[Sometimes less is more. Preventing overdiagnosis by sharing decisions]. / Moins, c'est parfois mieux . Prévenir le surdiagnostic en partageant les décisions.

In this article, we will define «quaternary prevention¼, which consists in minimizing the iatrogenic effects of medical interventions, and more specifically the notion of «overdiagnosis¼. We will then discuss how a poor appreciation of the risks, on the part of both patients and clinicians, seems to fuel the phenomenon. We will discuss the interest of placing quaternary prevention within the broader framework of Shared Decision Making. We will focus on one of the stages of Shared Decision Making process, that of risk communication. Finally, we'll conclude that, fundamentally, clinicians should not only share information with patients, but also the power to decide.

Dans cet article, nous définirons la «prévention quaternaire¼, qui consiste à minimiser les effets iatrogènes de nos interventions et plus particulièrement de la notion de «surdiagnostic¼. Ensuite, nous discuterons en quoi une mauvaise appréciation des risques, chez les patients comme chez les thérapeutes, semble nourrir le phénomène. Nous discuterons de l'intérêt de replacer la prévention quaternaire dans le cadre plus large de la prise de décision médicale partagée (DMP) («Shared Decision Making¼). Nous nous attarderons sur une des étapes du processus de prise de DMP, celle de la communication des risques. Enfin nous conclurons que, fondamentalement, il s'agit pour les thérapeutes de non seulement partager l'information avec les patients, mais aussi le pouvoir de décider.

Comparing the use of aggressive end-of life care among frail and non-frail patients with cancer using a claims-based frailty index.

INTRODUCTION: Despite mounting consensus that end-of-life (EOL) care for patients with cancer should focus on improving quality of life, many patients continue to receive aggressive, disease-oriented treatment until death. Within this group, patients with increased frailty may be at higher risk of adverse treatment-related outcomes. We therefore examined the relationship between degree of frailty and receipt of aggressive EOL care among Medicare-insured patients with cancer in Ohio. MATERIALS AND METHODS: From the Ohio Cancer Incidence Surveillance System (OCISS) linked with Medicare claims, we identified patients diagnosed with breast, colorectal, lung, or prostate cancer who died between 2012 and 2016. Frailty was operationalized using a validated claims-based frailty index. Six quality indicators reflecting receipt of aggressive EOL care were identified from claims: (1) any cancer-directed treatment, (2) >1 emergency department (ED) visit, (3) >1 hospital admission, (4) any intensive care unit (ICU) admission in the last 30 days of life, (5) entry to hospice in the last three days of life, and (6) in-hospital mortality. Multivariable logistic regression analysis was performed to control for demographic factors, Medicare and Medicaid dual enrollment, and cancer type and stage in the relationship between frailty and aggressive EOL care. RESULTS: Overall, 31,465 patients met selection criteria. Patients with moderate/severe frailty were less likely than non-/pre-frail patients to receive any aggressive EOL care (adjusted odds ratio [aOR] 0.92 [95% confidence interval 0.86-0.99]). This group was also less likely to undergo cancer-directed treatment in their last 30 days or to enter hospice in their last three days. Increasing frailty was associated with lower odds of admission to the ICU in the last 30 days of life (mild frailty: aOR 0.88 [0.83-0.94]; moderate/severe frailty: aOR 0.85 [0.78-0.92]) or of dying in-hospital (mild frailty: 0.85 [0.79-0.91]; moderate/severe frailty: aOR 0.74 [0.67-0.82]), but higher odds of having >1 ED visit in the last 30 days of life (mild frailty: aOR 1.43 [1.32-1.53]; moderate/severe frailty: aOR 1.61 [1.47-1.77]). DISCUSSION: These findings suggest the need for more explicit discussion of emergency care seeking for patients with cancer at the end of life.

Presenting a Quaternary Prevention Model for the Rural Family Physician Program in Iran with an Interpretive Structural Modeling Approach.

Background: Due to its ethical approach and its protection of patients and their interests, quaternary prevention can increase the quality-of-service provision and decrease costs and the wastage of resources. The present study used interpretive structural modeling (ISM) to classify the effective factors and determine a quaternary prevention model for Iran's Rural Family Physician Program. Methods: This study was a qualitative study with an ISM approach. Twenty-five health system experts and faculty members participated in the study. The interrelationships between the factors were determined using ISM, and after classification, the driving and dependence power of the factors were specified using MICMAC analysis. Results: The 20 factors were classified into five levels. The results indicated that patient interest and vulnerable groups had the highest effectiveness, and officials' and policymakers' commitment to providing serious support for family physicians had the highest affectability. The factors were placed into the two groups of linkage and dependence based on the MICMAC analysis. Conclusions: The new technologies are costly and sometimes only suitable for a specific group of patients. Costs and the issues of induced demand and defensive medicine necessitate a different view of health service distribution. The preventive and strategic view and the comprehensiveness of family physician services make quaternary prevention possible by providing high-risk and vulnerable groups with essential services based on patient needs and conditions with more benefit than harm.

