Implantación de la Guía de buenas prácticas en prevención de lesiones por presión: desarrollo, resultados y sostenibilidad / Implementation of the best practice guideline for pressure ulcer prevention: Development, results and sustainability

OBJETIVO: Evaluar el impacto de la implantación de la guía «Valoración del riesgo y prevención de úlceras por presión» sobre la adherencia a las recomendaciones de la guía, la prevalencia de lesiones por presión (LPP) y sostenibilidad de los resultados, así como analizar las estrategias de implantación, la sostenibilidad y las barreras detectadas. MÉTODO: Estudio observacional retrospectivo (de junio del 2015 a diciembre del 2018). Se estudiaron 2periodos (P1: preparación y P2: sostenibilidad). Se analizaron las memorias del programa y los datos de la historia clínica de pacientes dados de alta en los 4hospitales participantes sobre la adherencia de las recomendaciones preventivas y los resultados en salud en términos de presencia de LPP por cada centro. RESULTADOS: Se incluyó a 13.515 pacientes, de los cuales 4.523 tenían riesgo de LPP y 722 tenían LPP. El 82,9% de los pacientes recibieron una valoración del riesgo de LPP al ingreso. Se observó una disminución de esta valoración al ingreso: P1: 89,1% vs. P2: 81%; p < 0,001. El 42,1% de los pacientes de riesgo fueron reevaluados durante el ingreso, observándose un aumento significativo entre los períodos: P1: 30,7% vs. P2: 46%; p < 0,001. El 63,2% contaba con una superficie especial de manejo de presión, con un aumento significativo: P1: 55,3% vs. P2: 65%; p < 0,001. La prevalencia global de LPP fue del 5,5%, observándose una disminución significativa al comparar P1: 6,6% vs. P2: 5,1%; p = 0,003. La prevalencia de LPP nosocomiales fue del 2,1%, manteniéndose constante P1: 2% y P2: 2,1%; p = 0,708. El compromiso institucional, la designación de líderes, elaboración de planes de acción y la formación son estrategias destacables en todos los centros. CONCLUSIONES: El presente estudio muestra la existencia de una adecuada adherencia a las principales recomendaciones de la guía, observándose una mejoría estadísticamente significativa en la adherencia a 2 de las 3 recomendaciones evaluadas. Las estrategias de implantación y sostenibilidad puestas en marcha han contribuido en el mantenimiento o mejora de los resultados en el tiempo

AIM: To assess the impact of implementing the "Risk Assessment and Prevention of Pressure Injuries (PI)" guideline on adherence to its recommendations, the prevalence of PI and the sustainability of results, and to analyse the implementation strategies, sustainability and barriers detected. METHODS: A retrospective observational study (June 2015 to December 2018). Two periods were studied (P1: Preparation and P2: Sustainability). The programme reports and data from the medical records of patients discharged from the 4participating hospitals were analysed with regard to adherence to preventive recommendations and health outcomes in terms of the presence of pressure injuries per centre. RESULTS: A total of 13,515 patients were included, of whom 4,523 were at risk for PI and 722 had PI. Of the patients, 82.9% underwent a risk assessment for PI on admission. A decrease in this assessment on admission was observed between P1:89.1% vs. P2: 81% P<.001. Of the patients at risk, 42.1% were reassessed during their admission and a significant increase was observed between the periods P1: 30.7% vs. P2:46%; P<.001. 63.2% had a special pressure management surface, with a significant increase between P1:55.3% vs. P2: 65%; P<.001. The overall prevalence of PI was 5.5% and a significant decrease was observed on comparing P1: 6.6% vs. P2:5.1%; P=.003. The prevalence of nosocomial PI remained constant at 2.1%, P1:2% and P2:2.1%; P=.708. Institutional commitment, the appointment of leaders, drawing up of action plans, and training are outstanding strategies in all the centres. CONCLUSIONS: This study shows that there is adequate adherence to the main recommendations of the guideline. A statistically significant improvement was observed in adherence to 2 out of the 3 recommendations assessed. The implantation and sustainability strategies implemented have been contributed to maintenance and/or improving results over time

Programa de Melhoria do Acesso e da Qualidade da Atenção Básica: uma análise das principais mudanças normativas / National Program for Access and Quality Improvement in Primary Care: an analysis of the main regulatory changes

Resumo Este artigo realizou uma análise das principais mudanças no arcabouço normativo do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica, a partir de documentos oficiais do Ministério da Saúde divulgados de julho 2011 a julho de 2019. Os achados revelam que a maioria das mudanças não ficaram claras, dificultando a compreensão do desenho do programa e o acompanhamento dos resultados das equipes de atenção básica. Ocorreram mudanças no desenho geral do programa e mais intrinsecamente às fases ou componentes. Foram modicadas a arquitetura das fases; as regras na adesão ao programa; a forma de verificação da autoavaliação; o monitoramento dos indicadores em função da implantação de um novo sistema de informação ou por deficiências técnicas para utilização de determinado indicador; a avaliação externa com relação às regras para solicitação e prazos para receber a avaliação, ao descredenciamento das equipes, e aos parâmetros e método adotados; e a certificação mais radicalmente na valoração dos componentes e na metodologia de cálculo e categorias de classificação das equipes. O programa apostou em diversas estratégias para qualificação da atenção básica. Embora com limitações e incompletudes, percebê-las é uma oportunidade de buscar soluções viáveis para o refinamento da política de saúde.

Abstract This article carried out an analysis of the main changes in the normative framework of the National Program for Access and Quality Improvement in Primary Care, based on official documents from the Ministry of Health released from July 2011 to July 2019. The findings reveal that most changes were not clear, making it difficult to understand the design of the program and to monitor the results of primary care teams. There were changes in the overall design of the program and more intrinsically to the phases or components. The architecture of the phases was modified; the rules for joining the program; how to check self-assessment; the monitoring of indicators due to the implementation of a new information system or due to technical deficiencies in the use of a given indicator; the external evaluation in relation to the rules for requesting and deadlines for receiving the evaluation, the teams' disqualification, and the parameters and method adopted; and certification more radically in the valuation of the components and in the calculation methodology and classification categories of the teams. The program bet on several strategies for qualifying primary care. Although with limitations and incompleteness, perceiving them is an opportunity to seek viable solutions for the refinement of health policy.

