RESUMEN
Quality improvement (QI) in health generally focuses on the provision of health services with the aim of improving service delivery. Yet QI can be applied not only to health services but also to health systems overall. This is of growing relevance considering that due to deficiencies in health systems, the main countries affected by Ebola virus disease (EVD) outbreak in West Africa (2014-2016) were insufficiently prepared for the epidemic, and according to the WHO, epidemics are increasingly becoming a threat to global health. Our objective is to analyze QI constraints in health systems during that EVD epidemic and to propose a practical framework for QI in health systems for epidemics in developing countries. We applied a framework analysis using experiences shared at the "Second International Quality Forum" organized by the University of Heidelberg and partners in July 2015 and information gathered from a systematic literature review. Empirical results revealed multiple deficiencies in the health systems. We systemized these shortfalls as well as the QI measures taken as a response during the epidemic. On the basis of these findings, we identified six specific "priority intervention areas," which ultimately resulted in the synthesis of a practical QI framework. We deem that this framework that integrates the priority intervention areas with the WHO building blocks is suitable to improve, monitor, and evaluate health system performance in epidemic contexts in developing countries.
Asunto(s)
Epidemias , Fiebre Hemorrágica Ebola/epidemiología , Indicadores de Calidad de la Atención de Salud , África Occidental/epidemiología , Atención a la Salud/métodos , Atención a la Salud/organización & administración , Atención a la Salud/normas , Epidemias/prevención & control , Fiebre Hemorrágica Ebola/prevención & control , Fiebre Hemorrágica Ebola/terapia , Humanos , Indicadores de Calidad de la Atención de Salud/organización & administraciónRESUMEN
To determine whether spa therapy has a beneficial effect on pain and disability in patients with chronic shoulder pain, this single-blind randomised controlled clinical trial included patients with chronic shoulder pain due to miscellaneous conditions attending one of four spa centres as outpatients. Patients were randomised into two groups: spa therapy (18 days of standardised treatment combining thermal therapy together with supervised mobilisation in a thermal pool) and controls (spa therapy delayed for 6 months: 'immediate versus delayed treatment' paradigm). All patients continued usual treatments during the 6-month follow-up period. The main endpoint was the mean change in the French-Quick DASH (F-QD) score at 6 months. The effect size of spa therapy was calculated, and the proportion of patients reaching minimal clinically important improvement (MCII) was compared. Secondary endpoints were the mean change in SF-36, treatment use and tolerance. One hundred eighty-six patients were included (94 patients as controls, 92 in the spa group) and analysed by intention to treat. At 6 months, the mean change in the F-QD score was statistically significantly greater among spa therapy patients than controls (- 32.6 versus - 8.15%; p < 0.001) with an effect size of 1.32 (95%CI: 0.97-1.68). A significantly greater proportion of spa therapy patients reached MCII (59.3 versus 17.9%). Spa therapy was well tolerated with a significant impact on SF-36 components but not on drug intake. Spa therapy provided a statistically significant benefit on pain, function and quality of life in patients with chronic shoulder pain after 6 months compared with usual care.
Asunto(s)
Balneología , Dolor Crónico/terapia , Terapia por Ejercicio , Aguas Minerales/uso terapéutico , Dolor de Hombro/terapia , Adulto , Anciano , Anciano de 80 o más Años , Dolor Crónico/diagnóstico por imagen , Terapia por Ejercicio/efectos adversos , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Calidad de Vida , Dolor de Hombro/diagnóstico por imagen , Método Simple Ciego , Resultado del Tratamiento , Ultrasonografía , Rayos X , Adulto JovenRESUMEN
BACKGROUND: Data on the current management of inflammatory bowel disease are scarce. METHODS: This was a nationwide survey among 65 private gastroenterologists treating patients with inflammatory bowel disease in France in 2012. RESULTS: A total of 375 inflammatory bowel disease patients were analysed: 48% had ulcerative colitis. One third of inflammatory bowel disease patients had a history of hospitalisation, and 40% of Crohn's disease patients had prior surgery. Two thirds of inflammatory bowel disease patients had active disease. Significantly fewer ulcerative colitis patients were treated with anti-tumour necrosis factor therapy than Crohn's disease patients (18.9% vs. 38.9%; p<0.0001). Among patients treated with anti-tumour necrosis factor, only 4.5% were receiving concomitant immunomodulators. Half of inflammatory bowel disease patients had undergone a colonoscopy within the past year. For colorectal cancer screening, random biopsies and chromoendoscopy were performed in 75% and 40% of cases, respectively. An endoscopic score was used for only 10% of inflammatory bowel disease patients. About one third of inflammatory bowel disease patients had imaging studies within the past year (magnetic resonance enterography in 65%). An abdominal computed tomography scan was prescribed for 12% of inflammatory bowel disease patients. CONCLUSIONS: Many patients still have active disease in the biologics era, and the number of patients receiving combination therapy is low in private practice. Chromoendoscopy and endoscopy scores are not often used.