Enhancing Primary Care for Nursing Home Patients with an Artificial Intelligence-Aided Rational Drug Use Web Assistant.

Polypharmacy can result in drug-drug interactions, severe side-effects, drug-disease interactions, inappropriate medication use in the elderly, and escalating costs. This study aims to evaluate nursing home residents' medication regimens using a rational drug use web assistant developed by researchers to mitigate unnecessary medication usage. This analytical, cross-sectional study included data from nursing home residents recently recorded in a training family health center. Sociodemographic information, medical conditions, and prescribed medications of all patients in the nursing home (n = 99) were documented. Medications were assessed using an artificial intelligence-aided rational drug use web assistant. Instances of inappropriate drug use and calculations of contraindicated drug costs were also recorded. The study revealed that 88.9% (n = 88) of patients experienced polypharmacy, with a mean value of 6.96 ± 2.94 drugs per patient. Potential risky drug-drug interactions were present in 89.9% (n = 89) of patients, contraindicated drug-drug interactions in 20.2% (n = 20), and potentially inappropriate drug use in 86.9% (n = 86). Plans to discontinue 83 medications were estimated to reduce total direct medication costs by 9.1% per month. After the assessment with the rational drug use web assistant, the number of drugs that patients needed to use and polypharmacy decreased significantly. This study concludes that the rational drug use web assistant application, which is more cost-effective than the traditional manual method, assisted by artificial intelligence, and integrated into healthcare services, may offer substantial benefits to family physicians and their geriatric patients.

Revisitando Whitaker: psicofármacos e cuidado em Saúde Mental na Atenção Primária à Saúde / Revisiting Whitaker: psychotropic drugs and Mental Health care in Primary Health Care

RESUMO Os Problemas de Saúde Mental (SM) e o uso indiscriminado de psicofármacos são problemas de grande relevância para a Atenção Primária à Saúde (APS) e a saúde pública. O objetivo deste ensaio é apresentar uma fundamentação atualizada da tese de Robert Whitaker, desenvolvida no livro 'Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental'. É apresentada uma síntese do livro, acrescida de comentários sobre determinados temas, visando à melhor ancoragem científica dos argumentos. A tese defendida é que se deve evitar prescrever o uso de psicofármacos; e, caso seja iniciado o uso, que seja como sintomático agudo pelo menor tempo possível. Os argumentos giram em torno de que há evidências favoráveis apenas para redução de sintomas, para algumas dessas drogas e para curtos períodos de uso. Com seu uso crônico, há piora em longo prazo quanto à estabilidade, autonomia e funcionalidade social, com problemas graves de abstinência. Especialmente na APS (e também nos serviços especializados em SM), os profissionais deveriam ter uma abordagem mais crítica dos psicotrópicos e investir em outras abordagens terapêuticas, para fazerem algo melhor, menos iatrogênico e tão ou mais eficaz para os pacientes com problemas de SM no longo prazo.

ABSTRACT Mental Health (MH) issues and the indiscriminate use of psychotropic drugs are a great deal of a problem for the Primary Health Care (PHC) and public health. The aim of this article is to show an updated basis from Robert Whitaker theses in his book 'Anatomy of an epidemic: magic bullets, psychiatric drugs and the astonishing rise of mental illness'. It is presented a synthesis of the book, with specific comments about some topics, aiming for better scientific base of the arguments. The thesis endorses that prescribing psychotropic drugs must be avoided; and, if required, it must be as an acute symptomatic scenario for the least time as possible. The study has positive evidence that a few of these drugs only reduces symptoms, for a short period of time. If chronic used, in a long-term scenario, it seems to actually reduce stability, autonomy and social functionality, leaving the user with serious abstinence from the drug. Specially in PHC (and also in MH specialized services), professionals should have a mindful and discerning approach to psychotropic drugs, and invest in other therapeutic strategies, in order to do something better, less iatrogenic and as effective or more for the mental health patients in the long term.

Recomendaciones de “no hacer” en la consulta de Atención Primaria / Recommendations for “not to do” in primary care practice

Introducción: en los últimos años se ha observado un exceso de prácticas clínicas innecesarias en Pediatría que carecen de suficiente evidencia científica y generan costos significativos, además de resultar molestas para el paciente y no aportar beneficios adicionales. Por ello, diversas sociedades e instituciones científicas han propuesto recomendaciones para evitar estas intervenciones ineficaces y científicamente injustificadas. Material y métodos: el proyecto fue coordinado por el grupo de trabajo PrevInfad de la Asociación Española de Pediatría de Atención Primaria (AEPap). Se desarrolló en dos fases a través del intercambio de correos electrónicos. En la primera, se solicitó a los coordinadores que divulgaran el proyecto y recopilaran propuestas de intervenciones innecesarias. En la segunda, se realizó la selección de las recomendaciones mediante el método Delphi y dos rondas de votación. Resultados: en la primera fase se obtuvieron 40 propuestas de recomendaciones de “no hacer”. En la primera ronda de la segunda fase se aceptaron 7 propuestas. Cinco recomendaciones fueron rechazadas y 28 fueron consideradas dudosas y pasaron a una segunda valoración. En la segunda ronda se aceptó una recomendación adicional. En total, se aprobaron 8 recomendaciones de “no hacer”. Conclusiones: la AEPap elaboró una lista de recomendaciones de “no hacer” en Pediatría en colaboración con sus grupos de trabajo y asociaciones federadas utilizando la metodología Delphi para el consenso entre expertos. Estas recomendaciones buscan mejorar la calidad asistencial y promover la utilización adecuada de recursos en la Atención Primaria pediátrica (AU)