Guía de conteo poblacional / Population counting guide

Conteo poblacional se comprenderá como la serie de acciones y procedimientos de recolección de datos de personas, identificación de viviendas y familias, comunidades, sectores y territorios con fines eminentemente sanitarios, relacionando las condiciones de vida, los problemas de salud, sus determinantes sociales y factores de riesgo presentes en ellas. Debido a que las características de la población de una comunidad son dinámicas, se hace necesario realizar cada año una actualización de la información que es de uso necesario para las acciones de salud, lo cual lo diferencia del censo de población que es estático, de cohorte, con otro tipo de indicadores dado por el ente rector el Instituto Nacional de Estadística ­INE-. Además permite el contacto directo entre los equipos de salud del Ministerio de Salud y la población a su cargo Este documento además, forma parte de las herramientas para la implementación del Modelo de Atención y Gestión, junto a la "Guía para la elaboración de un croquis" y a la "Guía de acercamiento y negociación", que forman parte de los documentos que hay en esta App. Este documento contiene los lineamientos y ruta a seguir para el desarrollo del conteo poblacional, describe conceptos básicos, sus características, la secuencia de fases y pasos que incluyen preparación y organización de los equipos de trabajo, herramientas y registro de datos, revisión, análisis y certificación de la información recolectada. Los principales usuarios son el personal que conforman los equipos de salud ­ES- responsables de cada sector y territorio de los distritos de salud.

¿Qué es el Código Europeo contra el Cáncer, quiénes lo conocen y para qué sirve? / What is the European Code against Cancer, who knows it and why it serves?

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Visión crítica y argumentación sobre los programas de atención de la cronicidad en Atención Primaria y Comunitaria / Critical view and argumentation on chronic care programs in Primary and Community Care

El análisis detallado de los planes de atención a la cronicidad desarrollados por los servicios regionales de salud pone de manifiesto un sorprendente nivel de uniformidad en su diseño y despliegue, a pesar de las diferencias existentes entre dichos servicios. La revisión de la literatura sobre los modelos teóricos que lo sustentan y los instrumentos que lo desarrollan no aporta evidencias concluyentes que permitan afirmar que los modelos de atención a pacientes crónicos alcanzan mejores resultados que modelos de atención alternativos. A pesar de que todos los planes de atención a la cronicidad incluyen sistemas de evaluación de los mismos, no se han publicado hasta la fecha estudios rigurosos sobre su efecto. Dado que, por el contrario, sí existen pruebas sólidas y reiteradas de que modelos con una Atención Primaria fuerte obtienen mejores resultados, cabe preguntarse sobre la necesidad de buscar modelos alternativos, cuando las metas propuestas probablemente podrían alcanzarse de fortalecer realmente la Atención Primaria (AU)

The detailed analysis of the chronic care plans developed by the Spanish regional health services show a surprising level of uniformity in their design and deployment, despite differences between these services. The reviews about theoretical models that support it and tools they develop does not provide conclusive evidence to support the chronic care models achieve better results than another alternatives of care. Although the whole Spanish chronic care plans includes assessment proposals no rigorous studies on their effect have been published to date. Given that, on the contrary, there is a strong and repeated evidence that health systems with Primary Care high performance obtains better outcomes, it is necessary to ask about the need to look for alternative models, when the proposed goals could be reached strengthen Primary Care (AU)

Avaliação do acesso à Estratégia Saúde da Família na perspectiva dos usuários no município de Santo Antônio de Jesus-Bahia, Brasil / Assessment of access to the Family Health Strategy from the perspective of users in Santo Antônio de Jesus-Bahia, Brazil / Evaluación del acceso a Estrategia Salud de la Familia en la perspectiva de los usuarios en el municipio de Santo Antônio de Jesus-Bahia, Brasil

RESUMO Objetivo Avaliar o acesso à Estratégia Saúde da Família (ESF) no município de Santo Antônio de Jesus - BA, na perspectiva dos usuários. Métodos Estudo transversal com aplicação de questionários para amostra representativa de 430 usuários, cadastrados pelas 21 equipes de Saúde da Família do município. O inquérito de base domiciliar foi realizado entre os meses de dezembro de 2012 a janeiro de 2013. Indicadores considerados mais potentes para avaliar o acesso foram selecionados em duas dimensões - o conhecimento e a avaliação da Estratégia Saúde da Família. Resultados Os resultados apontam diminuição de barreiras e ampliação do acesso da população aos serviços de saúde, bem como, maior organização da porta de entrada do sistema. As mudanças apresentadas após a implantação da ESF nos bairros se refletem na satisfação dos usuários, o que legitima a organização do sistema de saúde com base em uma atenção primária abrangente.(AU)

ABSTRACT Objective To assess access to the Family Health Strategy (FHS) in Santo Antônio de Jesus - Brazil from the perspective of its users. Methods Cross-sectional study conducted with a representative sample of users registered by 21 family healthcare teams of the municipality, for a total of 430 questionnaires. A family-based survey was applied between December 2012 and January 2013. Indicators considered as the most powerful to evaluate access were selected and, subsequently, divided into two dimensions: knowledge and evaluation of the Family Health Strategy Program from the perspective of its users. Results The results point to decreasing barriers and increasing access to healthcare services, as well as to a greater organization of enrollment in the system. Changes observed after the implementation of the FHS in the districts are evident in the overall satisfaction with the primary health care service, which legitimizes the organization of the health system based on primary comprehensive care.(AU)

RESUMEN Objetivo Evaluar el acceso a la Estrategia Salud de la Familia (ESF) en el municipio de Santo Antônio de Jesus-BA, en la perspectiva de los usuarios. Métodos Estudio transversal con aplicación de cuestionarios a una muestra representativa de 430 usuarios, registrados por los 21 equipos de Salud de la Familia del municipio. La encuesta de base domiciliaria se realizó entre los meses de diciembre de 2012 a enero de 2013. Los indicadores considerados más potentes para evaluar el acceso, se seleccionaron en dos dimensiones: el conocimiento y la evaluación de la Estrategia Salud de la Familia. Resultados Los resultados apuntan la disminución de barreras y ampliación del acceso de la población a los servicios de salud, así como mayor organización de la puerta de entrada del sistema. Los cambios presentados después de la implantación de la ESF en los barrios se reflejan en la satisfacción de los usuarios, lo que legitima la organización del sistema de salud con base en una atención primaria integral.(AU)

La evaluación económica en el Sistema de Salud Cubano / Economical assessment in the Cuban health system

La Evaluación Económica representa un marco para la asignación de recursos sanitarios en un contexto de recursos limitados e incremento de la demanda. Tiene un papel clave en el proceso de toma de decisiones. Es por esta razón que el objetivo de este trabajo consiste en valorar el uso de las evaluaciones económicas en el sistema de salud cubano (AU).

The economical assessment is a frame for the assignment of economical resources in a context of limited resources and demand increase. It plays a key role in the decisionmaking process. For this reason, the aim of this work is evaluating the usage of the economical assessment in the Cuban health system (AU).

