Hacia un modelo de atención en salud para el siglo XXI: breve historia del modelo de atención integrada en Chile / Towards a Health Care Model for the 21st Century: a brief history of the integrated care model in Chile

El desarrollo y organización del sistema sanitario en Chile tuvo importantes cambios durante la segunda mitad del siglo pasado, los que permitieron al país mejorar sustantivamente algunos índices de salud poblacional. Por otra parte, tanto el cambio de paradigma biomédico que surgió en el mundo durante las últimas décadas del siglo XX y que se orientaba hacia un modelo biopsicosocial de salud, como la aparición del concepto de Atención Primaria de Salud (APS) como una estrategia de intervención social, se sumaron al cambio en el perfil epidemiológico y demográfico del país y a las expectativas de la población, para alzarse todos ellos como factores catalizadores de un nuevo cambio en la forma de organizar la atención de salud en Chile. Esto generó un espacio para el desarrollo y fortalecimiento del nivel primario de atención de salud y de la medicina ambulatoria, lo que impulsó también la aparición de una nueva generación de especialistas que fueran capaces de dar solución a la gran mayoría de los problemas de las personas y de las comunidades, los médicos especialistas en Medicina Familiar y Comunitaria. Esta nueva forma de organización sanitaria, actualmente vigente en Chile, y que se enmarca dentro del Modelo de Atención Integral de Salud iniciado a comienzos del siglo XXI, está basado en un sistema de salud sustentado en el modelo biopsicosocial y en la APS; y su eje primordial son las personas, las familias y las comunidades.

The development and organization of the health system in Chile underwent important changes during the second half of the last century that allowed the country to substantially improve some population health indices. On the other hand, both the change in the biomedical paradigm that emerged in the world during the last decades of the 20th century and which was oriented towards a biopsychosocial model of health, as well as the appearance of the concept of Primary Health Care as a social intervention strategy, they added to the change in the epidemiological and demographic profile of the country and the expectations of the population, all of them rising as catalysts for a new change in the way of organizing health care in Chile. This created a space for the development and strengthening of the primary level of health care and outpatient medicine, which also promoted the emergence of a new generation of specialists who were capable of solving the vast majority of people's problems. and from the communities, specialists in Family and Community Medicine. This new form of health organization, currently in force in Chile, and which is part of the Comprehensive Health Care Model initiated at the beginning of the 21st century, is based on a health system based on the biopsychosocial model and PHC; and its main axis are people, families and communities.

Estados emocionales de adultos mayores en aislamiento social durante la COVID-19 / Emotional states of older adults in social isolation during COVID-19 / Estados emocionais de idosos em isolamento social durante COVID-19

RESUMEN Introducción: La alta contagiosidad de la COVID-19, el crecimiento de casos confirmados, las muertes y el aislamiento social han ocasionado que las emociones y pensamientos negativos se extiendan, con amenaza a la salud mental de la población adulta mayor. Objetivo: Identificar los estados emocionales de adultos mayores en aislamiento social durante la COVID-19. Método: Se realizó un estudio descriptivo, transversal, entre mayo y junio de 2020, en el área de salud perteneciente al Policlínico Universitario "Dr. Rudesindo Antonio García del Rijo", Sancti Spíritus. La población de estudio fue de 100 adultos mayores. Se evaluaron las variables: edad, sexo, estado civil, convivencia, ocupación, comorbilidad, ansiedad, depresión, irritabilidad, estrés. La información se obtuvo mediante la entrevista semiestructurada, la observación y test psicológicos. Resultados: El 61,0 % correspondió al sexo femenino; el 57,0 % pertenecía al grupo de 70-79 años; la mayoría de los ancianos vivía acompañado con su pareja, un menor de edad o un discapacitado (64,0 %), solo el 36,0 % vivía efectivamente solo. El 65,0 % no tenía vínculo laboral. El 89,0 % presentaba patologías consideradas de riesgo para la COVID-19. Predominó un nivel de irritabilidad normal, tanto externa (68,0 %) como interna (70,0 %), un nivel leve de ansiedad (73,0 %) y un nivel leve de depresión (50,0 %). El 47,0 % mostró alteración en los niveles de estrés. Conclusiones: El aislamiento social como medida para evitar el contagio por COVID-19 ha repercutido en la salud mental de los adultos mayores.

