Epidemiology of chronic kidney disease in adults of Salvadoran agricultural communities.

INTRODUCTION: In El Salvador, chronic kidney disease is a serious and growing public health problem. Chronic renal failure was the first cause of hospital deaths in men and the fifth in women in 2011. OBJECTIVE: Determine prevalence of CKD, CKD risk factors (traditional and nontraditional) and renal damage markers in the adult population of specific rural areas in El Salvador; measure population distribution of renal function; and identify associated risk factors in CKD patients detected. METHODS: A cross-sectional analytical epidemiological study was conducted based on active screening for chronic kidney disease and risk factors in persons aged ≥18 years during 2009-2011. Epidemiological and clinical data were gathered through personal history, as well as urinalysis for renal and vascular damage markers, determinations of serum creatinine and glucose, and estimation of glomerular filtration rates. Chronic kidney disease cases were confirmed at three months. Multiple logistical regression was used for statistical analysis. RESULTS: Prevalence of chronic kidney disease was 18% (23.9% for men and 13.9% for women) in 2388 persons: 976 men and 1412 women from 1306 families studied. Chronic kidney disease with neither diabetes nor hypertension nor proteinuria ≥1 g/L (51.9%) predominated. Prevalence of chronic renal failure was 11% (17.1% in men and 6.8% in women). Prevalence of renal damage markers was 12.5% (higher in men): microalbuminuria, 6.9%; proteinuria (0.3 g/L), 1.7%; proteinuria (1g/L), 0.6%; proteinuria (2 g/L), 0.4 %; and hematuria, 1.5%. Prevalence of chronic kidney disease risk factors was: diabetes mellitus, 9%; hypertension, 20.9%; family history of chronic kidney disease, 16.5%; family history of diabetes mellitus, 18.5%; family history of hypertension, 30.6%; obesity, 21%; central obesity, 24.9%; NSAID use, 84.2%; smoking, 9.9%; alcohol use, 15%; agricultural occupation, 31.2%; and contact with agrochemicals, 46.7%. Chronic kidney disease was significantly associated with male sex, older age, hypertension, agricultural occupation, family history of chronic kidney disease and contact with the agrochemical methyl parathion. CONCLUSIONS: The results of this study support suggestions from other research that we are facing a new form of kidney disease that could be called agricultural nephropathy.

Evaluación de proceso de un Programa de Vigilancia de Eventos Adversos Hospitalarios, Clínica Dávila, Chile Clínica Dávila, Chile / Process evaluation of a SurveillancePprogram of Adverse Hospital Events: Davila Clinic, Chile

Objetivo: Evaluar el proceso de implementación de un Programa de Vigilancia de Eventos Adversos de un hospital privado de Chile (Clínica Dávila). Material y Método: Se utilizó el estudio de caso como marco metodológico, creando un marco de análisis basado en las recomendaciones de organismos internacionales e integrando técnicas cuantitativas y cualitativas de recopilación y análisis de la información. Resultados: Se identificó una alta congruencia entre el diseño y el marco de análisis construido. Se observó también una tendencia al alza en la tasa de notificaciones, siendo la administración errónea de medicamentos y las caídas (58 por ciento entre ambos) las motivaciones principales para desarrollar un análisis causa raíz (ACR). El 43,8 por ciento de causas identificadas calificó como factores individuales y sólo en un 15,73 por ciento, como factores institucionales/organizacionales. Los entrevistados valoraron el programa y creen que ha aportado a la cultura de aprendizaje, pero proponen mejorar la retroalimentación, los espacios de gestión y fortalecer las competencias para el análisis de los errores de procesos clínicos. Conclusiones: El programa ha sido un aporte para colaborar con un clima de aprendizaje, pero existe un desequilibrio entre los esfuerzos por recopilar información y el análisis sistémico de la misma. El sistema de notificación voluntario y anónimo se ha transformado en un espacio de comunicación organizacional, que excede los objetivos del programa y que debe ser tomado en cuenta en la implementación de programas similares.