La evaluación económica en el Sistema de Salud Cubano / Economical assessment in the Cuban health system

La Evaluación Económica representa un marco para la asignación de recursos sanitarios en un contexto de recursos limitados e incremento de la demanda. Tiene un papel clave en el proceso de toma de decisiones. Es por esta razón que el objetivo de este trabajo consiste en valorar el uso de las evaluaciones económicas en el sistema de salud cubano (AU).

The economical assessment is a frame for the assignment of economical resources in a context of limited resources and demand increase. It plays a key role in the decisionmaking process. For this reason, the aim of this work is evaluating the usage of the economical assessment in the Cuban health system (AU).

Avaliação da utilização das tecnologias simplificadas de contagem de linfócitos T-CD4+ no serviço nacional de saúde de Moçambique / Evaluation of the use of simplified T-CD4 + lymphocyte counting technologies in the national health service of Mozambique

A contagem dos Linfócitos TCD4+ no sangue periférico continua a ser um importante marcador para monitorar a progressão da doença e eficácia da terapia anti-retroviral (ART), apesar da introdução recentemente da testagem de carga viral, por ser um indicador mais sensível que a contagem de CD4; e continua a ser uma aposta para monitoramento por parte do Governo Moçambicano. Uma das formas de melhorar o acesso ao monitoramento da infecção aos pacientes vivendo com VIH-SIDA (PVHS), foi a introdução das tecnologias simplificadas de diagnóstico de CD4, os analisadores PIMATM Alere. A presente pesquisa pretende estudar a utilização dos analisadores PIMA em Moçambique. O objetivo foi avaliar a utilização das Tecnologias Simplificadas de Contagem de Células Sanguíneas Linfócitos TCD4 PIMATM, nas condições reais do Serviço Nacional de Saúde (SNS) de Moçambique. O estudo realizou-se entre Outubro e Dezembro de 2016, abrangeu todas as unidades sanitárias que fazem a contagem dos Linfócitos TCD4, usando o analisador automático PIMA. Baseou-se em pesquisa documental e visita a algumas unidades sanitárias nas Províncias de Niassa, Maputo e Cidade de Maputo (para observação direta e analise de processos clínicos dos PVHS para a determinação do tempo de inicio do TARV após o diagnósticos de VIH). Na pesquisa documental, usou-se a base de dados da Alere, que está conectado a todos os instrumentos de contagem de Linfócitos CD4 instalados nas unidades sanitárias do país, para descarregar a informação de testagem ao longo dos anos 2014, 2015 e 2016…

Peripheral blood TCD4 + lymphocytes count remains an important marker for monitor ing disease progression and antiretroviral therapy (ART) effectiveness, despite the recent intro duction of viral load testing, as it is a more sensitive indicator than the CD4 count; And remains a gamble for monitoring by the Mozambican Government. One of the ways to improve access to infection monitoring for patients living with VIH/AIDS (PLWHA) was the introduction of simplified CD4 diagnostic technologies, PIMATM Alere analyzers. The present research intends to study the use of PIMA analyzers in Mozambique. To evaluate the use of Simplified TCD4 PIMATM Hemodynamic Blood Cell Count Technologies under the real conditions of the Na tional Health Service (NHS) of Mozambique. The study was carried out between October and December 2016, and covered all health units that count TCD4 lymphocytes using PIMA equip ment. Documentary research and visits to some health units were carried out in the provinces of Niassa, Maputo and Maputo City (for direct observation and analysis of PLWHA clinical processes for the determination of time to start ART after VIH diagnosis). In documentary re search, the Alere database was used, which is connected to all the CD4 lymphocyte count in struments installed in the country's health units, to download the test information over the years 2014, 2015 and 2016. The results show that a number of 254 analyzers transmitted to the data base about 4519 records, which were analyzed in relation; the probability of survival, which was 50% in 6 months; The median use of each instrument was 80 tests per month; the median of waste in the order of 5%; In a total of 1349 SNS laboratories technicians, only 29% of them have been trained to operate with the PIMAs; A total of 146 clinical trials of 5 health units were analyzed, of which 68 were in agreement with the study. 50% of the patients started ART after 24 hours of diagnosis and up to 80% of the patients had already started ART in 15 days. This stud was concluded that the use of PIMA analyzers under the actual conditions of the National Health Service of Mozambique is not totally adequate. However, these analyzers reduced the time of initiation of antiretroviral therapy for PLWHA, to 24 hours after VIH diagnosis, and improved treatment accessibility.

Comprobemos también si las guías de práctica clínica se usan correctamente y funcionan. Respuesta de los autores / Let's also check if clinical practice guidelines are correctly used and if they do work. Authors reply

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Informe de la Fundación del Cerebro sobre el impacto social de la enfermedad de Parkinson en España / The social impact of Parkinson's disease in Spain: Report by the Spanish Foundation for the Brain

INTRODUCCIÓN: Conocer el alcance socieoeconómico de la enfermedad de Parkinson es esencial para la planificación de recursos y concienciación social. Desarrollo: Se ha realizado una revisión de los datos publicados hasta el momento sobre epidemiología, morbimortalidad, dependencia e impacto económico de la enfermedad de Parkinson en España. Además se ha llevado a cabo un estudio cuyo objetivo principal ha sido definir los recursos asistenciales públicos y privados que tienen los afectados por la enfermedad de Parkinson en nuestro país mediante una encuesta por mail a todos los neurólogos con dedicación especial a esta enfermedad, pertenecientes al grupo de Trastornos del Movimiento de la Sociedad Española de Neurología. CONCLUSIONES: La enfermedad de Parkinson en España tiene una incidencia y prevalencia similar al resto de Europa. Con la estimación de población actual se obtiene que debe haber en España al menos 300.000 pacientes con enfermedad de Parkinson y a al menos un nuevo caso por 10.000 habitantes año. Esta produce gran impacto en la calidad de vida del paciente y aumenta a casi el doble la mortalidad de los pacientes. Además supone un coste económico muy importante para el país, que puede llegar hasta más de 17.000 € anuales por paciente y que con el envejecimiento de la población y las nuevas terapias va a ir incrementándose. Los profesionales y administraciones realizan un gran esfuerzo para proporcionar una asistencia de calidad a los pacientes. A pesar de ello es mucho el camino que nos queda por recorrer para que una asistencia de calidad, eficaz y multidisciplinar sea universal para todos los pacientes con esta enfermedad