ABSTRACT Introduction: The high contagiousness of COVID-19, the increase of confirmed cases and deaths, and the social isolation have caused negative emotions and thoughts, threatening the mental health of the elderly population. Objective: To identify the emotional states of seniors in social isolation during COVID-19. Method: A descriptive, cross-sectional study was carried out between May to June 2020, in the health area part of the Policlínico Universitario "Dr. Rudesindo Antonio García del Rijo", in Sancti Spíritus. The study population was made of 100 seniors. The variables evaluated were: age, gender, marital status, coexistence, occupation, comorbidity, anxiety, depression, irritability, stress. The information was obtained through semi-structured interview, observation and psychological tests. Results: 61.0% were female; 57.0% in the 70-79 age group; most of them lived with their partner, a minor or a disabled person (64.0%), only 36.0% actually lived alone. 65.0% had no employment relationship. 89.0% had pathologies considered risky for COVID-19. A normal level of irritability prevailed, both external (68.0%) and internal (70.0%), a mild level of anxiety (73.0%) and a mild level of depression (50.0%). 47.0% showed alteration in stress levels. Conclusions: Social isolation as a measure to avoid contagion by COVID-19 has had an impact on the mental health of the elderly.

RESUMO Introdução: a alta contagiosidade do COVID-19, o crescimento de casos confirmados, mortes e isolamento social têm causado a disseminação de emoções e pensamentos negativos, ameaçando a saúde mental da população idosa. Objetivo: identificar os estados emocionais de idosos em isolamento social durante o COVID-19. Método: estudo descritivo, transversal, realizado entre maio e junho de 2020, na área de saúde pertencente ao Policlínico Universitario "Dr. Rudesindo Antonio García del Rijo", Sancti Spíritus. A população do estudo foi de 100 idosos. As variáveis avaliadas foram: idade, sexo, estado civil, convivência, ocupação, comorbidade, ansiedade, depressão, irritabilidade, estresse. As informações foram obtidas por meio da entrevista semiestruturada, observação e testes psicológicos. Resultados: 61,0% corresponderam ao sexo feminino; 57,0% pertenciam à faixa dos 70-79 anos; A maioria dos idosos morava com o companheiro, menor de idade ou com deficiência (64,0%), apenas 36,0% morava realmente sozinho. 65,0% não tinham vínculo empregatício. 89,0% tinham patologias consideradas de risco para COVID-19. Prevaleceu nível normal de irritabilidade, tanto externa (68,0%) quanto interna (70,0%), nível leve de ansiedade (73,0%) e nível leve de depressão (50,0%). 47,0% apresentaram alteração nos níveis de estresse. Conclusões: o isolamento social como medida para evitar o contágio pelo COVID-19 tem repercussões na saúde mental dos idosos.

Physician Home Visit Patterns and Hospital Use Among Older Adults with Functional Impairments.

BACKGROUND: Home-based primary care has been associated with reductions in hospital use among homebound older adults, but population-based studies on the general home visit patterns of primary care physicians are lacking. OBJECTIVE: We examined the association between the provision of home visits by primary care physicians and subsequent use of hospital-based care among their older adult patients with extensive functional impairments. DESIGN: Population-based retrospective cohort study. SETTING: The setting was Ontario, Canada, from October 2014 to September 2016. PARTICIPANTS: Older adults (aged ≥65 years) with extensive functional impairments receiving publicly funded home care. MEASUREMENTS: We measured the provision of home visits by a patient's most responsible primary care physician during the year before a comprehensive home care assessment. Physician home visit patterns were measured as the proportion of the total outpatient visits in a year that were home visits, categorized with quartiles. Multivariable, multilevel negative binomial regression models examined the associations between physician-level home visit provision and patient emergency department visits and hospital admissions over the 6 months following the home care assessment. RESULTS: There were 49,613 patients in the cohort who were linked to 8,096 unique primary care physicians. A total of 69.1% of physicians provided at least one home visit in a year, with the median proportion of home visits to total visits ranging from 0.057% to 3.19% across quartiles. Patients whose physicians were in the highest home visit provision quartile had lower rates of emergency department visits (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90-0.96) and hospital admissions (IRR = 0.89; 95% CI = 0.85-0.93) compared with patients whose physician did not do home visits. CONCLUSION: Home care patients with extensive functional impairments whose physicians provided higher levels of home visits had fewer emergency department visits and hospital admissions. Expanding home visits by primary care physicians could reduce hospital use by older adults living with functional impairments in the community.

