Hospital care direct costs due to ambulatory care sensitive conditions related to diabetes mellitus in the Mexican public healthcare system.

BACKGROUND: Hospitalizations for ambulatory care sensitive conditions (ACSC) incur substantial costs on the health system that could be partially avoided with adequate outpatient care. Complications of chronic diseases, such as diabetes mellitus (DM), are considered ACSC. Previous studies have shown that hospitalizations due to diabetes have a significant financial burden. In Mexico, DM is a major health concern and a leading cause of death, but there is limited evidence available. This study aimed to estimate the direct costs of hospitalizations by DM-related ACSC in the Mexican public health system. METHODS: We selected three hospitals from each of Mexico's main public institutions: the Mexican Social Security Institute (IMSS), the Ministry of Health (MoH), and the Institute of Social Security and Services for State Workers (ISSSTE). We employed a bottom-up microcosting approach from the healthcare provider perspective to estimate the total direct costs of hospitalizations for DM-related ACSC. Input data regarding length of stay (LoS), consultations, medications, colloid/crystalloid solutions, procedures, and laboratory/medical imaging studies were obtained from clinical records of a random sample of 532 hospitalizations out of a total of 1,803 DM-related ACSC (ICD-10 codes) discharges during 2016. RESULTS: The average cost per DM-related ACSC hospitalization varies among institutions, ranging from $1,427 in the MoH to $1,677 in the IMSS and $1,754 in the ISSSTE. The three institutions' largest expenses are LoS and procedures. Peripheral circulatory and renal complications were the major drivers of hospitalization costs for patients with DM-related ACSC. Direct costs due to hospitalizations for DM-related ACSC in these three institutions represent 1% of the gross domestic product (GDP) dedicated to health and social services and 2% of total hospital care expenses. CONCLUSIONS: The direct costs of hospitalizations for DM-related ACSC vary considerably across institutions. Disparities in such costs for the same ACSC among different institutions suggest potential disparities in care quality across primary and hospital settings (processes and resource utilization), which should be further investigated to ensure optimal supply utilization. Prioritizing preventive measures for peripheral circulatory and renal complications in DM patients could be highly beneficial.

[Practice guideline. Diagnosis and treatment of type 2 diabetes mellitus]. / Guía de práctica clínica. Diagnóstico y tratamiento de la diabetes mellitus tipo 2.

Our objective was to develop a guide based on the best available evidence that allow family physicians to establish criteria for screening, diagnosis, prevention, treatment of disease, early detection and management of complications; to standardize the organizing processes of the diabetic patient's care in the primary care level; and to achieve lifestyle modification for patients and promote self-care. Clinical questions were stated according to the diagram and structured patient-intervention-comparison-outcome. We used a mixed methodology-adoption adjustment, and include 32 guides. For recommendations not included in these, the search process was conducted in PubMed and Cochrane Library Plus with these terms: diabetes mellitus type 2, epidemiology, detection and diagnosis, classification, drug therapy, effects, prevention, control and complication. The clinical practice guideline emphasizes the fundamental change in lifestyle (diet and exercise), self-care and proactive participation of the patient, in addition to the dynamic prescription of medications that would achieve metabolic control in order to reduce late complications.

[Perspective on type 2 diabetes mellitus in the Instituto Mexicano del Seguro Social]. / Perspectiva de la diabetes mellitus tipo 2 en el Instituto Mexicano del Seguro Social.

The Instituto Mexicano del Seguro Social--always sensitive to the needs of health of the beneficiary population and to the demographic and epidemiological changes of the society--has developed and implemented DiabetlMSS, a program of attention to the diabetic patient. DiabetlMSS organizes care processes based on the needs and values of the patients, through simultaneous activities of individual consultation and group meetings granted by the multidisciplinary health team. These actions and activities are focused to affect patients' lifestyles positively. Through a plan of nutrition, physical activity, self-care and monitoring, this program increases the interaction between patients, by having an exchange of successful experiences about diabetes control. DiabetlMSS was created with the purpose that the patients achieve the metabolic control and identify complications early on, with the perspective of timely intervention that is reflected in the decrease of the catastrophic effects that causes the disease, both for patient's life expectancy and the quality of care provided by the Institute.