Objective: Evaluate the implementation process of a surveillance program for adverse events in a private hospital in Chile (Clínica Dávila). Materials and Methods: A case study methodology was used, using a framework for analysis based on the recommendations of international organizations, and integrating qualitative and quantitative techniques for gathering and analyzing data. Results: A high level of coherence was found between program design and the analysis framework. An increase in the notification rate, both for the administration of the wrong medication and for falls was also noted (58 percent among both), those being the principal motivations for root cause analysis (RCA). 43.8 percent of causes were identified as individual factors and only 15.73 percent as institutional or organizational factors. Interviewees valued the program and believe that it created a good learning environment, but they propose better feedback and management, and building competency for error analysis in clinical processes. Conclusions: The program contributed to a better learning environment, but there was an imbalance between the data collection efforts and systematic data analysis. The voluntary and anonymous notification system has been transformed into a space for communication within the hospital, which exceeded the program's objectives and should be taken into account in the implementation of similar programs.

Caracterización de pacientes hospitalizados en Clínica Dávila por ley de urgencia, 2003 / Characterization of patients admitted to Clínica Dávila under the medical emergency law (ley de urgencia), 2003

Antecedentes: La Ley de Urgencia vigente ampara la vida en situaciones de riesgo, independiente de la capacidad de pago. Objetivo: Realizar seguimiento y conocer las características de los pacientes hospitalizados por concepto de Ley de Urgencia en Clínica Dávila durante 2003. Material y Método: Se aplicó una encuesta a los pacientes hospitalizados durante 2003 utilizando además la base de datos de Clínica Dávila para completar información. Resultados: La población total fue de 165 pacientes, de los cuales se aplicó efectivamente la encuesta a 102. La edad promedio fue de 61 años, distribuyéndose en 41.8 (%) hombres y 58.18% mujeres. Los diagnósticos principales correspondieron a enfermedades cardiovasculares (34,5%) neurológicas (20 por ciento), respiratorias (14.5%, infecciosas (7.2 (%)), Diabetes Mellitus descompensada (6%) y patología quirúrgica (9.6%). El control de patología crónica en la población estudiada -previo a la hospitalización- fue de 53.8 (%), siendo en un 44.8 (%) en consultorios de atención primaria. El control posterior al alta de la Clínica fue de 85.7 (%), en un 39.7 (%) en la misma Clínica. De los pacientes fallecidos posterior al alta, 72.72 (%) no estaba en control y la mediana de edad fue 77 años. Discusión: Estos resultados indican que los principales beneficiarios de la Ley de Urgencia fueron pacientes de la tercera edad con alguna enfermedad crónica cuyo control parece insuficiente. El traspaso de pacientes del sistema público al privado, así como el impacto de la atención otorgada por el nivel primario, son situaciones a estudiar para propender a optimizar los recursos.

Background: The Medical Emergency Law which is currently in force protects life at-risk, irrespectively of the solvency of the patient. Purpose: To carry out a follow-up and to know the characteristics of patients admitted to Clínica Dávila under the protection of the Medical Emergency Law, during 2003. Materials and Methods: A survey was implemented within all inpatients admitted during 2003. Information data was completed with Clínica Dávila database. Results: The total population of inpatients under the protection of the Law was 165. A total of 102 patients were effectively surveyed. Patient mean age was 61; 41.8% were males while 58.18% were female. The main diagnoses were cardiovascular diseases (34,5%), neurological disorders (20%), respiratory diseases (14.5%), infectious diseases (7.2%), decompensated Diabetes Mellitus (6%) and surgical pathologies (9.6%). Among the study population, 53.8% of patients were under control for chronic diseases prior to admission; 44.8% of such controls were carried out at primary care outpatient facilities. After discharge, 85.7% of the study population carried out regular controls, in 39.7% of the cases, within the same admission Hospital. A total of 72.72% of the patients deceased after discharge was not undergoing any control, and the median age of such population was 77. Discussion: The results indicate that the main beneficiaries of the Medical Emergency Law were senior patients with a chronic disease who wouldn’t be undergoing a sufficient control of their condition. Transfer of patients from the public to the private health system, as well as the impact of the medical assistance delivered by the primary care level are situations that need further research to aim at optimizing the resources available.

