLit databases was undertaken in October to December 2016 without date restriction. Studies were included if they were published in English, presented empirical data related to the administration or findings of traditional format DCE and object-, profile- or multiprofile-case BWS, and were related to health. Study quality was assessed using the PREFS checklist. RESULTS: Fourteen articles describing 12 studies were included, comparing DCE with profile-case BWS (9 studies), DCE and multiprofile-case BWS (1 study), and profile- and multiprofile-case BWS (2 studies). Although limited and inconsistent, the balance of evidence suggests that preferences derived from DCE and profile-case BWS may not be concordant, regardless of the decision context. Preferences estimated from DCE and multiprofile-case BWS may be concordant (single study). Profile- and multiprofile-case BWS appear more statistically efficient than DCE, but no evidence is available to suggest they have a greater response efficiency. Little evidence suggests superior validity for one format over another. Participant acceptability may favour DCE, which had a lower self-reported task difficulty and was preferred over profile-case BWS in a priority setting but not necessarily in other decision contexts. CONCLUSION: DCE and profile-case BWS may be of equal validity but give different preference estimates regardless of the health context; thus, they may be measuring different constructs. Therefore, choice between methods is likely to be based on normative considerations related to coherence with theoretical frameworks and on pragmatic considerations related to ease of data collection.

Aumento das cargas de trabalho em técnicos de enfermagem na atenção primária à saúde no Brasil / Increased workloads for nurse technicians in primary health care in Brazil / Aumento de las cargas de trabajo en técnicos de enfermería en la atención primaria a la salud en Brasil

Resumo Este artigo analisa os principais aspectos que contribuem para aumentar as cargas de trabalho de técnicos de enfermagem que atuam na atenção primária à saúde no Brasil, identifica o tipo de cargas e classifica os aspectos mais prevalentes para esse grupo ocupacional. Baseia-se em estudo multicêntrico realizado com 24 profissionais das regiões Sul, Centro-Oeste e Norte do Brasil, de 2011 a 2013, por meio de entrevistas semiestruturadas. Os dados foram sistematizados no software Atlas.ti e submetidos à análise temática. Os aspectos que mais contribuem para aumentar as cargas de trabalho são a baixa remuneração mensal, falta de recursos materiais, sobrecarga de trabalho, desgaste e adoecimento, relação com o usuário, e escassez de recursos humanos, prevalecendo cargas psíquicas e fisiológicas. Adequação das condições e organização do trabalho se mostram primordiais para amenizar as cargas de trabalho no cenário da atenção primária à saúde, e para promover a saúde, o bem-estar e a qualidade de vida no ambiente de trabalho dos técnicos de enfermagem.

Abstract In this article we analyze the main aspects that contribute to increase the workloads of nurse technicians working in primary health care in Brazil, we identify the type of loads and rank the most prevalent aspects of this occupational group. It is based on a multicenter study with 24 professionals from the South, Center-west and North regions of Brazil, from 2011 to 2013, using data from semi-structured interviews. The data were systematized in Atlas.ti software and submitted to thematic analysis. The aspects that contribute to increasing workloads are low monthly remuneration, lack of material resources, work overload, wear and illness, relationship with the user, and lack of human resources, prevailing psychological and physiological loads. Adequacy of the conditions and organization of work are shown paramount to ease the workload on the primary health care setting, and to promote the health, wellbeing and quality of life in the nurse technicians working environment.

Resumen Este artículo analiza los principales aspectos que contribuyen para aumentar las cargas de trabajo de técnicos de enfermería que actúan en la atención primaria a la salud en Brasil, identifica el tipo de cargas y clasifica los aspectos más prevalentes para ese grupo ocupacional. Es basado en estudio multicéntrico realizado con 24 profesionales de las regiones Sur, Centro-Oeste y Norte de Brasil, de 2011 a 2013, por medio de entrevistas semiestructuradas. Los datos fueron sistematizados en el software Atlas.ti y sometidos al análisis temático. Los aspectos que más contribuyen para aumentar las cargas de trabajo son la baja remuneración mensual, falta de recursos materiales, sobrecarga de trabajo, desgaste y enfermedad, relación con el usuario, y escasez de recursos humanos, prevaleciendo cargas psíquicas y fisiológicas. Adecuación de las condiciones y organización del trabajo se muestran primordiales para amenizar las cargas de trabajo en el escenario de la atención primaria a la salud, y para promover la salud, el bien-estar y la cualidad de vida en el ambiente de trabajo de los técnicos de enfermería.

Nursing workloads in family health: implications for universal access.