Introduction: in recent years, there has been an excess of unnecessary clinical practices in pediatrics that lack sufficient scientific evidence and generate significant costs, in addition to being bothersome and not providing additional benefits. For this reason, various scientific societies and institutions have proposed recommendations to avoid these ineffective and scientifically unjustified interventions.Material and methods: the project was coordinated by the PrevInfad working group of the Spanish Association of Primary Care Pediatrics (AEPap). It was developed in two phases through the exchange of e-mails. In the first phase, the coordinators were asked to disseminate the project and to collect proposals for unnecessary interventions. In the second phase, the recommendations were selected using the Delphi method and two rounds of voting.Results: in the first phase, 40 proposals for 'do not do' recommendations were obtained. In the first round of the second phase, seven proposals were accepted. Five recommendations were rejected and 28 were considered doubtful and passed to a second assessment. One additional recommendation was accepted in the second round. In total, 8 'do not do' recommendations were approved.Conclusions: the AEPap developed a list of 'do not do' recommendations in pediatrics in collaboration with its working groups and federated associations using the Delphi methodology for consensus among experts. These recommendations aim to improve the quality of care and promote the appropriate use of resources in pediatric primary care. (AU)

Genealogia da Prevenção Quaternária: entre o uso da Medicina Baseada em Evidências e a reformulação do cuidado na Atenção Primária à Saúde / Genealogical analysis of Quaternary Prevention: between the use of Evidence-Based Medicine and care reformulation in Primary Health Care

Resumo Realizamos uma análise genealógica da Prevenção Quaternária, instrumento da Atenção Primária à Saúde de enfrentamento à medicalização e a iatrogenia, a partir de seus enunciados e de entrevistas com seus formuladores. Identificamos que a ferramenta tem sido tanto apresentada como uma reformulação do cuidado e da relação médico-paciente, como também reduzida ao cálculo do risco-benefício por meio da aplicação atualizada de evidências científicas. Analisamos os paradoxos da Medicina Baseada em Evidências e problematizamos sua relação com a Prevenção Quaternária e a Atenção Primária à Saúde. Por fim, sugerimos questionar a verdade das evidências para o desenvolvimento de outros paradigmas de saúde.

Abstract We conducted a genealogical analysis of quaternary prevention, an instrument of primary health care to address overmedicalization and iatrogenesis, based on related statements and interviews with the creators of this concept. This tool has been used in the reformulation of care and the doctor-patient relationship, but limited to the risk-benefit assessment by using current scientific evidence. In this study, we analyze the paradoxes of evidence-based medicine (EBM) and discuss the relationship of EBM and quaternary prevention and primary health care (PHC). Finally, we suggest questioning the truth of the evidence for the development of other health paradigms.

¿Por qué resulta cada vez más complicado "hacer lo que hay que hacer" y "dejar de hacer lo que no hay que hacer"? Estrategias para revertir las prácticas de bajo valor / Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices

En este trabajo se describen los factores que han propiciado la expansión de las prácticas de bajo valor (PBV) junto con las principales iniciativas para revertirlas. El artículo destaca las estrategias que han demostrado ser más útiles a lo largo de los años, desde la adecuación de la práctica clínica a las recomendaciones “no hacer”, pasando por la prevención cuaternaria y el abordaje de los riesgos asociados al intervencionismo. Revertir las PBV requiere un proceso planificado con un enfoque multifactorial que involucre a los diferentes agentes implicados. Además ha de tener en cuenta las barreras que dificultan la desimplementación de las PBV e incorpore las herramientas que facilitan la adherencia a las recomendaciones “no hacer”. El papel del médico de familia es especialmente relevante en la prevención, detección y desimplementación de las PBV, por su carácter coordinador e integrador de la atención que reciben los pacientes, y porque en el primer nivel asistencial se gestionan y resuelven la mayor parte de las demandas asistenciales.(AU)

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with “do not do” recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to “do not do” recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients’ healthcare, and because most of the citizens’ healthcare demands are managed and resolved at the first level of care.(AU)

[Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices]. / ¿Por qué resulta cada vez más complicado "hacer lo que hay que hacer" y "dejar de hacer lo que no hay que hacer"? Estrategias para revertir las prácticas de bajo valor.

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with "do not do" recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to "do not do" recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients' healthcare, and because most of the citizens' healthcare demands are managed and resolved at the first level of care.

