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1.
Artigo em Inglês | MEDLINE | ID: mdl-32354085

RESUMO

Many recommendations and innovative approaches are available for the development and evaluation of complex health interventions. We investigated the dimensions of complexity described in health research and how these descriptions may affect the adopted research methodology (e.g., the choice of designs and methods). We used a mixed method approach to review the scientific literature evaluating complex interventions in the health field. Of 438 articles identified, 179 were subjected to descriptive analysis and 48 to content analysis. The three principal dimensions of complexity were: stakeholder characteristics, intervention multimodality and context. Recognition of such dimensions influenced the methodological choices made during evaluation of the interventions with their use of designs and methods, which aimed to address the complexity. We analysed not only how researchers view complexity but also the effects of such views on researcher practices. Our results highlight the need for clarification of what complexity means and to consider complexity when deciding how to evaluate research interventions.

2.
Eur J Public Health ; 30(2): 206, 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32333780
3.
J Epidemiol Community Health ; 73(11): 990-992, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31315897

RESUMO

Population health interventions (PHIs) are generally complex; their results depend on their interaction with the context of their implementation. Moreover, the distinction between intervention and context is arbitrary: we need rather to consider an 'interventional system', including both interventional and contextual components. Evaluation must go beyond effectiveness and must include two key research questions: a viability analysis, to verify that the intervention can be routinised in a real-life context; and a theory-based evaluation, to analyse mechanisms and to understand what produces effects among components and their interactions with each other and with the context. PHI research is a question not only of the object but also of perspectives. This means doing research differently, making use of interdisciplinarity and involving stakeholders. Such an approach may contribute to the development, transfer, implementation and scaling-up of innovative interventions.

4.
J Affect Disord ; 257: 412-420, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31306992

RESUMO

BACKGROUND: The study compared treatment failure when using three therapeutic strategies in bipolar disorders: (i) mood stabilizers (MSs: lithium, valpromide, divalproate, carbamazepine, lamotrigine) without second-generation antipsychotic (SGAP); (ii) SGAPs (aripiprazole, olanzapine, risperidone, quetiapine) without MS; (iii) combination of MSs and SGAPs. METHODS: A historical cohort study was conducted using the French national healthcare databases in 20,086 outpatients aged 21+, newly treated with one of the three treatment strategies in 2011-2012, and diagnosed with a bipolar disorder. A composite outcome was based on indicators of treatment failure identified over 12 months: treatment discontinuation, switch or addition, psychiatric hospitalisation, suicide attempt, and death. For each strategy, the cumulative incidence of treatment failure was calculated while adjusting for covariates by propensity score weighting. RESULTS: A total of 8,225 patients (40.9%) were newly dispensed MSs, 9,342 (46.5%) SGAPs, and 2,519 (12.5%) both MSs and SGAPs. The one-year adjusted cumulative incidence of treatment failure was 75.7% (95%CI 74.9;76.3) in patients using MSs, 75.3% (74.6;76.0) in patients using SGAPs, and 60.5% (58.3;62.6) in patients with the combination. The adjusted difference in incidence for SGAPs compared with MSs was -0.40% (-1.4;0.6 p = 0.4) in the whole population, -2.2% (-3.3; -1.2 p < 0.002) in patients under 65 years and +6.7% (4.1;9.1 p < 0.002) in patients 65 years and over. LIMITATIONS: Combinations of MSs and SGAPs could not be directly compared with MS or SGAP monotherapies. CONCLUSIONS: One-year treatment failure was high. Overall, no difference in treatment failure was observed between MS or SGAP strategy but differences might exist depending on age.

