Hospital care direct costs due to ambulatory care sensitive conditions related to diabetes mellitus in the Mexican public healthcare system.

BACKGROUND: Hospitalizations for ambulatory care sensitive conditions (ACSC) incur substantial costs on the health system that could be partially avoided with adequate outpatient care. Complications of chronic diseases, such as diabetes mellitus (DM), are considered ACSC. Previous studies have shown that hospitalizations due to diabetes have a significant financial burden. In Mexico, DM is a major health concern and a leading cause of death, but there is limited evidence available. This study aimed to estimate the direct costs of hospitalizations by DM-related ACSC in the Mexican public health system. METHODS: We selected three hospitals from each of Mexico's main public institutions: the Mexican Social Security Institute (IMSS), the Ministry of Health (MoH), and the Institute of Social Security and Services for State Workers (ISSSTE). We employed a bottom-up microcosting approach from the healthcare provider perspective to estimate the total direct costs of hospitalizations for DM-related ACSC. Input data regarding length of stay (LoS), consultations, medications, colloid/crystalloid solutions, procedures, and laboratory/medical imaging studies were obtained from clinical records of a random sample of 532 hospitalizations out of a total of 1,803 DM-related ACSC (ICD-10 codes) discharges during 2016. RESULTS: The average cost per DM-related ACSC hospitalization varies among institutions, ranging from $1,427 in the MoH to $1,677 in the IMSS and $1,754 in the ISSSTE. The three institutions' largest expenses are LoS and procedures. Peripheral circulatory and renal complications were the major drivers of hospitalization costs for patients with DM-related ACSC. Direct costs due to hospitalizations for DM-related ACSC in these three institutions represent 1% of the gross domestic product (GDP) dedicated to health and social services and 2% of total hospital care expenses. CONCLUSIONS: The direct costs of hospitalizations for DM-related ACSC vary considerably across institutions. Disparities in such costs for the same ACSC among different institutions suggest potential disparities in care quality across primary and hospital settings (processes and resource utilization), which should be further investigated to ensure optimal supply utilization. Prioritizing preventive measures for peripheral circulatory and renal complications in DM patients could be highly beneficial.

[Quality of health information in Mexico in the OECD context: 2017-2021]. / Calidad de la información en salud de México en el contexto de la OCDE: 2017-2021.

OBJECTIVE: To evaluate the health information system (HIS) of Mexico according to the information reported to the Organization for Economic Co-operation and Development (OECD). The ultimate goal is to identify the improvements that should be considered. METHOD: Health indicators published by the OECD (2017 to 2021) are analyzed according to 11 thematic groups. Coverage (quantity and type of indicators reported by thematic group) and quality of information were assessed, according to OECD guidelines. RESULTS: Mexico reported annually 14 of 378 indicators (3.7%), and discontinuously 204. In no group were all indicators reported annually, except for the two on COVID-19. Three out of 88 were reported annually on use of services; and none on health status, quality of care and pharmaceutical market. Twelve indicators (5.5% of those reported by Mexico, 3.2% of the full OECD set) had optimal quality and annual reporting. 57.7% of the reported indicators had at least one quality defect. CONCLUSIONS: Within the framework of the standards set by the OECD, of which Mexico is a member, the Mexican HIS presents significant deficits in coverage and quality of information. These results should be considered to implement improvement initiatives.

Calidad de la información en salud de México en el contexto de la OCDE: 2017-2021 / Quality of health information in Mexico in the OECD context: 2017-2021

Objetivo Evaluar el sistema de información en salud (SIS) de México según la información reportada a la Organización para la Cooperación y el Desarrollo Económicos (OCDE). El fin último es evidenciar las mejoras que se deberían considerar. Método Se analizan indicadores sobre salud publicados por la OCDE (2017 a 2021) según 11 grupos temáticos. Se valoraron cobertura (cantidad y tipo de indicadores reportados por grupo temático) y calidad de la información, según lineamientos de la OCDE. Resultados México reportó anualmente 14 de 378 indicadores (3,7%) y de forma discontinua 204. En ningún grupo se reportaron anualmente todos los indicadores, excepto los dos sobre COVID-19. Se reportan anualmente tres de 88 sobre utilización de servicios y ninguno sobre estado de salud, calidad de la atención y mercado farmacéutico. Con calidad óptima y reporte anual fueron 12 indicadores (5,5% de los reportados por México, 3,2% del set completo OCDE). El 57,7% de los indicadores reportados tuvieron al menos un defecto de calidad. Conclusiones En el marco de los estándares marcados por la OCDE, de la cual México es miembro, el SIS mexicano presenta déficits importantes de cobertura y de calidad de la información. Estos resultados deberían considerarse para implementar iniciativas de mejora. (AU)

