Effects of dietary branched-chain amino acid supplementation on serum and milk metabolome profiles in dairy cows during early lactation.

The 3 branched-chain AA (BCAA), Val, Leu, and Ile, are essential AA used by tissues as substrates for protein synthesis and energy generation. In addition, BCAA are also involved in modulating cell signaling pathways, such as nutrient sensing and insulin signaling. In our previous study, dietary BCAA supplementation was shown to improve protein synthesis and glucose homeostasis in transition cows. However, a more detailed understanding of the changes in metabolic pathways associated with an increased BCAA availability is desired to fine-tune nutritional supplementation strategies. Multiparous Holstein cows (n = 20) were enrolled 28 d before expected calving and assigned to either the BCAA treatment (n = 10) or the control group (n = 10). Cows assigned to BCAA were fed 550 g/d of rumen-protected BCAA mixed with 200 g/d of dry molasses from calving until 35 DIM, whereas the cows assigned to the control were fed only 200 g/d of dry molasses. Serum samples were collected on d 10 before expected calving, as well as on d 4 and d 21 postpartum. Milk samples were collected on d 14 postpartum. From a larger cohort, we selected 20 BCAA-supplemented cows with the greatest plasma urea nitrogen concentration, as an indicator for greater BCAA availability, for the metabolomics analysis herein. Serum and milk samples were subjected to a liquid chromatography-mass spectrometry-based assay, detecting and measuring the abundance of 241 serum and 211 milk metabolic features, respectively. Multivariable statistical analyses revealed that BCAA supplementation altered the metabolome profiles of both serum and milk samples. Increased abundance of serum phosphocholine and glutathione and of milk Val, Ile, and Leu, and decreased abundance of milk acyl-carnitines were associated with BCAA supplementation. Altered phosphocholine and glutathione abundances point to altered hepatic choline metabolism and antioxidant balance, respectively. Altered milk acyl-carnitine abundances suggest changes in mammary fatty acid metabolism. Dietary BCAA supplementation was associated with a range of alterations in serum and milk metabolome profiles, adding to our understanding of the role of BCAA availability in modulating dairy cow protein, lipid, and energy metabolism on a whole-body level and how it affects milk composition.

Effects of Receiving Two Initial Feedings of Colostrum on the Average Daily Gain and Health of Pre-Weaning Group Housed Holstein Heifer Calves.

We studied the effect on average daily gain (ADG) and health of an additional colostrum feeding to Holstein dairy heifers 12-16 h after the first colostrum feeding, provided within 2 h of birth. Calves (n = 190) with an average birth weight of 38.8 kg (29.5-52.6 kg) were randomly enrolled in blocks to either the control (CON) or colostrum (COL). The CON received 3 L of acidified pasteurized whole milk, and the COL received 3 L of pasteurized colostrum [average: 25.5 (24.7-26.4)% Brix]. Calves were group-housed, weighed, withers height measured weekly. Serum was obtained and analyzed with a% Brix refractometer. Mixed linear models were used to assess the differences in ADG, body weight, and height between the treatment and control. There was no difference in ADG between the COL and CON. However, serum % Brix was higher in the COL group (9.7%) than in the CON group (9.2%). Calves in the COL had more antibiotic treatments for respiratory diseases but fewer antibiotic treatments for otitis than the CON. In conclusion, providing an extra feeding of colostrum did not contribute to ADG of Holstein heifers during the pre-weaning period but did provide them with a higher total serum protein concentration.

Blood ß-hydroxybutyrate concentrations and early lactation management strategies on pasture-based dairy farms in Colombia.

