Beyond the numbers: Classifying contributory factors and potentially avoidable adverse events in the gynaecology service of National Women's Health at Auckland District Health Board.

BACKGROUND: Adverse events (AEs) during health care are common and may have long-term consequences for patients. Although there is a tradition of reviewing morbidity and mortality in gynaecology, there is no recommended system for reporting contributory factors and potential avoidability. AIMS: To identify factors that contributed to AEs in the gynaecology service at National Women's Health at Auckland District Health Board and to determine potential avoidability, with the use of a multidisciplinary morbidity review. MATERIALS AND METHODS: Contributory factors from a review of AEs in gynaecology services were identified and classified as organisational and/or management factors, personnel factors and barriers to patients accessing and engaging with care. Potential avoidability of the AE was also considered. A descriptive analysis of the morbidity review of patients who had an AE from 2019 to 2022 was undertaken. RESULTS: One hundred and fifty-three cases of AEs were reviewed and 77 (50.3%) were associated with contributory factors. Of all cases, 45 (29.4%) had organisational factors, 54 (35.3%) had personnel factors and patient factors resulting in barriers to care contributing to 11 (7.2%) cases. Sixty-five cases (42.5%) were classified as potentially avoidable. Of these 65 cases, 38 (58.5%) had organisational factors, 48 (73.8%) had personnel factors and nine (13.9%) had barriers to care. CONCLUSIONS: The AE review process reported 50.3% of AEs had contributory factors that were classified as organisational, personnel and barriers to patients accessing care and that 42.5% of the AEs were potentially avoidable. These reviews can be used for making recommendations that potentially lead to improvements in gynaecology.

Impact of an e-learning training for interpreting intrapartum fetal heart rate monitoring to avoid perinatal asphyxia: A before-after multicenter observational study.

INTRODUCTION: Perinatal asphyxia, a condition that results from compromised placental or pulmonary gas exchange during the birth process, is rare but can lead to serious neonatal and long-term consequences. The visual analysis of cardiotocography (CTG) is designed to avoid perinatal asphyxia, but its interpretation can be difficult. Our aim was to test the impact of an e-learning training program for interpreting CTG on the rate of avoidable perinatal asphyxia at term. METHOD: We conducted a retrospective multicenter before-after study comparing two periods, before and after the implementation of e-learning training program from July 1, 2016 to December 31, 2016, in CTG interpretation for midwives and obstetricians in five maternity hospitals in the Paris area, France. The training involved theoretical aspects such as fetal physiology and heart rhythm abnormalities, followed by practical exercises using real case studies to enhance skills in interpreting CTG. We included all term births that occurred between the "before" period (July 1 to December 31, 2014) and the "after period (January 1 to June 30, 2017). We excluded multiple pregnancies, antenatal detection of congenital abnormalities, breech births and all scheduled caesarean sections. Perinatal asphyxia cases were analyzed by a pair of experts consisting of midwives and obstetricians, and avoidability of perinatal asphyxia was estimated. The main criterion was the prevalence of avoidable perinatal asphyxia. RESULTS: The e-learning program was performed by 83 % of the obstetrician-gynecologists and 65 % of the midwives working in the delivery rooms of the five centers. The prevalence of perinatal asphyxia was 0.45 % (29/7902 births) before the training and 0.54 % (35/7722) after. The rate of perinatal asphyxia rated as avoidable was 0.30 % of live births before the training and 0.28 % after (p = 0.870). The main causes of perinatal asphyxia deemed avoidable were delay in reactions to severe CTG anomalies and errors in the analysis and interpretation of the CTG. These causes did not differ between the two periods. CONCLUSION: One session of e-learning training to analyze CTG was not associated with a reduction in avoidable perinatal asphyxia. Other types of e-learning, repeated and implemented over a longer period should be evaluated.

Readmission rates and predictors of avoidable readmissions in older adults in a tertiary care centre.

