Disruption Of Non-COVID-19 Health Care In Latin America During The Pandemic: Effects On Health, Lessons For Policy

COVID-19 had severe direct and indirect effects on health and well-being in Latin America. To understand the extent to which disruptions among non-COVID-19-related health services affected population health, we used administrative data from the period 2015-21 to examine public hospital discharges and mortality for conditions amenable to health care in four Latin American countries: Brazil, Ecuador, Mexico, and Peru. Between March 2020 and December 2021, hospitalization rates for these conditions declined by 28 percent and mortality rates increased by 15 percent relative to prepandemic years. Noncommunicable diseases accounted for 89 percent of this rise in mortality. The poorest states in each country experienced relatively larger increases in mortality. Our results, which focus on the health effects of service disruption, suggest that maintaining health care services in this region during the pandemic could have avoided at least 96,000 deaths. Policies should focus on maintaining essential health care services during emergencies, particularly for patients with noncommunicable diseases, and on minimizing negative consequences by ensuring coordinated and continuous care; leveraging alternative modalities of care, such as telemedicine; broadening the role of nonphysician health care workers; and expanding options for medication delivery.

The Neglected Problem of Obesity during Pregnancy in Mexico: Secondary Data Analysis of the 2018 National Survey of Health and Nutrition

OBJECTIVES

To compare sociodemographic and clinical characteristics among obese and non-obese women in Mexico and analyze the association between obesity and pregnancy complications.

METHODS

We conducted a secondary data analysis of the 2018-2019 Mexican National Survey of Health and Nutrition. We included women aged 20-49 years who had at least one live birth in the five years preceding the survey (n = 1573). We performed a double-weighted (by IP-weights and survey-weights) multilevel multiple logistic regression analysis.

RESULTS

Obesity was prevalent in 32% of pregnant women. Obese and non-obese women received similar antenatal care. 42.6% of obese women, compared to 33.6% of non-obese had one or more pregnancy or labor complications. Compared with non-obese women, obese women were older and had more chronic diseases. Obesity was associated with a 48% increase in the probability of complications.

CONCLUSION

Due to the high prevalence of obesity among Mexican women of reproductive age and given the independent association between obesity and complications during pregnancy and labor, the development and implementation of specific clinical guidelines on weight management before conception, during pregnancy, and post-partum for women who are obese is an unmet need in Mexico.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

[Factors associated with a lack of postnatal care]

BACKGROUND

Postnatal care is essential to identify and treat at the appropriate time adverse health events in the puerperium. In Mexico, the factors that affect postnatal care have not been documented.

OBJECTIVE

To identify the factors associated with the lack of postnatal care.

MATERIAL AND METHODS

Cross-sectional study of 202 women of reproductive age affiliated with six primary care clinics of the Mexican Institute for Social Security. We analyzed these factors: (1) sociodemographic: age, education, schooling, distance between home and clinic; (2) psychosocial: social support; (3) obstetric and gynecologic: number of pregnancies, type of delivery, presence of comorbidity and suspected depression, and (4) health services: deficient prenatal control and incomplete postpartum hospital care. We performed multiple Poisson regression with a robust variance.

RESULTS

49.5% of women had postnatal control. Factors associated with a higher probability of lack of postnatal control were: distance ≥ 5 km between home and clinic (adjusted prevalence ratio [aPR] 1.48, 95% confidence interval [95% CI] 1.16-1.88, p = 0.001), poor prenatal care (aPR 1.21, 95% CI 1.001-1.46, p = 0.049), and incomplete postpartum care (aPR 1.42, 95% CI 1.23-1.63, p < 0.001).

CONCLUSIONS

The low attendance of postnatal care in primary care clinics highlights the need to seek and implement feasible healthcare alternatives, such as home care or telemedicine, to women who cannot attend to postnatal consultations.

Disruption in essential health services in Mexico during COVID-19: an interrupted time series analysis of health information system data

INTRODUCTION

The COVID-19 pandemic has disrupted health systems around the world. The objectives of this study are to estimate the overall effect of the pandemic on essential health service use and outcomes in Mexico, describe observed and predicted trends in services over 24 months, and to estimate the number of visits lost through December 2020.

METHODS

We used health information system data for January 2019 to December 2020 from the Mexican Institute of Social Security (IMSS), which provides health services for more than half of Mexico's population-65 million people. Our analysis includes nine indicators of service use and three outcome indicators for reproductive, maternal and child health and non-communicable disease services. We used an interrupted time series design and linear generalised estimating equation models to estimate the change in service use and outcomes from April to December 2020. Estimates were expressed using average marginal effects on the risk ratio scale.

RESULTS

The study found that across nine health services, an estimated 8.74 million patient visits were lost in Mexico. This included a decline of over two thirds for breast and cervical cancer screenings (79% and 68%, respectively), over half for sick child visits and female contraceptive services, approximately one-third for childhood vaccinations, diabetes, hypertension and antenatal care consultations, and a decline of 10% for deliveries performed at IMSS. In terms of patient outcomes, the proportion of patients with diabetes and hypertension with controlled conditions declined by 22% and 17%, respectively. Caesarean section rate did not change.

CONCLUSION

Significant disruptions in health services show that the pandemic has strained the resilience of the Mexican health system and calls for urgent efforts to resume essential services and plan for catching up on missed preventive care even as the COVID-19 crisis continues in Mexico.

Factors associated with COVID-19 preventive health behaviors among the general public in Mexico City and the State of Mexico

Objective

To evaluate factors associated with COVID-19 preventive health behaviors among adults in Mexico City and the State of Mexico.

Methods and findings

We conducted a cross-sectional survey from June to October 2020 through a structured, internet-based questionnaire in a non-probabilistic sample of adults >18 years living in Mexico City and the State of Mexico. The independent variables included sociodemographic and clinical factors; health literacy; access to COVID-19 information; and perception of COVID-19 risk and of preventive measures’ effectiveness. The dependent variable was COVID-19 preventive health behaviors, defined as the number of preventive actions adopted by participants. The data were analyzed through multivariate negative binomial regression analysis. The survey was completed by 1,030 participants. Most participants were women (70.7%), had a high school or above level of education (98.8%), and had adequate health literacy and access to COVID-19 information. Only 18% perceived having a high susceptibility to COVID-19, though 83.8% recognized the disease’s severity and 87.1% the effectiveness of preventive measures. The median number of COVID-19 preventive actions was 13.5 (range 0–19). The factors associated with preventive health behavior were being female, of older age, a professional worker, a homemaker, or a retiree; engaging in regular physical exercise; having high health literacy and access to COVID-19 information sources; and perceiving COVID-19 as severe and preventive measures as effective.

Conclusion

People with high education and internet access in Mexico City and the State of Mexico reported significant engagement in COVID-19 preventive actions during the first wave of the COVID-19 pandemic.