¿Tratamos igual el cáncer de mama en mujeres mayores de 70 años? / Do women with breast cancer older than 70 years receive equal treatment to younger women?

OBJETIVO: Determinar si las pacientes de más de 70 años con diagnóstico de cáncer de mama reciben un infratratamiento en comparación a las mujeres de menos de 70 años. PACIENTES Y MÉTODOS: Se han incluido 140 pacientes con diagnóstico de cáncer de mama en los años 2012 y 2013 en el Servicio de Patología Mamaria del Hospital Universitario Parc Taulí (Sabadell, Barcelona). Las pacientes se han clasificado en función de su edad en el momento del diagnóstico: <70 años (grupo A, n=70) y ≥70 años (grupo B, n=70). Entre ambos grupos se ha comparado si existen diferencias en el modo de presentación, el tipo y grado histológico, el estadio anatómico, el inmunofenotipo, la técnica quirúrgica utilizada en la mama y axila, así como el tratamiento adyuvante recibido. RESULTADOS: Las pacientes añosas presentan tumores de mayor tamaño y en estadios más avanzados en el momento del diagnóstico. También presentan una menor tasa de cirugía en la mama (grupo A: 98,6% vs. grupo B: 78,6%), axila (grupo A: 98,6% vs. grupo B: 69,1%), menor ampliación en caso de márgenes afectos (grupo A: 100% vs. grupo B: 55%) y mayor uso de la hormonoterapia como tratamiento primario (grupo A: 0% vs. grupo B: 17,1%). CONCLUSIONES: Hemos realizado un infratratamiento a igual estadificación en las pacientes añosas, especialmente a partir de los 85 años. En este subgrupo poblacional existe una mayor comorbilidad que ha sido un factor clave a la hora de indicar la opción terapéutica. Consideramos que las pacientes añosas deben recibir un asesoramiento geriátrico integral y multidisciplinar

OBJECTIVE: The aim of this study was to determine if patients older than 70 years with breast cancer received inferior treatment compared with women younger than 70 years. PATIENTS AND METHODS: The study population consisted of 140 patients with primary breast cancer treated at Parc Taulí Hospital (Sabadell, Barcelona) between 2012 and 2013. Patients were classified based on their age at diagnosis: <70 years (group A, n=70) and ≥70 years (group B, n=70). Age groups were compared to determine the presence of possible differences in the mode of presentation, tumoral grade and histology, anatomical stage, immunophenotype, the breast and axillary surgical technique used, and adjuvant therapy. RESULTS: Older patients had larger tumours in more advanced stages at the time of diagnosis. These patients were less likely to undergo breast surgery (group A: 98.6% and group B: 78.6%) and axillary surgery (group A: 98.6% and group B: 69.1%), underwent lower amplification of the affected margins (group A: 100% and group B: 55%) and were more likely to receive primary endocrine treatment (group A: 0% and group B: 17.4%). CONCLUSION: Elderly patients were under-treated compared with younger patients with the same tumoral stage, especially those older than 85 years. This subgroup has major comorbidity, which is a key factor in indicating the therapeutic option. We believe that elderly patients should receive multidisciplinary and comprehensive geriatric counselling

Aprender, desaprender y reaprender para asistir ancianos en urgencias: el secreto del cambio / Learn, unlearn, and learn again: the secret to changing how elderly patients are attended in the emergency department