The increasing global demand for food requires sustainable solutions to close the gap in agricultural yield between industrialized and non-industrialized countries. Our objectives in this cross-sectional study were to: 1) characterize farm populations, milk yield, and early lactation management strategies of dairy cows in three different regions of Colombia, and 2) determine the association of these management strategies with blood ß-hydroxybutyrate (BHB) concentrations in the first 42 days in milk (DIM). Dairy herds (n = 56) in the Antioquia, Caldas, and Cundinamarca regions of Colombia were visited once from May through July 2018. A survey was administered to farm owners to collect demographic, management, and herd nutrition information. Blood samples from dairy cows (n = 880) between calving and 42 DIM were used to measure blood BHB concentration. Associations between management and nutritional strategies and blood BHB concentration were examined using mixed models. Prevalence of hyperketonemia was calculated as the number of samples with BHB concentration ≥1.2 mmol/L divided by the total number of samples. The estimated diet composition for early lactation dairy cows was 65.5% pasture and 31.8% commercial concentrates. The farm median milk yield, protein concentration, and fat concentration were 21.0 kg (range = 13.1-36 kg), 3.2% (range = 2.7-4.1%), and 3.5% (range = 3.0-4.1%), respectively. Milk yield least squares means (95% confidence interval; CI) differed by region: 21.7 (20.3, 23.2), 18.5 (17.0, 20.2), and 20.3 (18.5, 22.4) kg in Antioquia, Caldas, and Cundinamarca, respectively. Median blood BHB concentration was 0.5 and ranged from 0.1-4.4 mmol/L; blood BHB concentration was not different among the three regions. Pasture fertilization, increased parity, and BCS were associated with changes in blood BHB concentration. The overall prevalence of hyperketonemia was 4.5%. Geographical region affected the prevalence of hyperketonemia at 2.5%, 4.0%, and 10.2% in Antioquia, Caldas, and Cundinamarca, respectively. Mean stocking density (95% CI) was greater in Cundinamarca than Antioquia or Caldas at 3.3 (2.2, 5.0), 2.8 (2.1, 3.9) and 1.7 (1.2, 2.6) animals per ha, respectively, and was associated with hyperketonemia prevalence. Farms that abruptly stop milking cows at dry-off had 80% of the hyperketonemia events in the study. Pasture-based dairies in Colombia had lower blood BHB concentrations and estimated milk yield compared with confined production systems in temperate zones. However, geographical region, stocking density, and abrupt cessation of milking at dry-off were associated with prevalence of hyperketonemia in pasture-based dairies.

Longitudinal Phenotypes Improve Genotype Association for Hyperketonemia in Dairy Cattle.

The objective of our study was to identify genomic regions associated with varying concentrations of non-esterified fatty acid (NEFA), ß-hydroxybutyrate (BHB), and the development of hyperketonemia (HYK) in longitudinally sampled Holstein dairy cows. Our study population consisted of 147 multiparous cows intensively characterized by serial NEFA and BHB concentrations. To identify individuals with contrasting combinations in longitudinal BHB and NEFA concentrations, phenotypes were established using incremental area under the curve (AUC) and categorized as follows: Group (1) high NEFA and high BHB, group (2) low NEFA and high BHB), group (3) low NEFA and low BHB, and group (4) high NEFA and low BHB. Cows were genotyped on the Illumina Bovine High-density (777K) beadchip. Genome-wide association studies using mixed linear models with the least-related animals were performed to establish a genetic association with HYK, BHB-AUC, NEFA-AUC, and the comparisons of the 4 AUC phenotypic groups using Golden Helix software. Nine single-nucleotide polymorphisms were associated with high longitudinal concentrations of BHB and further investigated. Five candidate genes related to energy metabolism and homeostasis were identified. These results provide biological insight and help identify susceptible animals thus improving genetic selection criteria thereby decreasing the incidence of HYK.

Udder and teat conformational risk factors for elevated somatic cell count and clinical mastitis in New York Holsteins.