Health care provider time in public primary care facilities in Lima, Peru: a cross-sectional time motion study

BACKGROUND

In Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care.

METHODS

This cross-sectional continuous observation time motion study took place from July - September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection.

RESULTS

Two hundred seventy-five providers were sampled from 60 facilities; 20% could not be observed due to provider absence (2% schedule error, 8% schedule change, 10% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors.

CONCLUSIONS

The time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.

Association of supportive care needs and quality of patient-centered cancer care with depression in women with breast and cervical cancer in Mexico

OBJECTIVE

To compare the prevalence of depression, supportive care needs (SC-needs), and quality of patient-centered cancer care (PCC-quality) between women with breast cancer and women with cervical cancer and to assess the association of SC-needs and PCC-quality with depression.

METHODS

We conducted a cross-sectional survey in a public oncology hospital in Mexico City with 247 breast cancer and 165 cervical cancer ambulatory patients aged ≥18 years with at least one hospitalization and ≤5 years since diagnosis. Participants completed the short-form Supportive Care Needs Survey, the Patient-Centered Quality of Cancer Care Questionnaire, and the Hospital Anxiety and Depression Scale. We performed multiple logistic regression analyses to evaluate the association between SC-needs, PCC-quality, and probable presence of depression.

RESULTS

Nearly all women reported SC-needs-mainly health system and information needs, followed by physical and psychological needs. PCC-quality was substandard in both groups. PCC-quality was lowest when addressing biopsychosocial needs, followed by information for treatment decision-making needs. Cervical cancer patients had probable depression more often (41.2%) than those with breast cancer (29.5%). Having unmet psychological and care needs was associated with increased odds of probable depression, while high-quality timely care was associated with reduced odds of probable depression.

CONCLUSION

In Mexico, women with cervical and breast cancer face unmet SC-needs, probable depression, and substandard PCC-quality, pointing to priority areas for improvements in cancer care.

Access to paediatric cancer care treatment in Mexico: responding to health system challenges and opportunities

In Mexico, paediatric cancer is the leading cause of death for children aged 0-18 years. This study analyses the main challenges for paediatric cancer care from the perspective of three key health systems functions: stewardship, financing and service delivery. The study used a mixed methods approach comprised of: (1) a scoping literature review, (2) an analysis of 2008-18 expenditures on paediatric cancer by the Fund for Protection against Catastrophic Expenditures (FPGC) of Seguro Popular and (3) a nation-wide survey of the supply capacity of 59 Ministry of Health (MoH) and 39 Mexican Institute of Social Security (IMSS) hospitals engaged in paediatric cancer care. The study found that while Mexico has made substantial progress towards universal health coverage (UHC) for paediatric cancer treatment, serious gaps persist. FPGC funds for paediatric cancer increased from 2008 to 2011 to reach US$36 million and then declined to US$13.6 million in 2018, along with the number of covered cases. The distribution of health professionals and paediatric oncology infrastructure is uneven between MoH and IMSS hospitals and across Mexican regions. Both institutions share common barriers for continuous and co-ordinated health care and lack monitoring activities that cripple their capacity to apply uniform standards for high-quality cancer care. In conclusion, achieving universal and effective coverage of paediatric cancer treatment is a critical component of UHC for Mexico. This requires periodic and ongoing assessment of health system performance specific to paediatric cancer to identify gaps and propose strategies for continued investment and improvement of access to care and health outcomes for this important cause of premature mortality.

Supportive care needs and quality of care of patients with lung cancer in Mexico: A cross-sectional study

PURPOSE

To assess the supportive care needs (SC-needs), quality of patient-centered care (PCC), and factors associated with increased SC-needs of patients with lung cancer (LC) in Mexico.

METHODS

We conducted a cross-sectional survey in the main oncology hospital of the Mexican Institute of Social Security in Mexico City. The study included LC ambulatory patients aged ≥18 years with at least one hospitalization before the survey, ≤five years since diagnosis, and without memory loss. Participants answered SC-needs and quality of PCC questionnaires. We performed a multiple negative binomial regression analysis to evaluate the factors associated with an increased number of SC-needs.

RESULTS

One hundred twenty-eight LC patients participated. Most participants had adenocarcinoma (61.7%) and were at an advanced disease stage (92.1%). In the month preceding the survey, 3.9% had undergone surgery and 78.9% had been receiving chemotherapy and/or radiotherapy; 28.9% had symptoms of depression and 21.9% had anxiety. All patients reported one or more SC-needs-predominantly physical, daily living, information, and psychological needs. The significant gaps in PCC-quality were in the domains of care that addressed biopsychosocial needs and information for treatment decision-making. Factors that decreased the probability of SC-needs were respectful and coordinated care, high-school education, and older age. The factors increasing the likelihood of SCneeds were the type of LC (adenocarcinoma, mesenchymal tumors), chemotherapy and/or radiotherapy, and anxiety.

CONCLUSION

PCC improvement initiatives to address SC-needs of LC patients should be prioritized and focus on: (1) information on physical suffering relief and treatment; (2) psychological support; and (3) SC-needs monitoring.

Patient and health service factors associated with delays in cancer treatment for children without social security in Mexico

BACKGROUND

The objective was to investigate factors associated with patient-related timing (PRT) to seek healthcare and health service-related timing (HSRT) to diagnose cancer and provide treatment to children without social security in Mexico.

PROCEDURE

A cross-sectional survey was conducted in 13 Ministry of Health hospitals in the states of Chihuahua, Jalisco, Mexico City, Morelos, Oaxaca, Puebla, Queretaro, State of Mexico, and Tlaxcala. Study participants were parents of recently diagnosed pediatric cancer patients (≤ 17 years of age). Three groups of factors were investigated: (1) patients (child and parent characteristics); (2) healthcare providers (HCPs) (first-contact HCP, institution, perceptions of barriers to healthcare, etc.); and (3) disease factors (cancer type/site, stage/risk at diagnosis). PRT and HSRT-associated factors were identified using multiple negative binomial regressions.

RESULTS

The study included 265 children; 49% sought care when symptoms first appeared. The median PRT was seven days, and the median HSRT was 40 days. Parents' perceptions of long wait times for appointments were associated with longer PRT and HSRT. Residing in the lowest or highest socioeconomic regions and persistent or worsening symptoms increased the probability of longer PRT. Older patient age, HCP requests for imaging tests or prescription for steroids, a higher number of doctors consulted, having a urinary tract cancer, and having an advanced stage or high-risk cancer increased the probability of longer HSRT.

CONCLUSION

Strategies to shorten lag time from symptom onset to diagnosis and treatment are urgently needed for childhood cancers in Mexico.

