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INTRODUCCIÓN: Para contribuir a reducir la mortalidad materno-infantil, el Ministerio de Salud de la Nación implementó la evaluación externa (EE) de maternidades públicas categorizadas como IIIB. OBJETIVOS: Evaluar la calidad y seguridad de las maternidades en Argentina. MÉTODOS: Se utilizó una herramienta con 254 estándares ponderados por riesgo, hubo 24 evaluadores capacitados, "trazamiento" de pacientes, entrevistas con personal y pacientes, revisión de documentos, recorridas, fotografías y observación. Se recurrió a fuentes de información primarias. RESULTADOS: Se evaluaron 16 maternidades (mediana: 4 125 partos anuales). Los procesos más riesgosos fueron: manejo de medicaciones, cirugías, reporte de errores, identificación del paciente, reanimación cardiopulmonar del adulto y emergencias obstétricas, comunicación, personal y servicios (atención continua, guardias, horarios de ecografías, anestesiólogos, camilleros, control de competencias, uso de guías), control de infecciones y seguridad del entorno. CONCLUSIONES: Las maternidades públicas de mayor complejidad tienen muchos procesos inseguros. Las EE son efectivas para obtener información sobre riesgos, priorizar procesos a mejorar y estimar la frecuencia de ocurrencia de problemas sistémicos. Deberían ser parte de una estrategia de calidad nacional que contemple apoyo, incentivos y obligatoriedades, a fin de que las instituciones logren las mejoras necesarias para disminuir riesgos.

INTRODUCTION: To contribute to reducing maternal and infant mortality, the National Ministry of Health implemented a project of external evaluation (EE) of public hospitals providing maternity care under category IIIB. OBJECTIVE: To evaluate the quality and safety in maternity hospitals in Argentina. METHODS: The study used a tool with 254 risk-weighted standards, including 24 trained evaluators, tracing of patient care, interviews with staff and patients, document review, visits to services, photos, and observation. Information was gathered from primary sources. RESULTS: A total of 16 hospitals were evaluated (median: 4125 births annually). The processes of highest-risk were: medication management, surgery, error reporting, patient identification, adult cardiopulmonary resuscitation and obstetric emergency preparedness, communication, staff and services (continuity of care, personnel on-duty, availability of ultrasound examinations, anesthesiologists, auxiliary personnel, control of competencies, use of guidelines), infection control, and safety of the environment. CONCLUSIONS: Many unsafe processes were identified in highcomplexity public maternity hospitals. EEs are effective for gathering information about risks, prioritizing processes for improvement, and estimating the frequency of occurrence of systemic problems. They should be part of a national quality strategy considering support, incentives, and mandatory requirements so that hospitals take action to reduce risk.

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Introducción El uso de inhibidores de la enzima convertidora de la angiotensina II (IECA) en el primer trimestre del embarazo se asocia con un incremento de 2,71 veces del riesgo de malformaciones congénitas mayores (MCM), lo cual genera preocupación debido a que los IECA constituyen uno de los medicamentos prescriptos con más frecuencia. Objetivos Cuantificar la prescripción de enalapril -un IECA- provisto por el Programa Remediar a mujeres en edad fértil y reflexionar acerca del posible número de MCM que podrían prevenirse. Material y métodos El estudio consta de dos diseños: 1. Estudio ecológico: cruce de diagnósticos, prescripciones, beneficiarios de las recetas del Programa Remediar (fuentes secundarias). Población objetivo: mujeres de 15 a 49 años atendidas en 6 mil centros de salud de la Argentina desde 2005 hasta 2006, con diagnóstico de hipertensión y/o prescripción de enalapril. 2. Evaluación sobre un enfoque contrafáctico del impacto que podría tener la reducción de la exposición a IECA en esa población. Resultados Se analizaron 15.001.041 Formularios R, universo de recetas grabadas en el año estudiado. Se identificaron 2.085.338 mujeres en edad fértil y se prescribió enalapril al 5,5% de ellas; esto elevaría la cantidad de MCM de 214 (IC 95% 199-229), si se hubieran prescripto otros medicamentos, a 579 con el uso de enalapril (IC 95% 296-863), de modo que con la reducción de la exposición podrían prevenirse alrededor de 365 (IC 95% 97-634) casos/año de MCM en la población cubierta por Remediar. Conclusiones La prescripción de IECA a mujeres en edad fértil es frecuente. En esta población se prevendrían numerosos casos de MCM si se evitaran la prescripción y el uso de IECA. Se requiere mayor evidencia para evaluar el riesgo descripto.