5.
Pharmacoepidemiol Drug Saf ; 28(11): 1489-1500, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31339629

RESUMO

PURPOSE: The purpose of the study is to describe the trajectories of oral medication prescriptions in patients with heart failure with reduced ejection fraction (HFrEF) over 3 years after discharge from hospitalization for heart failure. We then evaluated the adherence of these prescriptions to the European Society of Cardiology (ESC) guideline-recommended medications and identified patient characteristics associated with nonadherence. METHODS: We used data from the EPICAL2 cohort study. HFrEF patients who had completed prescriptions at discharge and at 6-month follow-up were included and followed for 36 months. The following medication agents were considered adherent to guidelines: renin-angiotensin system (RAS) blockers [angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin-receptor blocker (ARB)] plus a ß-blocker (BB) or RAS blocker plus BB plus mineralocorticoid receptor antagonists (MRAs). The evolution of drug prescriptions and the adherence to ESC guidelines were assessed by using sequence analysis and clustering approaches. Patient characteristics associated with nonadherence were identified by logistic regression analyses. RESULTS: A typology of four therapeutic clusters was obtained, among which two clusters were adherent to recommendations and two were not. The adherent clusters consisted of bitherapy (RAS blockers-BB) and tritherapy (RAS blockers-BB-MRA) for about 64% of patients and remain stable over time. The nonadherent clusters consisted of nonprescription of BB for about 22% of patients or nonprescription of RAS blocker for about 14%. The main reason for nonprescription of BB was a concomitant obstructive airway disease (asthma or COPD) but was a concomitant chronic kidney disease for nonprescription of RAS blocker. CONCLUSION: Adherence to guideline-recommended medications while being hospitalized is of great importance because prescriptions are quite stable over time after discharge. HFrEF patients are most often older, with various comorbidities, such as chronic kidney disease or asthma/COPD, which importantly limit physicians' ability to prescribe recommended drugs, leading to suboptimal adherence to guidelines.

6.
Trials ; 20(1): 285, 2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31186053

RESUMO

BACKGROUND: An international workshop on population health intervention research (PHIR) was organized to foster exchanges between experts from different disciplines and different fields. This paper aims to summarize the discussions around some of the issues addressed: (1) the place of theories in PHIR, (2) why theories can be useful, and (3) how to choose and use the most relevant of them in evaluating PHIR. METHODS: The workshop included formal presentations by participants and moderated discussions. An oral synthesis was produced by a rapporteur to validate, through an expert consensus, the key points of the discussion and the recommendations. All discussions were recorded and have been fully transcribed. RESULTS: The following recommendations were generated through a consensus in the workshop discussions: (i) The evaluation of interventions, like their development, could be improved through better use of theory. (ii) The referenced theory and framework must be clarified. (iii) An intervention theory should be developed by a partnership of researchers and practitioners. (iv) More use of social theory is recommended. (v) Frameworks and a common language are helpful in selecting and communicating a theory. (vi) Better reporting of interventions and theories is needed. CONCLUSION: Theory-driven interventions and evaluations are key in PHIR as they facilitate the understanding of mechanisms of change. There are many challenges in developing the most appropriate theories for interventions and evaluations. With the wealth of information now being generated, this subject is of increasing importance at many levels, including for public health policy. It is, therefore, timely to consider how to build on the experiences of many different disciplines to enable the development of better theories and facilitate evidence-based decisions.


Assuntos
Pesquisa Biomédica , Pesquisa sobre Serviços de Saúde , Saúde da População , Teoria Social , Humanos
7.
Trials ; 20(1): 309, 2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31146768

RESUMO

BACKGROUND: An international workshop on population health intervention research (PHIR) was organized to foster exchanges between experts from different disciplines and different fields. AIMS: This paper aims to summarize the discussions around one of the issues addressed: the place or role of pilot studies in PHIR. Pilot studies are well-established in biomedical research, but the situation is more ambiguous for PHIR, in which a pilot study could refer to different purposes. METHODS: The workshop included formal presentations of participants and moderated discussions. An oral synthesis was carried out by a rapporteur to validate by expert consensus the key points of the discussion and the recommendations. All discussions have been recorded and fully transcribed. DISCUSSION: PHIR generally addresses complex interventions. Thus, numerous tasks may be required to inform the intervention and test different aspects of its design and implementation. While in clinical research the pilot study mainly concerns the preparation of the trial, in PHIR the pilot study focuses on the preparation of both the intervention and the trial. In particular, pilot studies in PHIR could be used for viability evaluation and theory development. RECOMMENDATIONS FROM THE WORKSHOP PARTICIPANTS: The following recommendations were generated by consensus from the workshop discussions: i) terms need to be clarified for PHIR; ii) reporting and publication should be standardized and transparency should be promoted; iii) the objectives and research questions should drive the methods used and be clearly stated; iv) a pilot study is generally needed for complex intervention evaluation and for research-designed programs; and v) for field-designed programs, it is important to integrate evaluability assessments as pilot studies . CONCLUSION: Pilot studies play an important role in intervention development and evaluation. In particular, they contribute to a better understanding of the mechanisms of intervention and the conditions of its applicability and transferability. Pilot studies could therefore facilitate evidence-based decisions about design and conduct of main studies aimed to generate evidence to inform public health policy.