Experiences with health care and health-related quality of life of patients with hematologic malignancies in Mexico

BACKGROUND

In Mexico, patients with hematologic malignancies (HMs) are characterized by being at high risk and advanced stages at diagnosis and by having a low cure rate; yet information on their experiences with health care and health-related quality of life (HRQL) is scarce. We aimed to evaluate experiences with health care and HRQL of patients with HMs and the association between these patient-reported measures.

METHODS

We conducted a cross-sectional survey in two public oncology hospitals in Mexico City. The study included outpatient cancer patients aged ≥18 years with a diagnosis of leukemia, lymphoma, or multiple myeloma. We used a patient-centered quality of cancer care questionnaire to assess patient experiences with receiving 1) timely care; 2) clear information; 3) information for treatment decision-making; 4) care to address biopsychosocial needs; and 5) respectful and coordinated care. We applied the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) to measure HRQL. We performed a multiple linear regression to evaluate the association between patient-reported experiences (independent variables) and the QLQ-C30 summary score (dependent variable).

RESULTS

Of the 515 participating HM patients, 46.6% had lymphoma, 34% leukemia, and 19.4% multiple myeloma; 70.9% were at advanced stages or at high risk. Additionally, 15.1% had anxiety and 12.8% had depression. Over one third (35.9%) reported receiving clear information, 28.5% timely care, 20.6% information for treatment decision-making, 23.7% care that addressed their biopsychosocial needs, and 31% respectful and coordinated care. The mean QLQ-C30 summary score was 71.9 points. Timely care, clear information, and care that addresses biopsychosocial needs were associated with higher HRQL.

CONCLUSIONS

Health care services for HM patients at public oncology hospitals in Mexico need improvement. Notably, providing timely care, clear information, and care that addresses patients' biopsychosocial needs can increase the likelihood of better HRQL. Health care providers should measure and improve the experiences of HM patients with health care.

Gaps between supply and demand of acute myocardial infarction treatment in Mexico

OBJECTIVE

To analyze acute myocardial infarction (AMI) admissions and in-hospital mortality rates and evaluate the competence of the Ministry of Health (MOH) hospitals to provide AMI treatment.

MATERIALS AND METHODS

We used a mixed-methods approach: 1) Joinpoint analysis of hos-pitalizations and in-hospital mortality trends between 2005 and 2017; 2) a nation-wide cross-sectional MOH hospital survey.

RESULTS

AMI hospitalizations are increasing among men and patients aged >60 years; women have higher mortal-ity rates. The survey included 527 hospitals (2nd level =471; 3rdlevel =56). We identified insufficient competence to diagnose AMI (2nd level 37%, 3rd level 51%), perform pharmacological perfusion (2nd level 8.7%, 3rd level 26.8%), and mechanical reperfusion (2nd level 2.8%, 3rd level 17.9%).

CONCLUSIONS

There are wide disparities in demand, supply, and health outcomes of AMI in Mexico. It is advisable to build up the competence with gender and age perspectives in order to di-agnose and manage AMI and reduce AMI mortality effectively.

Psychometric validation of a Patient-Centred Quality of Cancer Care Questionnaire in Mexico

OBJECTIVES

To develop and validate a Patient-Centred Quality of Cancer Care Questionnaire in Spanish (PCQCCQ-S) appropriate to the Mexican context.

DESIGN

Psychometric validation of a questionnaire.

SETTING

Two public oncology hospitals in Mexico City.

PARTICIPANTS

1809 patients with cancer aged ≥18 years.

SOURCE OF INFORMATION

Cross-sectional survey.

METHODS

The validation procedures comprised (1) content validity through a group of experts and patients; (2) item reduction and evaluation of the factor structure, through an exploratory factor analysis based on the polychoric correlation matrix; (3) internal consistency using Cronbach's alpha; (4) convergent validity between the PCQCCQ-S and supportive care needs scale; (5) correlation analysis between the PCQCCQ-S and quality of life scale by calculating Spearman's rank-correlation coefficient; and (6) differentiation by 'known groups' through the Wilcoxon rank-sum test.

RESULTS

The PCQCCQ-S has 30 items with the following five factors accounting for 96.5% of the total variance: (1) timely care; (2) clarity of the information; (3) information for treatment decision-making; (4) activities to address biopsychosocial needs; and (5) respectful and coordinated care. Cronbach's alpha values ranged from 0.73 to 0.90 among the factors. PCQCCQ-S has moderate convergent validity with supportive care needs scale, revealing that higher quality is correlated with lower patient needs. PCQCCQ-S has acceptable ability to differentiate by 'known groups', showing that older patients and those with low levels of education perceived lower total quality of care as compared with their counterparts.

CONCLUSION

PCQCCQ-S has acceptable psychometric properties and can be used to measure quality of patient-centred cancer care in Mexico and serve as a reference to develop PCQCCQ-S in other Spanish-speaking countries.

QUALITY OF HEALTH CARE AND VIRAL SUPPRESSION AMONG HUMAN IMMUNODEFICIENCY VIRUS PATIENTS

Background

In Mexico, the quality of health care for human immunodeficiency virus (HIV) patients is unknown. The study objectives were to develop quality of care (QoC) indicators for outpatient care of HIV patients, evaluate the quality of the processes of care (QPC) and outcomes, and analyze the association between the QPC and viral suppression among HIV patients.

Methods

The study used a mixed-methods approach: (1) Development of QoC indicators through RAND/UCLA method; (2) cross-sectional study of QoC evaluation; and (3) multiple Poisson regressions to measure the association between the QPC and viral suppression. The study included 439 HIV patients, ≥ 19 years of age, with at least one outpatient consultation during 2017 at a public hospital in the State of Mexico.

Results

We developed 21 QoC indicators to evaluate HIV care. Based on these indicators, the QoC gaps that emerged were related to clinical history (24% of patient records included sexual history information), routine adherence assessment (no records demonstrated regular recording of antiretroviral treatment adherence), and screening and referral (50% were screened for depression, and 42% for tuberculosis; 1.2% of patients with abnormal body mass index were referred to a dietitian). On average, HIV patients received 63% of recommended QPC; 77.7% achieved viral suppression. Receiving over 75% of recommended QPC was associated with a higher probability of viral suppression (adjusted prevalence ratio 1.13, 95% confidence interval 1.03-1.24).

Conclusions

Evaluation of the QoC for HIV patients is essential to identify and address gaps in health-care quality to increase the probability of viral suppression.

User experience and satisfaction with specialty consultations and surgical care in secondary and tertiary level hospitals in Mexico

BACKGROUND

To evaluate the association between user experience and satisfaction with specialty consultations and surgical care at the Mexican Institute of Social Security (IMSS) secondary and tertiary level hospitals.