Background Use of angiotensin-converting enzyme inhibitors (ACEIs) during the first trimester of pregnancy is associated with a 2.71-fold increase in the risk of major congenital defects (MCDs), a matter of care as ACEIs are one of the most frequent medications prescribed. Objectives To quantify the prescription of enalapril -an ACEI- provided by the Remediar Program in women of childbearing age, and to think about the possible number of MCDs that could be prevented. Material and Methods The study has two designs: 1. Ecological study with cross comparisons of diagnoses, prescriptions and beneficiaries of the prescriptions of the Remediar Program (secondary sources). Target population: women between 15 to 49 years, treated at 6000 health care centers in Argentina from 2005 to 2006, with diagnosis of hypertension and/or prescription of enalapril. 2. Evaluation of a counterfactual approach of the impact following the reduction of exposure to ACEIs in such population. Results From a total of 15,001,041 R-Forms recorded during the year of the study, 2,085,338 women of childbearing age were identified; 5.5% of them received enalapril. Thus, considering that the number of MCDs expected using another medication would be 214 (95% CI 199-229) and the use of enalapril would increase the number of events to 579 (95% CI 296-863), the reduction of the exposure would prevent about 365 (95% CI 97-634) cases of MCD/year in the population covered by the Remediar Program. Conclusions Prescription of ACEIs in women of childbearing age is frequent. A significant number of cases of MCD would be prevented avoiding the prescription and use of ACEIs in this population. More evidence is needed to evaluate this risk.

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Introducción La enfermedad cardiovascular causa el 32% de las muertes en la Argentina. La aspirina reduce un 12% los eventos y está indicada cuando el riesgo cardiovascular (RCV) a los 10 años supera el 10%. El Programa Remediar provee aspirina gratuitamente en el primer nivel de atención pública para la población sin cobertura. Objetivo Analizar el uso de la aspirina y estimar su efectividad. Material y métodos El presente estudio consta de tres diseños: 1. Estudio ecológico: cruce de prescripciones de aspirina, diagnósticos, beneficiarios, por provincia, de las recetas de Remediar. Fuentes: recetas realizadas en 6 mil centros de salud desde marzo de 2005 hasta febrero de 2006. 2. Evaluación sobre un enfoque contrafáctico. 3. Cálculo de costos de medicamentos por resultado. Resultados A pesar de que el Programa contaba con disponibilidad, se prescribió aspirina a 60.408 beneficiarios, con una media que recibe 2,0 tratamientos mensuales por año, sobre una población de 708.470 beneficiarios identificados por el Programa mayores de 50 años con RCV aumentado. La cobertura nacional alcanzó al 6,8% de la población objetivo de 882.205 personas, con una gran variabilidad interprovincial. La evaluación del impacto potencial de la prescripción de aspirina en tres escenarios contrafácticos muestra que podrían haberse evitado 725 a 21.173 eventos. El costo de evitar cada evento sería para el Programa Remediar de 3.111 a 6.222 dólares a lo largo de 10 años. Conclusiones Se evidencia subprescripción de aspirina, falta de cumplimiento de un mínimo anual de tratamientos efectivos y problemas de acceso, lo cual limitaría el impacto sanitario.

Background Cardiovascular diseases cause 32% of deaths in Argentina. Aspirin produces a 12% reduction in the incidence of events and is indicated when cardiovascular risk at 10 years is above 10%. The Remediar Program provides aspirin to patients without medical coverage in the public primary care level. Objective To analyze the use of aspirin and estimate its indication. Material and Methods The present study has three designs: 1. Ecological study with cross comparisons of aspirin prescriptions, diagnoses and beneficiaries, by province, of the prescriptions of the Remediar Program. Sources: prescriptions from 6000 health care centers from March 2005 to February 2006. 2. Evaluation of a counterfactual approach. 3. Estimate of medication costs based on results. Results The Remediar Program identified 708 470 beneficiaries >50 years with increased cardiovascular risk. Aspirin was prescribed to 60 408 beneficiaries, with a mean of 2.0 treatments per month/year despite drug availability. The Program provided national coverage for 6.8% of the target population of 882 205 people, with an important variability among provinces. The evaluation of the potential impact of aspirin prescription in three counterfactual scenarios shows that 725 to 21 173 events could have been prevented, and that the cost of the Remediar Program to prevent one event would be of USD 3111 to 6222 during 10 years. Conclusions Underprescription of aspirin, failure to provide a minimum annual number of effective treatments and access issues might limit the impact on health care.