Assuntos
Pesquisa Biomédica , Pesquisa sobre Serviços de Saúde , Saúde da População , Medicina Baseada em Evidências , Humanos , Projetos Piloto , Projetos de Pesquisa
8.
BMC Med Res Methodol ; 19(1): 92, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31064323

RESUMO

BACKGROUND: Evaluation of complex interventions (CI) is challenging for health researchers and requires innovative approaches. The objective of this work is to present the main methods used to evaluate CI. METHODS: A systematic review of the scientific literature was conducted to identify methods used for the evaluation of CI. We searched MEDLINE via PubMed databases for articles including an evaluation or a pilot study of a complex intervention, published in a ten-year period. Key-words of this research were ("complex intervention*" AND "evaluation"). RESULTS: Among 445 identified articles, 100 research results or protocols were included. Among them, 5 presented 2 different types of design in the same publication, thus our work included 105 designs. Individual randomized controlled trials (IRCT) represented 21.9% (n = 23) of evaluation designs, randomized clinical trials adaptations 44.8% (n = 47), quasi -experimental designs and cohort study 19.0% (n = 20), realist evaluation 6.7% (n = 7) and other cases studies and other approaches 8.6% (n = 9). A process/mechanisms analysis was included in 80% (n = 84) of these designs. CONCLUSION: A range of methods can be used successively or combined at various steps of the evaluation approach. A framework is proposed to situate each of the designs with respect to evaluation questions. The growing interest of researchers in alternative methods and the development of their use must be accompanied by conceptual and methodological research in order to more clearly define their principles of use.

9.
BMC Public Health ; 19(1): 339, 2019 Mar 25.
Artigo em Inglês | MEDLINE | ID: mdl-30909891

RESUMO

BACKGROUND: Population health intervention research raises major conceptual and methodological issues. These require us to clarify what an intervention is and how best to address it. This paper aims to clarify the concepts of intervention and context and to propose a way to consider their interactions in evaluation studies, especially by addressing the mechanisms and using the theory-driven evaluation methodology. MAIN TEXT: This article synthesizes the notions of intervention and context. It suggests that we consider an "interventional system", defined as a set of interrelated human and non-human contextual agents within spatial and temporal boundaries generating mechanistic configurations - mechanisms - which are prerequisites for change in health. The evaluation focal point is no longer the interventional ingredients taken separately from the context, but rather mechanisms that punctuate the process of change. It encourages a move towards theorization in evaluation designs, in order to analyze the interventional system more effectively. More particularly, it promotes theory-driven evaluation, either alone or combined with experimental designs. CONCLUSION: Considering the intervention system, hybridizing paradigms in a process of theorization within evaluation designs, including different scientific disciplines, practitioners and intervention beneficiaries, may allow researchers a better understanding of what is being investigated and enable them to design the most appropriate methods and modalities for characterizing the interventional system. Evaluation methodologies should therefore be repositioned in relation to one another with regard to a new definition of "evidence", repositioning practitioners' expertise, qualitative paradigms and experimental questions in order to address the intervention system more profoundly.