Objective To evaluate the health information system (HIS) of Mexico according to the information reported to the Organization for Economic Co-operation and Development (OECD). The ultimate goal is to identify the improvements that should be considered. Method Health indicators published by the OECD (2017 to 2021) are analyzed according to 11 thematic groups. Coverage (quantity and type of indicators reported by thematic group) and quality of information were assessed, according to OECD guidelines. Results Mexico reported annually 14 of 378 indicators (3.7%), and discontinuously 204. In no group were all indicators reported annually, except for the two on COVID-19. Three out of 88 were reported annually on use of services; and none on health status, quality of care and pharmaceutical market. Twelve indicators (5.5% of those reported by Mexico, 3.2% of the full OECD set) had optimal quality and annual reporting. 57.7% of the reported indicators had at least one quality defect. Conclusions Within the framework of the standards set by the OECD, of which Mexico is a member, the Mexican HIS presents significant deficits in coverage and quality of information. These results should be considered to implement improvement initiatives. (AU)

[Comparative analysis of the accreditation of medical facilities in Canada, Chile, the Autonomous Community of Andalusia, Denmark, and MexicoAnálise comparativa da acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México]. / Análisis comparativo de la acreditación de unidades médicas en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México.

Objective: To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions. Methods: An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019-2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized. Results: The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico). Conclusions: The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

Objetivo: Comparar as características do processo de acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México, a fim de identificar elementos comuns e diferenças, bem como lições aprendidas que podem ser úteis para outros países e regiões. Métodos: Estudo observacional, analítico e retrospectivo usando fontes secundárias de livre acesso sobre acreditação e certificação de estabelecimentos de saúde durante o período 2019-2021 nos países e regiões supracitados. As características gerais do processo de acreditação e suas respostas a pontos-chave no delineamento de tais programas foram descritas. Além disso, foram geradas categorias de análise para o andamento de sua implantação e seu grau de complexidade, e os desfechos favoráveis e desfavoráveis relatados foram resumidos. Resultados: Os componentes operacionais do processo de acreditação são peculiares a cada país, embora compartilhem certas semelhanças. O programa canadense é o único que contempla algum tipo de avaliação responsiva. Houve grande variação entre países no percentual de estabelecimentos acreditados (de 1% no México a 34,7% na Dinamarca). Entre as lições aprendidas, destacam-se a complexidade da aplicação do sistema misto público-privado (Chile), o risco de burocratização excessiva (Dinamarca) e a necessidade de incentivos claros (México). Conclusões: Os programas de acreditação operam de forma peculiar em cada país ou região, têm diferentes escopos e também apresentam diversos problemas a partir dos quais podemos aprender. É preciso considerar os elementos que dificultam a implementação e realizar as adequações necessárias para os sistemas de saúde de cada país ou região.

Análisis comparativo de la acreditación de unidades médicas en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México

[RESUMEN]. Objetivo. Contrastar las características del proceso de acreditación de establecimientos de salud en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México, con el fin de identificar elementos comunes y diferencias, y las lecciones aprendidas que puedan ser de utilidad para otros países y regiones. Métodos. Estudio observacional, analítico y retrospectivo en el que se usaron fuentes secundarias de libre acceso sobre acreditación y certificación de establecimientos de salud durante el período 2019-2021 en estos países y regiones. Se describen las características generales del proceso de acreditación y sus res- puestas a puntos clave del diseño de estos programas. Además, se generaron categorías de análisis para el avance en su implementación y su nivel de complejidad, y se resumen los resultados favorables y desfavorables informados. Resultados. Los componentes operativos del proceso de acreditación son peculiares de cada país, aunque comparten similitudes. El programa de Canadá es el único que contempla algún tipo de evaluación responsiva. Hay una amplia variación en la cobertura de establecimientos acreditados entre países (desde 1% en México a 34,7% en Dinamarca). Entre las lecciones aprendidas, se destacan la complejidad de aplicación del sistema mixto público-privado (Chile), el riesgo de una excesiva burocratización (Dinamarca) y la necesidad de incentivos claros (México). Conclusiones. Los programas de acreditación operan de forma peculiar en cada país o región, logran alcances diferentes y presentan problemáticas también diversas, de las que podemos aprender. Es necesario considerar los elementos que obstaculizan la implementación y generar adecuaciones para los sistemas de salud en cada país o región.

[ABSTRACT]. Objective. To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions. Methods. An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019–2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized. Results. The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico). Conclusions. The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

[RESUMO]. Objetivo. Comparar as características do processo de acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México, a fim de identificar elementos comuns e diferenças, bem como lições aprendidas que podem ser úteis para outros países e regiões. Métodos. Estudo observacional, analítico e retrospectivo usando fontes secundárias de livre acesso sobre acreditação e certificação de estabelecimentos de saúde durante o período 2019-2021 nos países e regiões supracitados. As características gerais do processo de acreditação e suas respostas a pontos-chave no delineamento de tais programas foram descritas. Além disso, foram geradas categorias de análise para o andamento de sua implantação e seu grau de complexidade, e os desfechos favoráveis e desfavoráveis relatados foram resumidos. Resultados. Os componentes operacionais do processo de acreditação são peculiares a cada país, embora compartilhem certas semelhanças. O programa canadense é o único que contempla algum tipo de avaliação responsiva. Houve grande variação entre países no percentual de estabelecimentos acreditados (de 1% no México a 34,7% na Dinamarca). Entre as lições aprendidas, destacam-se a complexidade da aplicação do sistema misto público-privado (Chile), o risco de burocratização excessiva (Dinamarca) e a necessidade de incentivos claros (México). Conclusões. Os programas de acreditação operam de forma peculiar em cada país ou região, têm diferentes escopos e também apresentam diversos problemas a partir dos quais podemos aprender. É preciso conside- rar os elementos que dificultam a implementação e realizar as adequações necessárias para os sistemas de saúde de cada país ou região.