[Clinical practice guideline. Traumatic urethral stenosis in males]. / Guía de práctica clínica. La estenosis de uretra postraumática en el hombre.

The incidence of urethral stenosis in Mexico had not been documented. At the Centro Médico Nacional La Raza, during the year 2010, 629 patients with urethral stenosis were attended as outpatient consultation: 85 % with previous urethral stenosis and 15 % with urethral treatment complication. Urethral stenosis is a chronic illness, with multiple etiological origins and the handling is controversial. It has a great negative impact for the patients and the recurrence reaches 85 %. The treatment consisted of an invasive approach (urethral dilations, endoscopy procedure) and open surgery (urethroplasty). The World Health Organization and World Alliance take the world challenge about the urinary tract infections associated with the attention of patients, focused on urethral stenosis. The objective of the following clinical guide is to offer to the health professional a clinical tool for making decisions in the handling of the hardship or masculine urethral stenosis, based on the best available evidence, carrying out in systematized form with bibliographical research using validated terms of the MeSH: urethral structures, in the databases Trip database, PubMed, Guideline Clearinghouse, Cochrane Library and Ovid.

En México no está documentada la incidencia de la estenosis de uretra en forma consistente. En 2010, en el Centro Médico Nacional La Raza se reportaron 629 pacientes en consulta externa, 85 % de uretra anterior y 15 % de uretra posterior. La estenosis uretral es una enfermedad crónica, de etiología variada y manejo controvertido, con gran impacto negativo para los pacientes y recurrencia hasta de 85 %. El tratamiento puede ser instrumentado (dilataciones, cirugía endoscópica) y por cirugía abierta (uretroplastia). La Organización Mundial de la Salud y Alianza Mundial la consideran un reto de la atención de la salud. El objetivo de la siguiente guía es ofrecer al profesional de la salud, una herramienta clínica para la toma de decisiones en la atención de la estenosis uretral masculina, basada en la mejor evidencia identificada mediante la búsqueda bibliográfica sistematizada en las bases de datos Tripdatabase, PubMed, Guideline Clearinghouse, Cochrane Library y Ovid.

[Clinical practice guideline: a complete geriatric evaluation]. / Guía de práctica clínica. Valoración geriátrica integral.

The care of elderly patients requires an evaluation that deserves a host of special considerations, such as biological aspects of aging, those related to activities of daily living and functionality, neuro-psychological conceptions, family dynamics and economic conditions. The growth of the aging population in our country is accompanied by an increase in chronic diseases and more individuals have greater vulnerability, requiring a more consumption of resources because of the high demand for services. This requires the incorporation of specialized care in the institutional system, which has caused serious consequences in the current health system, benefiting specialization and technology, but with a loss of an integrated and horizontal view of the patient. Therefore it is necessary to develop a practical tool that allows the family physician to identify and differentiate the geriatric population that requires specialized care from who does not, identifying problems that may improve and allow the design of strategies to improve health status and maintain functional autonomy of the elderly. Comprehensive Geriatric Assessment (CGA) is a fundamental tool for clinical practice of any medical care to the elderly.

Avoidable Hospitalization Trends From Ambulatory Care-Sensitive Conditions in the Public Health System in México.

