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CONTEXT: Progress in palliative care (PC) necessarily involves scientific development. However, research conducted in South America (SA) needs to be improved. OBJECTIVES: To develop a set of recommendations to advance PC research in SA. METHODS: Eighteen international PC experts participated in a Delphi study. In round one, items were developed (open-ended questions); in round two, each expert scored the importance of each item (from 0 to 10); in round three, they selected the 20 most relevant items. Throughout the rounds, the five main priority themes for research in SA were defined. In Round three, consensus was defined as an agreement of ≥75%. RESULTS: 60 potential suggestions for overcoming research barriers in PC were developed in round one. Also in Round one, 88.2% (15 of 17) of the experts agreed to define a priority research agenda. In Round two, the 36 most relevant suggestions were defined and a new one added. Potential research priorities were investigated (open-ended). In Round three, from the 37 items, 10 were considered the most important. Regarding research priorities, symptom control, PC in primary care, public policies, education and prognosis were defined as the most relevant. CONCLUSION: Potential strategies to improve scientific research on PC in SA were defined, including stimulating the formation of collaborative research networks, offering courses and workshops on research, structuring centers with infrastructure resources and trained researchers, and lobbying governmental organizations to convince about the importance of palliative care. In addition, priority research topics were identified in the region.
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Enfermería de Cuidados Paliativos al Final de la Vida , Cuidados Paliativos , Humanos , Técnica Delphi , América del Sur , ConsensoRESUMEN
Colombia's health sector reform has been recognized for its universal health (UHC) coverage scheme. However, this reform evolved without palliative care (PC), thereby omitting a core element of UHC. In this paper, we analyze the Colombian health system reform and health policies in relation to PC. We present the history, innovations, successes, and shortcomings of the reform and summarize the lessons learned to strengthen efforts leading to PC integration. Our analysis is based on the WHO public health framework for PC (policy, access to medicines, education, service provision). For several years and especially during the last decade, the government enacted laws and regulations to improve access to essential medicines and to integrate PC. Relative to other countries in Latin America, Colombia was the first to launch a PC service and to accredit palliative medicine as a specialty, the second to establish a national PC association and one of the few countries with a specific PC law. However, data shows that there are still too few services to meet the PC needs of approximately 250,000 adult patients annually. Our analysis shows that the country's failure to integrate PC most likely is a result of limited health worker education. Advocacy efforts should include deans of schools and provosts, in addition to policy makers and regulators. Other possible factors affecting uptake and implementation of existing national policies are civil unrest and limited collaboration between government offices. Additional research is needed to evaluate the impact of these and other related factors on PC integration in Colombia.
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Enfermería de Cuidados Paliativos al Final de la Vida , Cuidados Paliativos , Adulto , Colombia , Política de Salud , Humanos , Análisis de SistemasRESUMEN
BACKGROUND: Formal recognition of palliative medicine as a specialty has been one of the main drivers in the development of palliative care. AIM: To provide a comparative, comprehensive overview on the status of palliative medicine as medical specialty across Latin America. METHODS: We conducted a comparative study of 19 Latin American countries. Key informants and persons in charge of the specialization training programs were identified and interviewed. We collected data on general recognition as specialty (title, process of certification) and on training program characteristics (title, start year, requirements, training length, and type full time or part time). RESULTS: Eight of 19 countries (42%) Argentina, Brazil, Colombia, Costa Rica, Ecuador, Mexico, Paraguay and Venezuela reported palliative medicine as medical specialty. Thirty-five (sub)specialization training programs in palliative medicine were identified in the region (eight as a specialty and 27 as a subspecialty), the majority in Colombia (43.5%) and Brazil (33.7%). A total of 20% of the programs have yet to graduate their first cohort. Length of clinical training as specialty varied from two to four years, and from 520 hours to three years for a subspecialty. CONCLUSION: Despite long-standing efforts to improve quality of care, and significant achievements to date, most Latin American countries have yet to develop palliative medicine as medical specialty. Specialty and sub-specialty training programs remain scarce in relation to regional needs, and the programs that do exist vary widely in duration, structure, and content.
