Background: A substantial proportion of patients receiving fibrinolytic therapy for myocardial infarction with ST-segment elevation have inadequate reperfusion or reocclusion of the infarct-related artery, leading to an increased risk of complications and death. Methods: We enrolled 3491 patients, 18 to 75 years of age, who presented within 12 hours after the onset of an ST-elevation myocardial infarction and randomly assigned them to receive clopidogrel 8300-mg loading dose, followed by 75 mg once daily) or placebo. Patients received a fibrinolytic agent, aspirin, and when appropriate, heparin (dispensed according to body weight) and were echeduled to undergo angiography 48 to 192 hours after the start of study medication. The primary efficacy end point was a composite of an ocluded infarct-related artery (defined by a Thrombolysus in Myocardial Infarction flow grade of 0 or 1) on angiography or death or recurrent myocardial infarction before angiography. Results: The rates of the primary efficacy end point were 21.7 percent in the placebo group and 15.0 percent in the clopidogrel group, representing an absolute reduction of 6.7 percentage points in the rate and a 36 percent reduction in the odds of the end point with clopidogrel therapy (95 percent confidence interval, 24 to 47 percent; P<0.001). By 30 days, clopidogrel therapy reduced the odds ol the composite end point of death from cardiovascular causes, recurrent myocardial infarction, or recurrent ischemia leading to the need for urgent revascularization by 20 percent (from 14.1 to 11.6 percent, P=0.03). The rates of major bleeding and intracranial hemorrhage were similar in the two groups. Conclusions: In patients 75 years of age or younger who have myocardial infarction with ST-segment elevation and who receive aspirin and a standard fibrinolytic regimen, the addition of clopidogrel improves the patency rate of the infarct-related artery and reduces ischemic complications.

Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation

As more is learned about the development of cervical cancer, the value of annual Pap smear screening for all women is being questioned. This study was conducted to investigate whether women at higher risk for the development of cervical cancer could be identified by testing for the presence of human papillomavirus (HPV) in the cervical smear. These women could be followed annually, and the interval between screening Pap smears for women at lower risk could be increased. Study participants were women enrolled in the Kaiser Permanente healthcare plan in Portland, Oregon, who underwent annual Pap smear screening between April 1989, and November 1990. More than 20,000 women (20,810 of 23,702) had satisfactory cervical smears with sufficient samples for HPV testing, which was conducted using a polymerase chain reaction-based method with MYO9/11 primers. Most women (83.6%) had at least one follow-up smear during the study period; however, women with atypical squamous cells (ASC) or worse had more smears than women with normal results (mean, 4.4 vs. 3.3). Follow-up was conducted more or less annually for a total period of 122 months. HPV results were not used in deciding patient management. Ninety-six percent of the 20,810 baseline Pap smears were diagnosed as negative (N = 20,156). Thirteen percent of these patients tested positive for HPV. The baseline smears of 654 of the 20,810 women (3.1%) were classified as ASC or worse. Of these 654 smears, 417 (63.8%) were positive for HPV. One hundred seventy-eight women had a cytologic diagnosis of a low-grade squamous intraepithelial lesion or worse; of these, 143 (80.3%) tested positive for HPV. During the 10 years of follow-up, 171 patients developed cervical intraepithelial neoplasia (CIN) 3 or cervical cancer. The baseline smear was normal in 112 of these women and ASC or worse in 59 (34.5%). Only half (49.2%) of the 58 patients diagnosed within the first 45 months of follow-up had an abnormal baseline smear. During this first 45 months, 7.85% of the women whose initial Pap test was at least ASC were diagnosed with CIN 3 or cancer. The cumulative incidence at 10 years of follow-up was 10.2%. Sixty of the 171 women with CIN 3 or cervical cancer had a negative baseline HPV test. Of the 118 women who were diagnosed during the first 45 months of follow-up, 89 (79.4%) were HPV positive initially. The cumulative incidence of CIN 3 or cancer among the group with a positive baseline HPV test was 6.92% over 10 years but only 1.73% at 45 months. The risk of developing CIN 3 or cancer remained elevated throughout the study in those women with a positive baseline HPV test. The predictive ability of the baseline Pap smear diminished as the follow-up interval increased. Fifteen percent of the patients (N = 3216) had a positive Pap smear, a positive HPV test, or both at the initial examination. One hundred twenty-three (71.9%) were among the 171 women who developed CIN 3 or cancer. Eighty-six percent (102 of 123) of the patients who were diagnosed within the first 45 months were positive with at least one of the screening studies. The cumulative incidence over 45 months for women who had positive HPV testing and/or abnormal Pap smear results was 4.54%. Women with negative results in both screening tests had a cumulative risk of 0.16% for the same period. At 10 years the cumulative risk incidence for these two groups was 6.83% and 0.79%, respectively, yielding a negative predictive value of 99.1% for combined testing.