OBJECTIVES: To estimate and identify the variations in rates of Avoidable Hospitalization for Ambulatory Care Sensitive Conditions (AH-ACSC) in public institutions of the Mexican health system during the period 2010-2017. METHODS: Secondary analysis of the hospital discharge database of the Ministry of Health (MoH) from 2010 to 2017. AH for ACSC was calculated by age group and sex per 100,000. Variations per year between institutions were calculated with the extreme quotient (EQ), coefficient of variation (CV) and systematic component of variance (SCV). Adjusted AH rates were calculated by group of causes (acute, chronic and preventable by vaccination). Adjusted AH trend rates were analyzed by Join Point Regression. RESULTS: For the period 2010-2017, the number of AH for ACSC decreased from 676,705 to 612,897, going from almost 13% to 10.7% of hospital discharges. There is consistency in terms of relative variance magnitude. But, with regards to SCV, the change remained constant, and in a second period of 2015-2017, high variation was observed by SCV ≥ 3. All-cause AH is diminishing in all institutions. AH rates for diabetes are the highest, but like other chronic diseases, there was a decline in the period from 2010 to 2017. The relative reduction varied from 15% for heart failure to 38% for complications from diabetes or hypertension, to 75% for angina. CONCLUSIONS: AH for ACSC is an indirect indicator of quality and access to first-level care. Variations by institutions are observed. This variation in CV and SCV across subsystems and states may be due to inequities in the provision of services. The factors that contribute to the burden of AH for ACSC in the Mexican Health System require detailed analysis.

Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico.

OBJECTIVE: Rehabilitation strategies have been developed to improve functional state in stroke patients. The main objective of this study was to evaluate the effectiveness of the early rehabilitation at hospital and its continuity at home provided by nurses, on the functional recovery of basic and social activities in stroke patients compared with conventional care. DESIGN: A randomised clinical trial was carried out in three general hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City between April 2003-May 2004. PARTICIPANTS: Stroke patients. METHODS: Two rehabilitation strategies provided by nurses for stroke patients were compared: physiotherapy plus caregiver education in rehabilitation (strategy 1, S1) vs. education alone (strategy 2, S2). The main outcome variables were the basic (Barthel index) and social (Frenchay activities index) activities of daily living, of each patient. Age, sex, morbidity, stroke symptoms, complications, neurological damage (Canadian Scale), cognitive state (mini-mental state examination questionnaire) and duration of hospitalisation were defined as the control variables. Patients were evaluated at baseline and months one, three and six thereafter. RESULTS: One hundred and ten patients with ischaemic stroke were enrolled and randomised; 59 were assigned to S1 and 51 to S2. Comparison of the outcome variables showed that patients improved significantly over time, but no differences were observed between groups. We observed no significant difference in strategy performance with regard to the basic and instrumental activities of daily living. RELEVANCE TO CLINICAL PRACTICE: Participants who received physiotherapy with additional caregiver education benefit no more than those whose caregivers received education alone. Those countries that do not have integral rehabilitation programmes for stroke patients should understand their importance and budget resources for them. Meanwhile, both caregiver education and nurses trained in specific care and physiotherapy are alternatives that benefit these patients.

[Guide for appropriate using of the non-opioid analgesics in the management of pain]. / Guía para la utilización de analgésicos no opioides en el manejo del dolor.

The purpose of this guide is to provide for general practitioners or physicians of primary care a comprehensive, evidence based tool that permits them to take an adequate decision about the appropriate use of the non-opioid analgesics in the management of pain.

[Characterization of stroke patients attended at IMSS hospitals in Mexico City]. / Caracterización de los pacientes con EVC atendidos en hospitales del IMSS en la Ciudad de México.

BACKGROUND: Cerebrovascular disease (CD) is considered a problem of huge social, economic and public health implications worldwide in adults and elderly. In Mexico, the information concerning the provision of services to people and their characteristics is limited. The objective is to describe the characteristics of patients with CV who attended the hospitals of the Instituto Mexicano del Seguro Social (IMSS) in Mexico City. METHODS: It was carried out a cohort study of patients with ischemic or hemorrhagic CD who arrived to IMSS. Patients were recruited from seven IMSS general hospitals in Mexico City from June, 2013, to October, 2014. RESULTS: We assigned 430 subjects with CD (78.14% had ischemic CD). There were no statistical differences regarding gender. The median age of patients was 74 years. During their first 72 hours of hospital stay, it was assessed language proficiency in 90%, the ability to walk in 16.3% and the ability to move extremities in 94%. The main risk factors were hypertension, 84%; diabetes mellitus, 46.3%; history of CD, 25.1%; smoking history, 13.7%. 80% of patients reported that their health was regular or poor. CONCLUSIONS: General characteristics of patients and vascular risk factors are similar to those reported by other studies. Secondary prevention strategies are performed in less time than that recommended by international standards. It is urgent to design strategies to build better ways of care during the acute phase of patients with CD.