METHODS

We conducted secondary data analysis of the cross-sectional 2017 IMSS National Satisfaction Survey. The dependent variables were user satisfaction with outpatient consultation and with surgery. The study's independent variables were user experience with these services. The Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Era framework was used to guide the analysis. For each dependent variable a double-weighted Poisson regression model with robust variance was performed and considered clustering of the observations within 111 secondary level and 25 tertiary level hospitals.

RESULTS

The study included 6713 outpatient consultation users and 528 surgery users. 83% of users attending outpatient consultations and 86.6% of users who underwent inpatient surgery at IMSS hospitals were satisfied with the service received. The common patient negative experiences with specialty consultations and surgical care were long waiting time (40%) and lack of hospital cleanliness (20%). An additional concern was the lack of clinical examination during the consultation (25%). Shorter waiting times, health provider courtesy, good communication, clinical examination, and hospital cleanliness were associated with patient satisfaction with specialty consultations. Having the surgery without prior postponement(s) and without complications increased the probability of patient satisfaction.

CONCLUSION

Patient satisfaction with hospital outpatient consultations and surgical care may be raised by focusing on improvement strategies to enhance positive patient experiences with care.

Assessing health system performance: effective coverage at the Mexican Institute of Social Security

Universal health coverage is a national priority in Mexico, with active efforts to expand public healthcare system access, increase financial protection and improve quality of care. We estimated effective coverage of multiple conditions within the Mexican Institute of Social Security (IMSS), which covers 62 million individuals. We identified routinely collected performance indicators at IMSS from 2016 related to use and quality of care for conditions avertable with high-quality healthcare; where candidate indicators were available, we quantified need for service from a population-representative survey and calculated effective coverage as proportion of individuals in need who experience potential health gains. We assessed subnational inequality across 32 states, and we weighted conditions by relative contribution to national disease burden to estimate composite effective coverage. Conditions accounting for 51% of healthcare-avertable disability-adjusted life years lost in Mexico could be assessed: antenatal care, delivery care, newborn care, childhood diarrhoea, cardiovascular disease and diabetes. Estimated effective coverage ranged from a low of 27% for childhood diarrhoea to a high of 74% for newborn care. Substantial inequality in effective coverage existed between states, particularly for maternal and child conditions. Overall effective coverage of these six conditions in IMSS was 49% in 2016. Gaps in use and quality of care must be addressed to ensure good health for all in Mexico. Despite extensive monitoring of health status and services in Mexico, currently available data are inadequate to the task of fully and routinely assessing health system effective coverage. Leaders at IMSS and similar healthcare institutions must be more purposeful in planning the assessment of population need, utilization of care and quality impacts of care to enable linkage of these data and disaggregation by location or population sub-group. Only then can complex health systems be fairly and fully evaluated.

Application of machine learning methodology to assess the performance of DIABETIMSS program for patients with type 2 diabetes in family medicine clinics in Mexico

Background

The study aimed to assess the performance of a multidisciplinary-team diabetes care program called DIABETIMSS on glycemic control of type 2 diabetes (T2D) patients, by using available observational patient data and machine-learning-based targeted learning methods.

Methods

We analyzed electronic health records and laboratory databases from the year 2012 to 2016 of T2D patients from six family medicine clinics (FMCs) delivering the DIABETIMSS program, and five FMCs providing routine care. All FMCs belong to the Mexican Institute of Social Security and are in Mexico City and the State of Mexico. The primary outcome was glycemic control. The study covariates included: patient sex, age, anthropometric data, history of glycemic control, diabetic complications and comorbidity. We measured the effects of DIABETIMSS program through 1) simple unadjusted mean differences; 2) adjusted via standard logistic regression and 3) adjusted via targeted machine learning. We treated the data as a serial cross-sectional study, conducted a standard principal components analysis to explore the distribution of covariates among clinics, and performed regression tree on data transformed to use the prediction model to identify patient sub-groups in whom the program was most successful. To explore the robustness of the machine learning approaches, we conducted a set of simulations and the sensitivity analysis with process-of-care indicators as possible confounders.

Results

The study included 78,894 T2D patients, from which 37,767patients received care through DIABETIMSS. The impact of DIABETIMSS ranged, among clinics, from 2 to 8% improvement in glycemic control, with an overall (pooled) estimate of 5% improvement. T2D patients with fewer complications have more significant benefit from DIABETIMSS than those with more complications. At the FMC’s delivering the conventional model the predicted impacts were like what was observed empirically in the DIABETIMSS clinics. The sensitivity analysis did not change the overall estimate average across clinics.

Conclusions

DIABETIMSS program had a small, but significant increase in glycemic control. The use of machine learning methods yields both population-level effects and pinpoints the sub-groups of patients the program benefits the most. These methods exploit the potential of routine observational patient data within complex healthcare systems to inform decision-makers.

Cost-effectiveness of the use of the continuous subcutaneous insulin infusion pump versus daily multiple injections in type 1 diabetes adult patients at the Mexican Institute of Social Security

Background

To estimate the incremental cost-effectiveness ratio (ICER) of the use of continuous subcutaneous insulin infusion (CSII) therapy versus multiple daily injections (MDI) therapy in adult patients with type 1 diabetes (T1D) at the Mexican Institute of Social Security (IMSS).

Methods

An analysis was developed using the internationally validated Core Diabetes Model (CDM) with which the incidence and progression of acute and chronic complications and the mortality of T1D was simulated throughout life. The baseline characteristics of the simulated cohorts were obtained from Mexican T1D adult patients aged ≥ 18 years that received care at two national IMSS medical centres in 2016. In the base case, the costs of the complications and treatment of the disease with both therapies were estimated in Mexican currency from the perspective of the institution, using Diagnosis Related Groups for outpatient and inpatient care. Utilities were taken from the international bibliography. In a secondary analysis, indirect costs were included using a human capital approach. The model used a lifetime time horizon, and a discount rate of 5% was applied for health outcomes and costs. A one-way sensitivity analysis was conducted on key variables and patient sub-groups; uncertainty was evaluated using a Cost-Effectiveness Acceptability Curve.

Results

The average age of the cohort was 32 years, with diabetes duration of 19 years, an average HbA1c of 9.2%; 29% were men. A gain of 0.614 Quality Adjusted Life Years (QALYs) was estimated with the use of CSII therapy. The estimated ICER was MXN$478,020 per QALY in the base case, and MXN$369,593 when indirect costs were considered. The sensitivity analysis showed that, in adult patients with HbA1c > 9.0%, the ICER was MXN$262,237.

Conclusions

This is the first economic evaluation study that compares CSII therapy versus MDI therapy for T1D adult patients in Mexico. The insulin pump therapy can be considered cost-effective in the context of the IMSS when considering a threshold of three GDPs per capita with 43.9% probability. Results improve substantially when patients have an HbA1c above 9%.

