What is the burden of multimorbidity and the factors associated with its occurrence in elderly Brazilians? / ¿Cuál es la carga de multimorbilidad y los factores asociados a su ocurrencia en personas mayores brasileñas? / Qual é a carga de multimorbidade e os fatores associados à sua ocorrência em pessoas idosas brasileiras?

ABSTRACT Objective: To estimate the prevalence of multimorbidity in elderly people and its association with sociodemographic characteristics, lifestyle, and anthropometry. Methods: This was a cross-sectional study using data from the National Health Survey, 2019. A total of 22,728 elderly individuals from all 27 Brazilian states were randomly selected. Poisson regression models with robust variance were employed, and a significance level of 5% was adopted. Results: The prevalence of multimorbidity was 51.6% (95% CI: 50.4-52.7), with the highest estimates observed in the South and Southeast. Multimorbidity was associated with being female (aPR = 1.33; 95% CI: 1.27-1.39), being 80 years old or older (aPR = 1.12; 95% CI: 1.05-1.19), having low education (aPR = 1.16; 95% CI: 1.07-1.25), past cigarette use (aPR = 1.16; 95% CI: 1.11-1.21), insufficient physical activity (aPR = 1.13; 95% CI: 1.06-1.21), and screen use for 3 hours or more per day (aPR = 1.13; 95% CI: 1.08-1.18). Conclusion: Multimorbidity affects more than half of the elderly population in Brazil and is associated with social, demographic, and behavioral factors.

RESUMEN Objetivo: Estimar la prevalencia de multimorbilidad en personas mayores y su asociación con características sociodemográficas, estilo de vida y antropometría. Métodos: Estudio transversal, con datos de la Encuesta Nacional de Salud, 2019. Se seleccionaron aleatoriamente 22.728 personas mayores de los 27 estados brasileños. Se emplearon modelos de regresión de Poisson con varianza robusta y se adoptó un nivel de significancia del 5%. Resultados: La prevalencia de multimorbilidad fue del 51,6% (IC95%: 50,4-52,7), siendo las mayores estimaciones observadas en el Sur y Sudeste. La multimorbilidad se asoció con el sexo femenino (RPa=1,33; IC95%: 1,27-1,39), tener 80 años o más (RPa= 1,12; IC95%: 1,05-1,19), baja escolaridad (RPa=1,16; IC95%:1,07-1,25), consumo de cigarrillo en el pasado (RPa=1,16; IC95%:1,11-1,21), práctica insuficiente de actividad física (RPa= 1,13; IC95%:1,06-1,21) y uso de pantallas por 3 horas o más al día (RPa=1,13; IC95%:1,08-1,18). Conclusión: La multimorbilidad afecta a más de la mitad de la población anciana de Brasil y está asociada a factores sociales, demográficos y conductuales.

RESUMO Objetivo: Estimar a prevalência de multimorbidade em pessoas idosas e sua associação com características sociodemográficas, estilo de vida e antropometria. Métodos: Estudo transversal, com dados da Pesquisa Nacional de Saúde, 2019. Foram selecionadas aleatoriamente 22.728 pessoas idosas dos 27 estados brasileiros. Empregaram-se modelos de regressão de Poisson com variância robusta e adotou-se um nível de significância de 5%. Resultados: A prevalência de multimorbidade foi de 51,6% (IC95%: 50,4-52,7), sendo as maiores estimativas observadas no Sul e Sudeste. A multimorbidade foi associada ao sexo feminino (RPa=1,33; IC95%: 1,27-1,39), ter 80 anos ou mais (RPa= 1,12; IC95%: 1,05-1,19), baixa escolaridade (RPa=1,16; IC95%:1,07-1,25), consumo de cigarro no passado (RPa=1,16; IC95%:1,11-1,21), prática insuficiente de atividade física (RPa= 1,13; IC95%:1,06-1,21) e uso de telas por 3 horas ou mais por dia (RPa=1,13; IC95%:1,08-1,18). Conclusão: A multimorbidade afeta mais da metade da população idosa do Brasil e está associada a fatores sociais, demográficos e comportamentais.

Educación en enfermería y cuidado de personas con condiciones crónicas: avances y desafíos / Nursing education and care for people with chronic conditions: advances and challenges

INTRODUCCIÓN: El escenario mundial actual de las enfermedades crónicas (EC) es preocupante. Representan el grueso de la carga de enfermedad, en una población envejecida y con alta prevalencia de factores de riesgo. Para mejorar los resultados de las personas con EC, una de las líneas de trabajo prioritarias es la incorporación del apoyo al automanejo, como parte del rol profesional de profesionales de la salud. La principal debilidad percibida hoy es la falta de formación teórico-práctica desde la formación de pregrado. OBJETIVO: evaluar la enseñanza acerca del cuidado en condiciones crónicas de salud, en la formación de pregrado de la Escuela de Enfermería. METODOLOGÍA: Estudio mixto que incluyó a) Análisis del plan de estudios de pregrado vigente 2) Exploración de la experiencia previa de la unidad en investigación y educación continua en cuidados crónicos; consulta con expertos, incluyendo miembros clínicos de equipos de salud que participan en la atención a crónicos. 3) Revisión de la literatura de modelos teóricos para los cuidados crónicos 4) Explorar, a través de las percepciones de los profesores, el grado de implementación de los cuidados de enfermería para las EC. RESULTADOS: Se detectó un bajo nivel de incorporación de la educación para el cuidado crónico en el currículum y ausencia de uso de conceptos claves relacionados con esto. Esto debe hacerse a lo largo de un proceso educativo que progresivamente aumenta el nivel de complejidad en la aplicación de los cuidados a las personas con EC y que se encuentra en implementación en un nuevo plan de estudio en ejecución desde el año 2022.