INTRODUCCIÓN: la enfermedad vascular cerebral (EVC) es un problema de grandes implicaciones a nivel mundial en población adulta y adultos mayores. Es limitada la información en México sobre la provisión de servicios a población con EVC y sus características. El objetivo es presentar las características de la población con EVC que acude a unidades hospitalarias del Instituto Mexicano del Seguro Social (IMSS) en la Ciudad de México. MÉTODOS: estudio de cohorte en pacientes con EVC isquémica o hemorrágica que llegaron a los servicios de urgencias de hospitales del IMSS. Los pacientes fueron reclutados de siete hospitales generales de zona en la Ciudad de México, de junio del 2013 a octubre del 2014. RESULTADOS: fueron 430 sujetos con EVC (78.14% presentó EVC isquémica). No hubo diferencias estadísticas entre hombres y mujeres. La mediana de edad fue 74 años. Durante las primeras 72 horas de su estancia hospitalaria, en 90% se evaluó la capacidad del lenguaje, en 16.3% la capacidad para caminar y en 94% la capacidad para mover las extremidades. Los factores de riesgo fueron hipertensión arterial (84%), diabetes mellitus (46.3%), antecedentes de EVC (25.1%), antecedentes de tabaquismo (13.7%). El 80% refirió que su salud era regular o mala. CONCLUSIONES: las características generales de los pacientes y los factores de riesgo vascular son similares a los reportados en otros estudios. Las estrategias de prevención secundaria se hacen en menos tiempo que el recomendado por los estándares internacionales. Es importante diseñar estrategias para mejorar la atención en la fase aguda de los pacientes con EVC.

Barriers and opportunities to improve the foundations for high-quality healthcare in the Mexican Health System.

This study aimed to describe the foundations for quality of care (QoC) in the Mexican public health sector and identify barriers to quality evaluation and improvement from the perspective of the QoC leaders of the main public health sector institutions: Ministry of Health (MoH), the Mexican Institute of Social Security (IMSS) and the Institute of Social Security of State Workers (ISSSTE). We administered a semi-structured online questionnaire that gathered information on foundations (governance, health workforce, platforms, tools and population), evaluation and improvement activities for QoC; 320 leaders from MoH, IMSS and ISSSTE participated. We used thematic content and descriptive analyses to analyse the data. We found that QoC foundations, evaluation and improvement activities pose essential challenges for the Mexican health sector. Governance for QoC is weakly aligned across MoH, IMSS and ISSSTE. Each institution follows its own agenda of evaluation and improvement programmes and has distinct QoC indicators and information systems. The institutions share similar barriers to strengthening QoC: poor organizational structure at a facility level, scarcity of financial resources, lack of training in QoC for executive/managerial staff and health professionals and limited public participation. In conclusion, a stronger legal framework and policy dialogue is needed to foster governance by the MoH, to define and align health sector-wide QoC policies, and to set common goals and articulate QoC improvement actions among institutions. Robust QoC organizational structure with designated staff and clarity on their responsibilities should be established at all levels of healthcare. Investment is necessary to fund formal and in-service QoC training programmes for health professionals and to reinforce quality evaluation and improvement activities and quality information systems. QoC evaluation results should be available to healthcare providers and the population. Active public participation in the design and implementation of improvement initiatives should be strengthened.

Health and working conditions of pregnant women working inside and outside the home in Mexico City.