Indicadores trazadores de gestión hospitalaria: revisión, análisis y propuesta / Indicators for hospital planning management: revision, analysis and proposals

Las instituciones prestadoras de servicios de atención médica han debido asumir una postura de adaptación continua y permanente a los cambios, ya sea frente a sus clientes, al recambio tecnológico y a las variaciones de la práctica clínica, como a su propia sustentabilidad financiera. En consecuencia la toma de decisiones se ha complejizado con el aumento de la cantidad, variedad y tipos de resultados de las intervenciones sanitarias. Al mismo tiempo se ha creado un infinito volumen de mediciones de recursos, procesos, resultados e impacto de tales acciones, sin que exista hoy un consenso absoluto respecto de la utilidad, validez o confiabilidad de tales mediciones. Se realizó una revisión conceptual de definiciones y características de indicadores en salud (bibliográfica y entrevistas), una investigación bibliográfica de experiencias nacionales e internacionales, y una discusión y definición de dimensiones de indicadores trazadores de gestión para la Clínica Dávila, en el marco de su plan de trabajo del año 2003. Se definieron 5 dimensiones: la calidad técnica, efectividad, eficiencia, relación con seguros y relación con usuarios. Para cada una, la revisión de experiencias mostró una distribución de indicadores de 58.6 por ciento, 9.7 por ciento, 45.2 por ciento, 3.2 por ciento y 22.6 por ciento respectivamente, mientras que el análisis local presentó una distribución de 37.4 por ciento, 0.0 por ciento, 17.14 por ciento, 22.9 por ciento respectivamente, el que resultó concordante con la mayor prevalencia de indicadores de calidad técnica. Por otra parte, destacan los indicadores locales de relación con usuarios y seguros, dimensiones poco o nada abordadas en otras experiencias. Finalmente, se realizan sugerencias para una propuesta de trabajo en este ámbito para ser desarrollada al interior de la institución.

[Epidemiology of severe acute renal failure in Metropolitan Santiago]. / Epidemiología de la insuficiencia renal aguda grave. Un estudio prospectivo multicéntrico en la Región Metropolitana.

BACKGROUND: There is a paucity of information about the epidemiology of acute renal failure in Chile. AIM: To perform a prospective multicentric survey of severe acute renal failure in Chile. MATERIAL AND METHODS: All patients admitted to ten hospitals in Metropolitan Santiago, during a period of six months with severe acute renal failure, were studied. The criteria for severity was the requirement of renal replacement therapy. All patients information was gathered in special forms and the type of renal replacement therapy and evolution was registeres. RESULTS: One hundred fourteen patients were studied (65 males, age range 18 to 87 years). The calculated incidence of acute renal failure was 1.03 cases per 1000 hospital discharges. The onset was nosocomial in 79 subjects (69%) and community acquired in the rest. Renal failure was oliguric in 64 cases (56%) and in 60% of patients it had two or more causative factors. Sepsis, isolated or combined with other causes, was present in 51 of patients. Other causes included ischemia in 47%, surgery in 26%, exogenous toxicity in 25%, endocenous toxicity in 11%, acute glomerular damage in 6% and obstructive uropathy in 6%. Cardiac surgery was responsible for 47% of post operative cases of acute renal failure. Intermittent conventional hemodialysis, continuous renal replacement techniques and daily prolonged hemodialysis were used in 66%, 29% and 2% of patients, respectively. Overall mortality was 45% and it was higher in oliguric patients. Gender, age, cause or the type of therapy did not influence survival. Nine percent of surviving patients had some degree of kidney dysfunction at discharge. CONCLUSIONS: There is still a great space for prevention of severe acute renal failure in Chile, considering the main etiologies found in this study.

[Causes of the crisis of medical profession in Chile]. / Causas de la crisis de la profesión médica en Chile.

There is a growing dissatisfaction among physicians towards their professional practice. This article tries to identify causes of this dissatisfaction and to explain the fears that physicians experience during their practice. The authors pose the hypothesis that physicians have non resolved internal problems with the application of technological advances and that medical practice has not changed along with the dramatic social changes that have occurred in the last decades. Medical organizations work in a confusing environment. Considering the main characteristics of medical work, the causes of difficulties and the reasons to explain the slowness of physicians to identify the problems and react, are analyzed. Finally some solutions are proposed to overcome this crisis.