Asunto(s)
Colitis Ulcerosa/diagnóstico , Colitis Ulcerosa/terapia , Enfermedad de Crohn/diagnóstico , Enfermedad de Crohn/terapia , Gastroenterología , Pautas de la Práctica en Medicina , Adalimumab , Adulto , Antiinflamatorios no Esteroideos/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Biopsia , Colonoscopía , Femenino , Francia , Encuestas de Atención de la Salud , Hospitalización , Humanos , Inmunosupresores/uso terapéutico , Infliximab , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos X , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
Investigation on the sensivity to temperature variations has been achieved on a full-scale experimental dairy wastewater treatment plant including an unheated but insulated upflow anaerobic sludge blanket. A simple steady-state heat transfer model based on energy balance has been designed to forecast the biogas production depending on ambient air and dairy wastewater temperatures variations. Energy balance has been described for any part of the digestion plant. Calculated heat losses were in the same range than observed losses with an uncertainty of about 10%. From the equalization tank to the digester the average heat loss under cold period was close to 10°C due to convection and conduction. Mesophilic conditions are not respected for couples of ambient air and wastewater temperatures ranging respectively from 8-35 to 35-29°C. Technical solutions are suggested to increase the biogas production.
Asunto(s)
Clima , Calor , Anaerobiosis , Concentración de Iones de Hidrógeno , Cinética , Modelos Teóricos , Temperatura , IncertidumbreRESUMEN
BACKGROUND: The association of genetic profiles with biological or clinical assessments is not clearly established especially among apparently healthy subjects. METHODS: A multivariate statistical analysis was performed on 24 polymorphisms related to the main metabolic pathways involved in cardiovascular diseases (CVDs). They were collected among 1551 healthy subjects of the Stanislas cohort to obtain genetic profiles. Association with biological variables was then studied at baseline (t0) and 5 years later (t5). RESULTS: Six genetic clusters were identified with relevant profiles and five polymorphisms from the selectin, apolipoprotein C3 and lipoprotein lipase genes (SELE-98G/T, APOC3-3175C/G, APOC3-482C/T, APOC3-1100C/T, LPL-93T/G) were sufficiently characteristic to associate 99.6% of the subjects with their corresponding cluster. A 5-year follow-up showed that clinical and biological measurements in relation to CVD risk factors already differ with triglyceride (p=0.009 for t0 and p=0.005 for t5) and high-density lipoprotein cholesterol (p=0.014 for t0 and p=0.003 for t5) for these previous genetic clusters. CONCLUSIONS: This study presents the hypothesis that SELE could be protective, whereas APOC3 could be associated with risk. It remains to be seen whether these polymorphisms will be predictive of CVD events among the selected clusters of different metabolic subtypes after a 10-year follow-up.