BACKGROUND: To explore differences related to health and working conditions by comparing socio-demographic parameters, reproductive and prenatal care characteristics and working conditions among pregnant women who are employed outside the home (extra-domestic) while still performing a domestic workload versus those who perform exclusively domestic work in the home (intra-domestic). METHODS: A cross-sectional study was carried out at Family Medicine Unit N 31 of the Mexican Institute of Social Security (IMSS) in Mexico City between April and July 2003. Interviews were conducted with 537 pregnant women engaged in either extra-domestic work plus intra-domestic tasks, or those performing strictly intra-domestic work. Information was obtained regarding their demographic status, prenatal care, reproductive, work characteristics, and health during pregnancy. RESULTS: One hundred ninety-six (36.5%) of the interviewed women had paid jobs outside the home in addition to domestic tasks, while three hundred forty-one (63.5 %) engaged in exclusively intra-domestic occupations. Of the women with paid jobs, 78.6% worked as clerks. Among domestic tasks, we found that the greatest workload was associated with washing of clothes, and our micro-ergonomic analysis revealed that women who worked strictly inside the home had a higher domestic workload versus employed women (69.2 vs. 44.9%). When we analyzed the effect of work on health during pregnancy, we observed that women who worked strictly inside the home were at a higher risk for musculoskeletal and genitourinary symptoms than those employed outside the home. CONCLUSION: These findings suggest that the effect of intra-domestic work should not be ignored when considering women's health during pregnancy, and that greater attention should be paid to women's working conditions during intra and extra-domestic work.

Potential drug-drug and drug-disease interactions in prescriptions for ambulatory patients over 50 years of age in family medicine clinics in Mexico City.

BACKGROUND: In Mexico, inappropriate prescription of drugs with potential interactions causing serious risks to patient health has been little studied. Work in this area has focused mainly on hospitalized patients, with only specific drug combinations analyzed; moreover, the studies have not produced conclusive results. In the present study, we determined the frequency of potential drug-drug and drug-disease interactions in prescriptions for ambulatory patients over 50 years of age, who used Mexican Institute of Social Security (IMSS) family medicine clinics. In addition, we aimed to identify the associated factors for these interactions. METHODS: We collected information on general patient characteristics, medical histories, and medication (complete data). The study included 624 ambulatory patients over 50 years of age, with non-malignant pain syndrome, who made ambulatory visits to two IMSS family medicine clinics in Mexico City. The patients received 7-day prescriptions for non-opioid analgesics. The potential interactions were identified by using the Thompson Micromedex program. Data were analyzed using descriptive, bivariate and multiple logistic regression analyses. RESULTS: The average number of prescribed drugs was 5.9 +/- 2.5. About 80.0% of patients had prescriptions implying one or more potential drug-drug interactions and 3.8% of patients were prescribed drug combinations with interactions that should be avoided. Also, 64.0% of patients had prescriptions implying one or more potential drug disease interactions. The factors significantly associated with having one or more potential interactions included: taking 5 or more medicines (adjusted Odds Ratio (OR): 4.34, 95%CI: 2.76-6.83), patient age 60 years or older (adjusted OR: 1.66, 95% CI: 1.01-2.74) and suffering from cardiovascular diseases (adjusted OR: 7.26, 95% CI: 4.61-11.44). CONCLUSION: The high frequency of prescription of drugs with potential drug interactions showed in this study suggests that it is common practice in primary care level. To lower the frequency of potential interactions it could be necessary to make a careful selection of therapeutic alternatives, and in cases without other options, patients should be continuously monitored to identify adverse events.

[Partner violence against pregnant women in Mexico City]. / Violencia de pareja en mujeres embarazadas en la Ciudad de México.

OBJECTIVE: To assess factors related to partner violence against pregnant women. METHODS: Data were collected from 383 pregnant women eligible attending five family medicine units of the Mexican institute of social security in Mexico City, Mexico, between September 2003 and August 2004. Data collection was carried out using a questionnaire developed for the study. RESULTS: Of all women interviewed, 120 (31.1%) reported that they had been exposed to psychological and/or physical and/or sexual violence perpetrated by their partners during the current pregnancy; 10% reported combined violence and 21% isolated violence. Psychological violence was most frequently reported (in 93% of the "experienced violence" group). As for their perception of violence there was not found any significant differences between those women who had experienced versus those who did not experience violence. Only about 20% of women had knowledge of centers for women victims of violence. The factors significantly associated with partner violence among pregnant women included: being single (OR=3.02; 95% CI: 1.17;7.83), being unmarried and living with a partner (OR=2.22; 95% CI: 1.11;4.42), history of violence during childhood (OR= 3.08; 95% CI: 1.62;5.85), alcohol consumption by the partner (OR=1.87; 95% CI: 1.02;3.42) and emotional distress among women (OR=4.17; 95% CI: 1.12;15.51). CONCLUSIONS: The study results stress other research findings that violence against pregnant Mexican women is still common.