Our primary objective was to identify udder and teat conformational risk factors associated with the occurrence of elevated somatic cell count (SCC) and clinical mastitis using a prospective cohort study design with careful assessment of exposure and disease outcomes. Mastitis prevalence was evaluated by parity across 6 sampling periods representing key physiological transitions during lactation: 0-1 day in milk (DIM), 3-5 DIM, 10-14 DIM, 50-60 DIM, 90-110 DIM, and 210-230 DIM. Cows were scored for front and rear teat length, width, end shape, and placement, fore udder attachment, udder cleft, udder depth, rear udder height, and rear udder width. Two independent multivariable logistic regression models were used to generate odds ratios (OR) for elevated SCC (≥ 200,000 cells/ml) and farm-diagnosed clinical mastitis. We identified that loose fore udder attachment (reference level: strong fore udder attachment, OR = 2.1, 95% confidence interval (CI) = 1.2-3.8) and flat teat end shape (reference level: round teat end shape, OR = 1.4, 95% CI = 1.1-1.9) increased the odds of an elevated SCC event, whereas a negative California Mastitis Test score at 0-1 DIM decreased the odds of an elevated SCC event (OR = 0.6, 95% CI = 0.4 to 0.8). Loose fore udder attachment (reference level: strong fore udder attachment, OR = 3.7, 95% CI = 1.3-10.7), flat teat end shape (reference level: round teat end shape, OR = 1.5, 95% CI = 1.0-2.4), low rear udder height (reference level: intermediate rear udder height, OR = 2.8, 95% CI = 0.3-6.2), and increasing rear teat width (OR = 2.2, 95% CI = 1.2-4.4) heightened the odds of developing clinical mastitis. We identified that within our study cohort, loose fore udder attachment and flat teat ends had an important association with increased odds of both an elevated SCC event and clinical mastitis diagnosis. The identification of these udder and teat conformational risk factors for mastitis can provide farmers an effective and inexpensive tool to manage mastitis.

The effect of the transition period and postpartum body weight loss on macrophage infiltrates in bovine subcutaneous adipose tissue.

The transition period in dairy cattle is characterized by a rapid increase in metabolic demands due to the onset of lactation in parallel with a voluntary drop in dry matter intake, which slowly increases compared with the rapidly increasing milk production. The resulting deficit in energy intake is largely met by lipolysis of adipose tissue stores liberating nonesterified fatty acids (NEFA) as energy substrates to support milk production and for the synthesis of milk fat. Previous work in cattle and other species has documented an increase in adipose tissue macrophages (ATM) during periods of feed restriction and lipolysis; however, alterations in ATM during the transition period have only recently received interest because of the role that adipose tissue remodeling and inflammation may play during this time. The primary objective of this study was to evaluate the number of macrophages in subcutaneous adipose tissue from dairy cattle at multiple time points throughout the transition period. Secondary objectives included the evaluation for potential associations of ATM with changes in body condition score (BCS) and concentrations of circulating NEFA and ß-hydroxybutyrate. Holstein cows (n = 25) were enrolled in the study 28 d before expected parturition and fed the same prepartum and postpartum rations for ad libitum consumption. On d 10 before expected parturition, and on d 4 and 21 after calving, subcutaneous adipose tissue biopsies were taken from the paralumbar fossa and preserved in formalin. Paraffin-embedded sections of tissue from each of the 25 cows at the 3 time points (total of 75 samples) were labeled with an immunohistochemical marker of macrophages, ionized calcium-binding adapter molecule 1 (Iba1, also known as allograft inflammatory factor 1). The number of Iba1-positive cells, the number of crown-like structures, and the number of immunopositive aggregates were enumerated in each sample. The number of Iba1-positive macrophages increased by 60 and 93% on d 4 and 21, respectively, when compared with the average prepartum number. Additionally, cows that lost ≥0.50 points of BCS had a 57 and 52% higher number of ATM on d 4 and 21 postpartum, respectively, when compared with cows that lost ≤0.25 points of BCS. No association was found between ATM numbers and NEFA and ß-hydroxybutyrate concentrations or milk production in early lactation. Cows experiencing a more pronounced decrease in BCS postpartum had the largest increase in adipose tissue macrophage counts, suggesting that a greater degree of adipose tissue remodeling during the period of greatest nutrient deficit may be associated with higher numbers of ATM.