Context: Thirty-day readmissions are used to gauge health care accountability, which occurs as part of the natural course of the illness or due to avoidable fallacies during the index admission. The utility of this metric is unknown in older adults from developing countries. Aim: To ascertain the unplanned 30-day readmission rate and enumerate predictors of avoidable hospital readmission among early (0-7 days) and late (8-30 days) readmissions. Settings and Design: A retrospective chart audit of 140 older adults who were readmitted to a premier tertiary care teaching hospital under Geriatrics from the neighboring states of Tamil Nadu, Andhra Pradesh, and Kerala were undertaken. Methods and Materials: Data from health records were collected from the hospital electronic database from May 2015 to May 2020. The data was reviewed to determine the 30-day readmission rate and to ascertain the predictors of avoidable readmissions among both early and late readmissions. Results: Out of 2698 older adults admitted to the geriatric wards from the catchment areas, the calculated 30-day hospital readmission rate was 5.18%, and 41.4% of these readmissions were potentially avoidable. The median duration from discharge to the first readmission was ten days (Interquartile range: 5-18 days). Patients had to spend INR 44,000 (approximately 602 USD) towards avoidable readmission. The most common causes for readmission included an exacerbation, reactivation, or progression of a previously existing disease (55.7%), followed by the emergence of a new disease unrelated to index admission (43.2%). Fifty-eight patients (41.4%) were readmitted within seven days following discharge. Early readmissions were seen in patients with malignancies [8 (13.5%) vs. 4 (4.8%); P = 0.017], on insulin (P = 0.04) or on antidepressants (P = 0.01). Advanced age was found to be an independent predictor of avoidable early readmission (OR 2.99 95%CI 1.34-6.62, P = 0.007), and admission to a general ward (as compared to those admitted in a private ward) was an independent predictor of early readmissions (OR 2.99 95%CI 1.34-6.62, P = 0.007). Conclusion: The 30-day readmission rate in a geriatric unit in a tertiary care hospital was 5.2%. Advanced age was considered to be an independent predictor of avoidable early readmission. Future prospective research on avoidable readmissions should be undertaken to delineate factors affecting 30-day avoidable hospital readmissions in developing nations.

Safety of Antibiotics in Hospitalized Children in Romania: A Prospective Observational Study.

Antibiotics are among the most prescribed drugs in pediatric inpatients and are frequently associated with adverse drug reactions (ADRs) in children. This study aimed to assess the frequency and type of ADRs related to the use of antibiotics in pediatric inpatients through a prospective observational study, conducted over 6 months, covering the winter and spring seasons when the incidence of infections peaks in Romania. ADRs were evaluated for causality, avoidability and severity. Among the 266 included children, 25 (9.4%) experienced 30 ADRs. ADR frequency tended to be higher in ≤2-year-olds (13 of 25, 52.0%) than in other age categories. Gastrointestinal and hematological ADRs were most frequently observed. Diarrhea was the most common ADR associated with antibiotics (8 of 30, 26.7%). Ceftriaxone (16 of 30, 53.3%), cefuroxime, ceftazidime and azithromycin (3 of 30, 10.0% each) were most commonly responsible for ADRs. After causality assessment, 2 (6.7%) ADRs were considered definite, 12 (40.0%) probable and 16 (53.3%) possible. One ADR was classified as definitely avoidable and one as possibly avoidable. Seven children required treatment for ADRs. Antibiotic treatment was discontinued in 4 children. Antibiotics frequently caused ADRs in ≤ 2-year-olds and were commonly associated with gastrointestinal symptoms. Close monitoring of antibiotic-associated ADRs remains important in the pediatric population.

Adverse reactions caused by antimicrobials in hospitalized pediatric patients: causality and avoidability analysis

Abstract In pediatrics, drug therapy is commonly performed through adaptations of the dosage forms to adult use, increasing the risk of adverse drug reactions. In this context, studies assessing the severity and avoidability of the adverse reactions in children, especially those caused by antimicrobials, are still scarce. This work aimed to investigate suspected antimicrobial adverse reactions (ATM-ADRs) in pediatric patients admitted to a public hospital in northeastern Brazil, focusing on causality and avoidability analysis. A cohort study was carried out over a period of six months in a 64-bed pediatric unit. The incidence of suspected adverse reactions caused by antimicrobials was 14.65%. Most reactions were rated as probable (89.13%), with moderate severity (84.78%) and possibly avoidable (45.65%). The analysis indicated that the use of a larger number of medications (p<0.0001) and longer hospital stay (p=0.004) were related to the occurrence of ATM-ADR. Our findings demonstrated that almost half of the suspected reactions could be prevented and that the antimicrobial's clinical management is relevant in this context. Besides, increasingly accurate adverse reaction classification instruments are essential. These results can support the development of therapeutic guidelines addressed to a safe and effective pharmacotherapy in the pediatric area

Avoidability of drug-induced liver injury (DILI) in an elderly hospital cohort with cases assessed for causality by the updated RUCAM score.