[Quality of medication prescribing for elderly patients with non-malignant pain syndrome attending family medicine clinics]. / Calidad de la prescripción en los adultos mayores con síndrome doloroso de origen no oncológico usuarios de los servicios de medicina familiar.

OBJECTIVE: To assess the quality of medication prescribing in ambulatory elderly patients attending to family medicine clinics due to non-malignant pain syndrome. PATIENTS AND METHODS: By doing a secondary data analysis we evaluated the quality of medication prescribing in 495 subjects aged 60 or more years, which were seen due to non-malignant pain syndrome in family medicine clinics belonging to Instituto Mexicano del Seguro Social. The analyzed information included general patient characteristics, medical histories, and medication (complete data). The quality of medication prescribing was assessed by using the Beers criteria and the MAI. All data were analyzed by using descriptive statistics. RESULTS: The total number of medicines prescribed was 3017, with an average number of prescribed drugs of 6 (+/- 2.5). About 35% of patients had prescriptions with at least one inappropriate medication according to the Beers criteria. The mean MAI score was 3.5 (+/- 4.3) for drug and 20.9 (+/- 10.7) per patient. According to MAI criteria, the most frequent errors were: failure to provide practical directions, prescription of drug combinations with potential drug-drug interactions, and inappropriate indications. CONCLUSION: Inappropriate prescription is a common problem in elderly patients with nonmalignant pain syndrome attending to primary care facilities.

[Breast cancer. Evidence and recommendations for the timely detection in primary care]. / Cáncer de mama. Detección oportuna en el primer nivel de atención.

The steady increase of cases and toll of deaths due to breast cancer in the last decades has prompted to analyze in depth current screening methods and their contributions to decrease mortality rates. A literature review was performed at the Ovid-Medline, Cochrane, Synergy, Medic Latina, Science Direct, EBSCO-e-Journal services. The review focused on the epidemiology of breast cancer, its risk factors and the benefits and limitations of current screening methods. The literature review had the aim to contribute in updating primary care practitioners concerning effective screening methods to timely detect breast cancer.

[Pertussis: a case study by PCR and culture]. / Indentificación de un caso de tos ferina y estudio de sus contactos. Utilidad y estudio de la PCR y del cultivo.

OBJECTIVE: To describe an epidemiological study of one case of pertusis. CLINICAL CASE: a five-year old boy was diagnosed with pneumonia and he had incomplete DPT vaccination scheme; pertusis was diagnosed by using the PCR technique and culture. An epidemiological study with family contacts was carried out, in which 20 samples for both tests were obtained. These were taken twice. RESULTS: The average age of the family members was 26.5 years, 50 % were women, 62 % did not have social security and 30 % had three doses of DPT. 35 % were positive to PCR and, 20 % out of these had positive cultures. CONCLUSIONS: In children smaller than five years suffering from pneumonia, is relevant to ascertain about DPT vaccination status and to consider the possibility of carrying out an epidemiological study with the family.-

Direct medical costs for partial refractory epilepsy in Mexico.

BACKGROUND: The aim was to determine the direct medical costs in patients with partial refractory epilepsy at the Mexican Institute of Social Security (IMSS) in Mexico. METHODS: We carried out a multicenter, retrospective-cohort partial-economic evaluation study of partial refractory epilepsy (PRE) diagnosed patients and analyzed patient files from four secondary- and tertiary-level hospitals. PRE patients >12 years of age with two or more antiepileptic drugs and follow-up for at least 1 year were included. The perspective was institutional (IMSS). Only direct healthcare costs were considered, and the timeline was 1 year. Cost techniques were microcosting, average per-service cost, and per-day cost, all costs expressed in U.S. dollars (USD, 2004). RESULTS: We reviewed 813 files of PRE patients: 133 had a correct diagnosis, and only 72 met study inclusion criteria. Fifty eight percent were females, 64% were <35 years of age, 47% were students, in 73% maximum academic level achieved was high school, and 53% were single. Fifty one percent of cases experienced simple partial seizures and 94% had more than one monthly seizure. Annual healthcare cost of the 72 patients was 190,486 USD, ambulatory healthcare contributing 76% and hospital healthcare with 24%. CONCLUSIONS: Annual mean healthcare cost per PRE patient was 2,646 USD; time of disease evolution and severity of the patient's illness did not affect costs significantly.