Asunto(s)
Enfermedades Cardiovasculares/genética , Marcadores Genéticos , Polimorfismo Genético , Adulto , Apolipoproteína C-III/genética , Apolipoproteína C-III/metabolismo , Enfermedades Cardiovasculares/diagnóstico , Colesterol/genética , Colesterol/metabolismo , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Lipoproteína Lipasa/genética , Lipoproteína Lipasa/metabolismo , Lipoproteínas HDL/genética , Lipoproteínas HDL/metabolismo , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valores de Referencia , Factores de Riesgo , Selectinas/genética , Selectinas/metabolismo , Triglicéridos/genética , Triglicéridos/metabolismoRESUMEN
UNLABELLED: The influence of guidelines is more and more important in the medicine using standardised knowledge as Clinical Practice Guideline (CPG). OBJECTIVES: 1) Determine the impact of different CPGs on a working population 2) Using the Framingham risk calculation as gold standard to check the CPG classifications. METHODS: This work is done in the context of two hypertension management CPGs published in 1997 and 2000, and one dyslipidemia CPG by the French agency HAS. A French regional study sample of 2817 patients was selected. The results of the classification system by CPG were compared to those given by the chosen gold standard: Framingham cardiovascular risk calculation. RESULTS: The HBP CPG concerns more of the quarter of the working population. The mean of the cardiovascular risk calculation for the patients with drug treatment is higher than for the patients with no drug treatment and for those not screened by the CPG. Some patients with a very high calculated risk, are not selected by the screening CPG based on too few or on not adequate variables. CONCLUSIONS: For the two High Blood Pressure Management CPGs, the selected patients are not distributed the same way in the two CPGs. Observed agreement is poor between the two hypertension CPG versions. Screening people for specific health care should be based on risk calculation not on few variables. Feeding back our results to the CPG creator group should reduce the variability of recommendations.
Asunto(s)
Enfermedades Cardiovasculares/prevención & control , Pautas de la Práctica en Medicina/normas , Adulto , Dislipidemias/tratamiento farmacológico , Femenino , Francia , Humanos , Hipertensión/tratamiento farmacológico , Masculino , Persona de Mediana EdadRESUMEN
In France, cancer care is evolving to the design of regional networks, so as to coordinate expertise, services and resources allocation. Existing information systems along with data-mining tools can provide better knowledge on the distribution of patient flows. We used one year data of the French Diagnosis Related Groups (DRGs) based system to perform our analysis. Formal Concept Analysis has been used to build Iceberg Lattices of cancer patient flows in the French region of Lorraine. This unsupervised conceptual clustering method allowed us to describe patients flows with an easily understandable visual representation.
Asunto(s)
Continuidad de la Atención al Paciente , Bases de Datos como Asunto , Grupos Diagnósticos Relacionados , Neoplasias/terapia , Francia , Humanos , Sistemas de Información , Neoplasias/clasificaciónRESUMEN
The aim of this study is to demonstrate that it can be relevant to implement medicalized data in the African hospitals in order to establish morbidity statistics and economical evaluation. A retrospective survey has been carried out on 300 children hospitalized in the paediatrics service in the Yopougon University Hospital from January 1st to December 31st 1999. Data have been collected on forms similar to the ones used in France for discharge summaries. The file batching used for these 300 files is the French DRG named GHM: it shows that, once the files have been divided up in main categories(CMD), CMD 18 (infectious and parasitic diseases) amounts to nearly half of the stays (43.7%). Likewise, in the Case Mix, GHM 611 (others infectious or parasitic diseases) represents, with 38%, more than one third of the stays. The most frequent diagnosis is the B50.9, plasmodium falciparum malaria without precision, with 24.3% of the stays. The patients' stays are shorter than in France. But according to the quality of the collected data, the inadequacy of the tools used and the category of the patients taken into consideration, these results have to be interpreted with restriction. However, this survey shows that it is possible to collect medicalized data in the African hospitals. Other services should feel concerned and more appropriate classifications that would reckon with epidemiological specificities should be applied.
Asunto(s)
Grupos Diagnósticos Relacionados/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Registros Médicos , Pediatría/estadística & datos numéricos , Adolescente , Niño , Preescolar , Côte d'Ivoire/epidemiología , Recolección de Datos , Departamentos de Hospitales/estadística & datos numéricos , Hospitalización , Humanos , Lactante , Tiempo de Internación , Malaria Falciparum/epidemiología , Estudios RetrospectivosRESUMEN
In the context of current evolution of healthcare, hospitals will have to share medical files with different structures. Thus, it is necessary to establish procedures to identify the patients. A team professionals working with such medical information proposes a system of identification based on the matching of identification traits respecting various regulations in order to retrieve the information. We will see how this is made possible, with the help of a correlation engine enabling us to exchange medical documents between different health-care organizations.