Clasificación según nivel de morbilidad e intensidad del uso de recursos de una población con patologías crónicas en Atención Primaria de Salud utilizando “Adjusted Clinical Groups” (ACG) / Adjusted Clinical Groups Method (ACG) to allocate resources according to the disease burden of each health center

Background: Health care must be provided with strong primary health care models, emphasizing prevention and a continued, integrated and interdisciplinary care. Tools should be used to allow a better planning and more efficient use of resources. Aim: To assess risk adjustment methodologies, such as the Adjusted Clinical Groups (ACG) developed by The Johns Hopkins University, to allow the identification of chronic condition patterns and allocate resources accordingly. Material and Methods: We report the results obtained applying the ACG methodology in primary care systems of 22 counties for three chronic diseases, namely Diabetes Mellitus, Hypertension and Heart Failure. Results: The outcomes show a great variability in the prevalence of these conditions in the different health centers. There is also a great diversity in the use of resources for a given condition in the different health care centers. Conclusions: This methodology should contribute to a better distribution of health care resources, which should be based on the disease burden of each health care center.

Aplicación de grupos clínicos ajustados como herramienta de ajuste de riesgo: evaluación en la distribución de recursos en programa de enfermedades crónicas / Adjusted Clinical Groups as a risk assessment model for healthcare resource allocation

Background: There is increasing interest in the study and improvement of health system resource allocation. The Adjusted Clinical Groups (ACG) System measures the morbidity burden of patient populations based on disease patterns, age and gender. This system can be used in primary health care settings. Aim: To report the use of the ACG system as a risk based patient classification system and its potential as a resource allocation mechanism in primary health care. Material and Methods: Patient diagnoses from a sample of primary care establishments were processed using the Johns Hopkins ACG System. Linear regressions were used to measure the ACG System's ability to explain resource use and ambulatory visit rates. Results: The ACG System had a statistically significant capacity to explain primary health care costs with an adjusted R² of 0.26. These results are significantly better, compared with risk assessment models based on patients' age and sex, whose adjusted R² is 0.05. Conclusions: The use of risk adjustment mechanisms will contribute to improve health care resource allocation as well to know the disease profile of the population.

Fundamentos para la Institucionalización de la Evaluación de Tecnologías Sanitarias en Chile / Foundations for the institutionalization of health technology assessment in Chile

The Chilean health system has not been completely oblivious to health technology assessment (HTA). In fact, significant advances in the areas of health prioritization using criteria of disease burden, effectiveness and cost-effectiveness among others, can be acknowledged. The introduction of the reform of Explicit Health Guarantees (GES) has been an important milestone in this arena, allowing the consideration of other dimensions such as social preferences in health. However, the application of HTA encompasses the entire health system and in that sense the institutionalization of a process properly defined and extensively validated in our country, is imminent. This paper discusses the foundations on which progress must be made in institutionalizing HTA, starting from the architecture of our health care system and in light of the economic and social reality. We review some background information first, and then discuss some important considerations in our context, including information on the institutional and legal framework. It concludes with the authors' view on some key elements to consider in HTA in Chile, which does not necessarily represent the vision of the Ministry of Health.

Análisis de los determinantes de la eficiencia hospitalaria: el caso de Chile / Analysis of hospital efficiency determinants in Chile

Background: The knowledge of variables influencing hospital efficiency is of paramount importance to carry out initiatives of management improvement and optimization. Aim: To explore on the hospital technical efficiency factors. Material and Methods: Data from 255,439 hospital discharges from 28 hospitals from May to October 2011 were analyzed. The efficiency index developed by Santelices et al was calculated. Proxy variables of hospital practices, human resource productivity, strategic performance, financing mechanisms, geographical territory and specialization, were considered. The analysis was carried out estimating econometric models. Results: The most significant variables to explain efficiency are the length of stay adjusted by complexity, the discharges per nurse and midwife and the performance of the Hospital Balancea Score Card. Conclusions: The suggested analysis contributes to identify hospital efficiency causes. The results suggest ways to improve performance of hospitals.

Análisis de la eficiencia técnica hospitalaria 2011 / Analysis of hospital technical efficiency during 2011

Background: Efficiency in the use ofresources in health systems and hospitals has been a matter ofinterestfor administrators as well asforpolicy makers. The growing costs due to higher levéis of demand from the population require a better use and allocation ofsuch costs. Aim: To assess the technical efficiency in 28 hospitals in Chile, considering the period from May to October, 2011. Material and Methods: The average number ofavailable beds, the number ofstaffand the expenses on consumer and service goods were used as production inputs and, on the other hand, the expenditures adjusted by the Diagnosis-Related Groups (IR-DRG) were used as producís. To assess the technical efficiency, the Data Envelopment Analysis technique was used. Results: The levéis of inefficiency fluctuóte from 20 to 23.3%. In other words, with a 20% increase in hospital discharges and maintainingfixed inputs, hospitals could become efficient. Conclusions: The incorporation of methodologies to determine efficiency allows gathering new knowledge for people who manage resources as well asforpolicy makers by optimizing practices and having better allocation criteria.