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La hipertensión arterial (HTA) es un motivo frecuente de prescripción. La Argentina fue afectada a fines de 2001 por una severa crisis socioeconómica que disminuyó el acceso de la población a los medicamentos, con los consiguientes riesgos sanitarios. Como respuesta desde el Estado, se implementó el Programa Remediar para proveer en forma gratuita medicamentos a la población de escasos recursos y sin cobertura social. Objetivos Analizar el uso de medicamentos antihipertensivos en la población atendida en el primer nivel de atención (PNA) pública de la Argentina y estimar en forma proyectada su efectividad en términos de cobertura de la población esperada con HTA. Material y métodos El presente es un estudio ecológico con cruce de diagnósticos, prescripciones y beneficiarios por provincia de las recetas del Programa Remediar. Población objetivo: pacientes con diagnóstico de HTA atendidos en 6 mil centros de salud de la Argentina desde marzo de 2005 hasta febrero de 2006. Resultados En 15 millones de recetas, la frecuencia referida de HTA fue del 10,4%: 126.097 recetas mensuales. Este porcentaje no fue homogéneo, ya que resultó 3 a 4 veces mayor en la ciudad de Buenos Aires y la provincia de La Pampa que en las provincias de Jujuy o Salta. La frecuencia de prescripción fue: enalapril 77,0%, atenolol 22,1%, hidroclorotiazida 12,5% y aspirina 7,1%. Sobre la base de estadísticas poblacionales previas y la prevalencia esperada de HTA, se pudo estimar que el Programa Remediar alcanzó a cubrir porcentajes variables de la población con cobertura pública exclusiva: 57,3% en todo el país, con grandes variaciones. El 74,9% de los beneficiarios hipertensos recibió tratamientos suficientes para 4 o menos meses por año. Conclusión La utilización de tiazidas y de aspirina fue menor que la esperada de acuerdo con las guías de práctica clínica basada en evidencias. Es posible que el impacto sanitario positivo de la provisión de medicamentos se haya visto limitado por la falta de cumplimiento de un mínimo anual de tratamientos efectivos.

Background Hypertension (HT) is a frequent cause of drug prescription. Argentina experienced a severe socioeconomic crisis at the end of 2001 that caused a drop in access to drugs among the population, with subsequent risks in public health. In response to this situation, the Argentine State implemented the Remediar Program to supply free medications to people with scarce resources and lack of medical coverage. Objectives To analyze the use of antihypertensive drugs in the population assisted by the public primary care level (PCL) in Argentina, and to estimate its effectiveness in terms of the number of people with HT covered by this program. Material and Methods Ecological study with cross comparisons of diagnoses, prescriptions and beneficiaries by individual provinces of Remediar forms. Target population: patients with diagnosis of HT seen at 6000 health care centers in Argentina from March 2005 to February 2006. Results The prevalence of HT was 10.4% among 15 millions of prescriptions: 126097 prescriptions per month. This percentage was not homogeneous; it was 3 to 4 times greater in the city of Buenos Aires and in the province of La Pampa compared to the provinces of Salta and Jujuy. Drugs were prescribed as follows: enalapril 77.0%, atenolol 22.1%, hydrochlorothiazide 12.5% and aspirin 7.1%. Based on previous population statistics and on the expected prevalence of HT, we estimated that the Remediar Program fulfilled variable percentages of the population exclusively under public medical coverage: 57.3% nationwide, with important variations. In total, 74.9% of hypertensive beneficiaries received medication for 4 months a year or less. Conclusion The use of thiazide diuretics and aspirin was less than expected according to evidence based practice guidelines. Probably the positive impact on health care related to the supply of drugs was limited by the failure to provide a minimum annual number of effective treatments.