Análisis comparativo de la acreditación de unidades médicas en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México / Comparative analysis of the accreditation of medical facilities in Canada, Chile, the Autonomous Community of Andalusia, Denmark, and Mexico / Análise comparativa da acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México

RESUMEN Objetivo. Contrastar las características del proceso de acreditación de establecimientos de salud en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México, con el fin de identificar elementos comunes y diferencias, y las lecciones aprendidas que puedan ser de utilidad para otros países y regiones. Métodos. Estudio observacional, analítico y retrospectivo en el que se usaron fuentes secundarias de libre acceso sobre acreditación y certificación de establecimientos de salud durante el período 2019-2021 en estos países y regiones. Se describen las características generales del proceso de acreditación y sus respuestas a puntos clave del diseño de estos programas. Además, se generaron categorías de análisis para el avance en su implementación y su nivel de complejidad, y se resumen los resultados favorables y desfavorables informados. Resultados. Los componentes operativos del proceso de acreditación son peculiares de cada país, aunque comparten similitudes. El programa de Canadá es el único que contempla algún tipo de evaluación responsiva. Hay una amplia variación en la cobertura de establecimientos acreditados entre países (desde 1% en México a 34,7% en Dinamarca). Entre las lecciones aprendidas, se destacan la complejidad de aplicación del sistema mixto público-privado (Chile), el riesgo de una excesiva burocratización (Dinamarca) y la necesidad de incentivos claros (México). Conclusiones. Los programas de acreditación operan de forma peculiar en cada país o región, logran alcances diferentes y presentan problemáticas también diversas, de las que podemos aprender. Es necesario considerar los elementos que obstaculizan la implementación y generar adecuaciones para los sistemas de salud en cada país o región.

ABSTRACT Objective. To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions. Methods. An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019-2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized. Results. The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico). Conclusions. The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

RESUMO Objetivo. Comparar as características do processo de acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México, a fim de identificar elementos comuns e diferenças, bem como lições aprendidas que podem ser úteis para outros países e regiões. Métodos. Estudo observacional, analítico e retrospectivo usando fontes secundárias de livre acesso sobre acreditação e certificação de estabelecimentos de saúde durante o período 2019-2021 nos países e regiões supracitados. As características gerais do processo de acreditação e suas respostas a pontos-chave no delineamento de tais programas foram descritas. Além disso, foram geradas categorias de análise para o andamento de sua implantação e seu grau de complexidade, e os desfechos favoráveis e desfavoráveis relatados foram resumidos. Resultados. Os componentes operacionais do processo de acreditação são peculiares a cada país, embora compartilhem certas semelhanças. O programa canadense é o único que contempla algum tipo de avaliação responsiva. Houve grande variação entre países no percentual de estabelecimentos acreditados (de 1% no México a 34,7% na Dinamarca). Entre as lições aprendidas, destacam-se a complexidade da aplicação do sistema misto público-privado (Chile), o risco de burocratização excessiva (Dinamarca) e a necessidade de incentivos claros (México). Conclusões. Os programas de acreditação operam de forma peculiar em cada país ou região, têm diferentes escopos e também apresentam diversos problemas a partir dos quais podemos aprender. É preciso considerar os elementos que dificultam a implementação e realizar as adequações necessárias para os sistemas de saúde de cada país ou região.

Acreditación de servicios y calidad de la atención a neonatos en hospitales mexicanos.

OBJETIVO: Comparar la calidad de atención a neonatos con sepsis neonatal, hipoxia intrauterina, prematuridad y asfixia perinatal en hospitales acreditados (HA) y no acreditados (HNA). Material y métodos. Se evaluaron 28 hospi-tales de la Secretaría de Salud en 11 estados de México; la evaluación incluyó infraestructura, equipamiento e insumos, procesos de gestión de calidad e indicadores de calidad clínica. Se utilizó LQAS y se estimó el cumplimiento promedio de criterios e indicadores en HA y HNA. RESULTADOS: Hubo diferencias significativas en favor de HA en equipamiento e insumos y no significativas en existencia y funcionamiento de los comités hospitalarios. No hubo diferencias consistentes ni significativas en cumplimiento de indicadores clínicos entre los HA y HNA. CONCLUSIONES: La acreditación para la atención de neonatos con los diagnósticos seleccionados no se asocia a diferencias en la calidad de la atención.