Alta utilidad de monitorización hemodinámica con ecocardiografía transesofágica intraoperatoria en cirugía ortopédica / Intraoperative hemodynamic monitoring using transesophageal echocardiography in orthopedic surgery

Background: Orthopedic surgery is commonly performed in elderly patients with higher cardiovascular surgical risk. Hemodynamic monitoring in these patients may prevent perioperative complications. Aim: To assess the usefulness of transesophageal echocargiography (TEE) for intraoperative cardiovascular monitoring during orthopedic surgery. Material and methods: Patients older than 65 years subjected to orthopedic surgery using general anesthesia and with a high cardiovascular risk were studied. Intraoperative TEE was performed to assess intravascular volume, myocardial contractility and the presence of myocardial ischemia. Results: Fifty three patients aged 72±5 years were studied. Hemodynamic stability was detected in 68 percent of patients, mainly reflected as episodes of hypovolemia. Myocardial ischemia was detected in two patients and embolic episodes in six (11 percent). Conclusions: Intraoperative TEE was useful for the hemodynamic evaluation of patients with high cardiovascular risk.

Ecocardiografía transesofágica intraoperatoria: monitorización hemodinámica durante cirugía no cardíaca / Intraoperative transesophageal echocardiography: hemodynamic monitoring during non cardiac surgery

Introducción: La ecocardiografía transesofágica (ETE) puede ser de utilidad para monitorizar la hemodinamia intraoperatorio de pacientes con riesgo cardiovascular durante cirugía no cardíaca. Sin embargo sus indicaciones y utilidad clínica han sido poco estudiadas en nuestro medio. Objetivo: evaluar el uso de ETE intraoperatorio realizado por anestesiólogos durante cirugía no cardíaca. Métodos: Se monitorizó con un transductor transesofágico multiplanar a 218 pacientes (66 ± 8 años) con alto riesgo cardiovascular sometidos a cirugía no cardíaca; 61 por ciento fueron hombres. Se evaluó la utilidad de la monitorización hemodinámica con ETE en cada enfermo respecto de decidir cambios en el manejo perioperatorio dependientes de los hallazgos ecocardiográficos. Los pacientes fueron clasificados en 4 grupos: grupo 1= sin cambios en el manejo; grupo 2= cambio en manejo de volúmenes y drogas; grupo 3= cambios en el manejo postoperatorio y grupo 4= sustituto de catéter de arteria pulmonar. Resultados: En todos los casos se logró insertar el transductor y obtener visiones satisfactorias. En 96 casos (44 por ciento) hubo cambios en el aporte de volúmenes y fármacos guiados por ETE (grupo 2). En un 25 por ciento de los pacientes, por hallazgos ecocardiográficos hubo cambios postoperatorio (grupo 3). En 30 por ciento no se indicó Swan Ganz guiándose el manejo hemodinámico por la ETE (grupo 4). Conclusiones: La monitorización hemodinámica intraoperatoria con ETE realizada por anestesiólogos demostró alta utilidad, ya que implicó cambios de diagnóstico y conducta en la mayoría de pacientes monitorizados durante cirugía no cardíaca incluidos en esta serie.

Monitorización hemodinámica intraoperatoria con ecocardiografía transesofágica: experiencia clínica / Intraoperatory hemodynamic monitoring with transesophageal echocardiography

Background: Transesophageal echocardiography allows a semi-invasive hemodynamic monitoring, during cardiac and non cardiac surgery. The benefits of such surveillance must be assessed, since it may help to change patient management. Aim: To assess the usefulness of transesophageal echocardiography during surgical procedures in critical patients. Material and methods: Based on the indications of the North American Societies of Cardiology and Anesthesiology, 264 patients were monitored using a multiplanar transducer. The type of surgery, insertion difficulties, quality of visualization, complications and usefulness of the method were recorded. Results: One hundred eleven cardiac and 153 non cardiac surgical procedures were monitored. In 97 percent of cases, visualization was good. In 2 cases, it was impossible to obtain a transgastric axis. No complications of the procedure were recorded. The method was useless in nine patients, helpful to change drug and volume management in 126 (48 percent) patients, helpful to change perioperative management in 49 (19 percent) patients and was a substitute for pulmonary artery catheterization in 79 (30 percent) patients. Conclusions: Intraoperative transesophageal echocardiography is a safe technique that renders high quality images, with a low incidence of complications and that, when well indicated, orients therapeutic changes in 98 percent of patients.