INTRODUCTION: Understanding the social and economic impact of Parkinson's disease is essential for resource planning and raising social awareness. Development: Researchers reviewed the data published to date on epidemiology, morbidity and mortality, dependency, and economic impact of Parkinson's disease in Spain. In addition, a study has been carried out in order to define the public and private health care resources of Spanish patients affected by Parkinson's disease by means of an e-mail survey of all neurologists specialising in this disease and belonging to the Spanish Society of Neurology's study group for movement disorders. CONCLUSIONS: The incidence and prevalence rates of Parkinson's disease in Spain are similar to those in the rest of Europe. According to current population estimates, there are at least 300.000 patients with Parkinson's disease and one new case per 10.000 habitants per year in Spain. This has a major impact on the patient's quality of life and nearly doubles patient mortality. In addition, the disease generates sizeable costs for the country that may exceed 17.000 € per year per patient; costs will rise due to the ageing of the population and the new therapies employed. Healthcare professionals and administrators dedicate their efforts to providing quality care to patients. Despite the above, we still have a long way to go in order to provide quality, efficient, multidisciplinary, and universal healthcare

Exames realizados para o diagnóstico de tuberculose pulmonar no município de ribeirão preto, brasil / Exámenes realizados para el diagnóstico de tuberculosis pulmonar en la ciudad de ribeirão preto, brasil / Tests performed for pulmonary tuberculosis diagnosis in ribeirao preto city, brazil

Objetivou-se analisar o processo de realização de exames para o diagnóstico da tuberculose pulmonar, no município de Ribeirão Preto. Estudo epidemiológico descritivo do tipo inquérito a partir de uma abordagem quantitativa. A população de estudo foi constituída por 84 doentes de tuberculose pulmonar em tratamento (com idade igual ou superior a 18 anos, residentes em Ribeirão Preto), no período de janeiro a abril de 2009. Os dados foram coletados por meio de entrevistas e para tal utilizou-se um questionário estruturado. De forma complementar, foram levantados todos os exames realizados pelos doentes entrevistados no período do seu diagnóstico no Sistema de Controle de Pacientes com Tuberculose do Estado de São Paulo (TB-WEB). Para análise dos dados, foram utilizadas técnicas de estatística descritiva. Observou-se que a realização de exames no processo de elucidação diagnóstica da tuberculose pulmonar precisa transpor algumas barreiras organizacionais, culturais, geográficas e econômicas, visto que o acesso ao diagnóstico tem ocorrido por meio dos serviços especializados e de referência para controle da doença.

RESUMEN El objetivo fue analizar el proceso de realización de exámenes para el diagnóstico de la tuberculosis pulmonar, en la ciudad de Ribeirão Preto, Brasil. Estudio epidemiológico descriptivo del tipo averiguación a partir de un enfoque cuantitativo. La población estudiada consistió en 84 pacientes en tratamiento de la tuberculosis pulmonar (con edad igual o superior a 18 años, que viven en Ribeirão Preto), en el periodo de enero a abril de 2009. Los datos fueron recolectados a través de entrevistas, utilizando un cuestionario estructurado. Por otra parte, se plantearon todos los exámenes realizados por los enfermos entrevistados en el momento de su diagnóstico en el Sistema de Control de Pacientes con Tuberculosis del Estado de São Paulo (TB-WEB). Para el análisis de los datos, se utilizaron técnicas de estadística descriptiva. Se observó que la realización de exámenes en el proceso de elucidación diagnóstica de la tuberculosis pulmonar necesita superar algunas barreras organizacionales, culturales, geográficas y económicas, ya que el acceso al diagnóstico se ha producido a través de servicios especializados y de referencia para el control de la enfermedad.

ABSTRACT The objective was to analyze the process of examinations for the diagnosis of pulmonary tuberculosis in Ribeirao Preto. This is a survey type study with a quantitative approach. The study population consisted of 84 patients with pulmonary tuberculosis under treatment (aged over 18 years old, living in Ribeirão Preto), from January to April 2009. Data were collected through interviews using a structured questionnaire. Moreover, all tests performed by patients interviewed at the time of diagnosis were raised from the System of Tuberculosis Patients Control of the State of São Paulo (TB-WEB). For data analysis, descriptive statistics were used. It was observed that the performance of tests in the laboratory diagnosis of pulmonary tuberculosis process needs to overcome some organizational, cultural, geographical and economical barriers, since the access to diagnosis has occurred through specialized services, reference for disease control.

Prevalencia de la afección musculoesquelética no traumática como motivo de consulta y su impacto asistencial en un servicio de urgencias / Prevalence of non-traumatic musculoskeletal pathology as main complaint and its impact in a emergency department

Introducción. La afección musculoesquelética atraumática (AMA) genera gran carga asistencial en los servicios sanitarios a nivel de atención primaria, sin embargo, son escasos los estudios europeos diseñados para determinar su proporción dentro de los servicios de urgencias. Nuestro objetivo es determinar la prevalencia de AMA y su impacto asistencial y administrativo en el funcionamiento del servicio de urgencias de un hospital universitario de Madrid. Material y método. Se revisaron 2.000 historias clínicas electrónicas aleatorizadas entre 2008-2010. Se recogieron los motivos de consulta, el tiempo consumido hasta el alta desde la primera valoración, la demanda de pruebas de imagen y la necesidad de nuevas valoraciones antes de trascurrido el primer mes de la valoración inicial. Resultados. La prevalencia de AMA fue del 13,8% IC 95% (12,1-15,4%) de todos los pacientes. El motivo más frecuente de consulta fue la lumbalgia. De todos los casos de AMA valorados, en el 79,1% se solicitó una prueba de imagen. Los pacientes con AMA consumieron una media de 79 min y un 17% de los pacientes consultaron por el mismo motivo en menos de 30 días. Conclusiones. Los resultados del presente estudio ubican a la AMA en el primer lugar de los motivos de consulta urgente en nuestro medio, generando el más alto consumo de tiempo y la mayor frecuencia de consultas nuevas por el mismo motivo en menos de un mes. La falta de formación médica en el manejo de este tipo de afecciones puede ser causa de este fenómeno. Durante el diseño de líneas estratégicas para optimizar la atención en los servicios de urgencias se debe tener en cuenta la importancia de este tipo de procesos patológicos (AU)

Background. Non-traumatic musculoskeletal pathology (NTMP) generates a high healthcare demand in primary care, however, European studies designed to assess its real impact in Emergency Departments are scarce. The present study aims to determine the prevalence of NTMP and its impact in Emergency Department of a university hospital in Madrid. Material and method. Two thousand randomized medical registries were reviewed from 2008 to 2011. The epidemiological data collected were, main complaints, time consumed, image test requests, and need of further assessment within a month. Results. Prevalence of NTMP was 13.8% (95% CI; 12.1%-15.4%) of all patients. The most frequent musculoskeletal complaint was lumbar pain. An imaging test was requested in 79.1% of all the NTMP cases assessed. Patients with NTMP consumed an average of 79 minutes, with 17% of them requesting a new urgent assessment within the first month. Conclusions. The results of this study show that NTMP is the leading cause for emergency department visits in our area, producing the highest consumption of time and the highest frequency of new queries for the same reason within a month. The overuse of the emergency services and the lack of medical training in the management of this type of pathology can cause this phenomenon. During the design of strategies to optimize patients care in emergency departments, the importance of this type of pathology should be taken into account (AU)

