Cost-effectiveness analysis of 3D versus 2D transesophageal echocardiography for the evaluation of patients with primary mitral regurgitation with indication of surgical treatment

OBJECTIVES: To perform the cost-effectiveness analysis of three-dimensional transesophageal echocardiography (3DTEE) in comparison to two-dimensional transesophageal echocardiography (2DTEE) for the anatomic-functional evaluation and surgical planning of severe primary mitral regurgitation. METHODS: a complete economic study was based on a systematic review of 3DTEE and 2DTEE accuracy and private health system costs of two different surgical interventions: mitral valve plasty and mitral valve replacement. The prevalence of common postoperative complications was also predicted for elective procedures: atrial fibrillation (8.6%); acute myocardial infarction (1.4%); thrombosis (3.5%); bleeding (1.5%); endocarditis (6.3%). The decision tree method was adopted as a data analysis model. The Bayes" theorem was used based on sensitivity and specificity measurements. The costs, considering literature and professional tables, were: 3DTEE = US$ 349; 2DTEE = US$ 204; diagnostic evaluation = US$ 597; surgical procedure = US$ 3,643; surgical treatment = US$ 374. RESULTS: The deterministic analysis of the diagnostic test shows that 3DTEE (non-dominated) is superior to 2DTEE (absolutely dominated). The 3DTEE presents a cost reduction of US$ 1,147 and incremental effectiveness (true identification) of 22% when compared to 2DTEE. The multivariate probabilistic sensitivity analysis showed that after 100,000 iterations, the diagnosis based on the 3DTEE becomes the first choice regardless of the willingness to pay threshold. CONCLUSIONS: 3DTEE was cost-effective compared to 2DTEE. Thus, 3DTEE is a potential device to promote health compared to 2DTEE for surgical planning of severe primary mitral regurgitation. (AU)

Estudio de clima ético hospitalario en tres instituciones hospitalarias de Bogotá, Colombia / Study on the ethical climate in three hospital institutions in Bogotá, Colombia

Se realizó un estudio en dos fases: la primera de ellas orientada a hacer ajustes al instrumento -Percepción del Clima Ético Hospitalario- diseñado por la doctora Linda Olson; con base en las recomendaciones formuladas por Gutiérrez; e introducirle nuevas preguntas; acordes al contexto colombiano; para luego evaluar psicométricamente la validez y confiabilidad del instrumento. La segunda fase consistió en aplicar dicho instrumento a 219 enfermeras en tres IPS: una privada; una pública y una de un régimen especial. Los resultados sugieren que el instrumento con las nuevas preguntas registra una validez de contenido que oscila entre 0;66 y 1 y una confiabilidad global de 0.94 con una correlación superior a 0;38 y una validez de constructo donde los 8 primeros factores obtenidos explican el 60;22% de la varianza total; con una carga mínima para cada ítem de 0;3 . Las preguntas elaboradas por el grupo investigador tuvieron un Alpha de Cronbach de 0;87. Los resultados demuestran que este instrumento; a nivel global; tiene una alta validez y confiabilidad para medir Clima Ético Hospitalario como herramienta diagnóstica necesaria para la intervención sobre esta temática y el clima organizacional en general en las instituciones hospitalarias. La aplicación del instrumento arrojó como resultados que en el clima ético organizacional en las IPS objeto de estudio es relevante la ausencia de la confianza en las relaciones del enfermero con la empresa y con los demás profesionales; su actuar se orienta hacia el respeto a la autoridad; hay heteronomía en la relación con el médico y unas conductas mediadas más por los códigos y señales de la profesión que por las señales organizacionales. La responsabilidad de empleados con la empresa y los pacientes es mayor que aquella de la institución con los empleados. Se sugiere investigar en mayor profundidad si las conductas consideradas "responsables" obedecen a una necesidad de cumplir con la obligación legal o si se trata de una genuina responsabilidad moral.

In order to measure the nursing-perceived ethics status prevailing in three Health Service Providers HSP in Bogota, a two-stage project was performed. In the first stage, Dr. Linda Olson´s designed perception instrument "Ethics Status Perception in Hospitals" was adjusted according to Gutierrez suggestions to include new items applicable to the Colombian context, and to re-asses its reliability. In the second stage, the adjusted instrument was applied to 219 nurses from three HSP: One public, and one special. The reliability of the new instrument included a Cronback´s alpha of 0.87, a validity index of 0.66, a trustworthiness index of 0.94, and an inter-item correlation of 0.38. Accounting for 60.22% of the total variance, eigth factors were obtained. The corresponding statistics showed that the adjusted instrument is highly reliable to measure the ethics status in hospitals, and that it could be usedas an organizational diagnostic tool. A HSP nursing-perception finding was the lack of confidence among nurses, hospitals, and other professionals. They perceived that organizational ethics are oriented towards respect to the authority, unilateral commanding, and behavior mediated, more by professional codes, than by organizational signal. They also perceived that more responsibility on patients is deposited on nurses than on other institutional employees. It is suggested to further insight if the "responsible" conducts arise from a legal obligation or from a genuine moral attitude.

[Disability in the private pension system in Chile]. / Invalidez en el sistema privado de pensiones en Chile.

BACKGROUND: The degree of disability of workers ascribed to the private allowances system in Chile, is judged by Medical Commissions that apply norms that establish percentages of incapacity, without considering prognosis. AIM: To communicate the causes of disability among Chilean workers ascribed to the private allowances system, their mortality and to correlate the causes of death with diagnoses. SUBJECTS AND METHODS: We analyzed 13,456 consecutive cases judged between August 1990 and April 1992. Mortality was registered up to 12 months after judgment. RESULTS: Total incapacity was determined in 4,158 cases (30.9%), partial incapacity in 1,340 (9.9%) and minor incapacity in 7,958 (59.1%). Osteoarticular diseases were the main cause of disability in 4,460 patients (33.1%) and 77.8% of patients with malignant tumors were considered as having total incapacity. Mortality was 17% among subjects with total incapacity, 1.5% among those with partial disability and 1% among those with minor disability. The cause of death was related to the main disabling disease in 94% of subjects with total incapacity and 66.6% of those with partial incapacity. CONCLUSIONS: Osteoarticular diseases are the main cause of inability among workers ascribed to a private pension system.