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UNLABELLED: Community acquired pneumonia in children remains an important cause of childhood deaths throughout the world that can be prevented by the use of antibiotics and access to medical care. Both were reduced in 2001 when Argentina suffered a severe social crisis. Among the responses to the crisis, the Remediar Program provided free essential medicines to the socially vulnerable population. OBJECTIVES: Assess the health impact and costs of the provision of free medicines at the first level of public attention for childhood pneumonia. MATERIALS AND METHODS: Three designs: 1. Ecological study with cross comparisons of diagnoses, prescriptions, beneficiaries by individual provinces of Remediar forms. TARGET POPULATION: children under 15 years old attended at 6 thousand health centres in Argentina, encompassing 24 Argentine provinces from March 2005 until February 2006. 2. Counterfactual approach. 3. Calculation of drug costs per unit of outcome. RESULTS: Over 15 million prescriptions were identified, 2,420 children under 1 year, 19,205 of 1 to 4 years and 15,977 from 5 to 14 years old with pneumonia. 90% of beneficiaries received antibiotics, most often amoxicillin. In children's under 5 years of age, Remediar coverage was 27.8%, with greater impact in the poorest provinces. The likely impact was 4,322 lives saved or 310,325 years of life lost avoided if mortality without antibiotics was 20%. Indigents who had children with pneumonia saved by medicines 14.3% of their income. Each life saved could have cost US $ 6.46 and each year of life lost averted US $ 0.09. CONCLUSION: This work highlights the impact of a low-cost health program for the treatment of vulnerable populations with childhood pneumonia in Argentina.

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OBJECTIVES: To estimate the direct and indirect cost of iron deficiency (ID) and iron-deficiency anemia (IDA) in Argentina and compare it with the cost of a prevention and treatment program. METHODS: Analysis of a prior scenario to gage the relative cost-benefit of an IDA prevention and treatment program for all low-income children and expectant mothers without social coverage/benefits in Argentina. The economic consequences of ID and IDA were estimated as direct (cost of care for premature birth) and indirect costs (future lost productivity due to poor cognitive development due of children with ID and current reduced productivity of adults with IDA) employing the specific methodology designed by The Micronutrient Initiative (Ottawa, Canada). The interventions were defined according the practical clinical guidelines in use in Argentina and the item costs were taken from Ministry of Health price lists. RESULTS: Each US$ 1.00 invested in an ID and IDA prevention and treatment program, assuming 90% coverage of breastfeeding/pregnant uninsured low-income mothers, would save US$ 33.40 by preventing the economic losses that would otherwise result from these conditions. CONCLUSIONS: DH interventions not only significantly improve the health status of the population, but also offer a considerable savings.

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OBJETIVOS: Estimar los costos directos e indirectos de la deficiencia de hierro (DH) y la anemia ferropénica (AF) en Argentina y compararlos con los costos de un programa específico para su prevención y tratamiento. MÉTODOS: Análisis de escenario previo (ex ante) de la relación costo-beneficio de un programa de prevención y tratamiento de la AF dirigido a todos los niños y las embarazadas pobres y sin cobertura social de Argentina. Las consecuencias económicas de la DH y la AF se estimaron a partir de los costos directos - gastos vinculados a la atención de un parto prematuro - e indirectos - pérdidas en la productividad futura de los niños por su peor desarrollo cognitivo debido a la DH y la menor productividad de los adultos por la AF - mediante la metodología específica desarrollada por The Micronutrient Initiative. Las intervenciones se definieron según las Guías de Práctica Clínica vigentes en Argentina y los costos de los componentes se tomaron de los precios de las licitaciones del Ministerio de Salud de la Nación. RESULTADOS: Cada US$ 1,00 invertido en un programa de prevención y tratamiento de la DH y la AF, con una cobertura de 90 por ciento de la población de lactantes y embarazadas pobres sin seguro explícito de salud, representaría un ahorro de US$ 33,40 por la prevención de las pérdidas económicas debidas a estas enfermedades. CONCLUSIÓN: Las intervenciones para enfrentar la DH no solo mejoran significativamente el estado de salud de la población, sino que representan un ahorro considerable de recursos.