Acreditación de servicios y calidad de la atención a neonatos en hospitales mexicanos / Accreditation of services and quality of care for newborns in mexican hospitals

Resumen: Objetivo: Comparar la calidad de atención a neonatos con sepsis neonatal, hipoxia intrauterina, prematuridad y asfixia perinatal en hospitales acreditados (HA) y no acreditados (HNA). Material y métodos: Se evaluaron 28 hospitales de la Secretaría de Salud en 11 estados de México; la evaluación incluyó infraestructura, equipamiento e insumos, procesos de gestión de calidad e indicadores de calidad clínica. Se utilizó LQAS y se estimó el cumplimiento promedio de criterios e indicadores en HA y HNA. Resultados: Hubo diferencias significativas en favor de HA en equipamiento e insumos y no significativas en existencia y funcionamiento de los comités hospitalarios. No hubo diferencias consistentes ni significativas en cumplimiento de indicadores clínicos entre los HA y HNA. Conclusiones: La acreditación para la atención de neonatos con los diagnósticos seleccionados no se asocia a diferencias en la calidad de la atención.

Abstract: Objective: To compare the quality of care for neonates with neonatal sepsis, intrauterine hypoxia, prematurity and perinatal asphyxia in accredited hospitals (HA) and unaccredited (HNA). Materials and methods: 28 hospitals of the Ministry of Health were evaluated in 11 states in Mexico; the evaluation included infrastructure, equipment and supplies, quality management processes, and clinical quality indicators. LQAS was used, and average fulfillment of criteria and indicators in AH and NAH was estimated. Results: There were significant differences in favor of HA in equipment and supplies and, not significant, in the existence and functioning of hospital committees. There were no consistent or significant differences in compliance with clinical indicators between the AH y NAH. Conclusions: Accreditation for the care of newborns with the selected diagnoses is not associated with differences in the quality of care.

Potentially inappropriate prescribing in older adults in Mexico.

OBJECTIVE: To identify and quantify potentially inappropriate prescribing (prescripción potencialmente inapropiada, PPI) and other drug prescribing problems in public health care services in a population-based study at the three existing levels of complexity in Mexico. METHODS: Descriptive analysis of the Study on Satisfaction of Users of the Social Protection System in Health 2014-2016, prescription and drug supply section, to obtain the prevalence of PPI in older adults (≥ 65 years), based on Beers, STOPP, Prescrire and BSP listings using AM (older adults) prescription indicators, one for each listing. RESULTS: Most older adults (67%) were prescribed at least one medication, with a mean of 2.7 medications per prescription. The PPI prevalence was 74% according to the BSP criteria, 67% according to the STOPP listing, 59% with the Beer criteria, and 20% with Prescrire. The most frequent PPI prescriptions were NSAIDs, vasodilators and sulfonylureas. CONCLUSIONS: The use of PPIs in AM is high in Mexico. The higher prevalence found in this study may reflect the use of a source with population representativeness. The partial use and adaptations of the criteria make difficult comparing the studies; however, the STOPP criteria are the ones with the highest prevalence, as they cover a greater number of drugs and their use is more common in the first level of care.

Barreras y facilitadores en la implementación de guías de práctica clínica en México: perspectiva del personal de salud / Barriers and facilitators in the implementation of clinical practice guidelines in Mexico: perspective of health workers

Resumen: Objetivo: Identificar barreras, facilitadores y propuestas de mejora en la implementación de Guías de Práctica Clínica (GPC) desde la perspectiva de los profesionales de la salud. Material y métodos: Estudio cualitativo a través de 85 entrevistas semiestructuradas a responsables de implementación, difusión y aplicación, y del personal operativo en centros de atención primaria y hospitales en siete estados de México. El contenido fue codificado y analizado con ATLAS.ti 7.0. Resultados: Las principales barreras encontradas fueron la no actualización de las GPC y baja alineación con otras normas, e imposibilidad de implementarlas debido a la sobrecarga de trabajo y los recursos limitados. Conclusiones: El esfuerzo por implementar GPC parece haber sido errático e insuficiente, y la evaluación de su utilización inexistente. Se propone crear estrategias integradas y contextualizadas que resulten ser más efectivas y eficientes para la implementación exitosa de GPC.

Abstract: Objective: To identify barriers, facilitators and proposals for improvement in the implementation of CPG from the perspective of health professionals. Materials and methods: Qualitative study through 85 semi-structured interviews with those responsible for the implementation, dissemination and application activities, and of the operational personnel in primary care centers and hospitals in seven states of Mexico. The content was coded and analyzed with ATLAS.ti 7.0. Results: The main barriers found were the failure to update the CPGs and low alignment with other standards, and the impossibility of implementing them due to work overload and limited resources. Conclusions: The effort to implement CPG seems to have been erratic and insufficient, and the evaluation of its use non-existent. It is proposed to create integrated and contextualized strategies that prove to be more effective and efficient for the successful implementation of the CPG.