Necesidades de cobertura y atención del cáncer pulmonar en México

Objetivo. Analizar la cobertura en salud de cáncer pul­monar en México y ofrecer recomendaciones al respecto. Material y métodos. Mediante la conformación de un grupo multidisciplinario se analizó la carga de la enfermedad relativa al cáncer de pulmón y el acceso al tratamiento médico que ofrecen los diferentes subsistemas de salud en México. Resultados. Se documentan desigualdades importantes en la atención del cáncer de pulmón entre los distintos subsistemas de salud que sugieren acceso y cobertura en salud variable, tanto a los tratamientos tradicionales como a las innovaciones terapéuticas existentes, y diferencias en la capacidad de los prestadores de servicios de salud para garantizar el derecho a la protección de la salud sin distin­ciones. Conclusión. Se hacen recomendaciones sobre la necesidad de mejorar las acciones para el control del tabaco, el diagnóstico temprano y la inclusión de terapias innovadoras y la homologación entre los diferentes prestadores públicos de servicios de salud a través del financiamiento con la re­caudación de impuestos al tabaco

Adequate health literacy is associated with better health outcomes in people with type 2 diabetes in Mexico

This study evaluates the health literacy of people with type 2 diabetes and its association with health outcomes. We conducted a cross-sectional survey in two family medicine clinics of the Mexican Institute of Social Security that included 778 diabetic patients >19 years of age. The Spanish version of the European Health Literacy questionnaire served to measure health literacy. Multiple logistic regressions were performed to determine the association between the independent variable (health literacy) and dependent variables (good self-rated health, glycemic control, and diabetes-related hospitalizations) after controlling for conceptually relevant patient's characteristics. Only 17.6% of patients had adequate health literacy; while, the remaining percentage showed inadequate (23%), or problematic (59.4%) health literacy. After adjusting for the patients' characteristics, those with adequate health literacy had 4.66 (95%CI: 2.26-9.61) times the odds of good self-rated health compared to those with inadequate literacy. Patients with adequate health literacy had 0.65 (95%CI: 0.49-0.86) times the odds of hospitalization due to diabetes compared to those with inadequate literacy. Compared to inadequate health literacy, problematic literacy was associated with increased odds of glycemic control. In conclusion, healthcare providers should actively address the health literacy needs of patients to increase good self-rated health, glucose control and reduce hospitalizations.

Evaluating the quality of the processes of care and clinical outcomes of premature newborns admitted to neonatal intensive care units in Mexico

Objectives

To develop quality of care (QoC) indicators, evaluate the quality of the processes of care (QPC) and clinical outcomes, and analyze the association between the QPC and severe clinical outcomes of preterm newborns admitted to neonatal intensive care units (NICUs).

Design

Mixed methods approach: (1) development of QoC indicators via modified RAND/UCLA method; (2) cross-sectional study of QoC evaluation and (3) multiple logistic regression analysis to ascertain the association between the QPC and severe clinical outcomes.

Setting

Two NICUs belonged to the Mexican Institute of Social Security in Mexico City.

Participants

About 489 preterm neonates (<37 weeks of gestation) without severe congenital anomalies.

Main Outcome Measure(s)

The QoC indicators; ≥60% of recommended QPC and severe clinical outcomes.

Results

The QoC included 10 QPC indicators across four domains: respiratory, nutrition and metabolism, infectious diseases, and screening, and five outcome indicators. The lower QPC indicators were for the nutrition and metabolism domain (17.8% started enteral feeding with human milk, and 20.7% received sodium bicarbonate appropriately). The higher QPC indicator was for the screening domain (97.6% of neonates <30 weeks gestation underwent early (≤14 days) transfontanelar ultrasound). The mean recommended QPC that neonates received was 47.5%. Only 26.6% of neonates received ≥60% of recommended QPC. About 60.7% of neonates developed severe clinical outcomes including mortality and healthcare-related major morbidity. Receiving ≥60% of recommended QPC was associated with a decrease of nearly half of odds of severe clinical outcomes.

Conclusion

The evaluation of the QoC in NICUs is essential to address modifiable gaps in quality.

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.

Socio-demographic and clinical characteristics of type 1 diabetes patients associated with emergency room visits and hospitalizations in Mexico

BACKGROUND

To describe the demographic and clinical characteristics of Type 1 diabetes (T1D) patients affiliated with the Mexican Institute of Social Security (IMSS) and ascertain the socio-demographic and clinical risk factors associated with emergency room (ER) visits and diabetes-related hospitalizations.

METHODS

We conducted secondary data analysis of a cross-sectional study. The study included T1D patients 18 years of age and older who in 2016 attended follow-up visits at the endocrinology department of two IMSS tertiary care hospitals in Mexico City. The study variables included demographics, acute and chronic complications, and healthcare services utilization. Multiple Poisson and negative binomial regressions served to determine the association between the study covariates and the dependent variables: ER visits and diabetes-related hospitalizations.

RESULTS

The study included 192 patients, of which 29.2% were men; average age was 32.3 years, with only 13.6% controlled (glycosylated hemoglobin (HbA1C) < 7%); the mean HbA1C was 9.2, and 64.6% presented chronic complications. During 2016, 39.0% visited ER services, and 33.9% were hospitalized. The common risk factors for ER visits and hospitalization were older age at the beginning of diabetes, severe acute complications, chronic microvascular and macrovascular complications, and other comorbidities. Female sex, high school education, depression, and repeated visits to the endocrinologist were associated with ER visits, whereas active smoking and the interaction between diabetes duration > 10 years and HbA1c > 9.0% were additional risk factors for hospitalization.

CONCLUSION

The poor clinical conditions of T1D patients contribute to explain the escalating demand for health services for diabetes patients at the IMSS. The identification of risk factors enables focalizing interventions to improve the health outcomes of T1D patients and reduce the proportion of ER visits and hospital admissions.

Understanding public perception of the need for major change in Latin American healthcare systems

The opinions and experiences of the public regarding health services are valuable insights into identifying opportunities to improve healthcare systems. We analyzed the 2012-2013 Public Opinion Health Policy Survey carried out in Brazil (n = 1486), Colombia (n = 1485), El Salvador (n = 1460), Jamaica (n = 1480), México (n = 1492) and Panama (n = 1475). In these countries between 82 and 96% of participants perceived that their health systems needed fundamental changes. The most frequent barrier to access to healthcare was lack of the primary medical home, difficulties in obtaining medical care during the weekends and financial barriers. Type of health insurance and challenges in obtaining medical care during the weekends were associated with an increased opinion for the need for fundamental changes in healthcare systems, whereas having a primary medical home showed a protective effect. Focusing on tackling organizational and financial barriers and ensuring access to a primary medical home should be placed on the agenda of Latin American countries.