A systematic review of serious games in medical education: quality of evidence and pedagogical strategy.

INTRODUCTION: The literature shows an optimistic landscape for the effectiveness of games in medical education. Nevertheless, games are not considered mainstream material in medical teaching. Two research questions that arise are the following: What pedagogical strategies do developers use when creating games for medical education? And what is the quality of the evidence on the effectiveness of games? METHODS: A systematic review was made by a multi-disciplinary team of researchers following the Cochrane Collaboration Guidelines. We included peer-reviewed journal articles which described or assessed the use of serious games or gamified apps in medical education. We used the Medical Education Research Study Quality Instrument (MERSQI) to assess the quality of evidence in the use of games. We also evaluated the pedagogical perspectives of such articles. RESULTS: Even though game developers claim that games are useful pedagogical tools, the evidence on their effectiveness is moderate, as assessed by the MERSQI score. Behaviourism and cognitivism continue to be the predominant pedagogical strategies, and games are complementary devices that do not replace traditional medical teaching tools. Medical educators prefer simulations and quizzes focused on knowledge retention and skill development through repetition and do not demand the use of sophisticated games in their classrooms. Moreover, public access to medical games is limited. DISCUSSION: Our aim was to put the pedagogical strategy into dialogue with the evidence on the effectiveness of the use of medical games. This makes sense since the practical use of games depends on the quality of the evidence about their effectiveness. Moreover, recognition of said pedagogical strategy would allow game developers to design more robust games which would greatly contribute to the learning process.

[Healthcare and maternal morbidity and mortality: a hospital-based case-control study in two regions of Colombia (Bogotá and Antioquia), 2009-2011]. / Atención a la salud y morbimortalidad materna: un estudio de casos y controles de base hospitalaria en dos regiones de Colombia (Bogotá y Antioquia), 2009-2011.

The study aimed to identify whether payment forms and insurance schemes are associated with severe obstetric complications and maternal mortality. A hospital-based case-control study was conducted in two regions of Colombia, 2009-2011. Data were obtained from each woman's clinical history. Unconditional logistic regression was used. The sample included 1,011 patients: 337 cases and 674 controls. No quality component was statistically significant in either region. In Bogotá, the risk of obstetric complications was significantly higher in the contributive insurance scheme than in subsidized coverage or uninsured; Antioquia showed similar associations, but not statistically significant. Differences in maternal morbidity according to payment scheme were not statistically significant in either Antioquia or Bogotá. Factors associated with maternal morbidity and mortality differed according to the study population, suggesting the need for local studies to identify determinants and make appropriate decisions.

Cultura innovadora y grupos relacionados de diagnóstico en un hospital de alta complejidad, Colombia / Innovative culture and diagnosis related groups in a high complexity hospital, Colombia

Objetivos Caracterizar la percepción sobre los Grupos Relacionados de Diagnóstico GRD como una innovación entre el personal médico, de enfermería y de soporte administrativo, en un Hospital en Colombia. Métodos Estudio de caso de la cultura innovadora en un hospital. Se realizaron encuestas y grupos focales con el personal médico, de enfermería y de soporte administrativo. Se calcularon estadísticos descriptivos para las percepciones de la cultura innovadora y análisis comparativos entre los grupos profesionales en mención. Los grupos focales fueron trascritos y analizados para profundizar en los hallazgos de las encuestas. Resultados Se encontraron diferencias significativas en las percepciones de la cultura innovadora. El personal de enfermería fue más entusiasta que los médicos al evaluar la cultura innovadora y el liderazgo de las directivas del Hospital. Los médicos se sintieron más autónomos para discutir asuntos profesionales. Los administrativos, por su parte, evaluaron la voluntad del Hospital para adquirir nuevas tecnologías más alto que los médicos. Los tres grupos conocen poco sobre los GRD. Conclusiones Al implementar una innovación en salud es recomendable analizar su efecto sobre los profesionales que participarán en su implementación. El personal médico percibe los GRD como una amenaza a su autonomía profesional; en tanto el personal de enfermería aparece como una fuerza pro-innovación, por lo cual a la gerencia le conviene involucrarlo en el proceso de implementación de los GRD junto al personal administrativo.(AU)