Recomendaciones de no hacer en distintos ámbitos de la atención pediátrica / Do not do recommendations in different paediatric care settings

Introducción: Muchas son las iniciativas encaminadas a eliminar intervenciones clínicas de poco valor en la asistencia sanitaria. Desde el Comité de Calidad Asistencial y Seguridad del Paciente de la Asociación Española de Pediatría, se ha propuesto la elaboración de recomendaciones de «no hacer» (RNH) con el objetivo de señalar una serie de prácticas evitables en la atención del paciente pediátrico en atención primaria, urgencias, hospitalización y domicilio. Material y métodos: Este trabajo se desarrolló en 2fases: una primera en la que se propusieron posibles RNH y una segunda en la que se consensuaron las recomendaciones finales mediante el método Delphi. Tanto las propuestas como las evaluaciones partieron de miembros de los grupos y sociedades pediátricas a los que se les realizó la propuesta, coordinados por miembros del Comité de Calidad Asistencial y Seguridad del Paciente. Resultados: Fueron propuestas un total de 164 RNH por la Sociedad Española de Neonatología, la Asociación Española de Pediatría de Atención Primaria, la Sociedad Española de Urgencias de Pediatría, la Sociedad Española de Pediatría Interna Hospitalaria y el Comité de Medicamentos de la Asociación Española de Pediatría con el Grupo Español de Farmacia Pediátrica de la Sociedad Española de Farmacia Hospitalaria. Se logró reducir el conjunto inicial a 42 RNH y en sucesivas fases se llegó a la selección final de 25 RNH, 5 RNH por cada grupo o sociedad. Conclusiones: Este proyecto ha permitido seleccionar y consensuar una serie de recomendaciones para evitar prácticas inseguras, ineficientes o de escaso valor en distintos ámbitos de la atención pediátrica, lo que podría resultar útil para mejorar la seguridad y la calidad de nuestra actividad asistencial. (AU)

Introduction: There are many initiatives aimed at eliminating health care interventions of limited utility in clinical practice. The Committee on Care Quality and Patient Safety of the Spanish Association of Pediatrics has proposed the development of «do not do» recommendations (DNDRs) to establish a series of practices to be avoided in the care of paediatric patients in primary, emergency, inpatient and home-based care. Material and methods: The project was carried out in 2 phases: a first phase in which possible DNDRs were proposed, and a second in which the final recommendations were established by consensus using the Delphi method. Recommendations were proposed and evaluated by members of the professional groups and paediatrics societies invited to participate in the project under the coordination of members of the Committee on Care Quality and Patient Safety. Results: A total of 164 DNDRs were proposed by the Spanish Society of Neonatology, the Spanish Association of Primary Care Paediatrics, the Spanish Society of Paediatric Emergency Medicine, the Spanish Society of Internal Hospital Paediatrics and the Medicines Committee of the Spanish Association of Pediatrics and the Spanish Group of Paediatric Pharmacy of the Spanish Society of Hospital Pharmacy. The initial set was limited to 42 DNDRs, and the selection over successive rounds yielded a final set of 25 DNDRs, with 5 DNDRs for each paediatrics group or society. Conclusions: This project allowed the selection and establishment by consensus of a series of recommendations to avoid unsafe, inefficient or low-value practices in different areas of paediatric care, which may contribute to improving the safety and quality of paediatric clinical practice. (AU)

Do not do recommendations in different paediatric care settings.

INTRODUCTION: There are many initiatives aimed at eliminating health care interventions of limited utility in clinical practice. The Committee on Care Quality and Patient Safety of the Spanish Association of Pediatrics (AEP) has proposed the development of "DO NOT DO" recommendations (DNDRs) to establish a series of practices to be avoided in the care of paediatric patients in primary, emergency, inpatient and home-based care. MATERIAL AND METHODS: The project was carried out in 2 phases: a first phase in which possible DNDRs were proposed, and a second in which the final recommendations were established by consensus using the Delphi method. Recommendations were proposed and evaluated by members of the professional groups and paediatrics societies invited to participate in the project under the coordination of members of the Committee on Care Quality and Patient Safety. RESULTS: A total of 164 DNDRs were proposed by the Spanish Society of Neonatology, the Spanish Association of Primary Care Paediatrics, the Spanish Society of Paediatric Emergency Medicine, the Spanish Society of Internal Hospital Paediatrics and the Medicines Committee of the AEP and the Spanish Group of Paediatric Pharmacy of the Spanish Society of Hospital Pharmacy. The initial set was limited to 42 DNDRs, and the selection over successive rounds yielded a final set of 25 DNDRs, with 5 DNDRs for each paediatrics group or society. CONCLUSIONS: This project allowed the selection and establishment by consensus of a series of recommendations to avoid unsafe, inefficient or low-value practices in different areas of paediatric care, which may contribute to improving the safety and quality of paediatric clinical practice.

