Effect of the quality of health care on permanent inability secondary to femoral fractures due to occupational accidents.

OBJECTIVE: To construct and validate an indicator for evaluating the quality of care for femoral fractures, and to assess the contribution of the quality of health care as a determinant of partial permanent inability secondary to femoral fractures due to occupational accidents. MATERIALS AND METHODS: The study was conducted from January to December 1995 at Mexican Institute of Social Security. The instrument was designed with experts' contribution along different stages and validated using implicit criteria and factorial analysis. A case-control study was then conducted to evaluate the contribution of the quality of care to inability secondary to femoral fractures. Cases were 108 active workers with permanent inability secondary to femoral fracture; controls were 94 active workers with fracture of femur but no permanent inability. Logistic regression modeling was used to establish the association between quality of care and partial permanent inability, adjusting by relevant variables. RESULTS: The ultimate indicator of quality of care consisted of the following: Timely care, presurgical management, surgical management, and fracture complications. A final score over 229 points meant that the worker had received good quality of care. Workers getting 229 or less points had received poor quality of care. Forty-eight (44%) cases and 66 (70%) controls received good quality of medical care. The likelihood of partial permanent inability was almost three times higher among workers given poor quality of care (OR 2.95; 95% CI 1.5-5.5). According to the multivariate model, predictors of partial permanent inability were: Having exposed or epiphysiary fractures, being re-submitted to surgery, having less than 90 days of rehabilitation care, and receiving deficient medical care. CONCLUSIONS: The constructed instrument was validated. The level of the quality of care received by workers is a determining factor for the generation of partial permanent inability. In workers having femoral fractures, it is important to consider timely medical care and early rehabilitation, to reduce the high incidence and prevalence of this medical problem in Mexico. The English version of this paper is available too at: http://www.insp.mx/salud/index.html.

Pragmatic randomized trial of home visits by a nurse to elderly people with hypertension in Mexico.

BACKGROUND: In Mexico, hypertension is a major cause of disability and death in the elderly, but the most effective way to promote behaviour change in old people is unknown. Low resource interventions that are effective in normal healthcare settings are urgently needed. We report the results of a randomized trial of nurse-provided health and lifestyle advice during home visits to elderly people with hypertension in Mexico City. METHODS: Subjects were 718 people with hypertension aged > or =60 years, who were residents of Mexico City and were registered with the Family Medicine Clinics of the Mexican Institute of Social Security (IMSS). A randomized controlled trial was carried out in which the intervention group was offered nurse visits over 6 months with blood pressure checks and negotiated lifestyle changes. The control group continued to receive usual care. RESULTS: After 6 months, 36.5% of the intervention versus 6.8% of the control group had a blood pressure of <160/90 mmHg. The difference in the mean change in systolic blood pressure was 3.31 mmHg (P = 0.03, 95% CI : 6.32, 0.29) and the same difference in diastolic blood pressure was 3.67 mmHg (P = 0.00, 95% CI : 5.22, 2.12). Weight and sodium excretion fell more in the intervention group, but the difference was not significant. CONCLUSIONS: Nurse home visits are effective in reducing blood pressure in hypertensive patients aged > or =60 years.

Family physician job satisfaction in different medical care organization models.

OBJECTIVES: The aim of the present study was to estimate physician job satisfaction at the Mexican Institute of Social Security (IMSS), the Ministry of Health (SSA) and in the private sector, and to measure the association between these different family medical care organization models. METHODS: A comparative cross-sectional design was used to investigate the job satisfaction of family physicians in private and institutional family medicine clinics. Satisfaction was measured with a previously constructed and validated instrument. The instrument measures the satisfaction in four areas: 'global satisfaction', 'institution where the physician works', 'the patients' and 'themselves as physicians'. RESULTS: One hundred and seven IMSS physicians, 106 SSA physicians and 97 private physicians were selected randomly from a census according to the sample size. The sample was weighted. Fifty-one percent of IMSS and SSA physicians were dissatisfied, against 25% in the private sector, in the first three areas. Comparing the private model and the IMSS, differences were found (P < 0.0001) in the area of 'global satisfaction' [odds ratio (OR) = 2.47, 95% confidence interval (CI) 1.69-3.67], 'institution where the physician works' (OR = 2.12, CI 1. 45-3.13) and 'themselves as physicians' (OR = 1.84, CI 1.28-2.65). When the private/SSA groups were compared, the differences were similar (P < 0.0001). No differences were found in terms of 'the patients'. When stratifying, the risks increased in females, in the group aged 31-40 years and in specialists in family medicine. CONCLUSIONS: The organization model is associated with dissatisfaction in all areas, except in 'the patients'.

Development and validation of an inventory to measure satisfaction of users of family medicine clinics in Mexico.

The object of this study was to construct and validate an inventory to measure the satisfaction of users of Family Medicine Clinics. The satisfaction construct was theoretically developed, then the semantic network technique was applied to write 45 items with a dichotomized response. The scale was validated for 4,134 users. Cronbach coefficient alpha was .78. In a factor analysis, 8 factors were obtained, which explained 43.3% of the variance. The content of the first factor referred to the Family Physician dimension, Factors 3, 4, and 5 to the Family Medicine Clinic, and Factors 2, 6, 7, and 8 to Other Services of the Clinic. The questionnaire is being integrated to the Quality of Care Evaluation System to assess satisfaction of users. It may be useful in other venues to assess cultural and organizational aspects of satisfaction with health care.