Objectives To characterize the perception of Diagnosis-Related Groups (DRGs) as an innovation among physicians, nurses and administrative staff in a hospital in Colombia. Methods A case study of innovative culture in a hospital. Surveys and focus groups were carried out with the medical, nursing and administrative staff. Descriptive statistics were calculated for the perceptions of innovative culture. Comparative analysis was done between professional groups. The results of the focus groups were transcribed and analyzed to deepen the findings of the surveys. Results Significant differences were found in perceptions of the innovative culture. The nursing staff were more enthusiastic than doctors when evaluating the innovative culture and leadership. Physicians felt more autonomy when discussing professional issues. Administrative staff assessed the Hospital's disposition to acquire new medical technologies as higher than that of physicians. The three groups know little about DRG's. Conclusions When implementing a health innovation it is advisable to analyze its effect on the professionals who participate in the implementation. Physicians perceive DRGs as a threat to their professional autonomy, while nurses see it as a pro-innovation force. It is important to involve nursing and administrative staff when implementing this kind of innovation.(AU)

[Innovative culture and diagnosis related groups in a high complexity hospital, Colombia]. / Cultura innovadora y grupos relacionados de diagnóstico en un hospital de alta complejidad, Colombia.

Objectives To characterize the perception of Diagnosis-Related Groups (DRGs) as an innovation among physicians, nurses and administrative staff in a hospital in Colombia. Methods A case study of innovative culture in a hospital. Surveys and focus groups were carried out with the medical, nursing and administrative staff. Descriptive statistics were calculated for the perceptions of innovative culture. Comparative analysis was done between professional groups. The results of the focus groups were transcribed and analyzed to deepen the findings of the surveys. Results Significant differences were found in perceptions of the innovative culture. The nursing staff were more enthusiastic than doctors when evaluating the innovative culture and leadership. Physicians felt more autonomy when discussing professional issues. Administrative staff assessed the Hospital's disposition to acquire new medical technologies as higher than that of physicians. The three groups know little about DRG's. Conclusions When implementing a health innovation it is advisable to analyze its effect on the professionals who participate in the implementation. Physicians perceive DRGs as a threat to their professional autonomy, while nurses see it as a pro-innovation force. It is important to involve nursing and administrative staff when implementing this kind of innovation.

Atención a la salud y morbimortalidad materna: un estudio de casos y controles de base hospitalaria en dos regiones de Colombia (Bogotá y Antioquia), 2009-2011 / Healthcare and maternal morbidity and mortality: a hospital-based case-control study in two regions of Colombia (Bogotá and Antioquia), 2009-2011 / Atenção à saúde e morbimortalidade materna: estudo caso-controle de base hospitalar em duas regiões de Colômbia (Bogotá e Antioquia), 2009-2011

Resumen: El objetivo fue identificar si formas de pago y regímenes de aseguramiento están asociados con la mortalidad materna y morbilidad obstétrica extrema. Estudio de casos y controles de base hospitalaria en dos regiones de Colombia, 2009-2011. Los datos se obtuvieron de la historia clínica de cada gestante. Se utilizó regresión logística no condicional. El resultado fue: 1.011 pacientes, 337 casos y 674 controles. Ningún componente de calidad fue estadísticamente significativo en ambas regiones. En Bogotá, el riesgo de complicación obstétrica, significativamente mayor en Régimen Contributivo que en Subsidiado y no aseguradas; Antioquia, aunque hubo asociaciones similares, no estadísticamente significativas. Diferencias en morbilidad por régimen de pago no estadísticamente significativas en Antioquia ni Bogotá. Factores asociados a la morbimortalidad materna diferentes, según la población estudiada, lo que sugiere la necesidad de estudios locales para identificar factores determinantes propios y tomar decisiones pertinentes.