Assuntos
Promoção da Saúde , Saúde da População , Projetos de Pesquisa , Humanos
10.
Hellenic J Cardiol ; 2019 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-30690140

RESUMO

BACKGROUND: The accuracy of surgical scores in predicting in-hospital mortality for nonsurgically treated patients with infective endocarditis (IE) has not yet been explored. METHODS: Patients with definite IE who did not undergo valve surgery were selected from the database of seven French administrative areas (Association pour l'Étude et la Prévention de l'Endocardite Infectieuse [AEPEI] Registry, 2008). The patients were scored using (a) six systems specifically devised to predict in-hospital mortality after surgery for IE, (b) three commonly used risk scores for heart surgery, and (c) a risk score for predicting six-month mortality in IE after either surgery or medical therapy. Calibration (Hosmer-Lemeshow test) and discriminatory power (receiver operating characteristic [ROC] analysis) were assessed for each score. Areas under ROC curves were compared one-to-one (Hanley-McNeil method). RESULTS: A total of 192 patients (mean age, 65.2±15.2 years) were considered for analysis. There were 38 (19.8%) in-hospital deaths. Age >70 years (p=0.001), Staphylococcus aureus as causal agent (p=0.05), and severe sepsis (p=0.027) were independent predictors of in-hospital mortality. Despite many differences in the number and type of variables, all but two of the investigated scores showed good calibration (p>0.66). However, discriminatory power was satisfactory (area under ROC curve >0.70) only for three of the scores specific for IE and two of the scores used to predict mortality after cardiac surgery. CONCLUSIONS: Among the 10 surgical scores evaluated in this study, five could be adopted to predict in-hospital mortality even for IE patients receiving medical treatment only.

11.
Sante Publique ; 30(3): 321-331, 2018.
Artigo em Francês | MEDLINE | ID: mdl-30541261

RESUMO

INTRODUCTION: Public health tries to modify existing social norms by setting up strategies to promote the emergence of norms that are more adapted to the objectives of good health and well-being. Prevention policies and the corresponding interventions concern health behaviours and are designed to modify the individual's habits, and contribute to defining new ways of being, acting and living. Prevention therefore involves numerous personal, cultural, social and collective values. An ethical reflection concerning the meaning, rationale and justice of these actions is therefore essential. The objective of this study is to characterize the ethical reflection at the time of creation of public health norms. METHODS: A narrative review, based on the Web of Science database covering journals of the various disciplines concerned, was conducted to address this issue. RESULTS: Thirty-four publications were selected, illustrating the numerous definitions and types of norms used in public health intervention strategies. Many stakeholders are involved in the creation of public health norms specialists, opinion leaders, and social stakeholders. Finally, although some publications stress that the use of prevention norms raises a number of ethical issues, no publication refers to the presence of a structured ethical reflection as part of this process. CONCLUSION: Ethical reflection is an essential part of prevention interventions and tools. What is the best way of achieving the best results? How to resolve conflicts of interests? These issues must be addressed when developing policies or programmes and can more effectively guide public health strategies and help to improve their acceptability and efficacy in populations.


Assuntos
Política de Saúde , Prevenção Primária/ética , Saúde Pública/ética , Saúde Pública/normas , Humanos
12.
BMC Public Health ; 18(1): 1087, 2018 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-30170577

RESUMO

BACKGROUND: In 2009, the World Health Organization's Commission on Social Determinants of Health set out its recommendations for action, which included establishing equity from early childhood onwards by enabling all children and their mothers to benefit from a comprehensive package of quality programmes. In order to address social inequalities in health, it is recommended that action be taken from early childhood, and actions providing support for parenting are an effective lever in this respect. The aim of this review of systematic reviews is to analyse, on the one hand, the components and characteristics of effective interventions in parenting support and, on the other, the extent to which the reviews took into account social inequalities in health. METHODS: A total of 796 reviews were selected from peer-reviewed journals published between 2009 and 2016 in French or English. Of these, 21 reviews responding to the AMSTAR and selected ROBIS criteria were retained. These were analysed in relation to the consideration they gave to social inequalities in health according to PRISMA-equity. RESULTS: The reviews confirmed that parenting support programmes improved infants' sleep, increased mothers' self-esteem and reduced mothers' anger, anxiety and stress levels. The mainly authors noted that the contexts in which the interventions had taken place were described either scantly or not at all, making it difficult to evaluate them. Only half of the reviews had addressed the question of social inequalities in health. In particular, there had been little research conducted on the relational aspect and the social link. CONCLUSION: In terms of addressing social inequalities in perinatal health, the approach remains both modest and reductive. Understanding how, for whom and in what conditions interventions operate is one way of optimising their results. Further research is needed to study the interactions between the interventions and their contexts.