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Medicina Paliativa , Brasil , Colombia , Humanos , América Latina/epidemiología , México , EspecializaciónAsunto(s)
Cuidados Paliativos/organización & administración , Espiritualidad , Estrés Psicológico/diagnóstico , Encuestas y Cuestionarios/normas , Evaluación de Síntomas/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los ResultadosRESUMEN
Background: Spiritual issues are an important dimension of health care, but seldom addressed by professionals. Thus, a scale that assesses the presence and intensity of seven spiritual symptoms was developed. Aim: To validate the instrument in palliative care settings. Material and Methods: The spiritual symptoms scale was applied to 103 patients, aged 59 ± 17 years (58% women), admitted to hospice care in two centers located in Santiago. The reproducibility of the scale was evaluated in 33 patients and its internal consistency and liability in 70. Results: The Fleiss Kappa to assess reproducibility was 0.82 and the analysis of variance had a p of 0.94. Cronbach alpha to assess internal consistency was 0.74. Conclusions: The scale renders similar results when applied by different evaluators and has a good liability. Therefore, it can be a reliable instrument to assess spiritual symptoms in palliative care settings. Further studies would be needed to verify its utility in other settings.
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Cuidados Paliativos/organización & administración , Estrés Psicológico/diagnóstico , Encuestas y Cuestionarios/normas , Espiritualidad , Evaluación de Síntomas/instrumentación , Estudios Transversales , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: A World Health Assembly (WHA) resolution adopted in 2014 strongly encourages member states to integrate palliative care (PC) in undergraduate training for health professionals. OBJECTIVE: The study objective was to describe a consensus-based process workshop to develop PC competences for medical and nursing schools in Colombia and to present a summary of the findings. METHODS: The workshop included 36 participants representing 16 medical and 6 nursing schools from 18 universities in Colombia. Participants were distributed in four thematic groups. Using the International Association for Hospice and Palliative Care (IAHPC) List of Essential Practices (LEP) as guidance, they were asked to discuss and define PC competencies at the undergraduate level. Participants provided feedback and approved each recommendation, and then were asked to complete an evaluation. RESULTS: The resulting competences were separated into six categories: (1) Definition and Principles of PC, (2) Identification and Control of Symptoms, (3) End-of-Life Care, (4) Ethical and Legal Issues, (5) Psychosocial and Spiritual Issues, and (6) Teamwork. A comparative analysis revealed that treatment of several symptoms in the IAHPC LEP (pain, dyspnea, constipation, nausea, vomit, diarrhea, delirium, and insomnia) were included in the competencies. All of the IAHPC LEP related to psychological/emotional/spiritual care was included. The evaluation rate of return was 80%. The assessment was very positive: total score of 4.7/5.0; SD = 0.426), with 89% considering the workshop to be helpful. CONCLUSION: The workshop provided an opportunity for individuals from different disciplines to discuss competencies and achieve consensus. The resulting competencies will be helpful in the development of PC curricula for physicians and nurses throughout schools in Colombia and other countries.
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Competencia Clínica/normas , Curriculum/normas , Educación Médica/normas , Cuidados Paliativos al Final de la Vida/normas , Enfermeras y Enfermeros/normas , Cuidados Paliativos/normas , Médicos/normas , Colombia , Femenino , Humanos , Masculino , Universidades/estadística & datos numéricosRESUMEN
HIV prevention strategies must be based on evidence of risk behaviours among people with HIV infection. This study aimed to determine the demographic, behavioural and self-reported disease/treatment variables that predict sexual risk behaviour, defined as unprotected intercourse with a partner of unknown or negative HIV status, among HIV-infected outpatients in Buenos Aires, Argentina. Two hundred consecutive outpatients (response rate 76.5%) participated in a self-complete cross sectional survey. The majority (49.5%) identified as heterosexual, and most were on antiretroviral therapy (ART) (75.5%). Undetectable viral load was currently achieved by 63%. Unprotected intercourse with a person of unknown or discordant status in the previous three months was reported by 20%. In multivariate analysis, risk was associated with lower distress from physical symptoms (p=0.012), greater distress from psychological symptoms (p=0.038) and being on treatment had borderline association with risk (p=0.058). The data reveal an important link between self-reported experience of disease, and treatment, with risk. Secondary prevention, care and treatment should not be conducted in isolation from each other if outcomes are to be optimised.