Abstract: The study aimed to identify whether payment forms and insurance schemes are associated with severe obstetric complications and maternal mortality. A hospital-based case-control study was conducted in two regions of Colombia, 2009-2011. Data were obtained from each woman's clinical history. Unconditional logistic regression was used. The sample included 1,011 patients: 337 cases and 674 controls. No quality component was statistically significant in either region. In Bogotá, the risk of obstetric complications was significantly higher in the contributive insurance scheme than in subsidized coverage or uninsured; Antioquia showed similar associations, but not statistically significant. Differences in maternal morbidity according to payment scheme were not statistically significant in either Antioquia or Bogotá. Factors associated with maternal morbidity and mortality differed according to the study population, suggesting the need for local studies to identify determinants and make appropriate decisions.

Resumo: O presente estudo objetiva identificar se as formas de pagamento e regimes de seguros de saúde estão associados com a mortalidade materna e morbidade materna grave. Trata-se de um estudo caso-controle de base hospitalar em duas regiões da Colômbia entre 2009-2011. Os dados foram obtidos através da história clínica de cada gestante. Foi utilizada a regressão logística não condicionada. A mostra incluiu 1.011 pacientes: 337 casos e 674 controles. Nenhum componente de qualidade foi estatisticamente significativo em ambas as regiões. Em Bogotá, o risco de complicações obstétricas foi significativamente maior no Regime Contributivo do que no Subsidiado e em mulheres sem seguro de saúde. Em Antioquia, embora existam associações similares, não foram estatisticamente significativas. Tanto em Antioquia quanto em Bogotá não se encontraram diferenças significativas de morbilidade por regime de pagamento. Foram encontrados diferentes fatores associados à morbimortalidade materna, segundo a população estudada, o que sugere a necessidade de estudos locais para identificar fatores determinantes próprios e tomar decisões adequadas neste contexto.

Percepción de Grupos Relacionados de Diagnóstico y cultura innovadora por profesionales de enfermería / Perception of diagnosis related groups and the innovative culture by nursing professionals

Los profesionales de enfermería desempeñan un importante rol en el Hospital a la hora de implementar innovaciones. Se desconoce su percepción frente a los Grupos Relacionados de Diagnóstico como una innovación. Objetivos: Caracterizar la percepción de los profesionales del departamento de enfermería sobre los Grupos Relacionados de Diagnóstico como una innovación, en un Hospital de alta complejidad en Colombia. Metodología: Estudio de caso. La información se obtuvo de encuesta y grupo focal. Se calcularon estadísticos descriptivos para las percepciones de la innovación; se transcribieron y analizaron los datos del grupo focal. Resultados: La percepción de la cultura innovadora fue positiva y se encontraron diferencias según educación, posición jerárquica y sexo; las demás variables no fueron significativas. Frente a los Grupos Relacionados de Diagnóstico como innovación sólo el 12,5 % de los participantes los conocían, predominando una actitud positiva. El atributo que generó menos entusiasmo y mayor dispersión, fue la complejidad de los GRD. No hubo diferencias en la percepción frente a los cinco atributos por ninguna variable demográfica. Conclusiones: La homogeneidad de la percepción sugiere un ambiente favorable para implementar los Grupos Relacionados de Diagnóstico.