Effects of an internet-based educational intervention to prevent high-risk sexual behavior in Mexican adolescents

To evaluate the effect of an internet-based educational intervention to increase knowledge of sexually transmitted infections (STIs), attitudes and self-efficacy toward consistent condom use in Mexican adolescents. A field trial with an intervention and control group was conducted in 14- to 15-year-old students in two secondary schools. The intervention was delivered via a website that included four educational sessions during a 4-week period and six 30-min class discussions during a 3-month period. In the control group, the investigators observed the general sex education provided by the school. Outcome variables were 1) knowledge about STIs, 2) attitudes regarding condom use, and 3) self-efficacy toward consistent condom use. Differences-in-differences (Diff-in-Diff) treatment effect was estimated for each outcome variable. There were 246 adolescents in the intervention group and 210 in the control group. The intervention had a positive effect on improving knowledge of STIs, attitudes and self-efficacy toward consistent condom use. The major effect was observed on adolescents' knowledge on STIs (Diff-in-Diff 30.34 points, P < 0.0001). A youth-friendly, culturally-contextualized, internet-based educational intervention complemented by class discussions may be a significant addition to the regular secondary school sex education program to improve knowledge of STIs, attitudes and self-efficacy toward consistent condom use among adolescents.

TRIAL REGISTRATION

The study was registered at the ClinicalTrials.gov ID: NCT02686736.

Distress and its association with self-care in people with type 2 diabetes

Introduction. Low adherence to diabetes self-care affects glycemic control and increases the risk of diabetes complications and premature deaths. Studies from the United States have found a relationship between distress and adherence to self-care in patients with diabetes; however, there is a lack of research on distress and its association with self-care in Mexican patients with diabetes. Objective. To evaluate the prevalence and association of distress with low self-care in patients with type 2 diabetes. Method. A cross-sectional study was carried out in two family medicine clinics of the Mexican Institute of Social Security in Mexico City. Four hundred eighty-nine type 2 diabetic patients ≥ 19 years of age participated. The statistical analysis incorporated a multiple Poisson regression. Results. Of the patients 18.8% had distress, 44.8% had low adherence to medication, 43.8% had low adherence to regular physical exercise, 82.4% did not consume the recommended amount of vegetables and 51.1% consumed foods with high sugar content. The distress was associated with poor adherence to medication and lack of regular physical exercise. Discussion and conclusion. The high prevalence of distress in type 2 diabetic patients in comparison with the general population reveals the importance of distress screening and health care at family practice clinics

Improvement of quality of life and menopausal symptoms in climacteric women treated with low-dose monthly parenteral formulations of non-polymeric microspheres of 17β-estradiol/progesterone

OBJECTIVE

To evaluate the short term effect over menopausal symptoms and quality of life (QoL) of monthly parenteral formulations of 17β-estradiol (E)/progesterone (P) non-polymeric microspheres.

METHODS

This is a secondary analysis of a multicenter, randomized, single-blinded study that included peri- and post-menopausal symptomatic women assigned to receive a monthly intramuscular injection of 0.5 mg E + 15 mg P (Group A, n = 34), 1 mg E + 20 mg P (Group B, n = 24), or 1 mg E + 30 mg P (Group C, n = 26) for 6 months. Intensity of menopausal symptoms was assessed before and after treatment with the Greene Climacteric Scale (GCS) and QoL with the Utian Quality of Life Scale (UQoLS).

RESULTS

Menopausal symptoms improved for all groups at six months evidenced by lower cluster/sub-cluster GCS scores. Equally, there was an overall trend for QoL improvement for all groups evidenced by higher domain UQoLS scores at six months; but only significant for the emotional (Groups A and B) and occupational domains (Groups A and C).

CONCLUSION

The three low-dose continuous sequential intramuscular monthly formulations of E/P microspheres exerted a positive effect over menopausal symptoms and QoL. Long-term research is warranted with these formulations.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov Identifiers NCT 00775242.

Association of hypertension-related distress with lack of self-care among hypertensive patients

Research on factors associated with poor adherence to self-care focuses primarily on psychiatric emotional disorders such as depression and anxiety, whereas non-psychiatric chronic-disease-related emotional distress has received little attention in hypertensive patients. The objective of this study was to evaluate the association of hypertension-related distress with the lack of self-care including low adherence to pharmacological treatment, lack of regular physical activity, low intake of fruits and vegetables and frequent intake of high-salt foods. A cross-sectional survey was conducted in 2014 in two family medical units affiliated with the Mexican Institute of Social Security. The study included 487 hypertensive patients >19 years of age. The conceptual framework for the study was based on the Health Promotion Model. The analysis included multiple Poisson regression models. We found that 21.1% of participants had hypertension-related distress. Low adherence to pharmacological treatment was identified in 45.8% of patients, whereas 46.8% lacked regular physical activity, 30.8% reported a low consumption of fruits and vegetables, and 54.6% frequently consumed foods high in salt content. Hypertension-related distress was associated with lack of regular physical activity and low intake of fruits and vegetables. These findings highlight the importance of addressing distress in order to improve self-care of hypertensive patients.

Factors associated with regular physical exercise and consumption of fruits and vegetables among Mexican older adults

Background

To analyze the factors associated with regular physical exercise and routine consumption of fruits and vegetables, and both healthy behaviors among Mexican older adults.

Methods

We conducted a secondary data analysis of the baseline data (2014) of the Study on Obesity, Sarcopenia and Fragility in older adults affiliated with the Mexican Institute of Social Security. The study included 948 adults who were ≥60 years of age. Multiple Poisson regression was performed.

Results

Routine consumption of fruits and vegetables was reported by 53.8 % of older adults, 42.7 % reported engaging in regular physical exercise and 23.1 % reported participating in both types of healthy behaviors. Women, adults with a stable income, those with a self-perception of good health and those with a history of physical exercise at the age of 50 years had an increased likelihood of engaging in healthy eating and regular physical activity.

Conclusions

Many older adults do not routinely consume fruits and vegetables or engage in regular physical exercise despite the fact that most have a fixed income and a social network. It is relevant to conduct research-based interventions that take into account the contextual factors to promote healthy behaviors.

Internet-based educational intervention to prevent risky sexual behaviors in Mexican adolescents: study protocol

BACKGROUND

Risky sexual behaviors of adolescents in Mexico are a public health problem; 33.4 % of adolescent girls and 14.7 % of boys report not having used any protection at their first intercourse. The fertility rate is 77 births/1000 girls aged 15-19 years. The infrequent contact of adolescents with health services and the limited extent of school sex and reproductive health education require the support of innovative strategies. The objective of this paper is to present the design of an internet-based educational strategy to prevent risky sexual behaviors in Mexican adolescents.