Análise da compatibilidade epistemológica e metodológica entre a homeopatia e a medicina baseada em evidências / Analysis of the epistemological and methodological compatibility between homeopathy and evidence-based medicine

Trata-se de um ensaio teórico que objetiva analisar as relações epistemológica e metodológica entre a homeopatia e a medicina baseada em evidências, com ênfase nos ensaios clínicos randomizados (ECR). Discute a viabilidade e os cuidados necessários na utilização dos ECR para a avaliação da eficácia e da efetividade da homeopatia, e é constituído por três partes: uma primeira, de análise das bases epistemológicas da homeopatia e da produção científica na área; uma segunda, que sistematiza as bases epistemológicas da biomedicina e uma crítica à medicina baseada em evidências (MBE) e uma terceira, que discute as possibilidades de diálogo entre a homeopatia e a MBE. (AU)

This is a theoretical essay that aims to analyze the epistemological and methodological relations between homeopathy and evidence-based medicine, with emphasis on randomized controlled trials (RCTs). Discusses the feasibility and the necessary precautions in the use of RCTs to evaluate the efficacy and effectiveness of homeopathy, and consists of three parts: the first, an analysis of the epistemological foundations of homeopathy and scientific production in the area; a second, which explores the epistemological foundations of biomedicine and develops a critique of evidence-based medicine (EBM) and a third, discussing the possibilities of dialogue between homeopathy and EBM.(AU)

Évaluation des défibrillateurs cardiaques implantables avec sonde sous-cutanée / Evaluation of implantable cardiac defibrillators with subcutaneous probe

OBJECTIF: L'objectif du présent rapport d'évaluation des technologies est de réaliser un état des connaissances sur l'utilisation et la performance du DCI-S pour déterminer sa valeur ajoutée par rapport au DCI-E, préciser ses indications et cibler les possibles enjeux qui résultent de son utilisation. L'étude s'insère dans un projet de plus grande envergure qui inclut un avis et une évaluation sur le terrain du remplacement des DCI et des dispositifs de resynchronisation cardiaque (TRC). Elle servira de base à l'élaboration de recommandations pour l'utilisation et le remplacement de ces dispositifs pour le Québec. MÉTHODOLOGIE: Une revue de la littérature a été effectuée sur : 1) les indications relatives au DCI-S; 2) l'efficacité et l'innocuité du DCI-S; 3) les enjeux professionnels et organisationnels; 4) les coûts associés au dispositif; 5) les aspects éthiques reliés au recours à la technologie. La méthodologie a respecté les normes de production des revues systématiques de l'Institut national d'excellence en santé et en services sociaux (INESSS). La recherche documentaire a ciblé les guides de pratique clinique (GPC), les rapports d'évaluation des technologies de la santé (ÉTS), les publications de conférences consensuelles canadiennes, les revues systématiques avec ou sans méta-analyse et les études primaires qui n'étaient pas incluses dans les publications précédentes. La recherche de l'information a été effectuée à partir de trois bases de données (PubMed, EBM Reviews et Embase) et des registres internationaux des essais cliniques en cours. La recherche a été complétée en consultant les sites. du Guidelines International Network (G-I-N), du National Guideline Clearinghouse (NGC) ainsi que la base de données d'évaluation des technologies de l'International Network of Agencies for Health Technology Assessment (INAHTA) et du Centre for Reviews and Dissemination (CRD) (University of York). Enfin, les moteurs de recherche Google et Google Scholar ont servi à repérer d'autres publications pertinentes dans le cadre du projet. La sélection et l'évaluation de la qualité ont été effectuées par deux professionnels scientifiques, alors qu'une seule personne a extrait les données, et une autre les a validées. Des renseignements fournis par les parties prenantes sur l'utilisation du DCI-S au Québec ont été ajoutés. Les membres du Comité consultatif ainsi que les experts externes ont assuré la qualité scientifique du projet. RÉSULTATS: Ces dernières années, nombreuses sont les études publiées sur le DCI-S. Il s'agit le plus souvent d'études descriptives de séries de cas dont certaines reposent sur des données de registre. Seulement quelques-unes comparent le DCI-S et le DCI-E. Généralement, les études comportent des échantillons de faible taille et sont de courte durée. Rares sont celles qui ont un suivi d'au moins cinq ans, qui permettrait de mieux évaluer certaines performances techniques du DCI-S. Le présent rapport comprend les résultats intermédiaires des études cliniques en cours (études de cohorte, essais cliniques randomisés [ECR]), mais les résultats définitifs sont attendus dans quelques années. Onze études de synthèse et trois études observationnelles qui n'avaient pas été incluses dans les études de synthèse ont été retenues. Les études de synthèse présentent les résultats d'un nombre variable d'études primaires. Il s'agit pour la plupart de rapports d'évaluation des technologies et d'analyses destinées à la décision de remboursement des dispositifs. Les trois études primaires utilisent des données du même registre, EFFORTLESS ( Evaluation oF FactORs ImpacTing CLinical Outcome and Cost EffectiveneSS), et les combinent à celles de l'étude IDE (Investigational Device Exemption). Ce sont des études de cohorte (une étude) ou de séries de cas (deux études). Les quatorze études retenues portent sur les indications relatives au DCI-S, ainsi que sur l'efficacité et l'innocuité du dispositif. Les aspects organisationnels, économiques et éthiques ont été peu abordés. Les analyses de coûts proviennent des États-Unis, de l'Australie et du Royaume - Uni. Elles tiennent compte d'un coût unitaire du DCI-S équivalent ou même inférieur par rapport au DCI-E. Le coût du recours au DCI-S serait similaire à celui du DCI-E dans ces trois pays. Toutefois, les résultats ne sont pas applicables au contexte québécois, où le coût d'un DCI-S serait presque trois fois plus élevé que celui d'un DCI-E. Il ressort que le DCI-S évite les principales faiblesses du DCI-E, soit le besoin d'avoir un accès vasculaire et la nécessité d'installer une sonde intracardiaque et peut être une solution de rechange à ce dernier chez certains patients qui répondent à un ou à plusieurs critères de sélection pour recevoir un DCI, mais qui satisfont également à d'autres indications cliniques bien précises. Il permet aussi d'écarter certains risques associés au DCI-E. Les résultats préliminaires et à court terme sont prometteurs et soutiennent l'utilisation du DCI-S chez les patients bien sélectionnés. Toutefois, ils s'appuient sur des études non comparatives et la démonstration sur l'équivalence ou la supériorité de ce dispositif par rapport au DCI-E n'a pas été faite. Des ECR qui ont un suivi à long terme sont toutefois nécessaires pour définir clairement les risques, les avantages et les coûts des DCI-S. La détection appropriée des arythmies ventriculaires spontanées par le DCI-S qui a été observée se situe entre 84 % et 100 %, avec un taux de succès de traitement également très élevé (de 96 % à100 %). Le succès de la conversion est obtenu avec le premier choc, dans la majorité des cas (58 %1 à 98 %). La capacité de discrimination entre les arythmies ventriculaires et supraventriculaires atteint 98 %, comparativement à des taux de 77 % et de 68 % en ce qui concerne le DCI-E à simple ou à double chambre, respectivement. En dépit de ces bénéfices, tout comme le DCI-E, le DCI-S peut occasionner des infections (entre 0 et 10 % des cas ; entre 0,4 % et 12,3 % pour le DCI-E) et des chocs inappropriés (environ 8 % pour les DCI-S en comparaison avec 5 % pour les DCI-E dans les études les plus récentes). La fréquence de ces événements indésirables est similaire avec les deux dispositifs. Comme pour les DCI-E, la surdétection de l'onde T constituerait la cause la plus fréquente de chocs inappropriés chez les patients avec un DCI-S. Une meilleure programmation des dispositifs et une expérience accrue des professionnels pourraient réduire considérablement l'incidence de chocs inappropriés. En effet, des études montrent que les taux de complications et de chocs inappropriés sont moins élevés lorsque les médecins implanteurs ont plus d'expérience. Les études citées utilisent le DCI-S de première génération dont la durée de vie prévue est de cinq ans. Par ailleurs, au Québec, on implante déjà les modèles de deuxième génération qui ont une durée de vie d'environ sept ans. Toutefois, il n'existe pas actuellement d'études qui portent sur ces modèles plus récents. Enfin, le National Institute for Health and Care Excellence (NICE) considère que l'efficacité du DCI-S en matière de prévention de la mort subite d'origine cardiaque à court et moyen termes est adéquate, mais qu'il est nécessaire de recueillir des données à plus long terme. CONCLUSION: Au terme de la présente revue de la littérature scientifique, l'INESSS conclut que: -le DCI-S est une technologie prometteuse qui permet d'offrir la possibilité d'un défibrillateur à certains groupes particuliers de patients pour lesquels le DCI-E est contre-indiqué; -le DCI-S est une technologie innovatrice dont les preuves d'efficacité et d'innocuité à court et moyen termes (de 6 mois à 5,8 ans) s'appuient sur des études observationnelles, majoritairement descriptives; les résultats à long terme font actuellement l'objet d'études (études de cohorte, ECR) et leur publication est attendue dans les prochaines années; -les enjeux professionnels, organisationnels, économiques et éthiques, y compris la perspective des patients, ont été peu étudiés dans la littérature publiée et mériteraient d'être analysés dans le contexte québécois; -le DCI-S a une place dans la prévention primaire ou secondaire de la mort subite cardiaque d'origine arythmique chez des patients bien ciblés qui répondent aux critères de sélection pour recevoir un DCI; qui n'ont pas d'indication quant à une stimulation cardiaque ou un TRC et pour qui un DCI-E est contre-indiqué pour une ou plusieurs raisons qui suivent: -accès veineux difficile ou besoin de préserver l'accès veineux; -patients qui se sont vu retirer un DCI-E en raison d'une complication; - patients qui sont jeunes et qui ont besoin d'un DCI à long terme. Cette indication repose sur l'opinion d'experts. Les conclusions tirées de la littérature scientifique contribueront à l'élaboration des recommandations futures sur l'utilisation et le remplacement des dispositifs cardiaques implantables au Québec, préparées avec des experts du milieu.