El importante cambio demográfico, con el incremento de personas ancianas con multimorbilidad y dependencia funcional, conlleva un aumento de presión sobre los servicios de urgencias (SUH). En esta población, la atención clásica desarrollada en los SUH no es resolutiva, comporta riesgos para las personas, implica tasas altas de ingreso y contribuye a aumentar la saturación del propio SUH. Las sociedades científicas recomiendan incorporar estrategias de valoración geriátrica en el SUH a cargo de equipos multidisciplinares, y procurar entornos seguros. Una organización de este estilo requiere de un profundo cambio del propio servicio, de sus profesionales y de las conexiones con el entorno post-hospitalario. Exponemos la experiencia del SUH de un hospital terciario y los mecanismos utilizados para conseguir ese cambio. El objetivo es garantizar que el equipo del SUH lleve a cabo unos cuidados y un diagnóstico y tratamiento correctos de los procesos urgentes en la población anciana, tome decisiones ajustadas a las necesidades clínicas, sociales, funcionales, a los deseos del paciente y su familia, y elija el entorno de tratamiento mejor en cada caso. Todo ello son cambios imprescindibles para atender adecuadamente una nueva demanda, conseguir resultados óptimos para los pacientes y para el funcionamiento del SUH y del hospital

The demographic shift toward ever greater numbers of older patients with multiple conditions and functional dependency has increased pressure on emergency departments (EDs). The traditional approach to emergency treatment does not resolve problems in this population, creates risk, leads to high admission rates, and collapses the ED itself. Medical associations recommend that multidisciplinary teams incorporate geriatric assessment strategies and procure safe care enviroments. Implementing such recommendations will require profound changes in ED processes and staff and in connections between the ED and the community the patient is discharged to. This paper describes the processes we used in our tertiary-care hospital to achieve the necessary level of change. Our aims were to ensure that the ED staff provides correct diagnoses and treatments for elderly patients; bases decisions on the patients’ clinical, social and functional needs and the preferences of both patient and family; and arranges for the most appropriate treatment environment in each case. All these changes were essential for properly addressing new care demands while achieving optimal patient outcomes and contributing to better ED and hospital performance

Strategies for inclusion of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) education throughout pharmacy school curricula

Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others (LGBTQIA+) patients face stigma and barriers to health care, including a lack of health care professionals' knowledge and confidence in treating this patient population. Pharmacists are in prime position to decrease this health disparity. United States pharmacy schools have limited LGBTQIA+ content, continuing the concern of recent graduates without knowledge and confidence. This commentary discusses potential barriers to introducing LGBTQIA+ content into school of pharmacy curricula and presents five strategies currently in use by nursing, medical, and pharmacy schools. Schools of Pharmacy should consider proactive incorporation of this content to graduate practitioners able to provide quality care to LGBTQIA+ patients

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2020 debe ser el año para la salud de los niños y adolescentes a pesar de las amenazas emergentes / No disponible

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Comprehensive eye care - Issues, challenges, and way forward.

As we move from a disease-specific care model toward comprehensive eye care (CEC), there is a need for a more holistic and integrated approach involving the health system. It should encompass not only treatment, but also prevention, promotion, and rehabilitation of incurable blindness. Although a few models already exist, the majority of health systems still face the challenges in the implementation of CEC, mainly due to political, economic, and logistic barriers. Shortage of eye care human resources, lack of educational skills, paucity of funds, limited access to instrumentation and treatment modalities, poor outreach, lack of transportation, and fear of surgery represent the major barriers to its large-scale diffusion. In most low- and middle-income countries, primary eye care services are defective and are inadequately integrated into primary health care and national health systems. Social, economic, and demographic factors such as age, gender, place of residence, personal incomes, ethnicity, political status, and health status also reduce the potential of success of any intervention. This article highlights these issues and demonstrates the way forward to address them by strengthening the health system as well as leveraging technological innovations to facilitate further care.