Carencias y variabilidad en la calidad de la atención a neonatos hospitalizados en México. Estudio transversal en 28 hospitales públicos.

Objetivo. Evaluar la calidad de la atención a neonatos con indicadores de proceso, en patologías seleccionadas. Ma-terial y métodos. Evaluación multicéntrica, transversal de nueve indicadores en 28 hospitales de 11 entidades de México. Se utilizó Lot Quality Assurance Sampling (LQAS) para estándares de calidad y muestra por hospital. Casos seleccio-nados al azar del Subsistema Automatizado de Egresos Hos-pitalarios. Se clasifican hospitales como "cumplimiento con estándar"/"no cumplimiento" por indicador y, cumplimiento con IC95% exacto binomial, regional y nacional, según mues-treo estratificado no proporcional. Resultados. Ningún indicador cumple el estándar de 75% en hospitales, con 0 a 19 hospitales que cumplen, según indicador. Excepto la iden-tificación oportuna de asfixia perinatal e inicio de antibiótico correcto en sospecha de sepsis temprana, el cumplimiento es <50% en todos los demás indicadores. Conclusiones. La calidad de la atención a neonatos en hospitales es heterogé-nea y deficiente. Se proponen indicadores para monitorizar iniciativas de mejora.

Barreras y facilitadores en la implementación de guías de práctica clínica en México: perspectiva del personal de salud.

Objetivo. Identificar barreras, facilitadores y propuestas de mejora en la implementación de Guías de Práctica Clínica (GPC) desde la perspectiva de los profesionales de la salud. Material y métodos. Estudio cualitativo a través de 85 entrevistas semiestructuradas a responsables de implementa-ción, difusión y aplicación, y del personal operativo en centros de atención primaria y hospitales en siete estados de México. El contenido fue codificado y analizado con ATLAS.ti 7.0. Resultados. Las principales barreras encontradas fueron la no actualización de las GPC y baja alineación con otras normas, e imposibilidad de implementarlas debido a la sobre-carga de trabajo y los recursos limitados. Conclusiones. El esfuerzo por implementar GPC parece haber sido errático e insuficiente, y la evaluación de su utilización inexistente. Se propone crear estrategias integradas y contextualizadas que resulten ser más efectivas y eficientes para la implementación exitosa de GPC.

Avoidable Hospitalization Trends From Ambulatory Care-Sensitive Conditions in the Public Health System in México.

OBJECTIVES: To estimate and identify the variations in rates of Avoidable Hospitalization for Ambulatory Care Sensitive Conditions (AH-ACSC) in public institutions of the Mexican health system during the period 2010-2017. METHODS: Secondary analysis of the hospital discharge database of the Ministry of Health (MoH) from 2010 to 2017. AH for ACSC was calculated by age group and sex per 100,000. Variations per year between institutions were calculated with the extreme quotient (EQ), coefficient of variation (CV) and systematic component of variance (SCV). Adjusted AH rates were calculated by group of causes (acute, chronic and preventable by vaccination). Adjusted AH trend rates were analyzed by Join Point Regression. RESULTS: For the period 2010-2017, the number of AH for ACSC decreased from 676,705 to 612,897, going from almost 13% to 10.7% of hospital discharges. There is consistency in terms of relative variance magnitude. But, with regards to SCV, the change remained constant, and in a second period of 2015-2017, high variation was observed by SCV ≥ 3. All-cause AH is diminishing in all institutions. AH rates for diabetes are the highest, but like other chronic diseases, there was a decline in the period from 2010 to 2017. The relative reduction varied from 15% for heart failure to 38% for complications from diabetes or hypertension, to 75% for angina. CONCLUSIONS: AH for ACSC is an indirect indicator of quality and access to first-level care. Variations by institutions are observed. This variation in CV and SCV across subsystems and states may be due to inequities in the provision of services. The factors that contribute to the burden of AH for ACSC in the Mexican Health System require detailed analysis.

Disrespect and Abuse in Obstetric Care in Mexico: An Observational Study of Deliveries in Four Hospitals.

INTRODUCTION: To identify and describe the frequency and characteristics of disrespect and abuse practices towards women during facility-based delivery in four hospitals in two Mexican states in 2017, using a mixed method of direct observation and women's reports of health care experiences. METHODS: A cross-sectional study was performed to describe disrespect and abuse practices in obstetric care (interactions or conditions that are experienced as or intended to be humiliating or undignified) committed by healthcare providers. We included all pregnant women admitted for childbirth (vaginal and cesarean). Semi-structured interviews were also conducted with women, prior to discharge, regarding their experience at delivery. RESULTS: 867 deliveries were observed. 18.8% of women (n = 163) experienced at least one disrespect and abuse event, especially at secondary care facilities. There were a total of 493 disrespect and abuse events, which, on average, represents three events per woman (39.4% were verbal abuse, 32% were physical abuse, and 28.6% were discrimination). In the majority of cases (> 50%), women did not give consent to not recommended invasive procedures and were not provided with adequate information to those procedures. CONCLUSIONS FOR PRACTICE: Direct observation and interviews was a useful tool to identify disrespectful and abusive practices during delivery care. Our findings provide new evidence of the frequency and characteristics of disrespect and abuse during delivery care in Mexico, which can be used to inform maternal health programs. Additionally, these results encourage the creation of surveillance policies and committees in order to guarantee violence-free and dignified treatment of women during delivery care.