Assuntos
Disparidades nos Níveis de Saúde , Mães/psicologia , Poder Familiar/psicologia , Apoio Social , Feminino , Humanos , Lactente , Literatura de Revisão como Assunto , Determinantes Sociais da Saúde , Fatores Socioeconômicos
13.
Artigo em Inglês | MEDLINE | ID: mdl-29938201

RESUMO

Staphylococcus aureus induces severe infective endocarditis (IE) where embolic complications are a major cause of death. Risk factors for embolism have been reported such as a younger age or larger IE vegetations, while methicillin resistance conferred by the mecA gene appeared as a protective factor. It is unclear, however, whether embolism is influenced by other S. aureus characteristics such as clonal complex (CC) or virulence pattern. We examined clinical and microbiological predictors of embolism in a prospective multicentric cohort of 98 French patients with monomicrobial S. aureus IE. The genomic contents of causative isolates were characterized using DNA array. To preserve statistical power, genotypic predictors were restricted to CC, secreted virulence factors and virulence regulators. Multivariate regularized logistic regression identified three independent predictors of embolism. Patients at higher risk were younger than the cohort median age of 62.5 y (adjusted odds ratio [OR] 0.14; 95% confidence interval [CI] 0.05-0.36). S. aureus characteristics predicting embolism were a CC30 genetic background (adjusted OR 9.734; 95% CI 1.53-192.8) and the absence of pIB485-like plasmid-borne enterotoxin-encoding genes sed, sej, and ser (sedjr; adjusted OR 0.07; 95% CI 0.004-0.457). CC30 S. aureus has been repeatedly reported to exhibit enhanced fitness in bloodstream infections, which might impact its ability to cause embolism. sedjr-encoded enterotoxins, whose superantigenic activity is unlikely to protect against embolism, possibly acted as a proxy to others genes of the pIB485-like plasmid found in genetically unrelated isolates from mostly embolism-free patients. mecA did not independently predict embolism but was strongly associated with sedjr. This mecA-sedjr association might have driven previous reports of a negative association of mecA and embolism. Collectively, our results suggest that the influence of S. aureus genotypic features on the risk of embolism may be stronger than previously suspected and independent of clinical risk factors.


Assuntos
Embolia/diagnóstico , Endocardite Bacteriana/diagnóstico , Endocardite/diagnóstico , Enterotoxinas/genética , Plasmídeos/genética , Infecções Estafilocócicas/diagnóstico , Staphylococcus aureus/genética , Staphylococcus aureus/isolamento & purificação , Proteínas de Bactérias/genética , DNA Bacteriano/genética , Embolia/complicações , Embolia/microbiologia , Endocardite/complicações , Endocardite/microbiologia , Endocardite Bacteriana/complicações , Endocardite Bacteriana/microbiologia , Feminino , França , Genes Bacterianos/genética , Genótipo , Humanos , Modelos Logísticos , Masculino , Staphylococcus aureus Resistente à Meticilina/genética , Pessoa de Meia-Idade , Análise Multivariada , Proteínas de Ligação às Penicilinas/genética , Estudos Prospectivos , Fatores de Risco , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/classificação , Staphylococcus aureus/patogenicidade , Superantígenos , Fatores de Virulência/genética
14.
Pharmacoepidemiol Drug Saf ; 27(7): 763-770, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29763992