INTRODUCTION: The global current scenario in non-communicable diseases (NCD) is worrisome. In Chile these conditions represent the bulk of the disease burden, in an ageing population with a high prevalence of risk factors for NCDs. Thus, the training of health professionals in this field is paramount. PURPOSE: to share our experience at the school of nursing (SON) in designing and integrating chronic care and self-management support for people with chronic conditions in the undergraduate program. METHODOLOGY: a) Revision of the undergraduate curriculum 2) Exploring SON previous experience in research and continuing education in chronic care; consultation with experts including clinical members of health teams that participate in delivering chronic care. 3) Review of the literature to find theoretical models for chronic care 4) explore, through the lecturers' perceptions, the degree of implementation of nursing care for NCDs in clinical practice. RESULTS AND CONCLUSIONS: We found that there was a lack of incorporation of subjects and contents on chronic care in the curriculum and in clinical settings. It is important to incorporate chronic care and self-management support in nursing education at the theoretical and the clinical level. This should be done throughout an education process that increases progressively the level of complexity in the application of caring for people with NCDs. The SON will implement this approach in the new curricula starting on 2022.

Calidad de vida relacionada con la salud en niños y niñas con síndrome de Down / Health-related quality of life in children with Down syndrome

Introducción. Los pacientes con síndrome de Down (SD) presentan características que pueden afectar su calidad de vida. El objetivo de este trabajo fue evaluar la calidad de vida relacionada con la salud (CVRS) en pacientes con síndrome de Down. Población y métodos. Se realizó un estudio de corte transversal para evaluar CVRS con el cuestionario PedsQL 4.0 a pacientes de 2 a 4 años con síndrome de Down y a pacientes sanos en 2020-2021 en un hospital universitario. Resultados. Se incluyeron 51 pacientes en cada grupo. El puntaje de CVRS en infantes con SD fue 82,1 vs. 88 (p = 0,003) comparado con población sin SD. La salud psicosocial fue la más afectada (p = 0,007), especialmente, en el funcionamiento social y el escolar (p = 0,0001). Conclusión. Se observó que los niños y niñas con SD de 2 a 4 años tuvieron menor CVRS. La escala de la salud psicosocial fue más afectada, especialmente, el funcionamiento social y el escolar.

Introduction. The characteristics of patients with Down syndrome (DS) may affect their quality of life. The objective of this study was to assess the health-related quality of life (HRQoL) in patients with DS. Population and methods. This was a cross-sectional study to assess the HRQoL with the PedsQL 4.0 questionnaire administered to patients with DS and healthy patients aged 2 to 4 years in 2020­2021 at a teaching hospital. Results. Each study group included 51 patients. The HRQoL score in children with DS was 82.1 compared to 88 (p = 0.003) in the population without DS. Psychosocial health was impacted the most (p = 0.007), especially in terms of social and school functioning (p = 0.0001). Conclusion. Children with DS aged 2 to 4 years were observed to have a lower HRQoL. The psychosocial health scale was affected the most, especially in terms of social and school functioning.

Multimorbidity of chronic noncommunicable diseases: Data from the Brazilian National Health Survey

Objective: To estimate the prevalence of simultaneity of obesity, hypertension and/or diabetes and the association with sociodemographic and lifestyle-related behavior variables. Methods: This is a cross-sectional study with data from the 2013 National Health Survey. The presence of two/three diseases (obesity, hypertension, and diabetes) was considered multimorbidity of noncommunicable diseases (NCDs). Proportional odds logistic regression model, stratified by sex, was used to assess the sociodemographic and lifestyle factors associated with multimorbidity of NCDs, considering the sample complexity and sample weights. Results: The prevalence of multimorbidity of NCDs was 9.6%. The odds of multimorbidity are higher with increasing age, among blacks, but lower in the north region when compared with other regions of the country for both sexes. The odds of multimorbidity of NDCs increased among women who had lower levels of education and spent more time TV watching, and among men who lived with a partner and did not practice the recommended leisure-time physical activity. Conclusion: Sociodemographic factors and lifestyle-related behaviors were associated with the presence of obesity, hypertension, and/or diabetes.

Objetivo: Estimar la prevalencia de simultaneidad de obesidad, hipertensión y/o diabetes y la asociación con variables sociodemográficas y relacionadas con el estilo de vida. Métodos: Los datos fueron obtenido en la Encuesta Nacional de Salud Brasileña, una encuesta a nivel nacional, realizada en los hogares brasileños y llevada a cabo en 2013. La presencia de dos /tres enfermedades (obesidad, hipertensión y diabetes) se consideró multimorbilidad de las enfermedades no transmisibles (ENT). El modelo de regresión logística de probabilidades proporcionales, estratificado por sexo, se utilizó para evaluar los factores sociodemográficos y de estilo de vida asociados con la multimorbilidad de las ENT, considerando la complejidad de la muestra y los pesos de la muestra. Resultados: La prevalencia de multimorbilidad de las ENT fue del 9,6%. Las probabilidades de multimorbilidad son más altas con el aumento de la edad, entre los negros, pero más bajas en la región norte en comparación con otras regiones del país para los dos sexos. Las probabilidades de multimorbilidad de las ENT aumentaron entre las mujeres que tenían niveles más bajos de educación y pasaban más tiempo viendo la televisión, y entre los hombres que vivían con una pareja y no practicaban la actividad física recomendada para el tiempo libre. Conclusión: Los factores sociodemográficos y los comportamientos relacionados con el estilo de vida se asociaron con la presencia de obesidad, hipertensión y/o diabetes.