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Baseline Cytology, Human Papillomavirus Testing, and Risk for Cervical Neoplasia: A 10-Year Cohort Analysis

Health financing reforms in low- and middle- income countries (LMICs) over the past decades have focused on achieving equity in financing of health care delivery through universal health coverage. Benefit and financing incidence analyses are two analytical methods for comprehensively evaluating how well health systems perform on these objectives. This systematic review assesses progress towards equity in health care financing in LMICs through the use of BIA and FIA. Key electronic databases including Medline, Embase, Scopus, Global Health, CinAHL, EconLit and Business Source Premier were searched. We also searched the grey literature, specifically websites of leading organizations supporting health care in LMICs. Only studies using benefit incidence analysis (BIA) and/or financing incidence analysis (FIA) as explicit methodology were included. A total of 512 records were obtained from the various sources. The full texts of 87 references were assessed against the selection criteria and 24 were judged appropriate for inclusion. Twelve of the 24 studies originated from sub-Saharan Africa, nine from the Asia-Pacific region, two from Latin America and one from the Middle East. The evidence points to a pro-rich distribution of total health care benefits and progressive financing in both sub-Saharan Africa and Asia-Pacific. In the majority of cases, the distribution of benefits at the primary health care level favoured the poor while hospital level services benefit the better-off. A few Asian countries, namely Thailand, Malaysia and Sri Lanka, maintained a pro-poor distribution of health care benefits and progressive financing. Studies evaluated in this systematic review indicate that health care financing in LMICs benefits the rich more than the poor but the burden of financing also falls more on the rich. There is some evidence that primary health care is pro-poor suggesting a greater investment in such services and removal of barriers to care can enhance equity. The results overall suggest that there are impediments to making health care more accessible to the poor and this must be addressed if universal health coverage is to be a reality.

/pdf/equity-in-health-care-financing-in-low-and-middle-income-13vb60vf2e.pdf

Equity in Health Care Financing in Low- and Middle-Income Countries: A Systematic Review of Evidence from Studies Using Benefit and Financing Incidence Analyses.

Background
Increasingly there is a focus on self-care strategies for both malignant and non-malignant conditions. Models of self-care interventions have focussed on the individual and less on the broader context of family and society. In many societies, decision-making and health seeking behaviours, involve family members.

Objective
To identify elements of effective family-centred self-care interventions that are likely to improve outcomes of adults living with chronic conditions.

Design
Review paper.

Data sources
MEDLINE (Ovid), CINAHL, Academic Search Complete, PsychInfo and Scopus between 2000–2014.

Review methods
Quantitative studies targeting patient outcomes through family-centred interventions in adults were retrieved using systematic methods in January, 2015. Search terms used were: ‘family’, ‘spouse’, ‘carer’, ‘caregiver’, ‘chronic’, ‘chronic disease’, ‘self-care’, ‘self-management’ and ‘self-efficacy’. Reference lists were reviewed. Risk of bias assessment was performed using the Cochrane Collaboration's tool. Data were reported using a narrative summary approach.

Results
Ten studies were identified. Improvements were noted in readmission rates, emergency department presentations, and anxiety levels using family-centred interventions compared with controls. Elements of effective interventions used were a family-centred approach, active learning strategy and transitional care with appropriate follow-up.

Conclusions
Involving the family in self-care has shown some positive results for patients with chronic conditions. The benefits of family-centred care may be more likely in specific socio-cultural contexts.

Limitations
The review has year limits and further research needs to identify support for both the patients and family caregivers.