OBJECTIVES: To estimate the direct and indirect cost of iron deficiency (ID) and iron-deficiency anemia (IDA) in Argentina and compare it with the cost of a prevention and treatment program. METHODS: Analysis of a prior scenario to gage the relative cost-benefit of an IDA prevention and treatment program for all low-income children and expectant mothers without social coverage/benefits in Argentina. The economic consequences of ID and IDA were estimated as direct (cost of care for premature birth) and indirect costs (future lost productivity due to poor cognitive development due of children with ID and current reduced productivity of adults with IDA) employing the specific methodology designed by The Micronutrient Initiative (Ottawa, Canada). The interventions were defined according the practical clinical guidelines in use in Argentina and the item costs were taken from Ministry of Health price lists. RESULTS: Each US$ 1.00 invested in an ID and IDA prevention and treatment program, assuming 90 percent coverage of breastfeeding/pregnant uninsured low-income mothers, would save US$ 33.40 by preventing the economic losses that would otherwise result from these conditions. CONCLUSIONS: DH interventions not only significantly improve the health status of the population, but also offer a considerable savings.

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BACKGROUND: In the last decades, a sustained increment of Clinical Practice Guidelines (CPG) production in the world has been accompanied by a growing concern about their quality. Many studies related to quality assessment of guidelines produced in High Income Countries were published; however, evidence on this topic is scarce in Low and Middle Income Countries (LMIC). The objectives of this research were: a) to describe guideline production in Argentina at different levels of the health system (macro, meso and micro) from 1994 to 2004; and b) to assess their quality by using the AGREE instrument. METHODS: A cross-sectional study was undertaken to describe guidelines production in Argentina between 1994 and 2004. CPG were identified through Internet and electronic databases (MEDLINE and LILACS). Explicit inclusion and exclusion criteria were used to select guidelines. Each CPG was independently assessed by two reviewers using the AGREE instrument. Domain scores were calculated as recommended by the AGREE Collaboration. The internal consistency of each domain was evaluated using Cronbach's alpha and inter-observer agreement by the Intraclass Correlation Coefficient (ICC). RESULTS: A total amount of 431 potential CPG were identified, but only 144 were considered CPG. At the end, 101 CPG were included for further assessment. Median standardized score for each domain were: scope = 39%; stakeholder involvement = 13%; rigour of development = 10%; clarity = 42%; applicability = 6%; editorial independence = 0%. Only 22 CPG were recommended with modifications by both appraisers. ICC and Cronbach's alpha for each domain were in all cases moderate or high (greater than 0.40), except for editorial independence. CONCLUSION: This study has systematically employed the AGREE instrument for the critical assessment of guidelines produced in a LMIC. Guideline development and diffusion in Argentina from 1994 to 2004 shows a constant increment, although quality of reporting did not improve; moreover, in some aspects it seemed to decline. Much room for improvement of the guideline development process was found at all levels of the health system.

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UNLABELLED: Iron deficiency and anemia have a very high prevalence and serious consequences for infants and pregnant women. Since late 2002, the Remediar Program provided free iron to the vulnerable population. Question arises whether free provision favors access to the drug. OBJECTIVES: To describe the iron prescription frequency at the primary care level in Argentina, and to estimate variability in clinical practice. MATERIALS AND METHODS: Retrospective observational study based on the Remediar Program with cross comparisons of diagnosis and prescriptions by individual provinces and centers. The Program's prescriptions forms constitute the secondary sources of information. The target population of the study is the universe of infants and women in fecund age that were attended in 6,000 centers encompassing 24 Argentine provinces between March of 2005 and February of 2006. RESULTS: Fifteen million prescriptions were reviewed. Only in one out of every 25 infant consultations and in one of every 71 women of child bearing age prescriptions iron is prescribed through Remediar. Provided diagnoses are more associated with treatment of, than prevention of, anemia. The likelihood of prescribing iron varies up to four fold depending on the facility and the province where the medical visit takes place. CONCLUSION: Underprescription of iron generates difficulties in patient access to an essential drug. Variability in medical practice may be a possible cause of unequal medical care.

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