Upcoming Scenarios for the Comprehensive Management of Obstructive Sleep Apnea: An Overview of the Spanish Sleep Network / Escenarios futuros en el manejo integral de la apnea obstructiva del sueño: perspectiva del Spanish Sleep Network

Sleep is considered an essential part of life and plays a vital role in good health and well-being. Equally important as a balanced diet and adequate exercise, quality and quantity of sleep are essential for maintaining good health and quality of life. Sleep-disordered breathing is one of the most prevalent conditions that compromises the quality and duration of sleep, with obstructive sleep apnea (OSA) being the most prevalent disorder among these conditions. OSA is a chronic and highly prevalent disease that is considered to be a true public health problem. OSA has been associated with increased cardiovascular, neurocognitive, metabolic and overall mortality risks, and its management is a challenge facing the health care system. To establish the main future lines of research in sleep respiratory medicine, the Spanish Sleep Network (SSN) promoted the 1st World Café experts' meeting. The overall vision was established by consensus as "Sleep as promoter of health and the social impact of sleep disturbances". Under this leitmotiv and given that OSA is the most prevalent sleep disorder, five research lines were established to develop a new comprehensive approach for OSA management: (1) an integrated network for the comprehensive management of OSA; (2) the biological impact of OSA on comorbidities with high mortality, namely, cardiovascular and metabolic diseases, neurocognitive diseases and cancer; (3) Big Data Analysis for the identification of OSA phenotypes; (4) personalized medicine in OSA; and (5) OSA in children: current needs and future perspectives

El sueño se considera una parte esencial de la vida y es vital para una buena salud y para el bienestar. De igual importancia que una dieta equilibrada y una adecuada actividad física, la calidad y la cantidad del sueño son esenciales para mantener una buena salud y calidad de vida. Las alteraciones respiratorias del sueño son los trastornos más prevalentes que comprometen la calidad y duración del sueño, siendo el síndrome de la apnea obstructiva del sueño (SAHS) el más frecuente. El SAHS es una enfermedad de elevada prevalencia que se considera un problema de salud pública. Se ha asociado con aumento del riesgo cardiovascular, neurocognitivo, metabólico y especialmente de mortalidad, y su manejo representa un reto para el sistema de salud. Para establecer las principales líneas futuras de investigación en medicina respiratoria del sueño, el Spanish Sleep Network promovió la primera edición del World Cafe experts' meeting. El mensaje principal «El sueño como promotor de la salud y el impacto social de los trastornos del sueño» se estableció por consenso. Bajo este lema y dado que el SAHS es el trastorno del sueño más prevalente, se establecieron cinco líneas de investigación para desarrollar una aproximación completa para el manejo de este síndrome: 1) Una red integrada para el manejo del SAHS; 2) El impacto biológico del SAHS en las comorbilidades con elevada mortalidad como la enfermedad cardiovascular, las enfermedades metabólicas y neurocognitivas y el cáncer; 3) El análisis de grandes bases de datos para la identificación de fenotipos del SAHS; 4) Medicina personalizada en el SAHS, y 5) El SAHS en niños: necesidades actuales y perspectivas futuras

COVID-19 Pandemic spurs policy changes benefi ting older adults

This article reviews recent federal and state policy changes in response to the COVID-19 pandemic that affect health care and quality of life for older adults. Specifi c regulations and guidelines issued at the state and federal level have increased access and provided additional funding for essential services and supports. Many of these changes are temporary and have the potential to improve care beyond the immediate crisis. This period of greater fl exibility offers the opportunity to accrue evidence on quality and access to infl uence sustained change.(AU)

Down syndrome in adults: success and challenge / Síndrome de Down em adultos: sucessos e desafios

The estimated average survival of people with Down syndrome (DS) is currently over 50 years of age. This demographic finding warrants attention of health professionals who will care for an increasing number of adults with DS. Clinical evaluation of adults with DS should correlate characteristics inherent to the age group, especially the peculiarities produced by the syndrome. The present article proposes the development of preventive and vaccination programs ­ according to gender and age ­ and screening of diseases and conditions associated with the syndrome: 1) endocrine diseases; 2) cardiac diseases; 3) mental health; 4) dental care; 5) sensory organs; 6) osteoarticular abnormalities; 7) skin and appendages; 8) gastrointestinal diseases; and 9) cancer. However, there is scant information on the impact of comorbidities on life expectancy and quality of life or on the social and hospital costs of adults with DS.