/pdf/family-centred-approaches-to-healthcare-interventions-in-2ioad3a933.pdf

Family-centred approaches to healthcare interventions in chronic diseases in adults: a quantitative systematic review.

Objetivo Contribuir al conocimiento sobre el acceso a los servicios en Colombia tras la reforma del sistema de salud, exponiendo los principales resultados y vacios en las investigaciones. Metodos Se realizo una revision sistematica de la bibliografia, a traves de la busqueda exhaustiva y analisis de articulos originales publicados entre 1994 y 2009. Se incluyeron 27 investigaciones cuantitativas y cualitativas que cumplian los criterios de seleccion. El analisis se enmarco en los modelos teoricos de Aday y Andersen y Gold, que diferencian entre acceso potencial y realizado y consideran las caracteristicas de la poblacion, proveedores y aseguradoras que influyen en la utilizacion. Resultados Los analisis explicativos de la utilizacion de los servicios de salud a partir de modelos de determinantes resultan escasos y parciales (limitados a areas geograficas, patologias o colectivos especificos). Pocos estudios profundizan en factores de contexto -politicas y caracteristicas de proveedores y aseguradoras- o en la perspectiva de los actores sobre los factores que influyen en el acceso. Los estudios no parecen indicar un aumento del acceso realizado -salvo en el regimen subsidiado- y, en cambio, senalan la existencia de importantes barreras relacionadas con factores poblacionales (aseguramiento, renta y educacion) y caracteristicas de los servicios (accesibilidad geografica, organizativas y calidad). Conclusiones La revision muestra limitaciones importantes en el analisis del acceso en Colombia que indican la necesidad de reorientar la evaluacion hacia el acceso realizado, e incorporar variables de contexto y la perspectiva de los actores para comprender mejor el impacto de la reforma en el uso de servicios.

/pdf/acceso-a-la-atencion-en-salud-en-colombia-3guyx33pzw.pdf

Acceso a la atención en salud en Colombia

Fundamento: en paises en desarrollo no se han logrado suficientes avances en reduccion de la carga de la enfermedad por cancer cervical, por lo que es importante mejorar la cobertura, condiciones de acceso y efectividad de los programas de tamizaje. El objetivo de este trabajo es analizar el acceso real de mujeres usuarias del tamizaje citologico ofrecido por la Secretaria de Salud de Medellin (Colombia). Metodos: se analizaron 1.519 registros de mujeres, provenientes de un estudio transversal realizado en un area urbana de Medellin (Colombia). Se realizo un analisis descriptivo y se estimo un modelo de regresion logistica para explicar la practica de citologia reciente (aquella realizada hace maximo 36 meses, previos a la aplicacion de la encuesta). Resultados: El 68,7% de las mujeres se habian practicado una citologia recientemente, el 17,2% tenia citologias previas pero no recientes, y el 14,2% era la primera vez que acudia al servicio. La probabilidad de haberse realizado una citologia reciente es mayor para mujeres con mas edad, antecedente familiar de cancer cervical, antecedente personal de infecciones de transmision sexual, mujeres con algun grado de educacion y las que se encuentran en union estable o estan (o estuvieron) casadas. Conclusiones: hay indicios de que la demanda por la citologia esta concentrada, con una buena frecuencia para un numero limitado de mujeres, mientras otras no la practican o dejan de hacerlo.

/pdf/accesibilidad-a-la-citologia-cervical-en-medellin-colombia-3y97zzgvnm.pdf

Accesibilidad a la citología cervical en Medellín, Colombia en 2006

Fundamento: en paises en desarrollo no se han logrado
suficientes avances en reduccion de la carga de la enfermedad
por cancer cervical, por lo que es importante mejorar la cobertura,
condiciones de acceso y efectividad de los programas de
tamizaje El objetivo de este trabajo es analizar el acceso real
de mujeres usuarias del tamizaje citologico ofrecido por la
Secretaria de Salud de Medellin (Colombia)
Metodos: se analizaron 1519 registros de mujeres, provenientes
de un estudio transversal realizado en un area urbana
de Medellin (Colombia) Se realizo un analisis descriptivo y se
estimo un modelo de regresion logistica para explicar la practica
de citologia reciente (aquella realizada hace maximo 36
meses, previos a la aplicacion de la encuesta)
Resultados: El 68,7% de las mujeres se habian practicado
una citologia recientemente, el 17,2% tenia citologias previas
pero no recientes, y el 14,2% era la primera vez que acudia
al servicio La probabilidad de haberse realizado una
citologia reciente es mayor para mujeres con mas edad, antecedente
familiar de cancer cervical, antecedente personal de
infecciones de transmision sexual, mujeres con algun grado de
educacion y las que se encuentran en union estable o estan (o
estuvieron) casadas
Conclusiones: hay indicios de que la demanda por la citologia
esta concentrada, con una buena frecuencia para un
numero limitado de mujeres, mientras otras no la practican o
dejan de hacerlo