Application of scenario simulation teaching model of multimorbidity co-treatment in standardized training for general practice residents / 中华全科医师杂志

From February 1 to April 30, 2021, 48 general practice resident physicians in the First Affiliated Hospital of Naval Medical University were randomly divided into study group and control group with 24 in each group. The common comorbidities of the community-dwelling elderly, namely diabetes, diabetic retinopathy and osteoporosis were selected as teaching cases. The residents in control group received conventional teaching, while the scenario simulation teaching model of multicomorbity co-treatment was applied for the study group. The teaching effect, satisfaction and self-efficacy scores were compared between two groups. After training, the knowledge levels, the mastery of referral indicators and the performance of fundus ophthalmoscopy in the study group were significantly better than those in the control group ( t=2.27, 6.34, 4.09; P<0.05). They were (80.96±11.27) vs. (73.96±10.09), (10.33±2.41) vs. (6.38±1.88), (70.27±10.44) vs. (63.50±7.98), and students′ satisfaction and self-efficacy evaluation were higher than those of the observation group (all P<0.05). It is suggested that the simulation teaching of multi-disease co-treatment scenario is more beneficial than the traditional teaching to improve the comprehensive care ability of standardized training physicians in general practice for patients with chronic disease.

Crianças hospitalizadas com necessidades de saúde especiais complexas: estudo de casos múltiplos / Infantes hospitalizados con necesidades de salud especiales complejas: estudio de casos múltiples / Hospitalized children with complex special healthcare needs: multiple case studies

Resumo Objetivo Descrever os casos clinicamente complexos de crianças com necessidades de saúde especiais em hospitalização contínua e analisar a natureza das demandas de cuidados clinicamente complexos durante a hospitalização. Métodos Estudo de casos múltiplos de três crianças clinicamente complexas hospitalizadas. A coleta de dados ocorreu, entre janeiro e março de 2020, em prontuário, na observação de cuidados e interação espontânea registrada em diário de campo e entrevista. Participaram sete pessoas, sendo dois familiares, três técnicos de enfermagem e duas enfermeiras. Aplicou-se a análise temática, orientando-se pela tipologia de demandas de cuidados de crianças com necessidades de saúde especiais e classificação de Collière. Resultados Os casos de meninas e menino, com três, dez e 11 anos de idade, e tempo de internação de 4 meses a 6 anos, geraram linhas de convergências com as demandas de cuidados de crianças com necessidades de saúde especiais, proporcionando sobrevivência, bem-estar e conforto. Desses casos extraíram-se demandas contínuas e complexas de cuidados de estimulação, apaziguamento, confortação e parecer convergentes com o de desenvolvimento e habituais modificados (banho, arrumar-se, alimentação e mobilidade); os cuidados de compensação, no manejo de tecnologias corporais e a administração de medicamentos de uso contínuo, convergiram para demandas de cuidados tecnológicos e medicamentosos Conclusão A necessidade de sobrevivência, determinada pela natureza clinicamente complexa da criança, direciona a prioridade dos cuidados no uso contínuo de múltiplos medicamentos e manejo de tecnologias, na segurança do ambiente hospitalar. Embora essenciais, precisa-se contemplar as outras demandas de cuidados de desenvolvimento e social integrando-as às clinicamente complexas.

Resumen Objetivo Describir los casos clínicamente complejos de infantes con necesidades de salud especiales en hospitalización continua y analizar la naturaleza de las demandas de cuidados clínicamente complejos durante la hospitalización. Métodos Estudio de casos múltiples de tres infantes hospitalizados clínicamente complejos. La recopilación de datos se realizó de enero a marzo de 2020, en la historia clínica, en la observación de cuidados e interacción espontánea registrada en un diario de campo y en entrevista. Participaron siete personas, de las cuales dos eran familiares, tres técnicos de enfermería y dos enfermeras. Se aplicó el análisis temático, orientándose por la tipología de demandas de cuidados de infantes con necesidades de salud especiales y clasificación de Collière. Resultados Los casos de las niñas y el niño, de 3, 10 y 11 años, entre 4 meses y 6 años de tiempo de internación, generaron líneas convergentes con las demandas de cuidados de infantes con necesidades de salud especiales, donde se proporciona supervivencia, bienestar y consuelo. De estos casos se observaron demandas continuas y complejas de cuidados de estimulación, apaciguamiento, consuelo y opinión convergentes con los del desarrollo y los habituales modificados (baño, arreglarse, alimentación y movilidad); los cuidados de compensación, con el manejo de tecnologías corporales y la administración de medicamentos de uso continuo, convergieron en las demandas de cuidados tecnológicos y medicamentosos. Conclusión La necesidad de supervivencia, determinada por la naturaleza clínicamente compleja del infante, direcciona la prioridad de los cuidados en el uso continuo de múltiples medicamentos y en el manejo de tecnologías para la seguridad del ambiente hospitalario. Aunque sean esenciales, es necesario contemplar otras demandas de cuidados de desarrollo y sociales e integrarlas a las clínicamente complejas.