Construção e evidência de validade do Instrumento de Avaliação do Conhecimento sobre Prevenção Quaternária / Construction and evidence of validity of the knowledge assessment instrument on quaternary prevention / Construcción y pruebas de validez del instrumento de evaluación de los conocimientos sobre prevención cuaternaria

Objetivo: desenvolver e estimar a evidência de validade de um instrumento para avaliar a percepção dos acadêmicos de medicina sobre a prevenção quaternária. Método: Trata-se de um estudo metodológico desenvolvido em três etapas: 1) construção do instrumento para avaliação do conhecimento sobre Prevenção Quaternária a partir de referenciais teóricos; 2) evidência de validade baseada no conteúdo, realizada por 13 juízes; 3) evidência de validade baseada na estrutura interna, realizada por 180 acadêmicos de medicina. Análises fatoriais foram realizadas para verificar a estrutura hierárquica do modelo a partir das duas dimensões inicialmente construídas: Domínio Conhecimento e Domínio Prático. Resultados: O coeficiente de evidência de validade de conteúdo da escala total (CVCt) foi de 0,98, demonstrando uma alta concordância entre os avaliadores com a conceituação teórica subjacente. Quanto à precisão do instrumento, todos os itens apresentaram valores de Alfa de Cronbach acima de 0,7, indicando boa precisão. Verificou-se bons indicadores de precisão para a escala com dois fatores (Domínio Conhecimento e Domínio Prático) ƛ2= 109.746, gl= 103; p<0,001; ƛ2/gl= 0,30; CFI= 0,98 e RMSEA 0,019. Conclusão: o instrumento IP4-15 apresentou as evidências de validade de conteúdo, estrutura interna, precisão e propriedades dos itens adequadas para avaliar o conhecimento e a prática da prevenção quaternária de acadêmicos do curso de medicina. Serão necessários estudos futuros para investigar a aplicabilidade do IP4-15 para outras populações.(AU)

Objective: to develop and estimate the evidence of validity of an instrument to assess the perception of medical students about Quaternary Prevention. Method: this is a methodological study carried out in three steps: 1) construction of the instrument to assess knowledge about Quaternary Prevention based on theoretical references; 2) content-based evidence of validity, performed by 13 judges; 3) internal structure-based evidence of validity, performed by 180 medical students. Factor analyzes were performed to verify the hierarchical structure of the model based on the two dimensions initially constructed: Knowledge Domain and Practical Domain. Results: The total scale content validity evidence coefficient (CVCt) was 0.98, demonstrating a high inter-rater agreement with the underlying theoretical conceptualization. As for instrument precision, all items had Cronbach's Alpha values above 0.7, indicating good precision. Good precision indicators were found for the scale with two factors (Knowledge Domain and Practical Domain) ƛ2= 109,746, gl= 103; p<0.001; ƛ2/gl=0.30; CFI=0.98 and RMSEA 0.019. Conclusion: the IP4-15 instrument presented adequate evidence of content validity, internal structure, precision, and properties of the items to assess the knowledge and practice of Quaternary Prevention of medical students. Future studies will be needed to investigate the applicability of IP4-15 to other populations.(AU)

la percepción de los estudiantes de medicina sobre la Prevención Cuaternaria. Método:se trata de un estudio metodológico desarrollado en tres etapas: 1) construcción de un instrumento para evaluar el conocimiento sobre Prevención Cuaternaria basado en referencias teóricas; 2) prueba de validez basada en el contenido, realizada por 13 jueces; 3) prueba de validez basada en la estructura interna, realizada por 180 estudiantes de Medicina. Se realizaron análisis factoriales para verificar la estructura jerárquica del modelo a partir de las dos dimensiones construidas inicialmente: Dominio del conocimiento y dominio práctico. Resultados: el coeficiente de evidencia de validez de contenido de la escala total (CVCt) fue de 0,98, lo que demuestra...(AU)

Recomendaciones de «no hacer» en cuidados intensivos pediátricos en España: selección por método Delphi / Paediatric intensive care ‘do not do’ recommendations in Spain: Selection by Delphi method

Introducción: La asistencia sanitaria no está exenta de prácticas diagnósticas y terapéuticas poco efectivas, inseguras o ineficientes. Como reacción han sido propuestas recomendaciones de «no hacer» por diferentes sociedades científicas y autoridades sanitarias. Nuestro objetivo fue seleccionar y consensuar un grupo de recomendaciones de «no hacer» (RNH) en cuidados intensivos pediátricos en España. Material y método: Esta investigación se desarrolló en dos fases: primera, recopilación de posibles RNH; segunda, selección por método Delphi de las más importantes según prevalencia de la práctica a modificar, gravedad de sus potenciales riesgos, y facilidad con la que podría ser modificada. Tanto las propuestas como las evaluaciones fueron realizadas por miembros de grupos de trabajo de la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) coordinados por correo electrónico. El listado inicial de RNH fue reduciéndose en base al coeficiente de variación (<80%) de sus evaluaciones. Resultados: Fueron propuestas 182 RNH por 30 intensivistas. Los 14 evaluadores del Delphi lograron reducir el set inicial a 85 RNH y tras una segunda ronda se llegó a la selección final de 26 RNH. Las dimensiones de calidad más representadas en nuestro set final son la efectividad clínica y la seguridad de pacientes. Conclusiones: Nuestro trabajo ha permitido seleccionar y consensuar una serie de recomendaciones para evitar prácticas inseguras, ineficientes o inefectivas en intensivos pediátricos en España, lo que podría ser útil para mejorar la calidad de nuestra actividad clínica. (AU)