[Effect of maternal death on family dynamics and infant survival]. / Efecto de la muerte materna sobre la dinámica familiar y la sobrevivencia infantil.

Family adjustments, which are generated by a maternal death, have been analysed previously in Mexico by using a reduced number of cases in rural areas. This study was design in order to establish changes in family dynamic generated b y a maternal death and to analyse child surviving after one year of birth. Family members of maternal deaths cases, which occurred during 1988-89 in the Federal District, were interviewed by first time in order to know information related to family dynamic and women's characteristics. A second interview was made after one year of birth for cases in which the newborn survived hospital discharge. Simple frequencies were calculated and using X2 test compared groups. Main consequences were family disintegration, child acquiring new roles and economic problems when woman was the main or the only one support of the family. Child surviving was higher than we expected considering other national or international reports. Children were mainly integrated to their grandparent's family.

Maternal mortality regionalization and trend in Mexico (1937-1995)

BACKGROUND: The objectives were to establish regions by level of maternal mortality in order to evaluate its trend from 1937-1995 and to analyze characteristics of cases which occurred from 1990-1995. METHODS: Regionalization of the country by maternal mortality level was carried out using Poisson regression. Level and mortality trends were analyzed globally and compared by regions using Poisson and linear regression. Characteristics of cases were analyzed from 1990-1995 using proportions and X2 test. RESULTS: Four well-differentiated and independent regions were established. Low and medium maternal mortality rate regions were found in northern and northwestern Mexico. High and very high maternal mortality regions were found in the South and the Southeast of the country. Even when maternal mortality had descended, the speed of the descent has decreased and in the last few years, maternal mortality has increased. The quality of health care is a challenge for regions with low mortality rates, while the problem of accessibility is present in those with very high mortality rates. CONCLUSION: The employment of this regionalization approach in maternal mortality analysis would be useful to determine specific problems for each region. The establishment of programs according to this analysis could contribute to decrease in maternal mortality cases in Mexico.

[Adequate utilization of prenatal care at the Mexican Institute of Social Security]. / Utilización adecuada de la atención prenatal en el Instituto Mexicano del Seguro Social.

OBJECTIVE: To establish what proportion of women utilize antenatal care adequately and analyze obstetric, economic, social and cultural factors related to the adequacy of antenatal care use at the Mexican Institute of Social Security (IMSS). MATERIAL AND METHODS: This cross-sectional study included 394 women from 12 to 49 years of age at twenty-eight to forty-two weeks of gestation. A questionnaire was applied that collected information on the following: demographic, social economic and cultural variables; knowledge about pregnancy and complications; gyneco-obstetric history, and barriers to use of antenatal health care services. Data were analyzed by using descriptive statistics, odds ratios and logistic regression modelling. RESULTS: Antenatal care was started during the first trimester by 75% of women, 23.8% of these made at least nine antenatal care visits (adequate utilization). Adequate utilization was associated to prenatal care in family medicine units with a computer system, knowledge and behavior regarding complications, parity, care by the same physician at IMSS, and the woman's occupation. CONCLUSIONS: The proportion of women who utilize prenatal care adequately is low at IMSS. Information about related factors could be used in order to improve institutional programs.

Development and validation of an inventory for measuring job satisfaction among family physicians.

The aim was to develop and validate a measure of job satisfaction among family physicians. The construct of job satisfaction was developed theoretically, then the semantic network technique was used for the construction of the items. 80 semantic differential items in a random order were related by nine physicians. Four dimensions integrated the construct: "job satisfaction," "health institutions where I work," "my patients," and "myself as a doctor." The average Cronbach alpha was .81. In the factor analysis, four factors were obtained in each dimension except that of "my patients," for which two were obtained. These factors accounted for at least 44% of the construct developed. The semantic network technique may be useful.

[Magnitude and causes of maternal mortality in the Federal District (1988-1989)]. / La magnitud y las causas de la mortalidad materna en el Distrito Federal (1988-1989).

Despite the availability of health resources to provide prenatal and delivery care for all pregnant women in the Federal District, the maternal mortality ratio is extremely high. Based on the study of all the maternal deaths which occurred in the Federal District during 1988 and the first semester of 1989 (n = 433), a ratio of 11.4 deaths per 10,000 registered live births was estimated. This is almost twice as high as the ratio reported through vital statistics. The maternal mortality ratio is higher among women delivered in public assistance hospitals as compared with those delivered in social security hospitals. This is due to the high percentage of women arriving with severe complications and to the lower standards of obstetric care in the former. About 75% of the deaths were due to one of the following causes: hypertensive disease of pregnancy, hemorrhage and infection. A detailed study of hospital records undertaken by a maternal mortality committee revealed that 85% of the deaths were preventable with the technology and resources available. The committee identified errors in medical judgment as the main factor involved in the chain of causation leading to potential preventable deaths.