Nursing professionals play an important role at Hospitals when innovation is to be implemented. However, their perception regarding diagnosis related groups as an innovation is unknown. Objective: to characterize how the professionals of a nursing department of a high complexity hospital in Colombia perceive the innovation of diagnosis related groups. Methodology: A case study. Data were collected from surveys and focus groups. Descriptive statistics were calculated for the perception of innovation, and the data from the focus groups were transcribed and analyzed. Results: The perception of the innovative culture was positive and there were differences according to education, hierarchical position and sex; the other variables were not significant. As for the diagnosis related groups as an innovation, only 12.5% of the participants were familiar with them, and their attitude was predominantly positive. The attribute that generated less enthusiasm and greater dispersion, was the complexity of said groups. No differences were observed in the perception of the five attributes for any demographic variable. Conclusions: The homogeneity of perception suggests a favorable environment for implementing the system of diagnosis related groups.

[Why are diagnosis-related groups unpopular in Colombia?]. / ¿Por qué los grupos relacionados de diagnóstico no se implementan en Colombia?

The aim of this study was to explore the determinants of non-implementation of diagnosis-related groups (DRGs) by hospitals in Colombia. A qualitative case was carried out to analyze the directors' perceptions in six hospitals with and without DRGs in Bogotá. The interviews are based on the Innovation Diffusion Theory. The directors had similar perceptions of the determinates. DRGs were seen as positive, but encountered organizational and institutional obstacles. Without a targeted public policy, the likelihood of implementing DRGs in Colombia is slight.

Editorial: ¿Por qué la crisis multisistémica de la salud? / Editorial: Why is the multisystemic health crises? / Editorial: Por que a crise multisistêmica da saúde?

La crisis actual del sistema de saludcolombiano ha tenido un proceso de gestaciónlargo y tortuoso. Sus manifestaciones son lasde una crisis multisistémica que acusa fallasen lo financiero, en la salud pública, en laprestación de los servicios y, particularmente,en los resultados sobre el nivel de salud dela población colombiana...

Percepciones del personal hospitalariosobre la preparación institucional para la implementación de innovaciones en el sector salud, específicamente grupos relacionados con el diagnóstico (GRD) / Hospital Staff Perceptions of Institutional Readiness for Implementation of Innovations in the Health Sector, Specifically Diagnostic Related Groups (DRG)

Objetivos: Caracterizar el estado de la cultura innovadora y la actitud del personalhospitalario frente a los grupos relacionados de diagnóstico (GRD) como innovaciónpara el sector de la salud en Colombia. Métodos: Estudio de caso mediante unamuestra por conveniencia realizada entre el personal clínico y administrativo dequienes depende el éxito del proyecto de los GRD. El análisis estadístico se realizapor medio de la estadística descriptiva, la regresión y el análisis de correspondencia.Resultados: El estado de la cultura innovadora en el hospital es favorable parala innovación. No se observan diferencias significativas entre las perspectivasa la innovación que tienen el personal clínico y el administrativo. El personaladministrativo y los médicos jóvenes desconocen los GRD. En cambio, los médicoscon experiencia y los que ocupan puestos de mando, conocen los GRD. Se encontróuna correlación significativa entre la cultura innovadora y la actitud frente a los GRD.Conclusiones: La homogeneidad de la cultura innovadora en el hospital augura unambiente favorable para implementar los GRD...

Objectives: To characterize the state of the innovativeculture and attitude of hospital staff towardsDiagnosis Related Groups (DRG) like an innovationfor the Colombian health care. Methods: Acase study through convenience sampling amongclinical and administrative staff who determinethe success of the DRG. Statistical analysis wasperformed using descriptive statistics, regressionand correspondence analysis. Results: The stateof innovative culture in the Hospital is favorablefor the innovation. There were no significant differencesbetween the views on the innovationof the clinical and administrative staff. The administrativestaff and junior doctors are unawareof the DRG. In contrast, experienced doctors andthose in management positions know DRG. Significantcorrelation was found between innovativeculture and attitude to the DRG. Conclusions:The homogeneity of the innovative culture in theHospital predicts a favorable climate for DRGimplementation...