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Terapia Antirretroviral Altamente Activa/psicología , Infecciones por VIH/psicología , Sexo Inseguro/psicología , Adulto , Anciano , Anciano de 80 o más Años , Argentina , Estudios Transversales , Femenino , Seropositividad para VIH/psicología , Heterosexualidad , Homosexualidad Masculina , Humanos , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Análisis de Regresión , Autoinforme , Parejas Sexuales , Sexo Inseguro/estadística & datos numéricos , Carga Viral , Adulto JovenRESUMEN
The aim of this study was to determine by consensus the components of an opioid essential prescription package (OEPP) to be used when initiating a prescription for the control of moderate to severe chronic pain. Palliative care physicians (n=60) were sampled from the International Association for Hospice and Palliative Care (IAHPC) membership list to represent a range of countries of varying economic levels and diverse geographical regions. Using a Delphi study method, physicians were asked to rank preferences of drug and dosing schedule for first-line opioid, antiemetic, and laxative for the treatment of adults with chronic pain due to cancer and other life-threatening conditions. Overall response rates after two Delphi survey rounds were 95% (n=57) and 82% (n=49), respectively. A consensus (set at ≥75% agreement) was reached to include morphine as first-line opioid at a dose of 5 mg orally every 4 hours. Consensus was reached to include metoclopramide as a first-line antiemetic, but there was no consensus on "regular" or "as needed" administration. No consensus was reached regarding a first-line laxative, but a combination of senna and docusate secured 59% agreement. There was consensus (93% agreement) that laxatives should always be given regularly when opioid treatment is started. Further work is needed to establish a recommended dose of metoclopramide and a type and dose of laxative. The resulting OEPP is international in scope and is designed to ensure that opioids are better tolerated by reducing adverse effects of opioids, which could lead to more sustained improvements in pain management.
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Analgésicos Opioides/administración & dosificación , Protocolos Clínicos , Medicamentos Esenciales , Manejo del Dolor/métodos , Cuidados Paliativos , Analgésicos Opioides/efectos adversos , Antieméticos/administración & dosificación , Estreñimiento/inducido químicamente , Estreñimiento/prevención & control , Técnica Delphi , Ácido Dioctil Sulfosuccínico/administración & dosificación , Esquema de Medicación , Quimioterapia Combinada , Infecciones por VIH/terapia , Humanos , Laxativos/administración & dosificación , Metoclopramida/administración & dosificación , Morfina/administración & dosificación , Morfina/efectos adversos , Náusea/inducido químicamente , Náusea/prevención & control , Neoplasias/terapia , Extracto de Senna/administración & dosificaciónRESUMEN
Access to palliative care is insufficient in many countries around the world. In an effort to improve access to palliative care services and treatments, a public health approach as suggested by the World Health Organization was implemented in Colombia to improve opioid availability, increase awareness and competences about palliative care for healthcare workers, and to include palliative care as a component of care in legislation. As a result, opioid availability has improved, a mandatory palliative care course for medical undergraduate students has been implemented and a palliative care law is being discussed in the Senate. This article describes the strategy, main achievements and suggestions for implementing similar initiatives in developing countries.