Abstract Objective To describe the medically complex cases of children with special healthcare needs in continuous hospitalization and to analyze the nature of medically complex care demands during hospitalization. Methods This is a multiple case study of three hospitalized medically complex children. Data collection occurred between January and March 2020 in the medical records in the observation of care and spontaneous interaction documented in a fieldwork note and interview. Seven people participated, two family members, three nursing technicians, and two nurses. Thematic analysis was applied, guided by the typologies of Collière's care and the demands of children with special healthcare needs. Results The cases included girls and a boy aged three, ten, and 11 years, and hospitalization time from 4 months to 6 years. They all generated lines of convergence with the care demands of children with special healthcare needs, providing survival, well-being, and comfort. These cases extracted continuous and complex care demands of stimulation, pacification, and comfort; and seemed convergent with developmental and modified daily life activities (bath, grooming, feed, and mobility) care. Compensating care in managing bodily technologies and administering continuous-use medication converged with demands for technological and medication care. Conclusion The need for survival, determined by children's medically complex nature, directs the priority of care to the continuous use of multiple medications, the management of technologies, and the safety of hospital environments. Although essential, it is necessary to consider the other developmental and social care demands, integrating them with the medically complex ones.

Multimorbidity patterns: obesity as the main modifiable risk factor in adult women in Southern Brazil

ABSTRACT Objective: To identify multimorbidity patterns in women in southern Brazil, and its relationship with sociodemographic, lifestyle characteristics, and nutritional status, as well as to explore the main independent risk factor for the identified patterns. Subjects and methods: This is a cross-sectional, population-based study with 1,128 women (20-69 years), southern Brazil. Chronic conditions were identified using the therapeutic and chemical anatomical classification of continuous use of medications. Multimorbidity was assessed as ≥2 or ≥3 chronic conditions to identify dyads and triads. Poisson regression was used to explore risk factors in the different adjustment models. As independent variables evaluated, in addition to sociodemographic characteristics, lifestyle variables were included: consumption of fruits and vegetables, physical activity, alcohol consumption, smoking and nutritional status. Results: Eleven dyads (frequencies between 2.0% and 6.4%) and three triads (frequencies between 1.9% and 2.1%) of morbidities were identified in the study. Aging was related to a higher prevalence of all patterns, and obesity was a risk factor for multimorbidity patterns that contained conditions related to the cardiovascular and metabolic system and mental health. After adjustment, obesity increased the probability of "hypertension + common mental disorders (CMD)" (PR 3.63; 95% CI 1.94-6.78) and "dyslipidemia + CMD" (PR 3.69; 95% CI 1.08-12.65) by more than three times. Conclusion: This study identified common and important diseases in the patterns, associated with a common risk factor, obesity, that must be addressed by public health policies to prevent multimorbidity.

Epidemiology and outcomes of septic shock in children with complex chronic conditions in a developing country PICU

Abstract Objective: To investigate the role of Complex Chronic Conditions (CCCs) on the outcomes of pediatric patients with refractory septic shock, as well as the accuracy of PELOD-2 and Vasoactive Inotropic Score (VIS) to predict mortality in this specific population. Methods: This is a single-center, retrospective cohort study. All patients diagnosed with septic shock requiring vasoactive drugs admitted to a 13-bed PICU in southern Brazil, between January 2016 and July 2018, were included. Clinical and demographic characteristics, presence of CCCs and VIS, and PELOD-2 scores were accessed by reviewing electronic medical records. The main outcome was considered PICU mortality. Results: 218 patients with septic shock requiring vasoactive drugs were identified in the 30-month period and 72% of them had at least one CCC. Overall mortality was 22%. Comparing to patients without previous comorbidities, those with CCCs had a higher mortality (26.7% vs 9.8%; OR = 3.4 [1.3-8.4]) and longer hospital length of stay (29.3 vs 14.8; OR 2.39 [1.1-5.3]). Among the subgroups of CCCs, "Malignancy" was particularly associated with mortality (OR = 2.3 [1.0-5.1]). VIS and PELOD-2 scores in 24 and 48 hours were associated with mortality and a PELOD-2 in 48 hours > 8 had the best performance in predicting mortality in patients with CCC (AUROC = 0.89). Conclusion: Patients with CCCs accounted for the majority of those admitted to the PICU with septic shock and related to poor outcomes. The high prevalence of hospitalizations, use of resources, and significant mortality determine that patients with CCCs should be considered a priority in the healthcare system.

Lifestyle, high Body Mass Index, and markers of socioeconomic conditions associated with multimorbidity in women

ABSTRACT: Objective: This study aimed to identify the prevalence of multimorbidity and its associated factors in women in southern Brazil. Methods: We conducted a cross-sectional, population-based study with a sample of 1,128 women (age 20-69 years), living in São Leopoldo, southern Brazil. Multimorbidity was defined as two or more chronic conditions measured using the therapeutic and chemical anatomical classification of continuous use medications prescribed by a physician. Poisson regression model with robust variance was used to assess the association between sociodemographic and lifestyle variables and multimorbidity. Results: The prevalence of multimorbidity was 21.7% (95%CI 19.3-24.2), and 26 chronic conditions were identified. A direct linear association was observed with age and income and an inverse association with education. Being unemployed was a risk factor for multimorbidity (PR 1.95; 95%CI 1.51-2.52). Alcohol consumption (moderate or excessive) had a protective effect. Overweight and obese women were 53% (PR 1.53; 95%CI 1.09-2.15) and 76% (PR 1.76; 95%CI 1.27-2.45) more likely to have multimorbidity than eutrophic women. Conclusion: Over 20% of the adult women had multimorbidity, and its occurrence was strongly associated with socioeconomic characteristics, such as fewer years of schooling, higher income, and not having an occupation. The results regarding alcohol consumption are still insufficient to propose a public policy for the prevention of multimorbidity. Excess weight was an independent risk factor and should be addressed in public health policies for the prevention and management of multimorbidity.