[Pay for performance explained by transaction costs theory]. / Pago por desempeño explicado desde la teoría de costos de transacción.

OBJECTIVE: To evaluate the ability of transaction costs theory to explain incentives in the health care chain. METHODS: We performed a case study of CPS, a health insurance company in Bogota (Colombia), which preferred not to publish its name. RESULTS: CPS moves in the environment of high transaction costs and uses the hybrid form of governance at the outpatient level. Incentive intensity, administrative control and the contract all agree with the theory. At the hospital level, the market is used, despite greater uncertainty. Because of the discrete form (1.0) of the incentives and the absence of administrative control, it is difficult for CPS to relate payment to hospital performance. CONCLUSIONS: Transaction costs theory explains the configuration of incentives. Another contribution made by this theory to the literature is the criterion to differentiate between the market and the hybrid. We propose that the market uses discrete-type (1.0) incentives, while the hybrid uses continuous, commission-like incentives.

[Pay for performance in Colombian healthcare]. / Pago por desempeño en el sistema colombiano de salud.

OBJECTIVE: Describing the extent and forms of use of pay for performance (P4P) in Colombian healthcare. METHODS: This was a descriptive study based on interviews and surveys of health insurance agency managers in Bogotá, Colombia. The authors relied on transaction cost theory to interpret the results. RESULTS: P4P was found to be used by contribution scheme insurers in an outpatient setting, basically in promotion and prevention; P4P is not being used in a hospital setting. Subsidized scheme insurers do not use P4P. Similarly, P4P is not being used in the case of so called associated users. CONCLUSIONS: P4P use in Colombia is limited. Colombian practice only partially validates the transaction costs theory approach to governance model attributes, one of which is incentive intensity.

[What do living standard surveys show about the health system in Colombia?]. / Qué muestran las Encuestas de Calidad de Vida sobre el sistema de salud en Colombia?

This paper analyzes the main advances in health coverage and health services demand in Colombia using the 1997 and 2003 living standards surveys. The study showed an increase in health coverage associated with expansion of the subsidized care system, although a large proportion of the population is still not entitled to health care. The type of entitlement also directly affects the demand for services. There was an increase in preventive medical consultations in 2003 and a decrease in the use medical care for acute illness, due mainly to lack of money. Access to medicines increased from 1997 to 2003, as reflected by a decrease in out-of-pocket expenditure on medicines.

¿Qué muestran las Encuestas de Calidad de Vida sobre el sistema de salud en Colombia? / What do living standard surveys show about the health system in Colombia?

This paper analyzes the main advances in health coverage and health services demand in Colombia using the 1997 and 2003 living standards surveys. The study showed an increase in health coverage associated with expansion of the subsidized care system, although a large proportion of the population is still not entitled to health care. The type of entitlement also directly affects the demand for services. There was an increase in preventive medical consultations in 2003 and a decrease in the use medical care for acute illness, due mainly to lack of money. Access to medicines increased from 1997 to 2003, as reflected by a decrease in out-of-pocket expenditure on medicines.

En este documento se esbozan los principales avances en cuanto a aseguramiento en salud y demanda de servicios médicos en Colombia, a partir de las Encuestas de Calidad de Vida de 1997 y 2003. Se encuentra un aumento en el aseguramiento en salud de la población, con un mayor incremento del régimen subsidiado; aún así, persiste una gran proporción que no cuenta con aseguramiento. También se encuentra que el tipo de afiliación afecta directamente la demanda de servicios. Se evidencia un aumento en la consulta por prevención para 2003 y una disminución en las consultas médicas cuando el individuo se siente enfermo, esta disminución se debe principalmente a la falta de dinero. El acceso a los medicamentos aumenta entre 1997 y 2003, lo que se refleja en la disminución del gasto privado en medicamentos.