/pdf/accesibilidad-a-la-citologia-cervical-en-medellin-colombia-y9gcbgkgol.pdf

Accesibilidad a la citología cervical en Medellin, Colombia en 2006

Introduction: Economic evaluation is a tool that can provide useful information to decision-makers in health. The methodological quality of Colombian studies has not been assessed in a systematic way. Objective: To assess the methodological quality of economic evaluations in health care in Colombia. Materials and methods: Systematic review of economic studies that assessed both costs and effectiveness of at least two technologies related to a decision problem in Colombia. Search was performed in international and Colombian databases and was completed with manual searches and contact with authors. Data was synthesized in tables that included relevant information about the studies. Methodological quality was evaluated using a predefined instrument. Searches were performed between January and February. Results: 48 studies were included in the review. Perspective of the study, incremental analyzes and description of alternatives were usually well specified. However, more than half of the articles  did not state clearly the time horizon or discount rate and most studies did not address equity and implementation issues. Management of uncertainty was also problematic. Conclusions: Economic evaluation in health care in Colombia has grown considerably in recent years. However, methods vary considerably between studies and therefore their usefulness for decision making in health is limited. It is necessary to standardize methods in order to generate evidence of higher quality to support decisions within the Colombian health care system. doi: http://dx.doi.org/10.7705/biomedica.v33i4.1464

/pdf/evaluacion-de-la-calidad-metodologica-de-la-literatura-en-1f5iuru5zn.pdf

Evaluación de la calidad metodológica de la literatura en evaluación económica en salud en Colombia: una revisión sistemática

Cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme compared with usual care using a CBT manual alone for patients with heart failure: secondary analysis of data from the SEMAPHFOR trial.

Objective: The objective of this study was to determine the cost-effectiveness of zinc supplementation for the treatment of acute diarrhea (AD) in children younger than 5 years in Colombia. Methods: The cost-effectiveness analysis was performed from the perspective of the Colombian health system. The standard treatment with the addition of zinc was compared with the standard treatment without zinc in children younger than 5 years. The time horizon was 1 month. Effectiveness was extracted from a systematic review of literature. The specific data for Colombia were taken from local databases and observational studies. To determine the costs a typical case was constructed by reviewing guidelines and medical records and validated by experts. To evaluate the resources consumed Colombian tariff manuals were used. Costs were stated in Colombian pesos (COP) and US dollar (USD) for 2010. Deterministic sensitivity analysis was performed to evaluate the impact of changes in cost and effectiveness of the strategies on the results from the model. Results: The results from the model indicate that zinc supplementation is a dominant strategy; it is less costly and more effective than standard treatment without zinc (reduction of $15210 COP [8.14 USD] per child). The results are sensitive to changes in the probability of hospitalization and of persistent diarrhea. Conclusions: Zinc for the treatment of AD is a highly cost-effective strategy and is recommended for inclusion in the benefit plan of the Colombian health system. This intervention is more cost-effective in children with a higher risk of persistent diarrhea and hospitalization.

Aurelio Mejía

Papers

Accesibilidad a la citología cervical en Medellín, Colombia en 2006

Accesibilidad a la citología cervical en Medellin, Colombia en 2006

Evaluación de la calidad metodológica de la literatura en evaluación económica en salud en Colombia: una revisión sistemática

Cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme compared with usual care using a CBT manual alone for patients with heart failure: secondary analysis of data from the SEMAPHFOR trial.

Cost-effectiveness analysis of zinc supplementation for treatment of acute diarrhea in children younger than 5 years in Colombia.