Introduction: Health care is not free of ineffective, unsafe or inefficient diagnostic and therapeutic practices. To address this, different scientific societies and health authorities have proposed ‘do not do’ recommendations (DNDRs). Our goal was the selection by consensus of a set of DNDRs for paediatric intensive care in Spain. Material and method: The research was carried out in two phases: first, gathering potential DNDRs; second, selecting the most important ones, using the Delphi method, based on the prevalence of the practice to be modified, the severity of its potential risks and the ease with which it could be modified. Proposals and evaluations were both made by members of working groups of the Sociedad Española de Cuidados Intensivos Pediátricos (SECIP, Spanish Society of Paediatric Intensive Care), coordinated by email. The initial set of DNDRs was reduced based on the coefficient of variation (<80%) of the corresponding evaluations. Results: A total of 182 DNDRs were proposed by 30 intensivists. The 14 Delphi evaluators managed to pare down the initial set to 85 DNDRs and, after a second round, to the final set of 26 DNDRs. The care quality dimensions most represented in the final set are clinical effectiveness and patient safety. Conclusions: This study allowed the selection by consensus of a series of recommendations to avoid unsafe, inefficient or ineffective practices in paediatric intensive care in Spain, which could be useful for improving the quality of clinical care in our field. (AU)

Incorporating Quaternary Prevention: Understanding the Full Scope of Public Health Practices in Sexual Abuse Prevention.

This discussion piece argues for a refinement in our understanding of prevention in sexual abuse, suggesting that we include quaternary prevention on the grounds that this concept from medical literature has potential and helpful application to criminal justice and particularly to work with those who cause sexual harm. Located within the paradigm of Epidemiological Criminology (EpiCrim), quaternary prevention extends the prevention spectrum to enable a stronger distinction between tertiary level responses and long-term safe, sustainable reintegration into communities, particularly of those who sexually abuse others. The key principles of quaternary prevention are adapted and refined from current medical literature, and the potential usefulness of quaternary prevention to crime and sex abuse prevention is explored.

Paediatric intensive care 'do not do' recommendations in Spain: Selection by Delphi method.

INTRODUCTION: Health care is not free of ineffective, unsafe or inefficient diagnostic and therapeutic practices. To address this, different scientific societies and health authorities have proposed 'do not do' recommendations (DNDRs). Our goal was the selection by consensus of a set of DNDRs for paediatric intensive care in Spain. MATERIAL AND METHOD: The research was carried out in 2 phases: first, gathering potential DNDRs; second, selecting the most important ones, using the Delphi method, based on the prevalence of the practice to be modified, the severity of its potential risks and the ease with which it could be modified. Proposals and evaluations were both made by members of working groups of the Sociedad Española de Cuidados Intensivos Pediátricos (SECIP, Spanish Society of Paediatric Intensive Care), coordinated by email. The initial set of DNDRs was reduced based on the coefficient of variation (<80%) of the corresponding evaluations. RESULTS: A total of 182 DNDRs were proposed by 30 intensivists. The 14 Delphi evaluators managed to pare down the initial set to 85 DNDRs and, after a second round, to the final set of 26 DNDRs. The care quality dimensions most represented in the final set are clinical effectiveness and patient safety. CONCLUSIONS: This study allowed the selection by consensus of a series of recommendations to avoid unsafe, inefficient or ineffective practices in paediatric intensive care in Spain, which could be useful for improving the quality of clinical care in our field.

Prevenção quaternária na saúde na percepção de profissionais de saúde / Quaternary prevention in health in the perception of health professionals / Prevención cuaternaria en salud en la percepción de los profesionales de la salud

Objetivo: compreender as percepções de profissionais de saúde atuantes em um hospital acerca da prevenção quaternária. Método: foi conduzido um estudo exploratório de cunho qualitativo, cuja fundamentação teórica baseou-se no interacionismo simbólico e na análise de conteúdo como referencial metodológico. A população foi composta por onze profissionais de saúde. Os dados foram obtidos por meio de entrevistas com roteiro semiestruturado. Resultados: A análise dos discursos determinou a construção das unidades temáticas agrupadas em três categorias temáticas para discussão: significado da prevenção quaternária para profissionais de saúde, experiências com a prevenção quaternária no contexto clínico-assistencial e interações sociais. À luz do interacionismo simbólico, identificaram-se experiências positivas e negativas com destaque às dificuldades dos profissionais e instituições para atuarem com a prevenção quaternária. Conclusão: Para concretização dessa proposta é necessário que uma reorientação da prática clínica dos profissionais seja almejada por meio de condutas técnicas e éticas desejáveis

Objective: to understand the perceptions of health professionals who work in a hospital about quaternary prevention. Method:an exploratory qualitative study was conducted, whose theoretical basis was based on symbolic interactionism and content analysis as a methodological reference. The population consisted of thirteen health professionals. The data were obtained through interviews with a semi-structured script. Results: The analysis of the discourses determined the construction of thematic units grouped into three thematic categories for discussion: meaning of quaternary prevention for health professionals, experiences with quaternary prevention in the clinical-care context and social interactions. In the light of symbolic interactionism, positive and negative experiences were identified, highlighting the difficulties of professionals and institutions to work with quaternary prevention. Conclusion: To implement this proposal, it is necessary that a reorientation of the clinical practice of professionals is desired through desirable technical and ethical conducts