RESUMO

PURPOSE: Access to claims databases provides an opportunity to study medication use and safety during pregnancy. We developed an algorithm to identify pregnancy episodes in the French health care databases and applied it to study antiepileptic drug (AED) use during pregnancy between 2007 and 2014. METHODS: The algorithm searched the French health care databases for discharge diagnoses and medical procedures indicative of completion of a pregnancy. To differentiate claims associated with separate pregnancies, an interval of at least 28 weeks was required between 2 consecutive pregnancies resulting in a birth and 6 weeks for terminations of pregnancy. Pregnancy outcomes were categorized into live births, stillbirths, elective abortions, therapeutic abortions, spontaneous abortions, and ectopic pregnancies. Outcome dates and gestational ages were used to calculate pregnancy start dates. RESULTS: According to our algorithm, live birth was the most common pregnancy outcome (73.9%), followed by elective abortion (17.2%), spontaneous abortion (4.2%), ectopic pregnancy (1.1%), therapeutic abortion (1.0%), and stillbirth (0.4%). These results were globally consistent with French official data. Among 7 559 701 pregnancies starting between 2007 and 2014, corresponding to 4 900 139 women, 6.7 per 1000 pregnancies were exposed to an AED. The number of pregnancies exposed to older AEDs, comprising the most teratogenic AEDs, decreased throughout the study period (-69.4%), while the use of newer AEDs increased (+73.4%). CONCLUSIONS: We have developed an algorithm that allows identification of a large number of pregnancies and all types of pregnancy outcomes. Pregnancy outcome and start dates were accurately identified, and maternal data could be linked to neonatal data.


Assuntos
Anticonvulsivantes/efeitos adversos , Anticonvulsivantes/uso terapêutico , Epilepsia/tratamento farmacológico , Complicações na Gravidez/epidemiologia , Resultado da Gravidez , Adolescente , Adulto , Algoritmos , Anticonvulsivantes/administração & dosagem , Bases de Dados Factuais , Epilepsia/epidemiologia , Feminino , França , Humanos , Recém-Nascido , Pessoa de Meia-Idade , Gravidez , Complicações na Gravidez/tratamento farmacológico , Fatores de Risco , Adulto Jovem
16.
Circ Cardiovasc Qual Outcomes ; 11(4): e004356, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29653999

RESUMO

BACKGROUND: ß-blockers have been among the first medications shown to improve outcomes after acute myocardial infarction (AMI). With the advent of reperfusion therapy and other secondary-prevention medications, their role has become uncertain, and large-scale experience after AMI in the contemporary era is lacking. In particular, the effect of stopping ß-blockers in patients initially treated after AMI is unknown. METHODS AND RESULTS: Using the French healthcare databases, 73 450 patients (<80 years of age), admitted for AMI in 2007 to 2012, without acute coronary syndrome (ACS) in the previous 2 years and no evidence of heart failure, having received optimal treatment with myocardial revascularization and all recommended medications in the 4 months after index admission, and not having discontinued ß-blockers before 1 year, were followed for 3.8 years on average. ß-Blocker discontinuation was defined as 4 consecutive months without exposure. If ß-blocker treatment was resumed later on, follow-up was stopped. Both the risk of the composite outcome of death or admission for ACS and the risk of all-cause mortality were assessed in relation with ß-blocker discontinuation during follow-up. Adjusted hazard ratios were estimated using marginal structural models accounting for time-varying confounders affected by previous exposure. A similar analysis was performed with statins. Of 204 592 patient-years, 12 002 (5.9%) corresponded to discontinued ß-blocker treatment. For ß-blocker discontinuation, the adjusted hazard ratio for death or ACS was 1.17 (95% confidence interval, 1.01-1.35); for all-cause death, the adjusted hazard ratio was 1.13 (95% confidence interval, 0.94-1.36). In contrast, for statin discontinuation, the adjusted hazard ratios for death or ACS and for all-cause death were 2.31 (95% confidence interval, 2.01-2.65) and 2.57 (95% confidence interval, 2.19-3.02), respectively. CONCLUSIONS: In routine care of patients without heart failure, revascularized and optimally treated after AMI, discontinuation of ß-blockers beyond 1 year after AMI was associated with an increased risk of death or readmission for ACS, while statistical significance was not reached for the association with all-cause mortality. A contemporary randomized clinical trial is needed to precise the role of ß-blockers in the long-term treatment after AMI.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Prevenção Secundária/métodos , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Antagonistas Adrenérgicos beta/efeitos adversos , Adulto , Idoso , Bases de Dados Factuais , Esquema de Medicação , Feminino , França/epidemiologia , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Readmissão do Paciente , Recidiva , Fatores de Tempo , Resultado do Tratamento
19.
J Epidemiol Community Health ; 72(4): 319-323, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29321174