Uso de serviços de saúde e multimorbidade: contribuições para o debate sobre desigualdades sociais em saúde / Use of health services and multimorbidity: contributions to the debate on social inequalities in health

A multimorbidade tem sido cada vez mais comum em todo o mundo. O acesso a serviços de saúde eficazes e equitativos que atendam às necessidades das doenças crônicas não-transmissíveis (DCNT) ainda é limitado em muitos países. Nesse sentido, o presente estudo teve por objetivo identificar a relação entre a multimorbidade e a utilização de diferentes serviços de saúde e avaliar a associação entre fatores contextuais e individuais e o uso de serviços de saúde em indivíduos com multimorbidade no Brasil de 1998 a 2013. Trata-se de um estudo em painéis utilizando dados do suplemento de saúde da Pesquisa Nacional de Amostras por Domicílios de 1998, 2003 e 2008 e dados da Pesquisa Nacional de Saúde realizada em 2013. A população de estudo foi composta por adultos com idade maior ou igual a 18 anos e classificados como tendo multimorbidade (presença de dois ou mais problemas crônicos em um mesmo indivíduo). Foram considerados três desfechos de utilização de serviços de saúde: busca por serviços de saúde nos últimos quinze dias, consulta médica nos últimos doze meses e hospitalizações nos últimos doze meses. Modelos de regressão de Poisson estratificados por sexo foram utilizados para estimar as razões de prevalência brutas e ajustadas e seus respectivos intervalos de confiança de 95% para cada desfecho de uso de serviços de saúde e multimorbidade, por ano. Modelos de regressão de Poisson multinível em dois níveis foram utilizados para estimar as razões de prevalência ajustadas por variáveis independentes individuais e contextuais e seus respectivos intervalos de confiança a 95%, para os três desfechos, por ano de painel. Houve aumento da prevalência de procura por serviços de saúde e consultas médicas nos últimos 12 meses entre 1998 e 2013, independentemente da classificação de multimorbidade. A prevalência de hospitalizações diminuiu ao longo do período do estudo e foi duas vezes maior em indivíduos com multimorbidade. Ter multimorbidade aumentou a utilização de serviços de saúde para os três desfechos em estudo, sendo mais expressivo entre os homens. Fatores individuais relacionados ao uso de serviços de saúde se modificaram segundo tipo de serviço de saúde investigado. Características contextuais de vulnerabilidade social, organização dos serviços de saúde e índices de saúde mostraram influência na busca por serviços de saúde e nas hospitalizações, não apresentando associação com consultas médicas. Este estudo constatou que indivíduos com multimorbidade apresentam níveis mais elevados de utilização de serviços de saúde. Além disso, revelou que o uso de serviços de saúde está associado de forma variável com os fatores predisponentes, capacitantes e de necessidade em pessoas com multimorbidade. Esses resultados apontam para a necessidade de integrar todos os fatores individuais e contextuais no planejamento do acesso à saúde e, assim, reduzir as desigualdades no acesso aos serviços de saúde nessa população.

Background: Multimorbidity has been increasingly common throughout the world. Access to effective and equitable health services that address the needs of chronic non-communicable diseases (NCDs) is still limited in many countries. In this sense, the present study aimed to identify the relationship between multimorbidity and the use of different health services and to assess the association between contextual and individual factors and the use of health services in individuals with multimorbidity in Brazil from 1998 to 2013. Methods: This is a panel study using data from the health supplement of 1998, 2003, and 2008 National Survey of Samples by Households and data from the National Health Survey conducted in 2013. The study population consisted of adults of age 18 years of age or older and classified as having multimorbidity (presence of two or more chronic problems in the same individual). Three health service utilization outcomes were considered: search for health services in the last fifteen days, medical consultation in the last twelve months, and hospitalisations in the last twelve months. Poisson regression models stratified by sex were used to estimate the crude and adjusted prevalence ratios and their respective 95% confidence intervals for each health service use and multimorbidity outcome per year. Two-level multilevel Poisson regression models were used to estimate the prevalence ratios adjusted for individual and contextual independent variables and their respective 95% confidence intervals, for the three outcomes, by panel year. Results: There was an increase in the prevalence of demand for health services and medical consultations in the last 12 months between 1998 and 2013, regardless of the multimorbidity classification. The prevalence of hospitalisations decreased over the study period and was twice as high in individuals with multimorbidity. Having multimorbidity increased the use of health services for the three outcomes under study, being more expressive among men. Individual factors related to the use of health services changed according to the type of health service investigated. Contextual characteristics of social vulnerability, organization of health services, and health indices influenced the search for health services and hospitalisations, with no association with medical appointments. Conclusion: This study found that individuals with multimorbidity have higher levels of use of health services. Furthermore, it revealed that the use of health services is variably associated with predisposing, enabling, and need factors in people with multimorbidity. These results point to the need to integrate all individual and contextual factors in planning access to health and, thus, reduce inequalities in access to health services in this population.