Carencias y variabilidad en la calidad de la atención a neonatos hospitalizados en México. Estudio transversal en 28 hospitales públicos / Deficiencies and variability in the quality of care for hospitalized neonates in Mexico. Cross-sectional study in 28 public hospitals

Resumen: Objetivo: Evaluar la calidad de la atención a neonatos con indicadores de proceso, en patologías seleccionadas. Material y métodos: Evaluación multicéntrica, transversal de nueve indicadores en 28 hospitales de 11 entidades de México. Se utilizó Lot Quality Assurance Sampling (LQAS) para estándares de calidad y muestra por hospital. Casos seleccionados al azar del Subsistema Automatizado de Egresos Hospitalarios. Se clasifican hospitales como "cumplimiento con estándar"/"no cumplimiento" por indicador y, cumplimiento con IC95% exacto binomial, regional y nacional, según muestreo estratificado no proporcional. Resultados: Ningún indicador cumple el estándar de 75% en hospitales, con 0 a 19 hospitales que cumplen, según indicador. Excepto la identificación oportuna de asfixia perinatal e inicio de antibiótico correcto en sospecha de sepsis temprana, el cumplimiento es <50% en todos los demás indicadores. Conclusiones: La calidad de la atención a neonatos en hospitales es heterogénea y deficiente. Se proponen indicadores para monitorizar iniciativas de mejora.

Abstract: Objective: To evaluate the quality of care to newborns with process indicators, in selected pathologies. Materials and methods: Multi-centric, cross-sectional evaluation of 9 indicators in 28 hospitals in 11 States of Mexico. Lot Quality Assurance Sampling (LQAS) was used for quality standards and sample per hospital. Randomly selected cases from the Automated Hospital Discharge Subsystem. The hospitals are classified as "standard compliance"/"non-compliance" by indicator and, compliance with 95%CI exact binomial, regional and national, according to non-proportional stratified sampling. Results: No indicator meets the standard of 75% in hospitals, with range from 0 to 19 hospitals that meet, according to indicator. Except for timely identification of perinatal asphyxia and onset of correct antibiotics in suspected early sepsis, the compliance is <50% on all other indicators. Conclusions: The quality of care for newborns in hospitals is heterogeneous and poor. Indicators are proposed to monitor improvement initiatives.

Potentially inappropriate prescribing in older adults in Mexico / Prescripción potencialmente inapropiada en adultos mayores en México

ABSTRACT OBJECTIVE To identify and quantify potentially inappropriate prescribing (prescripción potencialmente inapropiada, PPI) and other drug prescribing problems in public health care services in a population-based study at the three existing levels of complexity in Mexico. METHODS Descriptive analysis of the Study on Satisfaction of Users of the Social Protection System in Health 2014-2016, prescription and drug supply section, to obtain the prevalence of PPI in older adults (≥ 65 years), based on Beers, STOPP, Prescrire and BSP listings using AM (older adults) prescription indicators, one for each listing. RESULTS Most older adults (67%) were prescribed at least one medication, with a mean of 2.7 medications per prescription. The PPI prevalence was 74% according to the BSP criteria, 67% according to the STOPP listing, 59% with the Beer criteria, and 20% with Prescrire. The most frequent PPI prescriptions were NSAIDs, vasodilators and sulfonylureas. CONCLUSIONS The use of PPIs in AM is high in Mexico. The higher prevalence found in this study may reflect the use of a source with population representativeness. The partial use and adaptations of the criteria make difficult comparing the studies; however, the STOPP criteria are the ones with the highest prevalence, as they cover a greater number of drugs and their use is more common in the first level of care.

RESUMEN OBJETIVO Identificar y cuantificar la prescripción potencialmente inapropiada (PPI) y otros problemas en la prescripción de medicamentos en los servicios públicos de atención médica en un estudio poblacional en los tres niveles de complejidad existentes en México. MÉTODOS Análisis descriptivo del Estudio de Satisfacción de Usuarios del Sistema de Protección Social en Salud 2014-2016, sección de prescripción y surtimiento de medicamentos, para obtener la prevalencia de PPI en adultos mayores (≥ 65 años) con base en listados Beers, STOPP, Prescrire y BSP mediante indicadores de prescripción en AM, uno por cada listado. RESULTADOS Al 67% de los AM se les prescribió al menos un medicamento, con una media de 2.7 medicamentos por receta. La prevalencia de PPI fue del 74% según los criterios BSP, del 67% según el listado STOPP, del 59% con los criterios Beer y del 20% con Prescrire. Las prescripciones PPI más frecuentes fueron los AINES, vasodilatadores y las sulfonilureas. CONCLUSIONES El uso de PPI en AM es alto en México. La mayor prevalencia encontrada en este estudio puede ser reflejo de la utilización de una fuente con representatividad poblacional. La utilización parcial y adaptaciones de los criterios dificultan la comparabilidad entre estudios, sin embargo, los criterios STOPP son los que más altas prevalencias han presentado debido a que abarca un mayor número de medicamentos y su uso más habitual en el primer nivel de atención.