RESUMO

BACKGROUND: Public health interventions are increasingly being recognised as complex and context dependent. Related to this is the need for a systemic and dynamic conception of interventions that raises the question of delineating the scope and contours of interventions in complex systems. This means identifying which elements belong to the intervention (and therefore participate in its effects and can be transferred), which ones belong to the context and interact with the former to influence results (and therefore must be taken into account when transferring the intervention) and which contextual elements are irrelevant to the intervention. DISCUSSION: This paper, from which derives criteria based on a network framework, operationalises how the context and intervention systems interact and identify what needs to be replicated as interventions are implemented in different contexts. Representing interventions as networks (composed of human and non-human entities), we introduce the idea that the density of interconnections among the various entities provides a criterion for distinguishing core intervention from intervention context without disconnecting the two systems. This differentiates endogenous and exogenous intervention contexts and the mediators that connect them, which form the fuzzy and constantly changing intervention/context interface. CONCLUSION: We propose that a network framework representing intervention/context systems constitutes a promising approach for deriving empirical criteria to delineate the scope and contour of what is replicable in an intervention. This approach should allow better identification and description of the entities that have to be transferred to ensure the potential effectiveness of an intervention in a specific context.


Assuntos
Promoção da Saúde/métodos , Saúde da População , Saúde Pública , Lógica Fuzzy , Humanos , Pesquisa em Sistemas de Saúde Pública
20.
Eur J Intern Med ; 51: 53-60, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29305071

RESUMO

BACKGROUND: We aimed to assess the effectiveness of recommended drug prescriptions at hospital discharge on 1-year mortality in patients with heart failure (HF) and reduced ejection fraction (HFREF). MATERIALS AND METHODS: We used data from the EPICAL2 cohort study. HF patients ≥18years old with left ventricular ejection fraction (LVEF) <40% and alive at discharge were included and followed up for mortality. Socio-demographic, clinical and therapeutic data were collected at admission. Therapeutic data were collected at discharge and at 6month. Prescription of an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin II receptor blocker [ARB] in case of ACE inhibitor intolerance) and a ß-blocker at discharge were considered "guideline-consistent discharge prescription" (GCDP). A frailty Cox model after propensity score (PS) matching was used to assess the association of GCDP with survival. RESULTS: Among 624 patients included, the mean (SD) age was 73.6 (12.8) years; 65% were male. A total of 412 (65.6%) patients received GCDP, and 82.8% still had guideline consistent prescription at 6months. A total of 166 patients died during the follow-up, 78 in the GCDP group and 88 in the other group. Before PS matching, patients with GCDP were younger (|StDiff|=48.32%) and had higher body mass index (BMI) (|StDiff|=11.71%), lower LVEF (|StDiff|=23.13%) and lower Charlson index (|StDiff|=55.27%) than patients without GCDP. After PS matching, all characteristics were balanced between the two treatment groups, and GCDP was associated with reduced mortality (pooled HR=0.51, 95% CI [0.35-0.73]). CONCLUSION: Prescription of ACE (or ARB) inhibitors and ß-blockers for patients with HFREF may be low despite the evidence for morbidity and mortality improvement with these medications but remains associated with reduced 1-year mortality in unselected HFREF patients.


Assuntos
Prescrições de Medicamentos/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/mortalidade , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Feminino , França/epidemiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Prospectivos , Volume Sistólico , Função Ventricular Esquerda
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