A estimativa da sobrevida média de indivíduos com síndrome de Down (SD) passa atualmente dos 50 anos de idade. Esse dado demográfico justifica a atenção de profissionais da saúde que prestarão cuidados a um número crescente de adultos com SD. A avaliação clínica desse grupo de pacientes adultos deve correlacionar características inerentes à faixa etária, principalmente as peculiaridades produzidas pela síndrome. O presente artigo propõe o desenvolvimento de programas de prevenção e vacinação ­ conforme gênero e idade ­ e triagem de doenças e quadros associados à síndrome: 1) doenças endócrinas; 2) doenças cardíacas; 3) saúde mental; 4) saúde bucal; 5) órgãos sensoriais; 6) anomalias osteoarticulares; 7) pele e anexos; 8) doenças gastrointestinais; 9) câncer. Entretanto, há poucas informações sobre o impacto das comorbidades na expectativa de vida e na qualidade de vida, além dos custos hospitalares e sociais de adultos com SD.

Atención integral al paciente ostomizado. Apertura de consulta de ostomía / No disponible

En el siguiente trabajo analizamos la puesta en marcha y la actividad de la consulta de enfermería especializada en Ostomía del Hospital Severo Ochoa de Leganés

In this paper we analyse the implementation and the activity of nursing consultation specializing on Ostomy in Severo Ochoa Hospital in Leganes

[Fostering Mixed-skill Pharmacists for Careers in Health Support Pharmacies-Education to Overcome the Barrier of Limited Occupational Expertise].

For becoming a talented pharmacist at a health support pharmacy, the practitioner must obtain ability in two significant skill sets: "Technical skill" and "Non-technical skill". Technical skills are that required for a pharmacist's specialty/expertise, such as a wide variety of specialized knowledge and techniques. Non-technical skills are those required for effective communication and cooperation with patients, as well as with professionals from multiple fields, and also leadership/problem-solving ability within a team. Therefore, technical skill and non-technical skill go hand-in-hand like the two wheels on an axle. In a community-based integrated care system, medical professionals are expected to support a patient's overall health more effectively, even extending into his/her private life. In order to enable pharmacists to expand their scope of activity and fully execute their expertise, Yakugaku Seminar Lifelong Learning Center supports pharmacists from the standpoint of education with various themes, for example: the simulated experience of doctor conducting patient education and formulation on a daily basis, learning a basic way of thinking when clinical decisions are made for a patient nearby, mature decision making by combining vital signs, communication that takes into consideration a patient's background, and improved communication or problem-solving abilities within a broader team.

India's health and wellness centres: realizing universal health coverage through comprehensive primary health care.

In common with other countries in the World Health Organization South-East Asia Region, disease patterns in India have rapidly transitioned towards an increased burden of noncommunicable diseases. This epidemiological transition has been a major driver impelling a radical rethink of the structure of health care, especially with respect to the role, quality and capacity of primary health care. In addition to the Pradhan Mantri Jan Arogya Yojana insurance scheme, covering 40% of the poorest and most vulnerable individuals in the country for secondary and tertiary care, Ayushman Bharat is based on an ambitious programme of transforming India's 150 000 public peripheral health centres into health and wellness centres (HWCs) delivering universal, free comprehensive primary health care by the end of 2022. This transformation to facilities delivering high-quality, efficient, equitable and comprehensive care will involve paradigm shifts, not least in human resources to include a new cadre of mid-level health providers. The design of HWCs and the delivery of services build on the experiences and lessons learnt from the National Health Mission, India's flagship programme for strengthening health systems. Expanding the scope of these components to address the expanded service delivery package will require reorganization of work processes, including addressing the continuum of care across facility levels; moving from episodic pregnancy and delivery, newborn and immunization services to chronic care services; instituting screening and early treatment programmes; ensuring high-quality clinical services; and using information and communications technology for better reporting, focusing on health promotion and addressing health literacy in communities. Although there are major challenges ahead to meet these ambitious goals, it is important to capitalize on the current high level of political commitment accorded to comprehensive primary health care.