BACKGROUND: Drug-induced liver injury (DILI) represents an increasing morbidity in the general population, but more so in the elderly cohort of patients. Despite this, the concept of its prevention through prospective analysis has largely remained unexamined. We evaluated the utility of recently validated adverse drug reactions (ADR) avoidability tool in a cohort of elderly patients with DILI. METHODS: We examined 38 DILI-drug pairs from n=38 patients in a prospective cohort of patients presenting with adverse drug reactions to a Weill Cornell-affiliated tertiary hospital between February 2019 and January 2020. DILI outcomes were adjudicated by the updated Roussel Uclaf Causality Assessment Method (RUCAM). Two clinical pharmacologists and two general physicians utilized the Liverpool adverse drug reactions avoidability tool (LAAT) and the modified Hallas tools to rate the preventability of DILI-drug pairs. Inter-rater, exact agreement proportions, as well as intraclass correlation coefficients were generated and expressed as ordinal outcomes. RESULTS: The cases examined for the determination of DILI avoidability had probability likelihood of "probable" or "highly probable" by the updated RUCAM scale. Examination of the 38 DILI-drug pairs (n= 38 patients) resulted in a total of 152 ordinal outcome decisions. We found about 32.3% (50/152) and 34.2% (52/152) of DILI-drug pairs were rated as "avoidable" ("probable" or "definite") by the LAAT and the modified Hallas tools respectively. The overall median Krippendorf's kappa with the LAAT was 0.61 (SE 0.12, CI 0.36, 0.85) and for modified Hallas tool was 0.53 (SE 0.18; CI 0.16, 0.89). The inter-rater correlation coefficient (ICC) for the LAAT and modified Hallas were 0.50 [0.32, 0.65] and 0.63 [0.48, 0.76] respectively. Exact pairwise agreement was present in 30/38 (IQR 29.5, 34.5), and 28/38 (IQR 27.5-35.5) of DILI-ADR pairs using the LAAT and modified Hallas tools respectively. CONCLUSION: We found a significant proportion of drug-induced liver injury adjudicated by the updated RUCAM scale in elderly hospitalized cohort of patients were avoidable with significant implication for therapeutic commissioning as well as cost effectiveness interventions in this cohort of patients.

Towards a patient journey perspective on causes of unplanned readmissions using a classification framework: results of a systematic review with narrative synthesis.

BACKGROUND: Several literature reviews have been published focusing on the prevalence and/or preventability of hospital readmissions. To our knowledge, none focused on the different causes which have been used to evaluate the preventability of readmissions. Insight into the range of causes is crucial to understand the complex nature of readmissions. We conducted a systematic review to: (1) evaluate the range of causes of unplanned readmissions in a patient journey, and (2) present a cause classification framework that can support future readmission studies. METHODS: A literature search was conducted in PUBMED and EMBASE using "readmission" and "avoidability" or "preventability" as key terms. Studies that specified causes of unplanned readmissions were included. The causes were classified into eight preliminary root causes: Technical, Organization (integrated care), Organization (hospital department level), Human (care provider), Human (informal caregiver), Patient (self-management), Patient (disease), and Other. The root causes were based on expert opinions and the root cause analysis tool of PRISMA (Prevention and Recovery Information System for Monitoring and Analysis). The range of different causes were analyzed using Microsoft Excel. RESULTS: Forty-five studies that reported 381 causes of readmissions were included. All studies reported causes related to organization of care at the hospital department level. These causes were often reported as preventable. Twenty-two studies included causes related to patient's self-management and 19 studies reported causes related to patient's disease. Studies differed in which causes were seen as preventable or unpreventable. None reported causes related to technical failures and causes due to integrated care issues were reported in 18 studies. CONCLUSIONS: This review showed that causes for readmissions were mainly evaluated from a hospital perspective. However, causes beyond the scope of the hospital can also play a major role in unplanned readmissions. Opinions regarding preventability seem to depend on contextual factors of the readmission. This study presents a cause classification framework that could help future readmission studies to gain insight into a broad range of causes for readmissions in a patient journey.

How do studies assess the preventability of readmissions? A systematic review with narrative synthesis.