METHODS

A field trial with intervention and comparison group and with ex-ante and ex-post measurements will be conducted in two public secondary schools. Adolescents between 14 and 15 years of age will participate. The intervention will be conducted in one school and the second school will serve as a comparison group where the investigators will observe the usual sex education provided by the school. The intervention will be delivered using an internet web page that includes four educational sessions provided during a 4 week period. Follow-up will last 3 months. Information on the study variables will be obtained through an Internet-based self-applied questionnaire and collected on three occasions: 1) when the adolescents enter the study (baseline), 2) once the intervention is completed (at 1 month) and 3) after 3 months of follow-up (at the fourth month). There will be three outcome variables: 1) knowledge in regard to sexually transmitted infections, 2) attitudes regarding condom use, and 3) self-efficacy toward consistent condom use. The generalized linear model will be used to assess changes in each outcome variable controlling for baseline measures and for study covariates.

DISCUSSION

The design and evaluation of an Internet-based educational strategy to prevent risky sexual behaviors in Mexican adolescents is important in order to provide a new, large-scale, easily implemented preventive tool.

TRIAL REGISTRATION

The study was registered at the ClinicalTrials.gov ID: NCT02686736 .

Salud global 2035: implicaciones para México

En noviembre de 2014, la Secretaría de Salud de México fue sede de una mesa redonda con miembros de la Comisión de The Lancet para la Inversión en Salud (CIS) para analizar el informe de esta misma comisión titulado Salud global 2035 y sus posibles implicaciones para el mejoramiento de la salud pública...

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

Objective

To generate a global reference for caesarean section (CS) rates at health facilities.

Design

Cross‐sectional study.

Setting

Health facilities from 43 countries.

Population/Sample

Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.

Methods

We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.

Main outcome measures

Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results

According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions

This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Access to healthcare and financial risk protection for older adults in Mexico: secondary data analysis of a national survey

OBJECTIVES

While the benefits of Seguro Popular health insurance in Mexico relative to no insurance have been widely documented, little has been reported on its effects relative to the pre-existing Social Security health insurance. We analyse the effects of Social Security and Seguro Popular health insurances in Mexico on access to healthcare of older adults, and on financial risk protection to their households, compared with older adults without health insurance.

SETTING

Secondary data analysis was performed using the 2012 Mexican Survey of Health and Nutrition (ENSANUT).

PARTICIPANTS

The study population comprised 18,847 older adults and 13,180 households that have an elderly member.

OUTCOME MEASURES

The dependent variables were access to healthcare given the reported need, the financial burden imposed by health expenditures measured through catastrophic health-related expenditures, and using savings for health-related expenditures. Separate propensity score matching analyses were conducted for each comparison. The analysis for access was performed at the individual level, and the analysis for financial burden at the household level. In each case, matching on a wide set of relevant characteristics was achieved.

RESULTS

Seguro Popular showed a protective effect against lack of access to healthcare for older adults compared with those with no insurance. The average treatment effect on the treated (ATET) was ascertained through using the nearest-neighbour matching (-8.1%, t-stat -2.305) analysis. However, Seguro Popular did not show a protective effect against catastrophic expenditures in a household where an older adult lived. Social Security showed increased access to healthcare (ATET -11.3%, t-stat -3.138), and protective effect against catastrophic expenditures for households with an elderly member (ATET -1.9%, t-stat -2.178).

CONCLUSIONS

Seguro Popular increased access to healthcare for Mexican older adults. Social Security showed a significant protective effect against lack of access and catastrophic expenditures compared with those without health insurance.

[Evaluation of the quality of care of transient tachypnea in newborns affiliated with the Medical Insurance Siglo XXI program]

BACKGROUND

Evaluation of the quality of care of the newborn with complications is an indispensable element for the improvement of strategies directed to reduce newborn mortality rates. The aim of this work was to evaluate the quality of technical and interpersonal care in the management of transient tachypnea of the newborn (TTN) of patients affiliated with the program "Medical Insurance Siglo XXI".

METHODS

A cross-sectional study was conducted in 61 hospitals affiliated with the Health Ministry with at least two cases of TTN during the first semester of 2011. Variables such as mother's health, pregnancy, birth and birth complication characteristics were analyzed. Also, newborn interventions and health conditions upon discharge were included. To measure the quality of care according to prevention, diagnosis and treatment, quality indicators were defined and validated.

RESULTS

We analyzed 256 case files with a diagnosis of TTN; 8.9% of the mothers presented risk factors (asthma, diabetes) and 53.5% had complications during pregnancy. There were 60% of cases with TTN born by cesarean delivery; one third of these children had low birth weight and 14% were transferred to another hospital. As for the quality indicators in the area of prevention, more than 90% of risk factors (smoking, asthma, cesarean delivery) were identified. Diagnostic indicators showed that 86-98% of respiratory distress symptoms were sought. Indicators of treatment achieved satisfactory figures for monitoring and support measures.

CONCLUSIONS

Prevention, diagnosis and treatment indicators made it possible to consider that most TTN cases received appropriate treatment. It is advisable to develop effective strategies to prevent TTN, such as increasing efforts to reduce the increasing rates of cesarean deliveries.

Tele-care and tele-alarms for the elderly: preliminary experiences in Mexico

OBJECTIVE

To analyze the effect of a pilot program of tele-assistance and tele-alarms on the elderly's self-perception of health status and to identify the satisfaction with and acceptance of the program.

METHODS

Cross-sectional study that included interviews with 378 elderly individuals, 294 caretakers/relatives and 53 health care professionals. The program was run in Mexico City in 2010. The variables were socio-demographic characteristics, self-rated health, satisfaction and acceptance of the program. The information was gathered through a standardized questionnaire. The statistical analysis included descriptive analysis and nonparametric tests.

RESULTS

Significant effects on self-perception of health were observed, 6.17 (SD 17.9 p < 0.05) points above the average. The program was well received and accepted by the elderly, family caregivers and health professionals.

CONCLUSIONS

The program helps to maintain or improve quality of life, allows preventive care and is an ideal means of providing psychosocial support to the elderly.

Effects of the expansion of doctors' offices adjacent to private pharmacies in Mexico: secondary data analysis of a national survey

OBJECTIVES

To compare the sociodemographic characteristics, reasons for attending, perception of quality and associated out-of-pocket (OOP) expenditures of doctors' offices adjacent to private pharmacies (DAPPs) users with users of Social Security (SS), Ministry of Health (MoH), private doctor's offices independent from pharmacies and non-users.

SETTING

Secondary data analysis of the 2012 National Survey of Health and Nutrition of Mexico.

PARTICIPANTS

The study population comprised 25 852 individuals identified as having had a health problem 15 days before the survey, and a random sample of 12 799 ambulatory health service users.

