Evaluación de sesgos de género en las Guías de Práctica Clínica en Chile / Gender biases in Chilean clinical guidelines

BACKGROUND: Diseases and treatments have different presentations and impact in men and women due to sex and gender differences. This issue justifies a gender differentiated approach in clinical practice guidelines. AIM: To evaluate gender biases in the Clinical Practice Guidelines (CPG) of the Explicit Health Guarantees program (GES) in Chile. MATERIAL AND METHODS: GES CPGs documents published between 2005 and 2019 were reviewed. A keyword search was carried out in the CPGs, and they were classified into five groups according to their degree of incorporation of the sex / gender variables, following the methodology by Tannenbaum et al. Also, the correct use of the concepts about sex and gender was evaluated. RESULTS: Eighty five CPGs were evaluated and 25% have specific recommendations by sex (group 1 and 2). Two percent of guides determined specific parameters by sex in diagnostic tests (group 3). Sixty one percent mention the keywords superficially or only in the section of epidemiology and risk factors, without proposing a sex differentiated management (group 4 and 5). Sixty two percent of guides have an appropriate use of concepts, 22% a wrong usage, and 17% do not refer to sex or gender. CONCLUSIONS: Gender biases are evidenced in most of the GES guidelines.

Gender disparities in access to care for time-sensitive conditions during COVID-19 pandemic in Chile.

BACKGROUND: During the COVID-19 pandemic, reductions in healthcare utilization are reported in different contexts. Nevertheless, studies have not explored specifically gender disparities in access to healthcare in the context of COVID-19. METHODS: To evaluate gender disparities in access to medical in Chile we conducted an interrupted time series analysis using segmented regression. The outcome variable was the number of weekly confirmed cases of a set of oncologic and cardiovascular time-sensitive conditions at a national level. The series contained data from weeks 1 to 39 for 2017 to 2020. The intervention period started at week 12. We selected this period because preventive interventions, such as school closures or teleworking, were implemented at this point. We estimated the level effect using a dummy variable indicating the intervention period and slope effect using a continuous variable from weeks 12 to 39. To test heterogeneity by gender and age group, we conducted a stratified analysis. RESULTS: We observed a sizable reduction in access to care with a slowly recovery for oncologic (level effect 0.323; 95% CI 0.291-0.359; slope effect 1.022; 95% CI 1.016-1.028) and cardiovascular diseases (level effect 0.586; 95% CI 0.564-0.609; slope effect 1.009; 95% CI 1.007-1.011). Greater reduction occurred in women compared to men, particularly marked on myocardial infarction (level effect 0.595; 95% CI 0.566-0.627 versus 0.532; 95% CI 0.502-0.564) and colorectal cancer (level effect 0.295; 95% CI 0.248-0.35 versus 0.19; 95% CI 0.159-0.228). Compared to men, a greater absolute reduction was observed in women for oncologic diseases, excluding sex-specific cancer, (1352; 95% CI 743-1961) and cardiovascular diseases (1268; 95% CI 946-1590). CONCLUSION: We confirmed a large drop in new diagnoses for time-sensitive conditions during the COVID-19 pandemic in Chile. This reduction was greater for women. Our findings should alert policy-makers about the urgent need to integrate a gender perspective into the pandemic response.

Taking Care of Each Other: How Can We Increase Compliance with Personal Protective Measures During the COVID-19 Pandemic in Chile?

In the context of the COVID-19 pandemic, personal protective measures (e.g., social distancing, handwashing, and mask wearing) have been adopted as a cornerstone to limit the spread of the disease. Yet, the effectiveness of these measures depends on people's levels of adherence. In this article, we apply social-psychological research to the study of compliance with personal protective measures during the COVID-19 pandemic in Chile. We consider three possible models underlying adherence: (1) sociodemographic and socioeconomic factors, (2) instrumental factors, and (3) normative factors. We draw on data from a longitudinal nonrepresentative panel study (Study 1, n = 32,304) and a cross-sectional representative survey (Study 2, n = 1,078) to explore the impact of these different factors on personal protective measures compliance. Findings show the strongest support for the role of instrumental and normative factors, in that people who comply with protective measures report to a greater extent that relatives and friends comply too and tend to perceive high risk of COVID-19. We finish by proposing policy recommendations to promote effective strategies to contain the spread of the virus.

Association between gender inequality and population-level health outcomes: Panel data analysis of organization for Economic Co-operation and Development (OECD) countries.