Características de las mujeres de edad mediana / Characteristics of middle-aged women

Introducción: Pocos estudios han sido publicados en relación con las características del climaterio de la mujer de edad mediana. Por la importancia de esta información para realizar acciones de promoción de salud, en este grupo poblacional, se realizó la presente investigación. Objetivo: Describir las características sociodemográficas, identificar alteraciones de la salud y características biológicas relacionadas con el climaterio, en mujeres de edad mediana. Métodos: Se realizó un estudio descriptivo, de corte transversal. Se estudió una muestra aleatoria de 309 mujeres de 40 a 59 años, mediante muestreo por conglomerados bietápico, del área de salud del Policlínico "Julián Grimau", La Habana, en el primer semestre del año 2017. Para recoger los datos se utilizó un cuestionario semiestructurado, aplicado mediante entrevista. Como medida de resumen para las variables cualitativas se utilizó el porcentaje. Resultados: El 52,8 por ciento de las mujeres estudiadas era trabajadora y el 42,7 por ciento tenía escolaridad preuniversitaria. Recibieron información con mayor frecuencia las mujeres universitarias y las preuniversitarias. La hipertensión arterial fue declarada por el 35,0 por ciento de las féminas, la osteoartrosis 25,9 por ciento, diabetes mellitus en el 10,7 por ciento. La mayoría de las hipertensas era obesa o tenía sobrepeso. Conclusiones: Las mujeres de edad mediana del área de salud estudiada, tenían escolaridad preuniversitaria predominantemente, estaban en la perimenopausia, con sobrepeso y obesidad e hipertensión arterial(AU)

Introduction: Few studies have been published in relation to the climacteric characteristics of the middle-aged woman. Due to the importance of this information to carry out health promotion actions, in this population group, the present investigation was carried out. Objective: Describe the sociodemographic characteristics, identify health alterations and biological characteristics related to the climacteric. Methods: The study classifies as descriptive, cross-sectional. A random sample of 309 women aged 40 to 59 years was studied, by means of two-stage cluster sampling, from the health area of Julián Grimau Policlinic, Havana, in the first semester of 2017. To collect the data a semi-structured questionnaire was used, applied through an interview. The percentage was used as a summary measure for the qualitative variables. Results: 52.8 percent of the women studied were working and 42.7 percent had pre-university education. Information was received more frequently by university and pre-university women. Hypertension was declared by 35.0 percent of females, osteoarthrosis 25.9 percent, diabetes mellitus in 10.7 percent. The majority of hypertensive women were obese and overweight. Conclusions: The middle-aged women of the health area studied had predominantly pre-university education, in perimenopause, with overweight and obesity and arterial hypertension(AU)

Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea

BACKGROUND: The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists. METHODS: A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI). RESULTS: HG LOS (median, interquartile range [IQR], 8 [5–12] days) was lower than NHG LOS (median [IQR], 10 [7–15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5–12] vs. 10 [7–16] days, respectively, P < 0.001) with CCI of ≥ 5 points. CONCLUSION: Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.

Análise da linha de cuidado para pacientes com diabetes mellitus e hipertensão arterial: a experiência de um município de pequeno porte no Brasil / Analysis of the care of patients with Diabetes Mellitus and Hypertension: the experience of a small municipality in Brazil / Análisis de la línea de cuidado para pacientes con diabetes mellitus e hipertensión arterial: la experiencia de un municipio pequeño en Brasil

O artigo avalia a linha de cuidado de uma coorte de 260 indivíduos com diabetes mellitus e 295 indivíduos com hipertensão arterial sistêmica antes, durante e após a implantação do Laboratório de Inovações na Atenção às Condições Crônicas (LIACC). Essa intervenção buscou fortalecer a atenção primária à saúde, implantando o modelo de atenção às condições crônicas no município de Santo Antônio do Monte, Minas Gerais, Brasil, entre 2013 e 2014. Trata-se de um estudo observacional longitudinal que utiliza informações clínicas e laboratoriais dos prontuários dos pacientes dessas duas condições crônicas entre 2012 e 2017. Os desfechos avaliados foram baseados nas linhas guias da Secretaria de Estado de Saúde de Minas Gerais. Os resultados evidenciam o LIACC associado à universalização de macroprocessos da atenção primária, como o cadastramento e a classificação do risco familiar. Para pacientes com diabetes houve melhora em diversos marcadores no período, como o aumento da realização de consulta (de 90% em 2012 para 92% em 2017) e diminuição dos pacientes com exames fora das faixas de normalidade. Já para indivíduos com hipertensão, mesmo sendo observado um crescimento acentuado da realização de consultas (de 80% em 2012 para 84% em 2017), as melhorias clínicas foram menos evidentes. Conclui-se que o LIACC se configura como uma promissora intervenção para a melhoria do manejo de pacientes com doenças crônicas na atenção primária à saúde.

This article evaluates the care of a cohort of 260 individuals with diabetes and 295 individuals with hypertension before, during and after the implementation of the Innovative Care Laboratory for Chronic Conditions (LIACC). This intervention sought to strengthen Primary Health Care by implementing the Chronic Care Model in Santo Antônio do Monte, Minas Gerais, Brazil, between 2013 and 2014. This is a longitudinal observational study that uses clinical and laboratory information from medical records of patients with these two chronic conditions between 2012 and 2017. The outcomes evaluated were based on the guidelines of the Department of Health of Minas Gerais State. The results show the LIACC associated with the universalization of primary care macro-processes such as registration and classification of family risk. For patients with diabetes, there was an improvement in several markers in the period, such as increased consultation (from 90% in 2012 to 92% in 2017) and a decrease in patients with examinations outside the normal range. For individuals with hypertension, although there is a marked increase in medical appointments (from 80% in 2012 to 84% in 2017), clinical improvements were less evident. It can be concluded that LIACC is a promising intervention to improve the management of patients with chronic diseases in Primary Health Care.