OUTCOME MEASURES

Sociodemographic characteristics, reasons for attending healthcare services, perception of quality and associated OOP expenditures.

RESULTS

The distribution of users was as follows: DAPPs (9.2%), SS (16.1%), MoH (20.9%), private providers (15.4%) and non-users (38.5%); 65% of DAPP users were affiliated with a public institution (MoH 35%, SS 30%) and 35% reported not having health coverage. DAPP users considered the services inexpensive, convenient and with a short waiting time, yet they received ≥3 medications more often (67.2%, 95% CI 64.2% to 70.1%) than users of private doctors (55.7%, 95% CI 52.5% to 58.6%) and public institutions (SS 53.8%, 95% CI 51.6% to 55.9%; MoH 44.7%, 95% CI 42.5% to 47.0%). The probability of spending on consultations (88%, 95% CI 86% to 89%) and on medicines (97%, 95% CI 96% to 98%) was much higher for DAPP users when compared with SS (2%, 95% CI 2% to 3% and 12%, 95% CI 11% to 14%, respectively) and MoH users (11%, 95% CI 9% to 12% and 32%, 95% CI 30% to 34%, respectively).

CONCLUSIONS

DAPPs counteract current financial protection policies since a significant percentage of their users were affiliated with a public institution, reported higher OOP spending and higher number of medicines prescribed than users of other providers. The overprescription should prompt studies to learn about DAPPs' quality of care, which may arise from the conflict of interest implicit in the linkage of prescribing and dispensing processes.

Evaluation of the quality of antenatal care using electronic health record information in family medicine clinics of Mexico City

BACKGROUND

Evaluation of the quality of antenatal care (ANC) using indicators should be part of the efforts to improve primary care services in developing countries. The growing use of the electronic health record (EHR) has the potential of making the evaluation more efficient. The objectives of this study were: (a) to develop quality indicators for ANC and (b) to evaluate the quality of ANC using EHR information in family medicine clinics (FMCs) of Mexico City.

METHODS

We used a mixed methods approach including: (a) in-depth interviews with health professionals; (b) development of indicators following the RAND-UCLA method; (c) a retrospective cohort study of quality of care provided to 5342 women aged 12-49 years who had completed their pregnancy in 2009 and attended to at least one ANC visit with their family doctor. The study took place in four FMCs located in Mexico City. The source of information was the EHR. SAS statistical package served for programing and performing the descriptive statistical analysis.

RESULTS

14 ANC quality indicators were developed. The evaluation showed that 40.6% of women began ANC in the first trimester; 63.5% with low-risk pregnancy attended four or more ANC visits; 4.4% were referred for routine obstetric ultrasound, and 41.1% with vaginal infection were prescribed metronidazole. On average, the percentage of recommended care that women received was 32.7%.

CONCLUSIONS

It is feasible to develop quality indicators suitable for evaluating the quality of ANC using routine EHR data. The study identified the ANC areas that require improvement; which can guide future strategies aimed at improving ANC quality.

Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City

BACKGROUND

Mexico has the highest adult overweight and obesity prevalence in the Americas; 23.8% of children <5 years old are at risk for overweight and 9.7% are already overweight or obese. Creciendo Sanos was a pilot intervention to prevent obesity among preschoolers in Instituto Mexicano del Seguro Social (IMSS) clinics.

METHODS

We randomized 4 IMSS primary care clinics to either 6 weekly educational sessions promoting healthful nutrition and physical activity or usual care. We recruited 306 parent-child pairs: 168 intervention, 138 usual care. Children were 2-5 years old with WHO body mass index (BMI) z-score 0-3. We measured children's height and weight and parents reported children's diet and physical activity at baseline and 3 and 6-month follow-up. We analyzed behavioral and BMI outcomes with generalized mixed models incorporating multiple imputation for missing values.

RESULTS

93 (55%) intervention and 96 (70%) usual care families completed 3 and 6-month follow-up. At 3 months, intervention v. usual care children increased vegetables by 6.3 servings/week (95% CI, 1.8, 10.8). In stratified analyses, intervention participants with high program adherence (5-6 sessions) decreased snacks and screen time and increased vegetables v. usual care. No further effects on behavioral outcomes or BMI were observed. Transportation time and expenses were barriers to adherence. 90% of parents who completed the post-intervention survey were satisfied with the program.

CONCLUSIONS

Although satisfaction was high among participants, barriers to participation and retention included transportation cost and time. In intention to treat analyses, we found intervention effects on vegetable intake, but not other behaviors or BMI.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01539070.Comisión Nacional de Investigación Científica del IMSS: 2009-785-120.

[Human resources requirements for diabetic patients healthcare in primary care clinics of the Mexican Institute of Social Security]

OBJECTIVE

To estimate the requirements of human resources (HR) of two models of care for diabetes patients: conventional and specific, also called DiabetIMSS, which are provided in primary care clinics of the Mexican Institute of Social Security (IMSS).

MATERIALS AND METHODS

An evaluative research was conducted. An expert group identified the HR activities and time required to provide healthcare consistent with the best clinical practices for diabetic patients. HR were estimated by using the evidence-based adjusted service target approach for health workforce planning; then, comparisons between existing and estimated HRs were made.

RESULTS

To provide healthcare in accordance with the patients' metabolic control, the conventional model required increasing the number of family doctors (1.2 times) nutritionists (4.2 times) and social workers (4.1 times). The DiabetIMSS model requires greater increase than the conventional model.

CONCLUSIONS

Increasing HR is required to provide evidence-based healthcare to diabetes patients.

Recursos humanos para la atención de pacientes con diabetes en unidades de medicina familiar del Instituto Mexicano del Seguro Social

Objetivo. Evaluar las necesidades de recursos humanos (RH) para atender pacientes con diabetes en dos modelos de atención: convencional y específico para diabetes (DiabetIMSS) en clínicas de atención primaria del Instituto Mexicano del Seguro Social (IMSS). Material y métodos. Investigación evaluativa; un grupo de expertos, en congruencia con las mejores prácticas clínicas, definió las actividades y tiempos que los RH requieren para atender a pacientes diabéticos. Seguidamente, se utilizó el método de planificación basado en evidencia ajustado por objetivos. Los RH estimados se contrastaron con los existentes para determinar la necesidad. Resultados. Para otorgar atención a los pacientes diabéticos en congruencia con su control metabólico, el modelo convencional requiere aumentar la plantilla de médicos (1.2 veces), nutriólogos (4.2 veces) y trabajadores sociales (4.1 veces); el modelo DiabetIMSS requiere mayores incrementos. Conclusiones. Es indispensable aumentar los RH en el primer nivel para otorgar atención basada en evidencia a pacientes diabéticos.