OBJECTIVE: The objective of this evaluation is to document the current state of knowledge regarding the use and performance of the S-ICD in order to determine its added value in relation to the TV-ICD, to specify its indications and to identify issues that may arise from its use. This literature review is part of a more extensive project that includes a health technology assessment report and a field evaluation concerning the replacement of ICDs and cardiac resynchronization devices (CRT). It will serve as a basis for developing recommendations regarding the use of and replacement of these devices in Québec. METHODOLOGY: A literature review was conducted regarding: 1) indications for the S-ICD; 2) efficacy and safety of the S-ICD; 3) health professional-related and organizational issues; 4) costs associated with the device; and 5) ethical aspects of the use of this technology. The methodology adhered to the production standards for systematic reviews of the Institut national d'excellence en santé et en services sociaux (INESSS). The literature search targeted clinical practice guidelines (CPGs), health technology assessment (HTA) reports, Canadian consensus conference publications, systematic reviews with or without meta-analyses, and primary research studies that were not included in the former publications. The search was conducted in three databases (PubMed, EMB Reviews and Embase) and in international registries of current clinical trials. The search was complemented by consulting websites of the Guidelines International Network (G-I-N) and the National Guideline Clearinghouse (NGC), and by querying the technology assessment databases of the International Network of Agencies for Health Technology Assessment (INAHTA) and the Centre for Reviews and Dissemination (CRD) (University of York). Lastly, Google and Google Scholar search engines were used to identify other relevant publications. Study selection and quality assessment were performed by two research professionals. Data extraction was conducted by a single person and validated by a second professional. Information provided by stakeholders on the use of S-ICDs in Québec was also considered. The members of the advisory committee and an external reviewer assured the project's scientific validity. RESULTS: Numerous studies of S-ICDs have been published in the past few years. Most of these are descriptive case series, some of which are based on registry data. Only a few compare S-ICDs and TV-ICDs. The studies are generally of short duration and involve small samples. Studies with a follow-up of at least 5 years ­ enabling a better evaluation of particular aspects of the technical performance of S-ICDs ­ are rare. The present report includes the interim results of ongoing clinical studies (cohort studies and randomized controlled trials, RCT). Final results are expected in a few years. Eleven synthesis studies and three observational studies, that are not included in the synthesis group, were retained for this report. The synthesis documents present the results of a varying number of primary studies. For the most part, they are technology assessment reports and analyses intended for making coverage decisions regarding these devices. The three primary studies use data from the same registry, EFFORTLESS (Evaluation oF FactORs ImpacTing CLinical Outcome and Cost EffectiveneSS), and pool these with data from the IDE (Investigational Device Exemption) study. The primary studies include cohort (n=1) and case series (n=2) investigations. The 14 studies that were retained discuss indications for S-ICDs and the device's efficacy and safety. There is little discussion of the organizational, economic and ethical aspects related to use of S-ICDs. The available cost analyses arise from the United States, Australia and the United Kingdom. They take into account a unit cost for S-ICDs that is equal to or even less than that for TV-ICDs. The cost of using S-ICDs would be similar to that of using TV-ICDs in these three countries. Such results are not applicable to the Québec context, however, where the cost of an S-ICD is almost three times greater than that of a TV-ICD. On the basis of the literature reviewed, S-ICDs can be an alternative to TV-ICDs for certain patients who meet one or more criteria for an ICD implantation but who also have other very specific clinical indications. The S-ICD avoids the main drawbacks of the TV-ICD, which requires vascular access and implantation of an intra-cardiac lead. It also permits avoidance of certain risks associated with TV-ICDs. The preliminary and short-term results are promising and support the use of S-ICDs among carefully selected patients. However, they are based on non-comparative studies. The equivalence or superiority of S-ICDs compared to TV-ICDs has not been demonstrated. RCTs with long term follow-up are necessary to clearly define the risks, benefits and costs of S-ICDs. The observed rate of appropriate detection of spontaneous ventricular arrhythmias by a S-ICD is between 84% and 100%, with the treatment success rate also being very high (96% to 100%). Successful conversion is achieved with the first shock in the majority of cases, (58%2 to 98%), and its ability to discriminate between ventricular and supraventricular arrhythmias reaches 98%, compared to 77% and 68% for a single- and double-chamber TV-ICD, respectively. Despite these benefits, an S-ICD ­ like a TV-ICD ­ can lead to infection (0 to 10% of cases in comparison with 0.4% to 12.3% for TV-ICD) and inappropriate shocks (approximately 8% for S-ICDs compared with 5% for TV-ICDs in the latest studies) . The frequency of these adverse events thus appears comparable for both devices. As with TV-ICDs, T-wave over-detection is the most common cause of inappropriate shocks for S-ICD patients. Improved programming of the device and increased health professional experience with the technology can considerably reduce the incidence of inappropriate shocks. Indeed, studies show a lower rate of complications and inappropriate shocks when the implanting physicians have greater experience. The cited studies use first generation S-ICDs for which the anticipated life span is 5 years. Second generation S-ICDs, which last for about 7 years, are already being used in Québec. However, there are currently no studies of these more recent models. Finally, the National Institute for Health and Care Excellence (NICE) considers the efficacy of S-ICDs to be adequate for the prevention of sudden cardiac death in the short- and medium-term, but states that the collection of longer-term data is necessary. CONCLUSIONS: Based on the present review of the scientific literature, INESSS concludes that: - the S-ICD is a promising technology that provides the option of a defibrillator to certain specific patient populations for whom the TV-ICD is contraindicated; -the S-ICD is an innovative technology whose efficacy and safety evidence in the short- and long-term (6 months to 5.8 years) is based on observational studies, most of which are descriptive; long-term results are currently the focus of research (cohort studies, RCTs) and are expected to be published in the next few years; -the health professional-related, organizational, economic and ethical issues, including the patient's perspective, have been little examined in the published literature and merit an analysis in the Québec context; -the S-ICD plays a role in the primary and secondary prevention of sudden arrhythmic cardiac death in carefully selected patients who meet criteria for ICD implantation but for whom cardiac stimulation and CRT are not indicated; and for whom a TV-ICD is contraindicated due to one or more of the following: -difficult venous access or need to preserve venous access; - the patient has had a TV-ICD removed because of a complication; -the patient is young and needs an ICD for the long term. This last indication is based on expert opinion. The conclusions drawn from the scientific literature will serve as a basis for future recommendations, developed by experts in this field, regarding the use and replacement of implantable cardiac devices in Québec.