El artículo evalúa la línea de cuidado de una cohorte de 260 individuos con diabetes mellitus y de 295 individuos con hipertensión arterial sistémica antes, durante y después de la implantación del Laboratorio de Innovación en Atención a las Condiciones Crónicas (LIACC). Esta intervención buscó fortalecer la Atención Primaria en Salud implantando el Modelo de Atención a las Condiciones Crónicas en el municipio de Santo Antônio do Monte, Minas Gerais, Brasil, entre 2013 y 2014. Se trata de un estudio observacional longitudinal con informaciones clínicas y de laboratorio de registros médicos de los pacientes con las dos condiciones crónicas entre 2012 y 2017. Los desenlaces evaluados se basaron en las líneas guía de la Secretaría de Salud del estado de Minas Gerais. Los resultados evidencian el LIACC asociado con la universalización de los macroprocesos de atención primaria como el registro y la clasificación del riesgo familiar. Para los pacientes con diabetes se observó una mejora en muchos marcadores en el período, como el aumento de las consultas (de 90 % en 2012 a 92 % en 2017) y la disminución de los pacientes con exámenes fuera de los rangos normales. Aunque para las personas con hipertensión se ha observado un notable aumento en la concreción de las consultas (de 80 % en 2012 a 84 % en 2017), las mejorías clínicas fueron menos pronunciadas. Se concluye que el LIACC es una prometedora intervención para la mejora del manejo de pacientes con enfermedades crónicas en la atención primaria.

Pediatric Deaths Attributed to Complex Chronic Conditions over 10 Years in Korea: Evidence for the Need to Provide Pediatric Palliative Care

BACKGROUND: Pediatric palliative care (PPC) is the active total care of children suffering from life-threatening illnesses. Palliative care includes symptom management, psychosocial support, and end-of-life care. Despite significant advances in disease diagnosis and treatment, resources for PPC of children with serious illnesses are limited in Korea. This study aimed to investigate the scale, time trends, disease composition, regional distribution, and unmet needs of children dying from complex chronic conditions (CCCs). METHODS: We examined available information on children who died of CCCs from 2005 to 2014 using the cause of death statistics in Korea. RESULTS: There were 36,808 cases of pediatric deaths in Korea during that 10-year period, one-third (12,515 cases, 34.0%) of which were due to CCCs. In 2014, there were 1,044 cases of pediatric deaths due to CCCs (9.8 deaths per 100,000 children) in Korea. The rate of pediatric deaths due to CCCs has declined over this 10-year period. Among CCCs, malignancy was the most common cause of death overall, as well as in children and adolescents, whereas neonatal disorders were the most common cause of death in infants. Although over 1,000 children die from chronic illnesses each year, there are no hospitals or institutes in Korea that meet the minimum standards for specialized PPC. CONCLUSION: To improve the quality of life of children suffering from CCCs and to support their families who face enormous distress, children with CCCs should be able to access adequate palliative care services. Health authorities should consider supporting the establishment of PPC centers and increasing PPC accessibility in Korea.

Crianças e adolescentes com condições crônicas falam sobre saúde / Children and adolescents with chronic conditions speak about health / Niños y adolescentes con condiciones crónicas hablan sobre salud

Este artigo apresenta os resultados de uma pesquisa realizada com crianças e adolescentes com condições crônicas complexas internados em um hospital de referência localizado no município do Rio de Janeiro. O objetivo do estudo foi investigar os sentidos atribuídos por estas crianças e adolescentes à ideia de saúde. Como metodologia foi utilizada a perspectiva etnográfica. A observação participante e diferentes abordagens lúdicas foram utilizadas de modo a possibilitar a expressão das crianças e dos adolescentes garantindo, assim, o protagonismo deles como sujeitos da pesquisa. Ao longo do estudo ressaltou-se nas crianças sobretudo a capacidade normativa destas, capacidade a que se refere à Georges Canguilhem (1978) em sua obra "O Normal e o Patológico" que encontramos presente em circunstâncias do adoecimento como modos de lidar com as difíceis situações de sofrimento inerentes às condições crônicas. (AU)

This article presents the results of research carried out with children and adolescents with complex chronic conditions at one of Rio de Janeiro's most prominent hospitals for children, adolescents and women. Using an ethnographic approach as methodology, our study aims to investigate the meaning of health according to children and adolescents during their hospitalisations. Observation and various playful approaches were used to facilitate testimonials from the children and adolescents thus ensuring their subjective presence in the research. Throughout the study, the children's normative capacity particularly stood out, a capacity that can be referred to Georges Canguilhem's work On the Normal and the Pathological (1978) that we find present in all circumstances of illness as ways of coping with the difficulties of suffering implicit to chronic conditions. (AU)

Este artículo presenta los resultados de una investigación realizada con niños y adolescentes con condiciones crónicas complejas internados en un hospital referencia ubicado en la ciudad de Río de Janeiro. El objetivo del estudio fue investigar los sentidos atribuidos por estos pacientes a la idea desalud. Como metodología se utilizó la perspectiva etnográfica. La observación participante y diferentes enfoques lúdicos se utilizaron para permitir la expresión de los niños y adolescentes, garantizando así su protagonismo como sujetos de la investigación. A lo largo del estudio se observó en los niños sobre todo la capacidad normativa de estos, capacidad a que se refiere a Georges Canguilhem en su obra "Lo Normal y lo Patológico" que encontramos presente en todas las circunstancias de la enfermedad como modos de lidiar con las difíciles situaciones de sufrimiento inherentes a las condiciones crónicas. (AU)