Objetivo: comprender las percepciones de los profesionales de la salud que trabajan en un hospital sobre la prevención cuaternaria. Método: se realizó un estudio cualitativo exploratorio, cuya base teórica se basó en el interaccionismo simbólico y el análisis de contenido como referencia metodológica. La población estaba formada por trece profesionales de la salud. Los datos se obtuvieron a través de entrevistas con un guión semiestructurado. Resultados: El análisis de los discursos determinó la construcción de unidades temáticas agrupadas en tres categorías temáticas para la discusión: significado de la prevención cuaternaria para los profesionales de la salud, experiencias con la prevención cuaternaria en el contexto clínico-asistencial e interacciones sociales. A la luz del interaccionismo simbólico, se identificaron experiencias positivas y negativas, destacando las dificultades de los profesionales e instituciones para trabajar con la prevención cuaternaria. Conclusión: Para implementar esta propuesta, es necesario que se desee una reorientación de la práctica clínica de los profesionales a través de conductas técnicas y éticas deseables

Prevenção quaternária e suas implicações para a prática clínica: uma revisão sistemática / Quaternary prevention and its implications for the clinical practice: a systematic review

A crescente produção de iatrogenias justifica a discussão acerca da incorporação da prevenção quaternária na prática médica cotidiana. Este estudo identificou e sistematizou a produção de conhecimento sobre prevenção qua-ternária e sua implicação para a prática clínica. Trata-se de revisão sistemática descritiva apoiada na pergunta nor-teadora: "Quais são as evidências produzidas sobre prevenção quaternária e sua implicação para a prática clínica?" Realizou-se o levantamento bibliográfico entre agosto e setembro de 2020, utilizando-se o descritor "prevenção quaternária", nos idiomas inglês, português e espanhol. A análise dos 30 artigos produziu evidências sobre inter-venções médicas potencialmente danosas que justificariam a adoção da prevenção quaternária. O estudo provoca a comunidade médica a refletir sobre a incorporação da prevenção quaternária, visando uma prática assistencial menos iatrogênica, valorizando a medicina centrada na pessoa e os atributos da atenção primária à saúde. (AU)

The growing production regarding iatrogenesis justifies the discussion about the incorporation of quaternary pre-vention in the daily medical practice. This study identified and systematized the production of knowledge about quaternary prevention and its implications for the clinical practice. This is a systematic descriptive review supported by the guiding question: What evidence has been produced regarding quaternary prevention and its impact on the clinical practice? A bibliographic survey was carried out between August and September 2020 using the descriptor "quaternary prevention" in English, Portuguese and Spanish. The analysis of 30 articles produced evidence on po-tentially harmful medical interventions that would justify the adoption of quaternary prevention. The study invites the medical community to reflect on the incorporation of quaternary prevention, aiming for a less iatrogenic care practice, valuing person-centered medicine and the attributes of primary health care. (AU)

Planejando ações que contribuem para a prática da prevenção quaternária na atenção primária à saúde / Planeando acciones que contribuyen para la práctica de la prevención cuaternaria en la atención primaria de la salud / Planning actions that contribute to the practice of the quaternary prevention on the primary care to health

Objetivo: refletir com a equipe e desenvolver um planejamento de ações que contribuam para a prática da Prevenção Quaternária na Atenção Primária à Saúde. Método: Pesquisa Apreciativa com a participação de nove profissionais e cinco encontros, correspondentes as fases: discovery (descoberta), dream(sonho), design(planejamento) e destiny(destino). Foram explorados os encontros correspondentes às três últimas fases. Diários de campo foram utilizados, além da gravação dos depoimentos em áudio. Realizou-se a Análise Temática de Conteúdo.Resultados:emergiram três categorias: Organização do trabalho em equipe; Qualificação dos processos de trabalho;Desenvolvimento de ações de educação em saúde. Foram planejadas ações que contribuem para práticas voltadas à Prevenção Quaternária, como ações de educação permanente, escuta qualificada, garantia do acesso, trabalho colaborativo e reconhecimento do território. Conclusão:promoveu-se o diálogo e reflexões sobre as práticas e intervenções desnecessárias/inapropriadas realizadas nos serviços, bem como seus riscos, incorporando-se um planejamento de ações nessa direção

Objective:reflect with the team and develop a planning to the Quaternary Prevention that contribute to the practice on the Primary Care to Health. Method:Appreciative Inquiry with the participation of nine professionalsandfive meetings, corresponding the three stages: discovery, dream, design and destiny, with the three lasts been approached in this study, corresponding to the three lasts stages. Field journals were used, beyondbesides the record in audio of the depositions.Thematic Content Analysis was carried out. Results:in was emerged three categories: Team organization by means of meetings and channels of internal communication; Qualification of the work process on the Primary Care Health; and the Development the actions of education in health. It was planned collectively actions to contribute of practices facing the Quaternary Prevention, like team meetings, movements of Continued Education in Health, qualifies listening, time management, access ensure, collaborative work and territory recognizing. Conclusion:it was promoted the dialog and reflections on the necessary/unnecessary practices of intervention made on the services, as well as their risks, incorporating anaction plan in this direction