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Analgésicos Opioides/provisión & distribución , Prestación Integrada de Atención de Salud/organización & administración , Países en Desarrollo , Cuidados Paliativos/organización & administración , Administración en Salud Pública , Colombia , Prestación Integrada de Atención de Salud/legislación & jurisprudencia , Educación de Pregrado en Medicina/métodos , Educación de Pregrado en Medicina/normas , Política de Salud , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Cooperación Internacional , Cuidados Paliativos/legislación & jurisprudenciaRESUMEN
Latin America consumes less than 2.7% of the morphine in the world, as reported by the governments to the International Narcotics Control Board. Methods to improve access to opioids for the treatment of pain have been developed by the Pain & Policy Studies Group (PPSG), a World Health Organization Collaborating Center at the University of Wisconsin. This article describes the preparation and implementation of an action plan in Colombia as a part of an international fellowship program on opioid policy developed by the PPSG and funded by the Open Society Institute. The action plan for Colombia included three steps: 1) a survey of regulators and health care providers to identify the current situation and their perceptions of opioid availability in the regions of the country; 2) a workshop with representatives of the Ministry of Health, the national and state competent authorities, pain and palliative care physicians, and international leaders; and 3) implementation workshops at the local level throughout the country. For the survey, response rates of 47% and 96% were registered among physicians and competent authorities, respectively. The survey identified significant regional differences in perceived opioid availability between physicians and regulators. Focus group discussions during the workshop identified several reasons leading to limited availability of opioids in the country, including deficiencies in the procurement process, insufficient human resources, excessive bureaucratic tasks, insufficient number of pharmacies authorized to dispense controlled medications in the country, lack of training in the health care professions, and overly restrictive laws and regulations governing opioid availability. The third step of the action plan has not been implemented. Additional and continuous monitoring needs to be implemented to measure the progress of this project.
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Analgésicos Opioides/uso terapéutico , Planificación en Salud/legislación & jurisprudencia , Planificación en Salud/organización & administración , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/organización & administración , Dolor/tratamiento farmacológico , Dolor/epidemiología , Colombia/epidemiología , Utilización de Medicamentos , Encuestas de Atención de la Salud , Humanos , FarmaciasRESUMEN
This paper describes an innovative Pan-American survey on advanced-cancer care and examines the quality-of-care provided by Latin American institutions. A convenience sample of 777 physicians and nurses who treat cancer patients in Argentina, Brazil, Cuba, Mexico, and Peru were surveyed. Providers were identified through mass mailings, distribution at professional meetings and conferences, collaboration with regional institutions, professional organizations, and PAHO and online posting. Multiple linear regression analyses were conducted to identify predictors of quality-of-care assessments in each country. The five predictive models were subsequently compared descriptively. Higher access to care ratings and greater availability of end-of-life services corresponded with improved institutional quality-of-care ratings for all five countries. Barring respondents from Cuba, providers from the other four nations who practice in public institutions rated the quality of advanced-cancer care in their own institutions lower than those practicing in private hospitals or specialized cancer centers. Other institutional quality-of-care predictors included type of city, affordability-of-care ratings, availability of opioid analgesics, where patients die, barriers to cancer pain management, and the provider's specialty and gender. These findings highlight the need for providing accessible care and services to improve the quality of advanced-cancer care in Latin American institutions. Efforts should be aimed at improving the care offered in public institutions and addressing other types of disparities that may exist within countries by creating supportive and palliative cancer care programs that are accessible and affordable to those most in need.
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Actitud del Personal de Salud , Costos de la Atención en Salud , Accesibilidad a los Servicios de Salud , Neoplasias/terapia , Auditoría de Enfermería , Cuidados Paliativos , Argentina , Brasil , Instituciones Oncológicas , Cuba , Progresión de la Enfermedad , Encuestas Epidemiológicas , Hospitales Privados , Hospitales Públicos , Humanos , América Latina , México , Perú , Pautas de la Práctica en MedicinaRESUMEN
BACKGROUND: In recent years, there has been an increase in the amount of palliative care research in developing countries. However, it is still very limited in the developing regions of the world, including Latin America. OBJECTIVE: To determine the current status of palliative care research in Latin America. DESIGN: A survey was developed in Spanish and translated to Portuguese. Questions included demographic characteristics and specific research issues. Distribution was done through e-mail and personal hand-outs. MEASUREMENTS: Data were collected and analyzed using descriptive statistics and multivariate analysis. RESULTS: Two hundred sixty-three surveys (17.5% response rate) were received from 17 countries. A small number (10%, n = 263) reported participating in research within the last 5 years. Slightly over half of them received some training and had access to mentorship and guidance from an expert: multivariate analysis showed that training in research (odds ratio [OR] 3.46; 95% confidence interval [CI] 1.71-6.98) and support from an expert (OR 3.03; 95% CI 1.51-6.10) were positive predictor factors, even when adjusted for gender, age, years since graduation, and years working in palliative care. Barriers to conduct research most frequently cited were: lack of funding, insufficient knowledge and expertise, and lack of interest (54%, 21%, and 15%, respectively). CONCLUSIONS: Palliative care research in Latin America is very limited. Regional palliative care teams must adopt and implement systematic research in their practice to improve, guarantee, and sustain quality. Changes in policy, education, and allocation of funds are needed to guarantee the development of research in Latin America.