BACKGROUND: A large number of articles examined the preventability rate of readmissions, but comparison and interpretability of these preventability rates is complicated due to the large heterogeneity of methods that were used. To compare (the implications of) the different methods used to assess the preventability of readmissions by means of medical record review. METHODS: A literature search was conducted in PUBMED and EMBASE using "readmission" and "avoidability" or "preventability" as key terms. A consensus-based narrative data synthesis was performed to compare and discuss the different methods. RESULTS: Abstracts of 2504 unique citations were screened resulting in 48 full text articles which were included in the final analysis. Synthesis led to the identification of a set of important variables on which the studies differed considerably (type of readmissions, sources of information, definition of preventability, cause classification and reviewer process). In 69% of the studies the cause classification and preventability assessment were integrated; meaning specific causes were predefined as preventable or not preventable. The reviewers were most often medical specialist (67%), and 27% of the studies added interview as a source of information. CONCLUSION: A consensus-based standardised approach to assess preventability of readmission is warranted to reduce the unwanted bias in preventability rates. Patient-related and integrated care related factors are potentially underreported in readmission studies.

[Epidemiology of maternal mortality in France, 2010-2012]. / Épidémiologie de la mortalité maternelle en France, 2010­2012.

OBJECTIVE: To describe, for the period 2010-2012, the frequency, the causes, the risk factors, the adequacy of care and the avoidability of maternal deaths in France. METHOD: Data from the National Confidential Enquiry into Maternal Deaths for 2010-2012. RESULTS: For the period 2010-2012, 256 maternal deaths occurred in France, a maternal mortality ratio of 10.3 per 100,000 live births (95% CI: 9.1-11.7), stable compared to 2007-2009. Compared to women aged 25-29, the risk is multiplied by 2.4 for women aged 35-39, and by 3 for women over 40 years. There are territorial disparities: 1 out of 7 maternal deaths occurs in the French overseas departments, and the maternal mortality ratio in those departments is 4 times that of metropolitan, France; and social disparities: the mortality of migrant women remains 2.5 times higher than that of women born in France, particularly for women born in sub-Saharan Africa whose RMM is 3.5 times that native women. A major finding is the 1/3 decrease in direct maternal mortality over the last 10 years, mainly due to for the first time the statistically significant decrease in mortality from obstetric hemorrhage, the frequency of which was divided by 2 in 10 years. However, almost all of the remaining deaths from hemorrhage are considered preventable and this is still the leading cause of maternal mortality in France (11% of deaths). Overall, 56% of these maternal deaths are considered "avoidable" or "possibly avoidable" and in 59% of cases the care provided was not optimal. CONCLUSION: Direct maternal mortality and in particular maternal mortality from hemorrhage has decreased significantly over the past 10 years, indicating improved obstetric care. However, territorial and social inequalities persist, and the majority of deaths remain preventable, which shows that the identification of opportunities for improvement must continue. To go even further in understanding the mechanisms involved, and to identify precise avenues of prevention, it is necessary to analyze in detail the stories of each maternal death in order to identify the repetitive elements in the series of deaths. This is what the following articles in this issue propose, with an analysis by cause of death, according to the idea that the same cause produces the same effects.

Hospital re-admission associated with adverse drug reactions in patients over the age of 65 years.

CONTEXT: Adverse drug reactions (ADRs) are responsible for 5 % of hospital admissions, but hospital re-admission induced by ADRs remains poorly documented. OBJECTIVE: The aim of this study was to estimate the rate of hospital re-admission and the factors associated with re-admission in the patients over the age of 65 years. Secondary, we described the characteristics of cases of ADRs leading to re-admission for drugs other than chemotherapy agents. METHODS: Data were extracted from hospital discharge summaries provided by the Department of Medical Information of Toulouse University Hospital. All patients over the age of 65 years admitted to the hospital in 2010 for an ADR, identified from ICD-10 codes, were selected. All subsequent admissions of members of this cohort within 1 year of discharge following the index admission were reviewed retrospectively. The risk factors associated with hospital re-admission for ADRs were analyzed. Medical records were used for descriptive analysis of re-admission due to drugs other than chemotherapy agents. RESULTS: We found that 553 of the 1000 patients admitted for ADRs in 2010 were re-admitted to hospital within 1 year. Among them, 87 cases were re-admitted for ADRs (estimated rate of 87/1000 re-admission for an ADR within 1 year). A comparison of the patients re-admitted for ADRs (n = 87) with those of patients re-admitted for other causes (n = 410) suggested that only cancer increased the risk of re-admission for ADRs (OR = 7.69 [4.59-12.88] 95 % CI). ADRs due to the same drug combination were the suspected cause of repeat admission in half the cases (other than chemotherapy). Hospital re-admission was considered avoidable in four cases (22 %). CONCLUSION: This study shows an estimated rate of re-admission for an ADR around 87/1000 within 1 year, and the same drug combination were the suspected cause of repeat admission in half the cases. At least, 11 % of cases were avoidable.