BACKGROUND: Gender plays a well-recognized role in shaping health inequities. However, the population-level health consequences of gender inequalities have not been measured comprehensively. The goal of this study was to evaluate the association between gender inequality and health indicators in organization for Economic Co-operation and Development (OECD) countries. METHODS: Ecological study based on 1990-2017 panel data for OECD member countries. Gender inequality was measured using the Gender Inequality Index (GII). The population health parameters evaluated were life expectancy (LE), healthy life expectancy (HALE), years of life lost (YLL), years lived with disability (YLD), disability-adjusted life years (DALYs), and specific-cause mortality. Two-way fixed-effects linear models were used to assess the relationship between gender inequality and health outcomes. Models included potential mediating and confounding factors such as health spending, political model, and income inequalities. FINDINGS: Greater gender inequality was associated with lower LE (-0·49%; CI95 -0·63%- -0·31%; p-value < 0·0001), HALE (-0·47%; CI95 -0·63%- -0·31%; p-value < 0·0001) and with increased premature mortality YLL (6·82%; CI95 3·63%-10·75%; p-value < 0·0001) and morbidity measured in DALYs (1·50%; CI95 0·48%-2·46%; p-value = 0·0028) and YLD (2·59%; CI95 0·67%-4·77%; p-value = 0·0063) for each 0·1 increments on the GII. The sensitivity analysis indicated that the results were robust to the various specifications of the causal models. INTERPRETATION: Our results suggest that gender inequality pose a sizable impact on population health outcomes. Promoting gender equality as part of public policies is vital for optimizing health on a population scale. FUNDING: Agencia Nacional de Investigación y Desarrollo (ANID)/Programa Becas/Magister Becas Chile/2017- 22,170,332.

[Gender biases in Chilean clinical guidelines]. / Evaluación de sesgos de género en las Guías de Práctica Clínica en Chile.

BACKGROUND: Diseases and treatments have different presentations and impact in men and women due to sex and gender differences. This issue justifies a gender differentiated approach in clinical practice guidelines. AIM: To evaluate gender biases in the Clinical Practice Guidelines (CPG) of the Explicit Health Guarantees program (GES) in Chile. MATERIAL AND METHODS: GES CPGs documents published between 2005 and 2019 were reviewed. A keyword search was carried out in the CPGs, and they were classified into five groups according to their degree of incorporation of the sex / gender variables, following the methodology by Tannenbaum et al. Also, the correct use of the concepts about sex and gender was evaluated. RESULTS: Eighty five CPGs were evaluated and 25% have specific recommendations by sex (group 1 and 2). Two percent of guides determined specific parameters by sex in diagnostic tests (group 3). Sixty one percent mention the keywords superficially or only in the section of epidemiology and risk factors, without proposing a sex differentiated management (group 4 and 5). Sixty two percent of guides have an appropriate use of concepts, 22% a wrong usage, and 17% do not refer to sex or gender. CONCLUSIONS: Gender biases are evidenced in most of the GES guidelines.

National Health Insurance: A conceptual framework from conflicting typologies.

In the path to universal health coverage, policymakers discuss different alternative health system's financing schemes. Classical typologies have been posited, including models such as National Health Service, Social Health Insurance and Private Health Insurance. More recently, National Health Insurance (NHI) has been suggested as a separate model. Nevertheless, there are discrepancies regarding what defines an NHI model. The purpose of this article is to propose a comprehensive definition of an NHI model, aimed to disentangle the current discrepancies in the conceptualization and the scope of this type of arrangement. Based on the previous literature we identified some common characteristics across NHI definitions, namely universal coverage, pooling in a single fund and a purchasing function based on a single-payer financing mechanism. Areas of controversy were also identified. While some authors emphasized the importance of an effective separation between the purchaser and provider functions, others highlighted the relative importance of privately-owned provision to define a system like NHI-type. Based on empirical data, we suggest that the ownership is not a critical variable to distinguish an NHI from other models, and instead, suggest that a pivotal characteristic of the NHI is the single payer mechanism that is not integrated with the health providers.

Assessment of Devices, Diagnostics and Digital Technologies: A Review of NICE Medical Technologies Guidance.

BACKGROUND: The Medical Technologies Evaluation Programme (MTEP) of NICE in England aims to evaluate medical devices that are deemed to be cost-saving or cost-neutral and produce Medical Technology Guidance (MTG) to encourage their adoption. OBJECTIVE: To review the MTGs since MTEP's inception in 2009 until February 2017. METHODS: One researcher assessed all published MTGs and extracted data on the clinical and economic evidence supporting each technology. The NICE Committee's decision outcome for each assessment was also recorded. A qualitative analysis was performed on technologies that were not supported for adoption to identify the main drivers of the decision. RESULTS: Thirty-one MTGs were reviewed. The committee fully supported the medical devices in 14 MTGs, 11 were partially supported and six were not supported. Of the MTGs, 58% had no RCT data available and the main source of evidence came from non-experimental studies. There was no statistically significant difference in the average number of RCTs and non-experimental studies between the fully-supported, partially-supported, and not-supported technologies. Whilst all the fully-supported MTGs demonstrated cost-saving results, only 50% of the not-supported MTGs did. The sponsor estimated a higher average cost-saving than the EAC in most of the cases (20/31). The qualitative evaluation suggests that the main drivers for negative decisions were the quantity or quality of studies, and costs incurred in the economic evaluation results. CONCLUSIONS: The main drivers of the decision-making process are the quality and quantity of the submitted evidence supporting the technologies, as well as the economic evaluation results.