Validação de um instrumento para avaliar a qualidade da atenção em saúde bucal de crianças de 0 a 5 anos na atenção primária à saúde na visão do cirurgião dentista / Validation of an instrument for assessing the quality of attention to oral health of children from 0 to 5 years in primary health care in view of the dental surgeon

A incorporação do cirurgião-dentista na Estratégia de Saúde da Família foi reconhecida como parte integrante da saúde geral e qualidade de vida da população, tornando-se crescente o interesse em monitorar e avaliar os resultados do cuidado em saúde bucal na Atenção Primária à Saúde (APS). Não foi encontrado nenhum instrumento que avaliasse a atenção em saúde bucal na APS para crianças de 0 a 5 anos na perspectiva do cirurgião-dentista. Assim o objetivo desse estudo foi verificar a confiabilidade do instrumento através da avaliação de sua reprodutibilidade e homogeneidade e realizar a validação de construto do instrumento para preencher essa lacuna. Como etapa teórico-metodológica foi feito o teste-reteste com 107 CD da APS dos municípios de Belo Horizonte, Diamantina e Montes Claros, por e-mail, utilizando-se a plataforma SurveyMonkey. Para a validação de construto utilizou-se a Análise Fatorial Exploratória (AFE) com método de Fator Principal a partir da Correlação Policórica e Rotação Oblimim utilizando-se o software Stata versão 14.0. O alfa de Cronbach foi calculado para avaliação da consistência interna. Para o teste de hipótese, os escores estimados de cada fator foram comparados entre os grupos definidos pela autoavaliação dos cirurgiõesdentistas quanto à qualidade dos serviços (teste Kruskal Wallis). O instrumento enviado para o teste-reteste continha 46 itens divididos em duas partes: 1ª Parte com 13 para caracterização profissional e a 2ª parte com 33 itens para avaliar a qualidade da atenção em saúde bucal de crianças de 0 a 5 anos. Responderam o instrumento 41 profissionais. Foram excluídos 9 itens com Coeficiente Kappa inferior a 0,60. O instrumento passou a ter 24 na 2ª parte e foi enviado para 402 cirurgiõesdentistas dos três municípios. O instrumento foi respondido por 185 dentistas. Foi feita a análise descritiva dos 24 itens da 2ª parte e foram excluídos 2 itens por apresentarem mais de 98% de tendência à resposta "sempre". A AFE excluiu 5 itens. A versão final do instrumento foi composta por 13 itens de caracterização do profissional e 17 para avaliação da qualidade da atenção em saúde bucal de crianças de 0 a 5 anos na APS. "Apresentou dois fatores que agruparam itens relacionados ao Fator 1 "atenção integral à saúde bucal na APS" e ao Fator 2 "Longitudinalidade". Para todos os 17 itens as cargas fatoriais foram maiores que 0,40. Sua consistência interna foi calculada pelo alfa de Cronbach (≥ 0,70) foi de 0,87 para o conjunto de itens e para o Fator 1, 0,88 e, para o Fator 2, 0,72. O teste de hipótese apontou que os cirurgiões-dentistas que avaliaram de forma positiva a atenção apresentaram um menor escore de qualidade. O instrumento foi considerado confiável e válido podendo ser uma ferramenta para o planejamento e gestão do sistema de saúde na avaliação de suas potencialidades e necessidades, qualificando a atenção profissional em saúde bucal das crianças de 0 a 5 anos na APS