Potential avoidability of planned cesarean sections in a French national database.

OBJECTIVE: To study the frequency and determinants of potentially avoidable planned cesarean sections, with a classification based on their indications, maternal obstetric history, and information about the current pregnancy. DESIGN: Cross-sectional population-based study. SETTING: All maternity units in France (n = 535). POPULATION: A total of 14,681 women from the 2010 French National Perinatal Survey, a routine survey of a representative sample of births. METHODS: Planned cesareans were classified in two groups: potentially avoidable and unavoidable. The classification was based on the French national guidelines and used data from medical records. We used logistic regression analyses to compare characteristics of the mothers with potentially avoidable cesareans with those of women who had a trial of labor. Analyses were performed separately in primiparas and multiparas. MAIN OUTCOME MEASURE: Rate of potentially avoidable planned cesarean sections. RESULTS: The overall planned cesarean rate was 10.9%; 28% of these cesareans were found to be potentially avoidable. Breech presentation and history of one previous cesarean accounted for 83% of them. Determinants of potential avoidability were maternal age >35 years, intensive surveillance during pregnancy, and private status of the unit [adjusted odds ratio (OR) 1.9, 95% CI 1.2-3.2 among primiparas; adjusted OR 2.5, 95% CI 1.5-4.3 among multiparas]. Obesity was also a significant determinant but only among multiparas (adjusted OR 2.7, 95% CI 1.9-3.8). No association was found with maternal social characteristics. CONCLUSION: Our results suggest a high proportion of potentially avoidable cesareans and highlight the associated obstetric situations. They can help to target policies aimed at reducing cesarean rates.

Mortalidade infantil e classificação de evitabilidade: pesquisando municípios da 15 Regional de Saúde Paraná / Infant mortality and avoidance classification: researching cities of the 15 Parana Health Regional / Mortalidad infantil y clasificación de evitación: investigando los municipios de la 15ª Regional de Salud Paraná

Este estudo avaliou o perfil da mortalidade infantil e a evitabilidade dos óbitos de crianças menores de um ano dos municípios da 15ª Regional de Saúde. Foram investigados 74 óbitos de crianças no ano de 2008, em 15 municípios da 15a Regional de Saúde do Estado do Paraná. Foram coletados dados dos registros do comitê de prevenção do óbito infantil e fetal, estes contabilizados por meio de frequência e porcentagens simples e apresentados na forma de tabela. Dos 74 óbitos investigados, 51 (69%) foram neonatais e 23 (31%) pós-neonatais, com destaque para os municípios com menos de 20 mil habitantes, onde a mortalidade neonatal ocorreu em maior percentual com 82%. Quanto à evitabilidade dos óbitos, 82%, poderiam ser evitados, com percentual maior nos municípios acima de 50 mil habitantes. As causas de morte encontradas foram relacionadas ao período perinatal e as malformações congênitas. Segundo as medidas de evitabilidade, em 30 (40,5%) dos óbitos assim classificados, as mais encontradas foram às relacionadas com atenção à mulher na gestação. As medidas mais indicadas pelo comitê foram as de promoção de saúde e prevenção primária, 84(34%) das recomendações, com destaque para ações de educação em saúde, avaliação do risco gestacional e planejamento familiar.