[Approach to the quality of care during pregnancy,delivery and postpartum in women withobstetric risk factors in Mexico]. / Aproximación a la calidad de la atención durante el embarazo, parto y posparto en mujeres con factores de riesgoobstétrico en México.

OBJECTIVE: To assess the quality of care of women with obstetric risk factors during pregnancy, childbirth, and post-partum. MATERIALS AND METHODS: We use data from The National Survey of Health and Nutrition 2018-19. Women were classified by the presence of obstetric risk factors (ORF) in their last pregnancy. The quality of care provided to women was evaluated with indicators of structure and process dur-ing antenatal care (ANC) and, delivery and postpartum care (DPC). RESULTS: Compliance with process indicators in ANC and DPC for women with ORF was 56.9%. In the face of complications during pregnancy or delivery, it decreased in ANC, and in the face of social vulnerability compliance of ANC and DPC indicators decreases. CONCLUSIONS: It is necessary to systematically improve the quality of care during pregnancy, childbirth, and postpartum, regardless the presence of ORF, with special attention to vulnerable groups.

OBJETIVO: Evaluar la calidad de la atención a mujeres con factores de riesgo obstétrico durante el embarazo, parto y posparto. MATERIAL Y MÉTODOS: Con datos de la Encuesta Nacional de Salud y Nutrición 2018-19, se clasificó a las mu-jeres de acuerdo con los factores de riesgo obstétrico (FRO) presentes en su último embarazo y se evaluó la calidad de la atención con indicadores de estructura y proceso en la atención prenatal (APN), y en la atención del parto y posparto (APP). RESULTADOS: El cumplimiento de indicadores de pro-ceso en APN y APP para mujeres con FRO fue de 56.9%. Ante complicaciones durante el embarazo o el parto, disminuyó en la APN, y ante variables socioeconómicas desfavorables, disminuyó en la APN y en la APP. CONCLUSIONES: Es nece-sario mejorar sistemáticamente la calidad de la atención en el embarazo, parto y posparto en mujeres con y sin riesgo obstétrico, principalmente en grupos vulnerables.

[Polypharmacy in Mexico: a challengefor prescription quality]. / Polifarmacia en México: un reto para la calidad en la prescripción.

OBJECTIVE: To analyze the prevalence of polypharmacy, as well as the factors that identify the groups with higher risk, in population study in Mexico. MATERIALS AND METHODS: Descriptive analysis of the Encuesta Nacional de Salud y Nutrición 2018-19 (Ensanut 2018-19), Utilization of services (medicine section) and Household questionnaires, to obtain prevalence of polypharmacy (simultaneous consumption ≥5 medicines). A logistic regression model was used to estimate the association of polypharmacy with sociodemographic and health care factors. RESULTS: Prevalence of polypharmacy: 18 years, 15.5%, and 65 years, 26.5%. Higher prevalence in: nephropathies (61.5%), heart disease (42.2%), chronic ob-structive pulmonary disease (38.5%), diabetes (29.3%) and hypertension (26.4%). Increased possibility in adults 65 years (OR:1.95), low schooling (OR:1.54), social security (OR:1.64), serviced in public services (OR:1.7) and chronic illness (OR:1.84). CONCLUSIONS: Polypharmacy is associated with chronic disease and some sociodemographic factors. Large area of opportunity to improve quality of care, particularly pharmacological prescription to identified population with higher risk.

OBJETIVO: Analizar la prevalencia de polifarmacia, así como los factores que identifican a los grupos con mayor riesgo, en un estudio poblacional en México. MATERIAL Y MÉTODOS: Salud y Nutrición 2018-19 (Ensanut 2018-19), cuestionarios de Utilización de servicios (sección medicamentos) y del Hogar, para obtener la prevalencia de polifarmacia (consu-mo simultáneo ≥5 medicamentos). Se utilizó un modelo de regresión logística para estimar la asociación de polifarmacia con factores sociodemográficos y de atención a la salud. RESULTADOS: Prevalencia de polifarmacia: ≥18 años, 15.5%, y ≥65 años, 26.5%. Prevalencias superiores: nefropatías (61.5%), cardiopatías (42.2%), enfermedad pulmonar obstructiva crónica (38.5%), diabetes (29.3%) e hipertensión (26.4%). Mayor posibilidad en adultos ≥65 años (OR:1.95), con baja escolaridad (OR:1.54), seguridad social (OR:1.64), atendidos en servicios públicos (OR:1.7) y enfermedad crónica (OR:1.84). CONCLUSIONES: La polifarmacia se asocia con tener enfermedad crónica y con factores sociodemográficos. Es una gran área de oportunidad para mejorar calidad de la atención, particularmente la prescripción farmacológica a la población identificada con mayor riesgo.