From the Editor on Menopausal hormone therapy for the primary prevention of chronic conditions The U.S. Preventive Services Task Force draftrecommendation statement / Del Editor sobre la Terapia hormonal de reemplazo para la prevención primaria de enfermedades crónicas Borrador del documento de recomendación del Grupo de Trabajo de los Servicios de Prevención de los EE UU

On May 16, 2017, the U.S. Preventive Services Task Force requested comments on a draft recommendation statement and a draft evidence review on menopausal hormone therapy for the primary prevention of chronic conditions. Based on its review of the evidence, the Task Force recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. Based on this document, we present a short review on estrogen physiology during menopause and subsequent recommendations by specialized institutions on estrogen and progestin hormone therapy for the prevention of chronic cardiovascular, vasomotor, neurological and osteoporotic symptoms.

En 16 de mayo de 2017, el Grupo de Trabajo de Servicios de Prevención de los EE UU solicitó comentarios a una declaración de recomendación y revisión de la evidencia sobre la terapia hormonal para la menopausia en la prevención primaria de enfermedades crónicas. Basado en la revisión de la evidencia, el Grupo de Trabajo hace la recomendación contra el uso combinado de estrógeno y progestágeno para la prevención de condiciones crónicas en las mujeres posmenopáusicas. A partir de este documento, se realiza una breve consideración sobre la fisiología hormonal estrogénica durante la menopausia y las recomendaciones subsecuentes por instituciones especializadas sobre la terapia hormonal con estrógenos y progestágenos para la prevención de la sintomatología crónica cardiovascular, vasomotora, neurológica y osteoporótica.

Experiências de adoecimento por condições crônicas transmissíveis: revisão integrativa da literatura / Illness experiences due to communicable chronic conditions: integrative literature review

Resumo O objetivo deste artigo é identificar e descrever as experiências de adoecimento de pessoas que vivem com condições crônicas transmissíveis. Revisão integrativa da literatura foi realizada em maio de 2015 nas bases de dados PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) e Scopus. A partir do cruzamento de palavras-chave e de descritores controlados, foram adotadas oito estratégias de busca, que resultaram na seleção final de 12 artigos. Realizou-se fichamento dos artigos, sendo elaboradas duas categorias temáticas, tendo em vista o agrupamento de temas coincidentes: (1) experiências com as condições crônicas transmissíveis; e (2) estratégias de enfrentamento das condições crônicas transmissíveis. Identificou-se o estigma como sendo a experiência de maior impacto na vida dos sujeitos, o qual reverberou em sentimentos negativos. Apesar disso, os sujeitos adoecidos adotaram hábitos de vida saudáveis, bem como apoiaram-se na religiosidade/espiritualidade e no dimensionamento do tempo como forma de harmonizar sua convivência com as doenças. Observou-se, ainda, que a rede de apoio (família, serviços de saúde) tem papel fundamental na vivência das condições crônicas transmissíveis. Os sujeitos experimentam sensações e sentimentos negativos desde o diagnóstico, seja pela fragilidade que a doença impõe ao seu organismo, seja pela manutenção da condição que os torna mais vulneráveis à discriminação, ao preconceito e ao estigma. Torna-se necessário fortalecer a rede de apoio em torno do sujeito, no sentido de favorecer a melhoria na qualidade de vida das pessoas que vivem com condições crônicas transmissíveis.

Abstract The objective of this article is to identify and describe the illness experiences of people living with communicable chronic conditions. An integrative literature review was carried out in May 2015 in the PubMed, the Literature in the Health Sciences in Latin America and the Caribbean (LILACS) and in the Scopus databases. Through the intersection of keywords and controlled descriptors, eight search strategies were conducted and resulted in the final selection of 12 articles, which were catalogued into two theme categories, in order to group matching themes: (1) experiences with communicable chronic conditions; (2) coping strategies for communicable chronicle diseases. Stigma was identified as the most impacting experience in subjects' lives, which reverberated negatives feelings. In spite of their illness, subjects adopted healthy lifestyle habits and found support on religiosity/spirituality and on the dimensionality of time as a way to live harmoniously with diseases. We also noticed that the support network (family, health services) plays a key role in the process of living with communicable chronicle diseases. Since the diagnostic, the subjects experience negative feelings and sensations not only because of the fragileness that the disease imposes on their body but also because of the maintenance of the condition, which make them more vulnerable to discrimination, prejudice and stigma. It becomes necessary to strengthen the support network around the subject, in order to encourage improvements in the quality of life of people living with communicable diseases.

International Experience of Chronic Disease Management and Enlightenment / 中国药房

OBJECTIVE:To provide reference for comprehensive intervention and management of chronic disease in China.METHODS:The global chronic disease trends and disease burden were summarized;theoretical framework,practice and experience of international chronic disease management were summarized and analyzed as well as enlightenment on domestic chronic disease management.RESULTS&CONCLUSIONS:Worldwide prepresentative chronic disease theory model mainly involved USA chronic disease nursing model and WHO innovation care for chronic conditions.Main experience of international chronic disease management is that managing based on community,confirming preferential intervened disease types,adopting standardized clinical diagnosis and treatment pathway,designing rational transfer treatment system,providing patient self-management support.At pres ent,chronic disease management have been improved in China,but is still poor in community management.It is necessary to strengthen community medical staff training about chronic disease prevention and treatment and health education for social group.