Objetivo:reflexionar conel equipo ydesarrollar un plano de acciones que contribuyan para la práctica de la Prevención Cuaternaria en la atención Primaria de la Salud. Método: Investigación Apreciativa con la participación de nueve profesionales. Realizada en cinco reuniones, las cuales correspondieron a fases: discovery(descubrimiento), dream(sueño) design(planes) y destiny(destino), siendo tratadas, en este estudio, las reuniones que correspondieron a las tres últimas fases. Diarios de campo fueron usados para el registro de las informaciones, además de la grabación de las declaraciones en audios. Se realizó el Análisis Temático de Contenido. Resultados: surgieron tres categorías: Organización del trabajo en equipo; Calificación de los procesos de trabajo; Desarrollo de acciones de educación en salud. Fueron planeadas acciones que contribuyen para prácticas volcadas a la Prevención Cuaternaria, como acciones de educación permanente, escucha calificada, garantía del acceso, trabajo colaborativo y reconocimiento del territorio. Conclusión: se promovió el diálogo y reflexiones sobre las prácticas e intervenciones desnecesarias/inapropiadas, realizadas en los servicios, así como sus riesgos, incorporando unplan de acción enesta dirección

Sistematização da propedêutica de massas cervicais­da Atenção Primária à Terciária / Systematization of neck masses propaedeutics ­from Primary to Tertiary Care

Introdução: As massas cervicais são causas frequentes de encaminhamentos aos ambulatórios de otorrinolaringologia, muitas vezes com pouca abordagem na atenção primária à saúde. Sendo assim, a falta de uma rotina de manejo pode deixar o médico assistente inseguro e por vezes confuso quanto ao caminho de investigação a ser seguido, tornando-se necessário elaborar e aplicar uma rotina propedêutica que facilite e direcione o raciocínio clínico para diagnóstico de massas cervicais. Desenvolvimento: Através de revisão da literatura de artigos científicos coletados nos portais Medline, Lilacse PubMed,utilizando descritores específicos como: necklump; head and neck cancer; epidemiology of head and neck cancere consulta à literatura médica específica, foi elaborado um fluxograma para diagnóstico inicial das massas cervicais. Conclusão: Os autores elaboraram um fluxograma para a investigação e diagnóstico das massas cervicais de fácil memorização e aplicabilidade, adequado às condições estruturais de instituições públicas, e visando melhor atendimento, minimização de riscos, bem como qualificação dos profissionais. O fluxograma proposto visa ao diagnóstico diferencial entre doenças malignas e benignas, focando o que pode ser feito em nível de atenção primária à saúde.

Introduction: Neck masses are frequent causes of referrals to otorhinolaryngology clinics, often with a little approach in primary health care. Therefore, the lack of a usual approach can make the attending physician unsafe and prone to error, thus, it is necessary toelaborate a propaedeutic routine for the diagnosis of neck masses. Development: From a literature review of scientific articles collected on Medline, Lilacsand PubMedportals using specific descriptors such as: neck lump; head and neck cancer; epidemiology of head and neck cancer and using specific medical literature, a flowchart had been prepared for initial diagnosis of neck masses. Conclusion: The authors sought a practical form, easy to remember and applicable, appropriate to public institutions, aiming for better care, minimizing risks as well as the qualifications of professionals, targeting on the differential diagnosis between malignant and benign diseases, and what can be done at primary level of health care.

¿En qué puedo ayudarle? Entre la solución individual tecnológica y la metaperspectiva sociopolítica / “How can I help you?” Between the individual technological solution and the socio-political meta-perspective1

En este artículo se expone el condicionamiento sociocultural y político de la demanda (en forma y cantidad) y de la respuesta clínica individual que ofrecemos habitualmente. Se plantea una metaperspectiva sociopolítica que da cuenta del papel de los servicios de salud mental en la sociedad actual marcada por las políticas neoliberales. Se reflexiona sobre el daño que provoca el solucionismo individual y cómo reducirlo. Se hace hincapié en la necesidad de que los profesionales en formación aprendan sobre los sesgos, limitaciones y daños de la atención en salud mental, sobre prevención cuaternaria y su práctica, como la indicación de no-tratamiento. (AU)

The socio-cultural and political conditioning of the demand (in form and quantity) and of the individual clinical response we usually offer is exposed in this article. A socio-political meta-perspective is put forward to account for the role of mental health services in today’s society marked by neoliberal policies. It reflects on the harm caused by individual solutionism and how to reduce it. Emphasis is placed on the need for professionals in training to be aware of the biases, limitations, and harms of mental health care, on quaternary prevention and its practice, such as the indication for non-treatment. (AU)