Aproximación a la calidad de la atención durante el embarazo, parto y posparto en mujeres con factores de riesgo obstétrico en México / Approach to the quality of care during pregnancy, delivery and postpartum in women with obstetric risk factors in Mexico

Resumen: Objetivo: Evaluar la calidad de la atención a mujeres con factores de riesgo obstétrico durante el embarazo, parto y posparto. Material y métodos. Con datos de la Encuesta Nacional de Salud y Nutrición 2018-19, se clasificó a las mujeres de acuerdo con los factores de riesgo obstétrico (FRO) presentes en su último embarazo y se evaluó la calidad de la atención con indicadores de estructura y proceso en la atención prenatal (APN), y en la atención del parto y posparto (APP). Resultados: El cumplimiento de indicadores de proceso en APN y APP para mujeres con FRO fue de 56.9%. Ante complicaciones durante el embarazo o el parto, disminuyó en la APN, y ante variables socioeconómicas desfavorables, disminuyó en la APN y en la APP. Conclusiones: Es necesario mejorar sistemáticamente la calidad de la atención en el embarazo, parto y posparto en mujeres con y sin riesgo obstétrico, principalmente en grupos vulnerables.

Abstract: Objective: To assess the quality of care of women with obstetric risk factors during pregnancy, childbirth, and postpartum. Materials and methods: We use data from The National Survey of Health and Nutrition 2018-19. Women were classified by the presence of obstetric risk factors (ORF) in their last pregnancy. The quality of care provided to women was evaluated with indicators of structure and process during antenatal care (ANC) and, delivery and postpartum care (DPC). Results: Compliance with process indicators in ANC and DPC for women with ORF was 56.9%. In the face of complications during pregnancy or delivery, it decreased in ANC, and in the face of social vulnerability compliance of ANC and DPC indicators decreases. Conclusions: It is necessary to systematically improve the quality of care during pregnancy, childbirth, and postpartum, regardless the presence of ORF, with special attention to vulnerable groups.

Polifarmacia en México: un reto para la calidad en la prescripción / Polypharmacy in Mexico: a challenge for prescription quality

Resumen: Objetivo: Analizar la prevalencia de polifarmacia, así como los factores que identifican a los grupos con mayor riesgo, en un estudio poblacional en México. Material y métodos: Análisis descriptivo de la Encuesta Nacional de Salud y Nutrición 2018-19 (Ensanut 2018-19), cuestionarios de Utilización de servicios (sección medicamentos) y del Hogar, para obtener la prevalencia de polifarmacia (consumo simultáneo ≥5 medicamentos). Se utilizó un modelo de regresión logística para estimar la asociación de polifarmacia con factores sociodemográficos y de atención a la salud. Resultados: Prevalencia de polifarmacia: ≥18 años, 15.5%, y ≥65 años, 26.5%. Prevalencias superiores: nefropatías (61.5%), cardiopatías (42.2%), enfermedad pulmonar obstructiva crónica (38.5%), diabetes (29.3%) e hipertensión (26.4%). Mayor posibilidad en adultos ≥65 años (OR:1.95), con baja escolaridad (OR:1.54), seguridad social (OR:1.64), atendidos en servicios públicos (OR:1.7) y enfermedad crónica (OR:1.84). Conclusiones: La polifarmacia se asocia con tener enfermedad crónica y con factores sociodemográficos. Es una gran área de oportunidad para mejorar calidad de la atención, particularmente la prescripción farmacológica a la población identificada con mayor riesgo.

Abstract: Objective: To analyze the prevalence of polypharmacy, as well as the factors that identify the groups with higher risk, in population study in Mexico. Materials and Methods: Descriptive analysis of the Encuesta Nacional de Salud y Nutrición 2018-19 (Ensanut 2018-19), Utilization of services (medicine section) and Household questionnaires, to obtain prevalence of polypharmacy (simultaneous consumption ≥5 medicines). A logistic regression model was used to estimate the association of polypharmacy with sociodemographic and health care factors. Results: Prevalence of polypharmacy: 18 years, 15.5%, and 65 years, 26.5%. Higher prevalence in: nephropathies (61.5%), heart disease (42.2%), chronic obstructive pulmonary disease (38.5%), diabetes (29.3%) and hypertension (26.4%). Increased possibility in adults 65 years (OR:1.95), low schooling (OR:1.54), social security (OR:1.64), serviced in public services (OR:1.7) and chronic illness (OR:1.84). Conclusions: Polypharmacy is associated with chronic disease and some sociodemographic factors. Large area of opportunity to improve quality of care, particularly pharmacological prescription to identified population with higher risk.