Eutanasia en Chile: una discusión pendiente / Euthanasia in Chile

Euthanasia is a complex medical procedure. Even though end of life decisions are common situations in health practice, there is a lack of consensus about their terminology. In this manuscript, the main concepts about this issue are defined and delimited; including active and passive euthanasia and limitation of therapeutic effort. Then, a revision is made about the international experience on euthanasia, to then go through the Chile’s history in euthanasia and the population’s opinion. In Chile, euthanasia is an act that has been removed from the social dialogue and legislation. In order to have an open discussion in our population about the issue, the debate has to be opened to the citizens, accompanied by clear medical information about the procedure.

[Euthanasia in Chile]. / Eutanasia en Chile: una discusión pendiente.

Euthanasia is a complex medical procedure. Even though end of life decisions are common situations in health practice, there is a lack of consensus about their terminology. In this manuscript, the main concepts about this issue are defined and delimited; including active and passive euthanasia and limitation of therapeutic effort. Then, a revision is made about the international experience on euthanasia, to then go through the Chile’s history in euthanasia and the population’s opinion. In Chile, euthanasia is an act that has been removed from the social dialogue and legislation. In order to have an open discussion in our population about the issue, the debate has to be opened to the citizens, accompanied by clear medical information about the procedure.

Observatorio de políticas públicas en salud Universidad de Chile: experiencia local de control social en políticas públicas / Observatory on Public Health Policies: local experiences of social control in public policies

Los Observatorios de Políticas Públicas en Salud son organismos dedicados al monitoreo, seguimiento y evaluación de sistemas y políticas públicas, a través de revisión analítica de proyectos y/o estrategias establecidas a nivel nacional. En la Universidad de Chile, el Observatorio de Políticas Públicas en Salud (OPPS) se conforma el año 2011 al alero de las movilizaciones estudiantiles de la Facultad de Medicina, donde se concluye que las universidades públicas deben aportar al control social en las políticas públicas de salud, a través de la deliberación y empoderamiento ciudadano. Con este horizonte, se conforma la organización y se establecen sus objetivos y orgánica. El trabajo desarrollado hasta la fecha abarca cuatro ejes: 1) Revisión y análisis bibliográfico de políticas públicas de salud, 2) Formación en políticas y sistemas de salud, 3) Promoción del debate en torno a políticas públicas y 4) Articulación con actores del sector salud. Dada su composición estudiantil, sus principales limitantes corresponden a la ausencia de formación crítica efectiva en los currículos de las carreras de la salud, y la sobrecarga académica de los estudiantes, que en el contexto de su carácter de actividad extracurricular, dificulta el cumplimiento de los objetivos. La réplica y fortalecimiento de estas instancias requieren la participación de todos los actores de la comunidad universitaria, haciendo converger sus conocimientos, experiencias y perspectivas en torno a los temas estudiados. Además, su inclusión en la estructura institucional formalizaría el compromiso universitario con la formación estudiantil crítica, contribuyendo al debate nacional en políticas públicas.

Observatories of Public Health Policy are organizations dedicated to monitoring, tracking, and evaluating health systems and public policies through an analytical review of established national projects and strategies. At the University of Chile, the Observatory of Public Health Policy (OPPS) was created in 2011, inspired by the student's movement in the Faculty of Medicine, on the basis of the idea that public universities must contribute to the social control of Public Health Policies through deliberation and citizen empowerment. Guided by this aim, the Organization was formed, along with its objectives and organizational structure. To date, the Organization has focused on four areas: 1) Literature review and analysis of public health policies, 2) Training in Health Policy and Systems, 3) Promoting debate on public policies, and 4) Coordination with other actors in the health sector. Given its student composition, the main limitations are the lack of effective training in critical thinking at the health schools in our country, and the academic overload of the students, which in the context of its extra-curricular character, hinders the fulfillment of its objectives. Strengthening and replicating this kind of organizations requires the participation of all Stakeholders in the university community, to permit the convergence of their diverse knowledge, experiences, and perspectives on the topics studied. In addition, its inclusion in the institutional structure would formalize the University's commitment to the critical formation of future health professionals, in order to contribute to the national debate in public policy.