The incorporation of the dentist into the Family Health Strategy was recognized as an integral part of the general health and quality of life of the population, increasing interest in monitoring and evaluating the results of oral health care in Primary Health Care (PHC). No instrument was found to assess oral health care in PHC for children 0 to 5 years old from the perspective of the dental surgeon. Thus the purpose of this study is to validate an instrument to fill this gap. As a theoretical-methodological stage, the test-retest was carried out with 107 CDs of the PHC of the municipalities of Belo Horizonte, Diamantina and Montes Claros, by e-mail, using the SurveyMonkey platform. For the validation of the construct we used the Exploratory Factorial Analysis (EFA) with the Principal Factor method from the Polycoric Correlation and Oblimim Rotation using the software Stata version 14.0. Cronbach's alfa was calculated for internal consistency. For the hypothesis test, the estimated scores of each factor were compared between the groups defined by the dentists' selfassessment of the quality of services (Kruskal Wallis test). RESULTS: The instrument sent for the test-retest consisted of 46 items divided into two parts: 1st part with 13 items for professional characterization and the 2nd part with 33 items to evaluate the quality of oral health care of children from 0 to 5 years old. 41 professionals responded. We excluded 9 items with Coefficient Kappa lower than 0.60. The instrument started to have 24 in the second part and was sent to 402 dentists of the three municipalities. The instrument was answered by 185 dentists. The descriptive analysis of the 24 items of the 2nd part was done and 2 items were excluded because they presented more than 98% tendency to the "always" response. The EFA excluded 5 items. The final version of the instrument was composed by 13 professional characterization items and 17 to assess the quality of oral health care of children aged 0 to 5 years in the PHC. He presented two factors that grouped items related to Factor 1 "integral attention to oral health in PHC" and to Factor 2 "Longitudinality". For all 17 items the factor loads were greater than 0.40. Its internal consistency was calculated by the Cronbach's alfa (≥ 0.70) was 0.87 for the set of items and for Factor 1, 0.88 and, for Factor 2, 0.72. The hypothesis test pointed out that the dentist who evaluated the care positively presented a lower quality score. CONCLUSIONS: The instrument was considered reliable and valid and could be a tool for the planning and management of the health system in the evaluation of its potentialities and needs, qualifying the professional attention in oral health of children from 0 to 5 years in the PHC

El impuesto sobre bebidas azucaradas en España / Tax on sugar sweetned beverages in Spain

Este artículo aporta una revisión crítica acerca de los retos a los que se enfrentan los impuestos sobre las bebidas azucaradas como instrumento de políticas de salud, para revertir la tendencia epidémica de la obesidad. Se valoran las experiencias de los países más significados, en particular México, y se reflexiona sobre el contrapeso que ejerce la industria a las políticas antiobesidad y el poder de los lobbies. Esas políticas impositivas en pro de la salud pública han de sobreponerse a la enorme fuerza de la industria, que es ejercida en varios niveles-ciencia e investigación, reputación de marca, influencia en reguladores-. Se sugiere que un impuesto específico sobre bebidas azucaradas tiene bastante potencial para reducir enfermedades no transmisibles y riesgos -diabetes mellitus, hipertrigliceridemia, lipoproteínas de baja densidad, hipetensión diastólica-, a través de la reducción del consumo, al ser alta la elasticidad del precio de estas bebidas. Además, los efectos incluso se amplifican a medio plazo, una vez establecidos nuevos hábitos de consumo más saludable. Los impuestos podrían fomentar la innovación empresarial sin infligir costes de pérdida de empleos y contribuirían a reducir el gradiente social de la obesidad (AU)

This article provides a critical review about the challenges that taxes on sugary drinks as an instrument of health policy must face to reverse the trend of the current epidemics of obesity. We analyzed the experiences of the leading countries, particularly Mexico, and reflect on the counterweight exerted by the industry against obesity policies, and on the power of lobbyists. Those tax policies for public health have to overcome the enormous strength of the industry, which is exerted in several-science and research, brand reputation, influence on regulators-levels. We suggest that a specific tax on sugary drinks has enough potential to reduce noncommunicable diseases and risk -diabetes mellitus, hypertriglyceridemia, lipoproteins, LDL, blood pressure- via reduced consumption thanks to the high price elasticity of those drinks. Furthermore, the effects are amplified even in the medium term, once established new habits to healthier eating. These taxes could encourage business innovation without inflicting costs of lost jobs and contribute to reducing the social gradient in obesity (AU)

Diretrizes metodológicas: diretriz de avaliação econômica / Methodological guideline: economic evaluation of health technologies / Directrices metodológicas: evaluación económica de tecnologías em salud

As avaliações econômicas em saúde são definidas como técnicas analíticas formaispara comparar diferentes alternativas de ação propostas, levando em consideraçãocustos e consequências para a saúde, positivas e negativas5. Essas análises comparativasponderam os custos dos recursos aplicados e das consequências obtidas em termosde saúde, ajudando nas decisões sobre a priorização de intervenções e a alocação derecursos. Os estudos de avaliação econômica envolvem, frequentemente, estudos desíntese da informação (como revisão sistemática e metanálise) para a obtenção dasmelhores estimativas dos desfechos em saúde. Além disso, requerem conhecimentosmultidisciplinares, podendo envolver profissionais de disciplinas como epidemiologia,estatística, pesquisa clínica, administração em saúde e economia.As avaliações econômicas baseiam-se no conceito de custo de oportunidade, quesignifica que a aplicação de recursos em determinados programas e tecnologiasimplica a não provisão de outros programas ou tecnologias. Em verdade, o custo realde uma atividade (por exemplo, de serviços hospitalares) não corresponde somenteaos recursos diretamente despendidos na sua oferta, mas também no valor de todas asoutras atividades que podem deixar de ser fornecidas, na medida em que se aumentao montante alocado ao setor saúde6. Desse modo, em uma alocação eficiente derecursos, os custos de oportunidade são minimizados, obtendo-se um emprego ótimodos recursos disponíveis7...