[Non steroidal anti-inflammatory analgesics in pain treatment. Orientation for primary care use]. / Analgésicos antiinflamatorios no esteroideos en la terapia del dolor. Orientación para su uso en el primer nivel de atención.

The high use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the current practice at the primary care level, and their frequently inappropriate prescription, due to ignorance in pharmacological side effects could cause devastating consequences for the patient's health. It was considered necessary to make a review of the more recent evidence about the NSAIDs, with the intention that medical doctors can be updated on the use of these drugs. The literature review was performed at the Ovid-Medline, Cochrane, Synergy, Medic latina, Science direct, Ebsco-e-journal services. In this article there is an emphasis about NSAIDS adverse effects, and actions suggested during their use.

[Experience of the Mexican National Health System in the development of clinical practice guidelines]. / Experiencia del Sistema Nacional de Salud Mexicano en el desarrollo de guías de práctica clínica.

BACKGROUND: Clinical practice guidelines are tools that have been able to streamline decisions made in health issues and to decrease the gap between clinical action and scientific evidence. OBJECTIVE: The objective of the study is to share the experience in the development and to update the guidelines by the National Health System of Mexico. MATERIAL AND METHODS: The methodology in the development of the guidelines consists of 5 phases: prioritisation, establishment of work groups, development by adoption of international guidelines of de novo, validation and integration in the Master catalogue of clinical practice guidelines for its dissemination. RESULTS: The Master catalogue of clinical practice guidelines contains 664 guidelines, distributed in 42% Internal Medicine, 22% Surgery, 24% Pediatrics and 12% Gynecology. From the total of guidelines coverage is granted at an 85% of the Universal catalogue of health services, an 84% of the Catastrophic expenses protection fund and a 61% of the XXI Century Medical Insurance of the National Commission of Social Protection in Health. DISCUSSION: The result is the sum of a great effort of coordination and cooperation between the institutions of the National Health System, political wills and a commitment of 3,477 health professionals that participate in guidelines' development and update. CONCLUSION: Master catalogue guidelines' integration, diffusion and implantation improve quality of attention and security of the users of the National Health System.

Caregiver burden of Mexican dementia patients: the role of dysexecutive syndrome, sleep disorders, schooling and caregiver depression.

AIMS: As a result of the accelerated growth of the elderly population, reconfiguration of families and member roles, and the increase of mental disorders, it is necessary to investigate the effects of this set of factors on the caregivers of patients with dementia in Mexico. Mental disorders of individuals have a negative impact on their physical and emotional quality of life, leading to greater dependence and making the caring experience a heavy burden. Several studies (none in Mexico) have used either the characteristics of the patient or caregiver to determine the burden, but few studies have included both profiles within a single study. The objective of the present study was to analyze the characteristics of the patients and caregivers associated with caregiver burden. METHODS: A multicenter study was carried out in six health institutions located in Mexico City, including 175 patients (and their caregivers) diagnosed with different types of dementia. We used the Spanish Caregiver Burden Screen. Descriptive analysis and logistic regressions were used to estimate the effect of the covariates on the caregiver burden. RESULTS: The results showed that patient variables have a greater impact on caregiver burden than caregiver-associated variables. Dysexecutive syndrome, sleep disorders, schooling and caregiver depression are associated with a higher level of caregiver burden. CONCLUSIONS: Caregiver burden is a complex phenomenon. The results of the present study showed the need to implement multifactorial interventions targeting the caregiver to reduce the burden, strengthen the skills for patient management to avoid depression, improve patient health, and diminish functional dependence and future hospitalization.