OBJECTIVE: to identify the workloads of nursing professionals of the Family Health Strategy, considering its implications for the effectiveness of universal access. METHOD: qualitative study with nursing professionals of the Family Health Strategy of the South, Central West and North regions of Brazil, using methodological triangulation. For the analysis, resources of the Atlas.ti software and Thematic Content Analysis were associated; and the data were interpreted based on the labor process and workloads as theorical approaches. RESULTS: the way of working in the Family Health Strategy has predominantly resulted in an increase in the workloads of the nursing professionals, with emphasis on the work overload, excess of demand, problems in the physical infrastructure of the units and failures in the care network, which hinders its effectiveness as a preferred strategy to achieve universal access to health. On the other hand, teamwork, affinity for the work performed, bond with the user, and effectiveness of the assistance contributed to reduce their workloads. CONCLUSIONS: investments on elements that reduce the nursing workloads, such as changes in working conditions and management, can contribute to the effectiveness of the Family Health Strategy and achieving the goal of universal access to health.

Nursing workloads in family health: implications for universal access / Cargas de trabalho da enfermagem na saúde da família: implicações no acesso universal / Cargas de trabajo de enfermería en la salud de la familia: implicaciones para el acceso universal

Objective to identify the workloads of nursing professionals of the Family Health Strategy, considering its implications for the effectiveness of universal access. Method qualitative study with nursing professionals of the Family Health Strategy of the South, Central West and North regions of Brazil, using methodological triangulation. For the analysis, resources of the Atlas.ti software and Thematic Content Analysis were associated; and the data were interpreted based on the labor process and workloads as theorical approaches. Results the way of working in the Family Health Strategy has predominantly resulted in an increase in the workloads of the nursing professionals, with emphasis on the work overload, excess of demand, problems in the physical infrastructure of the units and failures in the care network, which hinders its effectiveness as a preferred strategy to achieve universal access to health. On the other hand, teamwork, affinity for the work performed, bond with the user, and effectiveness of the assistance contributed to reduce their workloads. Conclusions investments on elements that reduce the nursing workloads, such as changes in working conditions and management, can contribute to the effectiveness of the Family Health Strategy and achieving the goal of universal access to health.

Objetivo identificar as cargas de trabalho dos profissionais de enfermagem da Estratégia Saúde da Família, analisando suas implicações na efetividade do acesso universal. Método estudo qualitativo com profissionais de enfermagem da Estratégia Saúde da Família das Regiões Sul, Centro-Oeste e Norte do Brasil, utilizando triangulação metodológica. Na análise dos dados articularam-se recursos do software Atlas.ti e da Análise Temática de Conteúdo, interpretando-os com base nos referenciais de processo de trabalho e cargas de trabalho. Resultados o modo de trabalhar na Estratégia Saúde da Família tem, predominantemente, gerado aumento das cargas de trabalho dos profissionais de enfermagem, destacando-se a sobrecarga de trabalho, o excesso de demanda, problemas na estrutura física das unidades e falhas na rede de atenção, o que dificulta a sua efetividade enquanto estratégia privilegiada para atingir o acesso universal em saúde. Por outro lado, trabalho em equipe, afinidade com o trabalho, vínculo com o usuário e resolubilidade da assistência contribuíram para a redução das mesmas. Conclusões investimento nos elementos que reduzem as cargas de trabalho da enfermagem, como mudanças nas condições de trabalho e na gestão, poderá contribuir para a efetividade da Estratégia Saúde da Família e para atingir o objetivo de acesso universal em saúde.

Objetivo identificar las cargas de trabajo de los profesionales de enfermería de la Estrategia Salud de la Familia, analizando sus implicaciones para la efectividad del acceso universal. Método estudio cualitativo con profesionales de enfermería de la Estrategia Salud de la Familia de las Regiones Sur, Centro Oeste y Norte de Brasil, utilizando triangulación metodológica. Para el análisis, recursos del software Atlas.ti y del Análisis Temático de Contenido se asociaron y los datos fueron interpretados con suporte de las teorías del proceso de trabajo y de las cargas de trabajo. Resultados la forma de trabajar en la Estrategia Salud de la Familia ha, predominantemente, generado un aumento de las cargas de trabajo de los profesionales de enfermería, destacándose la sobrecarga de trabajo, el exceso de demanda, los problemas en la estructura física de las unidades y fallas en la red de atención, lo que dificulta su eficacia como estrategia privilegiada para lograr el acceso universal en salud. Por otro lado, trabajo en equipo, afinidad con el trabajo, vínculo con el usuario y eficacia de la asistencia han contribuido a la reducción de las mismas. Conclusiones inversión en elementos que reducen las cargas de trabajo de enfermería, como los cambios en las condiciones de trabajo y en la gestión, podrá contribuir a la eficacia de la Estrategia Salud de la Familia y a lograr el objetivo del acceso universal en salud.