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Cuidados Paliativos , Investigación/educación , Adulto , Femenino , Encuestas de Atención de la Salud , Humanos , América Latina , Masculino , Persona de Mediana Edad , MédicosRESUMEN
Cancer is now a leading cause of death among adults in most Latin American nations. Yet, until recently, there has been limited research on the quality of, and access to, advanced cancer care in developing regions such as Latin America. This landmark, cross-national study assessed the quality of advanced cancer care in five Latin American countries by surveying a convenience sample of 777 physicians and nurses, and identifying the most salient influences on their quality-of-care assessments based on multiple linear regression analyses. Strategies for disseminating this survey included mass mailings, distribution at professional meetings/conferences, collaboration with Latin American institutions, professional organizations, and the Pan American Health Organization, and online posting. Results indicate that the respondents' assessments of the quality of, access to, and affordability of advanced cancer care varied significantly across nations (P<0.001). The strongest predictor of providers' national-level assessments of the quality of care was their ratings of access to advanced cancer care (Beta=0.647). Other predictors included affordability of care, country (Cuba vs. the other four countries), income-gap quintile, and institutional availability of opioid analgesics. Low prioritization of palliative care in both health care policy formulation and provider education also predicted the quality-of-care ratings. Findings from this study suggest that providers from five different nations hold similar equitable notions of quality care that are dependent on the provision of accessible and affordable care. Measures of social equity, such as the income-gap quintile of nations, and measures of policy barriers, such as the scale developed in this study, should be replicated in future studies to enable policy makers to assess and improve advanced cancer care in their countries.
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Costos de la Atención en Salud , Accesibilidad a los Servicios de Salud , Neoplasias/terapia , Calidad de la Atención de Salud , Argentina , Brasil , Cuba , Progresión de la Enfermedad , Humanos , América Latina , México , PerúRESUMEN
Opioids are some of the most important analgesic medications for the management of both moderate to severe pain and several are included on the World Health organization (WHO) list of essential drugs. Opioid costs in developing countries have been reported to be higher than those in developed nations. This study documents retail prices and availability of several potent opioids in a number of developing and developed countries. Pain and Palliative Care specialists currently working in their countries were asked to collect data on the retail cost of a 30 day supply of 15 different opioid preparations in 5 developing and 7 developed countries. Data were analyzed to compare costs and costs as a percentage of gross national product (GNP) per capita per month. Opioid costs and availability varied widely in both developing and developed countries. Forty five of 75 opioid preparations were available in developing countries (40% of medications studied were not available) and 76 of 105 preparations were available in the developed countries (28% not available). In US dollars, the median cost of opioids differed between developed and developing countries ($53 and $112 respectively) The median costs of all opioid preparations as a percentage of GNP per capita per month were 36% for developing and 3% for developed nations; the difference was statistically significant (p < 0.001). In developing countries 23 of 45 (51%) of opioid dosage forms cost more than 30% of the monthly GNP per capita, versus only three of 76 (4%) in developed countries. The relative cost of opioids to income is higher in developing countries. Our data suggest that in developing countries opioid access for the majority of patients is likely to be limited by cost, and development of palliative care programs will require heavy or total subsidization of opioid costs.