The objective of this study was to evaluate the profile of infant mortality and avoidable deaths of children under one year old in the municipalities of the 15th Regional Health. There were investigated 74 deaths of children in 2008, in 15 cities of the 15th Heath Regional of the Paraná State. The data were collected from the records of the infant and fetal death prevention committee; these accounted for by means of frequency and simple percentages and presented in the form of table. Of the 74 investigated deaths, 51(69%) were neonatal and 23 (31%) were post-neonatal, highlighting the cities with less than 20 thousand inhabitants, where the neonatal mortality occurred in higher percentage, with 82%. Regarding the death avoidance, 82% could have been avoided, with higher percentage in cities with more than 50 thousand inhabitants. The causes of death found were related to the perinatal period and congenital malformations. According to the avoidance measures, in 30 (40,5%) of the classified deaths, the causes most found were those related to the attention provided to the pregnant woman. The main measures indicated by the committee were the promotion of health and primary prevention, 84 (34%) of the recommendations, highlighting actions towards health education, evaluation of gestational risk and family planning.

El objetivo de este estudio fue evaluar el perfil de la mortalidad infantil y la evitabilidad de los óbitos de niños menores de un año en los municipios de la 15ª Regional de Salud. Fueron investigados 74 óbitos de niños en el año de 2008, en 15 ciudades de la 15a Regional de Salud del Estado de Paraná. Fueron recolectados datos de los registros del comité de prevención del óbito infantil y fetal; éstos contabilizados por medio de frecuencia y porcentajes simples y presentados en la forma de tabla. De los 74 óbitos investigados, 51 (69%) fueron neonatales y 23 (31%) post neonatales, resaltando las ciudades con menos de 20 mil habitantes, donde la mortalidad neonatal ocurrió en mayor porcentaje, con 82%. En cuanto a la evitabilidad de los óbitos, 82% podrían ser evitados, con porcentaje mayor en las ciudades con más de 50 mil habitantes. Las causas de muerte encontradas fueron relacionadas al periodo perinatal y a las malformaciones congénitas. De acuerdo con las medidas de evitabilidad, en 30 (40,5%) de los óbitos así clasificados, las más encontradas fueron las relacionadas con la atención a la mujer embarazada. Las medidas más indicadas por el comité fueron las de promoción a la salud y prevención primaria, 84 (34%) de las recomendaciones, con destaque para las acciones de educación en salud, evaluación del riesgo gestacional y planificación familiar.

La equidad en los servicios de salud / Equity in healthcare services

Sobre la equidad se dice que tiene sus fundamentos en los derechos humanos fundamentales, la equidad no es igualdad; la desigualdad para ser equitativa requiere justificación ética y moral. En Cuba, la equidad es premisa para las decisiones como de forma implícita se anuncia en “ La Historia me absolverá.” El sistema de salud cubano tiene como finalidad fundamental producir salud de la mejor manera posible y tiene, además, dos indicadores principales: la eficacia social y la satisfacción social. La equidad es condición estratégica, necesaria, para el acceso a los servicios de salud según necesidades y posibilidades. Se muestra que en Cuba la reforma del sector de la salud es un proceso continuo y sostenible y que decisiones políticas, disposiciones legales, y los valores de la sociedad, aseguran el acceso a los servicios de salud de todos los cubanos. La accesibilidad se entiende como la facilidad de acceder y recibir la atención de salud que se necesite, de forma integral y oportuna pero es necesario avanzar más en ella; la lista de espera, el orden de llegada son medidas administrativas para adecuar de alguna forma la demanda con la capacidad real existente en los servicios. La evitabilidad, concepto clave para la equidad se considera fuente de acción para eliminar, reducir, neutralizar las causas, subjetivas más y objetivas menos, que demoran la atención aún dentro del sistema de salud único, estatal, integral y gratuito.

This article offered the following elements on the term equity. Equity is rooted in the fundamental human rights; equity does not mean equality. For inequality to be equitable it requires ethical and moral justification and in Cuba equity is a premise for decisions as it was implicitly announced in "History will abssolve me". The cuban healthcare system is aimed at producing health in the best possible way based on two main indicators, that is, social efficacy and social satisfaction. Equity is a necessary strategic condition for access to health services according to needs and possibilities. The article demonstrated that the health sector reform in Cuba is a steady and sustainable process and that political decision-making, legal provisions and the society´s values assure the access of every Cuban to healthcare services. Accesibility is understood as easy way to gain access to and receive health care services whenever needed in a comprehensive and timely way, but it is imperative to advance further in this regard. The waiting list, the order of arrival are administrative measures to somehow adjust the demand to the real health service capacities; however, avoidability is considered the key concept for equity as a source of action to eliminate, reduce, neutralize the causes, more subjective than objective, that delay care to patient even in a comprehensive free state-run and unique healthcare system like ours.